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.     

Patients' understanding of prescribed drugs

Patients must understand their physicians' recommendations if they are to follow medical advice. This study assesses the degree to which patients and physicians share basic information about medications. Patients who regularly attend the medical clinics of a large, urban teaching hospital were asked to recall the identity, purpose, and dose schedule of medications that were prescribed for them. Patients' responses were compared to the medications actually prescribed by their physicians. Patients identified 90% of medications prescribed during the visits, knew the purpose of 83%, and the correct dose schedule for 80%. Only 58% of patients knew the dosage schedule of all their medications correctly. Patients' knowledge of prescribed durgs was inversely related to the number of their medical problems and the number of medications prescribed. Lack of effective communication between physicians and patients about medications may be an important reason why patients do not follow medical advice.The authors were with the Department of Medicine and the Department of Epidemiology and Health, McGill University and the McGill University Clinic, Royal Victoria Hospital, Montreal, Quebec, Canada. Reprint requests should be addressed to Dr. S. Fletcher, Department of Medicine Medical Clinics, North Carolina Memorial Hospital, Chapel Hill, North Carolina 27514. This investigation was supported in part by a National Health Research Scholar Award, No. 605-1189-22 from the Department of National Health and Welfare, Canada, by the Robert Wood Johnson Clinical Scholars Program, and by an Establishment Grant, No. 750046, made by the Conseil de la Recherche en Santé du Québec. Portions of this paper were published in abstract form inClinical Research, Volume 24, 1976.     

Doctor-patient communication and outcomes among diabetic patients

This study reports on 242 diabetic patients from the practices of 42 physicians. Communication from physician to patient was studied to determine the effect of communication on subsequent patient outcomes. Patients and physicians were questioned on instructions provided for diabetic management and self-care. The average level of effective communication for all patients in the study was 67 percent. Insulin-dependent diabetics had the best communication scores, those controlled on diet alone the poorest, while oral medication patients were intermediate.Although overall communication scores showed to significant correlation with diabetic control status, patient satisfaction, compliance in taking prescribed medication, or frequency of hospitalization, specific communication items were highly correlated with corresponding behavioral outcomes.Dr. Hulka is Associate Professor, Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina 27514. Dr. Kupper is Assistant Professor, Department of Biostatistics, University of North Carolina, and Dr. Cassel is Professor and Chairman, Department of Epidemiology, University of North Carolina. Dr. Mayo is Professor and Chairman, Department of Family Practice, Medical College of Virginia/Virginia Commonwealth University. The project upon which this paper is based was performed persuant to Grant No. HS00026-03 between the National Center for Health Services Research and Development and the Department of Epidemiology, University of North Carolina.     

An assessment of emergency medical technicians' performance as related to seasonal population influx

The periodic influx of large numbers of people into resort areas substantially increases the use of emergency medical services. This investigation assesses the effects of such a threefold increase in the summer population of the Cape Cod area upon the accuracy of emergency medical technicians' diagnoses and treatments. The technicians' diagnoses for ambulance patients were evaluated against those given by the emergency room physicians during the months of August 1975 and February 1976. The distribution of conditions was similar for both months and the observed frequency of correct diagnoses for common conditions was more than 90% in both months. The overdiagnosis rate of 25% to 50% for common conditions and the correct treatment rate for suspected myocardial infarction of 65% did not vary significantly between summer and winter.Thus, a large influx in population does not seem to affect adversely EMT diagnosis rates. Although misdiagnoses were uncommon, a high frequency of overdiagnosis was found, as well as a 41% rate of failure to follow through with a correct treatment for patients with suspected myocardial infarctions, thus indicating the need for better quality control on EMT performance.The authors are with the Department of Medicine, Boston University School of Medicine, and Boston City Hospital, Thorndike Memorial Laboratories, Boston, Massachusetts. Requests for reprints should be addressed to Dr. Pozen, Cardiology Department, Sears 108, Boston City Hospital, 818 Harrison Avenue, Boston, Massachusetts 02118. This work was supported by research grants from the Massachusetts Regional Medical Program, the Emergency Medicine Foundation, and The Medical Foundation, Inc., Boston, Massachusetts.     

