Racial/ethnic inequities in continuity and site of care: location, location, location.

OBJECTIVE: To examine how continuity of care with the same provider varies by race/ethnicity and by site of care. DATA SOURCES/STUDY SETTING: Secondary data analyses of the 1996-97 Community Tracking Study household survey, a representative cross-sectional sample of 34,858 U.S. adults (aged 18 to 64 years), were employed. STUDY DESIGN: Logistic regression analyses were conducted to explore relationships between respondents' race/ethnicity and having a regular site of care, type of site, and continuity with the same provider at this site. PRINCIPAL FINDINGS: Racial/ethnic minority group members were less likely than whites to identify a regular site of care. Among respondents who identified a regular site, minorities, particularly Spanish-speaking Hispanics, reported less continuity of care with the same provider. However, these disparities in continuity were largely explained by racial/ethnic differences in the types of places where care was obtained. Compared to those who were seen in physicians' offices, continuity with the same provider was much lower among respondents who were seen in hospital out patient departments or health centers or other clinics. CONCLUSIONS: Racial and ethnic minority group members receive less continuity of care for reasons including lack of a regular site of care and less continuity with the same provider. Greater use of hospital clinics and community health centers by minorities also contributes to this discontinuity.

Racial and ethnic disparities in perceptions of physician style and trust.

CONTEXT: While pervasive racial and ethnic inequalities in access to care and health status have been documented, potential underlying causes, such as patients' perceptions of their physicians, have not been explored as thoroughly. OBJECTIVE: To assess whether a person's race or ethnicity is associated with low trust in the physician. DESIGN, SETTING, AND PARTICIPANTS: Data were obtained from the 1996 through 1997 Community Tracking Survey, a nationally representative sample. Adults who identified a physician as their regular provider and had at least 1 physician visit in the preceding 12 months were included (N = 32,929). MAIN OUTCOME MEASURE: Patients' ratings of their satisfaction with the style of their physician and their trust in physicians. The Satisfaction With Physician Style Scale measured respondents' perceptions of their physicians' listening skills, explanations, and thoroughness. The Trust in Physician Scale measured respondents' perceptions that their physicians placed the patients' needs above other considerations, referred the patient when needed, performed unnecessary tests or procedures, and were influenced by insurance rules. RESULTS: After adjustment for socioeconomic and other factors, minority group members reported less positive perceptions of physicians than whites on these 2 conceptually distinct scales. Minority group members who lacked physician continuity on repeat clinic visits reported even less positive perceptions of their physicians on these 2 scales than whites. CONCLUSIONS: Patients from racial and ethnic minority groups have less positive perceptions of their physicians on at least 2 important dimensions. The reasons for these differences should be explored and addressed. Arch Fam Med. 2000;9:1156-1163

Physicians' advice to quit smoking. The glass remains half empty.

BACKGROUND: We explored the relationships between advice from a physician to quit smoking and an array of respondents' characteristics, including sociodemographic factors, health status, health insurance status, physician continuity, and intensity of smoking. METHODS: We examined data from the nationally representative 1996-1997 Community Tracking Study Household Survey. We used multivariate logistic regression to model receipt of cessation advice in a sample of 8229 smokers aged 18 years and older who made at least one visit to a physician in the past year. RESULTS: Less than 50% of the subjects reported receiving cessation advice. Advice was less likely for patients who were younger, men, African American, uninsured, healthier, lower health care services users, or lighter smokers, and more likely for those with military health insurance, who attended hospital outpatient clinics, or who belonged to health maintenance organizations. CONCLUSIONS: Physicians continue to miss opportunities to provide smoking cessation advice, a potentially lifesaving intervention. Given the adverse health consequences of tobacco use and the demonstrated benefit of advice to quit, physicians need to improve their cessation counseling efforts.

To buy, or not to buy: factors associated with the purchase of nongroup, private health insurance.

BACKGROUND: Employment-based health insurance coverage is declining in the United States. Many recent efforts to increase coverage have promoted the individual purchase of insurance, with or without subsidies. OBJECTIVES: To study the associations of factors including minority group membership, education, income, wealth, and health status with the voluntary purchase of nongroup, private health insurance. DESIGN: Analysis of the 1987 National Medical Expenditure Survey (NMES). SUBJECTS: Adult respondents to the NMES who were younger than 65 years of age in 2,574 health-insurance eligibility units (HIEUs) and who either were uninsured or who purchased nongroup, private health insurance for all of 1987. MEASURES: Adjusted odds ratios and marginal effects for the associations of minority group membership, educational attainment, income, and wealth with the purchase of nongroup insurance. RESULTS: Lower-income and less-wealthy HIEUs were much less likely to purchase insurance than higher-income and wealthier HIEUs, with income and wealth measures having relatively independent effects. With simultaneous adjustment for income, wealth, and other factors, members of minority groups had less than half the odds of non-Hispanic whites and persons with less than a high school education had less than half the odds of college graduates of purchasing nongroup insurance. CONCLUSIONS: Minorities and the less educated are much less likely to buy their own health insurance, even after adjustment for income and wealth. Programs encouraging the voluntary purchase of health insurance are likely to widen coverage gaps between historically disadvantaged groups and others.

