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The authors evaluated determinants of response to Internet-based surveys in a sample (n = 5600) of Texas healthcare professionals. Participants were given the option of responding by mail or over the Web (response, 66%). Internet respondents were younger (p < .001), had worked fewer years in healthcare (p < .001), and were more likely to be male (p < .001) and to work in a hospital (p = .007). Missing questionnaire items were significantly higher among Web responders with regard to age, sex, race, body mass index, and smoking (p < .001). In the final multivariate logistic regression, only male gender (odds ratio [OR] = 2.09, 95% CI = 1.56-2.80) and younger age remained significantly associated with response over the Internet. Age quartile and responding electronically were inversely associated. Taken together with a priori knowledge of the demographic and professional profile of a study population, these findings can be useful in planning and implementation of surveys among healthcare workers. [ABSTRACT FROM AUTHOR]

Texas has a plan for statewide implmentation of Medicaid managed care by 2001. This article presents evidence from initial demonstration projects, which were implemented in 1993. The 1st-year experience is described and preliminary effects are examined in terms of reactions of clients and providers and changes in utilization patterns and costs of care. Results of the evaluation indicate implementation difficulties with several operational aspects of managed care, variable effects in terms of client and provider reaction to the reform, and little or no change in utilization patterns, but significant cost-savings to the state. Because of the implementation difficulties identified by the evaluation and the mixed results regarding effects, further research is recommended to determine the potential benefit of this reform. [ABSTRACT FROM AUTHOR]

Hospital revenue is the most important source for residency and fellowship stipends in internal medicine. Medicare is especially important for residency programs in voluntary hospitals and hospitals not closely affiliated with a medical school. In the last decade state and local government support and federal training grant support for residency stipends declined, whereas Veterans Administration support increased. Fellowship stipend sources are much more diverse; federal training grants, professional fees, foundations, medical school funds, and research grants contribute significantly. Medicare support appears to be focused on subspecialties particularly important to the elderly, including critical care, rheumatology, cardiology, hematology, gastroenterology, and nephrology. Geriatric medicine, however, receives substantial Veterans Administration support. With growing revenue constraints and increasing concerns about excess physicians we need to monitor the impact of government regulations and other factors on funds available for training internal medicine specialists. [ABSTRACT FROM AUTHOR]

The number of residents beginning training in internal medicine continued to increase slightly in 1985-86. However, the total number of residents in internal residency training decreased slightly from the previous year due to a decrease in the number of second- and third-year residents. The proportion of first-year residents who were foreign-trained physicians decreased from 21% to 20%, and the proportion of residents who finished training and went on to subspecialty training in 1985 decreased substantially to 56%. The number of physicians entering residency and fellowship training in internal medicine considerably exceeds the number projected by the Graduate Medical Education National Advisory Committee. In this article, we discuss implications of these trends for medical education and practice. [ABSTRACT FROM AUTHOR]

This study reports on a community health survey conducted among > or =30 year old rural residents of San Antonio, Nueva Ecija, Philippines, to serve as a basis for tailoring health programs for hypertension in the community. The focus of the analyses is the assessment of the prevalence of and risk factors for hypertension. A cluster survey was conducted among 336 residents in May 1998. Sixty clusters were drawn from areas comprising the town using probability proportionate to size sampling technique. Seven households were visited per cluster and one respondent was randomly chosen for interview and measurement of blood pressure, height and weight in each household. Eighty-four percent of eligible respondents participated. Hypertension prevalence was 23%. Only 42% had been diagnosed with hypertension (i.e., had been told and prescribed anti-hypertensive medication by their physician). Forty-seven percent reported taking anti-hypertensive medication (33 were prescribed by a physician while 4 were by self-medication) but only 17% of those identified as being hypertensive had it under control. Logistic regression showed that age > or =50 (p = 0.000), family history of hypertension (p = 0.004), and body mass index > or = 25 (p = 0.003) were significantly associated with hypertension. This study documents the prevalence and predictors of hypertension in a previously understudied population. In the absence of fully implemented programs to prevent and control hypertension, the current prevalence is only expected to increase, leading to substantial increases in morbidity and mortality and health care cost.

We describe barriers to care reported by racial/ethnic groups and explore the extent to which barriers vary between persons enrolled in managed care and those in non-managed care plans, using data from the 1996 Medical Expenditure Panel Survey (MEPS). Most respondents expressed satisfaction with their care; however, a substantial percentage reported experiencing barriers. Minorities, particularly Hispanics and Asian Americans, were more likely than non-Hispanic whites were to report barriers. Managed care enrollees across racial/ethnic groups faced different types of barriers than non-managed care enrollees did. Although managed care enrollees were more likely to report having a usual source of care and greater continuity of care, they also reported more difficulties obtaining care and less satisfaction with their care.

