Socioeconomic inequalities in health in the working population: the contribution of working conditions.
BACKGROUND: The aim was to study the impact of different categories of working conditions on the association between occupational class and self-reported health in the working population. METHODS: Data were collected through a postal survey conducted in 1991 among inhabitants of 18 municipalities in the southeastern Netherlands. Data concerned 4521 working men and 2411 working women and included current occupational class (seven classes), working conditions (physical working conditions, job control, job demands, social support at work), perceived general health (very good or good versus less than good) and demographic confounders. Data were analysed with logistic regression techniques. RESULTS: For both men and women we observed a higher odds ratio for a less than good perceived general health in the lower occupational classes (adjusted for confounders). The odds of a less than good perceived general health was larger among people reporting more hazardous physical working conditions, lower job control, lower social support at work and among those in the highest category of job demands. Results were similar for men and women. Men and women in the lower occupational classes reported more hazardous physical working conditions and lower job control as compared to those in higher occupational classes. High job demands were more often reported in the higher occupational classes, while social support at work was not clearly related to occupational class. When physical working conditions and job control were added simultaneously to a model with occupational class and confounders, the odds ratios for occupational classes were reduced substantially. For men, the per cent change in the odds ratios for the occupational classes ranged between 35% and 83%, and for women between 35% and 46%. CONCLUSIONS: A substantial part of the association between occupational class and a less than good perceived general health in the working population could be attributed to a differential distribution of hazardous physical working conditions and a low job control across occupational classes. This suggests that interventions aimed at improving these working conditions might result in a reduction of socioeconomic inequalities in health in the working population. (+info)
Views of managed care--a survey of students, residents, faculty, and deans at medical schools in the United States.
BACKGROUND AND METHODS: Views of managed care among academic physicians and medical students in the United States are not well known. In 1997, we conducted a telephone survey of a national sample of medical students (506 respondents), residents (494), faculty members (728), department chairs (186), directors of residency training in internal medicine and pediatrics (143), and deans (105) at U.S. medical schools to determine their experiences in and perspectives on managed care. The overall rate of response was 80.1 percent. RESULTS: Respondents rated their attitudes toward managed care on a 0-to-10 scale, with 0 defined as "as negative as possible" and 10 as "as positive as possible." The expressed attitudes toward managed care were negative, ranging from a low mean (+/-SD) score of 3.9+/-1.7 for residents to a high of 5.0+/-1.3 for deans. When asked about specific aspects of care, fee-for-service medicine was rated better than managed care in terms of access (by 80.2 percent of respondents), minimizing ethical conflicts (74.8 percent), and the quality of the doctor-patient relationship (70.6 percent). With respect to the continuity of care, 52.0 percent of respondents preferred fee-for-service medicine, and 29.3 percent preferred managed care. For care at the end of life, 49.1 percent preferred fee-for-service medicine, and 20.5 percent preferred managed care. With respect to care for patients with chronic illness, 41.8 percent preferred fee-for-service care, and 30.8 percent preferred managed care. Faculty members, residency-training directors, and department chairs responded that managed care had reduced the time they had available for research (63.1 percent agreed) and teaching (58.9 percent) and had reduced their income (55.8 percent). Overall, 46.6 percent of faculty members, 26.7 percent of residency-training directors, and 42.7 percent of department chairs reported that the message they delivered to students about managed care was negative. CONCLUSIONS: Negative views of managed care are widespread among medical students, residents, faculty members, and medical school deans. (+info)
Investigation into the attitudes of general practitioners in Staffordshire to medical audit.
OBJECTIVES: To investigate the attitudes of general practitioners to medical audit, and any associations between their attitudes and their personal characteristics. DESIGN: Postal questionnaire survey. SETTING --Staffordshire, United Kingdom. SUBJECTS: 870 Staffordshire general practitioners. MAIN MEASURES: Agreement or disagreement and associations between the attitudes to 16 statements about audit and the doctors' personal or practice characteristics--namely, sex, number of years since qualification, practice list size, number of partners, and the practices' experience of audit. RESULTS: 601 Staffordshire general practitioners (69%) responded. There was most agreement with the statements that audit is time consuming (86%), that ongoing training and education is needed (71%), that there is a compulsion applied on doctors to audit (68%), and that extra resources for audit should be provided by the medical audit advisory group (65%). There was considerable disagreement (53% of general practitioners) with the statement that inverted question markgovernment policy to expect general practitioners to do audit will enhance the population's health. inverted question mark The median response by the 601 general practitioners was four positive responses out of 14 statements about audit (two of the 16 statements could not be graded positive or negative to audit). Women doctors generally had more positive attitudes towards audit, and so had those working with smaller mean list sizes, those in larger partnerships, and those in practices that had carried out audit for a longer time. CONCLUSIONS: There was a generally negative attitude to medical audit, but it was encouraging that those doctors with the most experience of audit obtained the most job satisfaction from it. IMPLICATIONS: More effort is needed to convince general practitioners of the value of audit. Without this, attempts to involve other members of the primary care team in multidisciplinary clinical audit are unlikely to be effective. Successful audits that are shown to be cost effective as well as leading to improvements in patient care should be publicised and replicated. A higher proportion of resources should be devoted to audit. (+info)
Market-level health maintenance organization activity and physician autonomy and satisfaction.
