Donald K. Freeborn

Gender differences in the relationship between social network support and mortality: A longitudinal study of an elderly cohort

Despite well-recognized gender differences in patterns of social network support, few studies have explored whether the pathways by which social support affects mortality risk differ for men and women. In a 15-year follow-up study of elderly HMO members, we found that network size affected mens mortality risk indirectly, through their health status, while no such indirect effect was found for women. The data also suggested that network size had a direct protective effect on mortality risk for both men and women, with men gaining protection at a lower level of network size than women. These findings confirm the need for a gender-specific approach to further research on this subject, and suggest the need to measure variables that capture the different meaning and value of social network participation for men and women.

Consistently high users of medical care among the elderly

This study identified consistently high and low users of medical care services in a group of older HMO members continuously enrolled for six years. Consistently high users made up 26% of the sample, but accounted for more than 50% of total outpatient contacts and hospital admissions. Average ambulatory care costs were more than four times greater for the high users compared with the low users. Consistently high users were older than consistently low users, but did not differ significantly in other sociodemographic characteristics. Compared with the low users, the high users reported more total medical conditions and were more likely to indicate they had arthritis, high blood pressure, heart conditions, and other chronic problems. They perceived themselves to be in poorer health and reported higher levels of psychologic distress. The low users tended to be less satisfied, but the two user groups were not significantly different regarding use of services outside the HMO

Utilization patterns among long-term enrollees in a prepaid group practice health maintenance organization

Criteria used in this study established that 13% of long-term adult members of a prepaid group practice health maintenance organization (HMO) were consistently high users of outpatient medical care services. This population accounted for 31% of the total doctor office visits (DOVs), 35% of the hospital admissions, and 30% of the outpatient surgical services for long-term members. The most frequent reason for DOVs in this high user group was treatment and/or follow-up of chronic conditions. Patterns of utilization were unrelated to marital status, income, occupation, and perceived social class. Smoking and alcohol use also were not associated with utilization patterns. However, the consistently high users were more likely to perceive their health status as fair or poor and to report a higher number of physical symptoms. They were also more likely to be characterized by a higher degree of psychological distress, especially depression. Contacts with the HMOs mental health department constituted less than 1% of their total medical care contacts, and only 13% made at least one mental health contact over the study period. The findings are discussed in terms of their health and medical care implications.

Primary care physicians' use of lumbar spine imaging tests : effects of guidelines and practice pattern feedback

ObjectiveTo reduce variability in primary care physicians’ use of procedures for imaging the lumbar spine.DesignControlled intervention using clinical practice guideline and practice pattern feedback.Study SampleSixty-seven internists and 28 family practitioners in a large, group-model HMO.Measurements and Main ResultsIntervention group physicians received the clinical practice guideline for low back pain, followed after 4 months by three bim onthly feedback reports on their current use rates for lumber spine x-rays and computed tomography and magnetic resonance imaging scans of the lumbar spine. Control group physicians received neither the guideline nor the feedback reports. Automated radiology utilization data were used to compare intervention and control group physicians’ changes in use rates and variability in use rates over the course of the study period. Neither the guideline alone nor the guideline plus feedback was associated with a significant decrease in use rates or in the variability in use rates for the lumbar spine imaging procedures under study.ConclusionsClinical practice guidelines and practice pattern feedback fall to achieve their goals when features of the practice setting and patient expetations and behavior are not identified and addressed.

Comparing the Use of Medical Care Services by a Medically Indigent and a General Membership Population in a Comprehensive Prepaid Group Practice Program

The utilization of medical-care services by the general membership of a prepaid group practice program is compared with that of the participants of an OEO Comprehensive Neighborhood Health Center Program. This OEO program provides medical care for 1,500 urban indigent families by integrating them on a prepaid capitated basis into the Kaiser Foundation Health Plan in Portland, Oregon. Generally, the findings indicate that the rate and patterns of utilization between the two populations are essentially similar. The only major differences are: 1. that the adult males of the poverty population use a significantly higher rate of services with a high emotional component, and 2. that the poverty population fails to keep scheduled appointments at a significantly higher rate than the health plan members. The data indicate that much of the reported differences in medical care utilization between poverty groups and other sections of the general population seem to disappear when financial and other barriers are removed. Many of the reported differences in the behavior of poverty populations appear to relate to differential access to care.

