J. Warren Salmon

Psychometric Evaluation of the 12-Item Short-Form Health Survey (SF-12) in Osteoarthritis and Rheumatoid Arthritis Clinical Trials

BACKGROUND The psychometric properties of the 12-Item Short-Form Health Survey (SF-12), a subset of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), have been tested in the general population and certain disease states. OBJECTIVE The purpose of this study was to evaluate the psychometric properties of the SF-12 as a generic measure of health-related quality of life (HRQoL) in osteoarthritis (OA) and rheumatoid arthritis (RA) patient populations in clinical trials. METHODS Data were aggregated from 5 clinical trials evaluating the efficacy of non-steroidal anti-inflammatory drugs in OA (n = 651) and RA (n = 693) patients. Patient assessments in these trials were made using the SF-36 and commonly used clinical measures of OA and RA at baseline and after up to 6 weeks of treatment. For the items of the SF-36 contained in the SF-12, the item missing rate, computability of scores, floor and ceiling effects, factor structure, and item-component correlations were evaluated. Clinical variables and correlations of physical component summary (PCS-12) and mental component summary (MCS-12) scores of the SF-12 with the corresponding SF-36 component summary scores (PCS-36 and MCS-36) were also examined. Analyses were conducted separately for OA and RA patients. RESULTS A low individual SF-12 item missing rate (0.29% to 2.30%) and a high percentage score computability (90.9%-94.3%) were observed at baseline. No floor or ceiling effects at baseline were observed. The scree plot confirmed the 2-factor structure of the SF-12 items. Items belonging to the physical component correlated more strongly with the PCS-12 than with the MCS-12; similarly, items belonging to the mental component correlated more strongly with the MCS-12 than with the PCS-12. The correlations between the PCS-12 and PCS-36 and between the MCS-12 and MCS-36 ranged from 0.92 to 0.96 (P < 0.001) at baseline and at week 2, 4, or 6. Significant correlations ranging from -0.09 to -0.58 (P < 0.05) were observed between the SF-12 scores and clinical variables. CONCLUSION The SF-12 appears to be a psychometrically sound tool for the assessment of HRQoL in OA and RA patients.

The Holistic Alternative to Scientific Medicine: History and Analysis

The resurgence of the holistic health movement in the 1970s can be in part attributed to increasing consumer dissatisfaction with the present system of medical care delivery. This article traces the rise and decline of modern medicine by analyzing the assumption of hegemony by scientific medicine and its practitioners. Then it describes the challenges that holistic medicines theories and therapies currently pose to scientific medicines organizational form and practical content. Holistic medicine is assessed in terms of its organizational and conceptual basis, and the relationship between holistic medicine and the needs of advanced capitalist society is discussed.

Profit and Health Care: Trends in Corporatization and Proprietization:

Throughout this century, profit has been an underlying motor force for health sector developments. However, as the concentration and centralization of health care delivery has proceeded in the United States, the pursuit of profit has become central. Even before the Reagan policy redirections raised “marketplace efficiency” as the supreme determinant of how the populations health needs are to be (or actually will not be) met, the rise of the nationwide proprietary hospital conglomerates over the last 15 years signified a new organization form. No longer camouflaged under an out-moded “not-for-profit” designation, the delivery of health care is now officially to be a “business” run for economic gain. Corporatization and proprietization trends have unmasked that profit regulates which people in which social groups get care. This article focuses upon developments leading toward this monopolization within health services delivery. Specific attention is given to historical tendencies that have set the stage for its extension under conditions of a continuing general economic crisis, conservative health policy redirections, and rapid industrialization of the health sector. Scientific and technological advances have reshaped professional roles and relationships, and increased bureaucratization of provider organizations. Coinciding with these are major actions by the corporate class in health policy and planning, and an impending demographic shift where aging population cohorts give rise to expanding “markets” of middle-class patients for proprietary health care firms.

Factors Associated with Long-Stay Nursing Home Admissions Among the U.S. Elderly Population: Comparison of Logistic Regression and the Cox Proportional Hazards Model with Policy Implications for Social Work

Two statistical methods were compared to identify key factors associated with long-stay nursing home (LSNH) admission among the U.S. elderly population. Social Works interest in services to the elderly makes this research critical to the profession. Effectively transitioning the “baby boomer” population into appropriate long-term care will be a great societal challenge. It remains a challenge paramount to the practice of social work. Secondary data analyses using four waves (1995, 1998, 2000, and 2002) of the Health Retirement Study (HRS) coupled with the Assets and Health Dynamics among the Oldest Old (AHEAD) surveys were conducted. Multivariable logistic regression and Cox proportional hazards model were performed and compared. Older age, lower self-perceived health, worse instrumental activities of daily living (IADL), psychiatric problems, and living alone were found significantly associated with increased risk of LSNH admission. In contrast, being female, African American, or Hispanic; owning a home; and having lower level of cognitive impairment reduced the admission risk. Home ownership showed a significant effect in logistic regression, but a marginal effect in the Cox model. The Cox model generally provided more precise parameter estimates than logistic regression. Logistic regression, used frequently in analyses, can provide a good approximation to the Cox model in identifying factors of LSNH admission. However, the Cox model gives more information on how soon the LSNH admission may happen. Our analyses, based on two models, dually identified the factors associated with LSNH admission; therefore, results discussed confidently provide implications for both public and private long-term care policies, as well as improving the assessment capabilities of social work practitioners for development of screening programs among at-risk elderly. Given the predicted surge in this population, significant factors found from this study can be utilized in a strengths-based empowerment approach by social workers to aid in avoiding LSNH utilization.

