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Biomedical subjects

A R Tarlov

Publications and source records attributed to A R Tarlov.

15 recordsLinked to original sources
PubMed1992

Differences in the mix of patients among medical specialties and systems of care. Results from the medical outcomes study.

OBJECTIVE: To determine differences in the mix of patients among medical specialties and among organizational systems of care. STUDY DESIGN: Cross-sectional analysis of 20,158 adults (greater than or equal to 18 years of age) who visited providers' offices during 9-day screening periods in 1986. Patient and physician information was obtained by self-administered, standardized questionnaires. SETTING: Offices of 349 physicians practicing family medicine, internal medicine, endocrinology, and cardiology within health maintenance organizations, large multispecialty groups, and solo or small single-specialty group practices in three major US cities. OUTCOME MEASURES: Demographic characteristics, prevalence of chronic disease, disease-specific severity of illness, and functional status and well-being. RESULTS: Among patients with selected physician-reported chronic illnesses (diabetes, hypertension, recent myocardial infarction, or congestive heart failure), increasing levels of severity were associated with decreasing levels of functional status and well-being and with increased hospitalizations, more physician visits, and higher numbers of prescription drugs. Compared with patients of general internists, patients of cardiologists were older (56 vs 47 years, P less than .01), had worse functional status and well-being scores (P less than .01), and carried more chronic diagnoses (mean 1.32 vs 1.02, P less than .01); patients of family practitioners were younger (40 vs 47 years, P less than .01) and more functional (P less than .01), carried fewer chronic diagnoses (0.70 vs 1.02, P less than .01), and (among diabetic patients only) had lower disease-specific severity scores (2.06 vs 2.30 on a five-point scale, P less than .01). Compared with patients in health maintenance organizations, patients visiting solo practitioners under fee-for-service payment were older (50 vs 45 years, P less than .01) and sicker (had worse physical functioning) and had a higher mean number of chronic diagnoses (1.10 vs 0.93, P less than .01). CONCLUSION: Patient mix is related to utilization and differs significantly across medical specialties and systems of care. These differences must be taken into account when interpreting variations in utilization and outcomes across specialties and systems, and when considering alternative policies for payment.

Activities of Daily Living↗
PubMed1992

Variations in resource utilization among medical specialties and systems of care. Results from the medical outcomes study.

OBJECTIVE: To examine whether specialty and system of care exert independent effects on resource utilization. STUDY DESIGN: Cross-sectional analysis of just over 20,000 patients (greater than or equal to 18 years of age) who visited providers' offices during 9-day periods in 1986. Patient- and physician-provided information was obtained by self-administered questionnaires. SETTING: Offices of 349 physicians practicing family medicine, internal medicine, endocrinology, and cardiology within health maintenance organizations, large multispecialty groups, and solo practices or small single-specialty group practices in three major US cities. OUTCOME MEASURES: Indicators of the intensity of resource utilization were examined among four medical specialties (family practice, general internal medicine, cardiology, and endocrinology) and five systems of care (health maintenance organization, multispecialty group-fee-for-service, multispecialty group-prepaid; solo practice and single-specialty group-fee-for-service, and solo practice and single-specialty group-prepaid) before and after controlling for the mix of patients seen in these offices. The indicators of resource utilization were hospitalizations, annual office visits, prescription drugs, and common tests and procedures, with rates estimated on both a per-visit and per-year basis. RESULTS: Variation in patient mix was a major determinant of the large variations in resource use. However, increased utilization was also independently related to specialty (cardiology and endocrinology), fee-for-service payment plan, and solo and single-specialty group practice arrangements. After adjusting for patient mix, solo practice/single-specialty groups-fee-for-service had 41% more hospitalizations than health maintenance organizations. General internists had utilization rates somewhat greater than family physicians on some indicators. CONCLUSION: Although variations in patient mix should be a major determinant of variations in resource use, the independent effects of specialty training, payment system, and practice organization on utilization rates need further explication. The 2- and 4-year outcomes now being analyzed will provide information critical to interpretation of the variations reported herein.

