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Biomedical subjects

R L Kravitz

Publications and source records attributed to R L Kravitz.

70 records · Page 4Linked to original sources
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

Antecedents of adherence to medical recommendations: results from the Medical Outcomes Study.

A longitudinal study of patients with chronic medical diseases (hypertension, diabetes, heart disease) was conducted to identify antecedents of adherence to medical recommendations. Data are from 1198 patients in three health-care provision systems in Los Angeles, Chicago, and Boston. Nonadherence at the beginning of the study was the strongest predictor of nonadherence 2 years later. Other significant predictors varied by type of adherence outcome. Patients who were younger and who relied upon avoidant coping strategies tended to be less likely to follow their doctor's specific recommendations. Patients who were distressed about their health, used avoidant coping strategies, or who reported worse physical and role functioning were less likely to adhere in general. Patient satisfaction with two features of care (interpersonal quality and financial aspects) was positively related to adherence in some models, but satisfaction with the technical quality of care was negatively associated with adherence to specific recommendations among heart disease patients. Social support contributed to specific adherence among diabetic patients. Implications of the study for medical care providers are discussed.

Adaptation, Psychological↗
PubMed1992

Conditions that justify strikes as perceived by housestaff at a public hospital.

Although physicians' strikes provoke considerable controversy and are increasing in incidence, little information is available regarding house officers' attitudes towards the ethics of striking. To determine house officers' views of whether and when it is justified to strike, and to understand the factors affecting their judgments, in 1988 the authors surveyed 432 residents (including interns and fellows) at a large public hospital shortly following a four-day housestaff work action; 255 (59%) responded. In responding to 12 hypothetical scenarios, 218 residents (85%) thought striking was justified if vital equipment were in short supply and the strike was unlikely to cause lethal harm, but only 10 (4%) thought striking justified if the issue was low salaries and the risk to patients was high. Twenty-two residents (9%) thought striking unacceptable in all 12 cases. Training in obstetrics-gynecology or psychiatry, liberal politics, and low levels of job satisfaction were independent predictors of residents' believing that strikes were more often justified. Although the residents' responses to the hypothetical scenarios were related to their prior work action behaviors, the association was weakened by adjustment for contextual factors such as specialty and social norms. Implications for education in medical ethics are discussed.

Attitude of Health Personnel↗
PubMed1991

Malpractice claims data as a quality improvement tool. I. Epidemiology of error in four specialties.

OBJECTIVE: --To identify potentially preventable sources of medical injury in obstetrics and gynecology, general surgery, anesthesiology, and radiology. DESIGN: --Retrospective review of physician malpractice claim records. SETTING: --Large New Jersey physician malpractice insurer. PARTICIPANTS: --Physicians practicing obstetrics and gynecology, general surgery, anesthesiology, and radiology and covered by the insurance carrier during any portion of 1977 through 1989. MAIN OUTCOME MEASURES: --Proportion of claims due to negligence associated with errors in (1) patient management, (2) technical performance, and (3) medical and nursing staff coordination and the clinical and financial consequences of such errors. RESULTS: --Among 1371 claims ascribed to negligence, patient management errors were cited most frequently in all four specialties (48% to 75%) and, compared with performance and coordination problems, were generally associated with a higher frequency of serious injury and higher median payments. Coordination problems accounted for about 9% of claims. In obstetrics and gynecology, newborn delivery claims usually arose from management errors (57% to 68%), whereas gynecologic procedure claims were most often associated with performance errors (55% to 73%). Underperformance of cesarean section was cited more frequently than overperformance (31% vs 3%). General surgery claims were about equally divided between management and performance types regardless of procedure. Failure to perform appropriate diagnostic testing or monitoring was the main problem in 3% to 8% of claims. CONCLUSION: --Malpractice data can be used to identify problem-prone clinical processes and suggest interventions that may reduce negligence.

Anesthesiology↗
PubMed1991

Malpractice claims data as a quality improvement tool. II. Is targeting effective?

