Public health departments and the quality movement: a natural partnership?

This case study presents an example of a local health department's quality initiative process with regard to evaluating the key position of community health deputy administrator. The process of evaluation, as well as basic public health and quality movement tenets, are described. Conflicting and consonant philosophies among public health, health services, and the quality movement are also examined. The authors provide specific benchmark and programmatic examples of how the community health program is functioning. In addition, specific recommendations resulting from the quality evaluation process are provided. The authors conclude that this particular department has gone beyond the traditional public health department and successfully incorporated central concepts of the quality movement.

Patterns of hospital and physician utilization among the uninsured.

Despite numerous studies of access to care by the uninsured, few researchers have examined whether access to hospitals among the uninsured differs from access to physicians. This study employs a correlational, two-group design (n = 102,055) to analyze cross-sectional data from the 1989 National Health Interview Survey. Multiple logistic regression was used to compare the likelihood of hospitalization for the uninsured and insured in chronically ill, acutely ill, and well nonelderly subpopulations. When compared to data from a previous study on physician visits, disparities in hospitalization among the three subgroups differed in both magnitude and relative order from disparities in physician visits. The disparities between the insured and uninsured clustered at 38 percent for hospitalization, and 20 percent for physician visits. Overall, being uninsured resulted in a larger difference for hospital utilization than for physician utilization. These findings suggest that the uninsured face even greater access barriers for hospitalization than they do for physician care.

Birth choices, the law, and medicine: balancing individual freedoms and protection of the public's health.

To many Americans, the idea of home birth, the use of a "direct-entry midwife," or both seem archaic. Although much of the professional medical community disapproves of either, state laws regarding birth choices vary dramatically and are not necessarily based on empirical findings of childbirth outcomes. Public health practitioners, policymakers, and consumers view childbirth from the perspectives of safety, cost, freedom of choice, quality of the care experience, and legality, yet the professional, policy, and lay literatures have not offered an unemotional, balanced presentation of evidence. Reviewing the full spectrum of literature from the United States and abroad, we present a Constitutional medical-legal analysis of whether home birth with direct-entry midwives is in fact a safe alternative to physician-attended hospital births, and whether there is a legal basis for allowing alternative health policy choices is such an important yet personal family matter as childbirth. The literature shows that low- to moderate-risk home births attended by direct-entry midwives are at least as safe as hospital births attended by either physicians or midwives. The policy ramifications include important changes in state regulation of medical and alternative health personnel, the allowance of the home as a medically acceptable and legal birth setting, and reimbursement of this lower-cost option through private and public health insurers.

Physician utilization disparities between the uninsured and insured. Comparisons of the chronically ill, acutely ill, and well nonelderly populations.

BACKGROUND: This study examines the associations between lack of health insurance coverage and physician utilization for the chronically ill, acutely ill, and well nonelderly populations in the United States. METHODS: Cross-sectional data from the 1989 National Health Interview Survey, conducted by the National Center for Health Statistics, were analyzed for the nonelderly population using a correlational, two-group design (N = 102,055). Analytic models, using multiple logistic regression, were tested to predict the odds and likelihood of physician utilization for the uninsured and insured in the three subpopulations (ie, chronically ill, acutely ill, and well), controlling for health status, number of conditions, and geographic, sociodemographic, and economic factors. Disparities in utilization were then calculated between the uninsured and insured for each subpopulation. RESULTS: The nonelderly uninsured were consistently less likely than the insured to have received any health care within 12 months. Moreover, there were differential effects of being uninsured on utilization depending on whether an individual was chronically ill, acutely ill, or well. Whereas chronically ill and well uninsured persons were half as likely to have seen a physician as their insured counterparts (odds ratio, 0.50), acutely ill uninsured persons were almost two thirds as likely to receive physician care (odds ratio, 0.62). Thus, the disparity in physician utilization between the uninsured and insured was larger for the chronically ill and well than for the acutely ill; uninsured acutely ill were less likely to go without care. Of the three populations, those in the well population had average disparities with the largest magnitude (40%), compared with disparities of the chronically ill (20%) and acutely ill (10%). CONCLUSIONS: These disparities represent large inequities in utilization of care by the uninsured, particularly for the chronically ill and well. Whether these disparities result from lower access or individual choice cannot be determined from this study. When viewed in light of other studies examining the impact of utilization on health status, these results provide support for the development of comprehensive health insurance packages with universal coverage and better inclusion of chronic and preventive care models in benefit packages.