OBJECTIVE: To examine the effects of market-level managed care activity on the treatment, cost, and outcomes of care for Medicare fee-for-service acute myocardial infarction (AMI) patients.

DATA SOURCES/STUDY SETTING: Patients from the Cooperative Cardiovascular Project (CCP), a sample of Medicare beneficiaries discharged from nonfederal acute-care hospitals with a primary discharge diagnosis of AMI from January 1994 to February 1996.

STUDY DESIGN: We estimated models of patient treatment, costs, and outcomes using ordinary least squares and logistic regression. The independent variables of primary interest were market-area managed care penetration and competition. The models included controls for patient, hospital, and other market area characteristics.

DATA COLLECTION/EXTRACTION METHODS: We merged the CCP data with Medicare claims and other data sources. The study sample included CCP patients aged 65 and older who were admitted during 1994 and 1995 with a confirmed AMI to a nonrural hospital.

PRINCIPAL FINDINGS: Rates of revascularization and cardiac catheterization for Medicare fee-for-service patients with AMI are lower in high-HMO penetration markets than in low-penetration ones. Patients admitted in high-HMO-competition markets, in contrast, are more likely to receive cardiac catheterization for treatment of their AMI and had higher treatment costs than those admitted in low-competition markets.

CONCLUSIONS: The level of managed care activity in the health care market affects the process of care for Medicare fee-for-service AMI patients. Spillovers from managed care activity to patients with other types of insurance are more likely when managed care organizations have greater market power.

OBJECTIVE: To investigate the relative impact of physician groups and health plans on quality of care measures. DESIGN: Secondary data analysis of receipt of preventive care services included in the Health Plan Employer Data and Information Set (HEDIS) among 10 758 patients representing 21 health maintenance organizations and 22 large provider groups in the San Francisco and Los Angeles, California, areas in 1997. Each patient was eligible for (at least) one of six HEDIS-measured services. Data identify whether or not the service was provided, the patient's health plan, and the provider group responsible for the care. We used logistic regression to examine variations across plans in HEDIS rates, and whether variations persist after controls for provider groups are included.

SETTING: Patients from 21 health maintenance organizations serving San Francisco and Los Angeles, California, in 1997.

MAIN OUTCOME MEASURES: Breast cancer screening, childhood immunizations, cervical cancer screening, diabetic retinal exam, prenatal care in the first trimester, and check-ups after delivery among patients for whom these services are appropriate.

RESULTS: There are statistically significant differences across health plans in utilization rates for the six services examined. These differences are not substantially affected when we control for the provider group that cared for the patient. That is, controlling for provider group does not explain variations across plans, consistent with the view that health plans have an impact on HEDIS quality measures independent of the providers that they contract with.

CONCLUSIONS: There are activities that plans can undertake which influence their HEDIS scores. On the face of it, these results suggest that plans can independently improve quality, in contrast to hypotheses that plans would be "too far" from patients to have an influence. Continued attention to collecting plan-level data is warranted. Further work should address other possible sources of variations in HEDIS scores, such as variability in the quality of plan administrative databases.

Using data from a survey of deaths of children less than 5 years old conducted in 1997 in a county in Shaanxi Province, China, this paper examines gender differences in child survival in contemporary rural China. First, excess female child mortality in the county in 1994-96 is described, followed by an analysis of the mechanisms whereby the excess mortality takes place, and the underlying social, economic and cultural factors behind it. Excess female child mortality in this county is probably caused primarily by discrimination against girls in curative health care rather than in preventive health care or food and nutrition. Although discrimination occurs in all kinds of families and communities, discrimination itself is highly selective, and is primarily against girls with some specific characteristics. It is argued that the excess mortality of girls is caused fundamentally by the strong son preference in traditional Chinese culture, but exacerbated by the government-guided family planning programme and regulations. This suggests that it is crucial to raise the status of girls within the family and community so as to mitigate the pressures to discriminate against girls in China's low fertility regime. Finally, the possible policy options to improve female child survival in contemporary rural China are discussed.