Determinants of Medical Care Utilization: The Role of the Telephone in Total Medical Care

The importance of the telephone in the American medical care system is only beginning to receive appropriate attention. Fast studies indicate that a significant proportion of new diseases and a significant proportion of all medical care contacts take place by phone. A study of telephone use in a prepaid group practice system is presented. Data on telephone utilization are analyzed to determine the significance of telephone utilization of the population and to identify the patterns of telephone calls within total care seeking behavior. The purpose is to determine alternative modes of dealing with problems presented by phone or at least to assure that this important aspect of care is integrated into medical care. Telephone calls represented a significant proportion of the total medical care of the study population. About 50 per cent of all phone calls to medical core personnel were concerning symptoms of disease and approximately 40 per cent concerned laboratory results or prescriptions. Factors affecting the disposition of symptom phone calls were analyzed. It was hypothesized that the relative probability of a patient being told to come to the clinic after discussing a symptom would vary inversely with the certainty of the physician in his diagnosis and directly with the seriousness of the disease as perceived by the physician. The inferences from the data generally tended to support the hypotheses. These tendencies, however, were not strong enough to accurately predict when the physician would only discuss the symptom, give a prescription, or request a patient to visit. The concepts do not yet lend themselves to operational decision models for use by personnel trained to handle these kinds of calls, because of tremendous individual variation among physicians that confounds attempts to predict the disposition of symptom phone calls using only patient, disease, and situational variables.

Health status, socioeconomic status and utilization of outpatient services for members of a prepaid group practice.

When evaluating the effectiveness of medical care programs, one concern is whether receipt of care is based upon health care needs or upon socioeconomic status. This study describes the relation between health status and socioeconomic status and attempts to determine which has the greater effect on ambulatory care utilization. The study setting was an operating HMO serving a cross-sectional membership of nearly 200,000 persons. Outpatient utilization data were derived from the medical records of a five per cent sample of health plan members for 1969 and 1970. Social, economic, situational, and attitudinal data were provided by 2,603 respondents in a household interview survey. Since a populations perceived health status may reflect health need, information from the survey provided measures of health status that ranged from specific symptoms and complaints to a general measure of perceived health status. Although the findings varied somewhat according to which variables were considered, they generally showed health status to correlate more highly than socioeconomic factors with the utilization of services in this medical care system. An exception was the use of preventive services, which was not significantly related to health status measures but rather, for women, to education and, to a lesser extent, income

Drinking patterns, health care utilization, and costs among HMO primary care patients

A survey of 8,034 primary care patients in a health maintenance organization examined the relationship between alcohol consumption and health care costs and service use. Costs were estimated from service use data for 1 year before and 2 years after study enrollment. No strong, consistent relationships were identified between multiple indicators of drinking patterns and either health care costs or service use. Compared with total costs among very light drinkers, former drinkers were higher, lifetime abstainers were similar, and persons in the higher drinking levels tended to have lower but not significantly different costs. Drinking patterns did not appear to be an important predictor of short-term health care costs or service use in this setting. Further study of former drinkers is warranted to examine the role of alcohol-related illnesses in the decision to quit drinking.

Satisfaction and well-being of primary care providers in managed care.

We compared perceptions about the practice environment and the job satisfaction of physician assistants (PAs), nurse practitioners (NPs), and primary care physicians in a large group–model HMO. The data source was a self-administered mail survey (average response rate = 79%). PA/NPs and primary care physicians reported that professional autonomy was not a problem and were satisfied with most aspects of practice in this setting. Common areas of dissatisfaction included patient load and amount of time with patients. PA/NPs were more likely than the physicians to experience stress on a daily basis, however, and were less likely to report that they would choose the practice setting again. They also were significantly less satisfied than the physicians with their incomes and fringe benefits. Our findings suggest that more attention should be given to practice conditions and compensation of PAs and NPs in managed care.

Gender and Alcohol Use: The Roles of Social Support, Chronic Illness, and Psychological Well-Being

Men and women differ in their use of alcohol, in their rates of chronic illnesses and psychological symptoms, and in the social support they receive. In this paper, we assess how the latter three factors are associated with alcohol use, and how these associations differ by gender. Respondents were 3,074 male and 3,947 female randomly selected Health Maintenance Organization members who responded to a mail survey in 1990. Hierarchical multiple regression analyses indicate that social support is associated with alcohol consumption in similar ways for both genders, yet the associations between some demographic, physical health/functioning, and psychological well-being measures are different for men and women. Men with fewer role limits due to physical health drank more, while women with better psychological well-being drank less. Poor psychological well-being may be a modifiable risk factor for increased alcohol use among women; practitioners should be alert for greater consumption among men with few functional limitations and good health.