Biomedical subjects

J L Hargraves

Publications and source records attributed to J L Hargraves.

At least 19 recordsLinked to original sources

PubMed2001

Minority physicians' experiences obtaining referrals to specialists and hospital admissions.

CONTEXT: Over the past 15 years, policy makers, healthcare providers, and researchers have focused their attention on understanding and reducing ethnic disparities in access to healthcare. Efforts to understand and reduce these disparities in access are driven by the wealth of studies that document significant differences in the health of ethnic minority groups in the United States. OBJECTIVE: To assess differences in access to medical care from African American, Hispanic, and white physicians' perspectives. DESIGN: Using the Community Tracking Study Physician Survey, a nationally representative survey of US physicians, this study assesses physicians' abilities to obtain medically necessary services for their patients. Physicians were asked how often they could arrange referrals to specialists and inpatient admissions for their patients. RESULTS: Controlling for physician characteristics (eg, providing charity care, participation in managed care, Medicaid, and Medicare) and community characteristics (eg, average managed care participation, supply of hospital beds and specialists per capita) reduces the magnitude of differences between white and ethnic minority physicians. Nevertheless, after controlling for a wide range of practice and environmental characteristics, African American physicians were more likely to report problems obtaining hospital admissions, and Hispanic physicians were more likely to report problems obtaining referrals to specialists, compared with white physicians. CONCLUSIONS: Disparities in ethnic minority physicians' abilities to get medical services for their patients exist. This study corroborates that ethnic disparities are not limited to gaining access to primary health services (eg, having a doctor visit or a usual source of medical care) but extend into the healthcare delivery system itself (eg, getting a referral or hospital admission).

Black or African American↗

PubMed2001

Adjusting for patient characteristics when analyzing reports from patients about hospital care.

OBJECTIVES: To determine which patient characteristics are associated with reports and ratings of hospital care, and to evaluate how adjusting reports and ratings for hospital differences in such variables affects comparisons among hospitals. DESIGN: A telephone survey of a sample of patients hospitalized in 22 hospitals in a single city and a statewide mail survey of hospitalized patients. MEASURES: The surveys assessed: respect for patients' preferences, coordination of care, information exchange between patient and providers, physical care, emotional support, involvement of family and friends, and transition and continuity. The surveys also asked patients to rate their doctors, nurses, and other hospital staff. RESULTS: The variables with the strongest and most consistent associations with patient-reported problems were age and reported health status. Patient gender and education level also sometimes predicted reports and/or ratings. Models including these variables explained only between 3% and 8% of the variation in reports and ratings. CONCLUSIONS: The impact of adjusting for patient characteristics on hospital rankings was small, although a larger impact would be expected when comparing hospitals with more variability in types of patients. Nevertheless, we recommend adjusting at least for the most important predictors, such as age and health status. Such adjustment helps alleviate concerns about bias. It also may be useful to present data for certain groups of patients (ie, medical, surgical, obstetric) separately to facilitate interpretation and quality improvement efforts.

Age Factors↗

PubMed2001

Managed care, professional autonomy, and income: effects on physician career satisfaction.

CONTEXT: Career satisfaction among physicians is a topic of importance to physicians in practice, physicians in training, health system administrators, physician organization executives, and consumers. The level of career satisfaction derived by physicians from their work is a basic yet essential element in the functioning of the health care system. OBJECTIVE: To examine the degree to which professional autonomy, compensation, and managed care are determinants of career satisfaction among physicians. DESIGN: Cross-sectional analysis using data from 1996-97 Community Tracking Study physician telephone survey. SETTING AND PARTICIPANTS: A nationally representative sample of 12,385 direct patient care physicians. The survey response rate was 65%. MAIN OUTCOME MEASURE: Overall career satisfaction among U.S. physicians. RESULTS: Bivariate results show that physicians with low managed care revenues are significantly more likely to be "very satisfied" than are physicians with high managed care revenue (P < .05), and that physicians with low managed care revenues are significantly more likely to report higher levels of clinical freedom than are physicians with high managed care revenue (P < .05). Multivariate analyses demonstrate that, among our measures, traditional core professional values and autonomy are the most important determinants of career satisfaction after controlling for all other factors. Relative income is also an important independent predictor. Multiple dimensions of professional autonomy hold up as strong, independent predictors of career satisfaction, while the effect of managed care does not. Managed care appears to exert its effect on satisfaction through its impact on professional autonomy, not through income reduction. CONCLUSIONS: Our results suggest that when managed care (or other influences) erode professional autonomy, the result is a highly negative impact on physician career satisfaction.