Within many schools of public health, substantial ambiguity surrounds the process of defining and rewarding faculty contributions to practice-oriented scholarly activities. Ernest L. Boyer introduced a powerful and compelling new paradigm for assessing the core domains of scholarship: the scholarships of discovery, integration, teaching, and application. This article draws on Boyer's domains and his colleagues, Charles E. Glassick, and others' criteria for evaluating them in introducing a framework for assessing practice-oriented scholarship within schools of public health. The article presents concepts, content, and defining criteria of practice-oriented scholarship and identifies the principles that might guide tenure and promotion decisions related to it.

In response to growing concern for occupational health and safety in the public hospital system in Costa Rica, a cross-sectional survey of 1,000 hospital-based health care workers was conducted in 1997 to collect baseline data that are being used to develop worker training programs in occupational health in Costa Rica. The objectives of this survey were to: 1) describe the safety climate within the national hospital system, 2) identify factors associated with safety, and 3) evaluate the relationship between safety climate and workplace injuries and safety practices of employees. The safety climate was found to be very poor. The two most significant predictors of safety climate were training and administrative support for safety. Safety climate was a statistically significant predictor of workplace injuries and safety practices, respectively, and there was an underreporting rate of 71% of workplace injuries. These findings underscore the need for improvement of the safety climate in the public hospital system in Costa Rica.

This study assesses whether geographical area income based on census data is a good predictor of preventable (or ambulatory care-sensitive) hospitalizations in a large public hospital system in Texas, and how area income correlates with the socioeconomic status reported by patients. Documenting a correspondence between area and individual-level income, as well as meaningful variation in rates of avoidable hospitalizations across subgroups and areas with varying concentrations of low-income persons, points to the validity and utility of this approach for monitoring how well public hospital systems in Texas address the needs of those they most directly serve. Area income may not fully reflect the disproportionately lower socioeconomic status of patients seen in the public hospital system. Nonetheless, living in lower-income zip codes was associated with higher preventable hospitalization rates for the predominantly low-income population served by the public hospital system. A tenfold difference found in the adjusted rates of hospitalizations for preventable conditions compared with control (or marker) conditions among persons living in low-income areas signals the likelihood of substantial unmet needs in this population. Small-area analysis and related comparisons of rates of preventable hospitalizations in high- and low-income areas provide useful indicators for monitoring and assessing the performance of public hospital systems in Texas.

To meet current physical activity recommendations, a person may chose to adopt a continuous or an intermittent physical activity program, as long as they accumulate 30 minutes of moderate-intensity physical activity most days of the week. Sixty-four sedentary African-American women were surveyed to assess whether perceptions about continuous and intermittent walking programs differed. Specifically, we assessed whether perceptions of self-efficacy, outcome expectations, social support, and the environment varied with respect to walking programs. Results indicated that the women perceived higher self-efficacy for the intermittent walking program and associated this program with more favorable environmental factors (p < .05). However, they expected greater benefits from the continuous walking program (p < .05). Overall, 65% of the women reported that they would prefer to adopt the continuous walking program.

Despite substantial progress in establishing academic and public health partnerships over the past 20 years, two questions require further examination: (1) How are the most effective partnerships achieved? and (2) How well are these partnerships suited to the current and future problems of public health? The authors propose the "new public health" perspective, which offers challenges to develop a dialogue and power relationships among partners based on symmetry rather than conventional asymmetry. New forms of discourse and benchmarking of progress in improving the health of the public may be achieved by adopting this paradigm.

The methods for measuring health care outcomes and monitoring the health status of the child with a chronic health condition must be available, accessible, and meaningful. This review was evoked by this need to identify reliable and valid instruments for measuring the health status of children with special health care needs. The objectives are as follows: (1) to review the methodologic and substantive issues related to the selection of instruments and (2) to identify those instruments available currently for collecting data regarding health status of children with special health care needs. A Medline search of the literature published since 1966 through 1998 and restricted to human subjects and the English language was conducted. Indexing terms included health status, quality of life, outcome assessment, functional status, and patient satisfaction. Multiple reviewers selected instruments based on their usefulness in clinical settings as generic, disease nonspecific, child health status instruments. Few instruments were identified that can be used by pediatricians for tracking and monitoring the health status of children with special health care needs. In conclusion, to progress in the field of outcomes measurement of children with special health care needs, it will be necessary to develop new measurement tools. These instruments must (1) provide valid and reliable information on health status; (2) be useful in guiding the management of patients; and (3) not be a burden for physicians, patients, or patient's families.

