Self-instructional teaching of biostatistics for medical students

A growing body of literature deals with the use of self-instructional methods for teaching biostatistics to medical students. The University of Tennessee Department of Community Medicine tested the hypothesis that, in controlled, randomized situations, learning of statistical material by self-instruction is equivalent to learning identical material by the lecture method. An analysis of student performance, in terms of the grades obtained on two separate examinations, showed that students learning by self-instruction did as well or better than their colleagues taking lectures. On the basis of these results, self-instructional biostatistics for medical students at the University of Tennessee has been selected as the major teaching method of that subject.Dr. Robinson is Professor and Chief of Biostatistics in the Department of Community Medicine, University of Tennessee College of Medicine, 800 Madison Avenue, Memphis, Tennessee 38163. Mr. Burke is Instructor in the Department of Community Medicine, University of Tennessee, and Director of Statistical Services in the Memphis and Shelby County Health Department. Dr. Stahl was Assistant Professor of Community Health and Medical Practice, Section of Health Care Studies, University of Missouri, Columbia, Missouri, during this study. He is currently Assistant Professor of Sociology, Purdue University, School of Humanities, Social Science and Education, Lafayette, Indiana. Requests for reprints should be addressed to Dr. Robinson. John W. Runyan, Jr., M.D., and Stephen T. Miller, M.D., of the Department of Community Medicine, University of Tennessee, made valuable suggestions during the preparation of this paper.     

The treatment of patients with insulin-requiring diabetes mellitus by primary care physicians

The extent to which a sample of community based, primary care physicians follow current standards of care for the treatment of non-obese, insulin-requiring patients as defined and recently published by the American Diabetes Association (ADA) was studied. A total of 212 physicians responded with 191 indicating that they treat one or more non-obese, insulin-requiring patients. Of this sample, 97% used multiple injection, mixed insulin regimens. However, over 70% also used single injection regimens. Whereas 94% prescribed self-monitoring blood glucose (SMBG), only 31% did so for more than 75% of their patients and 37% did so for less than 50%. Twenty-five percent of respondents did not obtain HbA1 values on their patients. For respondents who do collect HbA1, only 28% did so for over 75% of their patients and 30% for less than 50%. Physicians with fewer patients were more likely to prescribe single injection insulin regimens (P=.02). Recent graduates from medical school also used HbAl's more frequently than earlier graduates (p=.001). These data suggest that while care practices recommended by the ADA are being implemented by primary care physicians, they are significantly under-utilized.David G. Marrero is an Associate Scientist, Medicine and Pediatrics; Naomi S. Fineberg is Associate Professor Medicine; Carl D. Langefeld is a statistician Medicine; Charles M. Clark is Professor Medicine; all in the Indiana University School of Medicine, Indianapolis, Indiana.Patricia S. Moore is research nurse, The Regenstrief Institute for Health Care, Indianapolis, Indiana.This study was supported by NIH Grant No. PHS P60DK20542-12, 50-825-80 (OTR), National Institutes of Diabetes, Digestive and Kidney Disease, and the Regenstrief Institute.The authors wish to thank Frank Vinicor, MD, Gary Ingersoll, Ph.D., and Michael Golden, MD for their helpful comments and suggestions. We also thank Debbie Mercier for typing numerous drafts.     

An interpretation of implicit judgments in chart review

The effects of methods that are commonly employed to summarize implicit judgments about quality-of-care assessments, based on medical records, are examined. A sample of 250 medical records, from three outpatient clinics in a municipal hospital, was studied. Two, or three, reviewers judged the quality of both the process of care and the outcome of care, as reflected in each medical record; the reviewers were medical school faculty members. Thirty-seven combinations of the data were used to summarize the judgments made on each medical record. These combinations resulted in significant differences in interpretation within each clinic, but there were only insignificant differences in interpretation across the three clinics. Hence, the use of a single method to summarize data may distort the conclusions. These results demonstrate that data often should be summarized by several methods and that measures of association should be used to supplement tests of significance so as to develop a comprehensive understanding of a set of data.Dr. Horn is Assistant Professor, Department of Health Care Organization, School of Hygiene and Public Health, The Johns Hopkins University, 615 North Wolfe Street, Baltimore, Maryland 21205. Dr. Pozen is presently Assistant Professor, Department of Medicine, Boston University School of Medicine at Boston City Hospital, Thorndike Memorial Laboratories. This study was begun while he was at the Department of Medicine at Baltimore City Hospitals and the Department of Health Care Organization at The Johns Hopkins University. This work was supported by DHEW grant 5-R01-HS-01590 from the National Center for Health Services Research and Development.     

