What happened to home HIV test collection kits? Intent to use kits, actual use, and barriers to use among persons at risk for HIV infection.

Through sequential cross-sectional surveys, we examined intent to use home HIV test collection kits, actual use and barriers to use among persons at high risk for HIV infection. Interest in kits was assessed in the 1995-96 HIV Testing Survey (HITS, n=1683). Kit use, knowledge of kits and barriers to use were assessed in the 1998-99 HITS (n=1788), after kits had become widely available. When asked to choose among future testing options, 19% of 1995-96 participants intended to use kits. Untested participants were more likely than previously tested HIV-negative participants to choose kits for their next HIV test (p < 0.001). Among 1998-99 participants, only 24 (1%) had used kits; 46% had never heard of kits. Predictors of not knowing about kits included never having been HIV tested and black or Latino race. Common reasons for not using kits among participants aware of home test kits were concerns about accuracy, lack of in-person counselling and cost. Despite high rates of anticipated use, kits have had minimal impact on the testing behaviour of persons at high risk for HIV infection. Increasing awareness of kits, reducing price and addressing concerns about kit testing procedures may increase kit use, leading to more HIV testing by at-risk individuals.

Ethnic and gender differences in the use of coronary artery revascularisation procedures in New Zealand.

AIMS: To examine ethnic and gender variations in the use of coronary artery revascularisation procedures in New Zealand and to determine whether the introduction of priority scores affected intervention trends. METHODS: Analysis of the National Minimum Database for coronary artery bypass graft (CABG) and percutaneous transluminal coronary angioplasty (PTCA) intervention rates for New Zealand Pacific, Maori and other men and women aged 40 years and over during the decade 1990-1999. RESULTS: Coronary artery revascularisation rates were lower in women than in men in all ethnic groups and in Pacific and Maori men compared with other New Zealand men. Compared to all men, the mean age-standardised CABG and PTCA intervention rate ratios in all women were 0.34 and 0.36. Compared to other New Zealand men, the mean age-standardised CABG and PTCA intervention rate ratios were 0.64 and 0.25 in Pacific and 0.40 and 0.29 in Maori men respectively. Compared to other New Zealand women, the rate ratios for CABG and PTCA were 0.73 and 0.21 in Pacific and 0.74 and 0.43 in Maori women respectively. Introducing priority scores was neither associated with reduced cardiac procedures nor significantly reduced variation in procedures across all ethnic groups. CONCLUSIONS: Although Pacific and Maori peoples had higher rates of coronary artery disease morbidity and mortality, revascularisation rates were lower in both groups. Strategies beyond the use of priority scores are needed to address ethnic and gender disparities in coronary artery revascularisation procedures in New Zealand.

Unlocking specialists' attitudes toward primary care gatekeepers.

OBJECTIVES: Many managed care plans rely on primary care physicians to act as gatekeepers, which may increase tension between these physicians and specialists. We surveyed specialist physicians in California to determine whether their attitudes toward primary care gatekeepers differed depending on how the specialists were paid and the settings in which they practiced. STUDY DESIGN: We performed a cross-sectional survey using a mailed questionnaire. The predictors of specialist attitudes toward gatekeepers were measured using chi-square, the t test, and regression analyses. POPULATION: A probability sample of 1492 physicians in urban counties in California in the specialties of cardiology, endocrinology, gastroenterology, general surgery, neurology, ophthalmology, and orthopedics was used. OUTCOMES: We used questions about specialists' attitudes toward primary care physicians in the gatekeeper role. A summary score of attitudes was developed. RESULTS: A total of 979 physicians completed the survey (66%). Attitudes toward primary care physicians were mixed. Relative to nonsalaried physicians, those who were salaried had a somewhat more favorable attitude toward gatekeepers (P = .13), as did physicians with a greater percentage of practice income derived from capitation (P =.002). CONCLUSIONS: Specialists' attitudes toward the coordinating role of primary care physicians are influenced by the practice setting in which the specialists work and by financial interests that may be threatened by referral restrictions. Policies that promote alternatives to fee for service and shift specialty practice toward more organized group settings may generate a common sense of purpose among primary care physicians and specialists.

Low-income Californians' experiences with health insurance and managed care.

