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Objective: Recent reforms in the federal Medicaid program have attempted to integrate beneficiaries into the mainstream by providing them with managed care options. However, the effects of mainstreaming have not been systematically evaluated.Design: Cross-sectional survey.Setting/participants: A sample of 478 adult, nonelderly asthmatics followed by a large Northern California medical group.Measurements and Main Results: We examined differences in self-reported access by insurance status. Compared to patients with other forms of insurance, patients covered by the state's Medicaid program (Medi-Cal) were more likely to report access problems for asthma-related care, including difficulties in reaching a health care provider by telephone, obtaining a clinic appointment, and obtaining asthma medication. Adjusting for relevant clinical and sociodemographic variables, Medi-Cal patients were more likely to report at least one access problem compared to non-Medi-Cal patients (adjusted odds ratio [AOR], 3.34; 95% confidence interval [CI], 1.43 to 7.80). Patients reporting at least one access problem were also more likely to have made at least one asthma-related emergency department visit within the past year (AOR, 4.84; 95% CI, 2.41 to 9.72). Reported barriers to care did not translate into reduced patient satisfaction.Conclusions: Within this population of Medicaid patients, the provision of health insurance and care within the mainstream of an integrated health system was no guarantee of equal access as perceived by the patients themselves. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Patients seeking help for symptoms frequently worry about the underlying causes of their symptoms; have specific expectations for care; and request (or demand) time, information, and services. Understanding patients' concerns, expectations, and requests is important for clinicians, health care policymakers, and researchers. One obstacle to progress in this area has been disagreement over the most appropriate methods for identifying, monitoring, and classifying these phenomena. This article reviews the conceptual relationships linking patients' expectations, requests, and satisfaction with care; surveys contemporary approaches to the measurement of expectations and requests; and highlights recent empirical findings. The literature reviewed supports the conclusion that patients' expectations are wide ranging, can be measured, and have potentially important clinical consequences. For clinicians and policymakers alike, learning to elicit, evaluate, and understand patients' expectations will be a major task for the early part of the new century. [ABSTRACT FROM AUTHOR]

Context: Continuing changes in the health care delivery system make it essential to monitor underuse of needed care, even for relatively well-insured populations. Traditional approaches to measuring underuse have relied on patient surveys and chart reviews, which are expensive, or simple single-condition claims-based indicators, which are not clinically convincing.Objective: To develop a comprehensive, low-cost system for measuring underuse of necessary care among elderly patients using inpatient and outpatient Medicare claims.Design: A 7-member, multispecialty expert physician panel was assembled and used a modified Delphi method to develop clinically detailed underuse indicators likely to be associated with avoidable poor outcomes for 15 common acute and chronic medical and surgical conditions. An automated system was developed to calculate the indicators using administrative data.Setting and Subjects: A total of 345,253 randomly selected elderly US Medicare beneficiaries in 1994-1996.Main Outcome Measures: Proportion of beneficiaries receiving care, stratified by indicators of necessary care (n = 40, including 3 for preventive care), and avoidable outcomes (n = 6).Results: For 16 of 40 necessary care indicators (including preventive care indicators), beneficiaries received the indicated care less than two thirds of the time. Of all indicators, African Americans scored significantly worse than whites on 16 and better on 2; residents of poverty areas scored significantly lower than nonresidents on 17 and higher on 1; residents of federally defined Health Professional Shortage Areas scored significantly lower than nonresidents on 16 and higher on none (P<.05 for all).Conclusions: This claims-based method detected substantial underuse problems likely to result in negative outcomes in elderly populations. Significantly more underuse problems were detected in populations known to receive less-than-average medical care. The method can serve as a reliable, valid tool for monitoring trends in underuse of needed care for older patients and for comparing care across health care plans and geographic areas based on claims data. JAMA. 2000;284:2325-2333. [ABSTRACT FROM AUTHOR]

