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

Context: Despite the substantial amount of health-related information available on the Internet, little is known about the accessibility, quality, and reading grade level of that health information.Objective: To evaluate health information on breast cancer, depression, obesity, and childhood asthma available through English- and Spanish-language search engines and Web sites.Design and Setting: Three unique studies were performed from July 2000 through December 2000. Accessibility of 14 search engines was assessed using a structured search experiment. Quality of 25 health Web sites and content provided by 1 search engine was evaluated by 34 physicians using structured implicit review (interrater reliability >0.90). The reading grade level of text selected for structured implicit review was established using the Fry Readability Graph method.Main Outcome Measures: For the accessibility study, proportion of links leading to relevant content; for quality, coverage and accuracy of key clinical elements; and grade level reading formulas.Results: Less than one quarter of the search engine's first pages of links led to relevant content (20% of English and 12% of Spanish). On average, 45% of the clinical elements on English- and 22% on Spanish-language Web sites were more than minimally covered and completely accurate and 24% of the clinical elements on English- and 53% on Spanish-language Web sites were not covered at all. All English and 86% of Spanish Web sites required high school level or greater reading ability.Conclusion: Accessing health information using search engines and simple search terms is not efficient. Coverage of key information on English- and Spanish-language Web sites is poor and inconsistent, although the accuracy of the information provided is generally good. High reading levels are required to comprehend Web-based health information. [ABSTRACT FROM AUTHOR]

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

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

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

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

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

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

Objective: --To evaluate the usefulness of malpractice claims data for identifying (1) physicians who are prone to negligent errors and (2) physician and hospital characteristics associated with particular kinds of errors.Design: --Retrospective review of physician malpractice claim records.Setting: --Large New Jersey physician malpractice insurer.Participants: --Physicians practicing obstetrics and gynecology, general surgery, anesthesiology, or radiology and covered by the insurance carrier for any portion of 1977 through 1989.Main Outcome Measures: --Claims were classified into 11 clinical error categories comprising three broad groups: patient management problems, technical performance problems, and staff coordination problems. Outcomes were expressed as per-physician frequency of claims due to negligence and proportion of claims associated with various types of errors.Results: --Using 5 years of claims history to predict long-term claims proneness was more accurate than chance alone by 57% in obstetrics and gynecology, 33% in general surgery, 11% in anesthesiology, and 15% in radiology. Cross-validated recursive partitioning showed that among physician characteristics, only specialty was predictive of physician error profiles. For physician claims arising in acute care hospitals, hospital size and location in addition to hospital services discriminated among different error profiles; the cross-validated accuracy of this method was 69% compared with 22% accuracy achieved by random prediction.Conclusion: --Use of physicians' malpractice claims histories to target individuals for education or sanctions is problematic because of the only modest predictive power of such claims histories. [ABSTRACT FROM AUTHOR]

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

Objective: To evaluate the educational strategies and experiences of residency programs regarding the training of primary care providers in the care of patients who have AIDS.Design: Cross-sectional, self-administered questionnaire survey.Setting: Survey conducted November 1988-April 1989.Participants: All 771 non-military U.S. internal medicine and family medicine program directors were surveyed; 80% responded.Interventions: None.Measurements and Main Results: While 91% of the directors felt that primary care of AIDS patients was an important educational experience and 94% reported that their programs usually had AIDS inpatients, only 16% reported that the majority of trainees cared for AIDS patients in their continuity clinics. Even at programs that typically had six or more AIDS inpatients, only 26% of directors reported that most residents had cared for an AIDS patient in their continuity clinics. Among the 57% who did not believe or were unsure whether their residents were adequately trained in AIDS ambulatory care, only 38% reported improving resident education in this area to be a high priority. Among the 39% who did not encourage residents' assumption of primary care, 60% had at least one of the following concerns: AIDS care too stressful for residents (24%), AIDS care too complicated for generalists (31%), or clinic faculty not qualified to supervise residents' caring for AIDS patients (39%).Conclusion: Although program directors view education in AIDS ambulatory care as important, most do not believe that residents are adequately trained, many do not encourage residents' assumption of primary care of AIDS patients, and residents usually have not provided such care in their programs. Strategies to augment residents' ambulatory experience in AIDS care are needed. [ABSTRACT FROM AUTHOR]

Objective: To evaluate U.S. and Canadian resident physicians' views about their health care systems.Design: Self-administered questionnaire survey in 1989.Participants: Senior family medicine and internal medicine residents in Canada and in ten geographically representative American states.Main Results: American and Canadian residents had similar levels of professional satisfaction and almost universally agreed on the ethical obligation to provide care to persons of all social circumstances, but U.S. residents were more likely to perceive a serious access problem in their country (75% compared with 18%) and to think that current controls on the medical profession interfere with patient care (81% compared with 58%; P less than 0.001). In addition, U.S. residents were more likely than Canadian residents to believe that primary care salaries were too low (78% compared with 38%) and that salaries of medical subspecialists (57% compared with 17%) and surgeons (85% compared with 28%) were too high. In general, residents preferred their own country's predominant health care system. Whereas 87% of U.S. physicians supported private fee-for-service health care, 85% of Canadian physicians supported government-funded national health insurance. Nonetheless, 42% of U.S. physicians supported and only 17% strongly opposed national health insurance as an alternative approach. About two thirds of respondents from both countries opposed a salaried national health service.Conclusions: American residents perceived greater problems with access, overall intrusions into medical practice, and fee disparities than did their Canadian counterparts. They preferred private fee-for-service health care, but few strongly opposed government-funded national health insurance as an alternative approach to the health care needs of the United States. [ABSTRACT FROM AUTHOR]

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

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

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