California is rapidly implementing mandatory managed care for most of its Medicaid (Medi-Cal) beneficiaries. To assess the impact of this delivery system change, the authors analyzed a 1996 statewide population-based random-sample telephone survey of 3,563 adults between the ages of 18 and 64. Respondents with Medi-Cal managed care and Medi-Cal fee-for-service rated access to care and quality of care significantly higher than uninsured respondents yet lower than low-income privately insured individuals. While the authors did not find a difference in health care access and quality among Medi-Cal managed care enrollees compared with Medi-Cal fee-for-service enrollees, they also did not find that managed care provided any observed advantages to Medi-Cal recipients.

Primary care groups in the United Kingdom: quality and accountability.

With the introduction of primary care groups (PCGs), the British National Health Service has attempted to integrate delivery, finance, and quality improvement into a locally directed care system with a strong sense of community accountability. PCGs will eventually hold the budgets for primary care, specialist, hospital, and community-based services and have the flexibility to reapportion these budgets. Through clinical governance, PCGs are attempting to coordinate education, guidelines, audit and feedback, and other quality improvement approaches around health problems that are relevant to their patient panels and local communities. PCGs offer other nations attempting to improve the quality and accountability of health care an innovative approach that merits consideration.

Primary care physicians' experience with disease management programs.

OBJECTIVE: To examine primary care physicians' perceptions of how disease management programs affect their practices, their relationships with their patients, and overall patient care. DESIGN: Cross-sectional mailed survey. SETTING: The 13 largest urban counties in California. PARTICIPANTS: General internists, general pediatricians, and family physicians. MEASUREMENTS AND MAIN RESULTS: Physicians' self-report of the effects of disease management programs on quality of patient care and their own practices. Respondents included 538 (76%) of 708 physicians: 183 (34%) internists, 199 (38%) family practitioners, and 156 (29%) pediatricians. Disease management programs were available 285 to (53%) physicians; 178 had direct experience with the programs. Three quarters of the 178 physicians believed that disease management programs increased the overall quality of patient care and the quality of care for the targeted disease. Eighty-seven percent continued to provide primary care for their patients in these programs, and 70% reported participating in major patient care decisions. Ninety-one percent reported that the programs had no effect on their income, decreased (38%) or had no effect (48%) on their workload, and increased (48%)) their practice satisfaction. CONCLUSIONS: Practicing primary care physicians have generally favorable perceptions of the effect of voluntary, primary care-inclusive, disease management programs on their patients and on their own practice satisfaction.

To help or hinder: Which is more important in explaining a physician's willingness to recommend a health plan?

PURPOSE: To examine how specific health plan practices contribute to physicians' willingness to recommend a health plan to a patient, and whether the relative importance of plan practices is viewed differently when patients are seriously ill. METHODS: The Physician's Evaluation of Health Plans Project has surveyed 1,757 generalist physicians in 16 health plans in 5 areas nationwide. Each physician reported on one plan. Three multi-item scales assessed physicians' perceptions of health plan activities that facilitated or impeded high-quality care in the plans and the clinical capabilities of plan physicians. Regression analyses were used to explore relations between facilitators, barriers, and clinical capabilities, and two global physician judgments (the physician's willingness to recommend a plan and their judgment that a plan provided lower quality for sicker patients). RESULTS: A physician's willingness to recommend a health plan is more highly related to what plans do to facilitate care than to the barriers created by plans in managing care. However, barriers to care were substantially more important when evaluating health plan quality for sicker patients. CONCLUSIONS: From the physician's perspective, the relative importance of plan strategies to manage care is different for typical patients and patients who are more seriously ill. Efforts to collect information on health plan quality should separately evaluate care for sicker patients, in addition to evaluating the overall performance of the health plan.

Specialists' and primary care physicians' participation in medicaid managed care.

