Health care policies for children in out-of-home care.

Placement in out-of-home care is one intervention used to protect children from abuse and neglect. While children are in such care, it is the child welfare agency's responsibility to ensure that their health needs are met. The study reported here examined health care policies and services for children in 46 state child welfare agencies. Virtually all states had some sort of written policies regarding health care for children in out-of-home care. Half, however, reported having no information management system to record health care data, and only six of the 23 had computerized systems. Most states fell short of meeting the standards set by the Child Welfare League of America for the health care of children in out-of-home care.

Physical fitness, physical activity, and functional limitation in adults aged 40 and older.

PURPOSE: A cohort of middle-aged and older men and women were followed for an average of 5.5 yr to examine the association between physical fitness, physical activity, and the prevalence of functional limitation. METHODS: The participants received medical assessments between 1980 and 1988 and responded to a mail-back survey regarding functional status in 1990. RESULTS: Among 3495 men and 1175 women over 40 yr of age at baseline, 350 (7.5%) reported at least one functional limitation in daily or household activities at follow-up. The prevalence of functional limitation was higher among women than men. Physically fit and physically active participants reported less functional limitation than unfit or sedentary participants. After controlling for age and other risk factors, the prevalence of functional limitation was lower for both moderately fit (odds ratio = 0.4, 95% CI = 0.2-0.6) and high fit men (odds ratio = 0.3, 95% CI = 0.2-0.4), compared with low fit men. Corresponding figures for women were 0.5 (0.3-0.7) and 0.3 (0.2-0.5) for moderately fit and high fit women. The association between physical activity and functional limitation was similar to the data for physical fitness. CONCLUSIONS: These data support a protective effect of physical fitness and physical activity on functional limitation among older adults and extend this protective effect to middle-aged men and women.

Antigovernment sentiment and support for universal access to care: are they incompatible?

OBJECTIVES: Attitudes toward universal access to medical care were examined to determine whether support for it among people opposed to government involvement in health care was modified by three proxy measures of self-interest: being uninsured, in poor health, or a high user of medical care. METHODS: Data on support for universal access, attitudes toward government involvement in health care, and the indicators of self-interest were obtained from a representative sample of adult Oklahomans (n = 1547) surveyed between October 1992 and December 1994. Forced-order multiple regression with interaction terms was the data analysis technique. RESULTS: People opposed to government involvement in health care were found to be less likely to favor universal access to medical care, but poor health, lack of insurance, and high usage of medical care moderated this effect. CONCLUSIONS: The findings support the view that antigovernment sentiment need not foreclose the public option for health policymakers. Other considerations such as self-interest may modify the effect of unfavorable attitudes toward government.

The relationship between resource constraints and physician problem solving. Implications for improving the process of care.

OBJECTIVES: Research suggests that physicians will engage in more vigilant problem-solving under conditions of resource constraints than under conditions of resource slack. Increased vigilance related to physicians' clinical strategies enhances care by disposing physicians toward more optimal care choices. The authors examine whether pressures for clinical resource constraints encourage increased and sustained vigilance in problem-solving among cardiologists treating acute myocardial infarction. METHODS: The physician problem-solving process is reconstructed from the medical records of all eligible cases of acute myocardial infarction treated by the physician sample set over a 6-year period. The sample period encompasses phases of both resource slack and resource constraints. The Herfindahl index is used to measure the relative amount of vigilant problem-solving activity exhibited in each of five major tactical areas of the physician care strategies in each year of the study. RESULTS: The results support the hypothesis that resource constraints initially promote a shift to increased vigilance in physician problem-solving. Only one of the five major tactical areas, however, is characterized by sustained vigilance over time. The other areas are, instead, associated with a substantial reduction in vigilant activity after the initial peak period. CONCLUSIONS: The results suggest that resource constraints do set the stage for improved clinical decision-making. Sustained vigilance, however, appears to apply only to those portions of the care strategy for which the physician can draw a clear link between optimizing clinical activity and reducing resource consumption. For those portions of the care strategy for which the physician cannot establish a clear link, ongoing pressures to conserve resources results in reduced vigilance and a potential reduction in quality of clinical decision-making.

Health, illness, and healing in an uncertain era: challenges from and for medical sociology.

