Biomedical subjects

Laurence C Baker

Publications and source records attributed to Laurence C Baker.

At least 19 recordsLinked to original sources

PubMed2007

Differences in neonatal mortality among whites and Asian American subgroups: evidence from California.

OBJECTIVE: To obtain information about health outcomes in neonates in 9 subgroups of the Asian population in the United States. DESIGN: Cross-sectional comparison of outcomes for births to mothers of Cambodian, Chinese, Filipino, Indian, Japanese, Korean, Laotian, Thai, and Vietnamese origin and for births to non-Hispanic white mothers. Regression models were used to compare neonatal mortality across groups before and after controlling for various risk factors. SETTING: All California births between January 1,1991, and December 31, 2001. PARTICIPANTS: More than 2.3 million newborn infants. MAIN EXPOSURE: Racial and ethnic groups. MAIN OUTCOME MEASURE: Neonatal mortality (death within 28 days of birth). RESULTS: The unadjusted mortality rate for births to non-Hispanic white mothers was 2.0 per 1000. The unadjusted mortality rate for births to Chinese and Japanese mothers was significantly lower (Chinese: 1.2 per 1000, P<.001; Japanese: 1.2 per 1000, P=.004), and for births to Korean mothers the rate was significantly higher (2.7 per 1000, P=.003). For infants of Chinese mothers, observed risk factors explain the differences observed in unadjusted data. For infants of Cambodian, Japanese, Korean, and Thai mothers, differences persist or widen after risk factors are considered. After risk adjustment, infants of Cambodian, Japanese, and Korean mothers have significantly lower neonatal mortality rates compared with infants born to non-Hispanic white mothers (adjusted odds ratios, 0.58 for infants of Cambodian mothers, 0.67 for infants of Japanese mothers, and 0.69 for infants of Korean mothers; all P<.05); infants of Thai mothers have higher neonatal mortality rates (adjusted odds ratio, 1.89; P<.05). CONCLUSIONS: There are significant variations in neonatal mortality between subgroups of the Asian American population that are not entirely explained by differences in observable risk factors. Efforts to improve clinical care that treat Asian Americans as a homogeneous group may miss important opportunities for improving infant health in specific subgroups.

Adult↗

PubMed2006

Effect of opening midlevel neonatal intensive care units on the location of low birth weight births in California.

OBJECTIVE: Despite evidence and recommendations encouraging the delivery of high-risk newborns in hospitals with subspecialty or high-level NICUs, increasing numbers are being delivered in other facilities. Causes for this are unknown. We sought to explore the impact of diffusion of specialty or midlevel NICUs on the types of hospitals in which low birth weight newborns are born. DESIGN: We used birth certificate, death certificate, and hospital discharge data for essentially all low birth weight, singleton California newborns born between 1993 and 2000. We identified areas likely to have been affected by the opening of a new nearby midlevel unit, analyzed changes over time in the share of births that took place in midlevel NICU hospitals, and compared patterns in areas that were and were not likely affected by the opening of a new midlevel unit. We also tracked the corresponding changes in the share of births in high-level hospitals and in those without NICU facilities (low-level). RESULTS: The probability of a 500- to 1499-g infant being born in a midlevel unit increased by 17 percentage points after the opening of a new nearby unit. More than three quarters of this increase was accounted for by reductions in the probability of birth in a hospital with a high-level unit (-15 points), and the other portion was resulting from reductions in the share of newborns delivered in hospitals with low-level centers (-2 points). Similar patterns were observed in 1500- to 2499-g newborns. CONCLUSIONS: The introduction of new midlevel units was associated with significant shifts of births from both high-level and low-level hospitals to midlevel hospitals. In areas in which new midlevel units opened, the majority of the increase in midlevel deliveries was attributable to shifts from high-level unit births. Continued proliferation of midlevel units should be carefully assessed.

Adult↗

PubMed2006

Quality improvement implementation and hospital performance on quality indicators.

