Search

Purpose: Social class is increasingly being recognized as an important factor in the development of population-based variation in health among teens. However, little consensus exists regarding its measurement or conceptualization. Methods: This study examined beliefs about social class of 48 working class and 50 upper middle class 16-year-old, white teens. Results: Working class teens were more likely to misclassify themselves with regard to social class position. Significant class differences were present in beliefs regarding social mobility, parents' equity, equality of opportunity within society, and financial status as adults. How this conceptualization of social class translates into population-based variation in health remains an important area for further inquiry.

A growing scientific literature highlights concern about the influence of social bias in medical care. Differential treatment of male and female patients has been among the documented concerns. Yet, little is known about the extent to which differential treatment of male and female patients reflects the influence of social bias or of more acceptable factors, such as different patient preferences or different anticipated outcomes of care. This paper attempts to ascertain the underlying basis for an observed differential in physicians' tendency to advice activity restrictions for male and female patients. We explore the extent to which the gender-based treatment differential is attributable to: (1) patients' health profile, (2) patients' role responsibilities, (3) patients' illness behaviors, and (4) physician characteristics. These four categories of variables correspond to four prominent social science hypotheses concerning gender differences in health and health care utilization (i.e, biological basis hypothesis, fixed role hypothesis, socialization hypothesis, physician bias hypothesis). Data are drawn from the Medical Outcomes Study (MOS), a longitudinal observational study of 1546 patients of 349 physicians practicing in three U.S. cities. Multivariate logistic regression is used to evaluate the likelihood of physician-prescribed activity restrictions for male and female patients, and to explore the absolute and relative influence of patient and physician factors on the observed treatment differential. Results reveal that the odds of prescribed activity restrictions are 3.6 times higher for female patients than for males with equivalent characteristics. The observed differential is not explained by differences in male and female patients' health or role responsibilities. Gender differences in illness behavior and physician gender biases both appear to contribute to the observed differential. Female patients exhibit more illness behavior than males, and these behaviors increase physicians' tendency to prescribe activity restrictions. After accounting for illness behavior differences and all other factors, the odds of prescribed activity restrictions among female patients of male physicians is four times that of equivalent male patients of those physicians. Medical practice, education, and research must strive to identify and remove the likely unconscious role of social bias in medical decision making.

Interest has increased in recent years in incorporating health status measures into clinical practice for use at the individual-patient level. We propose six measurement standards for individual-patient applications: (1) practical features, (2) breadth of health measured, (3) depth of health measured, (4) precision for cross-sectional assessment, (5) precision for longitudinal monitoring and (6) validity. We evaluate five health status surveys (Functional Status Questionnaire, Dartmouth COOP Poster Charts, Nottingham Health Profile, Duke Health Profile, and SF-36 Health Survey) that have been proposed for use in clinical practice. We conducted an analytical literature review to evaluate the six measurement standards for individual-patient applications across the five surveys. The most problematic feature of the five surveys was their lack of precision for individual-patient applications. Across all scales, reliability standards for individual assessment and monitoring were not satisfied, and the 95% CIs were very wide. There was little evidence of the validity of the five surveys for screening, diagnosing, or monitoring individual patients. The health status surveys examined in this paper may not be suitable for monitoring the health and treatment status of individual patients. Clinical usefulness of existing measures might be demonstrated as clinical experience is broadened. At this time, however, it seems that new instruments, or adaptation of existing measures and scaling methods, are needed for individual-patient assessment and monitoring.

Everywhere throughout the United States serious discussions are being held in search for the political and financial means to greatly expand the capacity and quality of early childhood development and education (ECDE) programs. A principal factor propelling this movement forward is clear evidence from the sciences of brain and child development that interventions in early childhood development and education can have a substantial benevolent and lasting effect throughout the life course of children and families. Significant portions of this volume are devoted to the scientific evidence.

The concepts described by Levitt in chapter 1 and by National Scientific Council on the Developing Child in chapter 2 can be depicted thus

Beginning in 2003, under the leadership of the Texas Early Childhood Education Coalition (TECEC) and the James A. Baker III Institute for Public Policy, Rice University, with input from hundreds of individuals from early childhood community organizations across the state, The Texas Plan (TTP) was formulated. The Texas Plan, now in its second edition, is a comprehensive document comprised of 50 specific public policy recommendations to establish a statewide program for early childhood development and education (ECDE) for all 3- and 4-year-old children in Texas. Recommendations include those for governance, administration, technical assistance, financing, standards and assessments, and more. TECEC and its 230 member organizations have provided information documents, knowledge summaries, and feedback on drafts for legislative consideration. ECDE is the only substantive issue considered in these four years that has garnered bipartisan support from the legislature. The comprehensive system envisioned by TTP does not yet exist. A beginning has been made. Popular and political traction is building. The Texas Plan is summarized in this chapter.