Objectives: To understand the nature of patients' expectations for parts of the physical examination and for diagnostic testing and the meaning patients ascribe to their desires.Design: Qualitative inquiry based on patient interviews and focused on perceived diagnostic omissions as "critical incidents."Setting: Three general internal medicine practices (21 practitioners) in one mid-sized northern California city.Patients: Of 687 patients visiting these practice sites and completing a detailed questionnaire, 125 reported one or more omissions of care and 90 completed an in-depth telephone interview. This study focuses on the 56 patients interviewed who did not receive desired components of the physical examination or diagnostic tests.Measurements: Qualitative analysis of key themes underlying patients' unmet expectations for examinations and tests, as derived from verbatim transcripts of the 56 interviews.Main Results: The 56 patients perceived a total of 113 investigative omissions falling into four broad categories: physical examination (47 omissions), conventional tests (43), high-cost tests (10), and unspecified investigations (13). Patients considered omitted investigations to have value along both pragmatic and symbolic dimensions. Diagnostic maneuvers had pragmatic value when they were seen to advance the technical aims of diagnosis, prognosis, or therapy. They had symbolic value when their underlying purpose was to enrich the patient-physician relationship. Patients in this study were often uncomfortable with clinical uncertainty, distrusted empiric therapy, endorsed early detection, and frequently interpreted failure to examine or test as failure to care.Conclusions: When patients express disappointment at failing to receive tests or examinations, they may actually be expressing concerns about the basis of their illness, the rationale for therapy, or the physician-patient relationship. [ABSTRACT FROM AUTHOR]

Objective: Drug manufacturers are intensely promoting their products directly to consumers, but the impact has not been widely studied. Consumers' awareness and understanding of, attitudes toward, and susceptibility to direct-to-consumer (DTC) drug advertising were examined.Design: Random-digit dialing telephone survey with a random household member selection procedure (completion and response rates, 58% and 69%, respectively).Setting: Respondents were interviewed while they were at their residences.Participants: Complete data were obtained from 329 adults in Sacramento County, California.Measurements and Main Results: Outcome measures included awareness of advertisements for 10 selected drugs, misconceptions about DTC advertising, attitudes toward DTC ads, and behavioral responses to such promotions. The influence of demographic characteristics, health status, attitudes, beliefs, and media exposure on awareness and behaviors was examined. On average, respondents were aware of advertisements for 3.7 of the 10 drugs; awareness varied from 8% for Buspar (buspirone) to 72% for Claritin (loratadine). Awareness was associated with prescription drug use, media exposure, positive attitudes toward DTC advertising, poorer health, and insurance status. Substantial misconceptions were revealed; e.g., 43% thought that only "completely safe" drugs could be advertised. Direct-to-consumer advertisements had led one third of respondents to ask their physicians for drug information and one fifth to request a prescription.Conclusions: Direct-to-consumer advertisements are reaching the public, but selectively so, and affecting their behaviors. Implications for public policy are examined. [ABSTRACT FROM AUTHOR]

Objective: To determine the relative importance of medical and nonmedical factors influencing generalists' decisions to refer, and of the factors that might avert unnecessary referrals.Design: Prospective survey of all referrals from generalists to subspecialists over a 5-month period.Setting: University hospital outpatient clinics.Participants: Fifty-seven staff physicians in general internal medicine, family medicine, dermatology, orthopedics, gastroenterology, and rheumatology.Measurements and Main Results: For each referral, the generalist rated a number of medical and nonmedical reasons for referral, as well as factors that may have helped avert the referral; the specialist seeing the patient then rated the appropriateness, timeliness, and complexity of the referral. Both physicians rated the potential avoidability of the referral by telephone consultation. Generalists were influenced by a combination of both medical and nonmedical reasons for 76% of the referrals, by only medical reasons in 20%, and by only nonmedical reasons in 3%. In 33% of all referrals, generalists felt that training in simple procedures or communication with a generalist or specialist colleague would have allowed them to avoid referral. Specialists felt that the vast majority of referrals were timely (as opposed to premature or delayed) and of average complexity. Although specialists rated most referrals as appropriate, 30% were rated as possibly appropriate or inappropriate. Generalists and specialists failed to agree on the avoidability of 34% of referrals.Conclusions: Generalists made most referrals for a combination of medical and nonmedical reasons, and many referrals were considered avoidable. Increasing procedural training for generalists and enhancing informal channels of communication between generalists and subspecialists might result in more appropriate referrals at lower cost. [ABSTRACT FROM AUTHOR]