How mothers treat their children's physical symptoms

An important area of concern in community health is the widespread practice of individuals undertaking courses of treatment in the absence of medical advice or direction. This is especially a problem when it involves the administration of medicines to children. This study examines the extent, determinants, and quality of the independent use by mothers of medications for treating their children's symptoms. Data on mother-initiated medication behavior (MIMB) were obtained from a random sample of 500 mothers of children at two pediatric ambulatory care sites. Six expert pediatric judges rated every reported medication use (N=3,908) along three dimensions (usefulness, correctness, and harmfulness/helpfulness) and also evaluated the overall appropriateness of each mother's MIMB. Results indicate that: 1) mothers keep available and use for their children a considerable number of different medications; 2) clear relationships exist between mothers' socioeconomic status and the different categories of medications they employ; 3) mothers' perceptions of their children's vulnerability to specific illnesses, and of the efficacy of over-the-counter medications for treating those illnesses, were related to the possession and use of relevant medications; and 4) judges' ratings indicated little enthusiasm for the mothers' therapeutic actions. These findings suggest the need for pediatricians to become aware of the medications their patients may be ingesting as a result of MIMB, and to educate mothers concerning use and misuse of over-the-counter (and other) treatments.Lois A. Maiman, Ph.D., is Assistant Professor, Department of Pediatrics, and Department of Preventive, Family and Rehabilitation Medicine, School of Medicine and Dentistry, University of Rochester, New York. Marshall H. Becker, Ph.D., M.P.H., is Professor and Chairman, Department of Health Behavior and Health Education, School of Public Health, and Professor, Department of Pediatrics and Communicable Diseases, School of Medicine, University of Michigan, Ann Arbor, Michigan. Anne W. Katlic, B.A., is Research Assistant, Department of Pediatrics, School of Medicine and Dentistry, University of Rochester, Rochester, New York. Address reprint requests to: Dr. Lois A. Maiman, Department of Pediatrics, Box 777, School of Medicine and Dentistry, University of Rochester, Rochester, New York 14642.This research was supported by Grants HD15357 and HD00538 from the National Institute of Child Health and Human Development, National Institutes of Health.     

Curing and caring—A proposed method for self-assessment in primary care organizations

Key research in the area of quality assessment is reviewed and a method for periodic assessment in primary care organizations is proposed. The suggested approach is designed for administrative, rather than research, purposes. Therefore, it focuses on indicators that are both practical and realistic for use in periodic monitoring.The proposed method is two-staged and includes both technical performance (curing) and satisfaction (caring). At the first level of evaluation, general areas of performance are examined; these are key performance indicators in prevention, diagnosis, and management of illness, and questionnaires dealing with the accessibility and acceptability of care, coupled with objective measures of satisfaction. Those areas of performance that are not up to management standards are then examined in greater detail at the second level of evaluation. Using this approach, organizations can build a longitudinal picture of performance and chart their progress annually.Ms. Howell, formerly an instructor in the Department of Community Medicine and International Health, Georgetown University School of Medicine, is now attending the John F. Kennedy School of Government, Harvard University. Dr. Osterweis is Assistant Professor, Department of Community Medicine and International Health, Georgetown University School of Medicine, Washington, D.C. 20007. Dr. Huntley is Professor and Chairman of that department. Reprint requests should be addressed to Dr. Osterweis. This work was supported in part by grant R18-HS-01040 from the National Center for Health Services Research.     

