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Patient-centered hospital units have grown out of the national trend to greater consumerism, but few of these units have been evaluated rigorously. We used a randomized controlled trial to compare patient outcomes on the Planetree Model Hospital Unit with other medical-surgical units in the hospital. Planetree patients were significantly more satisfied than controls with their hospital stay, the unit's environment and nursing care, but did not differ in ratings of physician care. Planetree patients reported more involvement in their care while hospitalized and higher satisfaction with the education they received. There were few differences between Planetree and controls in health behaviors. While Planetree patients reported better mental health status and role functioning after discharge, their health status was similar to controls after 3 to 6 months. There were no differences in length of stay and charges for the index hospitalization, readmissions or outpatient care during the following year.

The Community Health Promotion Grants Program, sponsored by the Henry J. Kaiser Family Foundation, represents a major health initiative that established 11 community health promotion projects. Successful implementation was characterized by several critical factors: (1) intervention activities; (2) community activation; (3) success in obtaining external funding; and (4) institutionalization. Analysis of the program was based on data from several sources: program reports, key informant surveys, and a community coalition survey. Results indicate that school-based programs focusing on adolescent health problems were the most successful in reaching the populations they were targeting. The majority of the programs were able to attract external funding, thereby adding to their initial resource base. The programs were less successful in generating health promotion activities and in achieving meaningful institutionalization in their communities.

Background. It has been previously shown that Japanese Americans in Seattle have significantly higher cholesterol levels than native Japanese. The present study examines the association of biological and lifestyle factors with plasma lipid and lipoprotein levels among Japanese Americans (JA) and native Japanese (NJ) to determine if these associations are consistent between these high and low cholesterol populations. Methods. Study samples consisted of 710 JA male and 728 JA female volunteers living in the Seattle area and a random sample of 3833 NJ male urban workers who participated in parallel cardiovascular disease screening and lifestyle surveys for 1989-1994. Multiple regression analysis was conducted to examine the association of lifestyle and biological factors with lipid and lipoprotein levels. Results. Alcohol consumption was positively and linearly associated with high density lipoprotein cholesterol (HDL-C) levels and negatively associated with both low density lipoprotein cholesterol (LDL-C) levels and the ratio of total cholesterol (TC)/HDL-C (P < 0.05 to P

This article examines physician compensation models in medical groups and the factors affecting physician compensation and their impact on individual physician behavior and group practice performance. Four categories of physician compensation models are identified: (1) production-based compensation, (2) salary, (3) group-based compensation unrelated to individual physician productivity, and (4) capitation-based compensation. The statistics and the economic incentives of different compensation methods are presented. Finally, the impacts on health resources consumption, charges in medical group procedures for utilization and care management, and quality of care are discussed.

The Medical Outcomes Trust is a depository and distributor of high-quality, standardized, health outcomes measurement instruments to national and international health communities. Every instrument in the Trust library is reviewed by the Scientific Advisory Committee against a rigorous set of eight attributes. These attributes consist of the following: (1) conceptual and measurement model; (2) reliability; (3) validity; (4) responsiveness; (5) interpretability; (6) respondent and administrative burden; (7) alternative forms; and (8) cultural and language adaptations. In addition to a full description of each attribute, we discuss uses of these criteria beyond evaluation of existing instruments and lessons learned in the first few rounds of instrument review against these criteria.

A 12-month data collection from medical records in Seattle/King County for acute ischemic heart disease among patients with diabetes mellitus was augmented with mailed questionnaires to personal physicians. The responsible Human Subjects Committee restricted the study to a one-time questionnaire mailing. Only 380 of 1,235 patients required physician contact when information was missing from primary data sources. Questionnaires were highly personalized, and most were limited to one page. Seventy-seven per cent of 330 physicians returned at least one questionnaire, and 62% of all questionnaires were returned with usable data. We conclude that useful data may be collected from physicians by way of mailed questionnaires if researchers use a brief and personal format.