Attitude of Health Personnel↗

PubMed2001

Race, ethnicity and preventive services: no gains for Hispanics.

Three years ago, the Clinton administration initiated multiple efforts to identify and eliminate health disparities among various populations, including ethnic minority groups. Recent findings from the Community Tracking Study Household Survey show that between 1997 and 1999 there was an increase in the percentage of white and African American persons receiving preventive care-such as mammography screening among women and physicians counseling cigarette smokers to quit-but that there was no such increase in preventive measures for Hispanics. If policy makers want to remove disparities in health status based on race and ethnicity, they need to promote preventive care for minorities and monitor progress by regularly measuring preventive care indicators. This Issue Brief focuses on change in key preventive care indicators between 1997 and 1999.

Black or African American↗

PubMed2001

Racial and ethnic differences in access to medical care in managed care plans.

OBJECTIVE: To examine the extent to which access differences between racial/ethnic minorities and whites in managed care plans are greater than such differences in other types of health plans. DATA SOURCE: A nationally representative sample of 4,811 African American, 3,379 Hispanic, and 33,737 white nonelderly persons with public or private health insurance. STUDY DESIGN/DATA COLLECTION: A cross-sectional survey of households was conducted during 1996 and 1997. Commonly used measures of access to and utilization of medical care were constructed for individuals: (1) percentage of visits with a usual provider, (2) percentage with a regular provider, (3) visit with a physician in the past year, (4) hospital ER use, (5) last visit was to a specialist. PRINCIPAL FINDINGS: Fewer than 74 percent of Hispanics and African Americans had a regular provider compared to more than 78 percent of white Americans. Hispanics were least likely to have had their last doctor visit with a specialist (22 percent) compared to African Americans (26 percent) and whites (28 percent). Differences between ethnic/racial minorities and whites in managed care plans are similar to differences observed in non-managed care plans. Americans of all racial and ethnic backgrounds in managed care plans with gatekeeping are more likely to have a usual source of care, a regular provider, and lower use of specialists compared to persons in plans without gatekeeping. CONCLUSION: Although greater access to primary care was shown among African Americans and Hispanics in managed care plans, the extent of the disparities between racial/ethnic minorities and whites in managed care is similar to disparities in other types of health plans.

Black or African American↗

PubMed2001

Managed care in the doctor's office: has the revolution stalled?

OBJECTIVE: To assess trends in the involvement of US physicians with managed care. STUDY DESIGN: Comparison of data from 2 consecutive rounds of a national survey. METHODS: Longitudinal data were obtained from the 1996/1997 (n = 12,528) and the 1998/1999 (n = 12,304) rounds of the Community Tracking Study (CTS) Physician Survey, a large, ongoing nationally representative survey of US physicians involved in patient care. Indicators used to assess involvement with managed care included global measures of managed care participation, risk contracting, exposure to financial incentives, and impact of care management tools. Changes in these measures over the 2 study periods are reported. Analyses were conducted for all physicians, as well as for primary care physicians (PCPs) and specialists separately. RESULTS: The percentage of practice revenue derived from managed care increased only modestly over the study period (from 42% to 45%). Mean numbers of managed care contracts per physician increased minimally (from 12 to 13). Trends in acceptance of capitation and exposure to financial incentives remained stable over the study period. Among PCPs, employment in staff/group health maintenance organizations declined slightly, whereas gatekeeping function increased modestly. Among care management tools, only treatment guidelines had a significantly increased impact on medical practice, primarily among PCPs (from 46% to 52%; P < .001). CONCLUSIONS: Many aspects of managed care leveled off between 1996 and 1999 in ways not accurately reflected by plan enrollment patterns. This "flattening of the curve" trend appears to hold generally across multiple measures. A stalling of the managed care "revolution," if it is sustained, may portend future escalation in healthcare costs.

Capitation Fee↗

PubMed2001

Patient-centered processes of care and long-term outcomes of myocardial infarction.

