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Biomedical subjects

R Lichtenstein

Publications and source records attributed to R Lichtenstein.

At least 19 recordsLinked to original sources
PubMed2001

The Detroit Community-Academic Urban Research Center: development, implementation, and evaluation.

There is increasing research evidence that stressors in the social and physical environment (e.g., poverty, inadequate housing, air pollution, and racism) are associated with poor health outcomes. Given the complex set of determinants of health status, the disproportionate burden of disease experienced within marginalized communities, and the limited effectiveness of traditional prevention research, particularly within communities of color, there have been growing calls for more comprehensive and participatory approaches to public health research and practice. The purpose of this article is to describe and analyze the process of establishing, implementing, and evaluating the Detroit Community-Academic Urban Research Center (URC), a community-based participatory research (CBPR) partnership involving community-based organizations, a local health department, academia, and an integrated health care system. Lessons learned and recommendations for creating effective CBPR partnerships are presented.

Community Participation↗
PubMed1998

A causal model of voluntary turnover among nursing personnel in long-term psychiatric settings.

Causal modeling was used to explore the processes by which individual characteristics, job satisfaction, and intention to quit explain turnover among nursing personnel in 29 Department of Veterans Affairs (VA) long-term psychiatric settings. The sample consisted of 1,106 registered nurses (RNs), licensed practical nurses (LPNs), and nurses' aides. We conceptualized turnover as a multistage process linking social and experiential orientations, attitudes toward the job, the decision to quit, and the behavior of actually quitting. Intention to quit was the strongest direct predictor of turnover. Professional growth opportunities and workload were important indirect predictors of turnover. Dissatisfaction with work hazards and relationships with coworkers were both indirect and direct predictors of turnover. Attitudes towards the job varied by nursing group. LPNs and aides were less satisfied than RNs with autonomy and work hazards. RNs were more dissatisfied with workload. We conclude that strategies to promote retention need to address aspects of jobs tailored to specific nursing groups.

Adult↗
PubMed1997

Determinants of mental health providers' expectations of patients' improvement.

OBJECTIVE: Characteristics of individual mental health providers and of treatment settings were examined to determine their effects on providers' expectations about the improvement of patients with serious mental illness. METHODS: The sample consisted of 1,567 treatment providers working in 107 inpatient and outpatient units or programs in 29 Veterans Affairs mental health facilities. They completed a questionnaire about their prognostic expectations and a broad range of attitudes toward job satisfaction, professional relations, and team functioning. Unit or program directors of all 107 units completed another questionnaire about the average functional ability of patients, unit workload, and unit size. Hierarchical linear modeling was used to assess the effects of both individual and unit-level attributes on providers' expectations of improvement in clinical symptomatology and social-functional skills of patients in their care. RESULTS: The providers had generally low expectations about the improvement of patients with serious mental illness. Expectations were higher among staff in units or programs that were smaller and that had an outpatient focus, a greater proportion of staff involved in the treatment team, and higher-functioning patients. Individual characteristics significantly associated with prognostic expectations were occupation, age, and membership on the treatment team. CONCLUSIONS: Prognostic expectations among providers of care to persons with serious mental illness vary with identifiable individual and unit or program characteristics. The latter may be amenable to manipulation and intervention to improve mental health providers' prognostic expectations.

Attitude of Health Personnel↗
PubMed1996

The effects of treatment team diversity and size on assessments of team functioning.

Team-based health care assumes that groups representing multiple disciplines can work together to implement care plans that are comprehensive and integrated. It also assumes that professionals can function effectively in an interdependent relationship with members of other occupational groups. However, we know little about what makes effective team functioning. This article examines the factors related to health care team functioning, with specific emphasis on team demographic composition and size. Hierarchical linear modeling is used to analyze 106 Veterans Affairs (VA) hospitals. Results indicate that individuals who operate on more heterogenous and larger teams have lower perceptions of team functioning.

Age Factors↗
PubMed1995

Benefits and challenges of school-based crisis response teams.

