Monitoring changes in home health care: a comparison of two national surveys.

Home health care is the fastest growing component of medical care in the United States. To understand better the nature and scope of changes taking place in home health, two current national surveys are described and compared. The two federally sponsored surveys are the National Home and Hospice Care Survey (NHHCS) conducted by the National Center for Health Statistics and the Medical Expenditure Panel Survey (MEPS) of the Agency for Health Care Policy and Research. Computer data files from both surveys are publicly available.

The new old market: trends in hospital services for the aged.

Hospital health care services for the rapidly aging population should continue to expand. Several recent trends include the following: The overall number and proportion of admissions for the aged have increased since 1967 and will probably continue to increase in the future; The overall percentage of older patients in smaller hospitals has dropped steadily since 1967, but smaller hospitals continue to have a higher percentage of older admissions than do larger hospitals; The aged have a different seasonal pattern of admission compared to younger persons, reaching a nadir in August and an apex between January and April. The average inpatient length of stay for the aged has been dropping steadily over the last twenty years, long before the recent cost containment emphasis; Community hospitals are expanding their operations into long-term care services, including skilled nursing home care, intermediate care, and psychiatric long-term care; Emphasis on early patient discharge has led many hospitals to concentrate on continuity of care between institutions and the community, including increased emphasis on discharge planning and the coordination of services; and Hospitals plan to continue to expand care for the aging and aged population. As the population of the nation ages, hospitals will increasingly address the needs of older persons and continue to plan actively and aggressively and market their services to the aged, not only for humanitarian reasons but also for survival in an increasingly competitive environment. In the future, hospitals seem likely to continue to acquire new and more costly technology to enhance their acute care delivery. At the same time, however, they will continue to provide an increasing array of health care services to older persons. They will convert acute care beds to long-term care use, construct and or purchase nursing homes, and expand into other areas of care for the aged. Thus, the authors predict that hospitals will indeed evolve beyond acute care and play a central function in the provision of the nation's long-term care system.

Rural hospital survival: an analysis of facilities and services correlated with risk of closure.

To test whether the facilities and services offered by rural hospitals can put them at risk of closure or protect against it, this study compares U.S. rural community hospitals that closed during the period 1980-1987, with a matched set of hospitals that remained open. Utilizing epidemiologic matched case-control methods and controlling for type of ownership, we found that (1) physical therapy, respiratory therapy, intensive care unit, computed tomography scanner, hospital auxiliary, and diagnostic radioisotope were negatively correlated with closure (i.e., had a protective effect); (2) the facilities and services correlated with risk of closure differed significantly between the pre-PPS (1980-1983) and post-PPS (1984-1987) periods; and (3) the presence of a skilled nursing or other long-term care unit was a significant risk factor during the period 1984-1987. Implications of these findings for hospital survival strategies and rural health care delivery under PPS are discussed.

Preventive control of AIDS by the dental profession: a survey of practices in a large urban area.

The purpose of this study was threefold: (1) to report the proportion of dental practitioners adhering to the 1987 Centers for Disease Control (CDC) procedures for using infection control techniques (ICTs); (2) to identify attitudes toward infection control and disease; and (3) to establish whether certain practitioner characteristics or use of certain ICTs were related to willingness to treat HIV-positive patients, willingness to volunteer for an HIV specialty clinic outside of regular practice, vaccination against hepatitis B, and a felt need for a specialty clinic within the practice to treat HIV patients effectively. A survey of approximately 3,800 members of a major metropolitan dental society found that 89 percent of respondents regularly used at least one CDC ICT beyond routine medical histories. Ninety-one percent indicated a moderate to extreme change in attitude toward the risks of infectious diseases and the regular use of ICTs (80.2% identified AIDS as the major factor in this change). Twenty-seven percent indicated that they would knowingly treat HIV-positive patients. No differences were found among practitioners willing to treat HIV-infected patients and those unwilling to treat these patients in terms of adherence to the CDC ICT recommendations for dentists. Statistical association between ICT use and other practitioner response variables are discussed.

Rural community hospitals and factors correlated with their risk of closing.

