Search

This study was conducted as an initial investigation of in vivo folate kinetics in healthy men (n = 4) and made use of a chronic-administration protocol with stable-isotope labeling. Subjects were given 0.453 micromol (200 micrograms) total folic acid in aqueous solution daily throughout the 18-wk study while they consumed self-selected folate-adequate diets. After a 2-wk pretrial period with unlabeled folic acid, subjects were given 0.227 micromol (100 micrograms) pteroyl-L-[2H4]glutamic acid/d ([2H4]folic acid) combined with 0.227 micromol nonlabeled folic acid or [2H2]pteroylhexaglutamic acid/d for the next 8 wk; then for the next 8 wk the [2H4]folic acid was withdrawn and the subjects received only nonlabeled folic acid. Little unmetabolized folic acid was excreted in urine. Isotopic enrichment of urinary folate during [2H4]folic acid administration and withdrawal was consistent with a kinetic model having a rapid turnover pool and a slow turnover pool. In contrast with previous two-pool models, provisions were made for folate turnover by urinary folate excretion (as measured here) and by fecal excretion and catabolic processes. The precision of modeling will be improved in future studies by measurement of enrichment of additional pools. However, this study shows clearly the slow turnover of the whole-body folate pool (

This article presents an instrument and data testing a theory of the Moral Construct of Caring in Nursing as Communicative Action. Pilot testing involved 185 items administered to 82 nurses in 3 countries. The instrument includes 7 subscales addressing the nurse's personal and professional selves, the patient's personal and illness selves, the bidirectional interaction, the moral maturity of both, and the current state of nursing practice. Results suggest that the theory provides predictive control of the phenomena, drawing attention to the founding of evidence-based practice on practical, workable theory. Research continues, focusing on refining construct definitions and improving reliabilities. [ABSTRACT FROM AUTHOR]

Proposals for incorporating information on the quality of human, social, and environmental conditions in more authentic and comprehensive versions of the Gross National Product (GNP) or Gross Domestic Product (GDP) date back to the foundations of econometrics. Typically treated as external to markets, these domains have lately been objects of renewed interest. Calls for accountability and transparency have expanded to include the now topical but previously neglected economic implications of human, social, and natural capital. Clear advantages for the measurement and management of these forms of capital can be drawn from econometric criteria for identifiable models of structurally invariant relationships. The United Nation's Millennium Development Goals (MDG) provide an example application of a probabilistic model for measurement used to evaluate data quality, reduce data volume with no loss of information, estimate linear units of comparison with known uncertainties, express measures from different sets of indicators in a common metric, and frame a meaningful interpretive context. Data on 22 MDG indicators from 64 countries are scored and analyzed. Model fit was reasonable, the item hierarchy tells a meaningful story of structural invariance in economic development, and Cronbach's alpha was 0.93. The measures estimated in this study correlated over 0.90 with independently produced measures of per-capita GDP and life satisfaction. These results provide a positive demonstration of relevant methods applicable in the context of today's Sustainable Development Goals 2030 Agenda.

Huge resources are invested in metrology and standards in the natural sciences, engineering, and across a wide range of commercial technologies. Significant positive returns of human, social, environmental, and economic value on these investments have been sustained for decades. Proven methods for calibrating test and survey instruments in linear units are readily available, as are data- and theory-based methods for equating those instruments to a shared unit. Using these methods, metrological traceability is obtained in a variety of commercially available elementary and secondary English and Spanish language reading education programs in the U.S., Canada, Mexico, and Australia. Given established historical patterns, widespread routine reproduction of predicted text-based and instructional effects expressed in a common language and shared frame of reference may lead to significant developments in theory and practice. Opportunities for systematic implementations of teacher-driven lean thinking and continuous quality improvement methods may be of particular interest and value.