OBJECTIVE: To examine whether patients' experiences with nontechnical aspects of care such as patient education and discharge planning are associated with long-term outcomes. DESIGN: Observational cohort study. SETTING: Twenty-three New Hampshire hospitals during 1996 and 1997. PARTICIPANTS: Acute myocardial infarction (AMI) patients (N=2,272) enrolled prior to discharge. MEASUREMENTS: Surveys asking about problems with care and health were mailed to patients 1, 3, and 12 months after discharge. Patients were stratified into "worse" or "better" care groups on the basis of their hospital care problem score. Outcomes included self-reported overall health, physical health, mental health, chest pain, and shortness of breath. Other clinical measures were obtained from hospital discharge abstracts. MAIN RESULTS: The 1-, 3-, and 12-month surveys were returned by 1,346 (59.2%), 1,046 (46%), and 964 (42.4%) enrolled patients, respectively. The primary analytic cohort consisted of the 762 patients who completed both the 1- and 12-month surveys. After adjustment for postdischarge health status and other clinical factors, patients experiencing worse hospital care had lower ratings of overall health (48.4 vs 52.5 on 100-point scale; P=.02) and physical health (59.7 vs 68.4; P <.001), and were more likely to have chest pain (odds ratio [OR], 1.6; confidence interval [CI], 1.0 to 2.4; P=.04) 12 months after their AMI than other patients. However, differences in reports of chest pain were reduced if patients reporting worse hospital care had better experiences with subsequent ambulatory care. CONCLUSIONS: Patients' experiences with nontechnical processes of AMI hospital care are associated with long-term outcomes; however the association between a negative hospital experience and subsequent chest pain may be offset by more positive outpatient experiences.

Aged↗

PubMed2000

Health care perceptions and experiences.

Survey results suggest that most people have negative attitudes about health maintenance organizations (HMOs), even members of HMOs who are satisfied with their own care. This Issue Brief illustrates how perceptions of HMOs may color peoples' ratings of their own health care. According to new findings from the Center for Studying Health System Change (HSC), differences in ratings between privately insured people in HMOs and other types of insurance are in part attributable to peoples' perceptions of the type of health plan they are in, not the actual type of plan they are covered by. These results, which have implications for efforts to regulate managed care, suggest that reliance on attitudinal surveys alone are likely to provide a somewhat distorted and more negative view of care in HMOs, thereby exaggerating differences in how people assess the care they receive.

Consumer Behavior↗

PubMed2000

Patients concerned about insurer influences.

This Data Bulletin presents findings from two rounds of the Household Survey, a nationally representative telephone survey of the civilian, noninstitutionalized population conducted as part of the Community Tracking Study. The 1996-1997 survey includes nearly 33,0000 families and 60,000 individuals, while the 1998-1999 survey includes about 32,000 families and 59,000 individuals. This analysis does not include people who lack health insurance. All comparisons and differences described are statistically significant as the p<.05 level.

Demography↗

PubMed1999

Making survey results easy to report to consumers: how reporting needs guided survey design in CAHPS. Consumer Assessment of Health Plans Study.

OBJECTIVES: CAHPS is designed to report information about health care quality from the consumer perspective. Enrollees are surveyed about their experiences with their health plan and medical care, and results are reported to other consumers choosing among health plans. Based on survey instruments designed to elicit reliable and valid information about health plan experiences from plan enrollees, the aim of the CAHPS team was to design a series of reporting products that present survey results so that consumers find the information understandable, meaningful, and useful in choosing among health plans. METHODS: Design of the survey instruments and reporting products were closely linked. The approach to reporting was based on previous research on consumers' information interests and needs in evaluating and choosing among plans. Cognitive tests were conducted with consumers to get their reactions to mock-ups of various approaches to reporting CAHPS survey results. RESULTS: Findings from previous research and cognitive testing, together with feedback from various experts and the public, were used to modify the survey questions, response options, and reporting formats to make it easier for consumers to understand and use reports. Changes included dropping topics of less interest to consumers, changing question wordings that were hard to understand, minimizing the number of different response categories, and revising questions to make them easier to group together for purposes of reporting. CONCLUSIONS: The CAHPS focus on reporting results to consumers presented an unusual challenge for survey design, requiring close coordination between instrument design and report development to produce a survey and reporting kit that serves consumers' information needs.

Adult↗

PubMed1996

The Ambulatory Care Medical Audit Demonstration Project. Research design.