The current situation in health care organizations, among providers and for people, dramatically challenges the "business as usual" roles of medicine, government, insurance companies, the community, and the university. Health care reform marks the first attempt in a century to consider a reconstruction of the social contract between society and medicine. While sociology stands as one of the earliest social sciences to systematically study the health care arena and create a health-focused subfield, there is a perception, not without support, of a desertion of identity from within, an encroachment by other areas from without, and abandonment by the parent discipline. We argue that these situations in medical arenas and in research fields require serious rethinking. The key lies in understanding how these phenomena are related to each other and to larger social forces, and how they offer opportunities, rather than signal limitations, to medical sociologists. We turn to the theoretical tools of sociology to help unravel the complicated challenges that face both policymakers and researchers. After framing these issues in a sociology of knowledge perspective, we use the case of "utilization theory" to illustrate the connections between society and systems of care (as well as studies of them) and to create a future agenda. We end by raising three basic questions: (1) Why is a sociological perspective critical to the understanding of change and reform in health care? (2) Why is medical sociology critical to the survival of the general sociological enterprise? and (3) Why is general sociology critical to the research agenda in medical sociology?

A comparison of the effect of regulation on health care for the older American: a tale of two states.

The enactment of changes in health care policy necessitates monitoring industry practice to assure a response in line with intent. Theory predicts that tightly controlled organizations produce too few services to meet needs. Those under milder restrictions produce too many services to compensate for perceived losses in revenue. This study explores the relationship, if any, between level of regulatory intensity upon, and subsequent service delivery within, the hospital industry. Some service retrenchment may be desirable, particularly if fewer iatrogenic events occur. Too few services proffered are harmful. A look at prior efforts may prove beneficial before the United States initiates overall health care reform.

Access to family planning services and health insurance among low-income women in Arizona.

This paper uses 1984 and 1989 Arizona survey data to explore the importance of insurance coverage for access to family planning services. In Arizona, Medicaid was provided through the Arizona Health Care Cost Containment System, a managed care model. Family planning was not provided in 1984 but had been added by 1989. Low-income women were 2.3 times more likely to receive services in 1989 than in 1984. Women in the system were 60% more likely to have received services. To improve access, health reform proposals should explicitly include family planning in managed care benefits packages.

Increasing home health service referrals, boon or bane?

Discharges to home health services (HHS) increased dramatically for the elderly after Medicare's prospective payment system (PPS) was enacted in October 1983. A longitudinal study of fourth quarter South Carolina discharge abstracts from 68 of 71 short term acute care hospitals in the state were analyzed to appraise hospital responses to implementation of this significant change in Medicare's reimbursement system. PPS caused shifts in hospital practices as financial incentives radically changed from a cost-based system that encourages expenditures to a PPS that evokes conservation of resources within a hospital stay. In so doing, the "output" (i.e., discharge) changed. One of those changes observed was an increase in referrals to HHS. Apparently, capping the amount reimbursed for a particular diagnosis left the more resource-intensive patient vulnerable and in want of care on discharge. Demand for HHS rose significantly (+47% in 1983; +234% by 1985). Though a HHS referral may be appropriate during the recuperative phase of an illness, questions arise as to hospital motivation. The HHS referral represented the most resource-intensive, but arguably unprofitable segment. Had hospitals sought earlier discharges to "protect their bottom line" as reimbursement essentially was capped? Was a referral to HHS appropriate to meet the existing patient-care needs that remained? Did HHS offer a more cost-effective substitution for care formerly provided the patient in the hospital? What provider and consumer characteristics are at risk and why? Both consumer and provider concerns need to be addressed. Answers to these questions are most critical to future health care reform. Allocation decisions of scarce resources need to be grounded in realistic expectations drawn from appraisals of what does and does not work in the health care market.

Safety hazards in households with young children.

Interviewed 230 mothers of young children concerning in-home observations of safety hazards related to burns, poisoning, and falls, and self-reported measures of maternal supervision, locus of control, social support, and safety attitudes. These were supplemented by measures of mothers' risk perceptions, stress and coping, their child's previous injury experience, and indicators of the family's socioeconomic status (SES) collected by telephone survey. SES was an important predictor of observed home hazards. Child-related variables, risk perceptions, and domain-specific attitudes had little influence on home hazards. Maternal supervisory style, rated on dimensions of protectiveness, was an important correlate of all types of household hazards. Results suggest that residential injury prevention strategies for young children should stress active as well as passive countermeasures.