Rasch's unidimensional models for measurement show how to connect object measures (e.g., reader abilities), measurement mechanisms (e.g., machine-generated cloze reading items), and observational outcomes (e.g., counts correct on reading instruments). Substantive theory shows what interventions or manipulations to the measurement mechanism can be traded off against a change to the object measure to hold the observed outcome constant. A Rasch model integrated with a substantive theory dictates the form and substance of permissible interventions. Rasch analysis, absent construct theory and an associated specification equation, is a black box in which understanding may be more illusory than not. Finally, the quantitative hypothesis can be tested by comparing theory-based trade-off relations with observed trade-off relations. Only quantitative variables (as measured) support such trade-offs. Note that to test the quantitative hypothesis requires more than manipulation of the algebraic equivalencies in the Rasch model or descriptively fitting data to the model. A causal Rasch model involves experimental intervention/manipulation on either reader ability or text complexity or a conjoint intervention on both simultaneously to yield a successful prediction of the resultant observed outcome (count correct). We conjecture that when this type of manipulation is introduced for individual reader text encounters and model predictions are consistent with observations, the quantitative hypothesis is sustained.

The State Performance Plan (SPP) developed under the 2004 reauthorization of the Individuals with Disabilities Education Act (IDEA 2004, Public Law 108-446) requires states to collect data and report on the impact of early intervention services on three key outcomes for participating families. The NCSEAM Impact on Family Scale (NIFS) and the NCSEAM Family Centered Services Scale (NFCSS) were developed to provide states with a means to address this new reporting requirement and to collect additional data that would inform program improvement efforts. Items suggested by stakeholder groups were piloted with a nationally representative sample of parents of children with developmental delays or disabilities ages birth to three participating in early intervention services in eight states. The 28-item NIFS had measurement reliabilities ranging from .93-.96 in a sample of 1,750; measurement reliabilities for the 135-item NFCSS ranged from .94 to .97 in a sample of 1,755 respondents. A 29-item version of the NFCSS had measurement reliabilities ranging from .87 to .92. Using data from the pilot study, stakeholders established a recommended performance standard, set at a meaningful point in the NIFS item hierarchy, for each of the three established outcome areas.

Capital is defined mathematically as the abstract meaning brought to life in the two phases of the development of "transferable representations," which are the legal, financial, and scientific instruments we take for granted in almost every aspect of our daily routines. The first, conceptual and gestational, and the second, parturitional and maturational, phases in the creation and development of capital are contrasted. Human, social, and natural forms of capital should be brought to life with at least the same amounts of energy and efficiency as have been invested in manufactured and liquid capital, and property. A mathematical law of living capital is stated. Two examples of well-measured human capital are offered. The paper concludes with suggestions for the ways that future research might best capitalize on the mathematical definition of capital.

Indicator 8 of the State Performance Plan (SPP), developed under the 2004 reauthorization of the Individuals with Disabilities Education Act (IDEA 2004, Public Law 108-446) requires states to collect data and report findings related to schools' facilitation of parent involvement. The Schools' Efforts to Partner with Parents Scale (SEPPS) was developed to provide states with a means to address this new reporting requirement. Items suggested by stakeholder groups were piloted with a nationally representative sample of 2,634 parents of students with disabilities ages 5-21 in six states. Rasch scaling was used to calibrate a meaningful and invariant item hierarchy. The 78 calibrated items had measurement reliabilities ranging from .94-.97. Using data from the pilot study, stakeholders established a recommended performance standard set at a meaningful point in the item hierarchy. Implications of the findings are discussed in relation to the need for rigorous metrics within state accountability systems.

Science is often described as nothing but the practice of measurement. This perspective follows from longstanding respect for the roles mathematics and quantification have played as media through which alternative hypotheses are evaluated and experience becomes better managed. Many figures in the history of science and psychology have contributed to what has been called the "quantitative imperative," the demand that fields of study employ number and mathematics even when they do not constitute the language in which investigators think together. But what makes an area of study scientific is, of course, not the mere use of number, but communities of investigators who share common mathematical languages for exchanging quantitative and quantitative value. Such languages require rigorous theoretical underpinning, a basis in data sufficient to the task, and instruments traceable to reference standard quantitative metrics. The values shared and exchanged by such communities typically involve the application of mathematical models that specify the sufficient and invariant relationships necessary for rigorous theorizing and instrument equating. The mathematical metaphysics of science are explored with the aim of connecting principles of quantitative measurement with the structures of sufficient reason.

