The tyranny of distance: maternity waiting homes and access to birthing facilities in rural Timor-Leste

Objective

To examine the impact of maternity waiting homes on the use of facility-based birthing services for women in two remote districts of Timor-Leste.

Methods

A before-and-after study design was used to compare the number of facility-based births in women who lived at different distances (0–5, 6–25, 26–50 and > 50 km) from the health centre before and after implementation of maternity waiting homes. Routine data were collected from health centre records at the end of 2007; they included 249 births in Same, Manufahi district, and 1986 births in Lospalos, Lautem district. Population data were used to estimate the percentage of women in each distance category who were accessing facility-based care.

Findings

Most facility-based births in Same (80%) and Lospalos (62%) were among women who lived within 5 km of the health centre. There was no significant increase in the number of facility-based births among women in more remote areas following implementation of the maternity waiting homes. The percentage of births in the population that occurred in a health facility was low for both Manufahi district (9%) and Lautem district (17%), and use decreased markedly as distance between a woman’s residence and the health facilities increased.

Conclusion

The maternity waiting homes in Timor-Leste did not improve access to facility-based delivery for women in remote areas. The methods for distance analysis presented in this paper provide a framework that could be used by other countries seeking to evaluate maternity waiting homes.     

Effects of introducing routinely ultrasound scanning during Ante Natal Care (ANC) clinics on number of visits of ANC and facility delivery: a cohort study

Background

Many countries have integrated antenatal care as an essential part of routine maternal health services. The importance of this service cannot be overemphasized as many women’s lives are usually saved particularly through early detection of pregnancy related complications. However, while many women would attend at least one visit for ante natal care (ANC), completion of recommended number of visits (4+) has been a challenge of many health systems particularly in developing countries like Tanzania.

Methods

We conducted a cohort study to include ultrasound scanning using a portable hand-held Vscan to test whether by integrating it in routine ANC clinics at dispensary and health centre levels would promote number of ANC visits by women.Health providers rendering ANC services in selected facilities were trained on how to use the simple technology of ultrasound scanning. Women living in catchment areas of the respective selected facilities were eligible to inclusion to the study when consented. A baseline status of the ANC attendance in the study area was established through baseline household and facility surveys. A total of 257 women consented and received the study treatment.

Results

Our results showed that, there was no a slight change between baseline (97.2 %) and endline (97.4 %) results among women attending ANC clinics at least once. However, there was a significant change in percentage of women attending ANC clinic four times or more (27.2 % during baseline and 60.3 %; p = 0001).

Conclusions

We conclude that, introduction of the simplified ultrasound scanning technology at lowest levels of care has an effect to improving ANC attendance in terms of number of visits and motivate facility delivery.     

Can vouchers deliver? An evaluation of subsidies for maternal health care in Cambodia

Objective

To evaluate the effect of vouchers for maternity care in public health-care facilities on the utilization of maternal health-care services in Cambodia.

Methods

The study involved data from the 2010 Cambodian Demographic and Health Survey, which covered births between 2005 and 2010. The effect of voucher schemes, first implemented in 2007, on the utilization of maternal health-care services was quantified using a difference-in-differences method that compared changes in utilization in districts with voucher schemes with changes in districts without them.

Findings

Overall, voucher schemes were associated with an increase of 10.1 percentage points (pp) in the probability of delivery in a public health-care facility; among women from the poorest 40% of households, the increase was 15.6 pp. Vouchers were responsible for about one fifth of the increase observed in institutional deliveries in districts with schemes. Universal voucher schemes had a larger effect on the probability of delivery in a public facility than schemes targeting the poorest women. Both types of schemes increased the probability of receiving postnatal care, but the increase was significant only for non-poor women. Universal, but not targeted, voucher schemes significantly increased the probability of receiving antenatal care.

Conclusion

Voucher schemes increased deliveries in health centres and, to a lesser extent, improved antenatal and postnatal care. However, schemes that targeted poorer women did not appear to be efficient since these women were more likely than less poor women to be encouraged to give birth in a public health-care facility, even with universal voucher schemes.     

Kangaroo mother care: a systematic review of barriers and enablers

Objective

To investigate factors influencing the adoption of kangaroo mother care in different contexts.