An important recent trend in health promotion and disease prevention has been the increasing number and scope of communitybased interventions. These programs are aimed at entire populations, which are usually geographically defined, and they attempt to change health behavior and disease risk through mass media campaigns, activation of existing community organizations, or changes in the physical or sociocultural environment. Several large programs of this kind have been

A study of health behaviors in four communities in the western United States in 1988 provided the opportunity to compare two methods of sampling elderly respondents for a telephone interview. The Polk telemarketing lists were used to identify 1,407 respondents aged 65 years and older in four communities, where 253 respondents in the same age group were also identified by the method of random digit dialing. Individuals identified from the Polk lists received a letter prior to the initial telephone contact. The overall response rate was 49.3% for random digit dialing and 57.3% for the Polk lists. On the average, the identification of one elderly respondent using the Polk lists required about 20-25% as much interviewer time per subject identified as was required by the random digit dialing method. The elderly identified by the Polk lists were significantly older than those identified by random digit dialing, and the proportions of the Polk sample who were married, white, or had an income of greater than $10,000 were slightly higher than those of the random digit dialing sample. Among 40 variables measuring various health behaviors, indicators of health status, and participation in health-related programs and classes, only three differed significantly between the two samples. The authors conclude that sampling from commercial telemarketing lists was an efficient method of identifying elderly respondents and that in these four communities, the estimates of health behaviors and health status were comparable with those obtained by random digit dialing techniques.

The growing interest in community-based approaches to health promotion and disease prevention (HP/DP) has been accompanied by a growing need to evaluate the effectiveness of such programs. Special issues that arise in these evaluation studies include (1) entire communities are assigned to intervention and control groups, (2) only a small number of communities can usually be studied, (3) the time course of changes in behavior and other outcomes is often of interest, and (4) surveys to measure such changes over time can be conducted with either repeated cross-sectional samples or with longitudinal samples. This paper shows how these issues can be addressed under a mixed-model analysis of variance approach. This approach serves to unify several ideas in the literature on evaluation of community studies, including use of time-series regression and the question of whether the individual or the community should be the unit of analysis. We also describe how the method can be used to estimate sample size requirements, statistical power, or minimum detectable program effect.

BACKGROUND. Although most widely used risk adjustment systems use diagnosis data to classify patients, there is growing interest in risk adjustment based on computerized pharmacy data. The Veterans Health Administration (VHA) is an ideal environment in which to test the efficacy of a pharmacy-based approach. OBJECTIVE. To examine the ability of RxRisk-V to predict concurrent and prospective costs of care in VHA and compare the performance of RxRisk-V to a simple age/ gender model, the original RxRisk, and two leading diagnosis-based risk adjustment approaches: Adjusted Clinical Groups and Diagnostic Cost Groups/Hierarchical Condition Categories. METHODS. The study population consisted of 161,202 users of VHA services in Washington, Oregon, Idaho, and Alaska during fiscal years (FY) 1996 to 1998. We examined both concurrent and predictive model fit for two sequential 12-month periods (FY 98 and FY 99) with the patient-year as the unit of analysis, using split-half validation. RESULTS. Our results show that the Diagnostic Cost Group /Hierarchical Condition Categories model performs best (R 2 = 0.45) among concurrent cost models, followed by ADG (0.31), RxRisk-V (0.20), and age/sex model (0.01). However, prospective cost models other than age/sex showed comparable R 2 : Diagnostic Cost Group /Hierarchical Condition Categories R 2 = 0.15, followed by ADG (0.12), RxRisk-V (0.12), and age/sex (0.01). CONCLUSIONS. RxRisk-V is a clinically relevant, open source risk adjustment system that is easily tailored to fit specific questions, populations, or needs. Although it does not perform better than diagnosis-based measures available on the market, it may provide a reasonable alternative to proprietary systems where accurate computerized pharmacy data are available.