This study employs existing data sources to develop a new measure of intensive care unit (ICU) admission risk for heart failure patients. Outcome measures were constructed from laboratory, accounting, and medical record data for 973 adult inpatients with primary or secondary heart failure. Several scoring interpretations of the laboratory indicators were evaluated relative to their measurement and predictive properties. Cases were restricted to tests within first lab draw that included at least 15 indicators. After optimizing the original clinical observations, a satisfactory heart failure severity scale was calibrated on a 0-1000 continuum. Patients with unadjusted CHF severity measures of 550 or less were 2.7 times more likely to be admitted to the ICU than those with higher measures. Patients with low HF severity measures (550 or less) adjusted for demographic and diagnostic risk factors are about six times more likely to be admitted to the ICU than those with higher adjusted measures. A nomogram facilitates routine clinical application. Existing computerized data systems could be programmed to automatically structure clinical laboratory reports using the results of studies like this one to reduce data volume with no loss of information, make laboratory results more meaningful to clinical end users, improve the quality of care, reduce errors and unneeded tests, prevent unnecessary ICU admissions, lower costs, and improve patient satisfaction. Existing data typically examined piecemeal form a coherent scale measuring heart failure severity sensitive to increased likelihood of ICU admission. Marked improvements in ROC curves were found for the aggregate measures relative to individual clinical indicators.

Is it possible to establish a consistent, stable relationship between the structure of number and additive amounts of mindfulness practice? A bank of thirty items, constructed from a review of the literature and from novice practitioners' journal responses to mindfulness practice, comprised the instrument. A convenience sample of students in a teacher education program participated. The WINSTEPS Rasch measurement software was used for all analyses. Measurement separation reliability was 0.92 and item separation reliability was 0.98, with satisfactory model fit. The 30 items measure a single construct of mindfulness practice. Construct validity was supported by the meaningfulness of the items perceived as easy to hard. The same scale was produced when the items were calibrated separately on the T1 and T2 groups (Rsq = 0.83). The experimental group's T2 measures were significantly different from both its own T1 measures and the control group's T1 and T2 measures. ANOVA showed significance for variance between the experimental and control groups for T2 (F = 43.66, 151 d.f., p < .001) for a nearly two-logit (20 unit) difference (48.9 vs. 68.0). The study is innovative in its demonstration of mindfulness practice as a measurable variable.

Context: National autopsy rates have declined for several decades, and the reasons for such decline remain contentious., Objective: To elicit the opinions of one group of crucial decision makers as to the reasons for this decline and possible modes of reversal., Design: A 2-part survey, composed of multiple choice questions and questions requesting specific data on autopsy rates and costs., Setting: Illinois, Iowa, Louisiana, Minnesota, Nebraska, North Dakota, South Dakota, and Wisconsin., Participants: Hospital administrators within the 8 states., Main Outcome Measures: Six-point survey scale relating to reasons for autopsy decline and possible remedial measures, as well as estimates of autopsy rates and costs., Results: The response rate was 43% and the median autopsy rate was 2.4% (mean 6.1%). The median cost of autopsy was estimated at $852 (mean $1275). Larger hospitals were associated with higher autopsy rates than smaller hospitals (9.6% vs 4.0%), and teaching hospitals had a significantly higher autopsy rate than nonteaching institutions (11.4% vs 3.8%). Autopsy rates also varied by type of hospital control, with federal government hospitals having the highest autopsy rate at 15.1%. Sixty-six percent of all respondents agreed that current autopsy rates were adequate. Of the respondents, the highest percent (86%) agreed that improved diagnostics contributed to the decline in autopsies, and the highest percent (78%) agreed that direct payment to pathologists for autopsies under the physician fee schedule might lead to an increase in autopsies., Conclusions: Our data support the conclusion that the decline in autopsy performance is multifactorial, although the variable that dominates in this analysis is the contentious perception that improved diagnostic technology renders the autopsy redundant. The rate of autopsy is conditional, at least in part, on individual hospital characteristics such as large hospital size, teaching status, and federal ownership. Three underlying factors may explain these associations: resources, mission, and case mix. An important factor in declining autopsy rates appears to be the changing economic landscape, with its increased focus on cost control within both the public and private healthcare sectors.