Background Population studies conducted in Sweden have revealed an association between attendance at cultural activities and health. Using data from US residents, we examined whether the association could be observed in the US. Methods Participants in the current study included 1,244 individuals who participated in the 1998 General Social Survey. Results A significant association between cultural activities and self-reported health (SRH) was observed, even after controlling for age, gender, marital status, race, number of children, subjective social class, employment status, household income, and educational attainment. Specifically, the more cultural activities people reported attending, the better was their SRH. Conclusion The data confirm that an association between cultural activity and health is present in a US sample. The data do not mean that the association is causal, but they suggest that further longitudinal research is warranted.

This paper contributes to a growing understanding of U.S. black-white health disparities by using national-level data to disaggregate the health status of black Americans into the following subgroups: U.S.-born blacks, black immigrants from Africa, black immigrants from the West Indies, and black immigrants from Europe. Using new data on the 2000 and 2001 National Health Interview Surveys (NHIS), the authors compare the status of U.S.- and foreign-born blacks to that of U.S.-born whites on three measures of health. The analysis finds that U.S.-born and European-born blacks have worse self-rated health, higher odds of activity limitation, and higher odds of limitation due to hypertension compared to U.S.-born whites. In contrast, African-born blacks have better health than U.S.-born whites on all three measures, while West Indian-born blacks have poorer self-rated health and higher odds of limitation due to hypertension but lower odds of activity limitation. These findings suggest that grouping together foreign-born blacks misses important variations within this population. Rather than being uniform, the black immigrant health advantage varies by region of birth and by health status measure. The authors conclude by exploring the implications of these findings for researchers, health professionals, and public policy.

This chapter will provide a modern definition of health that emphasizes health’s social context, summarize evidence for the view that the social determinants of health are paramount, and provide a conceptual framework for the production of health that accounts for differential vulnerability to disease according to the social hierarchy. A conjecture will be offered to explain how social characteristics are received as sensory stimuli by man and translated into biological signals that are antecedent to disease that becomes clinically manifest later in life. An emphasis on societal characteristics as powerful determinants of a population’s health has important relevance to policy formulations if the goal is to improve health.

To determine if patient assessments (reports and ratings) of primary care differ by patient ethnicity.A self-administered patient survey of 6,092 Massachusetts employees measured seven defining characteristics of primary care: (1) access (financial, organizational); (2) continuity (longitudinal, visit based); (3) comprehensiveness (knowledge of patient, preventive counseling); (4) integration; (5) clinical interaction (communication, thoroughness of physical examinations); (6) interpersonal treatment; and (7) trust. The study employed a cross-sectional observational design.Asians had the lowest primary care performance assessments of any ethnic group after adjustment for socioeconomic and other factors. For example, compared to whites, Asians had lower scores for communication (69 vs. 79, p = .001) and comprehensive knowledge of patient (56 vs. 48, p = .002), African Americans and Latinos had less access to care, and African Americans had less longitudinal continuity than whites.We do not know what accounts for the observed differences in patient assessments of primary care. The fact that patient reports as well as the more subjective ratings of care differed by ethnicity suggests that quality differences might exist that need to be addressed.

Four conceptual frameworks provide bases for constructing comprehensive public policy strategies for improving population health within wealthy (OECD) nations. (1) Determinants of population health. There are five broad categories: genes and biology, medical care, health behaviors, the ecology of all living things, and social/societal characteristics. (2) Complex systems: Linear effects models and multiple independent effects models fail to yield results that explain satisfactorily the dynamics of population health production. A different method (complex systems modeling) is needed to select the most effective interventions to improve population health. (3) An intervention framework for population health improvement. A two-by-five grid seems useful. Most intervention strategies are either ameliorative or fundamentally corrective. The other dimension of the grid captures five general categories of interventions: child development, community development, adult self-actualization, socioeconomic well-being, and modulated hierarchical structuring. (4) Public policy development process: the process has two phases. The initial phase, in which public consensus builds and an authorizing environment evolves, progresses from values and culture to identification of the problem, knowledge development from research and experience, the unfolding of public awareness, and the setting of a national agenda. The later phase, taking policy action, begins with political engagement and progresses to interest group activation, public policy deliberation and adoption, and ultimately regulation and revision. These frameworks will be applied to help understand the 39 recommendations of the Independent Inquiry into Inequalities in Health, the Sir Donald Acheson Report from the United Kingdom, which is the most ambitious attempt to date to develop a comprehensive plan to improve population health.

The authors propose a model memorandum of collaboration for use by state and community partnerships, support organizations, and grantmakers in working together to build healthier communities. Described as an idealized social contract, the model memorandum lays out interrelated responsibilities for the key parties.

