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.     

Ambulatory care groups and the profiling of primary care physician resource use: examining the application of case mix adjustments

A variety of profiling models and tools is utilized by payers, providers, and regulators to evaluate physician work, performance, and resource utilization. In physician profiling, the provider's pattern of practice is expressed as a rate of service or outcome. The article by Tucker, Weiner, Honigfeld, and Parton (this issue) compares the practice-based norms of primary care physicians by adjusting for case mix using ambulatory care groups (ACGs), a population-based classification method. Once the case mix is adjusted, the actual use of resources, as measured by overall charges, is compared with the expected value of resource use. In the Center for Research in Ambulatory Health Care Administration (CRAHCA) Physician Profiling Project, funded by The Robert Wood Johnson Foundation, physicians learn which services other physicians in their specialties perform. Physicians are able to compare their profiles with state and national level medians. The profiling project is one of the first demonstration projects in the field to profile ambulatory care practice patterns and collect patient demographics. An aspect of the project is to test the ACG classification system to data selected from 130 nonacademic practices representing over 5,000 physicians.     

Health services research and health policy

Health services research (HSR) has the potential to influence the decision-making process in a health services system that is acutely aware of its resource limitations. Nonetheless, health services researchers feel, with some truth, that their research has had only a limited effect on health policy. Some reasons for this are described, including the primacy of political, rather than technical, considerations in policy making, the lack of a comprehensive health policy, and the poor quality and irrelevance of much HSR. The role of funding for HSR by the Federal government is described; it is shown that the Federal effort is fragmented, despite the consolidation efforts made in 1968. Increased support for specific targeted, problem-solving health services research is proposed, and some possible methods to achieve this are described.Dr. Banta is a Professional Staff Member with the Office of Technology Assessment, Congress of the United States, Washington, D.C. 20510, and Associate Clinical Professor, Mount Sinai School of Medicine of the City University of New York. Ms. Bauman is a Professional Staff Member, Committee on Labor and Public Welfare, Senate of the United States, Washington, D.C. 20510. The authors would like to thank Carl Taylor of the Office of Technology Assessment, Arthur Viseltear of Yale University, and Richard Seggel of the Institute of Medicine for their helpful comments. Dr. Banta is grateful to the Robert Wood Johnson Foundation for its support of the Robert Wood Johnson Health Policy Fellowship and to the Institute of Medicine, which developed the Fellowship. A version of this paper was presented at the Medical Care Section, American Public Health Association meetings, Chicago, Illinois, November 19, 1975.     

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.     

Identification of health care problems in a county jail

The health care needs of prisoners often are not systematically addressed. To evaluate the ability of a questionnaire, that is administered at the time of arrest, to identify inmates' medical problems and to predict subsequent use of care, we reviewed and analyzed medical records and questionnaires for 594 individuals incarcerated in a county jail. Only 54% of subjects had a completed questionnaire filed in a medical record; the questionnaire identified only 48% of persons who eventually sought care for such major problems as drug and alcohol abuse and cardiopulmonary disease. No question screened for psychiatric problems, even though five percent of subjects were diagnosed as having major psychiatric disorders during their incarcerations. On the other hand, many items addressed problems that were far less common. Uniform screening of prison populations may be effective if conducted with greater rigor and better instruments than were employed in the institution studied. Health care for inmates might be served better by universal screening and follow-up, targeted to such important problems as drug and alcohol abuse and psychiatric disorders.Stanley Shapiro, M.D., M.S.P.H. is a Physician Specialist, Los Angeles County Department of Health Services. Martin F. Shapiro, M.D., Ph.D. is Associate Professor of Medicine UCLA School of Medicine, and Henry J. Kaiser Family Foundation Faculty Scholar in General Internal Medicine.Supported in part by a grant from The Robert Wood Johnson Foundation. 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.     

