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.     

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.     

Rating the lecturer

Faculty members from medicine, nursing, social work, and law, as well as a group of medical students, tested their own criteria for a good lecturer; each group focused on different aspects of the behaviors sought in the good lecture. The Dr. Fox paradigm was the lecture chosen; all groups failed to identify the deliberately incorporated failings. These results were then compared with the results obtained by using a standardized rating form in current use within a major university.Dr. Kane is an Associate Professor in the Department of Family and Community Medicine, University of Utah College of Medicine, 50 North Medical Drive, Salt Lake City, Utah 84132. Dr. Schorow was formerly the Director of the Office of Medical Sciences Education, University of Utah College of Medicine, and is now Coordinator of Educational Development at Columbia University College of Physicians and Surgeons, 630 West 168th Street, New York, New York 10032.     

More women enter medicine: young doctors' family origin and career choice

Summary. This study is part of the Finnish Junior Physicians 88 Study, the purpose of which was to shed light on the life situation, career choice and future plans of young doctors and their views on medical education. The survey population included all the medical doctors registered during the years 1977-1986 in Finland (n = 5208 ). A postal questionnaire was sent to a sample of 2632 doctors born on odd-numbered days. After a reminder letter, 1745 questionnaires (66%) were returned. Forty-nine per cent of the respondents were women. Typically both men and women doctors had a father who was an upper-level white-collar worker and a mother who was a housewife. More men than women had a father who was a doctor or other health professional. More women than men mentioned that a lifelong calling (42% vs 30%), success at school (58% vs 47%) and an interest in helping people (78% vs 71%) had considerable influence on their decision to become a doctor. Men more often than women emphasized the medical profession being regarded as a highly paid (56% vs 47%) and a high status profession (64% vs 56%) and also that a family member was a doctor (15% vs 11%).     

Virtual Medical Care: How Are Our Patients Using Online Health Information?

An increasing percentage of Internet users are seeking health information online. The purpose of our study was to determine the extent of Internet access and online health-seeking and the feasibility of implementing Internet services for our urban, residency-based practice. Using a self-administered survey, we obtained information on use of the Internet, demographics and socioeconomic profile, presence of a chronic medical condition and self-rated health from 300 consecutive patients. Complete surveys were obtained by 203 (68 percent). Responses were compared based on demographic, socioeconomic, and medical variables using Chi-square analysis. Results showed that our sample population tended to be under age 50, female, non-Hispanic Black, low income, and healthy. Seventy-seven percent of respondents had accessed the Internet at least once, 79 percent had used the Internet to find health-related information, 73 percent used the online information to make a health-related decision, 50 percent shared the information with their provider. In conclusion, we confirmed a high rate of Internet usage in our specific patient population, characterized by low socioeconomic status, low education level, and high minority percentages. Our patients not only access online health information, but also make changes based on this information, with only about half of all patients sharing this information with their physicians. It is unclear how this system of ‘virtual medical care’ influences overall patient health.Heather A. Liszka and Terrence E. Steyer are Assistant Professors of Family Medicine, William J. Hueston is Professor and Department Chair of Family Medicine, all at the Medical University of South Carolina, Charleston, SC.     

Prescription medicines: decision‐making preferences of patients who receive different levels of public subsidy

Objective To compare the relative importance of medicine attributes and decision‐making preferences of patients with higher or lower levels of insurance coverage in a publicly funded health care system. Design and setting Cross‐sectional telephone survey of randomly selected regular medicine users aged ≥18 years in the Hunter Valley, NSW, Australia. Main variables studied Questions about 27 medicine attributes and active involvement in decisions to start a new medicine. Results After adjustment, there were few differences between the 408 concession card holders (high insurance) and 410 general beneficiaries (low insurance) in their assessment of the importance of medicine attributes. For both groups, the explanation of treatment options, establishing the need for the medicine, and medicine efficacy and safety were the most important considerations. Medicine costs, the treatment burden and medicine familiarity were less important; the views of family and friends ranked lowest. There was a statistically significantly greater influence of the regular doctor for the concession card holders than general beneficiaries (93.6 vs. 84%, adjusted OR 2.80, 95% CI 1.31, 5.99). Concession card holders were more likely to favour doctors having more say in the decision‐making process (crude OR 1.69, 95% CI 1.28, 2.24), and more likely to report the most recent treatment decision being made by the doctor alone, compared with general beneficiaries (61.2 vs. 40.3%). Conclusion Medicine need, efficacy and safety are viewed as paramount for most patients, irrespective of insurance status. While patients report the importance of participation in treatment decisions, delegation of decision making to the doctor was common in practice.     

