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The article reports on research which was conducted to compare a cell phone based physical activity diary with a paper physical activity diary and to examine the reliability and validity of the cell phone diary. Researchers evaluated the diaries with 25 men and 25 women between the ages of 45 and 65. They concluded that a cell phone-based physical activity diary is equivalent to a paper diary, is acceptable to users and is a relatively reliable and valid approach to self-reported physical activity.

Objective: Healthcare reform will result in substantial numbers of newly insured, low-income adults with chronic conditions. This paper examines the costs of a chronic disease management program among newly insured adults with diabetes and/or hypertension., Research Design and Methods: Low-income adults with diabetes and/or hypertension were provided County-sponsored health insurance coverage and access to disease management. Health econometric methods were used to compare costs among participants in disease management to nonparticipants, both overall and in comparison between those who were newly insured versus previously insured under an alternative County-sponsored insurance product. Costs were also compared between those who qualified for County-sponsored coverage due to diabetes versus hypertension., Results: Annual inpatient costs were $1260 lower, and outpatient costs were $723 greater, among participants in disease management (P<0.001 each). Participants in disease management without previous County-sponsored coverage had higher pharmacy costs ($154, P=0.002) than nonparticipants; whereas participants with diabetes had marginally significant lower overall costs compared with nonparticipants ($-685, P=0.070)., Conclusions: Disease management was successful in increasing the use of outpatient services among participants. The offsetting costs of the program suggest that disease management should be considered for some newly insured populations, especially for adults with diabetes.

This paper presents the results of applying the case-specular method to two earlier studies of wire codes and childhood cancers (DA Savitz et al, Am J Epidemiol 1988;128:21-38, and SJ London et al, Am J Epidemiol 1991;9:923-937). The method compares the wire codes of case residences with the wire codes of specular residences constructed by switching the location of the case residence across the center of the street. The method was designed to discriminate between the magnetic field hypothesis, which postulates that childhood cancer is affected by magnetic fields and that wire codes are a proxy for magnetic fields, and the neighborhood hypothesis, which postulates that childhood cancer is affected by some characteristics of the neighborhood other than magnetic fields and that wire codes are a proxy for those characteristics. Although the results from the two applications of the method have limited precision, they support the results originally reported (odds ratios of around 2 for very high current configuration residences and childhood cancers) and do not support suggestions that the associations are due to confounding by socio-economic and neighborhood factors. The results leave open the question of whether or not control selection bias could have influenced the original associations, because there was no convincing evidence that the control-specular matrices were symmetric.

Background: Health plans commonly face the conflicting demands of trying to provide access to novel technologies, including new classes of medications, while trying to contain costs. These demands are particularly acute for California's Medicaid program, known as Medi-Cal, which is responsible for delivery of medical care to an unusually large population of mentally ill individuals in the context of a culturally diverse environment. To meet the challenge, Medi-Cal has instituted a formal process for technology assessment of new and existing pharmaceutical products known as the Therapeutic Class Review (TCR)., Objective: The purpose of this paper is to describe the information produced for Medi-Cal in the TCR process for antidepressant medications and the individual petition review of antipsychotic medications, and to synthesize our experience in a series of policy recommendations designed to improve the quality of coverage decisions., Outcome: A collaborative process between Medi-Cal and Lilly resulted in a substantive body of new evidence regarding the needs of Medi-Cal recipients, the quality of current treatment, and prospects regarding the cost-effectiveness of introducing newer treatments., Conclusion: Medi-Cal has a formal process for evaluating new medicines. This process allows researchers to understand the needs of those who make coverage decisions. We recommend increasing routine epidemiologic surveillance, including service use, and clinical trials that include aspects of usual medical care early in the drug development process.

This paper presents a technology assessment process based on systems engineering methodologies used in the aerospace and defense industries. Systems engineering, defined in the U.S. military manual for engineering management, is a logical sequence of activities and decisions transforming an operational need into a description of system performance parameters and a preferred system configuration. Like systems engineering, technology assessment is driven by a single, clear need. The objective of systems engineering is to design a new system configuration; technology assessment assesses existing technologies to address this need. A six-step technology assessment model based on systems engineering principles is presented, including: (1) needs assessment; (2) clinical feasibility analysis; (3) systems assessment; (4) approval; (5) implementation; and (6) follow-up/CQI.

This paper presents a meta-analysis of 22 studies of coffee use and myocardial infarction or coronary death. In the eight case-control studies, a fairly homogeneous increased risk was found among coffee users (geometric mean rate ratio of 1.42 for 5 cups per day vs none, with 95% confidence limits of 1.30, 1.55, homogeneity P-value of 0.89). The 14 cohort studies tended to exhibit lower but very heterogeneous rate ratios, with a trend toward larger rate ratios in studies with longer follow-up periods and later publication dates (geometric mean rate ratio of 0.92 for the five cohort studies published up to 1981, 1.27 for the nine cohort studies published in 1986 or later; overall homogeneity P-value of 0.0008). The evidence thus remains ambiguous regarding both the existence and size of a coffee effect, and although a rate ratio of over 1.5 for 5 cups per day appears unlikely, stronger effects for 10-cup-per-day drinkers cannot be ruled out.