The purpose of this study was to compare average cholesterol levels between Seattle based Japanese Americans and three other populations: U.S. population, native Japanese population and native Japanese urban workers. A total of 1,466 Japanese Americans (724 men and 742 women) participated in cardiovascular disease screening in the Seattle area during 1989 94. Data sources for comparisons are from the Third National Health and Nutrition Examination Survey for 1988-91, the results of the National Cardiovascular Disease Examination Survey in Japan for 1990, and cardiovascular disease screening conducted by the Epidemiological Arteriosclerosis Research Institute in Japan for 1989. Total cholesterol and triglyceride levels of Seattle Japanese American men and women were highest among the four populations. Among men, high density lipoprotein cholesterol (HDL-C) levels for Seattle Japanese Americans and native Japanese were similar and fell between those of urban Japanese workers and the U.S. population. In women, the average HDL C levels were highest in the Japanese urban workers, second highest in Seattle Japanese Americans, and lowest in both the U.S. population and native Japanese population. These differences in lipid levels may be caused by both genetic and environmental factors, which are now under investigation.

Currently, there is considerable interest in studies that use the community as the experimental unit. Health promotion programmes are one example. Because such activities are expensive, the number of experimental units (communities) is usually very small. Investigators often match communities on demographic variables in order to improve the power of their studies. Matching is known to improve power in certain circumstances. However, we show here that if the number of communities is small, the matched design will probably have less power than the unmatched design. This is due primarily to the loss of degrees of freedom in the matched design, which outweighs the benefits of matching on any but the strongest correlates of changes in behaviour. In the community intervention situation, even small differences in sample size between the matched and unmatched analyses can have expensive consequences.

The Kaiser Family Foundation's Community Health Promotion Grant Program (CHPGP) provides funding and technical assistance in support of community-based efforts to prevent major health problems. The first phase of the program was implemented in 11 communities in the western United States. This paper describes the evaluation design of the CHPGP in the West, the methods of data collection, and the baseline comparability of intervention and control communities. Major features of the evaluation design include: (1) the randomization of qualified communities making application into funded and unfunded comparison groups; (2) a second set of matched control communities for some intervention sites; (3) data gathering through repeated surveys of community residents (probability samples of adults and adolescents) and institutions (health-related organizations and randomly sampled grocery stores and restaurants); and (4) the use of secondary data to monitor health events. Selected baseline data show that intervention and control communities differ in racial/ethnic composition, but relevant health behaviors and ratings of community activation for health promotion appear comparable.

Outcomes research, quality improvement, and performance measurement are important activities in the cancer research community. They are, indeed, closely related activities because indicators of quality and performance can logically be regarded as the outcomes of interest in outcomes research. Considerable progress has been made in the past decade in broadening the definition and strengthening the measurement of the important outcomes of health care in general, and cancer care specifically. The real value of studying outcomes, according to the Donabedian paradigm, lies in understanding their relation to the structure and processes (eg, the health care) that have produced them, because it is these latter factors which we can control. Therefore, the methods that we have available to us by which we can infer this relation of causality become very important. Because the systems that we study in health care research are usually complex, we will need to invest more of our resources in the future in the development of methods of inference beyond what we have available now if we are to realize the full potential of health outcomes research. This presents a unique opportunity for leadership by the cancer outcomes research program.

Context.—Growth of at-risk managed care contracts between health plans and medical groups has been well documented, but less is known about the nature of financial incentives within those medical groups or their effects on health care utilization.Objective.—To test whether utilization and cost of health services per enrollee were influenced independently by the compensation method of the enrollee's primary care physician.Design.—Survey of medical groups contracting with selected managed care health plans, linked to 1994 plan enrollment and utilization data for adult enrollees.Setting.—Medical groups, major managed care health plans, and their patients/enrollees in the state of Washington.Study Participants.—Sixty medical groups in Washington, 865 primary care physicians (internal medicine, pediatrics, family practice, or general practice) from those groups and affiliated with 1 or more of 4 managed care health plans, and 200931 adult plan enrollees.Intervention.—The effect of method of primary care physician's compensation on the utilization and cost of health services was analyzed by weighted least squares and random effects regression.Main Outcome Measures.—Total visits, hospital days, and per member per year estimated costs.Results.—Compensation method was not significantly (P>.30) related to utilization and cost in any multivariate analyses. Patient age (P

Analysis of national survey data on physician-patient encounters raises questions about physician education and manpower policy. Data compiled by the University of Southern California Medical Activities and Manpower Projects and the United States Bureau of Health Professionals reveal differences among internists, cardiologists, family practitioners, and pediatricians in procedures used for diagnosing and treating several frequently encountered conditions. Differences are observed in expenditure of time and use of a broad range of diagnostic and therapeutic techniques. These differences remain significant even after several important characteristics of individual physicians, patients, and the practice environment have been controlled. Findings from this study underscore the necessity of reviewing the content of medical education and policies that encourage a broad range of specialists to provide primary care. The findings also emphasize the need to address the physician's knowledge base in promoting changes in practice patterns.