Background: Multi-item health status measures can be lengthy, expensive, and burdensome to collect. Single-item measures may be an alternative. We compared measurement properties of two single-item, general self-rated health (GSRH) questions to assess how well they captured information in a validated, multi-item instrument., Methods: We administered a general health survey (SF-12V) that included "standard" and "comparative" forms of a GSRH. We repeated the survey two weeks later to the same 75 medically stable outpatients to test for GSRH reproducibility, reliability, and validity using SF-12V Physical Functioning and Emotional Health subscales as a reference., Results: At each survey administration, the two GSRH questions demonstrated good alternate forms reliability (first administration: r = 0.74, p < 0.001; second administration: r = 0.74, p < 0.001) and good reproducibility ("standard": ICC 0.69; "comparative": ICC 0.85). Both GSRH items correlated with physical functioning ("standard": r = 0.66; "comparative": r = 0.56) and emotional health measures ("standard": r = 0.65; "comparative": r = 0.59). Mean subscale measures associated with responses in each GSRH category were significantly different (ANOVA, p < 0.001), indicating strong discriminant scale performance., Conclusions: Our single-item, GSRH questions demonstrated good reproducibility, reliability, and strong concurrent and discriminant scale performance with an established health status measure.

Aviation history provides an apt metaphor for the state of Rasch measurement practice, and its potential future. Flying was initially widely believed to be nothing but a spectacular and dangerous fad. Few saw in it any potential for the huge industry that it is today. The current state of Rasch measurement practice is quite akin to daredevil barnstorming in that the field is focused on isolated demonstrations of disconnected technical effects. Only when the analogues of air traffic control, airports, support staff, training programs, textbooks, and partner industries (hotels, restaurants) are in place will Rasch measurement come into its own as the technical medium of a widespread industry. The point at which current practice tips into a new paradigm depends on the realization of operationally validated theory in a supportive social context. The paper closes with speculations on what crossing Rasch measurement's tipping point might entail.

The purpose of this study was to evaluate the psychometric properties of the Diabetes Self-Care Scale (DSCS). A convenience sample of 175 adults with diabetes who met the inclusion criteria from a local hospital in southern Louisiana participated in this study. Data from a pilot study with 50 respondents were also used to calibrate the instrument. The analysis tested the hypothesis that the difference between any respondent's agreement with an item and the difficulty presented by that item is equal to the natural logarithm of the odds of a response. Results indicated that respondent separation reliability is acceptable (.80) and item separation reliability is high (.99). All 35 items measure a single construct of diabetes self-care. Construct validity was supported by the meaningfulness of the item endorsability order and by the consistency of that order across respondents. Seven recommendations for modification of the instrument, future research, and practice are proposed.

Purpose: This project demonstrates how to calibrate different samples and scales of genomic information to a common scale of genomic measurement., Materials and Methods: 1,113 persons were genotyped at the 13 Combined DNA Index System (CODIS) short tandem repeat (STR) marker loci used by the Federal Bureau of Investigation (FBI) for human identity testing. A measurement model of form ln[(P(nik))/(1-P(nik))] = B(n)-D(i)-L(k) is used to construct person measures and locus calibrations from information contained in the CODIS database. Winsteps (Wright and Linacre, 2003) is employed to maximize initial estimates and to investigate the necessity and sufficiency of different rating classification schema., Results: Model fit is satisfactory in all analyses. Study outcomes are found in Tables 1-6., Conclusions: Additive, divisible, and interchangeable measures and calibrations can be created from raw genomic information that transcend sample- and scale-dependencies associated with racial and ethnic descent, chromosomal location, and locus-specific allele expansion structures.