Methods

We searched PubMed, Embase, Scopus, Web of Science and the World Health Organization’s regional databases, for studies on “kangaroo mother care” or “kangaroo care” or “skin-to-skin care” from 1 January 1960 to 19 August 2015, without language restrictions. We included programmatic reports and hand-searched references of published reviews and articles. Two independent reviewers screened articles and extracted data on carers, health system characteristics and contextual factors. We developed a conceptual model to analyse the integration of kangaroo mother care in health systems.

Findings

We screened 2875 studies and included 112 studies that contained qualitative data on implementation. Kangaroo mother care was applied in different ways in different contexts. The studies show that there are several barriers to implementing kangaroo mother care, including the need for time, social support, medical care and family acceptance. Barriers within health systems included organization, financing and service delivery. In the broad context, cultural norms influenced perceptions and the success of adoption.

Conclusion

Kangaroo mother care is a complex intervention that is behaviour driven and includes multiple elements. Success of implementation requires high user engagement and stakeholder involvement. Future research includes designing and testing models of specific interventions to improve uptake.     

Providing skilled birth attendants and emergency obstetric care to the poor through partnership with private sector obstetricians in Gujarat, India

Problem

India has the world’s largest number of maternal deaths estimated at 117 000 per year. Past efforts to provide skilled birth attendants and emergency obstetric care in rural areas have not succeeded because obstetricians are not willing to be posted in government hospitals at subdistrict level.

Approach

We have documented an innovative public–private partnership scheme between the Government of Gujarat, in India, and private obstetricians practising in rural areas to provide delivery care to poor women.

Local setting

In April 2007, the majority of poor women delivered their babies at home without skilled care.

Relevant changes

More than 800 obstetricians joined the scheme and more than 176 000 poor women delivered in private facilities. We estimate that the coverage of deliveries among poor women under the scheme increased from 27% to 53% between April and October 2007. The programme is considered very successful and shows that these types of social health insurance programmes can be managed by the state health department without help from any insurance company or international donor.

Lessons learned

At least in some areas of India, it is possible to develop large-scale partnerships with the private sector to provide skilled birth attendants and emergency obstetric care to poor women at a relatively small cost. Poor women will take up the benefit of skilled delivery care rapidly, if they do not have to pay for it.     

Dietary Intakes,Obesity and Health Behaviors in Native Hawaiians Residing in Southern California

Objectives

Accessing dietary intakes, body mass index (BMI) and health behaviors in Native Hawaiians residing in Southern California.

Design

Cross-sectional, community based participatory research.

Participants

Native Hawaiian (N = 55); Mean age 59 (± 15).

Main Outcome Measures

Diet, body mass index (BMI), and diet/exercise health behaviors. Collected diet via 24-hr dietary recalls, health behaviors through questionnaires and BMI via measurement/self-report.

Analysis

Frequencies/means and multiple linear regression were used to assess diet, BMI, and health behaviors.

Results

Nearly 90% of the participants were either overweight or obese. Less than 20% met the vegetable, fruit, fiber, and whole grain recommendations. Most were a little or somewhat sure (relative to almost always sure) about their ability “to stick with an exercise program when attending a cultural gathering”, and “when visiting Hawai‘i”.

Conclusions and Implications

These results suggest that developing a culturally-based education program to reduce obesity and improve diet is critical for Native Hawaiians residing in Southern California.     

Delivery Site Preferences and Associated Factors among Married Women of Child Bearing Age in Bench Maji Zone,Ethiopia

Background

Efforts to reduce maternal mortality and morbidity must address societal and cultural factors that affect women''s health and their access to services. There was no research conducted previously on delivery site preferences and associated factors among married women of child bearing age in the study area. The aim of this study was to assess the delivery site preferences and associated factors among women of child bearing age in Bench Maji Zone, Southwest Ethiopia.

Methods

A community based cross sectional quantitative study design supplemented by qualitative data was conducted from April 20 to May 20, 2013. Simple random sampling to select kebeles and systematic random sampling to contact eligible woman were used. Data was collected using structured questionnaire. Data was analyzed by using SPSS version 16. Logistic regressions analysis was employed to identify potential predictor variables. Odds ratio with 95% confidence interval was used to assess the association of variables. P-value less than 5% was used to declare significant association.

Results

Three hundred five (61.9%) of the mothers gave birth at home. Three Hundred ninety six (78.7%) of them had Ante natal care. The preference of facility delivery was 412(88.3%). Age of women, mothers'' educational level, and place of delivery of the last baby, perception of mothers about pregnancy and health care workers significantly affected delivery site preference.