OBJECTIVE: To examine the association between the scope of quality improvement (QI) implementation in hospitals and hospital performance on selected indicators of clinical quality. DATA SOURCES: Secondary data from 1997 mailed survey of hospital QI practices, Medicare Inpatient Database, American Hospital Association's Annual Survey of Hospitals, the Bureau of Health Professions' Area Resource File, and two proprietary data sets compiled by Solucient Inc. containing data on managed care penetration and hospital financial performance. STUDY DESIGN: Cross-sectional study of 1,784 community hospitals to assess relationship between QI implementation approach and six hospital-level quality indicators. DATA COLLECTION/ABSTRACTION METHODS: Two-stage instrumental variables estimation in which predicted values (instruments) of four QI scope variables and control (exogenous) variables used to estimate hospital-level quality indicators. PRINCIPAL FINDINGS: Involvement by multiple hospital units in QI effort is associated with worse values on hospital-level quality indicators. Percentage of hospital staff and percentage of senior managers participating in formally organized QI teams are associated with better values on quality indicators. Percentage of physicians participating in QI teams is not associated with better values on the hospital-level quality indicators studied. CONCLUSIONS: Results supported the proposition that the scope of QI implementation in hospitals is significantly associated with hospital-level quality indicators. However, the direction of the association varied across different measures of QI implementation scope.

Cross-Sectional Studies↗

PubMed2006

Who searches the internet for health information?

OBJECTIVE: To determine what types of consumers use the Internet as a source of health information. DATA SOURCES: A survey of consumer use of the Internet for health information conducted during December 2001 and January 2002. STUDY DESIGN: We estimated multivariate regression models to test hypotheses regarding the characteristics of consumers that affect information seeking behavior. DATA COLLECTION: Respondents were randomly sampled from an Internet-enabled panel of over 60,000 households. Our survey was sent to 12,878 panel members, and 69.4 percent of surveyed panel members responded. We collected information about respondents' use of the Internet to search for health information and to communicate about health care with others using the Internet or e-mail within the last year. PRINCIPAL FINDINGS: Individuals with reported chronic conditions were more likely than those without to search for health information on the Internet. The uninsured, particularly those with a reported chronic condition, were more likely than the privately insured to search. Individuals with longer travel times for their usual source of care were more likely to use the Internet for health-related communication than those with shorter travel times. CONCLUSIONS: Populations with serious health needs and those facing significant barriers in accessing health care in traditional settings turn to the Internet for health information.

Adult↗

PubMed2006

Impact of instructional practices on student satisfaction with attendings' teaching in the inpatient component of internal medicine clerkships.

OBJECTIVE: To determine the prevalence and influence of specific attending teaching practices on student evaluations of the quality of attendings' teaching in the inpatient component of Internal Medicine clerkships. DESIGN: Nationwide survey using a simple random sample. SETTING: One hundred and twenty-one allopathic 4-year medical schools in the United States. PARTICIPANTS: A total of 2,250 fourth-year medical students. MEASUREMENTS AND MAIN RESULTS: In the spring of 2002, student satisfaction with the overall quality of teaching by attendings in the inpatient component of Internal Medicine clerkships was measured on a 5-point scale from very satisfied to very dissatisfied (survey response rate, 68.3%). Logistic regression was used to determine the association of specific teaching practices with student evaluations of the quality of their attendings' teaching. Attending physicians' teaching practices such as engaging students in substantive discussions (odds ratio (OR)=3.0), giving spontaneous talks and prepared presentations (OR=1.6 and 1.8), and seeing new patients with the team (OR=1.2) were strongly associated with higher student satisfaction, whereas seeming rushed and eager to finish rounds was associated with lower satisfaction (OR=0.6). CONCLUSION: Findings suggest that student satisfaction with attendings' teaching is high overall but there is room for improvement. Specific teaching behaviors used by attendings affect student satisfaction. These specific behaviors could be taught and modified for use by attendings and clerkship directors to enhance student experiences during clerkships.