Medication adherence and persistence in the last year of life in COPD patients.

OBJECTIVE To examine medication adherence and persistence among COPD patients during their last year of life. DATA SOURCE National VA databases were used to identify patients who had COPD and died between 1999 and 2003. STUDY DESIGN We examined use of inhaled corticosteroids (ICS), long acting beta(2) agonists (LABA), methylxanthines (MTX), and anticholinergics (AC), alone and in combination. Medication possession ratios (MPR) were compared between regimens by quarterly periods using General Estimating Equations (GEE). Medication persistence was examined in monotherapy users with Kaplan-Meier survival analysis and extended Cox proportional hazard models. PRINCIPAL FINDINGS Only half of the identified patients in the COPD cohort (5913 of 11,376) used any medications. Among 5913 patients, overall mean (SD) MPR was 0.44 (0.32) during the last year of life. A positive linear trend in MPR was observed across quarterly periods in AC users (beta=0.014, p<0.0001), and was highest for MTX users (beta=0.11, p<0.0001). Of 3436 on monotherapy only, 40% discontinued medication within 30 days, and 70% discontinued within 90 days. MTX users were less likely to discontinue (HR=0.714, p=0.012) than reference (AC) group. CONCLUSION COPD patients in their last year of life tended to use respiratory medications sporadically. Further research is needed to qualify whether minor differences in MPR between regimens reflect behavioral differences related to regimen or reflect refill policy and MPR calculation technique.

A Perspective on the Corporate Transformation of Health Care

The ever-increasing ownership of health service providers, suppliers, and insurers by investor-owned enterprises presents an unforeseen complexity and diversity to health care delivery. This article reviews the history of the for-profit invasion of the health sector, linking corporate purchaser directions to the now dominant mode of delivery in managed care. These dynamics require unceasing reassessment while the United States embarks upon implementation of national health care reform.

Strikes by Physicians: A Historical Perspective toward an Ethical Evaluation

Current conditions surrounding the house of medicine—including corporate and government cost-containment strategies, increasing market-penetration schemes in health care, along with clinical scrutiny and the administrative control imposed under privatization by managed care firms, insurance companies, and governments—have spurred an upsurge in physician unionization, which requires a revisiting of the issue of physician strikes. Strikes by physicians have been relatively rare events in medical history. When they have occurred, they have aroused intense debate over their ethical justification among professionals and the public alike, notwithstanding what caused the strikes. As physicians and other health care providers increasingly find employment within organizations as wage-contract employees and their work becomes more highly rationalized, more physicians will join labor organizations to protect both their economic and their professional interests. As a result, these physicians will have to come to terms with the use of the strike weapon. On the surface, many health care strikes may not ever seem justifiable, but in certain defined situations a strike would be not only permissible but an ethical imperative. With an exacerbation of labor strife in the health sector in many nations, it is crucial to explore the question of what constitutes an ethical physician strike.

The Proprietarization of Health Care and the Underdevelopment of the Public Sector

Failure of hospitals in urban areas is a well documented, spreading phenomenon that is resulting in decreased care for the medically indigent. As financial conditions force greater closures and cutbacks among providers, this dismantling of institutions that have historically served the unfortunate deepens the crisis in access to medical care. In this article, pressure on private health care institutions to adhere to a more bottom-line approach is viewed in the light of an overall attempt by government to divert public capital into private sector coffers, a trend that is particularly significant because of the ongoing concentration and centralization within the delivery system. Set in a historical analysis of the corporatization of health care, a case is made to reveal the underdevelopment of public hospitals, certain urban voluntary institutions, and community-based clinics, i.e., those institutions left to serve the most needy, in the face of rampant financial success by proprietary providers catering to a middle-class clientele requiring less intensity of care.

The Colombian Health Insurance System and its Effect on Access to Health Care

In 1993, the Colombian government sought to reform its health care system under the guidance of international financial institutions (the World Bank and International Monetary Fund). These institutions maintain that individual private health insurance systems are more appropriate than previously established national public health structures for overcoming inequities in health care in developing countries. The reforms carried out following international financial institution guidelines are known as “neoliberal reforms.” This qualitative study explores consumer health choices and associated factors, based on interviews with citizens living in Medellín, Colombia, in 2005–2006. The results show that most study participants belonging to low-income and middle-income strata, even with medical expense subsidies, faced significant barriers to accessing health care. Only upper-income participants reported a selection of different options without barriers, such as complementary and alternative medicines, along with private Western biomedicine. This study is unique in that the informal health system is linked to overall neoliberal policy change.

The health maintenance organization strategy: a corporate takeover of health services delivery.

This paper presents a political economic framework for viewing the social organization of the delivery of health care services and predicting a qualitatively different institutional configuration involving the health maintenance organization. The principal forces impacting American capitalism today are leading to a fundamental restructuring for increased social efficiency of the entire social welfare sector, including the health services industry. The method to achieve this restructuring involves health policy directed at raising the contribution to the social surplus from the delivery of health care services and eventual corporate domination. The health maintenance organization conceptualization is examined with suggestions as to how the HMO strategy promoted by the state leads to this corporate takeover. The mechanism and extent of the present corporate involvement are examined and implications of health services as a social control mechanism are presented.