Primary care,private physicians,and public health personnel: A conflict in expectations

The elimination of categorical grants and their replacement by block grants provides public health departments the opportunity to integrate their services and provide general primary care to the underserved. While some may consider this an opportunity long overdue such a change may generate considerable conflict with private physicians.Questionnaire data from private physicians and health department personnel collected in North Carolina during an experimental program of primary care delivery by health department shows that there is substantial conflict. Private physicians oppose health department involvement in general primary care and in acute ambulatory care for the medically underserved. Physicians expect health departments to focus on preventive services, especially environmental monitoring and communicable disease control. Health department personnel want to expand their efforts beyond these more traditional areas into primary care and are in apparent conflict with private physicians. The community attitudes of a group of physicians within a community as well as the attitudes of a group of public health workers were found to be a major determinant of each individual's attitude toward public health, followed by the individual's age, sex, and years of working in the community.Dr. Kirkman-Liff is Assistant Professor, Center for Health Services Administration, College of Business Administration, Arizona State University, Tempe, AZ 85287. Dr. Kaluzny is Professor, Department of Health Administration, School of Public Health 201 H, University of North Carolina, Chapel Hill, NC 27514.     

Effects of adding a Medex on practice costs and productivity

Archival data on ten rural practices employing a Medex and on ten matched controls were compared to determine changes in the volume of patients seen and changes in the practice finances before and after the employment of a Medex. There were no significant differences in the changes in patient volume; however, the practices that employed a Medex showed an increase in revenue and in net profit per physician. On the average, the net profit increased approximately $11,000 (22%) for the physicians with Medex, compared with $9,000 (21%) for the control physicians.The authors are with the Department of Family and Community Medicine, University of Utah College of Medicine, 50 North Medical Drive, Salt Lake City, Utah 84132. Requests for reprints should be addresed to Dr. Kane, c/o The Rand Corporation, 1700 Main St., Santa Monica, Ca. 90406. This work was supported by contract no. HRA 106-74-58, from the Health Resources Administration, Department of Health, Education, and Welfare.     

Determinants of dropout rate among hypertensive patients in an urban clinic

Noncompliance with follow-up is a serious problem in the management of hypertension. A retrospective cohort study examined dropout rates and their determinants among 249 randomly selected outpatients with essential hypertension from the medical clinic of an urban teaching hospital. Data were abstracted from hospital records and a subset of dropouts was interviewed. A lifetable analysis revealed that patients who were initiating therapy or who had been under therapy for less than six months had a 50% chance of remaining in care two years later, while 70% of patients who had been under therapy for more than six months at entry were still in care after this period. Patients who were less severely ill by several indicators were the most likely to drop out. It is hypothesized that the low perceived severity of illness, coupled with the costs and inconvenience of care and the lack of physician enthusiasm for the treatment of mild hypertension leads to noncompliance with follow-up.Dr. Gillum is with the Laboratory of Physiological Hygiene and the Department of Medicine, Schools of Public Health and Medicine, University of Minnesota, Minneapolis, Minnesota. Dr. Neutra is with the Division of Epidemiology of the School of Public Health, University of California at Los Angeles. Dr. Stason is with the Center for the Analysis of Health Practices at the Harvard School of Public Health, Boston, Massachusetts. Dr. Solomon is with the Department of Medicine at Peter Bent Brigham Hospital, Boston, Massachusetts. Reprint requests should be addressed to Dr. Gillum, Laboratory of Physiological Hygiene, University of Minnesota, Stadium Gate 27, 611 Beacon St. SE, Minneapolis, Minnesota 55455.     