Given the increasing prevalence of schoolchildren's experience with crises and resulting loss through sudden or violent death, adoption of a school-based crisis prevention and response plan becomes crucial. This article reviews a model of regional, district, and school-based levels of response designed collaboratively by four school districts and consultants from Yale University. The team approach on which the model is based is examined through benefits it affords students, staff, parents, and the community. Obstacles that can impede full implementation of the model are identified, and strategies for overcoming logistical and systemic resistances are offered. This proactive design helps promote individual and organizational resiliency to traumatic events by promoting communication, collaboration, and service provision in an efficient and comprehensive manner.

Child↗
PubMed1992

HMO marketing and selection bias: are TEFRA HMOs skimming?

The research evidence indicates that health maintenance organizations (HMOs) participating in the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) At-Risk Program tend to experience favorable selection. Although favorable selection might result from patient decisions, a common conjecture is that it can be induced by HMOs through their marketing activities. The purpose of this study is to examine the relationship between HMO marketing strategies and selection bias in TEFRA At-Risk HMOs. A purposive sample of 22 HMOs that were actively marketing their TEFRA programs was selected and data on organizational characteristics, market area characteristics, and HMO marketing decisions were collected. To measure selection bias in these HMOs, the functional health status of approximately 300 enrollees in each HMO was compared to that of 300 non-enrolling beneficiaries in the same area. Three dependent variables, reflecting selection bias at the mean, the low health tail, and the high health tail of the health status distribution were created. Weighted least squares regressions were then used to identify relationships between marketing elements and selection bias. Subject to the statistical limitations of the study, our conclusion is that it is doubtful that HMO marketing decisions are responsible for the prevalence of favorable selection in HMO enrollment. It also appears unlikely that HMOs were differentially targeting healthy and unhealthy segments of the Medicare market.

Advertising↗
PubMed1991

Selection bias in TEFRA at-risk HMOs.

The issue of selection bias was investigated using data from 22 HMOs who are enrolling Medicare beneficiaries under Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) at-risk contracts. The study differs from previously published analyses of this issue in that it deals with the current Medicare risk program (TEFRA) rather than with earlier Demonstration Programs; as an indicator of selection bias, it utilizes beneficiary functional health status at enrollment; and it examines selection not only at the mean of the health status distribution, but at the two tails (very disabled, very able) as well. For each of the participating HMOs, the functional health status of recent Medicare enrollees was compared with that of a control group of randomly chosen fee-for-service beneficiaries. None of the HMOs experienced adverse selection, whether measured in terms of overall (mean) health status of enrollees or in terms of the proportion of the very disabled population that chose to join. Nine of the 22 HMOs were considered to have experienced favorable selection on the basis of the mean health status of new enrollees. In addition, ten more HMOs were found to have experienced favorable selection in one or both tails of the health status distribution. Although a specific cause for the observed enrollment patterns is not identified, speculation is made on factors that may or may not contribute. Evidence suggests that beneficiary self-selection is probably a more important explanation of these patterns than purposeful actions of HMOs to discourage enrollment by sicker beneficiaries (i.e., "skimming").

Aged↗
PubMed1987

Including a measure of health status in Medicare's health maintenance organization capitation formula: reliability issues.

Medicare's formula for determining capitation levels for risk-based HMOs, the Adjusted Average Per Capita Cost (AAPCC), has been criticized as a poor basis for establishing payments. Among new adjusting factors suggested for the formula is a measure of beneficiaries' functional health status. The ability of such a measure to improve predictions of Medicare costs has been demonstrated in several studies. In addition to possessing predictive validity, a measure considered for inclusion in the AAPCC must also be reliable. In this paper, the authors examine a measure of functional health status for intrarater reliability or, equivalently, stability over time. A sample of 1,616 Medicare beneficiaries was surveyed twice--in late 1982 and in January 1984. Using a five-point scale, functional health status scores were calculated for each of the beneficiaries at two points in time. For 68.4% of the sample, functional health scores were unchanged over the year, and second-year scores were within one point of first-year scores for 94.3% of the sample. Based on the intraclass correlation coefficient, the scores on this functional health scale demonstrated substantial to "almost perfect" agreement over the 1-year period.

Aged↗
PubMed1986

Including health status in Medicare's Adjusted Average Per Capita Cost capitation formula.