Conclusion

Most of the women attended Ante natal care. However, only some had actually delivered at health facilities to their last pregnancy. Community members should get health education to reduce misconceptions on delivering in health facility.     

Improved neonatal survival after participatory learning and action with women’s groups: a prospective study in rural eastern India

Objective

To determine whether a women’s group intervention involving participatory learning and action has a sustainable and replicable effect on neonatal survival in rural, eastern India.

Methods

From 2004 to 2011, births and neonatal deaths in 36 geographical clusters in Jharkhand and Odisha were monitored. Between 2005 and 2008, these clusters were part of a randomized controlled trial of how women’s group meetings involving participatory learning and action influence maternal and neonatal health. Between 2008 and 2011, groups in the original intervention clusters (zone 1) continued to meet to discuss post-neonatal issues and new groups in the original control clusters (zone 2) met to discuss neonatal health. Logistic regression was used to examine neonatal mortality rates after 2008 in the two zones.

Findings

Data on 41 191 births were analysed. In zone 1, the intervention’s effect was sustained: the cluster-mean neonatal mortality rate was 34.2 per 1000 live births (95% confidence interval, CI: 28.3–40.0) between 2008 and 2011, compared with 41.3 per 1000 live births (95% CI: 35.4–47.1) between 2005 and 2008. The effect of the intervention was replicated in zone 2: the cluster-mean neonatal mortality rate decreased from 61.8 to 40.5 per 1000 live births between two periods: 2006–2008 and 2009–2011 (odds ratio: 0.69, 95% CI: 0.57–0.83). Hygiene during delivery, thermal care of the neonate and exclusive breastfeeding were important factors.

Conclusion

The effect of participatory women’s groups on neonatal survival in rural India, where neonatal mortality is high, was sustainable and replicable.     

How Effective Are Short Message Service Reminders at Increasing Clinic Attendance? A Meta-Analysis and Systematic Review

Background and Objectives

In the last few years there has been a steady uptake of mobile phone short message service (SMS) reminders to increase medical attendance rates. We undertook a review of studies that assessed the effectiveness of SMS reminders at increasing the uptake of appointments in health care settings.

Methods

We reviewed studies which involved a comparison of appointment attendance rates between patients who did and did not receive SMS reminders published prior to June 2010. We used meta-analysis methods to calculate the overall effect on attendance rates, stratified by study design and clinic type.

Results

The review criteria were met by 18 reports, made up of eight randomized controlled trials (RCTs) and 10 controlled observational studies. Across all studies, there was significant heterogeneity in the estimated effect measure of the relationship between use of SMS reminders and clinic attendance (I² = 90 percent; p < .01), so a summary effect estimate was not calculated. Stratification by study design showed that the heterogeneity was due to the observational studies. The summary effect from the RCTs was 1.48 (95% CI: 1.23–1.72) with no significant subgroup differences by clinic type (primary care clinics, hospital outpatient clinics), message timing (24, 48, and 72+ hours before the scheduled appointment), and target age group (pediatric, older).

Conclusions

Short message service reminders in health care settings substantially increase the likelihood of attending clinic appointments. SMS reminders appear to be a simple and efficient option for health services to use to improve service delivery, as well as resulting in health benefits for the patients who receive the reminders.     

The role of matched controls in building an evidence base for hospital-avoidance schemes: a retrospective evaluation

Objective

To test whether two hospital-avoidance interventions altered rates of hospital use: “intermediate care” and “integrated care teams.”

Data Sources/Study Setting

Linked administrative data for England covering the period 2004 to 2009.

Study Design

This study was commissioned after the interventions had been in place for several years. We developed a method based on retrospective analysis of person-level data comparing health care use of participants with that of prognostically matched controls.

Data Collection/Extraction Methods

Individuals were linked to administrative datasets through a trusted intermediary and a unique patient identifier.

Principal Findings

Participants who received the intermediate care intervention showed higher rates of unscheduled hospital admission than matched controls, whereas recipients of the integrated care team intervention showed no difference. Both intervention groups showed higher rates of mortality than did their matched controls.