Adult↗
PubMed1992

The coming influence of a social sciences perspective on medical education.

Medical education will change from within in response to continued advances in biological sciences and technology, but changes that are occurring outside the natural sciences can have greater impact, especially (1) the reconceptualization of the meaning of health, (2) the increase in the number and range of different health improvement strategies, (3) the growing awareness of the paradox of the relatively low health status of the U.S. population and high per-capita and national health care expenditures, and (4) shifts in the causes of illness and death. These changes make it necessary for medical students to be given a foundation in both the natural and the social sciences, for most ill health has causal roots in both the social and physical environment, even though it is not understood how some of these outside influences are translated into disease or biologic derangements that lead to disease. Consideration should be given to changes in medical education that include (1) interpreting the sociology as well as the biology of health, (2) expanding the horizons of medicine to incorporate health improvement as well as disease cure, (3) training for population-based health care at the community level, and (4) learning to assess medical outcomes with more than biometric measures to include measurements of functioning and well-being. The author presents in detail a health input-output model to show the complex interrelationships of socio-ecologic (i.e., outside) factors and the individual's genetic-biologic makeup (inside factors) that determine the individual's state of health.

Cause of Death↗
PubMed1979

Internal medicine.

Explore the source record for details and available documents.

Education, Medical↗
PubMed1979

A national study of internal medicine and its specialties: I. An overview of the practice of internal medicine.

A nationwide study of 24 medical and surgical specialties has been conducted by the University of Southern California School of Medicine, Division of Research in Medical Education. This article is the first in a series reporting findings for general internal medicine and 10 subspecialties of internal medicine. Populations for these 11 specialties are defined and enumerated, and the specialties are compared in terms of demographic and geographic distribution. Practice comparisons are presented based on characteristics such as workload, allocation of professional time, location of encounters with patients, distribution of primary problem diagnoses, and projections of annual patient encounters. Forthcoming specialty-specific articles will present highly detailed information for general internal medicine and for the subspecialties of cardiology, gastroenterology, pulmonary disease, allergy, hematology, endocrinology, nephrology, medical oncology, rheumatology, and infectious diseases.

California↗
PubMed1979

A national study of internal medicine and its specialties: II. Primary care in internal medicine.

A nationwide study of practitioners in 24 medical and surgical specialties was conducted by the University of Southern California School of Medicine, Division of Research in Medical Education. In this second report of a series presenting findings for internal medicine, general internal medicine and 10 subspecialties of internal medicine are compared using a care classification scheme designed for the study. On the basis of characteristics of the individual patient encounter, this care classification scheme distinguishes several dimensions associated with the concept of primary care. Five empirically derived types of care rather than a simple "primary" or "non-primary" dichotomy are described, and the distributions of each type for the 11 subspecialties examined are noted. Types of care (according to the care classification) are examined by the time per patient, the complexity of physician services, the severity and chronicity of problems, and the degree of specialization associated with providing different types of care. Estimates of the number of annual encounters, and the number of annual encounters for three of the five types of care, with the proportion of each accounted for by each subspecialty, are given.

Consultants↗
PubMed1979

National study of internal medicine manpower: III. Subspecialty fellowship training 1976-1977.

Questionnaire II of the National Study of Internal Medicine Manpower was directed to all of the 1502 subspecialty training programs in the United States and Puerto Rico. The overall response rate was 86%. For the years 1972-1973 through 1976-1977 the number of fellows in subspecialty training grew at an average rate of 10.6% per year, or one and one-half times greater than the growth rate of 7.2% in the number of first-year residents in training for the same time period. In 1976-1977 there were 5826 fellows in subspecialty fellowship training, of whom 26% were foreign medical graduates. Stipends for subspecialty fellows in 1976-1977 amounted to $90 million, 40% of which was derived from direct federal funds and 33% from hospital revenues. Most of the subspecialty fellowship programs were in large teaching hospitals, which are closely affiliated with the nation's medical schools. The 1976-1977 professional activities of former subspecialty trainees who had finished their training between 1972 and 1976 were distributed roughly in thirds between research-teaching, teaching-practice, and practice. We discuss public policy implications of the data.