A study of attitudes toward medical care and health behaviors among older adults

In order to understand the attitudes of older adults toward medical care, we interviewed 480 persons living in Yokohama, and 180 persons living in Aikawa, Kanagawa, aged 45 to 84 years old. The following results were obtained; 1) Attitudes toward medical care can be classified into four types; self-determined medical care, self treatment attitudes, high dependence on the medical care system, and distrust of medical care. Those interviewees who had high self-determination in medical care and self treatment attitudes showed strong distrust of medical care. 2) There were two groups with trend toward low compliance to the advice of a physician for a physician diagnosed illness: the group that had strong self-determination in medical care, and the group that had high distrust of medical care. The interviewees who had a strong tendency to see a physician for potentially serious illness had high self treatment attitudes, but disease prevention behaviors was not associated with all of four types. 3) In both communities, those interviewees who were younger and with higher educational levels showed strong distrust of medical care and had more self-determination attitudes. Those interviewees who had actually experienced problems in medical treatment showed less dependence on medical care and more distrust of medical care compared to those who had not. In Yokohama, distrust of medical care appeared to be higher among those interviewees who did not have a family doctor than those who had. 4) Distrust of medical care and self-determination in medical care was significantly higher in Yokohama than in Aikawa. The differences in the distribution of educational level and family doctors were a part of the reason for area differences in attitudes of distrust of medical care.     

Inanspruchnahme des Gesundheitswesens

More than 90% of adults have a family doctor. The more chronic diseases and the more subjective health problems the interviewees had, the more often they had been to see their family doctor. Senior citizens and people with lower social status or a higher BMI go to see their family doctors more frequently. People who say they consume a lot of alcohol consult a doctor less often than others. Privately insured people also go to see their family doctors less frequently. Almost two-thirds of the adult population in Germany have seen a doctor in the last 3 months, and 44% of people over 60 had an influenza vaccination this year. People are much more willing to have an influenza injection in eastern Germany than in the west. More than half of the people questioned over the age of 35 has had a general health check-up at least once in their lives. Men have health check-ups slightly more often than women do. Of the women, 80% have participated at least once in a cancer screening programme, and as many as 60% of women had a cancer scan during the last year. Men take up cancer screening offers less often than women do. Inpatients stay for an average of 2 weeks in hospital per year. Just under 30% of those questioned have had medical rehabilitation treatment.     

Predicting rural health care utilization with archival data

This study explored the usefulness of archival data in predicting rural health care utilization. A regression model was used to see how well observed utilization for local populations could be predicted by calculating expected values in advance from age- and sex-specific national rates applied to local age and sex profiles. Although the correlation between observed and expected utilization was reasonably high (r=0.92), an attempt was then made to improve prediction by considering other data that do not require independent collection. These archival data included indicators of historic utilization (local Medicaid payments, the percentage of births to county residents occurring in the mother's county of residence, percentage of children immunized, and infant mortality) and services already available. Observed utilization data were obtained by surveys in eight rural counties, and the predictor was tested on three additional rural communities. A predictor equation that added to the expected utilization only one variable (the percentage of births to county residents occurring in the mother's county of residence) was found to account for approximately 95% of the variance in observed utilization. This predictor is recommended for planners who need convenient, low-cost market feasibility estimates for proposed project sites and a way to establish intermediate goals or incentives during early project development.Dr. Wright and Mr. Altman were formerly with the Department of Family and Community Medicine, University of Utah College of Medicine. Dr. Kronhaus is a Robert Wood Johnson Clinical Scholar at the University of North Carolina, Chapel Hill. Dr. Woolley is with the Department of Family and Community Medicine, University of Utah College of Medicine. Dr. Kane is Professor at UCLA Schools of Medicine and Public Health and a Senior Researcher at The Rand Corporation. Work for this study was supported by the Department of Health, Education, and Welfare (Contract No. 298-76-R-0006). Reprints may be obtained from Robert L. Kane, The Rand Corporation, 1700 Main Street, Santa Monica, CA 90406.     

Health care needs for children of the recently homeless

Thirty families were surveyed at a shelter for the homeless in San Diego, California concerning the health care status and needs of their children. 56.7% of the families had no regular source of health care and 46.6% were not covered by any form of health coverage. Children whose families had a regular source of health care were more likely to have reported better health and more frequent checkups. Also, increased duration of homelessness was predictably correlated with poorer reported health of the children. Though the families sampled were representive of those recently made homeless i.e. less than six months, needs were identified that would be applicable to all homeless families. The most frequent needs the families expressed for their children were: general nonemergency clinics (76.7%), emergency services (66.7%), and dental services (66.7%). Nutritional and dietary counseling were chosen by 43.3% and only 6.7% of the parents rated social and psychological services as needed.Dale Hu, M.D. is Resident-in-Proventive. Medicine, Johns Hopkins University, Baltimore. Maryland. Ruth M. Covell, M.D. is Associate Dean and Clinical Professor Community and Family Medicine, University of California, San Diego, La Jolla, California; Jeffrey Morgan, M.D. is on staff at the Comprehensive Health Center, San Diego, CA; and John Arcia is a fourth year medical student, University of California, San Diego.     