Access to cancer screening services for women.

A major effort in preventive care for women has emphasized the obtaining of Pap smears and mammograms. This paper uses survey data from one state to examine issues of access to Pap smears and mammograms. Poor women receiving health care through a managed-care Medicaid program received these services at the same rate as women with other types of health insurance, while the uninsured were less likely to have had either type of service.

High risk channeling to improve Medicaid maternal and infant care.

To improve the medical care access of the poorest women and newborns, South Carolina began a High Risk Channeling Project since April 1986. The Project directs physicians to screen all Medicaid-eligible pregnant women and newborns for specified clinical high risk factors. High risk patients are channeled to designated clinics for prenatal and newborn care. Channeled pregnant women are directed to deliver their babies at regional referral hospitals. For the first two years of the Project, about two-thirds of pregnancies and 60% of newborns were actually screened. Channeled women were much more likely than the non-channeled to deliver at higher level hospitals. In counties where relatively few women were channeled, the rate of prematurity among Medicaid newborns was significantly higher than in other counties.

Patterns of non-response to a mail survey.

This paper describes a basic investigation of possible non-response bias in a mail survey. We compare characteristics of responders and non-responders to a mail survey of health outcomes among participants of a longitudinal study of physical activity, physical fitness, and health. Results indicate that, at the first clinic visit, the responders were essentially the same as the non-responders on personal health history and laboratory measurements, while reporting significantly more family history of specific chronic diseases (cardiovascular disease, hypertension, stroke). The male responders were younger and reported more positive health behaviors as well as better weight and treadmill times at the first clinic visit. These results suggest that both response groups were equally healthy at entry, and that individuals who had family members with certain chronic conditions and who had positive health behaviors were more likely to respond (participate) in this health-related survey. Differences of this type could affect interpretation of future analyses. This work illustrates the importance of incorporating methods to examine non-response into any epidemiologic study.

Regulation, retrenchment--the DRG experience: problems from changing reimbursement practice.

A study of 227,771 discharge abstracts from one U.S. state's short-term, acute care hospitals compares changes in the inpatient market available to the oldest old Medicare patients (85 and older) with those less than 70 and those 70-84 between 1981, the last year when all hospitals were under cost-based reimbursement, and 1984, the first year in which all hospitals were under a prospective payment system based on diagnosis related groups (DRGs). All three populations experienced retrenchment in services as hospitals pursued practice changes to enhance revenue potential. An older, sicker client was admitted as hospitals implemented changes in admission patterns to avoid denial of reimbursement for an admission deemed inappropriate by the Peer Review Organization (PRO). Evidence demonstrates compression in service markets and retrenchment in services for less profitable DRGs and/or cohorts. Inpatient services were reduced the most for the oldest old population although this cohort was the sickest. Changes were observed in utilization of special care units, such as in coronary and intensive care units. Large increases in readmissions in all three cohorts suggests that DRG incentives to reduce length of hospital stay may have promoted premature discharge. Or, perhaps these readmissions resulted from 'unbundling', a practice of splitting patient problems into multiple admissions, as hospitals sought ways to enhance revenue instead of practicing cost-containment. Policy, perceived to be economically stringent, can affect hospital practice and produce undesired results with long-reaching untoward effects on certain segments of the population.

Medicaid prospective payment: case-mix increase.

South Carolina Medicaid implemented prospective payment by diagnosis-related group (DRG) for inpatient care. The rate of complications among newborns and deliveries doubled immediately. The case-mix index for newborns increased 66.6 percent, which increased the total Medicaid hospital expenditure 5.5 percent. Outlier payments increased total expenditure further. DRG distribution change among newborns has a large impact on spending because newborn complication DRGs have high weights. States adopting a DRG-based payment system for Medicaid should anticipate a greater increase in case mix than Medicare experienced.

Age, physical activity, physical fitness, body composition, and incidence of orthopedic problems.