The issue of rural hospital closings in the United States in recent years has become of increasing concern to health care policy analysts. Rural communities face unique health needs, necessitating access to local health care. Much has been written about the social, economic, legislative, and technological changes that have increased the stress on rural hospitals in the 1980s. However, quantifiable models have been lacking with which to examine in detail factors associated with rural hospitals and to correlate such factors with individual hospitals' risks of closing. In this study, we identify variables correlated with rural community hospital closures in the period 1980-87. Using epidemiologic case-control methods, 161 closed rural hospitals were matched 1 to 3 with a control group of 483 rural hospitals which remained open during the same period. A series of hospital performance indicators and demographic, economic, and social community variables were entered into a multiple logistic regression model. Four variables were found to be positively correlated with risk of closure. They are for-profit ownership; nongovernment, not-for-profit ownership; presence of a skilled nursing or other longterm care unit; and the number of other hospitals in the county. Variables negatively correlated with risk of closure were accreditation by the Joint Commission on the Accreditation of Healthcare Organizations, the number of facilities and services, and membership in a multihospital system. Policy and research implications at the Federal, State, and local levels are discussed.

Cigarette smoking and attitudes toward quitting among black patients.

A sample of 1,388 black patients attending the medical clinic of a general public hospital were interviewed regarding smoking habits and attitudes toward quitting. Current smokers constituted 30% of respondents of both sexes, and approximately half of the sample were ex-smokers. Rates of current smoking were lower, and cessation rates higher, among older individuals and men. Two thirds of current smokers expressed a desire to quit, and of those an equal proportion wanted to participate in a formal cessation program. A majority of smokers reported attempting to quit on their own, and most had made more than one attempt. Given the large burden from cigarette-related disease in the black population, and the current absence of effective primary prevention efforts, smoking intervention in the clinical setting will remain an important obligation of health providers caring for black patients. This article demonstrates moderately high smoking prevalence rates of black individuals already under care for chronic illness, and a concomitant high level of desire to quit. The absence of effective programs appears to be the obstacle preventing significant progress in this important area of health promotion.

Hospital closure: management and policy issues.

As hospital closures have increased between the years 1980-1987, it has become essential for hospital administrators to be aware of the effects of an increasingly complex and competitive environment on their institutions. The purpose of this paper is to examine variables correlated with risk of closure, and to use these data in a context to suggest a managerial approach that will minimize risk. The open systems perspective, which emphasizes uncertainty as an essential component of the planning environment, is suggested as the optimal managerial approach.

Rural community hospital closure and health policy.

Closure of rural community hospitals in the U.S.A. is a growing and important trend with serious implications for rural communities and the overall health care system. This study analyzes characteristics of all U.S. rural hospitals that closed between 1980 and 1986. Variables correlated with risk of closure--for-profit ownership status, non-government not-for-profit ownership status, number of other hospitals in the county, presence of a nursing or other long-term care unit, few facilities and services offered, lack of accreditation by the Joint Commission of Accreditation of Hospitals, lack of membership in a multihospital system--indicate that a rural hospital's survival depends upon its ability to compete and adapt in a volatile, competitive health care marketplace. five policy options are discussed: changes in Medicare payments, expansion of the number of hospitals designated as sole Community Hospitals, the use of swing beds, establishment of state offices of rural health, and short-term federal and state grants. Allowing hospitals the flexibility to adapt and compete, while ensuring adequate quality health care to rural residents, is suggested as the priority in rural health policy.

Modeling hospital closure relative to organizational theory: the applicability of ecology theory's environmental determinism and adaptation perspectives.

The writers present a set of hypotheses testing the strength of organizational ecology theory's environmental determinism perspective and the adaptation perspective. Some of these hypotheses are analyzed relative to data on hospital closures in the United States between 1980 and 1985. Initial empirical analyses indicate that environmental determinism's liability of smallness holds relative to hospital closure, but the liability of newness doesn't hold. There are no published accounts where the liability of newness hypothesis hasn't held in research on other industries. The writers speculate that the inverse relationship between a highly changing health care environment and the liability of newness of hospitals may be because newer hospitals are better able to tap into the ongoing changes of the today's turbulent health care delivery environment in the United States. Also, analysis findings show that the environmental interdependence orientation of the adaptation models has some explanatory power in that hospitals with greater community support have much lower closure rates. Consideration of the more organization action oriented framework of the adaptation perspective is called for over the environmental determinism perspective that has been promoted in recent publications. The writers suggest that the more community sponsored a hospital is, the less likely its survival will hinge solely on standard environmental selection criteria, and that the ability of a hospital's administration to correctly adapt to environmental fluctuations is critical, especially in today's turbulent health care delivery environment in the United States.

Health care coalitions: continuity and change.