Substantial research links many of the defining characteristics of primary care to important outcomes; yet little is known about the relative importance of each characteristic, and several characteristics have not been examined. These analyses evaluate the relationship between seven defining elements of primary care (accessibility, continuity, comprehensiveness, integration, clinical interaction, interpersonal treatment, and trust) and three outcomes (adherence to physician's advice, patient satisfaction, and improved health status).Data were derived from a cross-sectional observational study of adults employed by the Commonwealth of Massachusetts (N = 7204). All patients completed a validated questionnaire, the Primary Care Assessment Survey. Regression methods were used to examine the association between each primary care characteristic (11 summary scales measuring 7 elements of care) and each outcome.Physicians' comprehensive ("whole person") knowledge of patients and patients' trust in their physician were the variables most strongly associated with adherence, and trust was the variable most strongly associated with patients' satisfaction with their physician. With other factors equal, adherence rates were 2.6 times higher among patients with whole-person knowledge scores in the 95th percentile compared with the 5th percentile (44.0% adherence vs 16.8% adherence, P.001). The likelihood of complete satisfaction was 87.5% for those with 95th percentile trust scores compared with 0.4% for patients with 5th percentile trust scores (P.001). The leading correlates of self-reported health improvements were integration of care, thoroughness of physical examinations, communication, comprehensive knowledge of patients, and trust (P.001).Patients' trust in their physician and physicians' knowledge of patients are leading correlates of three important outcomes of care. The results are noteworthy in the context of pervasive changes in our nation's health care system that are widely viewed as threatening to the quality of physician-patient relationships.

The authors examine the data quality and measurement performance of the Primary Care Assessment Survey (PCAS), a patient-completed questionnaire that operationalizes formal definitions of primary care, including the definition recently proposed by the Institute of Medicine Committee on the Future of Primary Care.The PCAS measures seven domains of care through 11 summary scales: accessibility (organizational, financial), continuity (longitudinal, visit-based), comprehensiveness (contextual knowledge of patient, preventive counseling), integration, clinical interaction (clinician-patient communication, thoroughness of physical examinations), interpersonal treatment, and trust. Data from a study of Massachusetts state employees (n = 6094) were used to evaluate key measurement properties of the 11 PCAS scales. Analyses were performed on the combined population and for each of the 16 subgroups defined according to sociodemographic and health characteristics.The 11 PCAS scales demonstrated consistently strong measurement characteristics across all subgroups of this adult population. Tests of scaling assumptions for summated rating scales were well satisfied by all Likert-scaled measures. Assessment of data completeness, scale score dispersion characteristics, and inter-scale correlations provide strong evidence for the soundness of all scales, and for the value of separately measuring and interpreting these concepts.With public and private sector policies increasingly emphasizing the importance of primary care, the need for tools to evaluate and improve primary care performance is clear. The PCAS has excellent measurement properties, and performs consistently well across varied segments of the adult population. Widespread application of an assessment methodology, such as the PCAS, will afford an empiric basis through which to measure, monitor, and continuously improve primary care.

The US Preventive Services Task Force recommends that physicians assess patients' health risk behaviors, addressing those needing modification.To examine the relationship between patient income, health risk behaviors, the prevalence of physician discussion of these behaviors, and the receptiveness of patients to their physicians' advice.Employee survey.A random sample of 6549 Massachusetts state employees in 12 health plans.Data were obtained using a patient-completed mail survey. Trend tests were used to discern differences in the prevalence of health risk behaviors, physician discussion of these behaviors, and patient receptiveness to discussions by patient income.Although unhealthy behaviors were common among all income groups, physician discussion of health risk behaviors fell far short of the universal risk assessment recommended by the US Preventive Services Task Force. Low-income patients were more likely to be obese and smoke than high-income patients and were less likely to wear seat belts and exercise. In contrast, stress and alcohol consumption increased with income, while the proportion of heavy drinkers did not vary significantly. Physicians were more likely to discuss diet and exercise with high-income patients in need of these discussions than with low-income patients, but were more likely to discuss smoking with low-income patients who smoked than with high-income patients who smoked. Among patients with whom discussions occurred, low-income patients were much more likely to report attempting to change their behavior based on physician advice.Physician counseling of patients regarding health risk behaviors should be greatly improved if the US Preventive Services Task Force recommendations are to be fulfilled. Improvement is especially needed in regard to alcohol consumption, safe sex, and seat belt use. Physicians also need to be more vigilant in properly identifying and counseling low-income patients at risk in regard to diet and exercise and high-income patients who smoke.

To examine how Asian-American patients' ratings of primary care performance differ from those of whites. Latinos, and African-Americans.Retrospective analyses of data collected in a cross-sectional study using patient questionnaires.University hospital primary care group practice.In phase 1, successive patients who visited the study site for appointments were asked to complete the survey. In phase 2, successive patients were selected who had most recently visited each physician, going back as far as necessary to obtain 20 patients for each physician. In total, 502 patients were surveyed, 5% of whom were Asian-American.After adjusting for potential confounders, Asian-Americans rated overall satisfaction and 10 of 11 scales assessing primary care significantly lower than whites did. Dimensions of primary care that were assessed include access, comprehensiveness of care, integration, continuity, clinical quality, interpersonal treatment, and trust. There were no differences for the scale of longitudinal continuity. On average, the rating scale scores of Asian-Americans were 12 points lower than those of whites (on 100-point scales).We conclude that Asian-American patients rate physicians primary care performance lower than do whites, African-Americans, and Latinos. Future research needs to focus on Asian-Americans to determine the generalizability of these findings and the extent to which they reflect differences in survey response tendencies or actual quality differences.