Objective: To study the experience of recently published authors with the news media.Design: A self-administered questionnaire.Participants: All first authors of scientific articles published in JAMA and The New England Journal of Medicine during a 6-month period. Of 397 surveyed, 92% responded.Main Outcome Measures: Researchers were asked about (1) their experience with the news media, (2) their attitudes toward the dissemination of health-related research to the general public, and (3) their attitudes toward the lay press.Results: Of respondents, 65% stated that their research was discussed in the lay press, and 60% reported that they were directly contacted by the press. Researchers had positive attitudes toward the press; 86% reported that news reports based on their research were accurate and 44% felt that media coverage would help them achieve their overall professional goals. Positive aspects of media coverage most frequently endorsed were that (1) it improves the image of the profession, (2) it informs the professional community of their research, and (3) it allows the public to understand the topic better. Negative aspects of media coverage were (1) it gives the impression that the researcher is seeking publicity, (2) it creates jealousy among colleagues, and (3) it takes too much time. Researchers were not eager to change the existing dissemination process, yet they endorsed the need for uniform standards concerning relations with the press.Conclusions: The majority of first authors in two leading medical journals reported substantial media coverage of their research, expressed generally positive sentiments about the press coverage of their work, and expressed a need for consensus on interactions involving the press. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Patients' expectations and the role they play in medical care are increasingly considered to be important, but the factors that influence these expectations have not been well studied.Objective: To examine the factors that influence patients' expectations for care in office practice.Design: Qualitative inquiry nested within a large clinical survey.Setting: Three general internal medicine practices in one mid-sized city in northern California.Patients: 688 patients visiting their internists' offices were surveyed (response rate, 86%); 88 patients who reported one or more omissions of care on a post-visit questionnaire and were available for a telephone interview 1 to 7 days after the visit were included in the qualitative inquiry.Measurements: Proportion of surveyed patients who reported one or more omissions of care, and qualitative analysis of the sources of patients' expectations, as determined from the telephone interviews. Interviews focused on the sources of expectations and perceptions of omission. Using an iterative process and working by consensus, investigators developed coding categories on a randomly selected 50% of the transcripts. The other 50% of the sample was used for validation.Results: The 125 patients who had unmet expectations perceived omissions that were related to physician preparation for the visit (23%), history taking (26%), physical examination (30%), diagnostic testing (28%), prescription of medication (19%), referral to specialists (26%), and physician-patient communication (15%). Unmet expectations were shaped by patients' current somatic symptoms (intensity of symptoms, functional impairment, duration of symptoms, and perceived seriousness of symptoms) (74%); perceived vulnerability to illness (related to age, family history, personal lifestyle, or previously diagnosed conditions) (50%); past experiences (personal or familial) with similar illnesses (42%); and knowledge acquired from physicians, friends, family, or the media (54%).Conclusions: Patients' expectations for care are derived from multiple sources; their complexity should discourage simple schemes for "demand management." Nevertheless, the results of this study may help physicians to take a more empathetic stance toward their patients' requests and to devise more successful strategies for clinical negotiation. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

To compare three different approaches to the measurement of patients' expectations for care, we conducted a randomized controlled trial. Medical outpatients (n = 318) of a small (six-physician), single-specialty (internal medicine), academically affiliated private practice in Sacramento, California, were contacted by telephone the night before a scheduled office visit and enrolled over a 5-month period in early 1994. Patients were randomly assigned to receive: (1) a self-administered, structured, previsit questionnaire combined with a postvisit questionnaire; (2) an interviewer-administered, semistructured, previsit interview combined with a postvisit questionnaire; or (3) a postvisit questionnaire only. We assessed the number and content of patients' expectations by previsit questionnaire versus interview; the interaction between sociodemographic characteristics and survey method in predicting number of reported expectations; the effect of unfulfilled expectations elicited by questionnaire and interview on visit satisfaction; and the effect of unfulfilled expectations elicited directly and indirectly on visit satisfaction. Patients reported more expectations by structured questionnaire than semistructured interview (median 12 vs 3, p = .0001). Although there was no main effect of sociodemographic characteristics on expectations, nonwhite patients reported more expectations than white patients by questionnaire and fewer by interview. The number of interventions desired before the visit but not received (indirectly reported unfulfilled expectations) was associated with lower visit satisfaction regardless of whether a questionnaire or interview was used to elicit previsit expectations (p value for the interaction between number of expectations and survey method, & gt; .20). Having more indirectly reported unfulfilled expectations was significantly associated with lower visit satisfaction even after controlling for the number of directly reported unfulfilled expectations (p = .021), but the incremental change in classification accuracy was small (increase in receiver-operating characteristic curve area, 3%). In conclusion, studies of patients' expectations for care must contend with a substantial "method effect." In this study from a single group practice, patients checked off more expectations using a structured questionnaire than they disclosed in a semistructured interview, but both formats predicted visit satisfaction. Asking patients about interventions received in relation to their previsit expectations added little to simply asking them directly about omitted care. The interaction of survey method with ethnicity and other sociodemographic characteristics requires further study. [ABSTRACT FROM AUTHOR]