Hospital-sponsored medical groups: Their impact on access to primary care in rural communities

Rural communities have traditionally been underserved in terms of the availability of primary medical care services and providers. The Robert Wood Johnson Foundation launched a major program in the mid-1970s to improve the delivery of primary care to previously underserved rural, small town, inner city and other urban communities through their Community Hospital Program (CHP). This program provided grant funds to over 50 community hospitals throughout the country to develop primary care-oriented group practices. Twelve of the 53 programs eventually funded were sampled for a national evaluation of the impact of the CHP groups on access to care in the communities they served. The analyses reported here summarize the access impact of this innovation on the four rural and small town communities included in the larger evaluation. Baseline surveys in these four communities established that, in general, access was poorer in the rural areas, in particular, compared to the national average. The new groups tended to attract a cross-section of the communities they served. In general, they tended to do as well or better as other sources of care in the area in providing access to care. The most successful groups were those that most closely mirrored the traditional private practitioner—family doctor—model of care.Lu Ann Aday, Ph.D. is a Research Associate (Associate Professor) and Associate Director for Research at the Center for Health Administration Studies, Division of Biological Sciences, Graduate School of Business, The University of Chicago.The research on which this paper was based was supported by grants from The Robert Wood Johnson Foundation (Princeton, New Jersey). This paper was presented at the Eighth Annual Institute of the American Rural Health Association, EPCOT Center, Florida, June 6, 1984.     

New report card compares end-of-life care initiatives across the country

A report card from Last Acts and the Robert Wood Johnson Foundation takes a first look on a state-by-state basis at how end-of-life care and related issues are approached by healthcare organizations across the country.     

Special report. Designing security for a garage serving a new medical school: from concept to reality

The Paterson Street Deck, New Brunswick, NJ, cited by the International Parking Institute (IPI) for excellence in design, employs a number of modern security concepts to protect its customers. The deck was built by the New Brunswick Parking Authority, which worked with the city's medical community to develop the 1,010-space structure located next to the newly built Robert Wood Johnson Medical School. The spaces are used by approximately 800 medical patrons--students of the medical school and employees of Robert Wood Johnson University Hospital, as well as an additional 200 visitors. Staffers and students pay for parking services biweekly on a graduated scale based on the level of their job title, according to Joseph Bernasz, director of administrator, Robert Wood Johnson Medical School. And they have been very receptive to the new facility, says Kevin McTernan, vice president of administrative services, Robert Wood Johnson University Hospital, New Brunswick. In this report, we'll present in detail the security concepts employed, the reasons behind them, and how they have been employed since the deck opened about two years ago.     

Aligning Forces for Quality: a program to improve health and health care in communities across the United States

The Robert Wood Johnson Foundation's Aligning Forces for Quality program features partnerships with leaders in targeted communities. The program is working to achieve dramatic, sustainable improvements in quality across the continuum of care by 2015. These improvements will affect patients of all races and ethnicities.     

Rural health care delivery amidst federal retrenchment: lessons from the Robert Wood Johnson Foundation's Rural Practice Project.

This paper examines the experience of the Robert Wood Johnson Foundation's Rural Practice Project (RPP), a major non-governmental effort in the last decade concentrating on the direct delivery of rural health services. The nine RPP sites started prior to 1977 showed a slow but steady increase in their utilization levels and improvement in their financial status during their initial operational years. The tempo of their development was remarkably similar to that of federally sponsored practices in underserved rural areas. After four years of operation, all of the practices had completed their period of grant support; the practices survived in all cases, with almost all of the practices still retaining community sponsorship, salaried physicians, and a commitment to comprehensive care. Practices in sparsely populated rural areas and in areas with fewer hospital beds grew more slowly than those set in rural areas with higher population density and more ancillary resources. We conclude that the use of time-limited initial subsidies is an effective strategy in starting new rural practices in underserved areas and that those practices have a good chance of surviving their start-up phase.     

Process evaluation of an educational intervention to improve end-of-life care: the Education for Physicians on End-of-Life Care (EPEC) program

Despite the growing importance of end-of-life care and the need to improve it, physicians receive little formal training in palliative care. The Education for Physicians on End-of-life Care (EPEC) project, developed by the American Medical Association and the Robert Wood Johnson Foundation, tested a train-the-trainer educational intervention to address this deficiency. This paper presents data from a process evaluation of the initial rollout of EPEC. By all accounts, EPEC provided a state-of-the-art curriculum covering important and clinically relevant topics to the care of the dying patient. It was less clear, however, if EPEC adequately prepared trainees to teach these new skills to other practicing physicians. Factors that may advance efforts to generalize EPEC to other settings and improve future applications of the program are discussed.     