Is our appearance important to our patients?

OBJECTIVES: We aimed to explore patients' attitudes towards family physicians' and nurses' appearance. METHODS: One hundred and sixty- eight patients from three teaching Family Medicine clinics in Beer- Sheva, Israel, were interviewed in the clinics regarding the medical staff's dress code. They were also asked to choose one picture for either a male or female physician which, in their opinion, was the most suited for their own family physician, from a selection of pictures of the same male and female doctors dressed in different attires. RESULTS: One hundred and twenty-six patients (75%) replied that the attire of the physician had no influence on their decision in choosing their own family doctor. Fifty-two per cent of the patients preferred the doctor in a white coat and 71 % had the same preference for the nurse. Older age was associated with increased preference for a white coat. The dressing items which scored high for male doctor were a name tag, a formal suit or a shirt with a tie and sports shoes. For a female doctor a name tag, short haircut, trousers and sports shoes ranked highly. Long hair, earrings, and sandals scored low for a male physician, while mini-dress, shorts and tight clothes scored low for a female physician. CONCLUSION: About half of patients still prefer the doctor to be dressed in a white coat. Patients prefer a more formal dressing for male and female physicians in family medicine clinics. Most of the patients claimed that the attire of the physician had no influence on their choice of family physician.      

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.     

贵州省村卫生室人力资源现况调查分析

目的了解贵州省村卫生室人力资源现状,为合理配置农村卫生人力资源提供参考。方法对贵州省村卫生室的选择采用多阶段分层整群随机抽样调查的方法;数据的收集由县（市、区）卫生局组织被抽中的村卫生室填报调查问卷。结果贵州省村卫生室卫生技术人员数量不足;卫生技术人员年龄结构不合理;性别比例失调,医护比例不合理,护士所占比例小,药师（士）所占比例小;高学历、高职称人员不足;村卫生室及卫生技术人员分布不平衡。结论增加卫生技术人员数量;合理调整卫生技术人员内部结构;合理分配卫生技术人员。     

Salient issues in choosing a new doctor

In this paper we argue that selecting a new doctor is one of three phases in the overall, iterative process of patient-practitioner encounters. Further, we assume that the factors which impact on individuals' decisions to seek and to use health services should also influence their choices of new physicians. Accordingly, we assess the extent to which traditional predictors of health services utilization (i.e. the predisposing, enabling, illness-morbidity, and consumer satisfaction characteristics) are directly associated with individuals' identifications of the important factors in their choices of new doctors. Discriminant function and multivariate contingency analyses of data from a national survey of 1530 adults reveal five major patterns of typical behavior. First, individuals with lower socioeconomic status and poorer access to medical care choose the psychosocial aspects of the patient-practitioner relationship as most important in selecting a new doctors. Second, individuals with lower socioeconomic status but better access to medical care focus on the cost of an office visit. Third, individuals with higher socioeconomic status but poorer access to medical care focus on the hospital affiliation of the physician. Fourth, individuals with higher socioeconomic status and better access to medical care focus on the physician's affiliation with a medical group. Fifth, individuals with higher socioeconomic status and moderate access to medical care focus on the recommendations of friends. Finally, we discuss the implications of these behavioral patterns for models of health services utilization, consumer satisfaction, the sick role, and medical school curricula and recruitment policies.     

Slander suit filed

A doctor in Tennessee has filed slander charges against two colleagues, alleging that they spread false rumors that she had AIDS to cripple her medical practice. Dr. Susan Johnson filed the claim that Dr. Susan Lowry and Dr. Anna Hopla tried to damage her reputation for refusing to take some of their patients. According to the claim, the doctors knowingly spread false stories about her to pharmacists, who then told other employees and customers.     

Positive Attitude toward Healthy Eating Predicts Higher Diet Quality at All Cost Levels of Supermarkets

Shopping at low-cost supermarkets has been associated with higher obesity rates. This study examined whether attitudes toward healthy eating are independently associated with diet quality among shoppers at low-cost, medium-cost, and high-cost supermarkets. Data on socioeconomic status (SES), attitudes toward healthy eating, and supermarket choice were collected using a telephone survey of a representative sample of adult residents of King County, WA. Dietary intake data were based on a food frequency questionnaire. Thirteen supermarket chains were stratified into three categories: low, medium, and high cost, based on a market basket of 100 commonly eaten foods. Diet-quality measures were energy density, mean adequacy ratio, and total servings of fruits and vegetables. The analytical sample consisted of 963 adults. Multivariable regressions with robust standard error examined relations between diet quality, supermarket type, attitudes, and SES. Shopping at higher-cost supermarkets was associated with higher-quality diets. These associations persisted after adjusting for SES, but were eliminated after taking attitudinal measures into account. Supermarket shoppers with positive attitudes toward healthy eating had equally higher-quality diets, even if they shopped at low-, medium-, or high-cost supermarkets, independent of SES and other covariates. These findings imply that shopping at low-cost supermarkets does not prevent consumers from having high-quality diets, as long as they attach importance to good nutrition. Promoting nutrition-education strategies among supermarkets, particularly those catering to low-income groups, can help to improve diet quality.     