Adult↗

PubMed2006

Quality improvement implementation and hospital performance on patient safety indicators.

This study examines the association between scope of Quality Improvement (QI) implementation in hospitals and hospital performance on patient safety indicators. Secondary data sources included a 1997 survey of hospital QI practices, Medicare Inpatient Database, American Hospital Association's Annual Survey of Hospitals, the Bureau of Health Professions' Area Resource File, and two proprietary data sets. Using a sample of 1,784 community hospitals, the study employed two-stage instrumental variables estimation in which predicted values of four QI scope variables and control variables were used to estimate four patient safety indicators. Involvement by multiple hospital units in the QI effort is associated with worse values on all four patient safety indicators. Percentages of hospital staff and of senior managers participating in QI teams exhibited no statistically significant association with any patient safety indicator. Percentage of physicians participating in QI teams is associated with better values on two patient safety indicators.

Health Care Surveys↗

PubMed2006

The role of organizational infrastructure in implementation of hospitals' quality improvement.

Quality improvement (QI) is an organized approach to planning and implementing continuous improvement in performance. Although QI holds promise for improving quality of care and patient safety, hospitals that adopt QI often struggle with its implementation. This article examines the role of organizational infrastructure in implementation of quality improvement practices and structures in hospitals. The authors focus specifically on four elements of hospital support and infrastructure for QI-integrated data systems, financial support for QI, clinical integration, and information system capability. These macrolevel factors provide consistent, ongoing support for the QI efforts of clinical teams engaging in direct patient care, thus promoting institutionalization of QI. Results from the multivariate analysis of 1997 survey data on 2350 hospitals provide strong support for the hypotheses. Results signal that organizations intent upon improving quality must attend to the context in which QI efforts are practiced, and that such efforts are unlikely to be effective unless appropriate support systems are in place to ensure full implementation.

Data Collection↗

PubMed2005

Internet use and stigmatized illness.

People with stigmatized illnesses often avoid seeking health care and education. The internet may be a useful health education and outreach tool for this group. This study examined patterns of internet use for health information among those with and without stigmatized illnesses. A national survey of internet users in the USA was conducted. Respondents who self-reported a stigmatized condition-defined as anxiety, depression, herpes, or urinary incontinence-were compared to respondents who reported having at least one other chronic illness, such as cancer, heart problems, diabetes, and back pain. The analytical sample consisted of 7014 respondents. Cross-sectional associations between stigmatized illness and frequency of internet use for information about health care, use of the internet for communication about health, changes in health care utilization after internet use, and satisfaction with the internet were determined. After controlling for a number of potential confounders, those with stigmatized illnesses were significantly more likely to have used the internet for health information, to have communicated with clinicians about their condition using the internet, and to have increased utilization of health care based on information found on the internet, than those with non-stigmatized conditions. Length of time spent online, frequency of internet use, satisfaction with health information found on the internet, and discussion of internet findings with health care providers did not significantly differ between the two groups. Results from this survey suggest that the internet may be a valuable health communication and education tool for populations who are affected by stigmatized illnesses.

Adolescent↗

PubMed2005

Free internet access, the digital divide, and health information.

BACKGROUND: The Internet has emerged as a valuable tool for health information. Half of the U.S. population lacked Internet access in 2001, creating concerns about those without access. Starting in 1999, a survey firm randomly invited individuals to join their research panel in return for free Internet access. This provides a unique setting to study the ways that people who had not previously obtained Internet access use the Internet when it becomes available to them. METHODS: In 2001-2002, we surveyed 12,878 individuals 21 years of age and older on the research panel regarding use of the Internet for health; 8935 (69%) responded. We analyzed respondents who had no prior Internet access, and then compared this group to those who had prior Internet access. RESULTS: Among those newly provided free Internet access, 24% had used the Internet for health information in the past year, and users reported notable benefits, such as improved knowledge and self-care abilities. Not surprisingly, the no-prior-Internet group reported lower rates of using the Internet (24%) than the group that had obtained Internet access prior to joining the research panel (40%), but the 2 groups reported similar perceptions of the Internet and self-reported effects. CONCLUSIONS: Those who obtained Internet access for the first time by joining the panel used the Internet for health and appeared to benefit from it. Access helps explain the digital divide, although most people given free access do not use the Internet for health information.