Conclusions

These are potentially powerful techniques for assessing impacts on hospital activity. Neither intervention reduced admission rates. Although our analysis of hospital utilization controlled for a wide range of observable characteristics, the difference in mortality rates suggests that some residual confounding is likely. Evaluation is constrained when performed retrospectively, and careful interpretation is needed.     

Macrosomic Births in a Tertiary Public Hospital: A Survey of Maternal Characteristics and Fetal Outcome

Background

Macrosomic fetuses are high risk with their delivery process being associated with potential risk to both mother and baby The aim of this study is to determine the incidence of macrosomic births and the associated maternal characteristics and to ascertain the fetal outcome.

Methods

It was a retrospective survey of maternal characteristics and pregnancy outcome of macrosomic births. Comparison was made with the next selected normal birth weight delivery during the study period.

Results

There were 8607 deliveries during the period (3 years) reviewed. Of this, 306 were macrosomic deliveries, a frequency of 3.6%. The mean weight for macrosomic babies was 4.23kg (range 4.01 – 5.62kg). There was a higher mean maternal weight and gestational age of mothers with macrosomic deliveries compared to mothers in the control group, (85.87 ± 19.39kg vs 74.92 ± 19.11kg P<0.01; and 41.51±1.46 vs 39.02±1.29, P<0.001). Caesarean delivery was significantly associated with macrosomic births compared to controls, p<0.0001, odds ratio 3.977. Also, asphyxia and shoulder dystocia occurred more in macrosomic babies, 10.4% vs 2.9% and 2.28% vs 0.65%, P<0.001. The majority of the asphyxiated babies amongst macroomic births were following vagina delivery compared to caesarean delivery, (65.6% vs 34.4%) p= 0.001. There were 3 cases of still birth in the macrosomic deliveries, but no maternal deaths were encountered.

Conclusion

Macrosomic births could be tragic. Although delivery outcome seems better with a caesarean section, good fetal outcome can only be assured on the premise of astute labour and delivery management.     

Community-directed interventions for priority health problems in Africa: results of a multicountry study

Objective

To determine the extent to which the community-directed approach used in onchocerciasis control in Africa could effectively and efficiently provide integrated delivery of other health interventions.

Methods

A three-year experimental study was undertaken in 35 health districts from 2005 to 2007 in seven research sites in Cameroon, Nigeria and Uganda. Four trial districts and one comparison district were randomly selected in each site. All districts had established ivermectin treatment programmes, and in the trial districts four other established interventions – vitamin A supplementation, use of insecticide-treated nets, home management of malaria and short-course, directly-observed treatment for tuberculosis patients – were progressively incorporated into a community-directed intervention (CDI) process. At the end of each of the three study years, we performed quantitative evaluations of intervention coverage and provider costs, as well as qualitative assessments of the CDI process.

Findings

With the CDI strategy, significantly higher coverage was achieved than with other delivery approaches for all interventions except for short-course, directly-observed treatment. The coverage of malaria interventions more than doubled. The district-level costs of delivering all five interventions were lower in the CDI districts, but no cost difference was found at the first-line health facility level. Process evaluation showed that: (i) participatory processes were important; (ii) recurrent problems with the supply of intervention materials were a major constraint to implementation; (iii) the communities and community implementers were deeply committed to the CDI process; (iv) community implementers were more motivated by intangible incentives than by external financial incentives.

Conclusion

The CDI strategy, which builds upon the core principles of primary health care, is an effective and efficient model for integrated delivery of appropriate health interventions at the community level in Africa.     

Community-based prevention of hepatitis-B-related liver cancer: Australian insights

Problem

Although most primary hepatocellular cancers (HCCs) are attributable to chronic viral hepatitis and largely preventable, such cancers remain a leading cause of cancer-related mortality wherever chronic hepatitis B is endemic.

Approach

Many HCCs could be prevented by increasing awareness and knowledge of hepatitis B, optimizing the monitoring of chronic hepatitis B and using antiviral treatments – but there are gaps in the implementation of such strategies.

Local setting

The “B Positive” programme, based in Sydney, Australia, is designed to improve hepatitis-B-related health outcomes among immigrants from countries with endemic hepatitis B. The programme offers information about disease screening, vaccination and treatment options, as well as optimized access to care.

Relevant changes

The B Positive programme has been informed by economic modelling. The programme offers culturally tailored education on chronic hepatitis B to target communities and their health practitioners and regular follow-up through a population-based registry of cases.