OBJECTIVE: To compare specialist and primary care physician participation in California's Medicaid fee-for-service and managed care programs. DESIGN: Cross-sectional survey. PARTICIPANTS: A probability sample stratified by county and by race of 962 specialist physicians and 713 primary care physicians practicing in the 13 largest counties in California in 1998. MEASUREMENTS AND ANALYSIS: We used physician self-report from mailed questionnaires to compare acceptance of new Medicaid and new Medicaid managed care patients by specialists versus primary care physicians and by physician demographics, practice setting, attitudes toward Medicaid patients, and attitudes toward Medicaid managed care. We analyzed results using logistic regression with data weighted to represent the total population of primary care and specialist physicians in the 13 counties. MAIN RESULTS: Specialists were as likely as primary care physicians to have any Medicaid patients in their practices (56% vs 56%; P=.9). Among physicians accepting any new patients, specialists were more likely than primary care physicians to be taking new Medicaid patients but were significantly more likely to limit their acceptance to only Medicaid fee-for-service patients. Thus, specialists were much less likely than primary care physicians to accept new Medicaid managed care patients. After controlling for physician demographics, practice settings, and attitudes toward Medicaid patients and Medicaid managed care, specialists remained much less likely to accept new Medicaid managed care patients. CONCLUSIONS: Expansion of Medicaid managed care may decrease access to specialists as specialists were less likely to accept new Medicaid managed care patients compared to Medicaid fee-for-service patients. Any decrease in access may be mitigated if states are able to contract with group model HMOs and to recruit minority physicians.

Friend or foe? How primary care physicians perceive hospitalists.

BACKGROUND: Increased use of hospitalists is redefining the role of primary care physicians. Whether primary care physicians welcome this transition is unknown. We examined primary care physicians' perceptions of how hospitalists affect their practices, their patient relationships, and overall patient care. METHODS: A mailed survey of randomly selected general internists, general pediatricians, and family practitioners with experience with hospitalists practicing in California. MAIN OUTCOME MEASURES: Physicians' self-reports of hospitalists' effects on quality of patient care and on their own practices. RESULTS: Seven hundred eight physicians were eligible for this study, and there was a 74% response rate. Of the 524 physicians who responded, 34% were internists, 38% were family practitioners, and 29% were pediatricians. Of the 524 respondents, 335 (64%) had hospitalists available to them and 120 (23%) were required to use hospitalists for all admissions. Physicians perceived hospitalists as increasing (41%) or not changing (44%) the overall quality of care and perceived their practice style differences as neutral or beneficial. Twenty-eight percent of primary care physicians believed that the quality of the physician-patient relationship decreased; 69% reported that hospitalists did not affect their income; 53% believed that hospitalists decreased their workload; and 50% believed that hospitalists increased practice satisfaction. In a multivariate model predicting physician perceptions, internists, physicians who attributed loss of income to hospitalists, and physicians in mandatory hospitalist systems viewed hospitalists less favorably. CONCLUSIONS: Practicing primary care physicians have generally favorable perceptions of hospitalists' effect on patients and on their own practice satisfaction, especially in voluntary hospitalist systems that decrease the workload of primary care physicians and do not threaten their income. Primary care physicians, particularly internists, are less accepting of mandatory hospitalist systems. Arch Intern Med. 2000;160:2902-2908

Cross sectional study of primary care groups in London: association of measures of socioeconomic and health status with hospital admission rates.

OBJECTIVES: To calculate socioeconomic and health status measures for the primary care groups in London and to examine the association between these measures and hospital admission rates. DESIGN: Cross sectional study. SETTING: 66 primary care groups in London, total list size 8.0 million people. MAIN OUTCOME MEASURES: Elective and emergency standardised hospital admission ratios; standardised admission rates for diabetes and asthma. RESULTS: Standardised hospital admission ratios varied from 74 to 116 for total admissions and from 50 to 124 for emergency admissions. Directly standardised admission rates for asthma varied from 152 to 801 per 100 000 (mean 364) and for diabetes from 235 to 1034 per 100 000 (mean 538). There were large differences in the mortality, socioeconomic, and general practice characteristics of the primary care groups. Hospital admission rates were significantly correlated with many of the measures of chronic illness and deprivation. The strongest correlations were with disability living allowance (R=0.64 for total admissions and R=0.62 for emergency admissions, P<0.0001). Practice characteristics were less strongly associated with hospital admission rates. CONCLUSIONS: It is feasible to produce a range of socioeconomic, health status, and practice measures for primary care groups for use in needs assessment and in planning and monitoring health services. These measures show that primary care groups have highly variable patient and practice characteristics and that hospital admission rates are associated with chronic illness and deprivation. These variations will need to be taken into account when assessing performance.