Applying the criteria for the development of health promotion and education programs to AIDS risk reduction programs for gay men

As a result of the AIDS (Acquired Immune Deficiency Syndrome) epidemic, many community health agencies are faced with the task of planning and implementing programs to prevent or reduce the risks of HIV (Human Immunodeficiency Virus) infection. Furthermore, the urgency of AIDS will force community groups to develop prevention programs prior to an analysis of substantial data relating to intervention efficacy. By using the five criteria for the development of health promotion and education programs enumerated by the American Public Health Association, planners can benefit from the experience of past health promotion initiatives, and insure a comprehensive approach to planning. The authors describe, using specific examples, how these criteria were used to develop and implement an AIDS risk reduction program for gay and bisexual men.Dr. Ronald Valdiserri is Associate Professor of Pathology and Assistant Professor of Infectious Diseases, University of Pittsburgh School of Medicine and Graduate School of Public Health. Dr. Lyter is a Research Associate, University of Pittsburgh Department of Medicine. Dr. Leviton is Assistant Professor in the Department of Health Services Administration, University of Pittsburgh Graduate School of Public Health. Mr. Kerry Stoner is Manager of the AIDS Prevention Project, and Mr. Anthony Silvestre is the Director of Community Relations for the Pitt Men's Study.The authors wish to thank the following individuals for their assistance: Mr. James Huggins; Mr. James Fauzio and Ms. Jill Hall.This research was supported by a grant from the Centers for Disease Control, DHHS, grant number U62/CCU3001060-01.     

Nutritional risk and survival in elderly veterans: A five-year follow-up

The purpose of this study was to identify predictors of survival over five years in a sample of 377 elderly (age 55+) chronically ill men. Subjects were selected at baseline from consecutive appointments at a geriatric clinic and given extensive medical and psychosocial assessment. Five years later, subjects who could be located were interviewed by telephone. Interviews were completed with 194 (51.4%) subjects, 90 others were confirmed as deceased, 29 subjects could not be interviewed, and 64 more were not located although VA records did not show that any were deceased. The predictor variable of interest was the Nutritional Risk Index (NRI), a 16 item index which measures nutritional dimensions of health status. Other variables included functional health status [Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL)], mental health status [Mini-Mental Status Exam (MMSE), morale], health habits (smoking, alcohol use and exercise), use of health services (physician visits, emergency room (ER) visits, hospital stays), and demographic factors (age, income, marital status and living arrangements). Proportional hazard models showed that the variables with statistically significant direct effects on survival time were younger age, higher functional health status on IADL, non-smoking, moderate alcohol use, and perception of adequate income. Nutritional status was indirectly associated with survival.Rodney M. Coe is Professor of Community and Family Medicine, Saint Louis University School of Medicine and Education Coordinator, Geriatric Research, Education and Clinical Center (GRECC), St. Louis VA Medical Center; James C. Romeis is Professor of Public Health, Saint Louis University and Coordinator, Health Services Research & Development (HSR&D), St. Louis VA Medical Center, Douglas K. Miller is Associate Professor of Internal Medicine, Saint Louis University School of Medicine; Fredric D. Wolinsky is Professor of Internal Medicine, Indiana University, Indianapolis; and Katherine S. Virgo is Assistant Professor of Surgery, Saint Louis University School of Medicine, St. Louis, Missouri.This project was supported in part by NIH grant R37-AG-09692 to Dr. Wolinsky.     

Psychosocial problems in chronically ill children

This study concerns the psychosocial aspects of treatment for chronically ill children. The English-speaking parents of 44 children 5–13 years of age being seen at five specialty clinics at a large county hospital in Los Angeles, and their attending physicians, were the subjects in this study. The parents were interviewed concerning their expectations for the current visit, and the doctor-patient interaction was tape-recorded. Identical categories of information were abstracted from the tape recording and from a chart review of the patients' medical records. Although parents expected 76% of the psychosocial aspects of care to be covered by the doctor, only one fourth were actually discussed in the visit. These unfulfilled expectations were associated with lower satisfaction with medical care received (r=.47, p<0.01). Finally, while doctors recorded about 80% of discussions of symptoms and physical examinations in the patient's medical record, they recorded only 25% of discussion of psychosocial problems.Dr. Lau is Assistant Professor of Social Psychology, Carnegie-Mellon University, Pittsburgh, Pennsylvania. Dr. Williams is Assistant Clinical Professor of Pediatrics, University of South Dakota School of Medicine, Mitchell, South Dakota. Ms. Williams is with the University of California, Los Angeles. Dr. Ware is Senior Social Scientist, The Rand Corporation, Santa Monica, California. Dr. Brook is Professor of Medicine and Public Health, UCLA Center for the Health Sciences, Los Angeles. Preparation of this article was assisted by a grant from The Robert Wood Johnson Foundation, Princeton, New Jersey. The opinions, conclusions, and proposals in the text are those of the authors and do not necessarily represent the views of The Robert Wood Johnson foundation.     