十堰市手术室医护人员对X线辐射防护认知情况调查

目的了解十堰市手术室医护人员对X线辐射防护知识的认知、防护意识及自身防护行为的状况,为开展辐射防护工作提供参考资料。方法对3所医疗机构249名手术室医护人员采用自行设计的X线辐射防护认知、防护意识和防护行为问卷进行调查评估,并对医生组和护士组的问卷结果进行简要的统计学分析。结果医护人员对X线辐射防护基本知识知晓率低,医生组掌握情况均优于护士组,但仅部分知识点存在差异性（P〈0．05）。91．57％的医护人员均担心工作中受到辐射伤害并认为“防护培训”是有必要的。护士组对这方面的担心和需求较医生组更为强烈（P〈0．05）。249名医护人员仅8．84％的人员“行X线检查时曾经向检查技师要求过对不照射部位进行防护”。249名医护人员均一致认可“非必要时妊娠妇女不应该行下腹部X线照射”,略超过半数的医护人员在“胸部X线照射时,选择X线透视还是胸部摄片”和“胸部X线摄片是否可以作为儿童常规体检项目”2项中有正确的认识,但医生组识别能力优于护士组（P〈0．05）。结论该市手术室医护人员对X线辐射防护意识高,对实际工作中的放射防护案例有一定的辨别能力,但辐射防护相关知识薄弱,自身采取的防护行为差,相关部门应加强对手术室医护人员薄弱环节的培训。     

Little communication between company doctors and private physicians with respect to hindrances to return to work after prolonged absence from work because of low back pain]

OBJECTIVE: To determine occurrence and reasons of contact between company doctors and treating physicians with respect to patients absent with low back pain for three months. DESIGN: Prospective cohort study. METHOD: A cohort of employees who were absent for 3 months with back pain were selected according to defined criteria. A questionnaire about medical status and communication with treating physicians was sent to their company doctors. RESULTS: The company doctors of 300 of 467 employees participated. In 19% of the employees the company doctor contacted the curative sector (56 contacts had taken place, 14 were planned). The contact consisted almost always of exchange of information and less frequently of co-operation towards a mutual policy. In almost 50% of the cases the company doctors regarded the clinical waiting period, length of treatment and opinion of the curative sector as disincentives to return to work. Psychosocial factors such as psychological problems, work-related motivation, private problems and a conflict between employer and employee all were mentioned less frequently. Although contacts were slightly more frequent when psychosocial factors, treatment or opinion of the curative sector inhibited return to work, only disincentives such as work-related motivation, motivation to return to work and the waiting period were significantly associated with the contact frequency. CONCLUSION: The communication rate between company doctors and the curative sector in employees long absent with back pain is low. Communication consists of exchange of information rather than co-operation towards a mutual policy. Although according to many company doctors the curative sector plays an inhibitive role in return to work, they do not communicate accordingly.     

深圳市中小学校校医和保健老师队伍现况调查

目的了解深圳市中小学校校医(保健老师)队伍现状,为加强校医(保健教师)队伍建设,提高其专业素质技能提供理论依据。方法采用调查表,对深圳市546所中小学校的607名校医(保健老师)进行调查。结果深圳中小学生与校医(保健老师)的人数配备比例为424∶1;校医(保健老师)以女性为主,共534人(88.00%);平均年龄(37.40±9.67)岁;以大专学历为主,共292人(48.11%);具有医学职称的有236人(38.90%);平均工作年限6.45年。结论深圳市中小学校校医(保健老师)存在配置不足、专业职称构成参差不齐和职龄较短等问题,应加强对校医(保健老师)的管理,稳定校医队伍,进一步做好我市学校卫生工作。     

西部某省乡村基本药物制度实施情况研究

目的:研究基本药物制度在西部某省村级医疗机构的实施情况。方法:对西部某省乡村医生和管理者进行个人深入访谈,了解基本药物零差率补助、一般诊疗费补偿及基本药物考核机制的实施现状及其对乡村医生用药行为的影响。结果:该调查地区基本药物干预并未达到预期目标:乡村医生的用药行为没有明显变化;一般诊疗费制度未能实现合理补偿;乡村医生管理者对乡村医生的考核流于形式。结论与建议:该地区应充分考虑乡村医生的特殊性,保证干预的可行性、有效性和可持续性。