To compare physical and mental health outcomes of chronically ill adults, including elderly and poor subgroups, treated in health maintenance organization (HMO) and fee-for-service (FFS) systems.A 4-year observational study of 2235 patients (18 to 97 years of age) with hypertension, non-insulin-dependent diabetes mellitus (NIDDM), recent acute myocardial infarction, congestive heart failure, and depressive disorder sampled from HMO and FFS systems in 1986 and followed up through 1990. Those aged 65 years and older covered under Medicare and low-income patients (200% of poverty) were analyzed separately.Offices of physicians practicing family medicine, internal medicine, endocrinology, cardiology, and psychiatry, in HMO and FFS systems of care. Types of practices included both prepaid group (72% of patients) and independent practice association (28%) types of HMOs, large multispecialty groups, and solo or small, single-specialty practices in Boston, Mass, Chicago, Ill, and Los Angeles, Calif.Differences between initial and 4-year follow-up scores of summary physical and mental health scales from the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) for all patients and practice settings.On average, physical health declined and mental health remained stable during the 4-year follow-up period, with physical declines larger for the elderly than for the nonelderly (P.001). In comparisons between HMO and FFS systems, physical and mental health outcomes did not differ for the average patient; however, they did differ for subgroups of the population differing in age and poverty status. For elderly patients (those aged 65 years and older) treated under Medicare, declines in physical health were more common in HMOs than in FFS plans (54% vs 28%; P.001). In 1 site, mental health outcomes were better (P.05) for elderly patients in HMOs relative to FFS but not in 2 other sites. For patients differing in poverty status, opposite patterns of physical health (P.05) and for mental health (P.001) outcomes were observed across systems; outcomes favored FFS over HMOs for the poverty group and favored HMOs over FFS for the nonpoverty group.During the study period, elderly and poor chronically ill patients had worse physical health outcomes in HMOs than in FFS systems; mental health outcomes varied by study site and patient characteristics. Current health care plans should carefully monitor the health outcomes of these vulnerable subgroups.

To examine differences in the quality of primary care delivered in prepaid and fee-for-service (FFS) health care systems.Longitudinal study of 1208 adult patients with chronic disease whose health insurance was through a traditional indemnity (FFS) plan, an independent practice association (IPA), or a health maintenance organization (HMO). Both IPA and HMO represent prepaid care systems. Patient- and physician-provided information was obtained by self-administered questionnaires.A total of 303 physician offices (family medicine, general internal medicine, endocrinology, or cardiology) in solo and group practices in three US cities.Seven indicators of primary care quality--accessibility (financial and organizational), continuity, comprehensiveness, coordination, and accountability (interpersonal and technical) of care. Performance on each was evaluated in FFS, IPA, and HMO settings. Analyses controlled for patient and physician characteristics.Financial access was highest in prepaid systems. Organizational access, continuity, and accountability were highest in the FFS system. Coordination was highest and comprehensiveness was lowest in HMOs.The results mark notable differences in core dimensions of primary care quality in each of three payment systems and raise questions regarding the associated cost inefficiencies and outcomes of care. In the current health care delivery reform climate, these findings call for consideration of the relative strengths and weaknesses of each system. We suggest strategies for elevating performance in each.

Medical education will change from within in response to continued advances in biological sciences and technology, but changes that are occurring outside the natural sciences can have greater impact, especially (1) the reconceptualization of the meaning of health, (2) the increase in the number and range of different health improvement strategies, (3) the growing awareness of the paradox of the relatively low health status of the U.S. population and high per-capita and national health care expenditures, and (4) shifts in the causes of illness and death. These changes make it necessary for medical students to be given a foundation in both the natural and the social sciences, for most ill health has causal roots in both the social and physical environment, even though it is not understood how some of these outside influences are translated into disease or biologic derangements that lead to disease. Consideration should be given to changes in medical education that include (1) interpreting the sociology as well as the biology of health, (2) expanding the horizons of medicine to incorporate health improvement as well as disease cure, (3) training for population-based health care at the community level, and (4) learning to assess medical outcomes with more than biometric measures to include measurements of functioning and well-being. The author presents in detail a health input-output model to show the complex interrelationships of socio-ecologic (i.e., outside) factors and the individual's genetic-biologic makeup (inside factors) that determine the individual's state of health.

To determine differences in the mix of patients among medical specialties and among organizational systems of care.Cross-sectional analysis of 20,158 adults (greater than or equal to 18 years of age) who visited providers' offices during 9-day screening periods in 1986. Patient and physician information was obtained by self-administered, standardized questionnaires.Offices of 349 physicians practicing family medicine, internal medicine, endocrinology, and cardiology within health maintenance organizations, large multispecialty groups, and solo or small single-specialty group practices in three major US cities.Demographic characteristics, prevalence of chronic disease, disease-specific severity of illness, and functional status and well-being.Among patients with selected physician-reported chronic illnesses (diabetes, hypertension, recent myocardial infarction, or congestive heart failure), increasing levels of severity were associated with decreasing levels of functional status and well-being and with increased hospitalizations, more physician visits, and higher numbers of prescription drugs. Compared with patients of general internists, patients of cardiologists were older (56 vs 47 years, P less than .01), had worse functional status and well-being scores (P less than .01), and carried more chronic diagnoses (mean 1.32 vs 1.02, P less than .01); patients of family practitioners were younger (40 vs 47 years, P less than .01) and more functional (P less than .01), carried fewer chronic diagnoses (0.70 vs 1.02, P less than .01), and (among diabetic patients only) had lower disease-specific severity scores (2.06 vs 2.30 on a five-point scale, P less than .01). Compared with patients in health maintenance organizations, patients visiting solo practitioners under fee-for-service payment were older (50 vs 45 years, P less than .01) and sicker (had worse physical functioning) and had a higher mean number of chronic diagnoses (1.10 vs 0.93, P less than .01).Patient mix is related to utilization and differs significantly across medical specialties and systems of care. These differences must be taken into account when interpreting variations in utilization and outcomes across specialties and systems, and when considering alternative policies for payment.

