Physician response to patient insurance status in ambulatory care clinical decision-making. Implications for quality of care.

OBJECTIVES: Individuals without health insurance in general receive fewer health services and are more likely than insured patients to experience poor outcomes. The main goal of this research was to study whether physicians' clinical recommendations vary for insured and uninsured patients, implying that physicians' choices of care may mediate insurance-related differences in health care use. METHODS: The authors designed clinical scenarios that describe routine decisions encountered by primary care physicians in ambulatory settings. Scenarios were designed to include discretionary, nondiscretionary, preventive, and diagnostic/therapeutic services. Insurance status of patients was indicated as either insured or uninsured for the service under consideration. Scenarios were presented to a nationally representative sample of primary care physicians (n = 1182) as part of the American Medical Association 1992 Socio-economic Monitoring System Survey. Physicians were assigned randomly to receive eight scenarios in which patients were either insured or uninsured. For each scenario, physicians were asked to indicate the percentage of patients for whom they would recommend a given service. RESULTS: After controlling for variables associated with nonresponse, we found that physicians who were presented scenarios with insured patients recommended service for 72% of patients, and physicians who were presented scenarios with uninsured patients recommended the same services for 67% of patients (P < 0.001). Physicians recommended both discretionary services (50% versus 42%; P < 0.001) and nondiscretionary services more often for insured than uninsured patients (93% versus 91%; P < 0.05). CONCLUSIONS: In self-reports, physicians are more likely to recommend services for insured than for uninsured patients, and more so when services are discretionary. This provides evidence that physicians' recommendations may be important mediators of insurance-related variation in the use of health-care services. Higher rates of use among the insured may not always reflect higher quality of care, particularly when the service is discretionary in nature.

Chronic stress and psychological well-being: evidence from Thailand on household crowding.

This paper examines the effect of one form of chronic stress--household crowding--on psychological well-being, as measured by multiple inverse indicators of psychological well-being. We rely on data from a large (n = 2017) random sample of households in Bangkok, Thailand, a context that has a higher level and broader range of crowding than typically found in the United States. Objective household crowding is found to be detrimental to psychological well-being, controlling for a number of background characteristics. The effect of objective crowding is mediated by subjective crowding, which has strong, consistent and direct detrimental effects on well-being. There is no evidence of a gender effect. Extended family households are not uncommon in Bangkok, but the effects of objective and subjective crowding are similar in both two- and three-generation households, as well as in one- and multiple-couple households. The argument that subjective crowding is an effect, rather than a cause, of psychological well-being is examined and rejected. The findings suggest that crowding, as a chronic source of stress, constitutes a major threat to psychological well-being. Although the empirical analyses are based on data from one city, we frame the issue of household crowding in a historical and theoretical context in order to suggest in which cultural settings household crowding is most likely to have detrimental effects on psychological well-being.

Time to discontinue the use of solutions A and B as a cyanide 'antidote'.

Solutions A and B (15.8% ferrous sulfate in 0.3% citric acid and 6% sodium carbonate, respectively) have been available as a first-aid treatment for cyanide ingestion for many decades. Controversy surrounding the efficacy of solutions A and B has existed for much of that time, the main protagonists being in the UK. The current opinion in the UK is that solutions A and B should no longer be used as a first-aid measure in the management of cyanide poisoning. Similarly, oral sodium thiosulfate or activated charcoal should not be used. The recommended first-aid treatment of symptomatic cyanide poisoning is 100% oxygen and amyl nitrite, irrespective of the route of exposure.

Gender and health: some Asian evidence.

In Thailand, like the U.S., women's higher rates of illness and health service use imply that they are "sicker." But, as in the U.S., females live longer than males. Based on a large representative sample of Bangkokians, we find that married women report more sickness, are more likely to utilize health services and, according to self-reports, have poorer health. Western literature suggests five prominent explanations for gender differences in health: biological risks, acquired risks, psychosocial aspects of symptoms and care, health-reporting behavior, and prior health care and caretakers. However, analyses show that these explanations largely fail to account for morbidity differences between Thai men and women. The observed gender differences in health among Thais remain significant after eliminating pregnant women and new mothers, and after controlling for several aspects of acquired risk. Problems associated with the reproductive system among Thai women, along with greater psychological distress, appear to account for most of the gender differences in health. The theoretical implications of these findings are discussed. As for the apparent contradiction between gender differences in health and mortality in Thailand, the evidence indicates that Thai men, like their American counterparts, suffer from more serious chronic ailments that may explain their higher mortality rates.

Housing, stress, and physical well-being: evidence from Thailand.