Is family care associated with reduced health care expenditures?

BACKGROUND: Specific components of family medicine associated with reduced health care costs are not well understood. We examined whether people who received "family care," the sharing of a personal physician across familial generations, had lower health care expenditures than those who received "individual care" that lacked generational continuity. METHODS: We studied 1728 children and 2543 adults using a data subset of the 1987 National Medical Expenditure Survey, a representative sample of the civilian noninstitutionalized US population, to examine the relationship between care category and total health care expenditures, adjusting for potential confounders and effect modifiers. Survey respondents from households with either a married or a single woman aged 18 to 55 years as head of household and at least 1 child younger than 18 years were included. Only individuals reporting a family physician (FP) or general practitioner (GP) as their personal doctor were examined, since intergenerational family care is provided almost exclusively by FPs and GPs. RESULTS: Family care provided by an FP or GP was associated with 14% lower expenditures for adults ($51), after adjustment for covariates (P = .04), compared with individual care provided by a family or general practitioner. Although not statistically significant, for children family care was associated with 9% lower expenditures ($19). CONCLUSIONS: These findings suggest that family care provided by FPs or GPs is associated with lower health care costs. Policies promoting family care may reduce health care costs.

Use of hormone replacement therapy in Washington State: is prevention being put into practice?

BACKGROUND: American women are using hormone replacement therapy (HRT) for long-term disease prevention, as well as symptom control, in increasing numbers. Our study examined the role of prevention in women's decisions to initiate HRT and their intended duration of therapy. METHODS: We analyzed the mailed survey responses of 2023 women aged 50 to 70 years from the practices of 46 physicians in the Puget Sound region for knowledge and attitudes about HRT, current use, and intended duration of therapy. Multiple logistic regression was used to model current HRT use and intended treatment length. RESULTS: A total of 71% of our respondents were using HRT. Women with osteoporosis, coronary heart disease (CHD), or risk factors for CHD were not more likely to be using HRT, and women with CHD or risk factors for CHD were not targeted by their physicians for discussion of HRT. Of women using HRT, 77% expected lifelong use, and this was not more common among women initiating HRT for disease prevention. CONCLUSIONS: Despite the high rates of HRT use and expected lifelong duration, use of HRT for prevention was neither higher among women most likely to benefit nor a major determinant of expected lifetime use.

Do physicians do as they say? The case of mammography.

OBJECTIVE: To assess the utility of survey-based physician policy in predicting actual mammography ordering behavior, as measured by medical record abstraction. DESIGN: Cross-sectional survey of practicing community physicians. Responses were correlated with data abstracted from the medical records of patients in the practices of the participating physicians. PARTICIPANTS: Family and general practitioners in Washington State. Medical records of female patients aged 40 to 80 years provided data on actual mammography performance. MAIN OUTCOME MEASURES: The proportions of female patients aged 40 to 49 and 50 to 80 years who had received a screening mammogram within the previous 2 years. RESULTS: Of the more than 100 potential predictors available, only 4 were significantly associated with screening rates for women younger than 50 years and only 3 were associated with screening rates for older women. Regression models explained only 21% to 25% of the variance in screening rates. Physician estimates of screening rates were poorly correlated with actual screening rates. CONCLUSIONS: Practicing physicians do not know how well they screen their patients using mammography. Extensive survey data, including direct estimates of behavior, demographics, policy measures, and case scenario responses, were of limited use in predicting actual screening rates. Our results underscore the importance of using data rather than proxy measures to study physician performance.

Physician policies on the use of preventive hormone therapy.