Does HIV reporting by name deter testing? MESH Study Group.

OBJECTIVE: Name-based HIV reporting is controversial in the United States because of concerns that it may deter high-risk persons from being tested. We sought to determine whether persons at risk of HIV infection knew their state's HIV reporting policy and whether they had delayed or avoided testing because of it. DESIGN: A cross-sectional anonymous survey. METHODS: We interviewed 2404 participants in one of three high-risk groups: men who have sex with men (MSM), heterosexuals attending a sexually transmitted disease (STD) clinic, and street-recruited injection drug users (IDU). Participants were asked standardized questions about their knowledge of reporting policies and reasons for having delayed or avoided testing. We recruited in eight US states: four with name-based reporting and four without; all offered anonymous testing at certain sites. RESULTS: Fewer than 25% correctly identified their state's HIV reporting policy. Over 50% stated they did not know whether their state used name-based reporting. Of the total, 480 participants (20%) had never been tested. Of these, 17% from states with name-based reporting selected concern about reporting as a reason for not testing compared with 14% from states without name-based reporting (P = 0.5). Comparing previously tested participants from states with name-based reporting to those from states without, concern about HIV reporting was given as a reason for delaying testing by 26% compared with 13% of IDU (P < 0.001), and for 26% compared with 19% of MSM (P = 0.06). CONCLUSION: Most participants did not know their state's HIV reporting policy. Name-based reporting policies were not associated with avoiding HIV testing because of worry about reporting, although they may have contributed to delays in testing among some IDU.

Do patients choose physicians of their own race?

This study seeks to determine whether minority Americans tend to see physicians of their own race as a matter of choice or simply because minority physicians are more conveniently located within predominantly minority communities. Using data from the Commonwealth Fund 1994 National Comparative Survey of Minority Health Care, we found that black and Hispanic Americans sought care from physicians of their own race because of personal preference and language, not solely because of geographic accessibility. As minority populations continue to grow, the demand for minority physicians is likely to increase. Keeping up with this demand will require medical school admissions policies and physician workforce planning to include explicit strategies to increase the supply of underrepresented minority physicians.

Effects of primary care coordination on public hospital patients.

OBJECTIVE: To evaluate the effect of primary care coordination on utilization rates and satisfaction with care among public hospital patients. DESIGN: Prospective randomized gatekeeper intervention, with 1-year follow-up. SETTING: The Adult General Medical Clinic at San Francisco General Hospital, a university-affiliated public hospital. PATIENTS: We studied 2,293 established patients of 28 primary care physicians. INTERVENTION: Patients were randomized based on their primary care physician's main clinic day. The 1,121 patients in the intervention group (Ambulatory Patient-Physician Relationship Organized to Achieve Coordinated Healthcare [APPROACH] group) required primary care physician approval to receive specialty and emergency department (ED) services; 1,172 patients in the control group did not. MEASUREMENTS AND MAIN RESULTS: Changes in outpatient, ED, and inpatient utilization were measured for APPROACH and control groups over the 1-year observation period, and the differences in the changes between groups were calculated to estimate the effect of the intervention. Acceptability of the gatekeeping model was determined via patient satisfaction surveys. RESULTS: Over the 1-year observation period, APPROACH patients decreased their specialty use by 0.57 visits per year more than control patients did ( P =.04; 95% confidence interval [CI] -1.05 to -0.01). While APPROACH patients increased their primary care use by 0.27 visits per year more than control patients, this difference was not statistically significant (P =.14; 95% CI, -0.11 to 0.66). Changes in low-acuity ED care were similar between the two groups (0. 06 visits per year more in APPROACH group than control group, P =. 42; 95% CI, -0.09 to 0.22). APPROACH patients decreased yearly hospitalizations by 0.14 visits per year more than control patients (P =.02; 95% CI, -0.26 to -0.03). Changes in patient satisfaction with care, perceived access to specialists, and use of out-of-network services between the 2 groups were similar. CONCLUSIONS: A primary care model of health delivery in a public hospital that utilized a gatekeeping strategy decreased outpatient specialty and hospitalization rates and was acceptable to patients.

