Risk adjusting capitation: applications in employed and disabled populations.

Risk adjustment may be a sensible strategy to reduce selection bias because it links managed care payment directly to the costs of providing services. In this paper we compare risk adjustment models in two populations (public employees and their dependents, and publicly-insured low income individuals with disabilities) in Washington State using two statistical approaches and three health status measures. We conclude that a two-part logistic/GLM statistical model performs better in populations with large numbers of individuals who do not use health services. This model was successfully implemented in the employed population, but the managed care program for the publicly insured population was terminated before risk adjustment could be applied. The choice of the most appropriate health status measure depends on purchasers' principles and desired outcomes.

Meta-analysis. A useful tool for the spine researcher.

Meta-analysis is a systematic and objective methodology for synthesizing research literature. The authors present the history and definition of meta-analysis, discuss the generic framework for design and implementation of a meta-analysis, and review the problems and pitfalls that can accompany meta-analyses. Their discussion draws on practical experience with several meta-analyses of the low back pain literature. Meta-analysis can be used to help answer the questions about various options for diagnosis and treatment of low back problems and also to point out gaps in our knowledge base that may have a high priority for research. Meta-analytic methods are an informative means of addressing health care controversies with major patient management and cost implications.

The evaluation of the Henry J. Kaiser Family Foundation's Community Health Promotion Grant Program: design.

The Kaiser Family Foundation's Community Health Promotion Grant Program (CHPGP) provides funding and technical assistance in support of community-based efforts to prevent major health problems. The first phase of the program was implemented in 11 communities in the western United States. This paper describes the evaluation design of the CHPGP in the West, the methods of data collection, and the baseline comparability of intervention and control communities. Major features of the evaluation design include: (1) the randomization of qualified communities making application into funded and unfunded comparison groups; (2) a second set of matched control communities for some intervention sites; (3) data gathering through repeated surveys of community residents (probability samples of adults and adolescents) and institutions (health-related organizations and randomly sampled grocery stores and restaurants); and (4) the use of secondary data to monitor health events. Selected baseline data show that intervention and control communities differ in racial/ethnic composition, but relevant health behaviors and ratings of community activation for health promotion appear comparable.

Correlation of auxotype and penicillin susceptibility of Neisseria gonorrhoeae with sexual preference and clinical manifestations of gonorrhea.

Strains of Neisseria gonorrhoeae requiring arginine, hypoxanthine, and uracil (Arg-Hyx-Ura-) are highly susceptible to penicillin G, and have been associated with asymptomatic urethral infection and disseminated gonococcal infection (DGI). The authors recovered Arg-Hyx-Ura- strains from 48% of 282 heterosexual men and women, versus only 9% of 69 homosexual or bisexual men (P less than 0.0001). In a separate population of consecutive men with urethral gonococcal infections, urethral discharge was absent in 0 of 96 homosexual men, versus 18 of 261 heterosexual men (P less than 0.025). Homosexual men accounted for none of 41 cases of DGI in men in 1970--1973, compared with 35% of men with uncomplicated gonorrhea in 1978. These findings suggest that asymptomatic urethral gonococcal infection and DGI are uncommon in homosexual men, perhaps because infection with Arg-Hyx-Ura- strains is relatively uncommon. Screening cultures of urethral specimens for N. gonorrhoeae had a low yield among homosexual men in the population studied. Strains of N. gonorrhoeae recovered from homosexual men were significantly more resistant to penicillin than were isolates from heterosexual subjects; this was true even for non-Arg-Hyx-Ura-strains. This difference may help to explain the lesser efficacy of ampicillin in treatment of rectal gonococcal infection in homosexual men.

Increased access to medical care: the impact on health.

Many federally financed programs have been launched to improve the access of the poor to medical care, under the assumption that this will improve their health. The effectiveness of these programs, however, has generally been measured by increased utilization rather than by improved health. The few studies which have considered health status have shown small or negative effects. Here, data are presented from a project which provided fully prepaid care to near poor families through existing sources in the community. A group of 748 enrollees was found to report worse health on four of five health indicators after one year of enrollment in the program; further, they appeared sicker on all five measures than a group without free medical care. It is suggested: 1) that the impact of health programs on the health of a population is a complex and poorly understood issue; and 2) that increasing access to health care may not be an effective way to improve health.

Rates of surgical care in prepaid group practices and the independent setting: what are the reasons for the differences?

The Seattle Prepaid Health Care Evaluation Project is a comparative study designed to assess the care received by persons enrolled in either a large prepaid group practice (PGP) or in a prepaid, independent practice setting in which physicians are reimbursed on a fee-for-service basis (IPP). As part of the study we assessed the patterns of surgical care for hysterectomy, cholecystectomy, appendectomy, and tonsillectomy/adenoidectomy. Overall, there were 215 such procedures with an exposure adjusted rate being five times higher in the IPP than in the PGP. After eliminating 43 per cent of procedures in the IPP and 22 per cent in the PGP which did not meet specified criteria for either necessary, appropriate or justifiable surgery, the exposure-adjusted rate differential was 3.9 times higher in the IPP with the difference in the rates being mainly attributable to hysterectomy and tonsillectomy/adenoidectomy. We conclude there were more unnecessary procedures in the IPP, but the fact that a significant difference in the incidence of surgery persisted even after elimination of such cases suggests that the differences in rates of surgery between the IPP and PGP cannot be solely attributed to a higher rate of inappropriate surgery in the IPP.

Tonsillectomies, adenoidectomies, audits: have surgical indications been met?

In the Seattle Prepaid Health Care Project, we studied medical records and claims information for all 97 children undergoing tonsillectomy and/or adenoidectomy in an independent practice plan from February 1971, through January 1975. Overall only 32 per cent of the procedures met commonly promulgated indications of surgery. Of 77 persons having one of these procedures performed because of recurrent pharyngeal or ear infections, 86 per cent did not meet the indications for surgery suggested by screening criteria adapted from model guidelines for PSRO use. The average number of episodes of illness was estimated to be 1.71/per year in the year prior to surgery using lenient assumptions. It is concluded that a major reduction in the frequency of these procedures would be effected by developing an audit strategy that assures the stated indications meet commonly recommended guidelines. The reduction in surgery would occur irrespective of the debate about the efficacy of these procedures.