An assessment of the adequacy of self-care by adult asthmatics

Little is known about how individuals who have chronic disease actually manage their symptoms. This study involving a community-based population of 157 adult asthmatics assesses their ability to take care of their disease and to alter their behavior following a change in symptoms. Multiple techniques (interview, direct observation, and diary) were used to determine their behavior with respect to medications and physician use; these were then compared with criteria defining the requisite level of a behavior to reduce symptoms. Of the population assessed, 66% had no bronchodilator medication at home, 24% used an inhaler ineffectively, and 68% did not see a physician regularly. When faced with increasing symptoms, at least 40% of the asthmatics did not perform three basic and appropriate behaviors in medication use and physician contact. If physicians and other health care providers could decrease the frequency of these inappropriate self-care behaviors, it could result in improved health.From the UCLA Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, School of Medicine and School of Public Health, University of California, Los Angeles, California 90024. Preparation of this paper 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. Requests for reprints may be addressed to Robert H. Brook, M.D., The Rand Corporation, 1700 Main Street, Santa Monica, California 90406. The authors are indebted to Dr. Donald Tashkin for valuable assistance in reviewing the criteria used in this study to judge quality of care, to Dr. Roger Detels and Mrs. Anne Coulson whose UCLA Chronic Obstructive Respiratory Disease Study provided the study population, to Mrs. Xuan Le for diligent administrative assistance, and to Ms. Karen Kashiwagi for fine technical assistance.     

Emergency room management of patients with sore throats in a teaching hospital: Influence of non-physician factors

The care of 169 patients with sore throats was evaluated retrospectively to determine if the quality of medical care received in a teaching hospital's emergency room is associated with the degree of control managing physicians have over the medical care process. Diagnostic evaluation (temperature, throat and cervical node examination, and throat culture) was controlled by physicians and was judged adequate in 78% to 98% of the patients. Therapy, defined as appropriate antibiotics prescribed only for patients with positive throat cultures for group A beta-hemolytic streptococcus, was dependent on hospital support services, and the patients, as well, and was judged adequate for 62% of the patients; however, in only one of the 67 patients treated with antibiotics was the culture result known before treatment. The bacteriology laboratory processed the cultures slowly; no administrative mechanism existed to follow up patients. Thus, when medical care involved factors outside physicians' direct control, lower quality care was given.From the Department of Medical Care and Hospitals, the Johns Hopkins University School of Hygiene and Public Health and the Department of Medicine, Baltimore City Hospitals. Address reprint requests to Dr. Fletcher, Department of Medicine, McGill University Clinic, Royal Victoria Hospital, Montreal, Quebec, H3A 1A1, Canada. This work was supported in part by grants from the Carnegie Corporation, the Commonwealth Fund of New York City, and the Robert Wood Johnson Foundation, and by grants 5 H01 HS 00110 and 5 T01 HS 00012 from the National Center for Health Services Research and Development and 5 D04 AH 00076 from the National Institutes of Health, Department of Health, Education and Welfare. Dr. Fletcher was a Carnegie Commonwealth Clinical Scholar.     

A proposed network to improve access to high-quality health care for medicaid-eligible families

There is today both a need and an opportunity to develop and test a variety of models—organizational and financial—for improving the delivery of health care services. This article describes the structure and functioning of one such model and highlights the organizational problems expected to arise during its implemèntation. The proposed health plan is intended to facilitate the access of Medicaideligible, inner-city families to already available health services. The central hypothesis is that in low-income urban areas the elementary schools offer an organizational focus for the development of a health plan. As a prepaid, community-based model, this plan is designed to address the issues of accessibility, equity, accountability, continuity of care, and consumer participation, primarily through the development of a coordinating agency, the health plan office (HPO), which assures the linking of consumers and providers of health care. Adapted from the Kaiser-Permanente model, the HPO also assumes responsibility for marketing, enrollment, coordination of services, consumer advocacy, and quality surveillance.Dr. Bosch is Professor and Deputy Chairman of the Department of Community Medicine, Mount Sinai School of Medicine, New York City 10029. Dr. Merino is Assistant Professor, Mrs. Daniels is Coordinator of Community Program Planning, and Ms. Fischer is a Technical Associate in the Department. Dr. Rosenthal is Director of Dental Services, East Harlem Council for Human Services Neighborhood Health Center. The work reported in this article was conducted under a grant from the Robert Wood Johnson Foundation.     