The purpose of this study has been to investigate how coalitions have changed during 1983-1986, to describe the current characteristics of coalitions, and to speculate about their future roles and likely evolution. Several insights emerge from the empirical findings of this study. First, the number of operational health care coalitions has greatly expanded over the last several years to the point where almost every state and metropolitan area of the country has at least one. Second, the service area of most coalitions is generally county-wide, although there has been significant growth in the number of coalitions that serve states. Third, coalitions are expanding their membership composition and including not only business members but also hospitals, physicians, insurance companies, and labor organizations. Fourth, coalitions are becoming more financially secure; most have annual cash budgets, and most rely on dues. Fifth, coalitions are increasingly hiring and using paid professional staff. Last, coalitions are expanding their agendas beyond investigating direct health care costs to examine some of the underlying issues (such as hospital and medical professional liability issues, the financing of uncompensated care, and ethical issues) and are developing programs to address them. For the near future, the extension of recent trends suggests how coalitions will look and function. Further down the road, health care coalitions may evolve into health care public/private policy forums or associations of health benefits managers and/or associations for managed care purchasers. In conclusion, the trends we documented and the projections of the future of coalitions appear to be in keeping with the summary perspective of John T. Dunlop (1987) who indicates: Coalitions provide a continuing forum in which parties become more interested and informed about health care costs, utilization and the problems and operations of the other participants. The discourse encourages a more extensive and informed development and sharing of data. Coalitions reflect and need to recognize the inevitable internal conflicts and interests of the constituent organizations. While some coalitions tend to flounder on internal conflicts and capacity to generate effective leadership; many are fruitfully addressing the hard issues of health care in a community, such as managed care, capitation payments, excess beds and capital requirements, and access to health care by the uninsured. As coalitions mature, beyond discourse and data, they are likely to concentrate on a few of the distinctive problems of their communities and the interaction within the health care environment to address these problems.

Black-white differences in health status: methods or substance?

Apparent differences in the health status of blacks and whites vary according to methods of measurement, errors in the measurement process and interpretation of the measures, and types of measures used. This article uses the literature and secondary analysis of available data to explore the impact of methods on health status comparisons by race. Methods to measure health status include records, direct observations, and self-reports. Blacks generally show the greatest health deficits based on observation and least on some types of self-reports. Major types of errors in health status estimates are random errors and biases. Random errors tend to be greater for blacks because samples used to estimate their characteristics have often been smaller than white samples. Biases include noncoverage or failure to include some types of individuals in the reporting systems at all, nonresponse or lack of complete information on some persons, and use of inaccurate information due to faulty data collection or processing. Such biases tend to be greater for black persons than for whites. Their impact often is to give the illusion that blacks may be in better health than is actually the case. The types of measures that show blacks in the poorest health status are those considered to be most objective: mortality rates and some clinical examinations and health provider records. Subjective measures of dissatisfaction with health level also show blacks to be much less healthy than whites. In contrast, self-reports of illness conditions, symptoms, and restricted-activity days show blacks, particularly children, to be relatively well off compared to whites. These self-reports may be misleading due to differential perceptions of illness and reporting biases between blacks and whites. There is no doubt that measured differences in the health status of blacks and whites often reflect substance. There are also significant methodological problems, however, in comparing health status by race, which tend to underestimate the problems experienced by the black population. This article and others in this volume stress the need to know much more about the sources and impact of these methodological problems. In the meantime, these problems need to be recognized and adjusted for, where possible, when health status measures are compared. It is particularly important to consider them when policy questions of equity and resource allocation are to be decided using indicators of health status.

Hospital characteristics and the use of computer processing and abstract services. A logistic analysis.

The use of computer processing and abstract services by hospitals is in a state of continuing change. Although many hospitals subscribe to abstract or turnkey systems, others are leaving shared services to set up their own in-house systems. To better understand the relationship between hospital characteristics and the use of computer processing and/or abstract services, data from the AHA 1982 Special Survey on Selected Hospital topic were analyzed using logistic regression analysis. Hospital size, ownership, and region were clearly related to the use of computer processing and/or abstract services for processing discharge data. Teaching status was also related to the use of abstract services, although teaching status hospitals also reported more reliance on in-house computer processing. Hospitals located in SMSAs and belonging to chains reported a higher use of discharge abstract services, and hospitals with higher operating margins were more likely to use abstract services on an "off-line" or batch-processing basis. The significance of these findings and their implications for abstract services are discussed.