Determinants of Contraceptive Availability at Medical Facilities in the Department of Veterans Affairs

OBJECTIVE: To describe the variation in provision of hormonal and intrauterine contraception among Veterans Affairs (VA) facilities. DESIGN: Key informant, cross-sectional survey of 166 VA medical facilities. Data from public use data sets and VA administrative databases were linked to facility data to further characterize their contextual environments. PARTICIPANTS: All VA hospital-based and affiliated community-based outpatient clinics delivering services to at least 400 unique women during fiscal year 2000. MEASUREMENTS: Onsite availability of hormonal contraceptive prescription and intrauterine device (IUD) placement. RESULTS: Ninety-seven percent of facilities offered onsite prescription and management of hormonal contraception whereas 63% offered placement of IUDs. After adjusting for facility caseload of reproductive-aged women, 3 organizational factors were independently associated with onsite IUD placement: (1) onsite gynecologist (adjusted odds ratio [OR], 20.35; 95% confidence interval [CI], 7.02 to 58.74; P<.001); (2) hospital-based in contrast to community-based practice (adjusted OR, 5.49; 95% CI, 1.16 to 26.10; P=.03); and (3) availability of a clinician providing women's health training to other clinicians (adjusted OR, 3.40; 95% CI 1.19 to 9.76; P=.02). CONCLUSIONS: VA's provision of hormonal and intrauterine contraception is in accordance with community standards, although onsite availability is not universal. Although contraception is a crucial component of a woman's health maintenance, her ability to obtain certain contraceptives from the facility where she obtains her primary care is largely influenced by the availability of a gynecologist. Further research is needed to determine how fragmentation of women's care into reproductive and nonreproductive services impacts access to contraception and the incidence of unintended pregnancy

The Self-Concept Life Cycle and Brand Perceptions: An Interdisciplinary Perspective

Consumer research has paid scant attention to the full spectrum of a consumer’s self-concept life cycle and its subsequent impact on brand attitude. This article presents a conceptual framework that provides the foundation for future research on how the self-concept, across its full life cycle, impacts brand attitude. The article considers the development of the self-concept from childhood to late adulthood, and integrates findings from various disciplines into a comprehensive framework. The factors in the framework affecting the self-concept are global culture, life events, as well as cognitive and desired age. The article offers six propositions to guide future research and encourage more interdisciplinary work, as well as guiding the application of a broader perspective in terms of the self-concept’s full life-span. Moreover, the article also presents methodological and managerial implications on how to use branding approaches that target specific consumer segments according to their self-concepts’ life cycle

Primary Care Experiences of Medicare Beneficiaries, 1998 to 2000

OBJECTIVE: To examine changes in the quality of primary care experienced and reported by Medicare beneficiaries from 1998 to 2000. DESIGN: Longitudinal observational study. SETTING: Thirteen states with large, mature Medicare HMO markets. PARTICIPANTS: Probability sample of noninstitutionalized Medicare beneficiaries aged 65 and older enrolled in traditional Medicare (FFS) or a Medicare HMO. MEASUREMENTS AND MAIN RESULTS: We examined 2-year changes in 9 measures derived from the Primary Care Assessment Survey (PCAS). The measures covered 2 broad areas of primary care performance: quality of physician-patient interactions (5 measures) and structural/organizational features of care (4 measures). For each measure, we computed the change in each beneficiary's score (1998 vs 2000) and standardized effect sizes (ES). Results revealed significant declines in 3 measures of physician-patient interaction quality (communication, interpersonal treatment, and thoroughness of physical exams; P≤ .0001). Physicians’ knowledge of patients increased significantly over the 2-year period (P≤ .001). Patient trust did not change (P = .10). With regard to structural/organizational features of care, there were significant declines in financial access (P ≤ .001), visit-based continuity (P < .001), and integration of care (P≤ .05), while organizational access increased (P ≤ .05). With the exception of financial access, observed changes did not differ by system (FFS, HMO). CONCLUSIONS: Over a 2-year period, the quality of seniors’ interactions with their primary physicians declined significantly, as did other hallmarks of primary care such as continuity, integration of care, and financial access. This decline is in sharp contrast to the marked improvements in technical quality that have been measured over this period. In an era marked by substantial national investment in quality monitoring, measures of these elements of care are notably absent from the nation's portfolio of quality indicators