OBJECTIVE: --To evaluate the usefulness of malpractice claims data for identifying (1) physicians who are prone to negligent errors and (2) physician and hospital characteristics associated with particular kinds of errors. DESIGN: --Retrospective review of physician malpractice claim records. SETTING: --Large New Jersey physician malpractice insurer. PARTICIPANTS: --Physicians practicing obstetrics and gynecology, general surgery, anesthesiology, or radiology and covered by the insurance carrier for any portion of 1977 through 1989. MAIN OUTCOME MEASURES: --Claims were classified into 11 clinical error categories comprising three broad groups: patient management problems, technical performance problems, and staff coordination problems. Outcomes were expressed as per-physician frequency of claims due to negligence and proportion of claims associated with various types of errors. RESULTS: --Using 5 years of claims history to predict long-term claims proneness was more accurate than chance alone by 57% in obstetrics and gynecology, 33% in general surgery, 11% in anesthesiology, and 15% in radiology. Cross-validated recursive partitioning showed that among physician characteristics, only specialty was predictive of physician error profiles. For physician claims arising in acute care hospitals, hospital size and location in addition to hospital services discriminated among different error profiles; the cross-validated accuracy of this method was 69% compared with 22% accuracy achieved by random prediction. CONCLUSION: --Use of physicians' malpractice claims histories to target individuals for education or sanctions is problematic because of the only modest predictive power of such claims histories.

Anesthesiology↗
PubMed1991

The U.S. and Canadian health care systems: views of resident physicians.

OBJECTIVE: To evaluate U.S. and Canadian resident physicians' views about their health care systems. DESIGN: Self-administered questionnaire survey in 1989. PARTICIPANTS: Senior family medicine and internal medicine residents in Canada and in ten geographically representative American states. MAIN RESULTS: American and Canadian residents had similar levels of professional satisfaction and almost universally agreed on the ethical obligation to provide care to persons of all social circumstances, but U.S. residents were more likely to perceive a serious access problem in their country (75% compared with 18%) and to think that current controls on the medical profession interfere with patient care (81% compared with 58%; P less than 0.001). In addition, U.S. residents were more likely than Canadian residents to believe that primary care salaries were too low (78% compared with 38%) and that salaries of medical subspecialists (57% compared with 17%) and surgeons (85% compared with 28%) were too high. In general, residents preferred their own country's predominant health care system. Whereas 87% of U.S. physicians supported private fee-for-service health care, 85% of Canadian physicians supported government-funded national health insurance. Nonetheless, 42% of U.S. physicians supported and only 17% strongly opposed national health insurance as an alternative approach. About two thirds of respondents from both countries opposed a salaried national health service. CONCLUSIONS: American residents perceived greater problems with access, overall intrusions into medical practice, and fee disparities than did their Canadian counterparts. They preferred private fee-for-service health care, but few strongly opposed government-funded national health insurance as an alternative approach to the health care needs of the United States.

Attitude of Health Personnel↗
PubMed1990

Physician satisfaction under the Ontario Health Insurance Plan.

To determine the level of professional satisfaction experienced by physicians practicing in Ontario, Canada, a probability sample of 1,028 physicians was surveyed; 69% responded. The majority of Ontario doctors were at least moderately satisfied with each of 16 aspects of their work, and the percentage who were dissatisfied exceeded 15% for only four aspects. Factor analysis suggested the presence of four underlying satisfaction facets: satisfaction with quality of care, with the rewards of practice, with patients, and with the practice environment. Multivariate regression analysis supported the validity of the four-facet model and demonstrated a consistent association between lower satisfaction and younger age, lower income, and the perception that it is difficult to obtain fair reimbursement for medical services (P less than 0.05). Least satisfied physicians were most likely to have participated in the June, 1986 Ontario doctors' strike (P less than 0.001). Despite some misgivings, the majority of physicians practicing under the Ontario Health Insurance Plan in 1987 were satisfied with their professional lives. They were least satisfied with their ability to make administrative decisions and to manipulate the system for the benefit of their patients. Policymakers should be cognizant of the effects various strategies may have upon physician satisfaction as they consider new approaches to health care organization.

Adult↗
PubMed1990

To strike or not to strike? House-staff attitudes and behaviors during a hospital work action.

Work actions by house staff are an infrequent response to sometimes difficult working conditions, but they can have a notable effect on institutional cohesiveness and represent a challenge to traditional notions of medical ethics. To determine the extent of participation in a hospital-wide doctors' strike and factors associated with participation, we surveyed 432 house officers at a university-affiliated public hospital where a contract dispute had recently led to a 4-day work action. Of 257 respondents, 69% approved of the strike and 50% participated in it. Both strikers and nonstrikers agreed that quality of care and specific contract issues were important precipitants of the event. By logistic regression, factors independently associated with strike participation (P less than .05) included being unmarried, training in internal medicine or psychiatry, being in earlier stages of training, being assigned to an outpatient service at the time of the strike, holding a favorable view of physician activism, and perceiving nurses, faculty, peers, and the public to have favored the strike. These associations may provide a basis for understanding the individual and social determinants of house-staff strike activity.

