Impact of increased physician supply on use of health services: a longitudinal analysis in rural Minnesota.

Prevalence studies of the use of ambulatory health care services have consistently reported relatively lower demand for services in rural areas. Such studies have implied that low use rates may be fixed characteristics of rural populations and may be resistant to the influence of manipulable variables such as supply of physicians. This longitudinal study suggests that use rates are in fact significantly changed after improvement of manpower resources, but that the effects are limited to the vicinity of new practice locations.

Hospital use in a fee-for-service system.

The population of Olmsted County, Minnesota, receives care virtually exclusively from two fee-for-service group practices: the Mayo Clinic and the Olmsted Medical and Surgical Group. Study of the use of acute-care hospital services by this population in 1976 reveals that the hospital discharge rate per 1,000 population, adjusted for age and sex, was 30% less than the national rate; the age-sex-adjusted rate of hospital days per 1,000 population was 38% less than the national rate. Analysis by length of stay, type of hospital service, frequency of selected diagnoses and surgical procedures, and certain demographic and economic characteristics did not explain the differences from national use rates. These rates are comparable, after age and sex adjustment, with those in larger prepaid group practices. The analysis suggests that the organization of medical care may have an important influence on hospital use.

The Mayo three-community hypertension control program. IV. Five-year outcomes of intervention in entire communities.

Beginning in 1974, the Mayo three-community hypertension control program initiated intervention studies in three southeastern Minnesota communities. This paper reports on the blood pressure outcomes 5 years after the inception of graduated programs involving public and professional education, detection, referral, and, in one community, systematic stepped care. Despite differences in local physician-population ratios and organization of medical care, perseverant long-term reductions of blood pressure were noted in all communities. However, the mean diastolic pressures were lower and the number of individuals at goal (diastolic blood pressure 90 mm Hg or less) was higher in the community offering categorical care. These data suggest that while programmatic efforts to control hypertension resulted in favorable blood pressure declines, the outcomes were particularly impressive in the community with a categorical hypertension clinic model offering systematic management of hypertensive patients.

The Mayo three-community hypertension control program. V. Cost-effectiveness of intervention.

This paper compares the costs of a categorical clinic model for community hypertension intervention with the costs of two less resource-intensive hypertension programs. Three categories of costs are measured for each program: program costs, patient costs, and time costs. Total costs are expressed in terms of costs per hypertensive patient controlled under each program. When adjusted for differences in hypertension prevalence and screening costs in the three community programs, the cost-effectiveness of the categorical clinic model is questionable. These results suggest that careful analyses of the categorical clinic model in other communities should be conducted before public resources are committed to the establishment of such models on a widespread basis.

Use of medical services and satisfaction with ambulatory care among a rural Minnesota population.

Patient satisfaction with health care services and the use of ambulatory care in rural southeastern Minnesota were surveyed before and after physician manpower was increased. This report is confined to the findings in 1974, before the three local practicing physicians were joined by two additional physicians. The physician to population ratio at the time of the initial survey was 1 to 6,200 in 1974 and 1 to 2,500 with the additional physicians in 1975.In this area the population of 12,400 centered around the town of Zumbrota. A total of 1,332 persons completed questionnaires, and 796 filled out a second questionnaire concerning patient satisfaction with health care. The scores on 40 items formed 18 satisfaction indices.Use of health services was lower than in the National Health Survey of 1969; the mean number of visits per year in Zumbrota was 3.3 compared with 4.3 for the national sample. The volume of use in the Zumbrota region was low, particularly among adults. Use of services was not significantly related to the education, occupation and income of the residents. About 10 percent of the population accounted for half of the total number of visits.Only a few of the 18 patient satisfaction indices were related to the respondent's income and occupation, but 5 were related to educational level. Satisfaction with health care services was generally higher in this rural population than among the people in four urban areas that were surveyed using the same satisfaction indices.The question raised by the findings in this survey-are rural areas in general as deprived and unsatisfied with health care as the literature suggests-remains unsettled. Changes over time in use and patient satisfaction are being assessed in the resurvey to seek possible explanations of the low utilization and high degree of patient satisfaction in this area.

The Mayo Three-Community Hypertension Control Program. I. Design and initial screening results.

The Mayo Three-Community Hypertension Control Program implemented graduated programs for the control of high blood pressure in three rural southeastern Minnesota communities, beginning in 1974. Prevalence of hypertension (when defined as diastolic blood pressure, at initial screening, of 95 mm Hg or more) was similar to that found for comparable groups by age and sex in the United States generally, but an atypically high frequency of known but untreated hypertension was found. Programs of public and professional information, systematic household screening, continuing professional education (two communities), and a new community hypertension clinic (one community) were initiated, and plans were made to evaluate the programs simultaneously by means of total rescreening of persons found to be hypertensive initially. The present report describes in detail the design of the program and the results of initial screening in relation to findings in other populations at the time. Subsequent reports assess the impact of each program on its target community and of a community hypertension clinic within the one setting where this component of a model program was established.

The Mayo Three-Community Hypertension Control Program. II. Outcome of intervention in entire communities.

A pronounced decline in blood pressure levels of hypertensive patients occurred in each of three rural Minnesota communities 1 to 2 years after the inception of community programs to control high blood pressure in these populations. An experimental hypertension clinic was established in one community to integrate a nurse practitioner into a physician-supervised program of long-term patient management. In the community with this innovative, partially subsidized practice arrangement, we observed declines in diastolic pressures of hypertensives. However, comparable degrees of blood pressure reduction occurred in the two other communities, with traditional solo or small group practice arrangements, where intervention was limited to detection and referral alone or was supplemented with continuing education of physicians in the management of hypertension. The evaluation of these three community programs suggests, among other conclusions, that this innovative community model for hypertension control, based on the recommendations of the Inter-Society Commission for Heart Disease Resources, contributed to favorable short-term blood pressure outcomes for the community. The observation of similar overall outcomes as measured by blood pressure reduction in all three communities was unexpected; the clinic's impact appears to have been matched by the effectiveness of screening and referral, alone or with continuing education, in the two other communities.

Quality assessment in hypertension: analysis of process and outcome methods.

Despite efforts to develop methods for measuring the quality of medical care, no satisfactory mechanism has been established. Our study, using hypertension as a clinical model, evaluated process and outcomes separately and then compared the two. Physician adherence to an extensive process list varied substantially from established criteria. No statistically significant association was detected between process and outcome. Regression analysis examined the relation between outcome diastolic pressure and 12 predictive variables that included patient satisfaction and social class. The only statistically significant variables (P less than 0.05) related to outcome blood pressure were age, initial blood pressure and weight. The inability to identify a relation between various process items and outcome suggests that, in determining a successful outcome for hypertensive patients, the selective use of process by the physician may be more effective than adherence to a rigid criteria list.