Objective: To study the cost-effectiveness of an early postoperative feeding protocol for patients undergoing bowel resections., Design: A nonrandomized, prospective, clinical trial. Surgeons elected to participate in the treatment arm before the study's outset., Subjects/setting: Treatment (n = 66) and control (n = 159) patients were admitted to a nonprofit general teaching hospital in the Texas Medical Center for similar diagnoses and subsequent bowel resections during an 18-month period., Intervention: Treatment patients who met specific inclusion criteria had a jejunal feeding tube placed during surgery. Tube feedings were initiated within 12 hours after surgery. Control patients who met the same inclusion criteria received usual care., Outcomes: A successful outcome was defined as a patient developing no postoperative infection. The average cost of a nosocomial infection is presented. Variable direct and total costs (fixed plus variable) are compared between patient groups., Statistical Analysis: Mean cost was adjusted for rate of success in each patient group according to an analytic model. The mean cost difference between groups was analyzed by independent-samples t tests. Nonparametric Mann-Whitney rank sum tests were used to determine the cost significance of a nosocomial infection., Results: The average variable direct cost savings per successful treatment patient was $1,531, which required an additional variable cost of $108.30 for the dietitian's time. The protocol resulted in a total cost savings of $4,450 per success in the treatment group., Conclusion: An early postoperative enteral feeding protocol as part of an outcomes management program for patients undergoing bowel resection is cost-effective.

Objective: To evaluate the effectiveness, efficiency, and equity of behavioral healthcare and to guide an assessment of the current state of the art of behavioral health-oriented health services research., Study Design: The framework is grounded in previous conceptual work by the authors in defining a prevention- and outcomes-oriented continuum of healthcare and in identifying and integrating the concepts and methods of health services research and policy analysis for assessing healthcare system performance., Patients and Methods: The defining assumptions are that (1) the denominator for behavioral healthcare services must encompass a look at the population, not just the patients, who manifest behavioral health risks; and (2) the delivery system to address these needs must extend beyond acute, treatment-oriented services to include both primary prevention and aftercare services for chronic relapsing conditions., Results: Current policy and practice in behavioral healthcare reveal the absence of a comprehensive, coordinated continuum of care; substantial variation in policy and financial incentives to encourage such development; and poorly defined or articulated outcome goals and objectives. The current state of the art of research in this area reflects considerable imprecision in conceptualizing and measuring the effectiveness, efficiency, and equity criteria. Further, these 3 criteria have not been examined together in evaluating system performance., Conclusions: The first era of behavioral healthcare focused on cost savings in managed care alternatives; the second is focusing on quality and outcomes; a third must consider the issues of equity and access to behavioral healthcare, especially for the most seriously ill and vulnerable, in an increasingly managed care-dominated public and private policy environment.

The steady increase in immigrants to the United States has fueled a critical analysis of the process of allocation of health and social benefits to these newcomers. The myriad of interests and values surrounding this issue precipitated the formulation and adoption of the Personal Responsibility and Work Opportunity (Welfare Reform) Act of 1996. This dramatic welfare reform impacts federal, state, and local agencies that are required to determine the eligibility of benefits and manage the attendant consequences to the public as well as members of this vulnerable group. Especially challenging are the decisions confronting public health professionals who struggle to reconcile the resulting policy, programmatic mandates, and compliance imperatives with prevailing public health principles and practice norms. This paper proposes a framework for understanding the incongruence between the provisions of the law as it pertains to legal and illegal immigrants and public health values. The impact of policy incongruence and professionals' dissonance on public health practice norms is explored with an explicit focus on public health outcomes and legal implications. The examination of tuberculosis as a health example reveals the policy conflicts and public health dilemmas. Finally, the paper elicits a range of options available to public professionals for responding to these legal mandates.