Background: To analyze whether internists are suited for their role in treating the growing numbers of obese patients, we surveyed residents about their knowledge and attitudes regarding obesity. Previous assessments have not analyzed familiarity with obesity measurement tools or the correlation between knowledge and attitudes., Methods: We administered a survey to 87 internal medicine residents in two urban, university-based residency programs., Results: Almost all respondents understood the medical consequences of obesity, but 60% did not know the minimum BMI for diagnosing obesity, 69% did not recognize waist circumference as a reasonable measure of obesity, and 39% incorrectly reported their own BMI. Although nearly all respondents agreed that treating obesity was important, only 30% reported treatment success. Forty-four percent felt qualified to treat obese patients, and 31% reported treatment to be futile. Knowledge and attitudes were not correlated. Rasch analysis of knowledge and attitude subscales showed satisfactory model fit and item reliability of at least 0.96., Conclusions: Despite solid knowledge of the comorbid conditions associated with obesity, residents have a poor grasp of the tools necessary to identify obesity. They also have negative opinions about their skills for treating obese patients. Residency training not only must improve knowledge of obesity measurement tools but also must address physicians' negative attitudes toward obesity treatment.

This article raises and tries to answer questions concerning what objectivity in psychosocial measurement is, why it is important, and how it can be achieved. Following in the tradition of the Socratic art of maiuetics, objectivity is characterized by the separation of meaning from the geometric, metaphoric, or numeric figure carrying it, allowing an ideal and abstract entity to take on a life of its own. Examples of objective entities start from anything teachable and learnable, but for the purposes of measurement, the meter, gram, volt, and liter are paradigmatic because of their generalizability across observers, instruments, laboratories, samples, applications, etc. Objectivity is important because it is only through it that distinct conceptual entities are meaningfully distinguished. Seen from another angle, objectivity is important because it defines the conditions of the possibility of shared meaning and community. Full objectivity in psychosocial measurement can be achieved only by attending to both its methodological and its social aspects. The methodological aspect has recently achieved some notice in psychosocial measurement, especially in the form of Rasch's probabilistic conjoint models. Objectivity's social aspect has only recently been noticed by historians of science, and has not yet been systematically incorporated in any psychosocial science. An approach to achieving full objectivity in psychosocial measurement is adapted from the ASTM Standard Practice for Conducting an Interlaboratory Study to Determine the Precision of a Test Method (ASTM Committee E-11 on Statistical Methods, 1992).

Interest in applying probabilistic conjoint measurement (PCM) models, such as those devised by the late Georg Rasch, to health status and quality of life data has grown significantly in the last few years. Applications have yet, however, to fully realize the opportunities for scientific generalization and practical convenience PCM offers. This article fleshes out the substance of some of these opportunities by comparing eight separate PCM calibrations of the SF-36 ten-item physical functioning scale (PF-10). The initial average correlation across the 28 pairs of calibrations is .84; after taking advantage of the PCM model's capacity to account for missing data by omitting from the comparisons items that vary due to sample idiosyncracies, the average correlation is .90. Opportunities for, and limitations on, generalization from PF-10 measures are explored.

This article addresses the relevance of probabilistic conjoint (Rasch) measurement to five issues of accountability and patient-centeredness in health care. Goals for research, data quality standards, and standard metrics are proposed. The article is intended to begin to address concerns voiced by health care researchers, policy analysts, and the public about ways in which health care outcome measures can be improved.

This study equates the physical functioning subscales of the Medical Outcomes Study Short Form 36 (SF36) and the Louisiana State University Health Status Instruments (LSU HSI). Data from the SF36's 10-item physical functioning scale, the PF10, and the LSU HSI's 29-item Physical Functioning Scale (PFS), were fit to separate and mixed Rasch rating scale models. Data were provided by a convenience sample of 285 patients waiting for appointments in a public hospital general medicine clinic. Difficulty estimates for a subset of similar items from the two instruments were highly correlated (.95), indicating that the items from the two scales are working together to measure the same variable. The measures from the two equated instruments correlate .80 (.86 when disattenuated for error). Of the two instruments, the PFS's error is lower, model fit is better, and reliability coefficients are higher. Both instruments measure physical functioning, and can do so in a common unit of measurement. Conversion tables are provided for transforming raw scores from either instrument into the common metric.