Objective: To describe U.S. and Canadian medical journals, their editors, and policies that affect the dissemination of medical information.Design: Mailed survey.Participants: Senior editors of all 269 leading medical journals published at least quarterly in the United States and Canada, of whom 221 (82%) responded.Main Measures: The questionnaire asked about characteristics of journal editors and their journals and about journals' policies toward peer review, conflicts of interest, prepublication discussions with the press, and pharmaceutical advertisements.Results: The editors were overwhelmingly men (96%), middle-aged (mean age 61 years), and trained as physicians (82%). Although 98% claimed that their journals were "peer-reviewed," the editors differed in how they defined a "peer" and in the number of peers they deemed optimal for review. Sixty-three percent thought journals should check on reviewers' potential conflicts of interest, but only a minority supported masking authors' names and affiliations (46%), checking reviewers' financial conflicts of interest (40%), or revealing reviewers' names to authors (8%). The respondents advocated discussion of scientific findings with the press (84%), but only in accord with the Ingelfinger rule, i.e., after publication of the article (77%). Fifty-seven percent of the editors agreed that journals have a responsibility to ensure the truthfulness of pharmaceutical advertisements, and 40% favored subjecting advertisements to the same rigorous peer review as scientific articles.Conclusions: The responding editors were relatively homogeneous demographically and professionally, and they tended to support the editorial status quo. There was little sentiment in favor of tampering with the current peer-review system (however defined) or the Ingelfinger rule, but a surprisingly large percentage of the respondents favored more stringent review of drug advertisements. [ABSTRACT FROM AUTHOR]

Objective: To describe internal medicine patients' expectations for care during office visits and to examine the relationship between fulfillment of expectations for care and visit satisfaction.Design: Survey of patients and their physicians.Setting: The internal medicine practice of faculty and housestaff at a large academic center in Southern California.Patients: 396 patients aged 18 to 65 years were approached in the clinic waiting room prior to their scheduled visits; 337 (85%) agreed to participate and 304 (77%) turned in completed questionnaires. Postvisit physician surveys were received in 88% of the cases.Main Measurements: The patients' previsit reports of the elements of care they thought necessary for their physicians to provide; the patients' and physicians' postvisit reports of the elements of care actually provided; and the patients' satisfaction with care.Results: Among 28 specific elements of care, seven were considered necessary by a majority of the patients (examination of the eyes/ears/nose/throat, lungs, heart, and abdomen; blood testing; prognostic counseling; and discussion of patients' own ideas about management). A higher number of elements of care were thought necessary by patients who were nonwhite and had not completed college. Up to 38% of the patients reported not receiving elements of care they had considered necessary; specific agreement between physicians and patients about care not received ranged from 63% to 100%. Not receiving certain "necessary" elements of care was associated with lower visit satisfaction.Conclusion: Internal medicine patients at the center studied had specific expectations for the content of their physician visits. However, they routinely failed to receive some of the items they thought necessary. Unless patients' expectations are carefully elicited and dealt with the physician-patient relationship may be adversely affected. [ABSTRACT FROM AUTHOR]

Editorial. Comments on ethnic differences in the use of cardiovascular care services in the United States. Interrelation of access, quality, and equity; Need for care providers to ensure that services are delivered in an effective manner.

Background: Healthcare worker attitudes toward obese individuals facilitate discrimination and contribute to poor health outcomes. Previous studies have demonstrated medical student bias toward obese individuals, but few have examined effects of the educational environment on these prejudicial beliefs. We sought to determine whether an innovative educational intervention (reading a play about obesity) could diminish obesity prejudice relative to a standard medical lecture., Methods: We conducted a randomized, controlled trial enrolling medical students (n = 129) from three universities. Students were assigned to play-reading or a standard lecture. Explicit attitudes and implicit bias toward obese individuals were assessed prior to intervention and after four months., Results: At baseline, students demonstrated moderate explicit and implicit bias toward obese people despite high scores on empathy. Students randomized to the play-reading group had significantly decreased explicit fat bias (P = 0.01) at follow-up, while students in the lecture group showed increased endorsement of a prescriptive model of care at the expense of a patient-centered approach (P = 0.03). There was a significant increase in empathy for those in both the theater (P = 0.007) and lecture group (P = 0.02). The intervention had no significant effect on implicit bias or regard for obesity as a civil rights issue., Discussion: Dramatic reading may be superior to traditional medical lectures for showcasing patient rights and preferences. The present study demonstrates for the first time that play-reading diminishes conscious obesity bias. Further research should determine whether nontraditional methods of instruction promote improved understanding of and care for obese patients.

