An episodes of care methodology examines the contiguous cluster of services related to a particular health condition. We developed an episodes methodology for evaluating the quality of health care delivery to privately insured adult asthma patients. Computer algorithms were used for episode construction beginning with an index asthma diagnosis and ending with a final clinical event, yielding a sample of 30,553 episodes. Only service claims with an asthma diagnosis were assigned to an episode. We used a database of private insurance claims from 1992 to 1993. Disease staging served as the framework for evaluating episodes with similar severity and resource use. We found that episodes of care can be constructed from claims data and have the potential for use in physician profiling and as quality screens. Certain limitations in using this methodology suggest that caution needs to be exercised in applying this approach to evaluation of health care services.

We evaluated the health care resource utilization between adult asthma patients in managed care organizations with those in indemnity plans using an episodes of care methodology. We also examined the importance of risk adjustment in explaining variation in resource utilization. Episodes were constructed using private insurance claims from 1992 to 1993. Bivariate and multivariate analyses were used to examine differences between managed care and indemnity plans on episode severity, resource utilization, and outcome measures (asthma-related hospitalizations and emergency room visits). Managed care plans showed higher resource utilization in terms of services and payments per episode compared with fee-for-service plans. Financial incentives to both providers and patients may have contributed to the higher utilization among managed care patients. An episodes of care methodology has potential to serve as a cost-effective "tool" in analyzing trends in medical care utilization within a health care plan. Validation of this methodology is necessary, however, before it can be used to compare trends in utilization across health plans.

Although the indicators described in this article were developed to provide the foundation for the Health Care Financing Administration’s hospital-based quality measurement system, the Medicare Quality Indicator System, the methodology and lessons learned can be applied to any group wishing to develop quality indicators and measure quality of care.

PURPOSE: The goals of this study were to develop and determine the feasibility of interventions designed to increase both primary care physician implementation of and patient adherence to recommendations from ambulatory-based consultative comprehensive geriatric assessment (CGA), and to identify sociodemographic and intervention-related predictors of physician and patient adherence.PATIENTS AND METHODS: One hundred thirty-nine community-dwelling older persons who failed a screen for functional impairment, depressive symptoms, falls, or urinary incontinence received outpatient CGA consultation. These patients and the 115 physicians who provided primary care for them received one of three adherence interventions, each of which had a physician education component and a patient education and empowerment component. Recommendations were classified as physician-initiated or self-care and as ''major'' or ''minor''; one was deemed ''most important.'' Adherence rates were determined on the basis of face-to-face interviews with patients.RESULTS: Based on 528 recommendations for 139 subjects, physician implementation of ''most important.'' recommendations was 83% and of major recommendations was 78.5%. Patient adherence with physician-initiated ''most important'' and ''major'' recommendations were 81.8% and 78.8%, respectively. In multivariate models, only the status of the recommendation of ''most important'' (odds ratio 2.4, 95% CI [confidence interval] 1.3 to 4.5) and health-maintenance organization (HMO) status of the patient (odds ratio 2.1, 95% CI 1.3 to 3.6) remained significant in predicting physician implementation. The logistic model predicting patient adherence to physician-initiated recommendations included male patient gender (odds ratio 3.1, 95% CI 1.3 to 7.0), the status of the recommendation of ''most important'' (odds ratio 1.9, 95% CI 1.0 to 3.8), total number of recommendations (odds ratio 0.7, 95% CI 0.5 to 0.9), and total number of problems identified by CGA (odds ratio 1.8, 95% CI 1.2 to 2.7).CONCLUSIONS: These findings indicate that relatively modest intervention strategies are feasible and lead to high levels of physician implementation of and patient adherence to physician-initiated CGA recommendations. These interventions appear to be particularly effective in HMO patients and for recommendations that were deemed to be ''most important.''

This article describes a geriatric wellness program in which social work practitioners played a major role. The focus of this article is twofold: to examine the use of a telephone screening test for depression among a well elderly population and to compare the results of that screening with the clinical judgment of social workers. Overall findings indicated that a telephone screening instrument incorporating the Rand Mental Health Inventory and the Center for Epidemiological Studies Depression Scale was an efficient tool for assessing a population with a higher rate of major depression. Furthermore, the social workers identified many previously undetected cases of major depression, and a majority of people referred for treatment completed those referrals.