Hospitals face a significant challenge to select and appropriately place clinically warranted, safe, and cost-effective medical devices. To meet this challenge, the Kaiser Permanente, Northern California Region developed a comprehensive medical device technology assessment and equipment planning program. This paper discusses the structure of the program, physician leadership and accountability, the role of clinical engineers and other support personnel, and the program's influence on strategic planning and policy development.

The purpose of this paper is to provide a systematic explanation of the use of traditional medicine among the native American population living in the San Francisco Bay area. Several hypotheses concerning the factors associated with this behavior are tested. These include tribal grouping, socioeconomic and sociocultural factors, as well as the relationship between traditional medicine and modern Anglo medicine. The analysis is based on a probability sample of 277 native American families, systematically drawn from a specially prepared list of 5,000 in three Bay area counties with the largest native American population (Alameda, San Francisco, and Santa Clara). Traditional medicine was used by almost one of three families in the sample and it is shown that use of traditional medicine, although related to sociocultural factors, did not detract from the use of modern Anglo medicine.

The health maintenance organization (HMO) can provide an alternative to the predominant form of health care delivery in the United States, fee-for-service. Although market penetration of the HMO is relatively low in most parts of the country, the HMO has achieved a significant market share in a number of states. This paper examines the competitive response of Blue Cross and Blue Shield to the introduction of the HMO in two geographic regions with significant HMO activity, northern California and Hawaii. The evidence obtained from extensive interviews indicates that Blue Cross and Blue Shield plans have responded to HMO competitive pressure by establishing their own HMOs and by altering traditional procedures. HMO competition has stimulated Blue Cross and Blue Shield to make greater cost control efforts and to offer larger benefit packages. These results can have important policy implications for the role that HMOs are to play in cost containment.

This paper presents the results of two studies that compared methods for measuring patient satisfaction with specific medical encounters. One form used six-point response scales ranging from "very satisfied" to "very dissatisfied" (S6 scale); the other used five-point scales ranging from "excellent" to "poor" (E5 scale). Forms were assigned randomly to outpatients in fee-for-service (N = 136) and prepaid systems of care (N = 363) and were compared in terms of response variability, reliability, and validity. In both studies, the E5 scales showed greater response variability and better predicted whether patients intended to return to the same doctor in the future, recommend the doctor to a friend, and comply with the medical regimen. Reliability was satisfactory and did not differ between methods. Results are discussed in terms of their implications for constructing visit-specific satisfaction rating scales.

Service or product diversification is a popular recommendation made to hospitals to increase profitability and reduce financial risk as they face a more hostile environment. This paper presents results from an empirical study of these claims. Using data from all California nonprofit hospitals, the study finds that diversification, regardless of whether it is related or unrelated to preexisting services, is not associated with either increased profitability or reduced financial risk. However, other variables that do have these effects are identified in the research. Future research should evaluate the effect of both the size of and the length of time since the initial diversifying investment on financial variables.

In light of recent evidence suggesting the importance of communication in the health care setting, an instrument to measure communication style preferences was developed. This reliable and content-valid paper-and-pencil measure consisted of six scenarios depicting physician-patient interactions, each followed by four potential verbal responses from the physician. The four responses, representing four communications styles--humor, hostility, reassurance, and neutrality--were ranked by respondents according to their preferences. Among both physicians and consumers, reassuring responses were the most preferred, followed by neutral, humorous, and hostile responses. The intercorrelations of the four preferences and their relationships to standardized tests of both facilitating verbal response preferences and nonverbal expressiveness are presented. Potential uses of the instrument are discussed.

This paper summarizes the results of three studies of bias in patient satisfaction questionnaires due to acquiescent response set (ARS), a tendency to agree with statements of opinion regardless of content. Three independent surveys (N = 1,280) were fielded using the Patient Satisfaction Questionnaire. Across the three field tests, 40 to 60 per cent of respondents manifested some degree of ARS and from 2 to 10 per cent demonstrated noteworthy ARS tendencies. Occurrences of ARS accounted for significant upward bias in satisfaction scores computed from favorably worded questionnaire items and scales constructed from those items and significant downward bias in scores computed from unfavorably worded items and scales constructed from those items. These biases were greatest for groups reporting lower educational attainment or less income. An example was presented to show that mean satisfaction scores for groups differing in education were biased by ARS to such an extent that group differences in satisfaction were overestimated by favorably worded items and were missed entirely by unfavorably worded items. Balanced satisfaction scales, i.e., those containing both favorably and unfavorably worded items, were not correlated or correlated only slightly with ARS; therefore, group means for balanced scales were not biased by ARS or were biased only slightly.