Actuarial factors currently comprising Medicare's HMO capitation formula, the Adjusted Average Per Capita Cost (AAPCC), are considered by many researchers to be inadequate as predictors of future period health care costs. While it is often suggested that the formula should incorporate beneficiary health status, no measure of health status suitable for this purpose has yet been identified. The authors present initial results from a study of 1,934 randomly selected Medicare beneficiaries in Michigan. Beneficiaries were surveyed to obtain data on several alternative measures of health status. Medicare claims were used to estimate beneficiary health care costs for periods before and after the survey. In regressions on future period Medicare payments, equations including the AAPCC factors plus a health status measure achieved R2 values ranging from 0.013 to 0.072, depending on the health status measure, compared with an R2 value of 0.003 for the equation with AAPCC factors alone.

Activities of Daily Living↗
PubMed1986

A comparison of PORP, TORP, and incus homograft for ossicular reconstruction in chronic ear surgery.

This report presents the results of 210 cases over a 10-year period using PORPs, TORPs, and notched incus homografts (NIH), for ossicular reconstruction in chronic ear surgery. There were 192 adults and 18 children. The surgical technique utilized temporalis fascia in an underlay technique with canal skin covering the outer surface of the fascia. Intact canal wall mastoid-tympanoplasty, as a one-stage procedure, was used for most cases. Homograft nasal cartilage was placed between the Plasti-Pore prosthesis and the graft. Notched incus homografts were prepared prior to surgery and stored in 4% formalin. There were 149 mastoid-tympanoplasties and 61 tympanoplasties performed. Revision of our cases was performed in 16.6%. Within 3 months of surgery, 86% of adults, and 44% (8/18) of children had dry, healed ears free of disease. The graft take rate was 96%. In adults, a total of 99 NIH, 50 TORPs, and 43 PORPs were implanted. In adults, the closure of the air-bone gap to 20 dB or less occurred in 58% using TORPs, 67% using PORPs, 76% using NIH-Partial replacement, and 20% using NIH-Total replacement. Excluding the cases that failed for reasons other than conductive hearing loss, the results improved to 69% for TORPs, 77% for PORPs, 77% for NIH-P, and 27% for NIH-T. In adults, the extrusion rate was 5.5% for Plasti-Pore and 3% for NIH. In children, the extrusion rate was 17% for Plasti-Pore prostheses. From this study, it appears that PORPs and TORPs with homograft nasal cartilage are satisfactory prostheses for chronic ear surgery in adults. In children, Plasti-Pore prostheses should be avoided unless the ear is healed, aerated, and stable. NIHs are good prostheses when the stapes is intact, but they are inferior to the TORP when placed on the footplate. Also, the NIH requires preparation prior to surgery and may be difficult to obtain. We plan to continue using PORPs and TORPs in chronic ear surgery until a better technique is found, or the complication rate becomes unacceptable.

Adult↗
PubMed1986

Functional health measure for adjusting health maintenance organization capitation rates.

Because of increasing interest in at-risk enrollment of Medicare beneficiaries by health maintenance organizations, a number of modifications to the adjusted average per capita cost (AAPCC) formula employed by the Health Care Financing Administration have been proposed recently. Researchers have found that new models, which include measures of prior years' utilization and costs, predict Medicare payments significantly better than does the purely demographic formula currently used. In this article, we show that inclusion of instrumental activities of daily living (IADL), a measure of beneficiaries' functional health status, can further improve AAPCC models that already incorporate measures of previous-period utilization and costs. Various models for predicting Medicare payments were examined and compared using survey data and Medicare claims for a random sample of 1,934 beneficiaries. For these models, explained variation in subsequent Medicare payments (as indicated by R2 values) increased considerably when the IADL variable was included. Although actuarial concerns are associated with inclusion of the IADL score in the AAPCC, use of this measure is likely to offset other, possibly more serious, actuarial problems associated with including measures of previous utilization and costs.

Activities of Daily Living↗
PubMed1986

Costs of illness: United States, 1980.