Access to Information↗

PubMed2005

Medicaid managed care and health care for children.

OBJECTIVE: Many states expanded their Medicaid managed care programs during the 1990s, causing concern about impacts on health care for affected populations. We investigate the relationship between Medicaid managed care enrollment and health care for children. DATA SOURCES AND MEASURES: Repeated cross-sections of Medicaid-covered children under 18 years of age from the 1996/1997 and 1998/1999 Community Tracking Study Household Surveys (n=2,602) matched to state-year CMS Medicaid managed care enrollment data. For each individual, we constructed measures of health care utilization (provider and emergency department visits, hospitalizations, surgeries); health care access (usual source of care, unmet medical needs, put-off needed care); and satisfaction (satisfaction overall, with doctor choice, and with last visit). STUDY DESIGN: Regression analysis of the relationship between within-state changes in Medicaid managed care enrollment rates and changes in mean utilization, access, and satisfaction measures for children covered by Medicaid, controlling for a range of potentially confounding factors. PRINCIPAL FINDINGS: Increases in Medicaid health maintenance organization (HMO) enrollment are associated with less emergency room use, more outpatient visits, fewer hospitalizations, higher rates of reporting having put off care, and lower satisfaction with the most recent visit. Medicaid primary care case management (PCCM) plans are associated with increases in outpatient visits, but also with higher rates of reporting unmet medical needs, putting off care, and having no usual source of care. CONCLUSIONS: Both Medicaid HMO and PCCM plans can have important impacts on health care utilization, access, and satisfaction. Some impacts may be positive (e.g., less ED use and more outpatient provider use), although concern about increasing challenges in access to care and satisfaction is also warranted.

Adolescent↗

PubMed2004

Use of the Internet for health information by the chronically ill.

INTRODUCTION: Chronic conditions are among the leading causes of death and disability in the United States. The Internet is a source of health information and advice for individuals with chronic conditions and shows promise for helping individuals manage their conditions and improve their quality of life. METHODS: We assessed Internet use for health information by people who had one or more of five common chronic conditions. We conducted a national survey of adults aged 21 and older, then analyzed data from 1980 respondents who had Internet access and who reported that they had hypertension, diabetes, cancer, heart problems, and/or depression. RESULTS: Adjusted rates for any Internet use for health information ranged from 33.8% (heart problems only) to 52.0% (diabetes only). A sizable minority of respondents - particularly individuals with diabetes - reported that the Internet helped them to manage their condition themselves, and 7.9% said information on the Internet led them to seek care from a different doctor. CONCLUSION: Use of the Internet for health information by chronically ill patients is moderate. Self-reported effects on choice of treatment or provider are small but noteworthy.

Adult↗

PubMed2004

Do health plans influence quality of care?

OBJECTIVE: To investigate the relative impact of physician groups and health plans on quality of care measures. DESIGN: Secondary data analysis of receipt of preventive care services included in the Health Plan Employer Data and Information Set (HEDIS) among 10 758 patients representing 21 health maintenance organizations and 22 large provider groups in the San Francisco and Los Angeles, California, areas in 1997. Each patient was eligible for (at least) one of six HEDIS-measured services. Data identify whether or not the service was provided, the patient's health plan, and the provider group responsible for the care. We used logistic regression to examine variations across plans in HEDIS rates, and whether variations persist after controls for provider groups are included. SETTING: Patients from 21 health maintenance organizations serving San Francisco and Los Angeles, California, in 1997. MAIN OUTCOME MEASURES: Breast cancer screening, childhood immunizations, cervical cancer screening, diabetic retinal exam, prenatal care in the first trimester, and check-ups after delivery among patients for whom these services are appropriate. RESULTS: There are statistically significant differences across health plans in utilization rates for the six services examined. These differences are not substantially affected when we control for the provider group that cared for the patient. That is, controlling for provider group does not explain variations across plans, consistent with the view that health plans have an impact on HEDIS quality measures independent of the providers that they contract with. CONCLUSIONS: There are activities that plans can undertake which influence their HEDIS scores. On the face of it, these results suggest that plans can independently improve quality, in contrast to hypotheses that plans would be "too far" from patients to have an influence. Continued attention to collecting plan-level data is warranted. Further work should address other possible sources of variations in HEDIS scores, such as variability in the quality of plan administrative databases.