Strategies for enhancing patient compliance

Patient noncompliance is a substantial obstacle to the achievement of therapeutic goals. This paper reviews a number of practical interventions with demonstrated efficacy in enhancing patient adherence, including (1) improving patients' levels of information concerning the specifics of their regimens, reinforcing essential points with review, discussion, and written instruction, and emphasizing the importance of the therapeutic plan, (2) taking clinically appropriate steps to reduce the cost, complexity, duration, and amount of behavioral change required by the regimen and increasing the regimen's convenience through tailoring and other approaches, (3) obtaining a compliance-oriented history of the patient's prior experiences and present health beliefs and, where necessary, employing strategies to modify those perceptions likely to inhibit compliance, (4) improving levels of patient satisfaction, particularly with the provider-patient relationship, (5) arranging for the continued monitoring of the patient's subsequent compliance to treatment, (6) increasing staff awareness of the magnitude and determinants of the noncompliance phenomenon and attempting to develop an active influence orientation in each member of the health care team, (7) using such techniques as patient-provider contracts to involve the patient in therapeutic decisions and in the setting of treatment objectives and creating incentives (through rewards and reinforcements) for achieving these objectives, (8) arranging for as much continuity of provider (and other staff) as possible, (9) establishing methods of supervising the patient, including involvement of the patient's social support network, and (10) involving fully the assistance of all available health care providers, assigning specific roles and responsibilities for activities directed at improving adherence to treatment.Dr. Becker is Professor, Department of Health Behavior and Health. Education, University of Michigan, School of Public Health, 1420 Washington Heights, Ann Arbor, Michigan 48109. Dr. Maiman is Assistant Professor, Department of Pediatrics, University of Rochester, School of Medicine, 601 Elmwood Avenue, Rochester, New York 14642. Work for this review was supported in part by Grant No. 5K04-HD00237 from the National Institute of Child Health and Human Development.     

Leveraging Health Information Exchange to Support Public Health Situational Awareness: The Indiana Experience

Public health situational awareness is contingent upon timely, comprehensive and accurate information from clinical systems. Ad-hoc models for sending non-standard clinical information directly to public health are inefficient and increasingly unsustainable. Information sharing models that leverage Health Information Exchanges (HIEs) are emerging. HIEs standardize, aggregate and streamline information sharing among data partners, including public health stakeholders, and HIE has supported public health practice in Indiana for more than 10 years. To accelerate nationwide adoption of HIE-supported situational awareness processes, the CDC awarded three HIEs across the nation, including Indiana, New York and Washington/Idaho. The Indiana partners included Indiana University School of Medicine, Regenstrief Institute, Indiana Health Information Exchange, Indiana State Department of Health, Health & Hospital Corporation of Marion County, and Children’s Hospital Boston. Activities included augmenting biosurveillance processes, enabling bi-directional communication, enhancing automated detection of notifiable conditions, and demonstrating technological advances at national forums. HIE transactions destined for public health were enhanced with standardized clinical vocabulary and more complete physician contact information. During the 2009 H1N1 flu outbreak, the HIE delivered targeted public health broadcast messages to providers in Marion County, Indiana. We will review the partnership characteristics, activities, accomplishments and future directions for our health information exchange.     

Ethical issues in primary health care: A survey of practitioners' perceptions

While most health care is provided at the primary care level, little research has been done to document the ethical issues of such care. A stratified random sample of 702 physicians, nurses, physical therapist, and physician assistants within one southeastern state was surveyed to determine the frequency of ethical issues in primary care. The most frequently occurring issue concerned moral decisions about the amount of time to spend with each patient. A comparison of physician and nonphysician professional groups revealed significant differences in frequencies of the issues. Age had a slight impact on the responses, while gender, religion, and region of practice had none. The study showed that the most frequently occurring issues are pragmatic, not dramatic, and center on patient self-determination, adequacy of care and professional responsibility, and distribution of resources.Helen M. Robillard, R.N.-C., M.S.N., is a doctoral student in Organizational Psychology at the University of Michigan, Ann Arbor. Dallas M. High, Ph.D., is Professor in the Department of Philosophy and Associate of the Sanders-Brown Center on Aging, University of Kentucky, Lexington. Juliann G. Sebastian, R.N., M.S.N., is Associate Professor, College of Nursing, University of Kentucky, Lexington. Janet I. Pisaneschi, Ph.D., is Associate Professor and Assistant Dean, College of Allied Health Professions, University of Kentucky, Lexington. Lea J. Perritt, Ph.D., is Assistant Professor, Allied Health Education and Research, College of Allied Health Professions, University of Kentucky, Lexington. D. Mark Mahler, M.D., is Assistant Clinical Professor, Indiana University School of Medicine, Indianapolis. Requests for reprints should be addressed to: Dallas M. High, Ph.D., Professor, Department of Philosophy, University of Kentucky, Lexington, KY, 40506.     