Objective: Our goal was to identify physician and patient characteristics associated with patient-centered beliefs about the sharing of information and power, and to determine how these beliefs and the congruence of beliefs between patients and physicians affect patients' evaluations., Study Design: Physicians completed a scale assessing their beliefs about sharing information and power, and provided demographic information. A sample of their patients filled out the same scale and made evaluations of their physicians before and after a target visit., Population: Physicians and patients in a large multispecialty group practice and a group model health maintenance organization were included. Forty-five physicians in internal medicine, family practice, and cardiology participated, as well as 909 of their patients who had a significant concern., Outcomes Measured: Trust in the physician was measured previsit, and visit satisfaction and physician endorsement were measured immediately postvisit., Results: Among patients, patient-centered beliefs (a preference for information and control) were associated with being women, white, younger, more educated, and having a higher income; among physicians these beliefs were unrelated to sex, ethnicity, or experience. The patients of patient-centered physicians were no more trusting or endorsing of their physicians, and they were not more satisfied with the target visit. However, patients whose beliefs were congruent with their physicians' beliefs were more likely to trust and endorse their physicians, even though they were not more satisfied with the target visit., Conclusions: The extent of congruence between physicians' and patients' beliefs plays an important role in determining how patients evaluate their physicians, although satisfaction with a specific visit and overall trust may be determined differently.

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.

Objectives: To examine patient, physician, and health care system characteristics associated with unvoiced desires for action, as well as the consequences of these unspoken requests., Patients and Methods: Patient surveys were administered before, immediately after, and 2 weeks after outpatient visits in the practices of 45 family practice, internal medicine, and cardiology physicians working in a multispecialty group practice or group model health maintenance organization. Data were collected at the index visit from 909 patients, of whom 97.6% were surveyed 2 weeks after the outpatient visit. Before the visit, patients rated their trust in the physician, health concerns, and health status. After the visit, patients reported on various types of unexpressed desires and rated their visit satisfaction. At follow-up, patients rated their satisfaction, health concerns, and health status, and also described their postvisit health care use. Evaluations of the visit were also obtained from physicians., Results: Approximately 9% of the patients had 1 or more unvoiced desire(s). Desires for referrals (16.5% of desiring patients) and physical therapy (8.2%) were least likely to be communicated. Patients with unexpressed desires tended to be young, undereducated, and unmarried and were less likely to trust their physician. Patients with unvoiced desires evaluated the physician and visit less positively; these encounters were evaluated by physicians as requiring more effort. Holding an unvoiced desire was associated with less symptom improvement, but did not affect postvisit health care use., Conclusions: Patients' unvoiced needs affect patients' and physicians' visit evaluations and patients' subjective perceptions of improvement. Implications of these findings for clinical practice are examined.

Objective: Recent reforms in the federal Medicaid program have attempted to integrate beneficiaries into the mainstream by providing them with managed care options. However, the effects of mainstreaming have not been systematically evaluated., Design: Cross-sectional survey., Setting/participants: A sample of 478 adult, nonelderly asthmatics followed by a large Northern California medical group., Measurements and Main Results: We examined differences in self-reported access by insurance status. Compared to patients with other forms of insurance, patients covered by the state's Medicaid program (Medi-Cal) were more likely to report access problems for asthma-related care, including difficulties in reaching a health care provider by telephone, obtaining a clinic appointment, and obtaining asthma medication. Adjusting for relevant clinical and sociodemographic variables, Medi-Cal patients were more likely to report at least one access problem compared to non-Medi-Cal patients (adjusted odds ratio [AOR], 3.34; 95% confidence interval [CI], 1.43 to 7.80). Patients reporting at least one access problem were also more likely to have made at least one asthma-related emergency department visit within the past year (AOR, 4.84; 95% CI, 2.41 to 9.72). Reported barriers to care did not translate into reduced patient satisfaction., Conclusions: Within this population of Medicaid patients, the provision of health insurance and care within the mainstream of an integrated health system was no guarantee of equal access as perceived by the patients themselves.