California↗

PubMed2004

Variation in access to health care for different racial/ethnic groups by the racial/ethnic composition of an individual's county of residence.

BACKGROUND: Although the majority of studies examining racial/ethnic disparities in health care have focused on the characteristics of the individual, more recently there has been growing attention to the notion that an individual's health practices could be influenced by the characteristics of the place where they reside. OBJECTIVE: The objective of this study was to examine whether access to care for individuals of different racial/ethnic groups varies by the prevalence of blacks and the prevalence of Latinos in their county of residence. STUDY DESIGN: We conducted a cross-sectional cohort. PARTICIPANTS: Individuals from the 1996 Medical Expenditure Panel Survey, a nationally representative sample of U.S. households, who described their race/ethnicity as white, black, or Latino, and who resided in 1 of 677 counties (n = 14740) were studied. MEASURES: Counties were assigned to 6 groups based on the prevalence of blacks and Latinos who resided there (<6% referred to as "low prevalence," 6-39% referred to as "midprevalence," >or=40% referred to as "high prevalence" separately for both blacks and Latinos). Outcomes included whether during the past year any family members: 1). experienced difficulty obtaining any type of health care, delayed obtaining care, or did not receive health care they thought they needed (referred to as "difficulty obtaining care"); or (2). did not receive a doctor's care or a prescription medication because the family needed money to buy food, clothing, or pay for housing (referred to as "financial barriers"). RESULTS: After controlling for other individual and area-level covariates, blacks reported lower rates of both outcome variables when they lived in a county with a high prevalence of blacks compared with blacks who lived in a county with a low prevalence of blacks (difficulty obtaining care: 4.3% vs. 18.8%, P <0.005; financial barriers: 1.6% vs. 10.5%, P <0.005). There was a similar association for Latinos by the prevalence of Latinos in the county for difficulty obtaining care (high: 5.0% vs. low: 13.4%, P <0.05), but not the financial barriers outcome (high: 2.2% vs. low: 2.4%, P = 0.90). Whites who lived in an area with a high prevalence of Latinos were more likely to report both outcomes compared with whites who lived in a county with a low prevalence of Latinos (difficulty obtaining care: 17.7% vs. 9.4%, P <0.05; financial barriers: 8.5% vs. 3.2%, P <0.005) . CONCLUSIONS: Blacks and Latinos may perceive fewer barriers to care when they live in a county with a high prevalence of people of similar race/ethnicity. Conversely, whites may perceive more difficulty receiving care when they live in an area with a high prevalence of Latinos. Diminishing disparities in access to health care may require interventions that extend beyond the individual.

Adult↗

PubMed2004

Are gatekeeper requirements associated with cancer screening utilization?