Clinical validation of a nutritional risk index

This research assessed the clinical validity of a nutritional risk index (NRI). Subjects were 377 male veterans, aged 55+, attending general medicine and geriatric outpatient clinics. Data were collected by personal interviews, anthropometric measurements, laboratory assay of nutritional parameters, three-day food records, and medical record reviews. Although the results showed that the NRI correlated significantly with only two nutritional measures (body mass index, total energy intake), critical values or threshold levels of NRI were identified that significantly discriminated low risk from high risk patients on four nutritional parameters (body mass index, total energy intake, laboratory risk, and medications risk). It was concluded that the NRI is a valid measure of health status and contains a nutritional dimension.John M. Prendergast, MD, MPH is Medical Director, Program on Aging, Mercy Hospital, Pittsburgh, PA 15219; Rodney M. Coe, PhD is Professor, Department of Community Medicine, St. Louis University School of Medicine and Education Coordinator, Geriatric Research, Education and Clinical Center (GRECC), VA Medical Center, St. Louis, MO 63104; M. Noel Chavez, PhD, RD is Assistant Professor, Department of Community Health Sciences, School of Public Health, University of Illinois, Chicago, IL 60612; James C. Romeis, PhD is Associate Professor, Center for Health Services, Education and Research, St. Louis University and Coordinator, Health Services Research and Development, VA Medical Center, St. Louis, MO 63104; Douglas K. Miller, MD is Assistant Professor, Department of Internal Medicine, St. Louis University School of Medicine, St. Louis, MO 63104; Fredric D. Wolinsky, PhD is Professor, Department of Sociology, Texas A&M University, College Station, TX 77843.This project was supported in part by grant #84-017 from the Veterans Administration and by K07-AG-00302 and K04-AG00328 from the National Institute on Aging.     

Some influences on public participation in a genetic screening program

To identify the psychosocial factors associated with voluntary cooperation in mass genetic testing, stratified random samples of 500 participants and 500 nonparticipants were drawn from an identified at-risk population for Tay-Sachs disease. Participants were relatively younger and better educated, reported higher levels of perceived susceptibility to being a carrier, and also stated more often that the impact of learning of being a carrier would be low. Participants were also more likely to indicate they would not alter plans for future progeny. Recommendations are made for enhancing participation in future genetic screening programs of this type.Dr. Becker is Associate Professor, Departments of Pediatrics (School of Medicine) and Behavioral Sciences (School of Hygiene and Public Health), The Johns Hopkins University, Edwards A. Park Building, Room B172, The Johns Hopkins Hospital, 601 North Broadway, Baltimore, Maryland 21205. Dr. Kaback is Associate Professor, Departments of Pediatrics and Medicine, and Associate Chief, Division of Medical Genetics, School of Medicine, University of California at Los Angeles. Dr. Rosenstock is Professor and Chairman, Department of Health Behavior, School of Public Health, University of Michigan. Ms. Ruth is Chairman, Department of Community Health Nursing, School of Nursing, University of Maryland.     

Physician competence and compulsory continuing education

Continuing medical education (CME) should be broadly defined as any intervention into the activities of a physician that produces behavioral change. Under this definition, it is unquestionable that CME influences quality of care. However, the current CME-accreditation system, with its narrow emphasis on course work, serves to inhibit the development of individualized educational activities geared to identified needs.Dr. Jessee is Assistant Dean for Continuing Medical Education and Assistant Professor of Social and Preventive Medicine at the University of Maryland School of Medicine, Baltimore, Maryland 21201.     