BACKGROUND: Current guidelines recommend that most postmenopausal women be offered preventive hormone therapy (PHT), but there have been no surveys of U.S. physicians' policies since these guidelines appeared. We sought to measure physicians' policies and attitudes about PHT and compare them with the American College of Physicians' guideline on the use of PHT. METHODS: We used a stratified, randomized survey of gynecologists, family physicians, and general internists in Washington, Alaska, Montana, and Idaho. RESULTS: Nearly all respondents reported strong belief in the benefits of PHT and felt that the vast majority of their patients should be offered PHT. Where they differed, gynecologists believed even more strongly in its benefits than other respondents. Physicians estimated that 3% of their patients with a uterus were on regimens without any progestin and 23% were on regimens including time without any hormones. Gynecologists ranked mammography first and PHT use second on a list of eight preventive services, while the other respondents ranked smoking cessation first and PHT fourth (P < .0001 for differences). CONCLUSIONS: Among surveyed physicians, there was near unanimous adoption of policies favoring the recommendation of PHT. Gynecologists believed in it even more strongly than family physicians and general internists and ranked it as more important than counseling about smoking cessation.

Estimating annual charges for ambulatory care from limited utilization data.

OBJECTIVE: This study explores the types of utilization information needed to produce a reasonable estimate of annual charges for ambulatory care that could be used in the absence of charge or cost data as an aggregate utilization measure. DATA SOURCE: Charge and utilization data from the RAND Health Insurance Experiment were used. STUDY DESIGN: Services provided to enrollees in the Health Insurance Experiment at each of the six sites for a one-year period were grouped into categories according to California Relative Value Studies (CRVS) codes. Using annual charges as the dependent variable, we evaluated linear regression models for their predictive accuracy, as indicated by adjusted R2-values. Categories of services were combined on the basis of clinical meaningfulness (e.g., all provider visits into one group), and predictive accuracy of models with these groupings of services examined. We examined model validity by applying the derived models to each of the 30 remaining site-years of data from the Health Insurance Experiment. PRINCIPAL FINDINGS: We were able to explain 84 percent of the variance in charges with a model containing counts of provider visits exclusive of mental health visits, mental health provider visits, days drugs were prescribed, days radiologic procedures were performed, procedural visits subdivided according to whether they were performed by a surgical or medical provider, days laboratory and/or pathology tests were performed, days a grouping of miscellaneous tests were performed, and days supplies were purchased. When applied to the validation data, this model predicted a mean of 77 percent of the variance and mean charges 102 +/- 9 percent of actual mean charges. A model with only the first four of the listed categories explained 77 percent of the variance in charges. CONCLUSIONS: Models using only counts of several broad categories of services perform rather well in predicting annual charges for ambulatory care.

Insurance, income, and access to ambulatory care in King County, Washington.

OBJECTIVES: We studied simultaneous effects of income and insurance on access measures in an indigent population, focusing on Medicaid and the marginal effects of increasing income. METHODS: Surveys were distributed in waiting rooms of county clinics and welfare offices. Models examined insurance (private, Medicaid, or none), income (to twice the poverty level), single-parent status, age, gender, and presence of a regular source of care; first-order interactions were evaluated. RESULTS: In terms of ease of access, postponing care, and having a regular source of care, uninsured respondents fared worst and Medicaid recipients were at an intermediate level. However, relative to those with private insurance, Medicaid recipients had four times the odds, and uninsured respondents twice the odds of being denied care. Income had no consistent effect; however, older, poorer people may have greater problems. For preventive services, income was significant, while differences between Medicaid and private insurance were generally not significant. CONCLUSIONS: Except for denial of care, access for indigent people is improved by Medicaid but remains worse than the access of those with private insurance. Income had variable effects, but support for income criteria used for public insurance eligibility was not found.

Ribulose-1,5-bisphosphate carboxylase: enzyme-catalyzed appearance of solvent tritium at carbon 3 of ribulose 1,5-bisphosphate reisolated after partial reaction.

When ribulose 1,5-bisphosphate is allowed to react with carbon dioxide in tritiated water in the carboxylation reaction catalyzed by ribulose-1,5-bisphosphate carboxylase from Rhodospirillum rubrum, the ribulose 1,5-bisphosphate reisolated after partial reaction is found to be labeled. The specific radioactivity of the remaining substrate pool rises during the course of the reaction. Experiments in deuterium oxide show that the isotopic label resides on carbon 3. Earlier failures to detect this exchange process probably derive from the use of enzyme that was, in the absence of carbon dioxide, inactive. The present results provide direct evidence for the intermediacy of the enediol between C-2 and C-3 of ribulose 1,5-bisphosphate and show that the enolization step is at least partially rate limiting in the overall carboxylase reaction. The specific radioactivity of the product 3-phospho-D-glycerate remains constant throughout the course of the reaction at about one-sixth that of the solvent. This strengthens the argument against the involvement of "sticky" protons in the reaction.