Medicaid managed care's impact on safety-net clinics in California.

A growing percentage of Medicaid patients are receiving medical care within a managed care system. This policy change has raised concerns about whether safety-net providers can maintain their share of Medi-Cal (California Medicaid) patients. From 1995 to 1997 several of California's counties implemented mandatory Medi-Cal managed care. The majority of California's safety-net primary care clinics experienced a decline in the percentage of their patients insured by Medi-Cal. However, after the overall decline in the number of Medi-Cal beneficiaries was controlled for, the increased penetration of Medi-Cal managed care in a county was not independently associated with a decline in clinics' share of Medi-Cal patients. Despite this fact, it may become increasingly difficult for clinics to maintain their current level of services with declining Medi-Cal enrollment and other anticipated reforms in their funding.

Name-based surveillance and public health interventions for persons with HIV infection. Multistate Evaluation of Surveillance for HIV Study Group.

Name-based surveillance of HIV infection is the law in 31 U.S. states but remains controversial. This policy can be advocated solely to support surveillance of the epidemic, but a frequent argument is that it also provides a public health benefit by allowing follow-up of HIV-infected persons. These persons can then receive timely medical care and can be assisted with notifying sex and needle-sharing partners. Few comparative data are available to evaluate the outcomes of these interventions. In five states with name-based surveillance of HIV infection, the Multistate Evaluation of Surveillance for HIV Study Group surveyed a cross-sectional probability sample of persons with AIDS who tested positive for HIV before the date of their AIDS diagnosis. Health department follow-up of a reported HIV infection was not associated with more timely receipt of medical care after a positive HIV test result. Only 8.6% of persons who delayed medical care after their first positive HIV test result gave concern about being reported by name as a reason; no person gave it as the main reason. Persons who were tested anonymously and those who were tested confidentially did not differ in the mean number of sex and needle-sharing partners notified: Those tested anonymously reported personally notifying 3.85 sex and needle-sharing partners, and those tested confidentially reported notifying-personally and through the health department-3.80 partners. Many researchers and policymakers believe that name-based surveillance of HIV infection will have positive or negative effects on partner notification and access to health care. These results suggest that the potential for such effects has been exaggerated.

Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists.

CONTEXT: Few data are available regarding how patients view the role of primary care physicians as "gatekeepers" in managed care systems. OBJECTIVE: To determine the extent to which patients value the role of their primary care physicians as first-contact care providers and coordinators of referrals, whether patients perceive that their primary care physicians impede access to specialists, and whether problems in gaining access to specialists are associated with a reduction in patients' trust and confidence in their primary care physicians. DESIGN, SETTING, AND PATIENTS: Cross-sectional survey mailed in the fall of 1997 to 12707 adult patients who were members of managed care plans and received care from 10 large physician groups in California. The response rate among eligible patients was 71%. A total of 7718 patients (mean age, 66.7 years; 32 % female) were eligible for analysis. MAIN OUTCOME MEASURES: Questionnaire items addressed 3 main topics: (1) patient attitudes toward the first-contact and coordinating role of their primary care physicians, (2) patients' ratings of their primary care physicians (trust and confidence in and satisfaction with), and (3) patient perceptions of barriers to specialty referrals. Referral barriers were analyzed as predictors of patients' ratings of their physicians. RESULTS: Almost all patients valued the role of a primary care physician as a source of first-contact care (94%) and coordinator of referrals (89%). Depending on the specific medical problem, 75% to 91% of patients preferred to seek care initially from their primary care physicians rather than specialists. Twenty-three percent reported that their primary care physicians or medical groups interfered with their ability to see specialists. Patients who had difficulty obtaining referrals were more likely to report low trust (adjusted odds ratio [OR], 2.7; 95% confidence interval [CI], 2.1-3.5), low confidence (OR, 2.2; 95% CI, 1.6-2.9), and low satisfaction (OR, 3.3; 95% CI, 2.6-4.2) with their primary care physicians. CONCLUSIONS: Patients value the first-contact and coordinating role of primary care physicians. However, managed care policies that emphasize primary care physicians as gatekeepers impeding access to specialists undermine patients' trust and confidence in their primary care physicians.