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)

We investigated the association between coronary heart disease (CHD) and vasectomy in a population of 10,632 men who were under surveillance for multiple CHD risk factors during participation in a university-based exercise testing program. We conducted a mail survey with telephone follow-up to determine the vasectomy status of individuals in the population. Responses were obtained from 6,159 individuals. The 4.944 males on whom information was complete enough to be included in the multivariate analysis comprised the study population. Among the 1,383 (28 per cent) vasectomized males in the study populations, the interval from vasectomy to the time of the survey ranged from less than one year to 37 years with a mean duration of 15 years. Although increased relative risks for CHD were found to be associated with family history of CHD, high blood pressure and smoking in this population, the relative risk of CHD associated with vasectomy was not increased in general, nor was it increased when the vasectomized males were classified by time since vasectomy. Likewise, serum antisperm-antibody titers were not predictive of CHD among vasectomized men. These studies support the findings from previous investigations of populations with shorter average post-vasectomy experience in which vasectomy has been shown to be unassociated with altered risk of CHD in humans.

Characterization ofthe distribution ofintervals between successive births affords both practical and theoretical advantages in the analysis of fertility data. Moreover, attempts to formulate a mathematical model describing the process of reproduction lead naturally to a consideration of the distribution of birth intervals. A class ofmodels has been formulated, applying to a woman who is not pregnant and fecundable at marriage and who after a variable length of time enters a pregnancy, which terminates in either a miscarriage, stillbirth, or live birth, with a given probability depending on the duration of the pregnancy. Each pregnancy is followed by a period of post-partum infecundability (physiological sterility), whose length depends on the outcome of the pregnancy. Eventually, the woman returns to the non-pregnant fecundable state. The durations of pregnancy and of post-partum infecundability are treated as variables whose distributions can depend on the next state (such as the outcome ofpregn...

Although prednisone has been effectively used to induce remission in acute leukemia, a controlled exploration of optimal dosage and of intermittent therapy has not been reported. Of 223 previously untreated children 86 received 2 mg/kg in three divided daily doses; 85 received 4 mg/kg in three divided daily doses; 28 received 8mg/kg every other day in a single dose and 24 received 16 mg/kg every fourth day in a single dose. Steroid side effects were minimal in intermittent therapy. The percentage of remissions on these two regimes, however, was significantly lower than on continuous therapy. Bone marrow remissions were found in 21% on 8 mg/kg every other day and 12% on 16 mg/kg every fourth day. Remission rates of 72% and 60%, respectively, were obtained on the 2mg/kg and 4 mg/kg regimens, indicating no significant difference between these two groups. Continuous prednisone therapy appears to be more effective than intermittent dosage regimens in inducing remission in acute childhood leukemia.

A comparison of five drugs used either sequentially or cyclically in maintenance therapy of acute leukemia of childhood is reported. The median length of maintenance for cyclic therapy was 17.8 months and for the sequential was 17.5 months. There is no significant difference in the length of maintenance with the two methods of drug usage.

A randomized controlled trial was conducted to assess efficacy and cost of sustained home nursing care for patients with chronic lung disease. Three hundred one patients were randomly assigned to a respiratory home care group (RHC) that received care from respiratory home care nurses, a standard home care group (SHC) that received care from regular home care nurses, or an office care group (OC) that received whatever care they needed except for home care. Patients were followed for 1 year. At the end of the study year, there was no difference in survival, pulmonary function, or everyday functioning among the three groups. Average annual cost of care for all study patients was $7,647 (1981-82 dollars). The average annual health care costs for patients in the RHC group was $9,768; for those in the SHC group, $8,058; and for those in the OC group, $5,051 (F = 6.45, df = 2/298, P = 0.02). These results suggest that the current policy of limited coverage of home nursing services by Medicare and other third-party payers may be appropriate.