Excerpt The article by Wachtel and colleagues concerning quality of life in persons with human immunodeficiency virus (HIV) infection, published in this issue (1), is noteworthy in at least two way...

Primary care performance has been shown to differ under different models of health care delivery, even among various models of managed care. Pervasive changes in our nation's health care delivery systems, including the emergence of new forms of managed care, compel more current data.To compare the primary care received by patients in each of 5 models of managed care (managed indemnity, point of service, network-model health maintenance organization [HMO], group-model HMO, and staff-model HMO) and identify specific characteristics of health plans associated with performance differences.Cross-sectional observational study of Massachusetts adults who reported having a regular personal physician and for whom plan-type was known (n = 6018). Participants completed a validated questionnaire measuring 7 defining characteristics of primary care. Senior health plan executives provided information about financial and nonfinancial features of the plan's contractual arrangements with physicians.The managed indemnity system performed most favorably, with the highest adjusted mean scores for 8 of 10 measures (P.05). Point of service and network-model HMO performance equaled the indemnity system on many measures. Staff-model HMOs performed least favorably, with adjusted mean scores that were lowest or statistically equivalent to the lowest score on all 10 scales. Among network-model HMOs, several features of the plan's contractual arrangement with physicians (ie, capitated physician payment, extensive use of clinical practice guidelines, financial incentives concerning patient satisfaction) were significantly associated with performance (P.05).With US employers and purchasers having largely rejected traditional indemnity insurance as unaffordable, the results suggest that the current momentum toward open-model managed care plans is consistent with goals for high-quality primary care, but that the effects of specific financial and nonfinancial incentives used by plans must continue to be examined.

Context. —The US Preventive Services Task Force recommends that physicians assess patients' health risk behaviors, addressing those needing modification. Objective. —To examine the relationship between patient income, health risk behaviors, the prevalence of physician discussion of these behaviors, and the receptiveness of patients to their physicians' advice. Design. —Employee survey. Particpants. —A random sample of 6549 Massachusetts state employees in 12 health plans. Main Outcome Measures. —Data were obtained using a patient-completed mail survey. Trend tests were used to discern differences in the prevalence of health risk behaviors, physician discussion of these behaviors, and patient receptiveness to discussions by patient income. Results. —Although unhealthy behaviors were common among all income groups, physician discussion of health risk behaviors fell far short of the universal risk assessment recommended by the US Preventive Services Task Force. Low-income patients were more likely to be obese and smoke than high-income patients and were less likely to wear seat belts and exercise. In contrast, stress and alcohol consumption increased with income, while the proportion of heavy drinkers did not vary significantly. Physicians were more likely to discuss diet and exercise with high-income patients in need of these discussions than with low-income patients, but were more likely to discuss smoking with low-income patients who smoked than with high-income patients who smoked. Among patients with whom discussions occurred, low-income patients were much more likely to report attempting to change their behavior based on physician advice. Conclusions. —Physician counseling of patients regarding health risk behaviors should be greatly improved if the US Preventive Services Task Force recommendations are to be fulfilled. Improvement is especially needed in regard to alcohol consumption, safe sex, and seat belt use. Physicians also need to be more vigilant in properly identifying and counseling low-income patients at risk in regard to diet and exercise and high-income patients who smoke.

To explore how gender and social class affect perceptions of health status among 16-year-old adolescents.Cross-sectional survey.University psychology laboratory. PARTICIPANS: Fifty upper-middle-class and 48 working-class adolescents stratified by gender.The general health perceptions (GHP) scale of the Medical Outcomes Survey 36-Item Short Form Health Survey (SF-36). The other self-reported health status domains and 3 measures of different aspects of psychological well-being were included as covariates in analysis of variance models.Upper-middle-class females reported the lowest and upper-middle-class males the highest GHP (76.7 vs 88.4, P=.003). A multivariate regression model (adjusted R2=0.08) revealed significant gender (P=.03) differences in GHP, but not a social class effect, and an interaction effect between gender and class (P=.01). With addition of psychological well-being covariates (P.001), gender remained significant (P=.04) and a significant portion of the interaction effect (P=.13) was explained. When the self-reported physical health status scales (P.001) were added to the model (adjusted R2=0.51), gender remained significant (P=.03) and the interaction effect was partially explained (P=.07).Gender is a crucial factor in understanding the complex relationships between sociostructural inequalities and health differentials. These data suggest that psychological well-being and self-reported physical health status mediate the effects of gender and the gender and social class interaction in explaining variation in GHP. Contrary to the social class gradient hypothesis, upper-middle-class females reported the lowest GHP. These results suggest that the paradigms applicable to early childhood and adulthood may not be appropriate to understand the complex dynamics of adolescence.