Adult↗
PubMed1989

Risk factors associated with participation in the Ontario, Canada doctors' strike.

To identify factors associated with participation in the 1986 Ontario, Canada doctors' strike, we surveyed 1,028 physicians; 69 percent responded, of whom 42 percent participated in the strike. Risk factors for participation included income greater than $135,000, being a surgeon or gynecologist, having previously "opted out" of the Ontario Health Insurance Plan, being professionally dissatisfied, being politically conservative, favoring political activism by physicians, holding a positive view of the social consequences of extrabilling, and perceiving family, associates, patients and the public to favor the strike. Eighty percent of strikers, but 32 percent of non-strikers, met criteria we established for four strike-prone groups: the "economically rational," the "ideologically committed," the "professionally disaffected," and the "socially malleable." Respondents belonging to one or more of these groups were much more likely to have participated in the strike (64 percent vs 17 percent). Strategies to deal with physician militancy should address the multiplicity of motives that appeared to have influenced doctors in Ontario.

Adult↗
PubMedDate not supplied

Health information on the Internet: accessibility, quality, and readability in English and Spanish.

CONTEXT: Despite the substantial amount of health-related information available on the Internet, little is known about the accessibility, quality, and reading grade level of that health information. OBJECTIVE: To evaluate health information on breast cancer, depression, obesity, and childhood asthma available through English- and Spanish-language search engines and Web sites. DESIGN AND SETTING: Three unique studies were performed from July 2000 through December 2000. Accessibility of 14 search engines was assessed using a structured search experiment. Quality of 25 health Web sites and content provided by 1 search engine was evaluated by 34 physicians using structured implicit review (interrater reliability >0.90). The reading grade level of text selected for structured implicit review was established using the Fry Readability Graph method. MAIN OUTCOME MEASURES: For the accessibility study, proportion of links leading to relevant content; for quality, coverage and accuracy of key clinical elements; and grade level reading formulas. RESULTS: Less than one quarter of the search engine's first pages of links led to relevant content (20% of English and 12% of Spanish). On average, 45% of the clinical elements on English- and 22% on Spanish-language Web sites were more than minimally covered and completely accurate and 24% of the clinical elements on English- and 53% on Spanish-language Web sites were not covered at all. All English and 86% of Spanish Web sites required high school level or greater reading ability. CONCLUSION: Accessing health information using search engines and simple search terms is not efficient. Coverage of key information on English- and Spanish-language Web sites is poor and inconsistent, although the accuracy of the information provided is generally good. High reading levels are required to comprehend Web-based health information.

Consumer Advocacy↗
PubMedDate not supplied

Program directors' attitudes towards residents' care of patients who have AIDS.

OBJECTIVE: To evaluate the educational strategies and experiences of residency programs regarding the training of primary care providers in the care of patients who have AIDS. DESIGN: Cross-sectional, self-administered questionnaire survey. SETTING: Survey conducted November 1988-April 1989. PARTICIPANTS: All 771 non-military U.S. internal medicine and family medicine program directors were surveyed; 80% responded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: While 91% of the directors felt that primary care of AIDS patients was an important educational experience and 94% reported that their programs usually had AIDS inpatients, only 16% reported that the majority of trainees cared for AIDS patients in their continuity clinics. Even at programs that typically had six or more AIDS inpatients, only 26% of directors reported that most residents had cared for an AIDS patient in their continuity clinics. Among the 57% who did not believe or were unsure whether their residents were adequately trained in AIDS ambulatory care, only 38% reported improving resident education in this area to be a high priority. Among the 39% who did not encourage residents' assumption of primary care, 60% had at least one of the following concerns: AIDS care too stressful for residents (24%), AIDS care too complicated for generalists (31%), or clinic faculty not qualified to supervise residents' caring for AIDS patients (39%). CONCLUSION: Although program directors view education in AIDS ambulatory care as important, most do not believe that residents are adequately trained, many do not encourage residents' assumption of primary care of AIDS patients, and residents usually have not provided such care in their programs. Strategies to augment residents' ambulatory experience in AIDS care are needed.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

How much explanation is enough? A study of parent requests for information and physician responses.