The authors describe the design of and statistical analyses involved in the Ambulatory Care Medical Audit Demonstration Project, which tested feasibility, cost, and effectiveness of cycles that met quality assurance requirements in eight pediatric and eight general medicine group practices at four teaching hospitals and six health centers. The authors used a concurrent crossover design using randomized cycles of quality assurance so that a practice was a control site for one guideline and an experimental site for another. For 12 months before and 18 months during and after quality assurance experimental interventions, the authors measured practitioner conformance to review criteria for patient-care guidelines believed to improve outcomes, including four internal medicine patient-care guidelines (ie, follow-up of low hematocrit, cancer screening for women, follow-up of high serum glucose, and monitoring of patients treated with digoxin) and four pediatric patient-care guidelines (ie, follow-up of positive urine cultures, screening for disease and immunizing infants, management of acute gastroenteritis, and management of acute ear infection). The authors distinguished review criteria whose performance depended on personal efforts of practitioners from those that concerned performance dependent on the practice's system for reporting test results and calling patients to return for care.

Adult↗

PubMed1996

Leadership for quality improvement in group practices.

OBJECTIVES: The authors studied influence of physician leaders on their colleagues' performance using data from a randomized, controlled trial of quality assurance interventions in 16 primary care practices. METHODS: The authors examined whether leaders performed better than their colleagues and looked for evidence of leaders' influence on their colleagues before intervention. As behavioral indicators of each leader's influence for improvement in response to quality assurance interventions, the authors (1) change in the leader's performance score and (2) an index of leader commitment derived from the leader's participation in quality assurance interventions; these indicators were used as covariates in a comparison in experimental practice sites of leaders' and colleagues' mean case performance scores before and after intervention. RESULTS: Leaders did not outscore their colleagues or influence their colleagues' performance scores before intervention. In response to quality assurance interventions, a leader's change in performance score significantly improved colleagues' score if the leader improved. A positive leader commitment index predicted colleagues' improvement independently of the leader change score. CONCLUSIONS: As hypothesized, physician leaders, by the example of their behavior, influenced colleagues' performance. However, leaders exerted their influence only after receiving external stimulation for quality improvement.

Adult↗

PubMed1996

Consistency in performance among primary care practitioners.

OBJECTIVES: The authors studied the consistency of performance of individual physicians to evaluate the identification of outlier practitioners as a strategy for improving patient care. METHODS: The authors used a data base containing information on 430 practitioners caring for 6,090 patients in 16 group practices. The authors analyzed inter- and intraphysician differences in performance on the basis of review criteria for 8 patient care guidelines. These criteria allowed for a variety of acceptable clinical strategies, incorporated decision tree logic, and included input from participating practitioners. The authors took steps to maximize validity and controlled for potentially confounding characteristics of patients and practitioners. The authors identified outliers, evaluated the significance of differences between outliers and nonoutliers, and studied variations in performance across cases and guidelines in conformance with guidelines. RESULTS: The authors identified a few statistically significant outliers. Correlations for performance across cases seen by a given physician were low. The highest positive correlation for performance between any pair of guidelines was 0.32. CONCLUSIONS: The performance of a given practitioner is highly variable from patient to patient and from guideline to guideline. Thus, strategies focusing solely on substandard outliers will miss opportunities to improve performance.

Adult↗

PubMed1996

Practice characteristics and performance of primary care practitioners.

OBJECTIVES: The authors examined organizational characteristics of 16 primary care group practices to determine their influence on quality or quality improvement. METHODS: The authors used a data base compiled during a randomized, controlled trial of quality assurance interventions consisting of measures of guideline-related performance for 630 practitioners. The authors distinguished performance under practitioners' control from performance determined partly by systems of care within each practice. The authors conducted analyses for all criteria (practitioner-controlled and system-dependent criteria) before and after quality assurance interventions using analysis of variance models with adjustments in performance scores for patient and practitioner characteristics. Specifically, the authors used as covariates the full-time versus part-time status of practitioners, whether practices were in hospitals or in health centers, and for practices within health centers, the effect of size of practice in terms of the average number of practitioners on staff during a time period. RESULTS: Full-time practitioners performed similarly before interventions but improved more after interventions overall and for practitioner-controlled criteria than did part-time practitioners. Health center practitioners performed better than did those in hospitals for system-dependent criteria before intervention. For system-dependent criteria, larger health centers performed better before interventions and improved more than did smaller health centers. CONCLUSIONS: Organizational characteristics including practice size and location (hospital-based or not) and full- or part-time status of practitioners should be considered in measuring quality and planning quality improvements, particularly in relation to care that is predominantly under system versus practitioner control.

