Physician perceptions of medical malpractice and defensive medicine

Using judgments obtained in interviews with 33 Massachusetts physicians, the annual statewide volume of expenditures incurred for defensive medical reasons in 1982 was estimated to be $1.0 billion, 12% of all medical care expenditures. Estimates for the nation were $37 billion, 14% of expenditures. Nationally, 180,000 cesarean deliveries were thought to be performed for defensive motives. In their own institutions, respondents judged 43% of all skull x-rays following injury to be medically justified, 30% to be defensive medicine, 16% to be placebos, and 11% to be physician misjudgments. In considering the economic and noneconomic costs of medical malpractice procedures, the dollar costs of insurance were considered most serious, followed closely by defensive medicine, unfairness, and poorer relations with patients. Thirty-two percent of the responsibility for the negative aspects of malpractice processes was assigned to lawyers, 21% to physicians, 18% to legislatures and courts, 16% to patients, and 13% to insurance companies.     

Intergenerational and career mobility in Britain: An integrated analysis

Mobility analysis has traditionally concentrated on the task of charting flows in the two-way contingency table which relates occupational origin to occupational destination. It has not yet undertaken a unified analysis of intergenerational and intragenerational aspects of mobility. And only rarely does it incorporate terms which represent ordered concepts such as inequality or vertical movement. In contrast, path analysis has typically imposed strong orderings on the data, and it has been employed to tease out the relations among several occupational variables. Its main defect is that it entirely abstracts from shifts in mean occupational position, and also from change in the shape of the occupational distribution. Yet both of these are important sources of mobility. The present paper shows how two innovations in mobility analysis may be generalized to constitute a technique which unites the strengths of path analysis with those of log-linear analysis. The two innovations are (a) the conceptual disaggregation of perfect and exchange mobility, and (b) the imposition of an ordered component within each (K. Hope, 1981, Sociology 15, 19–55). The outcome of this generalization is a simple yet powerful account of mobility in Britain.     

The impact of P.L. 93-641, the National Health Planning and Resources Development Act, upon health and mental health programming

Federal legislation regarding health care in the U.S. has increased rapidly in the past few years. A major law with potential far-reaching effects was enacted as a result of increasing legislation and rising health care costs. This law,The National Health Planning and Resources Development Act,has created a network of over 200 local, mostly nongovernment units, called health systems agencies. These agencies are responsible for areawide health planning, plan implementation, review and approval of federal health care expenditures for local programs, and facilities review. They will affect health and mental health programs at the local level. The article is directed to local health and mental health care providers who will, of necessity, deal directly with the local HSA's.     

Mental health program evaluation: Where you start?

Seduced by the elegance, sophistication and jargon characteristic of new developments in applied research, practicing evaluators are in danger of becoming distracted from achievement of their evaluative goal: that of providing timely, reliable and useful data to program management to facilitate rational data-based decision-making. To avoid such seduction, the author advocates adaptation of simple, inexpensive and efficient evaluative methods tailored to organizational needs and presentation of findings in language readily understood by constituent groups. Likewise, insistance by evaluators upon maintenance of a strict role boundary — that is, limiting role functioning exclusively to those tasks considered evaluation — may be dysfunctional. Rather than detract from accomplishment of his goals, the author maintains that such participation allows development of skills, insights and staff relationships which enhance the evaluator's effective functioning within the organizational context and contribute to organizational acceptance and use of his evaluative results.     

Program analysis using the client oriented cost outcome system.

The client oriented cost outcome system has been under development in Pennsylvania community and hospital programs since 1972. The system builds upon the behavioral and decision data generated with or on behalf of consumers. Flexibility for local program system design is permitted if the procedures of consumer intake, review, and termination document each consumer's (a) problems, resources, and goals, (b) overall functioning level in their ordinary community, and (c) services intended and rendered as related to (a), above. While the system's primary application is in providing feedback for local program quality assurance and evaluation procedures, aggregation of data permits program planning and evaluation at county, state, and federal levels in terms of (a) client demographic or diagnostic characteristics, and (b) program service characteristics and objectives.     

Evaluating a private foundation's health program

Public policy decisions in health are increasingly difficult and expensive. Although there will never be enough information available, private foundations can help to bridge the most important gaps in knowledge. Larger foundations may also wish to respond to those who doubt the value of foundation activities. This article reviews the experiences over the past eight years of The Robert Wood Johnson Foundation in employing evaluation and related social research procedures in the planning and implementation of a major philanthropic effort to improve the health and medical care of Americans. Discussed are the still evolving Foundation evaluation framework, the unanticipated problems in undertaking specific evaluations, and the substantive findings of some of the studies.     

Network analysis in evaluation: some words of caution

Network analysis, a methodology derived from general systems' theory, can be utilized as a community mental health administrative-evaluation procedure. Evaluation parameters derived from analysis of patient data as they “flow” through a network of agency services, provide measures of systemic functioning. These parameters include “longest paths” and various ratio relationships as evaluation measures of service delivery. The limitations of network analysis are examined by means of conceptual analyses, and phenomena that emerged from research experience. The necessity for both quantitative and qualitative data to ensure a meaningful evaluation of mental health services is explained. Conclusions about the value of the network analysis approach are considered.     

Artifact in client satisfaction assessment: experience in community mental health settings

Artifact in client satisfaction assessment is discussed and the results of a study of three factors thought to mediate client satisfaction ratings; (a) general life satisfaction, (b) mode of administration, and (c) psychological symptomatology, are reported. A standard client satisfaction questionnaire (CSQ) was modified to yield parallel forms and was administered orally and in writing to 92 clients in two mental health day treatment programs. Satisfaction ratings obtained from these clients were quite similar to out-patient ratings obtained in previous studies conducted in this setting and using the same measures. Oral administration of the CSQ produced 10% higher satisfaction ratings than written administration (p less than .05) and less missing data (p less than .01). Satisfaction ratings were also obtained using a simple graphic instrument. Graphic ratings were comparable to CSQ ratings. Satisfaction with life in general and level of psychiatric symptoms together accounted for 25% of CSQ variance. The implication of these findings for future client satisfaction research is discussed.     

Involving constituents in agency priority setting: a case study

Many government agencies have "constituents" who believe the agencies should hear and consider their needs and desires in establishing program priorities. This article describes how one involves interested constituents (consumers, industry, medical professionals, and state organizations) in the agency's annual priority-setting process. This participation has produced a number of beneficial results-some expected and some unexpected.     

The effects of psychiatric symptoms on quality of life assessments among the chronic mentally ill

This study of chronically mentally disabled persons in community residences examined the discriminant validity of subjective quality of life indicators and self-report mental health indices to determine the potential confounding effects of psychopathology on the assessment of quality of life (QOL). Factor analyses and difference-score reliabilities identified a general QOL construct and a general mental health construct with 27% common variance. However, psychiatric symptoms did not significantly (p less than .05) alter the bivariate and multivariate relationships among the QOL ratings, except in the health domain in which the correlations of health-related QOL indicators with global QOL were significantly (p less than .05) attenuated after removing the effects of psychopathology. The results suggest that psychopathology does not introduce bias into the overall structure of QOL data, but they also indicate the importance of controlling for mental health effects in the assessment of patients' self-rated health and satisfaction with health care.