Objectives: This study examines the stability of a physical disability construct across instruments and samples. The purpose is not to report a formal equating of instrument calibrations, but to indicate whether such an effort would be likely to succeed. Theory. The economics transforming health care from its orientation toward crisis-driven disease reactions to population- and evidence-based preventive health management and individualized disease management demand general scale-free measures of functional independence., Methods: A new method, pseudo-common item equating, is demonstrated. Similar, but not identical items, from different instruments, calibrated on different samples, are compared., Data: More than 30 articles presenting Rasch analyses of physical functioning scales were reviewed. Four instruments provided data from ten of these articles, for eleven different calibrations (two instruments are both included in one article)., Results: The final overall average correlation disattenuated for error is .93, with an average of 7 pseudo-common items, and an average p-value of .01, meaning that measures based on these calibrations should be linearly transformable versions of the same metric. Scientific importance. The quantitative stability of different areas of physical functional independence across instruments and samples suggests that the development and deployment of a universal metric is a realizable goal.

Probabilistic measurement models offered by Rasch and others can be used to link different functional assessment instruments into a single measurement system. This study assessed 54 subjects (diagnoses: 8 brain injuries, 7 neuromuscular, 22 musculoskeletal, 7 spinal cord, 10 stroke) admitted to a free-standing rehabilitation hospital at admission and discharge using both the Functional Independence Measure (FIM) and the Patient Evaluation and Conference System (PECS). Thirteen FIM and 22 PECS motor skills items were scaled together into a 35-item instrument, providing scale values for all items in the same unit of measurement. Separate FIM and PECS measures produced for each subject correlate .94 and .91 (p < .0001), respectively, with the cocalibration measures, and 0.91 (p < .0001) with each other. Either instrument's ratings are easily and quickly converted into the other's using the common unit of measurement, the rehabit (rehabilitation measuring unit). This article argues that the stability of the PECS and FIM item difficulty estimates over thousands of subjects, dozens of hospitals, hundreds of raters, and years of assessment is convincing evidence in support of the widespread use of their cocalibrated, common scale values as a functionometric ruler.

Advances in fundamental measurement have led to many exciting new developments in functional assessment. This paper presents fundamental measurement theory and method in summary form, and briefly describes its various applications to functional assessment, program evaluation, and outcomes analysis in physical medicine and rehabilitation. The implications of computerized medical records and longitudinal patient tracking in national or global computer networks for functional status and health status gold standards are briefly addressed.

Occupational therapists, like other rehabilitation professionals, have accepted ordinal raw scores as a sufficient basis for developing evaluation tools. This paper summarizes problems commonly found in evaluation methods based on summing ordinal raw item scores and demonstrates how Rasch measurement models provide a solution to the construction of calibrated (linear) measures. Rasch measurement models are contrasted with Steven's lax definition of measurement and Guttman's unreasonably rigid requirements. The simple Rasch model is a probabilistic formulation of the fundamental requirements for additive linear measurement. This formulation retains Guttman's concept of order, but construes it probabilistically, making it neither too lax (random) nor too rigid. When a measure is based on a theory of what counts as an observation of more or less of something, Rasch measurement models are useful for constructing valid measures.

A discriminant analysis was performed using Rasch ability estimates derived from four Patient Evaluation and Conference System (PECS) subscales, to distinguish among the functional independence and impairment profiles exhibited by patients admitted into any of three levels of medical rehabilitation delineated by the National Association of Rehabilitation Facilities (NARF): (1) inpatient hospital, (2) atypical nursing home (intermediate), or (3) day program. Two discriminant functions accounted for 91% and 9% of the between-group variance, respectively. Cross-validated classification of patients into one of the three levels of care, based on discriminant function scores, produced 75% correct classification; a 66% improvement over the percentage of correct classification likely by chance alone. Results support the construct validity of the PECS subscales and indicate they may be useful in validating clinically-based admission decisions among three of the levels of care promulgated by NARF.

The use of functional assessment total scores in arithmetic operations has proliferated despite the lack of evidence supporting their use as interval measures of patient ability. Such evidence is minimally necessary to assure the validity of functional assessment total scores for clinical and management decision-making. Two requirements of interval measurement are explained and a set of Rasch analyses of 5,500 assessments using the Patient Evaluation and Conference System (PECS) are presented. The analyses were performed to determine the extent to which four item subsets identified in a previously reported factor analysis of the PECS comprise interval measures of functional independence status. Results indicate that the PECS scales meet these requirements to varying degrees. The analyses also identify areas in which measurement quality can be improved.