The proposition that poor housing and congested living conditions have a detrimental impact on health has been promulgated for at least 150 years. At a minimum, two major causal mechanisms are thought to be involved in the relationship between crowding and physical health. First, high levels of household crowding can produce stress that leads to illness. Second, through shared physical proximity, household congestion contributes to the spread of communicable disease. The outcomes can be exacerbated by poor quality housing. A significant body of research, conducted primarily in affluent countries, has documented the detrimental effects of housing conditions on a variety of illnesses, including various contagious diseases. Poor housing has even been linked to high infant and adult mortality rates. The view that poor housing conditions and household crowding inevitably leads to poor health is challenged, however, by several observers, who question the role played by both crowding and housing quality. Most existing research has been conducted in affluent countries. Little is known, however, about the nature of these relationships within the context of less developed countries, where health status and housing quality are generally much poorer and where levels of household crowding are generally higher. Determination of the effects, if any, of housing quality--including household crowding--on physical health in developing countries is particularly important given the rapid growth of their urban populations and the difficulty of increasing the physical infrastructure fast enough to keep pace with this growth. This paper reports on an investigation of the impact of housing conditions and household crowding in the context of one developing country, Thailand. Using data from a representative sample of households in Bangkok (N = 2017), our results provide reason for some skepticism regarding the influence on housing on health, at least in its objective dimensions. While the skepticism of some is based on a reading of the evidence in Western countries, we likewise find that, in Bangkok, objective indicators of housing quality and household crowding are little related to health. We do find, however, that subjective aspects of housing and of crowding, especially housing satisfaction and a felt lack of privacy, have detrimental effects on health. Furthermore, psychological distress is shown to have a potent influence on the physical health of Bangkokians. Our analyses suggest that all three factors have independent effects on health outcomes bearing on both men and women.

Congenital pseudarthrosis of the clavicle.

Congenital pseudarthrosis of the clavicle is a rare anomaly in which the clavicle is formed in utero in two separate segments. Clinically, there is a bump and a palpable discontinuity at the middle of the clavicle. There is no swelling or tenderness, nor disability. Radiologically, the medial ends of both clavicular segments are blunt and there is no interruption of cortical bone. The differential diagnosis includes birth fracture of the clavicle and craniocleidal dysostosis. The obstetrician should be aware of this condition as, if it is misdiagnosed, he may be wrongly accused of birth fracture.

Starting over. Why remarriages are more unstable.

PIP: Previously divorced and remarried couples have a higher probability of divorce and decline in marital quality. Models which have explained this behavior focus on: willingness to leave marriage; selection; socioeconomic status; the remarriage market; and incomplete marriages. Each model is examined among a population of marrieds and remarrieds to distinguish attributes and the extent to which these attributes increase the probability of decline in marital quality or divorce. Data were obtained from a sample of 2033 marrieds 55 years old who were interviewed over the telephone in 1980, 1983, and 1988 in the Marital Instability Over the Life Course Study. Incomplete marriage was measured by whether and to what extent parents or parents-in-law made contact and the number of relatives that party was close to. Willingness to leave was based on attitudes to divorce and the ability to handle emotion and financial affairs if the marriage ended. Selection referred to poor marriage material (drugs or alcohol, criminal conduct, mismanagement of money, immature behavior. Socioeconomic status was reflected in occupational status, educational levels, and income. The marriage market was a measure of age, education, and religious differences. Marital quality was examined in terms of happiness, interaction, disagreement, and divorce proneness. Multiple classification analysis was used to compare attributes by marital history. The methods of Kessler and Greenberg were used to examine changes in marital quality over time in first time marriages and remarriages. The results indicate that individuals in remarriages have relationships with attributes which potentially lower marital quality and increase the probability of divorce. When both individuals have prior marriage and divorce experience, there is even lower social integration, greater willingness to leave marriage, higher probability of marrying as a teen, lower socioeconomic status, and greater likelihood of age differences. Remarriage variables and marital quality variables both showed linear relationships. Remarriage variables and marital quality variables both showed linear relationships. In the cross sectional analysis of the 1980 data there is a statistically significant relationship with attributes which potentially lower marital quality in 1980 indicates remarried persons are more prone to lower marital quality than people in first marriages.^ieng

Household crowding and reproductive behavior.

Ethological studies suggest that animal populations that live in crowded conditions display a number of behaviors that tend to limit the size of the population, such as aberrant forms of sexual behavior, small litter sizes, a higher incidence of spontaneous abortion, ineffectual maternal care, and even cannibalism of their young. Studies of household crowding in North America cities have produced only modest and selective evidence that crowding has similar effects among humans. In this paper, we examine the effect of household crowding on marital sexual relations, on desire for additional children, and on fetal and child loss in Bangkok, Thailand, a city with a much wider range of household crowding than is typically found in North America. In spite of the wider range, and higher mean level of crowding, we find that both the objective and subjective dimensions of crowding have only modest selective effects on sexual and reproductive behavior.