OBJECTIVE: To examine the relationship between doctor-parent communication patterns and parents' perceptions that they were listened to by the doctor. DESIGN: Cross-sectional, clinic-based survey. Before the visit, parents were asked about the strength of their desires/preferences for being listened to; after the visit, they were asked if their desires were fulfilled and to rate their satisfaction with care. Encounters were audiotaped, transcribed, and coded for parent requests for information and action and physician responses to those requests. Coding was performed using an adapted version of the Taxonomy of Requests by Patients (TORP). Physician responses to parental requests for information were coded as brief, moderate, or prolonged fulfillment or as partially fulfilled, ignored, or denied. SETTING: Two private pediatric practices, 1 community based and 1 university based. PARTICIPANTS: Ten of 13 eligible physicians (participation rate, 77%) and 306 of 356 eligible parents (participation rate, 86%) who sought care for their children's respiratory illnesses. Parents were invited to participate if they spoke and read English and if their child was 2-10 years old, had a chief complaint of cold symptoms, and was seeing one of the participating physicians. Complete data were obtained for 287 doctor-parent encounters (94%). RESULTS: Before the visit, 74% of parents reported that they considered it necessary for the physician to listen to their ideas about their child's illness. Among these parents, 62% (n = 130) reported after the visit that the physician had listened to their ideas. As the proportion of moderate-length responses to parent requests for information increased, parents were significantly more likely to report being listened to (P <.05). Multivariate results indicated a 59% probability of parents reporting that they were listened to when given moderate-length responses, 45% when given brief responses, 39% when given prolonged responses, and 12% when requests for information were only partially fulfilled, ignored, or denied. The length of response to parent requests for information was not related to overall parent satisfaction. CONCLUSIONS: Parents who received moderate-length answers to their questions were most likely to report that they were listened to. Although it is assumed that lengthier, in-depth explanations result in higher satisfaction, this study suggests that more doctor talk does not necessarily constitute better communication.

Adult↗
PubMedDate not supplied

Direct-to-consumer prescription drug advertising: trends, impact, and implications.

We provide an overview of what is known about the impact of direct-to-consumer (DTC) advertising of prescription drugs. Specifically, we explore the historical trends that led to the industry's increasing use of this form of promotion. Then, using the published literature to date, we review the impact of DTC advertising on the consumer, the medical profession, and the health care system. We conclude by offering policy suggestions for how the pharmaceutical industry can promote its products more responsibly, how the Food and Drug Administration (FDA) can regulate DTC advertising more effectively, and how the medical and public health communities can educate the public about drug therapies more constructively.

Advertising↗
PubMedDate not supplied

Validity of criteria used for detecting underuse of coronary revascularization.

OBJECTIVE: To assess criteria used for detecting underuse of coronary artery revascularization procedures in terms of patient outcomes. DESIGN: Retrospective cohort study using medical records supplemented by a telephone survey and review of county death records. SETTING: Four public hospitals and two academically affiliated private hospitals in Los Angeles County, California. PARTICIPANTS: A total of 671 patients who had coronary angiography between June 1, 1990 and September 30, 1991, and who met explicit clinical criteria for the necessity of coronary artery bypass graft (CABG) surgery or percutaneous transluminal coronary angioplasty (PTCA). MAIN OUTCOME MEASURES: For all patients (n = 671), we estimated the association between receipt of necessary revascularization and mortality (median follow-up after angiography, 797 days) after adjusting for potential confounders. For the patients completing the telephone interview (n = 374), we examined the relationship between receipt of necessary revascularization and frequency of chest pain. RESULTS: Patients who received necessary revascularization within 1 year of angiography had lower mortality than those who did not (8.7% vs 15.8%, P = .01), and this association persisted after adjustment for extent of coronary artery disease, clinical symptom complex, ejection fraction, and cardiac surgical risk index (adjusted odds ratio = 0.49; 95% confidence interval, 0.28 to 0.86). The same general results were obtained whether revascularization was received within 1 year or within 30 days of the catheterization, whether panelists' ratings or individual clinical variables were entered as covariates, and whether the statistical procedure used was logistic regression or Cox proportional hazards analysis. In addition, among patients responding to the telephone survey, those receiving necessary revascularization had less chest pain at follow-up (P = .03). CONCLUSIONS: Among patients meeting criteria for the necessity of revascularization, those receiving a revascularization procedure within 1 year had lower mortality than those treated medically. These results support the validity of the RAND/UCLA criteria for detecting underuse of these procedures, but more research is needed to confirm the findings and to determine the validity of guidelines for other procedures.

Aged↗