Objectives: To explore how parents communicate their preferences for antibiotics to their child's physician and to examine whether physicians can communicate why antibiotics are not being prescribed in a way that maintains satisfaction with the visit., Design: Previsit survey of parents, audiotaping of the study encounters, and a postvisit survey of parents and physicians., Setting: Two private pediatric practices., Participants: Ten physicians (response rate = 77%) and a consecutive sample of 295 eligible parents (response rate = 86%) who attended acute care visits for their children between October 1996 and March 1997., Main Outcome Measures: Physician-perceived pressure to prescribe antibiotics and parental visit-specific satisfaction., Results: Fifty percent of parents expressed a previsit expectation for antibiotics. Among these parents, only 1% made a direct verbal request for them. Even when no direct requests for antibiotics were made, physicians still perceived an expectation for antibiotics 34% of the time. Among parents who did not receive expected antibiotics, those offered a contingency plan from the physician (i.e., the possibility of receiving antibiotics in the future if their child did not get better) had a higher mean satisfaction score than parents not receiving a contingency plan (76 vs. 58.9; P<.05)., Conclusion: Physicians should consider providing a contingency plan to parents who expect antibiotics for their children when there is no clinical indication. Further study is needed to determine how parents indirectly communicate their desire for antibiotics and what additional communication techniques physicians can use to resist the overprescribing of antibiotics.

Purpose: An estimated 42% of cancer patients suffer from poorly controlled pain, in part because of patient-related barriers to pain control. The objective of this study was to evaluate the effect of an individualized education and coaching intervention on pain outcomes and pain-related knowledge among outpatients with cancer-related pain., Patients and Methods: English-speaking cancer patients (18 to 75 years old) with moderate pain over the past 2 weeks were randomly assigned to the experimental (n = 34) or control group (n = 33). Experimental patients received a 20-minute individualized education and coaching session to increase knowledge of pain self-management, to redress personal misconceptions about pain treatment, and to rehearse an individually scripted patient-physician dialog about pain control. The control group received standardized instruction on controlling pain. Data on average pain, functional impairment as a result of pain, pain frequency, and pain-related knowledge were collected at enrollment and 2-week follow-up., Results: At baseline, there were no significant differences between experimental and control groups in terms of average pain, functional impairment as a result of pain, pain frequency, or pain-related knowledge. At follow-up, average pain severity improved significantly more among experimental group patients than among control patients (P =.014). The intervention had no statistically significant impact on functional impairment as a result of pain, pain frequency, or pain-related knowledge., Conclusion: Compared with provision of standard educational materials and counseling, a brief individualized education and coaching intervention for outpatients with cancer-related pain was associated with improvement in average pain levels. Larger studies are needed to validate these effects and elucidate their mechanisms.

Objective: To examine the evaluation process for the CHAMPUS Reform Initiative (CRI) both to highlight issues that evaluators must consider when undertaking such projects and to provide policymakers with tools to better assess demonstration project evaluations., Data Sources: The CRI evaluation., Study Design: Case study., Data Collection: Review of CRI evaluation reports., Principal Findings: Although policymakers increasingly rely on the evaluations of demonstration projects to determine whether to extend the scope and funding of many public programs, the results of these evaluations are often difficult to assess. Despite its analytical sophistication, the CRI evaluation was no exception. The somewhat artificial time constraints imposed by policymakers made projection of the CRI's performance beyond the demonstration period particularly difficult., Conclusions: Much uncertainty generally remains even after well-planned and well-executed evaluations of demonstration projects.

Objective: To identify physicians' views regarding cost-containment and cost-effectiveness and their attitudes and experience using cost-effectiveness in clinical decision making., Design: A close-ended 30-item written survey., Subjects: 1,000 randomly selected physicians whose practices currently encompass direct patient care and who work in the California counties of Sacramento, Yolo, Placer, Nevada, and El Dorado., Outcome Measures: Physician attitudes about the role of cost and cost-effectiveness in treatment decisions, perceived barriers to cost-effective medical practice, and response of physicians and patients if there are conflicts about treatment that physicians consider either not indicated or not cost-effective., Results: Most physicians regard cost-effectiveness as an appropriate component of clinical decisions and think that only the treating physician and patient should decide what is cost-worthy. However, physicians are divided on whether they have a duty to offer medical interventions with remote chances of benefit regardless of cost, and they vary considerably in their interactions with patients when cost-effectiveness is an issue., Conclusion: Although physicians in the Sacramento region accept cost-effectiveness as important and appropriate in clinical practice, there is little uniformity in how cost-effectiveness decisions are implemented.