Objective: The behavioral model of utilization, developed by Andersen, Aday, and others, is one of the most frequently used frameworks for analyzing the factors that are associated with patient utilization of healthcare services. However, the use of the model for examining the context within which utilization occurs-the role of the environment and provider-related factors-has been largely neglected., Objective: To conduct a systematic review and analysis to determine if studies of medical care utilization that have used the behavioral model during the last 20 years have included environmental and provider-related variables and the methods used to analyze these variables. We discuss barriers to the use of these contextual variables and potential solutions., Data Sources: The Social Science Citation Index and Science Citation Index. We included all articles from 1975-1995 that cited any of three key articles on the behavioral model, that included all articles that were empirical analyses and studies of formal medical care utilization, and articles that specifically stated their use of the behavioral model (n = 139)., Study Design: Design was a systematic literature review., Data Analysis: We used a structured review process to code articles on whether they included contextual variables: (1) environmental variables (characteristics of the healthcare delivery system, external environment, and community-level enabling factors); and (2) provider-related variables (patient factors that may be influenced by providers and provider characteristics that interact with patient characteristics to influence utilization). We also examined the methods used in studies that included contextual variables., Principal Findings: Forty-five percent of the studies included environmental variables and 51 percent included provider-related variables. Few studies examined specific measures of the healthcare system or provider characteristics or used methods other than simple regression analysis with hierarchical entry of variables. Only 14 percent of studies analyzed the context of healthcare by including both environmental and provider-related variables as well as using relevant methods., Conclusions: By assessing whether and how contextual variables are used, we are able to highlight the contributions made by studies using these approaches, to identify variables and methods that have been relatively underused, and to suggest solutions to barriers in using contextual variables.

Purpose: An analytical cross-sectional survey was conducted to determine the prevalence of barriers to cancer treatment in Texas as perceived by diagnosed cancer patients. Results reported here address the role of insurance coverage, indirect costs (transportation, lodging, and work days lost), and direct costs of care as barriers to treatment for white, black, and Hispanic cancer patients. Specific objectives of the analyses undertaken here are to examine 1) racial/ethnic differences in insurance coverage; 2) barriers relating to insurance coverage experienced by cancer patients; and 3) role of treatment-related costs as barriers to cancer treatment., Description of Study: A mail questionnaire was developed to assess the perceived barriers to cancer treatment in Texas for adult cancer patients, 17 years and older, who had been diagnosed with breast, colon, cervical, prostate, or lymphoma during the period of 1989 to 1993. The sampling frame for this study was obtained from a network of cancer treatment facilities throughout the state of Texas within the University of Texas M.D. Anderson Cancer Center Texas Community Oncology Network. A total of 593 cancer patients returned their surveys, yielding a 65.2% response rate. Weighting adjustments were then made to correct for differential sampling and response rates by racial groupings and type of cancer. All of the analyses used adjusted weights., Results: The findings document the financial considerations (insurance, direct and indirect costs) as they relate to barriers to cancer treatment. Specific insurance premium-related barriers with regard to maintaining and affording coverage were more prevalent for blacks. Hispanics were less likely to have insurance coverage; however, more blacks reported being denied insurance coverage when they changed jobs compared with whites and Hispanics. Minorities, particularly Hispanics, were more likely to have experienced cost-related barriers associated with medications, diagnostic tests, and hospitalizations. In addition, Hispanics experienced significant out-of-pocket costs in paying for cancer treatment., Clinical Implications: This research shows the need for staff at cancer treatment facilities to be aware that there are nonclinical, financial factors that are important considerations in the treatment of cancer patients. Assessment of cancer patients during the diagnostic and treatment stages, possibly through case management, will provide information on potential barriers to treatment for individual patients. Hospital programs that reimburse out-of-pocket costs, transportation costs to obtain services, and lodging accommodations may be available. Additional services may be offered through cancer advocacy groups, such as the American Cancer Society and the National Coalition for Cancer Survivors, to assist patients with managing costs and overcoming barriers to care.

Background: This study examined the sources used by cancer patients to obtain helpful information regarding their treatment options and side effects and the major predictors that facilitated usage of information., Methods: The survey was administered to a representative sample of cancer patients in Texas. The cancer treatment facilities from which the patients were sampled were part of the University of Texas M. D. Anderson Cancer Center's Texas Community Oncology Network. A total of 593 patients (65%) out of 910 contacted responded to the survey., Results: The patients reported that providers such as physicians and nurses were the most helpful sources of information. White patients tended to use books and reference materials more heavily to gather additional information regarding their treatment, while black patients relied on pamphlets and television. Educational level appeared to have a major influence on the black patient's use of printed materials., Conclusions: The results document the important role that providers play in influencing patients' treatment decisions. Effective ways to communicate with cancer patients are different for patients with different racial backgrounds. Implications for the future development of patient education materials and cancer prevention initiatives targeting ethnic minorities are addressed.