Measuring outcomes of care in an ambulatory primary care population

This study developed a practical method for determining the functional outcome status of patients in an ambulatory setting. Health status of 1,840 primary care patients was compared at three points in time: patient's usual status, status at the initial visit, and status at time of telephone follow-up. Follow-up status was also compared with the physician's expectation, which was estimated at the time of the initial visit. Of the patients, 62% showed improvement, 31% remained at the same level, and 7% deteriorated from the time of their initial clinic visit. Physicians tended to overestimate either the speed or degree with which patients return to their usual functional status; 32% of the patients studied reported themselves as being less well than usual at the time of follow-up.Dr. Kane is Associate Professor, Drs. Woolley, Gardner, Snell, and Leigh are Assistant Professors, and Dr. Castle is Professor and Chairman of the Department of Family and Community Medicine, University of Utah College of Medicine, 50 North Medical Drive, Salt Lake City, Utah, 84132. Requests for reprints should be addressed to Dr. Kane. Work for this study was supported by Contract No. HSM 110-72-232 with the Health Services Administration, Department of Health, Education, and Welfare.     

An account of the management of a potential environmental/medical crisis by a local health department

This paper is an account of what steps were necessary in the epidemiological and medical investigation of an alleged cyanide outbreak by a local health department. It details, in chronological sequence, the events, groups, and individuals who impacted a situation which, at various points, caused considerable anxiety in the community.Judith Craven, M.D., M.P.H., is Director of Public Health for the City of Houston Health Department. She has previously served as Chief of Family Health Services for the department. Dr. Craven is the first woman and the second member of a minority to hold this position with the city.Madelyn D. Kamen, Dr. P.H., is Assistant to the Director of the City of Houston Health Department. She previously served as full-time faculty at Baylor College of Medicine.     

The content of care provided by Family Nurse Practitioners

The content of care provided by 30 graduates of the UCLA Primex (Family Nurse Practitioner) program was examined. An encounter form similar to that used in the National Ambulatory Medical Care Survey was employed to code patients' complaints. These practitioners had been specifically trained to provide care for ambulatory patients. Data were collected one year after the completion of the university didactic phase of the program. We found that Primex practitioners spent more time with patients, more often employed traditional nursing functions, and more often used medical investigative procedures, such as x-rays and laboratory tests than did the physicians in the NAMC survey. Although the types of problems seen varied according to the organizational setting, these nurse practitioners were more often assigned routine health examinations and less often saw certain kinds of acute health care problems than had been anticipated in their training; 116 different types of symptoms or problems were presented, with a total of 1,170 encounters.The authors are with the UCLA Primex Program; Dr. Lewis is Professor of Medicine and Dr. Linn is Associate Researcher in the Department of Medicine, University of California at Los Angeles, Los Angeles, California 90024. This work was supported by grant HS-00985 from the National Center for Health Services Research.     

Direct and indirect measures of patient satisfaction with physicians' services

This research examines alternative measures of patient satisfaction. Three measures were compared: (1) a direct measure to evaluate how the patient felt about his own personal physician, (2) an indirect measure that assessed attitudes about physicians in general, and (3) a measure designed to be intermediate between these two. Responses to the three measures were found to differ: the levels of satisfaction increased with the directness of the measure used; indirect evidence that this relationship could not be attributed solely to a patient's reluctance to criticize his own physician is also provided.The three measures were compared in terms of their association with other assessments of outcome and with indicators of the process of care. Although none of the associations was statistically significant, high scores on the intermediate measure tended to correspond with better outcomes and higher scores on the process of care. These findings are at least compatible with the contention that an intermediate measure provides the most valid assessment of patient satisfaction.Dr. Stewart, a National Health Research Scholar, was formerly with the Department of Epidemiology and Preventive Medicine, University of Western Ontario, and is now with the Department of Preventive Medicine, Dalhousie University, Halifax, Nova Scotia, Canada, B3H 4H7. Dr. Wanklin, is Professor in the Department of Epidemiology and Preventive Medicine, University of Western Ontario. Dr. Stewart has been supported by a Fellowship from the Physician's Services Incorporated Foundation (Ontario) and by a National Health Research Scholarship from Health and Welfare Canada. The authors wish to thank Drs. W. Weston, B. Halliday, D. Fuller, A. Hegde, P. Bartlett, and the staff and patients of the Tavistock Family Health Centre for their participation in this research.     