OBJECTIVE: There is widespread debate over whether health plans should require enrollees to use "gatekeepers," which are primary care providers that coordinate care and control access to specialists. However, little is known about whether health plan gatekeeper requirements improve or reduce quality-of-care. Our objective was to examine whether gatekeeper requirements are associated with the utilization of cancer screening for breast, cervical, and prostate cancer. DATA SOURCES: Three linked sources (N = 13,534): (1) 1996 Medical Expenditure Panel Survey (MEPS) Household Survey, a nationally representative, ongoing survey sponsored by the Agency for Healthcare Research and Quality; (2) 1996 MEPS Health Insurance Plan Abstraction, which codes data from health plan booklets obtained from privately insured respondents, and (3) 1995 National Health Interview Survey. STUDY DESIGN/DATA COLLECTION: Cross-sectional, multivariate logistic regression analysis using secondary data. PRINCIPAL FINDINGS: We found in multivariate analyses that women in gatekeeper plans were significantly more likely to obtain mammography screening (Odds Ratio [OR] = 1.22, 95 percent Confidence Interval [CI] 1.07-1.40), clinical breast examinations (OR = 1.39, 95 percent CI 1.23-1.57), and Pap smears (OR = 1.33, 95 percent CI 1.16-1.52) than women not in gatekeeper plans. In contrast, gatekeeper requirements were not associated with prostate cancer screening (OR = 1.11, 95 percent CI 0.93-1.33). We found no association between screening utilization and aggregate plan types (HMO, POS, PPO, FFS). CONCLUSIONS: Gatekeeper requirements are associated with higher utilization of widely recommended cancer screening procedures, but not with utilization of a less uniformly recommended cancer screening procedure. Researchers should consider the analysis of specific plan characteristics rather than aggregate plan types in conducting future research, and insurers and policymakers should consider the potential benefits of gatekeepers with respect to preventive care when designing health plans and legislation.

Breast Neoplasms↗

PubMed2004

The effect of area HMO market share on cancer screening.

OBJECTIVE: Managed care may have widespread impacts on health care delivery for all patients in the areas where they operate. We examine the relationship between area managed care activity and screening for breast, cervical, and prostate cancer among patients enrolled in more managed care plans and patients who are enrolled in less managed plans. DATA AND METHODS: Data on cancer screening from the 1996 Medical Expenditure Panel Survey (MEPS) were linked to data on health maintenance organization (HMO) and preferred provider organization (PPO) market share and HMO competition at the metropolitan statistical area (MSA) level. Logistic regression analysis was used to examine the relationship between area managed care prevalence and the use of mammography, clinical breast examination, Pap smear, and prostate cancer screening in the past two years, controlling for important covariates. RESULTS: Among all patients, increases in area-level HMO market share are associated with increases in the appropriate use of mammography, clinical breast exam, and Pap smear (OR for high relative to low managed care areas are 1.75, p < .01, for mammography, 1.58, p < .05, for clinical breast exam, and 1.71, p < .01, for Pap smear). In analyses of subgroups, the relationship is significant only for individuals who are enrolled in the nonmanaged plans; there is no relationship for individuals in more managed plans. No relationship is observed between area HMO market share and prostate cancer screening in any analysis. Neither the level of competition between area HMOs nor area PPO market share is associated with screening rates. CONCLUSIONS: Area-level managed care activity can influence preventive care treatment patterns.

Adolescent↗

PubMed2003

Is the prevalence of gatekeeping in a community associated with individual trust in medical care?

BACKGROUND: Consumer concerns about the restrictions of managed care may lead to distrust. OBJECTIVES: To examine whether a community's level of gatekeeping activity is associated with an individual's trust in medical care. RESEARCH DESIGN: Cross-sectional cohort (N = 49,929). SUBJECTS: Participants in a nationally representative sample derived from the Community Tracking Survey who had health insurance, had a usual source of care, made at least 1 physician visit, and resided in one of the sampled metropolitan areas with corresponding community-level data, including the prevalence of gatekeeping activity. MEASURES: Four questions measuring trust in physician. RESULTS: Individuals from communities with a higher prevalence of gatekeeping activity report less trust than individuals from areas with a lower prevalence of gatekeeping activity, after adjusting for whether that individual had a health plan with a gatekeeper requirement. For example, in communities with the highest prevalence of gatekeeping activity relative to the lowest, the odds ratio for individuals to agree strongly that they trusted their doctor to put their medical needs above all other considerations was 0.77 (95% confidence interval, 0.71-0.84). Also, a higher prevalence of gatekeeping in the community was positively associated with the perception that a physician was strongly influenced by insurance company rules when making decisions about medical care. Conversely, a higher prevalence of gatekeeping in the community was negatively associated with the perception that a doctor might perform an unnecessary test or procedure and with concern about restricted referral for specialty care. CONCLUSION: Individuals' trust in their physicians may be influenced by wider contextual variables, like the prevalence of gatekeeping in the community.