Translating evidence-based depression management services to community-based primary care practices

Randomized controlled trials have demonstrated the efficacy and cost-effectiveness of using treatment models for major depression in primary care settings. Nonetheless, translating these models into enduring changes in routine primary care has proved difficult. Various health system and organizational barriers prevent the integration of these models into primary care settings. This article discusses barriers to introducing and sustaining evidence-based depression management services in community-based primary care practices and suggests organizational and financial solutions based on the Robert Wood Johnson Foundation Depression in Primary Care Program. It focuses on strategies to improve depression care in medical settings based on adaptations of the chronic care model and discusses the challenges of implementing evidence-based depression care given the structural, financial, and cultural separation between mental health and general medical care.     

Addressing the nurse shortage to improve the quality of patient care

Nurses are the largest group of health care professionals providing direct patient care in hospitals, and the quality of care for hospital patients is strongly linked to the performance of nursing staff, according to an Institute of Medicine report. This paper describes the Robert Wood Johnson Foundation's (RWJF's) work in nursing, which focuses on improving the hospital work environment to attract and retain high-quality nursing staff, with the ultimate goal of improving patient care and outcomes in hospitals. Other organizations' efforts to address the nurse shortage are also explored.     

How the health and community development sectors are combining forces to improve health and well-being

The root causes of poor health experienced by many who live in low-income neighborhoods-such as the lack of access to health care, limited food choices, and exposure to environmental hazards-are well documented, but often go beyond the scope of the health care delivery system. But that is beginning to change. The health sector has begun to collaborate with the community development sector, which for decades has been working in low-income neighborhoods. Encouraging local and national examples of these new partnerships abound. They include an effort in Seattle, Washington, to reduce exposure to allergens and irritants among low-income asthmatic children, and a $500?million federal program to finance the operation of grocery stores in what have previously been urban "food deserts." To nurture such efforts, the Robert Wood Johnson Foundation, the Federal Reserve System, and others have sponsored a series of "healthy community" forums in US cities. In this article we explore the growing partnerships between the health and community development sectors as well as the challenges they face, and we offer policy recommendations that might help them succeed.     

Disparities in physician care: experiences and perceptions of a multi-ethnic America

This 2007 Harvard School of Public Health/Robert Wood Johnson Foundation survey of 4,334 randomly selected U.S. adults compared perceptions of the quality of physician care among fourteen racial and ethnic groups with those of whites. On each measure examined, at least five and as many as eleven subgroups perceived their care to be significantly worse than care for whites. In many instances, subgroups were at least fifteen percentage points more negative than whites. This was true for Central/South Americans, Chinese Americans, and Korean Americans on five of seven measures. Many of the differences remained after socioeconomic characteristics and language skills were controlled for.     

The 1974 reorganization of the British National Health Service: An analysis

The British National Health Service was reorganized on April 1, 1974, for the first time since its formation in 1948. The Reorganization attacked one serious problem: the anomalous separation of the general practitioners (and other nonhospital, non-local authority ambulatory services), hospitals, local government authority public health services, and teaching hospitals into different administrative units with different boundaries. These services are now integrated into one structure. However, other important problems will not be affected substantially.Dr. Jonas is Associate Professor of Community Medicine in the Health Sciences Center, State University of New York, Stony Brook, New York 11794. Dr. Banta is Associate Professor of Community Medicine at the Mount Sinai School of Medicine of the City University of New York and Robert Wood Johnson Health Policy Fellow in the Institute of Medicine, National Academy of Sciences, Washington, D.C. An earlier version of this paper was presented by Dr. Jonas at the American Public Health Association annual meeting, San Francisco, California, November 8, 1973. Dr. Banta is grateful to the Milbank Memorial Fund, whose support made possible visits to Britain in 1970, 1971, and 1974. The authors would like to thank Drs. Brian Abel-Smith, Peter Draper, Geoffrey Gibson, Wilfred Harding, David Stark Murray, and Julian Tudor-Hart for the helpful comments they made on the earlier paper by Dr. Jonas and also Dr. John Brotherston for his contributions to this work.