Education, Medical↗
PubMed1979

National study of internal medicine manpower: IV. Residency and fellowship training 1977-1978 and 1978-1979.

The National Study of Internal Medicine Manpower gathered data on the number of residents in training in internal medicine and the number of fellows in subspecialty training, for 1977-1978 and for 1978-1979. In the latter period, there were 16720 residents in all years of training. The 7.2% average annual increase in the number of first-year residents during the earlier half of the 1970s slowed in 1977-1978 and 1978-1979 to 4.6% and 4.2%, respectively, reflecting a similar decline in the number of medical school graduates. The most important finding of the study is that the steep rise (10.6% per year) in the number of subspecialty fellowship trainees characteristic of the years 1972-1973 through 1976-1977 has abated. The number of fellows in subspecialty training has remained essentially constant in the past 2 years. Thus, although the number of residents continued to increase and the number of fellows remained constant, the number (and percentage) of internists in training who intend to practice general internal medicine rose.

Career Choice↗
PubMed1979

University center and community hospital: problems in integration.

This study of health care in Chicago and its suburbs deals with a dilemma faced by many university hospitals located in our nation's metropolitan areas. Because of a massive displacement of population from the city to its suburban ring, some of the major medical centers in Chicago's inner zone have experienced a leveling-off of inpatient admissions. In contrast, outer zone and suburban community hospitals are in need of referral sources with specialized personnel and equipment to accommodate growing admissions. This imbalance would be corrected in a regional network based on an exchange of clients and services. A case study of the University of Chicago Medical Center highlights the tensions, strains, and resistances which inhibit the development of such a system and thus raises questions about the role of the research and teaching hospital in regional health care planning.

Chicago↗
PubMed1978

National study of internal medicine manpower: II. A typology of residency training programs in internal medicine.

This second paper of the National Study of Internal Medicine Manpower describes the differing environments of residency training programs. Using previous studies as prototypes, the authors apply factor analysis to data from questionnaires returned by residency training directors and residents to illustrate the myriad interrelations within training programs. The most important result of this study is the demonstration that the largest residency programs have the most subspecialty programs, and their residents are more likely to pursue subspecialty fellowships after completing their third residency year. However, preliminary findings show no associations between the typology (typologic categories of residencies and their trainees) used and desired practice locations in states having few physicians relative to the population or in states with fewer urban inhabitants. The typology also does not predict the future practice aspirations of residents who are more likely to care for the poor or minority populations. A separate set of factors, possibly unrelated to training environments, will help to predict such career outcomes. Further specification of these factors will be the subject of a later paper in this series.

Environment↗
PubMed1976

The exchange of erythrocyte membrane phospholipids with rat liver extracts in vitro.

Intact rat or human erythrocytes and their isolated (ghost) membranes were incubated with the high speed supernatant fraction of homogenates derived from 32P-labeled rat livers. Phospholipid molecules were transferred between the red cell membranes and the liver extracts, as reflected by the convergence of their specific radioactivities with time. Whereas ghosts usually approached isotopic equilibrium with the liver supernatant fraction during a few hours of incubation at 37 degrees C, the exchange of phospholipids by intact cells was no more than one-half, even after 18 hr. Phosphatidylcholine, phosphatidylethanolamine, phosphatidylserine and sphingomyelin were all exchanged in both intact cells and ghosts, albeit to different extents. (A control experiment, incubating 32P-labeled rat erythrocytes or ghosts with unlabeled rat liver extracts, also demonstrated the exchange of all four major phospholipids.) These data may signify that the phospholipids on the cytoplasmic side of the membrane of intact erythrocytes do not exchange with the phospholipids in exogenous liver extracts. If so, all four major phospholipid classes would appear to be present to some extent at both membrane surfaces. The first inference is in agreement with several other studies on this membrane, while the second inference is not.

Animals↗