In Reply. —We agree with the need for better understanding quasi-experimental (observational) methods for monitoring health care. Methods like those used in the MOS 1 will provide most of the information about changes in the utilization of health care services and health outcomes following health care reform. We disagree with Drs Barrett and Juhn that MOS conclusions were based on "inconsistent results" and "novel" contrasts. Contrasts were planned in advance, 1 and results were consistent. 2 As documented in Tables 4 and 5 of our article 2 for analyses of both average changes and categories of change, we could reject the hypothesis that the differences between FFS and HMO systems in physical health were the same across elderly and nonelderly and across poor and nonpoor subgroups. The change score cut points were based on other studies 3,4 and were not subject to gaming. Including elderly patients who died in the worse category

Objective. —To compare physical and mental health outcomes of chronically ill adults, including elderly and poor subgroups, treated in health maintenance organization (HMO) and fee-for-service (FFS) systems. Study Design. —A 4-year observational study of 2235 patients (18 to 97 years of age) with hypertension, non—insulin-dependent diabetes mellitus (NIDDM), recent acute myocardial infarction, congestive heart failure, and depressive disorder sampled from HMO and FFS systems in 1986 and followed up through 1990. Those aged 65 years and older covered under Medicare and low-income patients (200% of poverty) were analyzed separately. Setting and Participants. —Offices of physicians practicing family medicine, internal medicine, endocrinology, cardiology, and psychiatry, in HMO and FFS systems of care. Types of practices included both prepaid group (72% of patients) and independent practice association (28%) types of HMOs, large multispecialty groups, and solo or small, single-specialty practices in Boston, Mass, Chicago, III, and Los Angeles, Calif. Outcome Measures. —Differences between initial and 4-year follow-up scores of summary physical and mental health scales from the Medical Outcomes Study 36-ltem Short-Form Health Survey (SF-36) for all patients and practice settings. Results. —On average, physical health declined and mental health remained stable during the 4-year follow-up period, with physical declines larger for the elderly than for the nonelderly (P Conclusions. —During the study period, elderly and poor chronically ill patients had worse physical health outcomes in HMOs than in FFS systems; mental health outcomes varied by study site and patient characteristics. Current health care plans should carefully monitor the health outcomes of these vulnerable subgroups.

Although studies of adult and young children's health have clearly demonstrated the existence of a social class gradient, information regarding the gradient's relationship to adolescent health is lacking. This study examines whether adolescents from working class (WC) backgrounds report poorer health status than teens from upper middle class (UMC) backgrounds. A consecutive sample of 100 teens stratified by social class and gender was identified for participation in an experiment of biobehavioral correlates of social class identity. Inclusion criteria were:White, 16-17 years old, not adopted, lived in US since age 2, B to A- GPA for the past 2 years, and correct class position. Parental interviews determined eligibility and class position based on information regarding parental education and occupation and household income. This analysis utilizes self-report data collected prior to the experiment assessing health status [MOS SF-36 which measures 7 health domains including general health perceptions (GHP)] and psychological traits(optimism, mastery, social self efficacy, self esteem and sense of control) used as covariates. Self esteem and sense of control measures were not used in analyses due to poor internal reliability. 98 subjects completed the survey. Mean GHP scores ranged from 76.2 to 88.4 (P=0.006). UMC females reported the worst GHP, UMC males the best. There were no significant differences between groups in covariates or SF-36 scales other than GHP. For GHP differences, ANOVA revealed a significant effect for gender (P=0.026) but not for social class and an interaction effect between gender and class(P=0.014). When covariates were entered into the model, they explained a significant portion of the interaction effect (Pcov

Richard Cooper's article in this issue of JAMA titled "Perspectives on the Physician Workforce to the Year 2020" ignites controversy. 1 Cooper, extrapolating from physician staffing patterns in group- or staff-model health maintenance organizations (HMOs), forecasts the physician surplus to be trivial in the year 2000 and nonexistent by the year 2020 (his Figure 1). He proclaims that the contradiction of his forecast with the reports of the Graduate Medical Education National Advisory Committee (GMENAC) in 1981, 2 Weiner in 1994 and 1995, 3,4 the Council on Graduate Medical Education in 1994, 5 and the Bureau of Health Professions of the US Department of Health and Human Services in 1995 6 is attributable to the use of insupportable assumptions in the other studies. Cooper believes that newer data now available for US population projections, HMO staffing patterns, and physician work effort justify the assumptions he has adopted. See also p