We outline the implementation of a new method of measuring the quality of medical care that counts cases of unnecessary disease and disability and unnecessary untimely deaths. First of all, conditions are listed in which the occurrence of a single case of disease or disability or a single untimely death would justify asking, "Why did it happen?" Secondly, we have selected conditions in which critical increases in rates of disease, disability, or untimely death could serve as indexes of the quality of care. Finally, broad categories of illness are noted in which redefinition and intensive study might reveal characteristics that could serve as indexes of health. We describe how these inth of the general population and the effects of economic, political, and other environmental factors upon it, and to evaluate the quality of medical care provided both within and without the hospital to maintain health and to prevent and treat disease.

Applying the adjusted needs-based model developed by the Graduate Medical Education National Advisory Committee (GMENAC), physician requirements in neurology were estimated for the year 1990. A Delphi panel of physician experts estimated appropriate patterns of treatment for 56 neurologic conditions. Their median estimates implied a need for 14,500 neurologists in 1990, suggesting a shortage relative to the projected supply. An advisory panel of former GMENAC members reviewed those estimates and recommended certain adjustments to ensure internal consistency and compatibility with those for other specialties. Adoption of these adjustments significantly reduces requirements, implying a total need for 8,400 neurologists--a figure in near balance with the projected supply of 8,650. The difference between the Delphi and Advisory Panel estimates reflects divergent views, apparent as well among the Delphi panelists, of the appropriate role of neurologists--consultants versus principal care providers.

In 83 patients with liver cirrhosis, an esophagogram after administration of barium sulfate, an endoscopic examination of the esophagus, and a portogram after percutaneous injection of an opaque material into the spleen were compared for diagnostic value in demonstrating esophageal varices. The diagnosis was established by esophagoscopy in 81, by splenoportography in 61, and by barium esophagogram in 55. Large varices were frequently missed by barium esophagograms as well as by splenoportograms. The mean splenic-pulp pressure was similar when patients with endoscopically demonstrated varices and normal portograms were compared with those whose portogram showed varices. Moreover, there was no apparent relation between portal pressure and variceal size. A time lapse between studies of as long as two months had no apparent influence on the incidence of positive diagnoses obtained.

SUMMARY A class of stochastic models to approximate the reproductive process in the human female is presented. It is assumed that at marriage a woman is in a fecundable nonpregnant state and after a random length of time passes into a pregnant state, the pregnancy terminating in a miscarriage, a stillbirth or a live birth with a given probability. Each pregnancy is followed by an infecundable state from which the female eventually returns to the fecundable, nonpregnant state. The duration of stay in any state is taken to be a random variable whose distribution can depend on the state into which the woman will pass next, as well as on the state currently occupied. Expressions are derived for the moments of all first passage and renewal times (e.g. intervals between births, etc.) and for the asymptotic monthly probability of a live birth, under the model. Approximate expressions are given for the mean and variance of the number of events, such as live births, that occur within a given period after marriage. The degree of approximation attained by the asymptotic expressions to the exact results for a finite number of months is investigated in a special case and found to be satisfactory. The model is discussed in the light of biological knowledge and references are cited, to work in which these results receive applications.

THE ROLE of a portacaval shunt in the prevention of hemorrhage from esophagogastric varices and in the prolongation of life of patients with cirrhosis is unknown. Although two prospective studies 1-4 have reported early survival analysis of this operation as a prophylaxis against hemorrhage and death from bleeding varices, there has been no controlled attempt to determine its effect upon the full spectrum of hepatic disease and the management of gastrointestinal hemorrhage. Since Jan 1, 1962, investigators at 12 Veterans Administration hospitals have screened, classified, and randomized for therapy, patients admitted to their institutions and qualifying for the study under a uniform protocol. No patient was randomized until he was considered a satisfactory surgical risk and had agreed to accept an operation as a part of his treatment program. All patients were followed at regular intervals until death or lost to follow-up.