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.     

Medical care for vacationers

Medical services provided to vacationers and employees in Yellowstone National Park were reviewed for the years 1975 through 1977. Both ambulatory and inpatient data were obtained, including diagnoses, place of residence, medications prescribed, and methods of payment. The types of problems and modes of treatment did not differ from typical primary care practices. Health maintenance was the most common reason for outpatient visits. The distribution of diagnoses among park visitors and employees was the same within age categories, although the employees' rate of utilization was nearly twice that of the visitors. Distance from home was directly related to the frequency with which visitors used clinic services.Drs. Woolley, Wright, and Patrick and Mrs. Ford are with the Department of Family and Community Medicine, University of Utah College of Medicine, Salt Lake City, Utah, and Dr. Kronhaus is with Health Systems Research Institute, 715 East 3900 South, Salt Lake City, Utah. Work for this study was supported by Department of Health, Education and Welfare Contract No. 298-76-R-0006, Evaluation of the Utilization Effectiveness of Rural Health Programs. Reprints may be obtained from Dr. Ross Woolley, Department of Family and Community Medicine, 50 North Medical Drive, Salt Lake City, Utah 84132.     

Community-oriented health services education: A strategy for international cooperation

This paper describes the approach of the Department of Community Medicine of the Mount Sinai School of Medicine in the education of local and foreign physicians and their participation in the development of community oriented health care systems. It also presents the first steps taken by this medical school to create an international program whose aims are to develop long-term partnership agreements with foreign universities by bringing together and integrating medical education with the development of community-oriented health care services.Samuel J. Bosch, M.D., is Charles G. Bluhdorn Professor of International Community Medicine, Department of Community Medicine, The Mount Sinai School of Medicine of the City University of New York. One Gustave L. Levy Place, New York, N.Y. 10029.Alan Silver, M.D. is Assistant Professor and Director of the Education Unit, Department of Community Medicine, The Mount Sinai School of Medicine of the City University of New York. One Gustave L. Levy Place, New York, N.Y. 10029     

Health Maintenance Organizations: Are they for the inner cities?

Health Maintenance Organizations present some major limitations as a means to address the health care needs in our nation's inner cities. The HMO as it has been affected by HMO legislation is discussed and an identification made of those areas that may adversely affect the delivery of health services to inner-city residents where costs may be greatest for those who can least afford it.Dr. Roman is Director of Ambulatory Care, in the Department of Medicine at Boston City Hospital and the Department of Medicine at Boston University School of Medicine, 818 Harrison Avenue, Boston, Massachusetts 02118.     

Medical care as a commodity

A 10% household sample of high- and low-income census tracts was interviewed to assess the extent of doctor shopping. In 632 households studied, 53% of high socioeconomic status and 51% of low socioeconomic status families had shopped for or changed doctors of their own volition. During the previous year, 4% of each socioeconomic group had consulted more than one doctor without referral for the same episode of illness. Shoppers could be distinguished from non-shoppers—shoppers were younger, were better informed about medical specialties, were less self-reliant, more hypochondriacal, expressed less hostility toward physicians, and had less positive attitudes toward the medical care system. The differences between shoppers and non-shoppers were generally similar for both high and low socioeconomic status groups. In addition, 52% of the families studied had been forced to change doctors because of circumstances beyond their control, i.e., the patient moved or the doctor moved, retired, or died.Dr. Olsen is Instructor, Dr. Kane is Associate Professor, and Dr. Kasteler is Assistant Professor in the Department of Family and Community Medicine, University of Utah College of Medicine, 50 North Medical Drive, Salt Lake City, Utah 84132.     

