Medical Care Research and Review

In this article, the author reviews 78 studies addressing the relocation of the elderly. He begins by defining the four major forms of relocation and describing the trends in the current health care marketplace precipitating relocation events. Next, he reviews the major findings of studies assessing the potential negative and positive outcomes of relocation. These outcomes include changes in mortality rates, morbidity, and psychological or social changes. In addition, factors associated with successful relocation are presented. Finally, the primary contribution of this article is that the author assesses the strengths and limitations of this prior literature and combines the research he reviews in an analytic model. This model helps show some opportunities for future research in the relocation of the elderly.

To assess the public’s perceptions and attitudes about racial and ethnic differences in health care, the Kaiser Family Foundation surveyed a nationally representative sample of 3,884 whites, African Americans, and Latinos in 1999. The survey found that the majority of Americans are uninformed about health care disparities—many were unaware that blacks fare worse than whites on measures susch as infant mortality and life expectancy, and that Latinos are less likely than whites to have health insurance. Views on whether the health system treats people equally were strikingly different by race. For example, most minority Americans perceive that they get lower quality care than whites, but most whites think otherwise. Nonetheless, more minority Americans were concerned about the cost of care than racial barriers. Efforts to eliminate disparities will need to improve public awareness of the problems as well as address racial and financial barriers to care.

The authors examine determinants of satisfaction with medical care among 1,784 (781 African American and 1,003 white) cardiac patients. Patient satisfaction was modeled as a function of predisposing factors (gender, age, medical mistrust, and perception of racism) and enabling factors (medical insurance). African Americans reported less satisfaction with care. Although both black and white patients tended not to endorse the existence of racism in the medical care system, African American patients were more likely to perceive racism. African American patients were significantly more likely to report mistrust. Multivariate analysis found that the perception of racism and mistrust of the medical care system led to less satisfaction with care. When perceived racism and medical mistrust were controlled, race was no longer a significant predictor of satisfaction.

This article develops a conceptual model of cultural competency’s potential to reduce racial and ethnic health disparities, using the cultural competency and disparities literature to lay the foundation for the model and inform assessments of its validity. The authors identify nine major cultural competency techniques: interpreter services, recruitment and retention policies, training, coordinating with traditional healers, use of community health workers, culturally competent health promotion, including family/community members, immersion into another culture, and administrative and organizational accommodations. The conceptual model shows how these techniques could theoretically improve the ability of health systems and their clinicians to deliver appropriate services to diverse populations, thereby improving outcomes and reducing disparities. The authors conclude that while there is substantial research evidence to suggest that cultural competency should in fact work, health systems have little evidence about which cultural competency techniques are effective and less evidence on when and how to implement them properly.

Existing scales to measure trust in physicians have differing content and limited testing. To improve on these measures, a large item pool (n = 78) was generated following a detailed conceptual model and expert review. After pilot testing, the best-performing items were validated with a random national sample (n = 9) and a regional sample of HMO members (n = 99). Various psychometric tests produced a 10-item unidimensional scale consistent with most aspects of the conceptual model.Compared with previous scales, the Wake Forest physician trust scale has a somewhat improved combination of internal consistency, variability, and discriminability. The scale is more strongly correlated with satisfaction, desire to remain with a physician, willingness to recommend to friends, and not seeking second opinions; it is less correlated with insurer trust, membership in managed care, and choice of physician; and correlations are equivalent with lack of disputes, length of relationship, and number of visits.

Có sự khác biệt đáng kể trong quy trình điều trị và kết quả triệu chứng và chức năng trong các rối loạn trầm cảm đối với các bệnh nhân là dân tộc thiểu số và chủng tộc. Bằng cách sử dụng quan điểm về tiến hành qua các giai đoạn cuộc đời, các tác giả đã thực hiện một đánh giá có hệ thống về tài liệu để xác định các cơ chế có thể điều chỉnh và các can thiệp hiệu quả để phòng ngừa và điều trị tại các điểm cụ thể—hệ thống, cộng đồng, nhà cung cấp dịch vụ, và bệnh nhân cá nhân—trong bối cảnh chăm sóc sức khỏe. Những can thiệp quản lý bệnh mãn tính đa thành phần đã mang lại sự cải thiện trong kết quả của trầm cảm đối với các nhóm dân tộc thiểu số. Quản lý trường hợp dường như là một thành phần quan trọng của các can thiệp hiệu quả. Các can thiệp phòng ngừa và điều trị được điều chỉnh phù hợp về xã hội và văn hóa có thể hiệu quả hơn so với các chương trình điều trị tiêu chuẩn. Nghiên cứu trong tương lai nên tập trung vào việc xác định các thành phần chủ chốt của quản lý trường hợp và điều chỉnh phù hợp về xã hội và văn hóa cần thiết cho các can thiệp hiệu quả và phát triển các cơ chế phổ biến mới, chi phí thấp cho chương trình điều trị và phòng ngừa có thể được điều chỉnh cho các dân tộc thiểu số.

Previous reviews of research on electronic health record (EHR) data quality have not focused on the needs of quality measurement. The authors reviewed empirical studies of EHR data quality, published from January 2004, with an emphasis on data attributes relevant to quality measurement. Many of the 35 studies reviewed examined multiple aspects of data quality. Sixty-six percent evaluated data accuracy, 57% data completeness, and 23% data comparability. The diversity in data element, study setting, population, health condition, and EHR system studied within this body of literature made drawing specific conclusions regarding EHR data quality challenging. Future research should focus on the quality of data from specific EHR components and important data attributes for quality measurement such as granularity, timeliness, and comparability. Finally, factors associated with poor or variability in data quality need to be better understood and effective interventions developed.

The performance of medical groups is receiving increased attention. Relatively little conceptual or empirical work exists that examines the various dimensions of medical group performance. Using a national database of 693 medical groups, this article develops a scorecard approach to assessing group performance and presents a theory-driven framework for differentiating between high-performing versus low-performingmedical groups. The clinical quality of care, financial performance, and organizational learning capability of medical groups are assessed in relation to environmental forces, resource acquisition and resource deployment factors, and a quality-centered culture. Findings support the utility of the performance scorecard approach and identification of a number of key factors differentiating high-performing from low-performing groups including, in particular, the importance of a quality-centered culture and the requirement of outside reporting from third party organizations. The findings hold a number of important implications for policy and practice, and the framework presented provides a foundation for future research.

Physicians and hospitals are pioneering new and more coordinated organizational forms under pressure from market competition. Arms-length "doctor's workshop" relationships are yielding to integrated delivery systems and contractual delivery networks. This article analyzes organizational change in health care through the conceptual lens of institutional economics, defined broadly as including agency theory, transactions cost economics, and the dynamic capabilities view of the firm. These theoretical frameworks highlight three distinct functions of organization under managed care: coordination, governance, and innovation.

As part of a pragmatic trial to reduce hypertension disparities, we conducted a baseline organizational assessment to identify aspects of organizational functioning that could affect the success of our interventions. Through qualitative interviewing and the administration of two surveys, we gathered data about health care personnel’s perceptions of their organization’s orientations toward quality, patient centeredness, and cultural competency. We found that personnel perceived strong orientations toward quality and patient centeredness. The prevalence of these attitudes was significantly higher for these areas than for cultural competency and varied by occupational role and race. Larger percentages of survey respondents perceived barriers to addressing disparities than barriers to improving safety and quality. Health care managers and policy makers should consider how we have built strong quality orientations and apply those lessons to cultural competency.