Variability in demand for hospital services may have important effects on hospital costs, but this has been difficult to examine because data on within-year variations in hospital use have not been available for large samples of hospitals. We measure daily occupancy in California hospitals and examine variation in hospital utilization at the daily level. We find substantial day-to-day variation in hospital utilization, and noticeable differences between hospitals in the amount of day-to-day variation in utilization. We examine the impact of variation on hospital costs, showing that increases in variance are associated with increases in hospital expenditures, but that the effects are qualitatively modest

Chronic conditions are among the most common causes of death and disability in the United States. Patients with such conditions receive disproportionate amounts of health care services and therefore cost more per capita than the average patient. This study assesses the prevalence among the Department of Veterans Affairs (VA) health care users and VA expenditures (costs) of 29 common chronic conditions. The authors used regression to identify the marginal impact of these conditions on total, inpatient, outpatient, and pharmacy costs. Excluding costs of contracted medical services at non-VA facilities, total VA health care expenditures in fiscal year 1999 (FY1999) were $14.3 billion. Among the 3.4 million VA patients in FY1999, 72 percent had 1 or more of the 29 chronic conditions, and these patients accounted for 96 percent of the total costs ($13.7 billion). In addition, 35 percent (1.2 million) of VA health care users had 3 or more of the 29 chronic conditions. These individuals accounted for 73 percent of the total cost. Overall, VA health care users have more chronic diseases than the general population.

This study examined whether substance abuse patients who live farther from their source of outpatient mental health care were less likely to obtain aftercare following an inpatient treatment episode. For those patients who did receive aftercare, distance was evaluated as a predictor of the volume of care received. A national sample of 33,952 veterans discharged from Department of Veterans Affairs (VA) inpatient substance abuse treatment programs was analyzed using a two-part choice model utilizing logistic and linear regression. Patients living farther from their source of outpatient mental health care were less likely to obtain aftercare following inpatient substance abuse treatment. Patients who traveled 10 miles or less were 2.6 times more likely to obtain aftercare than those who traveled more than 50 miles. Only 40% of patients who lived more than 25 miles from the nearest aftercare facility obtained any aftercare services. Patients who received aftercare services had fewer visits if they lived farther from their source of aftercare. Lack of geographic access (distance) is a barrier to outpatient mental health care following inpatient substance abuse treatment, and influences the volume of care received once the decision to obtain aftercare is made. Aftercare services must be geographically accessible to ensure satisfactory utilization.

Background: Poison control centers (PCCs) reduce health care costs for childhood poisonings by providing telephone advice for home management of most cases. Past research suggests that PCCs are underutilized by low-income minority and Spanish-speaking parents because of lack of knowledge and misconceptions about the PCC. A videotape intervention was designed to address these barriers to PCC use.

Objective: To evaluate the effectiveness of a videotape intervention (videotape, PCC pamphlet, and PCC stickers) in improving knowledge, attitudes, behaviors, and behavioral intention regarding use of the PCC in a low-income and predominantly Spanish-speaking population in Northern California.

Methods: Two hundred eighty-nine parents of children 6 years of age, attending educational classes at 2 Women, Infant, and Children (WIC) clinics participated in a randomized, controlled trial. WIC classes were randomized to receive the video intervention (video group) or to attend the regularly scheduled WIC class (control group). Participants completed a baseline questionnaire and 2 to 4 weeks later, a follow-up telephone interview. Changes from baseline to posttest were compared in the treatment and control groups using analysis of variance.

Results: Compared with the control group, the video group showed an increase in knowledge about the PCC's function, its hours of operation, and staff qualifications; was more likely to feel confident in speaking with and carrying out recommendations made by the PCC; was less likely to believe the PCC would report a mother for neglect; was more likely to have the correct PCC phone number posted in their homes; and when presented with several hypothetical emergency scenarios, was more likely to correctly answer that calling the PCC was the best action to take in a poisoning situation.

Conclusions: This videotape intervention was highly effective in changing knowledge, attitudes, behaviors, and behavioral intentions concerning the PCC within this population. As a result, use of this video may help increase use of the PCC by low-income and Spanish-speaking families.

The Pacific Business Group on Health (PBGH) Physician Performance Project seeks to promote system change by measuring individual physician quality, efficiency and patient experience. Reducing variation in physician practice patterns can significantly improve quality of care and moderate costs. As appropriate physician performance information becomes available to consumers, market pressure will become an effective mechanism for improving health care quality and efficiency. Key project goals include:

• Use of comparative performance information for quality improvement among physicians;
• Adoption of benefit designs that incent consumers to make informed health care choices;
• Promotion of financial incentives that reward high quality and efficient physicians in health plan contracting and payment systems;
• Make performance information publicly available for consumer choice.

Advances in Health Care Organization Theory is a much-needed volume for faculty and students in health care administration. It highlights and explains key trends in health care organizations and organizational development, specifically, in the 1990s. This book will be essential for doctoral-level students studying health care organizational theory and research, as well as for those studying organizational sociology, organizational psychology, political science, and management.