Definition of terms and concepts applicable to clinical preventive medicine

This article defines the terms and concepts applied to the teaching of clinical preventive medicine by the Curriculum Development Project—a joint venture of the Center for Educational Development in Health (CEDH) at Boston University and the Association of Teachers of Preventive Medicine Foundation (ATPMF).Dr. Stokes is Professor of Medicine (Section of Preventive Medicine and Epidemiology), Boston University, Boston, MA 02118; Dr. Noren is Director (Administrative Medicine), University of Wisconsin, Madison, WI 53706; and Dr. Shindell is Professor and Chairman (Department of Preventive Medicine), Medical College of Wisconsin, Milwaukee, WI 53233.Supported in part by grants from the National Fund for Medical Education and the Kellogg Foundation.     

Toward understanding elders' health service utilization

Providing appropriate health services to the elderly is emerging as one of the major challenges of this decade. Using the theoretical framework developed by Andersen and Aday, this study attempts to improve our understanding of those factors which inhibit or facilitate elders' use of health services. The data come from a 1974 statewide random probability sample of 1,625 noninstitutionalized elders 65 years of age or older living in Massachusetts. Regression analysis is used to study the effects of predisposing, enabling, and need characteristics on the use of five health services: hospitals, physicians, dentists, home care, and ambulatory care. The model explains from 5% to 27% of the variance in health service utilization. Need characteristics, in general, account for most of the explained variance.Drs. Branch and Jette and Ms. Polansky are with the Department of Social Medicine and Health Policy, Division on Aging, Harvard Medical School, 643 Huntington Avenue, Boston, Massachusetts 02115; Dr. Jette is also with the Massachusetts General Hospital's Institute of Health Professions; Dr. Evashwick and Ms. Rowe are with the Department of Health Services and Long Term Care Gerontology Center, School of Public Health and Community Medicine, University of Washington; and Dr. Diehr is with the Department of Biostatistics, School of Public Health and Community Medicine, University of Washington. Work for this project was supported in part by a grant from the Massachusetts Department of Public Health while the first author was with the Center for Survey Research, a facility of the University of Massachusetts and the Joint Center for Urban Studies of M.I.T. and Harvard University; in part by Grant 90-A-1350/2 from the Administration on Aging of H.E.W. to the Harvard School of Public Health; and in part by Grant 90-AT-2159 from the Administration on Aging of H.E.W. to the Harvard Medical School.     

Compliance with medication regimens among chronically ill,inner city patients

Patient adherence to medication regimens is explored as a function of (1) patient beliefs, perceptions, and knowledge of the illness, (2) extent of social support for health actions, (3) complexity of and specific knowledge about the regimen, and (4) satisfaction with clinical encounters and the health care facility. One hundred and ninety patients receiving care on an outpatient basis at a municipal teaching hospital were interviewed. The patients' medical records provided an additional data source. Path analysis generally supported the stated hypotheses. The only variables that had a significant effect opposite to that hypothesized were perceived severity about and susceptibility to the illness. The factors with the greatest predictive power in regard to patient compliance were (1) patients' ability to state the names of or accurately describe their medicines, (2) patients' ability to state the functions of their drugs, and (3) the complexity of the medication regimen as measured by the number of drugs prescribed for the patient.Dr. Greene is a Research Associate in the Department of Medicine, Indiana University School of Medicine and Regenstrief Institute for Health Care, 1001 West Tenth Street, Indianapolis, Indiana 46202; Dr. Weinberger is Assistant Professor of Medicine, Indiana University School of Medicine and Regenstrief Institute for Health Care; Dr. Jerin is Assistant Professor of Sociology at Saint Ambrose College; and Dr. Mamlin is Professor of Medicine, Indiana University School of Medicine and Regenstrief Institute for Health Care.     

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.