Objective. —To compare the outcomes of patients with hypertension and non— insulin-dependent diabetes mellitus (NIDDM) who were cared for in three different systems of care and by generalist and subspecialist physicians. Design. —An observational study with follow-up at three periods: (1) a 2-year study of 532 patients with hypertension and 170 patients with NIDDM who had entrance and exit histories, physical examinations, and laboratory tests; (2) a 4-year follow-up of 1044 patients with hypertension and 317 patients with NIDDM based on patient-reported functional status; and (3) 7-year mortality for 1296 patients with hypertension and 424 patients with NIDDM. Setting and Participants. —Patients sampled from health maintenance organizations, large multispecialty groups, and solo or single-specialty group practices in Boston, Mass, Los Angeles, Calif, and Chicago, Ill. Patients were designated as belonging to one of three systems of care: fee for service; prepaid patients in solo or small single-specialty groups or in large multispecialty group practices, referred to as independent practice associations; and staff-model health maintenance organizations. The principal providers were family practitioners, general internists, cardiologists, or endocrinologists. Main Outcome Measures. —Physiological, functional, and mortality. For hypertension, we measured blood pressure and stroke incidence. For NIDDM, we measured blood pressure, glycosylated hemoglobin level, visual function, vibration sense, ulcers and infections in the feet, and albumin excretion rate. Functional outcomes were assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Mortality was assessed for the 7 years following the entrance examination. Results. —We found no evidence that any one system of care or physician specialty achieved consistently better 2-year or 4-year outcomes than others for patients with NIDDM or hypertension. Endocrinologists appeared to achieve better foot-ulcer and infection outcomes for patients with NIDDM, particularly when compared with family practitioners. However, no other specialist differences were found in any individual measures for either condition. Moreover, no adjusted mortality differences among systems or among physician specialties were observed in the 7-year follow-up period. Conclusion. —No meaningful differences were found in the mean health outcomes for patients with hypertension or NIDDM, whether they were treated by different care systems or by different physician specialists. Although prepaid medicine relies more heavily on generalist physicians than does fee for service, there is no evidence from these analyses that the quality of care of moderately ill patients with these two common diseases was adversely affected. These findings must be viewed in light of the historically higher costs of fee-for-service medicine and of subspecialty physician practice. (JAMA. 1995;274:1436-1444)

In Reply. —Dr Loftman's comments point to two important but separate issues. The first relates to whether indemnity (fee-for-service) insurance can fairly be considered separately from managed care. The second relates to whether employer-provided coverage can fairly be categorized as fee-for-service. With regard to the first point, we agree that there is an increasingly important distinction between traditional indemnity insurance and indemnity insurance with utilization review, sometimes called managed indemnity coverage. In 1994, traditional indemnity insurance is increasingly rare. But at the time that our data were collected (1986 to 1988), the distinction between traditional and managed indemnity insurance was much less important; traditional indemnity was the dominant form of indemnity coverage nationally and in our study. With regard to the second point, Loftman notes that the only true fee-for-service plan is indemnity insurance purchased by individuals (not employers or government) with no utilization review component. This form of coverage

Objective. —To examine differences in the quality of primary care delivered in prepaid and fee-for-service (FFS) health care systems. Study Design. —Longitudinal study of 1208 adult patients with chronic disease whose health insurance was through a traditional indemnity (FFS) plan, an independent practice association (IPA), or a health maintenance organization (HMO). Both IPA and HMO represent prepaid care systems. Patient- and physician-provided information was obtained by self-administered questionnaires. Setting. —A total of 303 physician offices (family medicine, general internal medicine, endocrinology, or cardiology) in solo and group practices in three US cities. Outcomes Measures. —Seven indicators of primary care quality—accessibility (financial and organizational), continuity, comprehensiveness, coordination, and accountability (interpersonal and technical) of care. Performance on each was evaluated in FFS, IPA, and HMO settings. Analyses controlled for patient and physician characteristics. Results. —Financial access was highest in prepaid systems. Organizational access, continuity, and accountability were highest in the FFS system. Coordination was highest and comprehensiveness was lowest in HMOs. Conclusions. —The results mark notable differences in core dimensions of primary care quality in each of three payment systems and raise questions regarding the associated cost inefficiencies and outcomes of care. In the current health care delivery reform climate, these findings call for consideration of the relative strengths and weaknesses of each system. We suggest strategies for elevating performance in each. (JAMA. 1994;271:1579-1586)

In Reply. —We agree with Drs Lasker and Shapiro that describing the mix of patients seen in different systems of care and by different specialists is important. In our article on the mix of patients among medical specialties and systems of care, 1 we documented differences in socioeconomic status, number and type of chronic diseases, clinical severity of some of the more prevalent conditions, and finally, general health status in terms of functioning and well-being. Resource use was not equivalent in the cross-sectional part of the MOS even after applying these controls. However, until we know whether these different levels of utilization are associated with different patient outcomes, we cannot address the issue of appropriateness. Our conclusions regarding differences in resource utilization rest on the adequacy of case mix (or as we prefer to call it, patient mix) and adjustment, which Lasker and Shapiro question. Specifically, they express concern about