Adult↗

PubMed2002

The burden of out-of-pocket payments for health care in Tbilisi, Republic of Georgia.

CONTEXT: In the 1990s, the Republic of Georgia instituted health care reforms to convert the centralized, state-operated health care system inherited from the Soviet Union to a decentralized, market-driven system of health care delivery. Under the new system, 87% of health care expenditures are financed through out-of-pocket payments at the point of service. OBJECTIVE: To describe the effects of health care reforms on access to care and health care financing among ill residents of Tbilisi, Georgia. DESIGN, SETTING, AND PARTICIPANTS: A probability-proportionate-to-size cluster survey conducted in 1999 of 248 households containing 306 household members who had been ill in the past 6 months in Tbilisi, Georgia. MAIN OUTCOME MEASURES: Reported health care utilization, out-of-pocket expenditures, and financing practices. RESULTS: Of sick household members, 51% used official health care services at hospitals and clinics; 49% did not use official services and sought advice from relatives or friends, used traditional medicines, or did nothing. Those with serious illness were more likely to seek care through official services (82%) than those with nonserious illness (27%). Ninety-three percent of respondents said costs were the major deterrent to obtaining health care. Ten percent of ill household members reported that they were unable to obtain health care because of high costs; 16% reported being unable to afford all the medications necessary to treat their illness. Sixty-one percent of ill household members used savings to pay for health care expenditures and 19% of those able to obtain care had to use strategies such as borrowing money or selling personal items to pay for health care. Total out-of-pocket health care expenditures (53%) were paid for by borrowing money or selling personal items. A significant portion of households with ill members (87%) reported an interest in purchasing health care insurance. CONCLUSIONS: Economic disruption and health care reforms have led to access problems and out-of-pocket financing strategies that include reliance on personal savings, selling personal items, and borrowing money. Future reforms should consider an appropriate system for health care insurance risk pooling for the population of Tbilisi, Georgia.

Cluster Analysis↗

PubMed2002

The relation between managed care market share and the treatment of elderly fee-for-service patients with myocardial infarction.

PURPOSE: To determine if greater managed care market share is associated with greater use of recommended therapies for fee-for-service patients with acute myocardial infarction. SUBJECTS AND METHODS: We examined the care of 112,900 fee-for-service Medicare beneficiaries aged > or = 65 years who resided in one of 320 metropolitan statistical areas and who were admitted with an acute myocardial infarction between February 1994 through July 1995. Use of recommended medical treatments and 30-day survival were determined for areas with low (<10%), medium (10% to 30%), and high (>30%) managed care market share. RESULTS: After adjustment for severity of illness, teaching status of the admission hospital, and area characteristics, areas with high levels of managed care had greater use of beta-blockers (relative risk [RR] for greater use = 1.18; 95% confidence interval [CI]: 1.06 to 1.29) and aspirin at discharge (RR = 1.05; 95% CI: 1.02 to 1.07), but less appropriate coronary angiography (RR = 0.93; 95% CI: 0.86 to 1.01) and reperfusion (RR = 0.95; 95% CI: 0.85 to 1.03) when compared with areas with low levels of managed care. CONCLUSIONS: Medicare beneficiaries with fee-for-service insurance who resided in areas with high managed care activity were more likely to have received appropriate treatment with beta-blockers and aspirin, and less likely to have undergone coronary angiography following admission for myocardial infarction. Thus, the effects of managed care may not be limited to managed care enrollees.

Adrenergic beta-Antagonists↗