Lessons learnt

As the costs of screening for chronic hepatitis B and follow-up are relatively low and less than one in every four cases may require antiviral drugs, optimizing access to treatment seems an appropriate and cost-effective management option. The identification and accurate staging of cases and the judicious use of antiviral medications are predicated upon an informed and educated health workforce. As establishing community trust is a lengthy process, delaying the implementation of programmes against chronic hepatitis B until antiviral drugs become cheaper is unwarranted.     

Mental Health and High‐Cost Health Care Utilization: New Evidence from Axis II Disorders

Objective

To analyze the associations between Axis II (A2) disorders and two measures of health care utilization with relatively high cost: emergency department (ED) episodes and hospital admissions.

Data Source/Study Setting

Wave I (2001/2002) and Wave II (2004/2005) of the National Longitudinal Survey on Alcohol and Related Conditions (NESARC).

Study Design

A national probability sample of adults. Gender-stratified regression analysis adjusted for a range of covariates associated with health care utilization.

Data Collection

The target population of the NESARC is the civilian noninstitutionalized population aged 18 years and older residing in the United States. The cumulative survey response rate is 70.2 percent with a response rate of 81 percent (N = 43,093) in Wave I and 86.7 percent (N = 34,653) in Wave II.

Principal Findings

Both men and women with A2 disorders are at elevated risk for ED episodes and hospital admissions. Associations are robust after adjusting for a rich set of confounding factors, including Axis I (clinical) psychiatric disorders. We find evidence of a dose–response relationship, while antisocial and borderline disorders exhibit the strongest associations with both measures of health care utilization.

Conclusions

This study provides the first published estimates of the associations between A2 disorders and high-cost health care utilization in a large, nationally representative survey. The findings underscore the potential implications of these disorders on health care expenditures.     

Characterization of Adverse Events Detected in a Large Health Care Delivery System Using an Enhanced Global Trigger Tool over a Five‐Year Interval

Objective

To report 5 years of adverse events (AEs) identified using an enhanced Global Trigger Tool (GTT) in a large health care system.

Study Setting

Records from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay ≥3 days were reviewed.

Study Design

We examined AE incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used AE-detection systems.

Data Collection

Professional nurse reviewers abstracted 9,017 records using the enhanced GTT, recording triggers and AEs. Medical record/account numbers were matched to identify overlapping voluntary reports or AHRQ Patient Safety Indicators (PSIs).

Principal Findings

Estimated AE rates were as follows: 61.4 AEs/1,000 patient-days, 38.1 AEs/100 discharges, and 32.1 percent of patients with ≥1 AE. Of 1,300 present-on-admission AEs (37.9 percent of total), 78.5 percent showed NCC-MERP level F harm and 87.6 percent were “preventable/possibly preventable.” Of 2,129 hospital-acquired AEs, 63.3 percent had level E harm, 70.8 percent were “preventable/possibly preventable”; the most common category was “surgical/procedural” (40.5 percent). Voluntary reports and PSIs captured <5 percent of encounters with hospital-acquired AEs.

Conclusions

AEs are common and potentially amenable to prevention. GTT-identified AEs are seldom caught by commonly used AE-detection systems.     

Expansion of antiretroviral treatment to rural health centre level by a mobile service in Mumbwa district, Zambia

Problem

Despite the Government’s effort to expand services to district level, it is still hard for people living with HIV to access antiretroviral treatment (ART) in rural Zambia. Strong demands for expanding ART services at the rural health centre level face challenges of resource shortages.

Approach

The Mumbwa district health management team introduced mobile ART services using human resources and technical support from district hospitals, and community involvement at four rural health centres in the first quarter of 2007. This paper discusses the uptake of the mobile ART services in rural Mumbwa.

Local setting

Mumbwa is a rural district with an area of 23 000 km² and a population of 167 000. Before the introduction of mobile services, ART services were provided only at Mumbwa District Hospital.

Relevant changes

The mobile services improved accessibility to ART, especially for clients in better functional status, i.e. still able to work. In addition, these mobile services may reduce the number of cases “lost to follow-up”. This might be due to the closer involvement of the community and the better support offered by these services to rural clients.

Lessons learnt

These mobile ART services helped expand services to rural health facilities where resources are limited, bringing them as close as possible to where clients live.     

