Patient, physician and presentational influences on clinical decision making for breast cancer: results from a factorial experiment.

This study examines the influence of six patient characteristics (age, race, socioeconomic status, comorbidities, mobility and presentational style) and two physician characteristics (medical specialty and years of clinical experience) on physicians' clinical decision making behaviour in the evaluation treatment of an unknown and known breast cancer. Physicians' variability and certainty associated with diagnostic and treatment behaviour were also examined. Separate analyses explored the influence of these non-medical factors on physicians' cognitive processes. Using a fractional factorial design, 128 practising physicians were shown two videotaped scenarios and asked about possible diagnoses and medical recommendations. Results showed that physicians displayed considerable variability in response to several patient-based factors. Physician characteristics also emerged as important predictors of clinical behaviour, thus confirming the complexity of the medical decision-making process.

Impact of pharmaceutical underutilization: a study of insurance drug claims data.

OBJECTIVES: To operationalize the measurement and interpretation of pharmaceutical underutilization using private insurance medical and drug claims data. This study also examined the relationship between underutilization of pharmaceuticals and patient outcomes. DESIGN: Five definitions of pharmaceutical underutilization were used to identify underutilizers of 14 pharmaceuticals in a population of people aged 55 and over. Definitions 1 to 4 required the calculation of the apparent daily dose of the drug versus a standard dose. Definition 5 identified underutilization by the variation in apparent daily dose. Average monthly health services utilization figures were compared among appropriate utilizers and both moderate and severe pharmaceutical underutilizers for each of the five definitions. RESULTS: The most consistent results were found using Definition 5, variability in dosage. There were statistically significant (p < 0.05) differences in use of medical services among patients whose use of the pharmaceutical was more variable than other patients taking the same medication. CONCLUSION: Viewing noncompliance from the perspective of stability of consumption rather than the absolute value of the consumption may be a better predictor of increased health services utilization.

A strategy for accurate collection of incremental cost data for cost-effectiveness analyses in field trials. Pawtucket's minimal contact cholesterol education intervention.

With many community field trials or education interventions, the cost-effectiveness analyses are not given a high priority. However, this type of evaluation is important for purposes of future adoption of the intervention. The accurate measurement of costs can best be served by prospective collection of data. This article describes a methodology for collection of cost data that coincides with the intervention implementation. This cost analysis strategy has seven discrete steps. The Minimal Contact Education for Cholesterol Change study is used as an example of the use of this strategy. This intervention provides cholesterol education at six different levels of intensity at four different sectors. The intensity levels vary along a continuum from very little education input to a maximum level of intervention that might be practical in a screening setting. The cost-effectiveness analysis component of the study will identify the incremental cost-effectiveness of each intervention along the continuum.

Informal care vs. formal services: changes in patterns of care over time.

Longitudinal data from a representative sample of community-residing older persons were used to document changes in patterns and costs of care, both informal and formal. It was found that use of formal services was usually in conjunction with, and secondary to, informal care. Limited availability of informal care as well as increased disability raised the odds of using services. Substitution of formal services for informal care was limited and usually temporary. Total costs of community care, including living expenses, were generally less than the cost of nursing home care.

How costly is it to care for disabled elders in a community setting?

This article describes the total cost of care, including both informal caregiving and formal services for a cohort of disabled elderly living in the community. The cost of informal caregiving hours was calculated using a market value approach. The total annual cost of caring was estimated to be $9,600. Increased disability was associated with increased costs. High-cost elders were more likely to be severely disabled, live with their caregiver, and become institutionalized. For most elders, even the cost of a complete substitution of informal care for formal services, plus living expenses, was less costly than nursing home care.

Costs and outcomes of inpatient versus outpatient hernia repair.

This study sought to compare treatment costs and outcomes for a large number of Medicare patients undergoing inpatient versus outpatient hernia repair around the country. Medicare physician and hospital claims were obtained for all Medicare enrollees residing in eleven states in 1987 and 1988, in order to take advantage of geographic variation in treatment location. All patients undergoing uncomplicated inguinal hernia repair were identified from the surgeon's bill; the location of surgery was then validated by the facility bill (n = 27,036). Over one-third of all hernia repairs in our sample were performed on an ambulatory basis, but with tremendous variation across states, ranging from 89.9% of cases in Washington in outpatient settings to almost none (6.3%) in Georgia. Treatment costs were 56% higher for hernias repaired on an inpatient basis, $2341 versus $1505 for those performed in outpatient settings. There were no detectable differences between inpatients and outpatients along such outcomes as complication rates, deaths and hernia recurrence, but readmission rates were higher for inpatients. The dramatic differences in costs, along with the apparent absence of adverse outcomes, suggests that Medicare should actively encourage surgeons to perform more hernia repairs on an outpatient basis.

Physician participation in alternative health plans.

In this article, physician participation in alternative health plans is examined, using cross-sectional data from the Physicians' Practice Costs and Income Survey, 1983-85. Overall, about one-third of physicians participated in one or more plans, ranging from 18 percent of general practitioners to 46 percent of medical subspecialists. Only 19 percent, however, received income from prepaid sources, averaging $5,275 per physician. Reasons for joining or not joining are also examined. Participants joined most often to maintain or increase workload, while nonparticipants most often declined to join because they would be giving up independence.

A profile of emergency physicians 1984-1985: demographic characteristics, practice patterns, and income.

Emergency physicians (EPs) were profiled using data from a recent national survey of physicians. In addition, we compared EPs to other physicians on demographic and practice characteristics. EPs were younger than physicians in other specialties and were less likely to be foreign medical graduates or board certified. EPs were far more likely to be employed by hospitals and on salary. Their net income averaged $93,000 in 1983, although hospital employees had lower average incomes ($83,000) than did those employed by a corporation or self-employed in a group practice ($101,000). Compared to other specialties, their average income was higher than nonsurgeons, but still far below surgeons. While EPs and other physicians spent about 50 to 51 hours per week in medical activities, EPs saw more patients per hour. EPs saw more uninsured individuals. These results have implications for patient access, "entrepreneurism" in the specialty, and credentialing.