While rehabilitation providers are facing increasing pressure to document treatment outcomes, critics have warned against the inappropriate use of ordinal functional assessment data in arithmetic operations. Two salient criticisms concern the combination of items representing multidimensional abilities into a single total score, and the indeterminate distances between hierarchical functional assessment scale categories. In this initial study, the factor structure of the Patient Evaluation and Conference System (PECS) was studied to assess the potential for unidimensional measurement. Factor analysis of a multidiagnostic dataset (n = 3,564) yielded eight factors accounting for 60% of the variance among 68 PECS items. The factors indicate that several unidimensional measures may underlie the PECS. These factors are delineated, and further studies of unidimensionality and additivity are recommended.

This paper evaluates changes in quantities and appropriateness of dosages and quantities of prescription in capitation and control pharmacies. The data indicate that, under capitation, changes were made in the quantities of ingredients so that the quantities dispensed were significantly different from those prescribed. However, the number of such modifications to prescriptions was small, and the reader is cautioned against drawing broad conclusions. The analysis, then, considers changes in days' supply of prescription ingredients during the study period. There were significantly increases in the average day's supply of prescription ingredients for maintenance drugs dispensed under the capitation reimbursement scheme; however, no such differences were observed for non-maintenance drugs. Appropriateness of the dosages and quantities of prescriptions were then compared for capitation and fee-for-service pharmacies for the study period, and no significant differences were found. Thus, it is concluded that although capitation was associated with increases in the average days' supply of ingredients dispensed for maintenance prescriptions, such changes did not adversely affect the quality of drug therapy as measured by two sets of criteria.

In Muscatine, Iowa, a medically underserved rural area, a cohort study of health care utilization was made before and after a significant increase in medical manpower. There was a slight increase, rather than a decrease, in the use of chiropractic services associated with the growth in the physician manpower pool. The level of access to physician services was not a significant predictor of chiropractice utilization.

This study describes an attempt to influence the outcome of outpatient psychotherapy by offering pretherapy information to application. The sample consisted of more than 1,300 applicants; the pretherapy information, in the form of a printed leaflet, was included with the application blank for alternate cases. The results suggest that the pretherapy information tended to discourage the completing of application blanks. Among those patients who eventually participated in psychotherapy, pretherapy information had no effect on the duration of treatment or on treatment outcomes as rated by the therapists. Incidentally, the data indicate that having health insurance has a strong, positive effect on the number of treatment interviews.

This article evaluates changes in the use of drug services and the corresponding costs when the conventional fee-for-service system for reimbursement of pharmacists under medicaid is replaced by a capitation system. The fee-for-service system usually covers ingredient costs plus a fixed professional dispensing fee. The capitation system provided a cash payment (which varied by aid category and season of the year) per Medicaid eligible the first of each month. We examined drug use and costs in two experimental rural counties during a 1-year preperiod in which the fee-for-service form of reimbursement was employed, as well as a 2-year postperiod in which the capitation system was used. We compared the results with use and cost patients in two other rural counties which remained on the fee-for-service system during the same 3-year period. Drug use was similar among control and experimental counties with the exception of nursing home patients; use in this category decreased under capitation and increased under fee-for-service. Using three measures of drug cost: 1) average cost of a day's drug therapy; 2) average drug costs per recipient; and 3) average Medicaid expenditures for drug services per recipient, we observed significant savings under the capitation reimbursement system as compared to the fee-for-service system. We attributed savings under capitation to shifts in prescribing and dispensing behavior, as well as changes in use by nursing home patients. Based upon these findings, the total savings resulting from implementing capitation would be approximately 16 percent compared to fee-for-service reimbursement.