Role disagreement in primary care practice

To measure the extent of disagreement on roles between nurse practitioners (NPs) and physicians working together and to look for characteristics of joint practices that are associated with disagreement, patient vignettes were sent to 15 NP/M.D. dyads, and both M.D.s and NPs were asked how appropriate it would be for them and for their co-practitioner to provide care for the problem presented in each vignette. Measures of disagreement on patient care roles were developed by comparing responses within the dyad. For all practices, there was moderate agreement on roles, and this agreement seemed to favor a complementary practice. Disagreement on the NP's role was most often in the direction of NP feeling capable of providing more care than the M.D. felt she could provide. Various factors, such as job satisfaction, age differences between providers, and training level of the NP, were associated with the disagreement that was found. Some disagreement on roles exists between NPs and M.D.s practicing together. Resolution of these differences may lead to greater job satisfaction and more effective interaction between providers.The authors are with the University of North Carolina, Chapel Hill where Dr. Davidson is an Assistant Professor of Medicine in the Division of General Medicine and Clinical Epidemiology, Dr. Earp is an Assistant Professor of Health Education in the School of Public Health and Dr. Fletcher is Co-Chief of the Division of General Medicine, Associate Professor of Medicine and Clinical Epidemiology, and Director of the Robert Wood Johnson Clinical Scholars Program. Reprints may be obtained from Richard Alan Davidson, M.D., M.P.H., Department of Medicine, 3041 Old Clinic Building, University of North Carolina, Chapel Hill, North Carolina 27514. This work was presented at the American Federation for Clinical Research Meetings, May, 1980. This project was supported in part by the Robert Wood Johnson Clinical Scholars Program. The authors would like to acknowledge the assistance of David McKay in the planning of this study.     

Teaching community-oriented primary care (COPC): A practical approach

To improve education in community-oriented primary care (COPC) and to promote its practice in the community, the University of California's School of Public Health in Berkeley and School of Medicine in San Francisco are collaborating in an innovative program in cooperation with several federally-funded community clinics in the San Francisco Bay Area. The School of Public Health designed a COPC track for graduate public health students from various departments of the school who wished to work in community health care. The track includes a seminar given in the spring of the students' first year in which COPC theory is taught and teams of students working with a faculty advisor and a clinic preceptor design COPC projects for the primary care sites. These projects are then implemented in the summer and fall by students who elect to use this experience to satisfy their fieldwork requirement. This paper is a report of the first year's experience with this collaborative effort.Emilie H.S. Osborn, M.D., M.P.H. is Assistant Professor, Family and Community Medicine, University of California at San Francisco. Norman Hearst, M.D., M.P.H. is Assistant Clinical Professor, Clinical Epidemiology and Family and Community Medicine, University of California at San Francisco. Joyce C. Lashof, M.D., is Dean, School of Public Health, University of California at Berkeley. W. McFate Smith, M.D., M.P.H. is Director, Preventive Medicine Residency, School of Public Health, University of California at Berkeley.This project has been supported in part with Federal funds from the Bureau of Health Care Delivery and Assistance, Health Resources and Services Administration, U.S. Public Health Service, under contract #240-84-0124. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services.     

Illness and injury in family day care: A seasonal survey

Many mothers with children under age 6 are employed and it is not usually feasible for a parent to stay home with a child who is mildly ill. Such ill children likely remain in child day care programs. The extent to which this occurs and the management of these children in family day care was studied. Over the course of a year, 1 to 3 visits were made to 714 family day care homes in order to survey providers. With enrollments ranging between 0 and 18 children per day care home at the time of each visit, information on 3,630 child enrollment days was collected. The median age of children in care was 2 years.An average of 16% of all children were ill on any one day (with seasonal variation); 1% were injured. Of ill children, 82% attended day care that day, 49% had contacted a physician about that illness, and 28% were administered a medication at the day care setting. Twenty-one percent of children receiving medication in day care had no contact with a physician for that illness. These data show that mild childhood illnesses are routinely managed by child day care providers. Physicians who traditionally limit their illness-management education to parents need to recognize the health education and consultation needs of day care providers.Howard L. Taras is an Assistant Professor of Pediatrics at the University of California at San Diego, School of Medicine, La Jolla, CA. Betty Z. Bassoff is Director of the California Child Care Standards Project at San Diego State University, Graduate School of Public Health (Division of Maternal and Child Health), San Diego, CA.Research Support: SPRANS Grant, Bureau of Maternal and Child Health, Public Health Service; and, Maternal and Child Health Division, Graduate School of Public Health, San Diego State University.     