PIP: In ethological studies, animals have been observed to exhibit aberrant forms of sexual behavior when forced to live in crowded conditions. Studies in humans have indicated a possible connection between crowding and frequency of coitus, desire for additional children, the effective use of birth control, and the survival of offspring. The psychological distress which may arise from crowding may also have an impact on reproductive behavior. Because these studies give very little indication of possible findings in a very crowded area, focus groups were convened to lend direction to the development of a questionnaire for use in Bangkok, Thailand, where people live in conditions (12.25/sq. meter) which would be comparable to 17 people in a 1,500 sq. foot house in the West. The choice of Thailand for a research site allowed an exploration of the role of culture in reactions to crowding. In fact, the modest demeanor of the Thai people did mean that the subject of privacy was consistently raised in the focus groups. The resultant survey was administered to 1,399 wives and 618 husbands in families living in Bangkok for at least 1 year in 1988 who had at least 1 child with the mother under 45 years old. The average household samples had 5.5 people, including nuclear and 3-generation families. Scales were composed for perceived crowding, lack of privacy, and psychological distress. Findings were also tabulated for 1) frequency of sexual relations/month by sex, age, years married, age of oldest child, education, income, number of generations, number of married couples in the household, and health of respondent; 2) zero-order correlations among crowding, sexual relations, and reproductive behavior by frequency, reluctance, temporary cessation, desire for additional children, using birth control, forgot to use birth control, lack of privacy prevents use of birth control, child loss, miscarriage, and abortion; and 3) a standardized coefficient regression for the relationship between measures of reproductive behavior and objective and subjective crowding with the following controls: persons/room, lack of privacy, and psychological distress. Analyzing the data revealed that the objective level of crowding (persons/room) leads to greater reluctance to engage in sexual relations and some periods of temporary cessation, but does not affect frequency, desire to have children, use of birth control, or fetal and child survival. Subjective crowding leads to similar results, but these parents are less likely to have ceased sexual relations or to have lost a child. Lack of privacy affects only one measure examined; it increases reluctance to have sexual intercourse. Thus, these findings suggest that household crowding has a very minor impact, if any, on sexual and reproductive behavior.

Physicians' responses to their changing environment.

The loss of physician autonomy, the changing shape of physicians' practices, and efforts to control the cost of health care have left American physicians increasingly dissatisfied with the U.S. health care system. A survey of 300 office and hospital-based physicians shows 59 percent favor reform of the U.S. system; only 31 percent favor retaining the current system. Doctors face increased competition for patients (the supply of physicians has increased three times faster than the population), reduced autonomy because of intervention by government and other third party payers, pressure from patients to provide unnecessary care including expensive new technology, and increased cost containment. Yet a majority of physicians believe the causes of rising health care costs are patient demand for services and the current medical malpractice system. A minority (23 percent) blame hospitals and physicians for rising costs.

Comparison of patient-controlled and nurse-controlled antiemetic therapy in patients receiving chemotherapy.

The purpose of this quasi-experimental pilot study was to compare the effect of patient-controlled (PCAE) and nurse administered (NCAE) antiemetic therapy for controlling chemotherapy-induced nausea and vomiting in patients receiving moderate emetogenic chemotherapy. Twenty subjects were randomly assigned to either the PCAE group who received IV antiemetic medication via a patient-controlled pump or the NCAE group who received antiemetic medication via nurse administered minibags. Nausea, vomiting, sedation, and drug consumption were measured. There was no difference in nausea scores between the two groups. Subjects in the PCAE group consumed significantly less medication than subjects in the NCAE group.

Changing family structure and youthful well-being: assessing the future.

PIP: The declining prevalence of the nuclear family in the United States is examined, and the consequences for the healthy development of children are considered. Attention is given first to research supporting the claim that nuclear families provide the optimum environment for child rearing and then to studies presenting differing results. Methodological and conceptual issues concerning studies in family structure are discussed. The author concludes that family structure in and of itself has little effect on child development and that an alternative theory, de-emphasizing structural inputs, is needed.^ieng

Divorce and marital instability over the life course.

"This study uses a [U.S.] national sample of married persons under age 55, interviewed in 1980 and again in 1983, to estimate why divorce and marital instability vary by age and duration of marriage. Results indicate that the accumulation of assets substantially reduces the propensity to divorce. We also find that several important correlates of divorce and instability (age at marriage, health, social integration, and income) interact with age and duration. In general, these factors seem to operate almost exclusively among young people and young marriages."