Objective. —To determine differences in the mix of patients among medical specialties and among organizational systems of care. Study Design. —Cross-sectional analysis of 20 158 adults (≥18 years of age) who visited providers' offices during 9-day screening periods in 1986. Patient and physician information was obtained by self-administered, standardized questionnaires. Setting. —Offices of 349 physicians practicing family medicine, internal medicine, endocrinology, and cardiology within health maintenance organizations, large multispecialty groups, and solo or small single-specialty group practices in three major US cities. Outcome Measures. —Demographic characteristics, prevalence of chronic disease, disease-specific severity of illness, and functional status and well-being. Results. —Among patients with selected physician-reported chronic illnesses (diabetes, hypertension, recent myocardial infarction, or congestive heart failure), increasing levels of severity were associated with decreasing levels of functional status and well-being and with increased hospitalizations, more physician visits, and higher numbers of prescription drugs. Compared with patients of general internists, patients of cardiologists were older (56 vs 47 years, P P P P P P P P P Conclusion. —Patient mix is related to utilization and differs significantly across medical specialties and systems of care. These differences must be taken into account when interpreting variations in utilization and outcomes across specialties and systems, and when considering alternative policies for payment. ( JAMA . 1992;267:1617-1623)

Objective. —To examine whether specialty and system of care exert independent effects on resource utilization. Study Design. —Cross-sectional analysis of just over 20 000 patients (≥18 years of age) who visited providers' offices during 9-day periods in 1986. Patient- and physician-provided information was obtained by self-administered questionnaires. Setting. —Offices of 349 physicians practicing family medicine, internal medicine, endocrinology, and cardiology within health maintenance organizations, large multispecialty groups, and solo practices or small single-specialty group practices in three major US cities. Outcome Measures. —Indicators of the intensity of resource utilization were examined among four medical specialties (family practice, general internal medicine, cardiology, and endocrinology) and five systems of care (health maintenance organization, multispecialty group—fee-for-service, multispecialty group—prepaid; solo practice and single-specialty group—fee-for-service, and solo practice and single-specialty group—prepaid) before and after controlling for the mix of patients seen in these offices. The indicators of resource utilization were hospitalizations, annual office visits, prescription drugs, and common tests and procedures, with rates estimated on both a per-visit and per-year basis. Results. —Variation in patient mix was a major determinant of the large variations in resource use. However, increased utilization was also independently related to specialty (cardiology and endocrinology), fee-for-service payment plan, and solo and single-specialty group practice arrangements. After adjusting for patient mix, solo practice/single-specialty groups—fee-for-service had 41% more hospitalizations than health maintenance organizations. General internists had utilization rates somewhat greater than family physicians on some indicators. Conclusion. —Although variations in patient mix should be a major determinant of variations in resource use, the independent effects of specialty training, payment system, and practice organization on utilization rates need further explication. The 2- and 4-year outcomes now being analyzed will provide information critical to interpretation of the variations reported herein. ( JAMA . 1992;267:1624-1630)

The practical relevance of physician manpower studies relates to the effects of variation in supply on improvements in (1) the availability of services, (2) the outcomes of medical care, including costs and benefits, and (3) the health of the nation. In this issue of JAMA , a frequent contributor to studies on physician supply, William Schwartz, with Daniel Mendelson, 1 applies standard economic theory in a secondary analysis of the American Medical Association's data for the years 1982 through 1987. The authors posit that a surplus of physicians is not developing. Their finding contradicts the projections of the Graduate Medical Education National Advisory Committee (GMENAC) made in 1980. 2 It is questionable, however, that the work of Schwartz and Mendelson provides useful information regarding the adequacy of the physician supply for the 1980s and the 1990s. Schwartz and Mendelson use the American Medical Association's data for 1982 through 1987, 3 which

The Medical Outcomes Study was designed to (1) determine whether variations in patient outcomes are explained by differences in system of care, clinician specialty, and clinicians' technical and interpersonal styles and (2) develop more practical tools for the routine monitoring of patient outcomes in medical practice. Outcomes included clinical end points; physical, social, and role functioning in everyday living; patients' perceptions of their general health and well-being; and satisfaction with treatment. Populations of clinicians (n = 523) were randomly sampled from different health care settings in Boston, Mass; Chicago, Ill; and Los Angeles, Calif. In the cross-sectional study, adult patients (n = 22 462) evaluated their health status and treatment. A sample of these patients (n = 2349) with diabetes, hypertension, coronary heart disease, and/or depression were selected for the longitudinal study. Their hospitalizations and other treatments were monitored and they periodically reported outcomes of care. At the beginning and end of the longitudinal study, Medical Outcomes Study staff performed physical examinations and laboratory tests. Results will be reported serially, primarily inThe Journal. (JAMA. 1989;262:925-930)

This paper describes the social processes that promoted a doubling of the capacity of the medical schools between 1965 and 1980 and a projected doubling of the number of actively practicing physicians between 1970 and 2000. This rapid increase in the supply of physicians is analyzed within the framework of other forces for change in the health-care system. Health care in the 1990s will be provided within a more formalized and structured health-services system. Medical practice will be affected greatly. In this presentation facts will be presented and observable trends will be described. Changes in the characteristics of the overall . . .