The incidence of orthopedic problems was examined in 5,582 men and women who attended the Cooper Clinic in Dallas, Texas between 1974 and 1982. The effects of age, physical activity, physical fitness, and body mass index (BMI) on the occurrence of these problems were examined using a proportional hazards approach. The expected risk of orthopedic problems per person-year was 0.045 for men and 0.046 for women. For men, physical fitness, BMI, and physical activity were associated with orthopedic problems, while for women, physical activity was the main predictor. Age was not a factor for either gender. The effect of change in physical fitness, physical activity, and BMI was examined in a subset of 2,325 persons with more than one visit to the clinic. For women, physical activity and a decrease in BMI were associated with orthopedic problems, while for men none of those factors were significant. Again, age was not a factor in either group. The absence of any age effect on the occurrence of problems suggests that with regard to orthopedic problems, moderate amounts of physical activity in generally healthy persons may be recommended without special consideration as to age.

An appraisal of organizational response to fiscally constraining regulation: the case of hospitals and DRGs.

Results from analysis of 227,771 discharge abstracts from 68 short-term, acute-care hospitals and from interviews with a stratified random selection of 24 of the 68 chief executives of these hospitals demonstrate that institutions perceive implementation of DRGs as fiscally constraining, especially in light of other resource-constraining conditions (an increase in unemployment resulting in fewer people with hospitalization insurance, in addition to severe cuts in Medicaid rolls and budget). Hospitals responded to DRGs by decreasing the use of affected resources or services available to the hospitalized Medicare patient. In order to survive a more economically stringent marketplace, hospitals no longer protected the traditional core within the Medicare inpatient market. They opted instead to change practices and products at the unregulated margins of the DRG system.

A mail survey of physical activity habits as related to measured physical fitness.

The associations of self-reported measures of physical activity from a mail survey with an objective measure of physical fitness were investigated. Respondents to a health status survey (n = 12,225), conducted in 1982 by the Institute for Aerobics Research in Dallas, TX, formed the population. From this group, males who also had a clinical examination within 60 days of the return of their questionnaire served as subjects. The study subjects (n = 375, mean age = 47.1 years) completed a maximal physical fitness assessment using a modified Balke protocol. The questionnaire included a section of inquiries concerning leisure time physical activity participation in which subjects were asked to quantitatively recall exercise participation for varying periods of time. Reported exercise participation values were converted to estimates of energy expenditure and combined into overall indices of physical activity participation. Multiple regression analyses were used to determine the individual contributions of the physical activity indices in predicting maximal treadmill performance (physical fitness). Significant predictors of physical fitness were age (beta = -0.34), an index of running, walking, and jogging participation (beta = 0.31), and the response to a question on frequency of sweating (beta = 0.35). The multiple correlation coefficient for these variables in predicting physical fitness was 0.65. These results indicate that exercise behavior can be accurately estimated in large populations by using simple questions in a mail survey.

Changing health practices: the experience from a worksite health promotion project.

This paper uses data from an employee health promotion project for government employees to examine initial health practices and their relationship to social and demographic variables. It then uses data collected one year later to examine changes in health behaviors and to try to explain what types of people are most likely to undertake health behavior changes in a year, within the context of a worksite health promotion project. Most people in this sample of employees do make positive changes in health habits in at least one of the following areas: smoking, seatbelt usage, diet, exercise, alcohol usage. While a variety of different social and demographic variables are important in explaining initial differences in health practices, these same variables along with measures of personal efficacy and job stress are poor predictors of whether people change their health behavior over a year. Future research might usefully focus on more detailed collection of qualitative data to help understand what factors motivate people to change health behavior. Future survey approaches may then incorporate broader and more diverse categories of explanatory variables into regression models.

School worksite wellness programs: a strategy for achieving the 1990 goals for a healthier America.

Employee health promotion programs, first developed for private business and industry, are being extended to governmental employees. South Carolina established a pilot health promotion program in 1982 for 20,000 state employees in the area surrounding Columbia, the state capital. In 1985, the Carolina Healthstyle program was institutionalized as an employee benefit, extended statewide, and was broadened to include all school district employees and state retirees. This article describes the Carolina Healthstyle program in school worksites as it is being implemented by one pilot school district, with a briefer description of the organization, funding, and evaluation of the overall state employee wellness program. The article describes contributions that schoolsite wellness programs can make to increase positive health behaviors of staff, parents, and community as part of the movement to achieve the health goals of the nation.