Out of plan. Certain HMO characteristics affect physicians' satisfaction and influence their decision to reenroll.

The authors examine the issue of continuity, which is directly associated with patient satisfaction, from the perspective of the physician. They attempt to determine which factors are most important in determining physician satisfaction with an HMO and the link between satisfaction with an HMO and intent to remain affiliated with that HMO. Their study reveals that 11 factors explain 71% of the variation in overall physician satisfaction and that a physician's satisfaction with a plan is closely linked to intentions to reenroll. Implications for HMOs, physicians, employers, and public policy makers are explored.

Who leaves the service area? Profiling the hospital outshopper.

Rural hospitals are facing a crisis of major proportions. Declining patient loads, revenues, and profits are the norm. The authors find that in rural communities, the likelihood of going to the local hospital increases with age and may decrease with income.

Physical environment as a hospital marketing tool.

People use tangible cues to form opinions about intangible products such as health care. This paper examines roles that physical environment tangible cues play in: (1) communicating with patients, doctors and staff members; (2) creating favorable patient attitudes; (3) developing positive service quality perceptions; and (4) market segmentation, targeting, and positioning.

Maternal and gestational factors in cryptorchidism.

Previous epidemiological studies of cryptorchidism have led to the hypothesis that the risk of undescended testis is associated with excess oestrogen exposure during pregnancy. A case-control study was undertaken to test this hypothesis, comparing mothers of affected boys (244) and normal male births (488) born within six months of a case selected randomly from the British Columbia population. Information was collected on the mother's reproductive history, family history, and past medical history, and events surrounding all pregnancies ending in a birth. The results were analysed using both the population-based sample of male births and the male sibs of cases as control groups. Neither exogenous oestrogen exposure, nor any of the pregnancy-related variables hypothesized to be indirect indicators of endogenous oestrogen exposure, including bleeding and nausea and/or vomiting, were found to be significantly associated with risk of undescended testes in either comparison. More mothers with later index births reported menstrual irregularity greater than half the time, and smoking, thought to have a protective effect, was more prevalent among case mothers than control mothers. No other variables were significantly different between case and control mothers. The results of this study do not support the hypothesis that elevated exogenous or endogenous oestrogen exposure during pregnancy increases the risk of undescended testis in male children.

The treatment of progressive non-Hodgkin's lymphoma with intensive chemoradiotherapy and autologous marrow transplantation.

Intensive chemoradiotherapy, with or without additional local radiotherapy, and unpurged autologous marrow transplantation was given to 68 patients with progressive non-Hodgkin's lymphoma. Responses were attained in 44 patients (65%, 95% confidence intervals [CI], 52% to 76%), including 37 who achieved complete responses. Fifteen patients (22%, 95% C.I. 13% to 34%) remain free of disease (including 11 continuously) at a median of 5.3 (range 3.1 to 9.1) years later. Higher Karnofsky scores (P less than .01, Mann-Whitney U test) and the absence of a history of prior radiotherapy (P = .02, chi 2 test) were associated with achievement of complete plus partial responses. Higher Karnofsky scores (P less than .01, Mann-Whitney U test) and less resistant disease status at transplantation (P = .04, chi 2 test) were significant when calculations were limited to complete responses. Karnofsky scores were also associated with the probability of freedom from progression (P = .02, log-rank) for responding patients. Also, Karnofsky scores and the absence of prior radiotherapy (P less than .01 and P = .01, respectively, log-rank) were associated with improved survival. Progressive lymphoma was the chief cause of failure; progression usually occurred less than 6 months after transplantation, most often at the sites of active disease before the transplant. However, five patients (including four with high-grade non-Hodgkin's lymphoma) suffered hematogenous patterns of relapse; four of these five patients had no prior history of marrow involvement. Other causes of mortality included interstitial pneumonitis, sepsis, hemorrhage and renal failure. Intensive chemoradiotherapy and autologous marrow transplantation produces durable remissions in some patients with progressive non-Hodgkin's lymphoma. Since such therapy is more effective when given to patients with signs of less advanced disease, earlier treatment would be the simplest way to produce improved results. However, improved conditioning regimens will also be needed, and measures to reduce occult lymphoma stem cell contamination with the autograft may also be required to increase the likelihood of cure in some patients.