No abstract available for this article.

Little is known about dental appearance in terms of the elderly population. The purpose of this paper is to compare self-reported dental appearance with dentist-rated appearance for individuals over 65. The subjects (N = 550) were participants in the Los Angeles based Medicare Screening and Health Promotion Trial. Most were female (57.3%), white (89.0%), and married (62.0%), with a mean age of 74.5 years. About one-third had incomes greater than $25,000. Results are based on a 45 minute telephone interview and onsite dental screening. Findings show that 40% of the self-ratings on a five point scale were higher than the dentist ratings, and 22% were lower. Bivariate analyses showed that both sets of ratings were related to dental status variables, self-reported health, and education. High self-ratings were also associated with being white and having a positive mental health status, while high dentist ratings were associated with patients who were younger, married, and who had higher income and social network scores. Comparison of results from two multiple regressions showed unique predictors for the self-ratings (marital status and GOHAI scores) and for the dentist ratings (sex and income). These discrepancies can raise barriers to effective treatment planning in the elderly, which could affect utilization and satisfaction.

Enrollment of senior citizens in a community Medicare demonstration project to explore the efficacy of preventive health screening and health education was accomplished by using a two-stage process. This process consisted of initial communication with community physicians through the University of California at Los Angeles Clinical Faculty Association to establish credibility for the program. Physicians who agreed to participate then selected potential participants to receive, by mail, a description of the study and an introductory letter from their own physician. Followup and actual enrollment of participants was then handled by the study team. A total of 57.6 percent of the elderly people approached agreed to participate in the study.

Over the past 30 years, an explosion In health care expenditures has occurred. Prior to 1960, health care accounted for 4.4% of the U.S. Gross National Product; today It Is 11%. Before rational solutions to controlling this rise can be proposed, we must determine whether the care that we are currently paying for Is appropriate to the needs of the elderly. This paper analyzes the literature regarding appropriateness of acute care provided to the elderly. We Identified 17 articles that explicitly cited appropriate or Inappropriate care (including under-, over- and misuse) provided in hospital and ambulatory settings and for procedures, and 19 articles that presented data on the appropriateness of medication use In the elderly. Virtually every study included In this review found at least double-digit levels of inappropriate care. Perhaps as much as one-fifth to one-quarter of acute hospital services or procedures were felt to be used for equivocal or Inappropriate reasons, and two-fifths to one-half of the medications studied were overused in outpatients. The few studies that examined underuse or misuse of services also documented the existence of these phenomena. This was especially true for the ambulatory care of chronic physical and mental conditions and concerned the use of low-cost technologies (visits, preventive services, some medications). Thus, we conclude that there appears to be a substantial problem in the matching of acute services to the needs of elderly patients. This mismatch occurs both in terms of overuse and underuse, at least for areas where research has been conducted.

Prologue: Today's new physicians are faced with an awesome array of often conflicting challenges: assimilating the vast and ever-increasing base of scientific knowledge, coping with societal concerns over the cost of medical care, dealing with ethical dilemmas surrounding life-sustaining technology, and recognizing the changing nature of the physician-patient relationship. To better equip physicians in training for the professional challenges that lie ahead, some medical schools have studied and experimented with innovations in curricula. In this article, the authors present a survey of the literature concerning medical school curricula innovations for the past ten years. The conclusion which emerges from this study is that “short-term programs not integrated into the medical school environment are not worth pursuing. A more radical restructuring of medical education is needed,” said Albert L. Siu, internist and Robert Wood Johnson Foundation Clinical Scholar at the University of California, Los Angeles (UCLA), In addition, Siu recommended that many of the innovations and experiments taking place in U.S. medical schools “need to be more agressively studied.” Coauthor S. Allison Mayer-Oakes is also an internist and Robert Wood Johnson Clinical Scholar at UCLA. Robert H. Brook is Senior Health Services Researcher at the Rand Corporation and professor of medicine and public health at UCLA. A member of the National Academy of Sciences' Institute of Medicine, Brook is well-known for his research in measurement of quality of care and was one of the original participants in the Clinical Scholars program. The authors are well equipped to discuss innovation in the medical school setting. UCLA's medical school has developed a number of innovative alternatives for young physicians in training and was an original site of the Johnson Foundations Clinical Scholars program, which has trained clinicians in the conduct of health services research.