The total costs of illness and injury in the U.S. civilian noninstitutionalized population in 1980 amounted to $381.7 billion. The direct costs of illness and injury--resource expenditures for the diagnosis, treatment, and management of medical and dental conditions--were $153.9 billion, or 40.3 percent of total costs. Indirect costs--economic losses from morbidity and mortality--were $227.9 billion, or 59.7 percent of total costs. Of indirect costs, $104.9 billion resulted from productivity losses because of morbidity, and $123.0 billion represent the present value of lost productivity from premature mortality based on a net effective discount rate of 4 percent. These estimates, based on data from the 1980. National Medical Care Utilization and Expenditure Survey (NMCUES), differ from other estimates of the costs of illness and injury in 1980 (Gibson and Waldo, 1982; Rice, Hodgson, and Kopstein, 1985). The differences, which can be resolved, are attributable to two major factors: (1) NMCUES includes only the civilian noninstitutionalized population, but the other estimates include the institutionalized population and the military; and (2) NMCUES indirect cost estimates for the population unable to work include persons who were retired for health reasons in 1979 and 1980, disabled homemakers, and other persons who were disabled for the entire year 1980 but were not retired for health reasons in 1979, but the Rice et al. estimates do not include the last two categories in the population unable to work. The principal NMCUES findings on the total costs of illness in the civilian noninstitutionalized population reinforce the importance of considering distributional effects. Persons 65 years of age and over represent one-tenth of this population yet account for more than one-fourth of direct costs and more than their share of total costs, even though the institutionalized elderly are excluded. More than two-thirds of total costs for this age category are accounted for by direct costs. Direct costs also account for more than two-thirds of total costs for people under 17 years of age. However, this youngest age category, which constitutes over one-fourth of the civilian noninstitutionalized population, generates only 12.3 percent of direct costs. In contrast, indirect costs account for well more than 60 percent of total costs for the working-age population (17-64 years of age). Within the working-age population, per capita direct costs are highest among persons who are not full participants in the work force, many of whom are not working full time or at all because of injury or ill health.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed1985

Health insurance coverage of the unemployed.

Of 1,332 unemployed individuals in the Detroit area interviewed in late 1983, 51% did not have health insurance. Lack of insurance was directly related to length of unemployment. Of those unemployed 3 months or less, 31% had no insurance, as compared with 56% of those unemployed more than 3 years. For the most part, these were not the chronically uninsured: 78% of them were insured when they were employed. Three fourths of those without insurance were not covered by Medicaid either. These findings suggest that during the latest economic recession, the problem of health insurance loss due to losing one's job was more severe than had been assumed by most policymakers.

Adult↗
PubMed1984

Predicting school performance of preschool children from parent reports.

Parents of 391 preschool children ages 49 to 64 months completed a brief developmental inventory as part of a preschool screening program operated by an urban school district. The 28-item developmental inventory assessed adaptive behavior and language development. In addition, preschool children were administered the Minneapolis Preschool Screening Instrument. Teacher ratings of kindergarten performance the following year provided criterion data to validate the screening measures. Correlations with the overall teacher rating [the mean of nine ratings] were .40 for the adaptive behavior scale and .57 for the language scale. Validity figures for the developmental inventory were significantly higher for low SES than for high SES children, for older children [57 to 64 months] than for younger children [49 to 56 months], and for firstborn children than for younger siblings. No effects were found by sex. While a positive relationship between parent reports of developmental functioning and early school performance was clearly established, validity levels did not justify use of parent information as a sole source of preschool screening information.

Achievement↗
PubMed1984

Measuring the job satisfaction of physicians in organized settings.

The accurate measurement of physician job satisfaction in organized practice settings is important for both policy and administrative purposes. Previous efforts to measure physician job satisfaction have been unsatisfactory because of either conceptual or methodologic weaknesses. New measures of physician job satisfaction were developed and field tested on a population of physicians working in highly bureaucratic settings--prison health programs across the United States. Analysis of the measures demonstrated their reliability, validity, and ability to predict physicians' intentions to leave the job. The measures can serve to identify elements of the work setting that need to be changed to improve physician job satisfaction.

Adult↗
PubMed1983

Increasing Medicare enrollment in HMOs: the need for capitation rates adjusted for health status.

Although the federal government has sought to increase enrollment of Medicare beneficiaries in HMOs, at the end of 1981 less than 2% were HMO members. Of these, only two-tenths of 1% were enrolled under the type of risk-sharing contracts characteristic of HMOs. HMOs might have greater incentives to market to Medicare beneficiaries if a factor that adjusts for health status could be incorporated into the capitation formula. This paper develops such a factor using measures based on prior-year utilization, perceived health status, and functional health status.

Capitation Fee↗