Background: The case for direct-to-consumer (DTC) prescription drug advertising has often been based on the argument that such promotions can educate the public about medical conditions and associated treatments. Our content analysis of DTC advertising assessed the extent to which such educational efforts have been attempted., Methods: We collected advertisements appearing in 18 popular magazines from 1989 through 1998. Two coders independently evaluated 320 advertisements encompassing 101 drug brands to determine if information appeared about specific aspects of the medical conditions for which the drug was promoted and about the treatment (mean kappa reliability=0.91). We employed basic descriptive statistics using the advertisement as the unit of analysis and cross-tabulations using the brand as the unit of analysis., Results: Virtually all the advertisements gave the name of the condition treated by the promoted drug, and a majority provided information about the symptoms of that condition. However, few reported details about the condition's precursors or its prevalence; attempts to clarify misconceptions about the condition were also rare. The advertisements seldom provided information about the drug's mechanism of action, its success rate, treatment duration, alternative treatments, and behavioral changes that could enhance the health of affected patients., Conclusions: Informative advertisements were identified, but most of the promotions provided only a minimal amount of information. Strategies for improving the educational value of DTC advertisements are considered.

Objectives: To evaluate a managed care demonstration project in CHAMPUS (Civilian Health and Medical Program of the Uniformed Services), the insurance program covering physical and mental health care services for the dependents of active duty military personnel, military retirees, and the retirees' dependents. The demonstration project added a health maintenance organization (HMO) option and a preferred provider organization (PPO) option to the standard CHAMPUS coverage and allowed beneficiaries to select the coverage option they preferred., Data Sources: Utilization, costs, access, and beneficiary satisfaction were measured using data from CHAMPUS claims records, the Defense Enrollment Eligibility Reporting System, the demonstration project contractor's HMO enrollment file, the contractor's list of network hospitals, and two surveys of CHAMPUS beneficiaries., Study Design: Changes in utilization at 11 demonstration sites were compared with changes in utilization at 11 matched control sites. The effect of the demonstration project on costs was evaluated by estimating the costs for the demonstration sites both with and without the managed care options based on data from the control sites. Access to care and satisfaction were compared between the demonstration sites and control sites based on beneficiary surveys., Data Collection: All claims in both demonstration and control sites were used in estimating utilization changes. Two mailed surveys were sent to a randomly selected sample of active duty and retiree households with CHAMPUS beneficiaries; the sample was stratified by beneficiary type (active duty or retiree) and site., Principle Findings: Overall utilization in the CHAMPUS system decreased at the demonstration sites but stayed approximately the same at the control sites. Utilization among the enrollees in the HMO demonstration option, however, increased dramatically. Patient access to care and satisfaction generally remained at the same levels at both demonstration and control sites, but enrollees in the HMO option reported higher satisfaction. Costs to the government at the demonstration areas, based on regression estimates from the control sites, were about the same or slightly higher than what they would have been under the standard CHAMPUS system., Conclusions: Managed care plans for large government-sponsored insurance programs can reduce utilization and maintain patient access and satisfaction. Careful structuring of such plans is needed, however, if they are to reduce costs.

Background: We conducted a content analysis of consumer-targeted prescription drug advertisements to explore trends in prevalence, shifts in the medical conditions for which drugs are promoted, reliance on financial and nonmonetary inducements, and appeals used to attract public interest., Methods: We collected the drug advertisements appearing in 18 consumer magazines from 1989 through 1998. Two judges independently coded each advertisement and placed it in a category pertaining to the target audience, use of inducements, and product benefits (mean kappa=0.93). We employed descriptive statistics, cross-tabulations, and curve estimation procedures., Results: A total of 320 distinct advertisements were identified, representing 101 brands and 14 medical conditions. New advertisement and brand introductions increased dramatically during this decade. Advertisements for drugs used for dermatologic, human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), and obstetric/gynecologic conditions were most common. Almost all of the advertisements were aimed at the potential user of the drug, not third-party intermediaries such as parents and spouses. Although most advertisements were gender-neutral, women were more likely to be exclusively targeted. One eighth of the advertisements offered a monetary incentive (eg, a rebate or money-back guarantee), and one third made an offer of additional information in printed or audio/video form. The most common appeals used were effectiveness, symptom control, innovativeness, and convenience., Conclusions: Consumer-directed prescription drug advertising has increased dramatically during the past decade. The pharmaceutical industry is turning to this type of advertising to generate interest in its products. Our data may be useful to physicians who want to stay abreast of the treatments that are being directly marketed to their patients.

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.