Improving Access to HIV and AIDS Information Resources for Patients,Caregivers, and Clinicians: Results from the SHINE Project

Background

Human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) remains a significant international public health challenge. The Statewide HIV/AIDS Information Network (SHINE) Project was created to improve HIV/AIDS health information use and access for health care professionals, patients, and affected communities in Indiana.

Objective:

Our objective was to assess the information-seeking behaviors of health care professionals and consumers who seek information on the testing, treatment, and management of HIV/AIDS and the usability of the SHINE Project’s resources in meeting end user needs. The feedback was designed to help SHINE Project members improve and expand the SHINE Project’s online resources.

Methods:

A convenience sample of health care professionals and consumers participated in a usability study. Participants were asked to complete typical HIV/AIDS information-seeking tasks using the SHINE Project website. Feedback was provided in the form of standardized questionnaire and usability “think-aloud” responses.

Results:

Thirteen participants took part in the usability study. Clinicians generally reported the site to be “very good,” while consumers generally found it to be “good.” Health care professionals commented that they lack access to comprehensive resources for treating patients with HIV/AIDS. They requested new electronic resources that could be integrated in clinical practice and existing information technology infrastructures. Consumers found the SHINE website and its collected information resources overwhelming and difficult to navigate. They requested simpler, multimedia-content rich resources to deliver information on HIV/AIDS testing, treatment, and disease management.

Conclusions:

Accessibility, usability, and user education remain important challenges that public health and information specialists must address when developing and deploying interventions intended to empower consumers and support coordinated, patient-centric care.     

Health Literacy,Cognitive Ability,and Functional Health Status among Older Adults

Objective

To investigate whether previously noted associations between health literacy and functional health status might be explained by cognitive function.

Data Sources/Study Setting

Health Literacy and Cognition in Older Adults (“LitCog,” prospective study funded by National Institute on Aging). Data presented are from interviews conducted among 784 adults, ages 55–74 years receiving care at an academic general medicine clinic or one of four federally qualified health centers in Chicago from 2008 to 2010.

Study Design

Study participants completed structured, in-person interviews administered by trained research assistants.

Data Collection

Health literacy was measured using the Test of Functional Health Literacy in Adults, Rapid Estimate of Adult Literacy in Medicine, and Newest Vital Sign. Cognitive function was assessed using measures of long-term and working memory, processing speed, reasoning, and verbal ability. Functional health was assessed with SF-36 physical health summary scale and Patient Reported Outcomes Measurement Information System short form subscales for depression and anxiety.

Principal Findings

All health literacy measures were significantly correlated with all cognitive domains. In multivariable analyses, inadequate health literacy was associated with worse physical health and more depressive symptoms. After adjusting for cognitive abilities, associations between health literacy, physical health, and depressive symptoms were attenuated and no longer significant.

Conclusions

Cognitive function explains a significant proportion of the associations between health literacy, physical health, and depression among older adults. Interventions to reduce literacy disparities in health care should minimize the cognitive burden in behaviors patients must adopt to manage personal health.     

Physician Styles of Patient Management as a Potential Source of Disparities: Cluster Analysis from a Factorial Experiment

Objective

To identify styles of physician decision making (as opposed to singular clinical actions) and to analyze their association with variations in the management of a vignette presentation of coronary heart disease (CHD).

Data Source

Primary data were collected from primary care physicians in North and South Carolina.

Study Design

In a balanced factorial experimental design, primary care physicians viewed one of 16 (2⁴) video vignette presentations of CHD and provided detailed information about how they would manage the case.

Data Collection Method

256 MD primary care physicians were interviewed face-to-face in North and South Carolina.

Principal Findings

We identify three clusters depicting unique styles of CHD management that are robust to controls for physician (gender and level of experience) and patient characteristics (age, gender, socioeconomic status, and race) as well as key organizational features of physicians'' work settings. Physicians in Cluster 1 “Cardiac” (N = 92) were more likely to focus on cardiac issues compared with their counterparts; physicians in Cluster 2 “Talkers” (N = 93) were more likely to give advice and take additional medical history; whereas physicians in Cluster 3 “Minimalists” (N = 71) were less likely than their counterparts to take action on any of the types of management behavior.

Conclusions

Variations in styles of decision making, which encompass multiple outcome variables and extend beyond individual-level demographic predictors, may add to our understanding of disparities in health quality and outcomes.