Data quality and DRGs: An assessment of the reliability of federal beneficiary discharge data in selected Manhattan hospitals

New York County Health Services Review Organization (NYCHSRO), the physicians' professional standards review organization of Manhattan, examined whether diagnostic coding errors identified in Manhattan hospitals would affect reimbursement under a diagnostic-related group (DRG) method of financing inpatient services. A sampling of 1,027 Medicare and Medicaid cases representing discharges from 18 Manhattan hospitals during 1982 and 1983 revealed incorrect DRG assignment for 17.5% of patient record abstracts, but these appear to have been unsystematic rather than deliberate errors. The difference between estimated reimbursement based on original and reabstracted records was not statistically significant either in the aggregate or for specific hospitals. It is emphasized that while New York State's Prospective Hospital Reimbursement Methodology (in effect during the study period) is not solely dependent upon DRG's case-mix is one of several factors used to make adjustments to existing per diem rates. A key recommendation is that hospitals conduct internal monitorings with all involved departments to improve the quality of the data abstracting process.Dr. Cohen is Director of the Data Division and Special Projects Development at New York County Health Services Review Organization (NYCHSRO). Ms. Bernier is Assistant Director for Data Collection and Quality, and Ms. Tam is Assistant Director for Data Analysis. Mr. Schimel was formerly NYCHSRO's Executive Director and Dr. Postel is NYCHSRO's Medical Director and is an Associate Professor of Surgery at New York University Medical School. Dr. Scheidt is NYCHSRO's Chairman of the Board of Directors and a Professor of Medicine at the Cornell University Medical College. Mr. Stamm is NYCHSRO's current Executive Director.     

Mental health case management as a locus for HIV prevention: Results from case-manager focus groups

HIV infection among people with severe mental illness (SMI) is a growing concern, and interventions have been designed to address HIV prevention among these individuals. However, little is known about the preparedness of mental health providers to support these interventions. This study concentrated on mental health case management as a locus for HIV-prevention services. Focus groups of case managers were conducted to learn participants' motivation to adopt HIV-prevention services and barriers/facilitators to such adoption. Participants reported they would be motivated to offer HIV prevention if services were to be presented in the context of existing client relationships and case-management tasks. Barriers and facilitators were discussed at client, provider, and community levels, and recommendations for training were offered. Findings have implications for diffusion of HIV-prevention services in case management, and the line of questioning in focus groups provides a basis for learning about other behavioral health service contexts as loci for disease prevention.During the time of research, Dr Encandela was Assistant Professor at the University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pa.Wynne S. Korr, PhD, was Professor at University of Pittsburgh School of Social Work, Pittsburgh, Pa, during the time of research. Dr Korr is now Dean and Professor at the University of Illinois School of Social Work, Urbana, Ill.Kathleen Hulton, MPH, was Graduate Student Assistant at University of Pittsburgh, Pittsburgh, Pa, during the time of research. Ms Hulton is now with the University of Massachusetts at Amherst, Northampton, Mass.     

Primary medical care for elderly patients part I: Service mix as seen by an expert panel

A survey of six geriatric experts concerning the normative role content of physicians providing primary care for the elderly emphasizes the importance of distinguishing reversible and irreversible components of a patient's problems and of conducting multidimensional functional assessments. Appreciation of the role of the environment in maintaining functional capacity should be inculcated in practitioners treating the elderly. Medicare payment methods should recognize that the elderly require more professional time for adequate care, and should address transportation needs.Charlotte Muller, PhD, is Professor of Economics and Sociology, City University of New York Graduate School, and Professor of Health Economics, Department of Community Medicine, Mount Sinai School of Medicine.Marianne C. Fahs, PhD, MPH, is Assistant Proffessor in Community Medicine, Mount Sinai School of Medicine.Malvin Schechter, MS, is an Assistant Professor, Ritter Department of Geriatrics and Adult Medicine, Mount Sinai School of Medicine.Supported by a conference grant from the National Center for Health Services Research, Herbert C. Traxler, PhD, project director.A briefer version of this paper was presented at the annual meeting of the Association for the Social Sciences in Health, Las Vegas, Nevada, 1986.The research assistance of Helen Hooke is gratefully acknowledged.