Managed care is widely expected to affect physicians throughout the healthcare system. In this study, we examined the relationship between health maintenance organization (HMO) activity and the level of competition, autonomy, and satisfaction perceived by physicians who do not work for HMOs. We obtained data on physicians from the 1991 Survey of Young Physicians, which contains a nationally representative sample of physicians younger than age 45 who had 2 to 9 years of practice experience in 1991. We examined the relationships between HMO market share and perceived competition, autonomy, and satisfaction using multivariate logistic regression. The main outcome measures were perceived level of competition; several measures of physicians' freedom to undertake common tasks that might be threatened by managed care (e.g., hospitalizing patients, ordering tests and procedures); satisfaction with current practice situation; perceived ability to practice quality medicine; whether the physician would attend medical school again; and satisfaction with medicine as a career. We found that an increase of 10 percentage points in HMO market share was associated with a 28% increase in the probability that physicians will regard their practice situation as very competitive as opposed to somewhat or not competitive (P < 0.01). Examinations of the relationship between HMO market share and autonomy and satisfaction revealed few significant results. We found no evidence that increases in HMO activity adversely affect physician autonomy. Only a limited amount of evidence indicates that increases in HMO activity reduce the satisfaction of specialist physicians, and no evidence associates HMO activity with the satisfaction of generalists. Although physicians perceive HMOs as competitors, HMO activity has not had a strong negative effect on the autonomy and satisfaction of physicians. (+info)
Effect of compensation method on the behavior of primary care physicians in managed care organizations: evidence from interviews with physicians and medical leaders in Washington State.
The perceived relationship between primary care physician compensation and utilization of medical services in medical groups affiliated with one or more among six managed care organizations in the state of Washington was examined. Representatives from 67 medical group practices completed a survey designed to determine the organizational arrangements and norms that influence primary care practice and to provide information on how groups translate the payments they receive from health plans into individual physician compensation. Semistructured interviews with 72 individual key informants from 31 of the 67 groups were conducted to ascertain how compensation method affects physician practice. A team of raters read the transcripts and identified key themes that emerged from the interviews. The themes generated from the key informant interviews fell into three broad categories. The first was self-selection and satisfaction. Compensation method was a key factor for physicians in deciding where to practice. Physicians' satisfaction with compensation method was high in part because they chose compensation methods that fit with their practice styles and lifestyles. Second, compensation drives production. Physician production, particularly the number of patients seen, was believed to be strongly influenced by compensation method, whereas utilization of ancillary services, patient outcomes, and satisfaction are seen as much less likely to be influenced. The third theme involved future changes in compensation methods. Medical leaders, administrators, and primary care physicians in several groups indicated that they expected changes in the current compensation methods in the near future in the direction of incentive-based methods. The responses revealed in interviews with physicians and administrative leaders underscored the critical role compensation arrangements play in driving physician satisfaction and behavior. (+info)
Perceived financial incentives, HMO market penetration, and physicians' practice styles and satisfaction.