Purpose: Patients with cancer must overcome many psychological, social, and economic barriers to obtain needed treatment. Because of the need for repeated visits for cancer treatment on either an outpatient or an inpatient basis, one of the major issues that patients with cancer must confront is that of arranging for transportation to care., Methods: This study compares the distance and mode of transportation to radiotherapy and chemotherapy and perceptions of transportation as a barrier to care among white, black, and Hispanic cancer patients receiving treatment from a consortium of cancer treatment facilities in Texas. A mail questionnaire was developed to assess the perceived barriers to cancer treatment for patients who had been diagnosed clinically with breast, colon, cervical, or prostate cancer, or lymphoma between 1989 and 1993. A total of 910 surveys were mailed to prospective participants. Of the surveys mailed, 593 were returned, yielding a 65.2% response rate. By race, the respondents included whites (42%), blacks (40%), Hispanics (15%), and Asian-Pacific Islanders (3%). Two respondents were 17 years of age; the remaining respondents were 18 years or older., Results: This study shows that some patients may forgo needed treatment because of problems with transportation. This was perceived as an issue more for minority patients than for white patients. Black and Hispanic patients consistently reported that barriers such as distance, access to an automobile, and availability of someone to drive them to the treatment center were potential major problems. The distance to the facilities was farther for whites than for blacks and Hispanics. Patients generally had to travel farther for chemotherapy than for radiotherapy., Clinical Implications: Patients, particularly minorities, may opt to forgo needed care in the absence of available and affordable means of transportation to treatment facilities. These findings demonstrate the need for healthcare providers to be aware of the transportation problems that patients with cancer experience in obtaining treatment. Healthcare providers must work with patients, their families, and volunteer agencies in the community to facilitate transportation to cancer treatment services.

Purpose: In this study, the authors examined the role of informal and formal social support networks in mitigating barriers to cancer treatment among whites, blacks, and Hispanics, based on a representative sample of cancer patients in Texas., Description of Study: The sample frame for this study was obtained from the University of Texas M. D. Anderson Cancer Center's Texas Community Oncology Network, a consortium of cancer treatment facilities in Texas. Of the 910 patients who were contacted, 593 (65%) responded to the survey., Results: The results show the value of social support networks in assisting cancer patients with continuing treatment. An important finding indicated that health professionals do not provide information regarding social support groups to patients with cancer at the time of diagnosis. Fewer than half of the respondents were asked whether they would be interested in joining a formal social support group. Individuals of all racial/ethnic groups reported that the formal support groups provided emotional assistance. Minorities were more apt to report that the formal support groups helped with continuing treatment. In addition, informal social support networks, such as extended families and civic clubs, were seen as more helpful for blacks and Hispanics as compared with whites., Clinical Implications: The need for formal and informal networks is indicated by the results of this study, which show that networks, such as relationships with family, friends, and relatives, play an important role in assisting patients in coping with their cancer. These networks are part of the patient's total treatment experience and must be acknowledged by healthcare professionals. A large number of patients are not asked to join social support groups, suggesting a need for training healthcare professionals to provide information regarding the potential benefits of support groups for cancer patients.

Purpose: When the goal of treatment is palliative, the most important outcome is improving patient quality of life. The authors describe the major concerns of terminally ill cancer patients with a prognosis of 6 months of less., Overview: In phase I of this three-part study, 74 terminally ill patients were interviewed to identify their major concerns. In phase II, interviews with 120 terminally ill cancer patients showed that their most important concerns encompass existential, spiritual, familial, physical, and emotional issues. Phase III will determine the validity and reliability of a quality-of-life scale based on these patients' most important concerns. The information presented here summarizes the results of interviews from phases I and II., Clinical Implications: Patients were receptive to being interviewed and remarked on the relevance and importance of these issues to their own experience. Several patients commented that although their disease was assessed and reassessed throughout their care, the existential, spiritual, familial, and emotional aspects of their illness rarely were a focus of their care. Healthcare professionals can create an atmosphere in which these patients feel comfortable exploring the quality-of-life issues that are most important to them. The systematic assessment of patient concerns about quality of life may complement disease assessment and facilitate referrals to appropriate members of the healthcare team. The wide range of concerns reported suggests that a team approach, including physicians, nurses, social workers, psychiatrists, psychologists, and chaplains, is the most effective way to meet the needs of terminally ill patients.

Motivated by the need for fundamental change, reform of the health care delivery system is continuing despite the recent failure of national initiatives. One aspect of this reform is the restructuring of managed care systems to include low-income, at-risk populations in their health delivery program: It is a move that threatens current "safety-net" providers, which already serve these populations with programs that combine public health and traditional primary care. This paper explores this potential conflict by providing a brief history and comparison of the main features of the community-oriented primary care (COPC) and health maintenance organization (HMO) models. The authors provide a frame-work that contrasts the structure, process, and outcome characteristics of these two models, delineating key similarities and differences. The frame-work is used in profiling a service delivery system model that integrates the two systems and in discussing issues related to operationalizing the proposed integration.