Differential misclassification bias and dietary recall for the distant past using a food frequency questionnaire.

Cases (n = 263) and controls (n = 200) returned self-administered food frequency questionnaires in 1980-1982 and again in 1986 as part of a case-control study of breast cancer. The questionnaire asked about consumption of specific food items as recalled for four different age periods. K-statistics comparing responses in the first and second questionnaires were generally similar for cases and controls and were consistent across the different age periods. The influence of recent dietary change on dietary recall diminished for the more distant past. The food frequency questionnaire was found to be more reliable for specific food items for the distant past than for the more recent past. Differential misclassification bias between cases and controls was less apparent for the more distant past. The frequency and interpretation of missing values is discussed.

Treatment of progressive Hodgkin's disease with intensive chemoradiotherapy and autologous bone marrow transplantation.

Twenty-six patients with progressive Hodgkin's disease after conventional chemotherapy received intensive chemoradiotherapy and autologous bone marrow transplantation (ABMT); 19 also received additional involved-field radiotherapy. Twenty-one patients [81%, 95% confidence intervals (CI) 61% to 94%] attained complete (n = 18) or partial responses. Ten patients (38%, 95% CI 20% to 59%) are disease-free a median of 4.5 years later (range 3.5 to 7.0 years), including seven patients with continuous complete responses. The likelihood of overall response was not significantly influenced by any clinical or treatment variable examined. However, there was a trend favoring patients with higher Karnofsky scores, and higher scores were associated with attainment of complete responses (P = .06 and P = .02, respectively, Mann-Whitney U test). Both higher Karnofsky scores and shorter durations of disease before transplantation were associated with improved survival in a stepwise Cox multivariate analysis. The chief cause of failure was progression at sites previously involved with Hodgkin's disease. No patient relapsed in the marrow, and two of three patients with a history of marrow involvement with Hodgkin's disease achieved durable complete responses after transplantation. These data suggest that inadequate pretransplant conditioning, and not the reinoculation of occult tumor cells in the autologous marrow, caused most relapses. Fatal treatment-related toxicity occurred in six patients. Three patients died of idiopathic interstitial pneumonitis; each had previously received local mediastinal irradiation before intensive chemoradiotherapy. Intensive chemoradiotherapy and ABMT produces durable responses in some patients with Hodgkin's disease incurable with conventional therapy. Use of such therapies at the first sign of failure with conventional chemotherapy and development of more effective conditioning regimens should further improve results.

Tailoring hospital marketing efforts to physicians' needs.

Marketing has become widely recognized as an important component of hospital management (Kotler and Clarke 1987; Ludke, Curry, and Saywell 1983). Physicians are becoming recognized as an important target market that warrants more marketing attention than it has received in the past (Super 1987; Wotruba, Haas, and Hartman 1982). Some experts predict that hospitals will begin focusing more marketing attention on physicians and less on consumers (Super 1986). Much of this attention is likely to take the form of practice management assistance, such as computer-based information system support or consulting services. The survey results reported here are illustrative only of how one hospital addressed the problem of physician need assessment. Other potential target markets include physicians who admit patients only to competitor hospitals and physicians who admit to multiple hospitals. The market might be segmented by individual versus group practice, area of specialization, or possibly even physician practice life cycle stage (Wotruba, Haas, and Hartman 1982). The questions included on the survey and the survey format are likely to be situation-specific. The key is the process, not the procedure. It is important for hospital marketers to recognize that practice management assistance needs will vary among markets (Jensen 1987). Therefore, hospitals must carefully identify their target physician market(s) and survey them about their specific needs before developing and implementing new physician marketing programs. Only then can they be reasonably confident that their marketing programs match their customers' needs.

Hospital benefit segmentation.

Market segmentation is an important topic to both health care practitioners and researchers. The authors explore the relative importance that health care consumers attach to various benefits available in a major metropolitan area hospital. The purposes of the study are to test, and provide data to illustrate, the efficacy of one approach to hospital benefit segmentation analysis.