Analysis of Variance↗

PubMed1996

Are differences in practitioners' acceptance of a quality assurance intervention related to their performance?

OBJECTIVES: The authors assessed whether practitioners' attitudes toward quality assurance after the intervention are related to their performance before and after the intervention. METHODS: A data base was compiled including a survey of practitioners participating in a randomized, controlled trial of externally coordinated quality assurance in 16 practices. The survey evaluated whether practitioners noticed changes in their performance or improvements in care as a result of the external review and whether they preferred internal review or external review that promoted practitioner input and a collegial atmosphere. RESULTS: Practitioners' differences in accepting quality interventions related to quality improvement. A minority of practitioners believed that they had changed their practice or that care had improved in response to quality assurance; these options were not associated with actual performance. Many practitioners approved of internal quality assurance; however, most preferred external review. A few totally disagreed with quality assurance. Greater approval of externally coordinated review was marginally associated with worse baseline performance and significantly associated with better postintervention performance. This relationship was reversed for internal review. CONCLUSIONS: It is commonly perceived that practitioners resent external quality assurance. Our results show the opposite. These findings predict practitioner acceptance for a mode of quality assurance now widely used.

Ambulatory Care↗

PubMed1996

Issues of variability and bias affecting multisite measurement of quality of care.

OBJECTIVES: Using data from a randomized trial to improve the quality of ambulatory care, the authors quantify the various sources of variability and bias that affect measures of quality of care and suggest experimental designs and analyses that reduce both bias and variability. METHODS: There is a growing desire among health care researchers and government agencies to profile and compare practitioner performance. Such efforts are complicated by extreme inherent variability in most measures of quality of care, as well as potential biases introduced by "experiments," where patients cannot act as the unit of randomization. When the authors measured practitioner performance for eight patient-care guidelines, they found little association of level of performance across guidelines. Thus, the authors considered performance for each guideline separately, also taking into account variability between patients, practitioners, and practice conditions. RESULTS: Randomization can reduce bias in large studies but should be supplemented by multivariate models. A preintervention and postintervention design can reduce variability, but much of the variability that remains is because of unmeasured patient/error variance. CONCLUSIONS: Incorporation of these concepts into future studies using quality measurements will help researchers design smaller and more sensitive trials to draw more accurate and precise conclusions.

Adult↗

PubMed1996

Quality improvement among primary care practitioners: an overall appraisal of results of the Ambulatory Care Medical Audit Demonstration Project.

OBJECTIVES: The authors appraised the overall conclusions of a randomized, controlled trial of quality assurance in 16 primary care group practices, addressing the relevance of findings to health maintenance organizations in the 1990s. METHODS: The framework was the analogy of opening the "black box" of quality assurance interventions to examine circumstances in which interventions worked. RESULTS: External pressures for quality improvement were weak during the study and knowledge of continuous quality improvement principles lacking. Correspondingly, within study practices, pre-existing mechanisms lacked the rigorous data-driven approach and system focus of the quality assurance cycles conducted. Additional barriers to demonstrating an effect of quality assurance included pre-existing good performance, high variability in performance measurements, and lack of time within the study for radical re-design of systems. Improvement in performance for one guideline was impeded by change of practice recommendations during the study. Nevertheless, clinically and statistically significant improvements in quality were obtained in five of the seven remaining guidelines, with effects peaking after feedback of performance results. A sixth guideline showed improvement in practices in which the physician leader influenced colleagues to improve. The seventh guideline showed improvement that did not reach statistical significance, in part because of lack of statistical power. CONCLUSIONS: This study demonstrated the effectiveness of cycles of quality measurement and improvement. The findings provide guidance for health-care practitioners and managers of the 1990s, for whom quality measurement and improvement has become a priority.

Ambulatory Care↗

PubMed1995

Relationships of patient satisfaction with experience of system performance and health status.

This article investigates the relationship between three types of measures obtained from consumer surveys: satisfaction, health status, and report of systems performance. Analyses demonstrate that patient reports of the quality of processes of care or system performance (such as receiving results of tests or receiving conflicting information from staff members) are significantly related to satisfaction independently of perception of health status. Since dissatisfaction is known to be associated with disenrollment, patient reports of system performance are of great interest to health plans.

Adult↗