Objective: To test the ability of two different clinical practice guideline formats to influence physician ordering of electrodiagnostic tests in low back pain., Data Sources/study Design: Randomized controlled trial of the effect of practice guidelines on self-reported physician test ordering behavior in response to a series of 12 clinical vignettes. Data came from a national random sample of 900 U.S. neurologists, physical medicine physicians, and general internists., Intervention: Two different versions of a practice guideline for the use of electrodiagnostic tests (EDT) were developed by the U.S. Agency for Health Care Policy and Research Low Back Problems Panel. The two guidelines were similar in content but varied in the specificity of their recommendations., Data Collection: The proportion of clinical vignettes for which EDTs were ordered for appropriate and inappropriate clinical indications in each of three physician groups were randomly assigned to receive vignettes alone, vignettes plus the nonspecific version of the guideline, or vignettes plus the specific version of the guideline., Principal Findings: The response rate to the survey was 71 percent. The proportion of appropriate vignettes for which EDTs were ordered averaged 77 percent for the no guideline group, 71 percent for the nonspecific guideline group, and 79 percent for the specific guideline group (p = .002). The corresponding values for the number of EDTs ordered for inappropriate vignettes were 32 percent, 32 percent, and 26 percent, respectively (p = .08). Pairwise comparisons showed that physicians receiving the nonspecific guidelines ordered fewer EDTs for appropriate clinical vignettes than did physicians receiving no guidelines (p = .02). Furthermore, compared to physicians receiving nonspecific guidelines, physicians receiving specific guidelines ordered significantly more EDTs for appropriate vignettes (p = .0007) and significantly fewer EDTs for inappropriate vignettes (p = .04)., Conclusions: The clarity and clinical applicability of a guideline may be important attributes that contribute to the effects of practice guidelines.

Background: The goal of our investigation was to facilitate research on clinical negotiation between patients and physicians by developing a reliable and valid classification system for patients' requests in office practice., Methods: We developed the Taxonomy of Requests by Patients (TORP) using input from researchers, clinicians, and patient focus groups. To assess the system's reliability and validity, we applied TORP to audiotaped encounters between 139 patients and 6 northern California internists. Reliability was assessed with the kappa statistic as a measure of interrater agreement. Face validity was assessed through expert and patient judgment of the coding system. Content validity was examined by monitoring the incidence of unclassifiable requests. Construct validity was evaluated by examining the relationship between patient requests and patient health status; patient request fulfillment and patient satisfaction; and patient requests and physician perceptions of the visit., Results: The 139 patients made 772 requests (619 requests for information and 153 requests for physician action). Average interrater agreement across a sample of 40 cases was 94% (kappa = 0.93; P <.001). Patients with better health status made fewer requests (r = -0.17; P = .048). Having more chronic diseases was associated with more requests for physician action (r = 0.32; P = .0002). Patients with more unfulfilled requests had lower visit satisfaction (r = -0.32; P <.001). More patient requests was also associated with physician reports of longer visit times (P = .016) and increased visit demands (P = .006)., Conclusions: Our study provides evidence that TORP is a reliable and valid system for capturing and categorizing patients' requests in adult primary care. Further research is needed to confirm the system's validity, expand its applicability, and explore its usefulness as a tool for studying clinical negotiation.

Objective: Drug manufacturers are intensely promoting their products directly to consumers, but the impact has not been widely studied. Consumers' awareness and understanding of, attitudes toward, and susceptibility to direct-to-consumer (DTC) drug advertising were examined., Design: Random-digit dialing telephone survey with a random household member selection procedure (completion and response rates, 58% and 69%, respectively)., Setting: Respondents were interviewed while they were at their residences., Participants: Complete data were obtained from 329 adults in Sacramento County, California., Measurements and Main Results: Outcome measures included awareness of advertisements for 10 selected drugs, misconceptions about DTC advertising, attitudes toward DTC ads, and behavioral responses to such promotions. The influence of demographic characteristics, health status, attitudes, beliefs, and media exposure on awareness and behaviors was examined. On average, respondents were aware of advertisements for 3.7 of the 10 drugs; awareness varied from 8% for Buspar (buspirone) to 72% for Claritin (loratadine). Awareness was associated with prescription drug use, media exposure, positive attitudes toward DTC advertising, poorer health, and insurance status. Substantial misconceptions were revealed; e.g., 43% thought that only "completely safe" drugs could be advertised. Direct-to-consumer advertisements had led one third of respondents to ask their physicians for drug information and one fifth to request a prescription., Conclusions: Direct-to-consumer advertisements are reaching the public, but selectively so, and affecting their behaviors. Implications for public policy are examined.