Four areas of cost were analyzed in the expanded capitation drug program: total program costs; drug costs, escrow account distribution, and administrative costs. Total program costs were, on average, 9% higher under capitation. Drug costs, however, were 3% lower than under fee-for-service (FFS) reimbursement. This discrepancy is probably because pharmacists were not at financial risk under the program, the capitation rates were higher than intended, there were many emergency claims, and other aspects of the research environment. Although administrative costs were large, almost two thirds of the development cost was for one-time work, which could be transferred to another state at little or no expense. One third of the total administrative costs can be attributed to complying with regulations of the Health Care Financing Administration. Significant refinement of the present capitation model may be necessary before this financing innovation is used elsewhere. Modifications might include limiting the system to nursing home patients, placing pharmacists at partial financial risk, restricting participation to pharmacies that service a large number of Medicaid eligibles, and basing capitation rates in part on the drug use behavior of cash-paying patients.

Results of a two-county pilot study in Iowa revealed that capitation may have significant advantages over fee-for-service (FFS) reimbursement in the Medicaid drug program. Consequently, the capitation program was expanded to 32 counties on April 1, 1981 and continued through December 31, 1981. Another 32 counties were used as part of a before:after/experimental:control design. Pharmacists were paid 80% of projected drug expenditures in advance based on the types of Medicaid eligibles who chose them as their providers. The remaining 20% was withheld in an escrow account to be used for supplemental, emergency, and bonus payments. Pharmacists who participated in this experiment were guaranteed that their gross profits on Medicaid prescriptions would remain at least equal to what they would have been if they had remained under the current FFS payment system. Major differences in drug use levels and pharmacist dispensing behavior under capitation financing were observed in the pilot study. However, no such changes associated with payment type were noted in the expanded program. Relative to these findings, a discussion of pharmacist attitudes is presented.

The opportunity to join a group practice has been identified as a successful inducement for physicians to locate in rural areas. Less is known of the effects of group practice on the health attitudes, behavior and status of the rural communities in which they are established. A random survey of households was conducted in 1972 in a rural Midwestern area, prior to the establishment of a community-sponsored multispecialty primary care group practice, and again on the same households in 1977, after establishment of this group practice (a total of 292 households representing 829 persons). Perceived access to health services before the establishment of the group practice did not significantly predict use of the group practice. Neither previous use of medical services nor health status measured by several indices was associated with eventual use of the group practice. The apparent impact on the community of the group practice was a significant improvement in access to physician services, shown by shorter average travel time to the place of primary care and a 62 per cent improvement in the ability to make a same-day appointment. Furthermore, a significant shift in the distribution of physician services was noted over the study period. The introduction of physician assistants significantly decreased the prior positive attitudes toward them. Despite improvement in access to care, no changes in population health status or receipt of preventive services were noted. Current users of the group practice appear similar to those utilizing conventional medical care sources in regard to access to services, use of services, as well as health status, attitudes and costs.

This article evaluates changes in the rate of generic substitution as well as the appropriateness of such changes in dispensing behavior when the conventional fee-for-service system for reimbursement of pharmacists is replaced by a capitation system. The fee-for-service system under Medicaid usually covers ingredient costs plus a fixed professional dispensing fee. The capitation system provides a cash payment per Medicaid eligible at the first of each month, which varies by aid category and season of the year. The dispensing behavior of pharmacists in two experimental rural counties is examined during a 1-year preperiod in which the fee-for-service form of reimbursement was employed, as well as a 2-year postperiod in which capitation was used in lieu of fee-for-service payments. The results are compared with pharmacist behavior patterns in two other rural counties which remained on the fee-for-service system over the same 3-year period. The data indicate highly significant increases in both the rate of generic substitution as well as the dollar savings per substitution in the experimental counties after the institution of capitation reimbursement. Using explicit criteria, no substantial differences in the appropriateness of generic substitution were noted between the two financing schemes.

Capitation is a system of reimbursement for services under which providers are paid a fixed amount per client served per time period. An experiment from April 1981 to December 1981 involved the use of a capitation system of reimbursement to pharmacies participating in the Iowa Medicaid drug program in 32 counties in Iowa. It was essential to demonstrate that cost savings were feasible and pharmacy reimbursement would be adequate before the capitation experiment was begun. An assessment of this issue was developed using simulation and data base management techniques. The positive results of this assessment gave evidence that cost savings due to capitation potentially could be realized by both the Medicaid drug program and pharmacists during the experiment.