This paper describes the reliability and validity of 10 easily administered and scored self-report measures of physicians' humanistic attitudes, values, and behaviors. This research also provides evidence that evaluations of physicians' humanistic behavior made by their outpatients, and non-physician staff with whom they worked, and the faculty physicians supervising them on inpatient ward rotations were positively and significantly correlated with one another. The potential usefulness of a multi-modal approach in evaluating humanistic physician attributes in which self-report measures are combined with direct feedback from all of those who interact with physicians is discussed.

This study reports on some factors related to scores on a recently developed pencil-and paper measure of communication style among physicians in training. High scores on this measure (the Facilitating Response Index) indicate a greater preference by the responded to explore or clarify the thoughts or feelings of the patient in a nondirective, open-ended fashion. Higher scores were attained by physicians who had been exposed to interpersonal skills training, who were evaluated by their teachers as being more clinically competent, who planned to enter private practice sometime to the future and whose patients were less likely to fail to show up for follow-up appointments without first calling to cancel.

This paper describes a computerized Hospital Information System (HIS) installed in Mount Zion Hospital and Medical Center along with the Clinical Engineering Department's involvement in the minor and major maintenance of the 48 data stations consisting of terminals and printers. This paper also includes a summary of maintenance man-hour distribution, data station repair problems and the type of repair equipment and personnel needed to maintain hospital computer systems.

This paper presents a new approach to the classification of ambulatory care into isoresource consumption groups. In contrast to classification schemes based on visits, this case-mix approach creates an index based on resources used by diagnostic categories by a patient during a year. An application of this method to a primary care, group practice data base produced resource consumption groups with coefficients of variation in an acceptable range compared with the coefficients of variation of the diagnosis-related groups used to classify inpatient care.

The increase in use, complexity, and cost of medical equipment requires a management response in both large and small hospitals. This paper describes the position of Clinical Equipment Coordinator (CEC) as it developed at Anaheim Memorial Hospital in Anaheim, California. The CEC can be highly effective in coordinating contract or shared services for a small hospital. In the larger hospital with an in-hospital Clinical or Biomedical Engineering Department, the CEC can take on the responsibilities of coordinating the services of the department. A detailed Job Description is presented along with typical forms and guidelines.

This paper describes an ECG/Respiration monitor calibrator used by the Biomedical Staff to check such units quickly, inexpensively and accurately. The calibrator can be constructed by the Biomedical Engineering Staff in one day for a parts cost of less than fifty dollars. Once the calibrator is connected to the patient cable of an ECG/Respiration monitor, the calibrator will generate concurrently a calibrated rate and amplitude ECG-pulse and respiration waveform.

The Journal of Clinical Engineering is pleased to present this FOCUS on the Biomedical Engineering Department of Watsonville Community Hospital (Watsonville, CA). Since the Department's inception in 1983, the growth of the hospital and the surrounding area has resulted in the expansion of the Department and its duties. This paper describes the responsibilities of the two-man Biomedical Engineering Department, which serves this 130-bed hospital and oversees the preventive maintenance and repair of approximately 800 pieces of equipment. In addition, the Department is involved with staff education, equipment inventory control, new equipment purchases, technical consultations, and special projects.

The purpose of this paper is to compare the overall health status of blacks with whites in Alameda County, California, using an index based on the mortality and disability experiences of the two population groups. It is demonstrated that this index, which requires disease-specific mortality and disability data, can be easily adapted to make use of existing data files containing data on mortality and any indicator of morbidity or disability. It was found that in the year 1974, the blacks lost approximately 10,000 productive years unnecessarily through higher mortality and disability rates than those of the white population. This disparity between the two populations may be underestimated because Chicano/Mexican Americans, who are known to enjoy a lower health status than whites, were included as part of the white population. The implications of the findings are discussed.

An unbiased evaluation of hospice effectiveness requires a randomized controlled trial (RCT), but the implementation of such a design is difficult. This paper describes the methods of the only RCT to date and reports on the validity and reliability of scales selected or developed to assess attainment of hospice goals. The patients involved are those in a VA hospital in Los Angeles who have cancer and a prognosis of about 6 months and who consent. They and their significant others are interviewed periodically until the patient's death to measure such hospice variables as pain, depression, anxiety, satisfaction with care and the environment, activities of daily living, and bereavement effects. Many of the scales, including McGill Pain, CES-D Depression, and Satisfaction with Care scales, have been validated in other studies with similar samples. The authors' test-retest reliability analyses show that these scales are reliable with advanced cancer patients and their significant others with coefficients ranging from 0.77 to 0.97.