OBJECTIVE: To estimate the effects of physicians' personal financial incentives and other measures of involvement with HMOs on three measures of satisfaction and practice style: overall practice satisfaction, the extent to which prior expectations about professional autonomy and the ability to practice good-quality medicine are met, and several specific measures of practice style. DATA SOURCES: A telephone survey conducted in 1997 of 1,549 physicians who were located in the 75 largest Metropolitan Statistical Areas in 1991. Eligible physicians were under age 52, had between 8 and 17 years of post-residency practice experience, and spent at least 20 hours per week in patient care. The response rate was 74 percent. STUDY DESIGN: Multivariate binomial and multinomial ordered logistic regression models were estimated. Independent variables included physicians' self-reported financial incentives, measured by the extent to which their overall financial arrangements created an incentive to either reduce or increase services to patients, the level of HMO penetration in the market, employment setting, medical specialty, exposure to managed care while in medical training, and selected personal characteristics. PRINCIPAL FINDINGS: About 15 percent of survey respondents reported a moderate or strong incentive to reduce services; 70 percent reported a neutral incentive; and 15 percent reported an incentive to increase services. Compared to physicians with a neutral incentive, physicians with an incentive to reduce services were from 1.5 to 3.5 times more likely to be very dissatisfied with their practices and were 0.2 to 0.5 times as likely to report that their expectations regarding professional autonomy and ability to practice good-quality medicine were met. They were also 0.2 to 0.6 times as likely to report having the freedom to care for patients the way they would like along several specific measures of practice style, such as sufficient time with patients, ability to hospitalize, ability to order tests and procedures, and ability to make referrals. These effects were generally reinforced by practicing in an area with a high level of HMO penetration and were offset to some extent by having had exposure to HMOs and the practice of cost-effective medicine while in medical training. CONCLUSIONS: Although financial incentives to reduce services are not widespread, there is a legitimate reason to be concerned about possible adverse affects on the quality of care. More research is needed to investigate directly whether changes in patients' health are affected by their physicians' financial incentives. (+info)
Predictors and consequences of unemployment in construction and forest work during a 5-year follow-up.
OBJECTIVES: The study investigated whether indicators of health, work conditions, or life-style predict subsequent unemployment and also the unemployment consequences related to health or life-style. METHODS: A questionnaire was administered to 781 male construction and 877 male forest workers (aged 20-49 years and working at the beginning of the study) in 1989 and 1994. Employment status during follow-up was ranked into the following 4 categories according to the employment status and unemployment time: continuously employed, re-employed, short-term (< or = 24 months) unemployed and long-term (> or =24 months) unemployed. RESULTS: The following base-line factors were associated with long-term unemployment during follow-up among the construction workers: age >40 years, poor subjective health, smoking, frequent heavy use of alcohol, low job satisfaction, marital status (single), and unemployment during the year preceding the initial survey. Among the forest workers, age >40 years, frequent stress symptoms, and preceding unemployment entered the model. In addition smoking predicted unemployment among the forest workers with no preceding unemployment. The proportion of regular smokers decreased among the long-term unemployed. Physical exercise was more frequent at the time of follow-up than it was initially, particularly among the unemployed. Stress symptoms increased among the construction workers, but musculoskeletal symptoms decreased significantly among the long-term unemployed. Among the forest workers stress symptoms decreased among the continuously employed and re-employed persons, but musculoskeletal symptoms decreased significantly for them all. CONCLUSIONS: Unemployment among construction workers is to some extent dependent on life-style, health, and job satisfaction in addition to age, marital status, and unemployment history. For forest workers, unemployment is less determined by individual factors. Changes in distress and musculoskeletal symptoms are dependent on employment, particularly among construction workers. (+info)
Sources and implications of dissatisfaction among new GPs in the inner-city.
OBJECTIVES: We aimed to examine the factors that were most stressful for new principals in inner-city general practice. In addition, given the concerns about retention of new principals, to ascertain whether high perceived stress translated into regret that they had joined their practice and factors that might protect from regret. METHODS: A questionnaire survey, within an inner-city Health Authority. The subjects were 101 GPs appointed as principals between 1992 and 1995. RESULTS: Eighty-three out of 101 GPs replied. The greatest sources of stress were, in order, patient expectations, fear of complaint, out-of-hours stress and fear of violence. Although these stresses were scored highly, 61% expressed no regret at having joined their practice with just 4% reporting considerable regret. Stress within the partnership and stress arising from patient expectations accounted for 23% of the variation in regret. Holders of the MRCGP were significantly protected against regret; there was no evidence that other factors such as medical positions outside the practice, membership of a young principals support group, fundholding status or training practices offered significant protection against regret. CONCLUSION: Despite reported difficulties in recruiting new young principals to the inner-city-and despite their reported high levels of stress-few have regrets about their decision to join their practice. For those who did regret joining their practice, the three principal associations were partnership stress, patient expectations and not possessing the MRCGP. Each of these factors may be amenable to intervention by policies geared to improve GP retention. (+info)