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The Multiattribute Asthma Symptom Utility Index

METHODSStudy SitesWe initially selected 40 VA nursing homes for possible inclusion in the study. Nursing homes were selected so as to meet the following three characteristics. First, they were to represent diverse geographic areas. Second, they were to vary in size, with approximately half having fewer than 100 beds. Third, nursing homes were to differ in their quality of care as measured by the rate of pressure ulcer development calculated from an administrative database. Two nursing homes were dropped from this initial list because we could not identify a local liaison to assist with data collection, two were dropped due to delays in obtaining institutional approval, and one was dropped from the analyses due to its exceptionally small size, with resulting limited information on performance. Thus, our final sample consisted of 35 nursing homes.

2. In what preventive services do we observe the comparative advantage of having a regular doctor over having a regular site?CONCEPTUAL FRAMEWORKIntuitively, individuals, especially those who have one or more chronic conditions, would prefer having a usual source of care in order to receive continuous monitoring and medical attention. Also, having a usual source of care can improve the timeliness and comprehensiveness of the receipt of preventive care for health conscientious or risk-averse individuals. Because both groups of individuals are concerned about their health, they may seek out services more aggressively (Ettner 1999). Thus, when a usual source of care is present in the service utilization process of these two groups of individuals, more observed service use does not necessarily imply that the usual source of care is the cause of the increased utilization of prevention. The endogeneity of having a usual source of care was also examined by Kuder and Levitz (1985), in which they conceptualized the relationship between having a usual source of care and physician visits under the behavioral model specification (Aday and Andersen 1984; Andersen and Aday 1978; Andersen and Newman 1973; Andersen 1995). In a traditional behavioral model, individuals'' predisposing, enabling, and need factors are used in predicting service use. Having a usual source of care, one of the enabling factors, is treated as predetermined (i.e., independent of predisposing, need, and other enabling factors) in explaining service use. However, numerous empirical studies rejected such an independence assumption (Hayward et al. 1991; Hayward et al. 1988; Merzel 2000; Rask et al. 1994; Schur, Albers, and Berk 1995). In these studies, the probability of having a usual source of care was modeled by using a subset of predisposing, enabling, and need factors, such as insurance status, as explanatory variables. Thus, the traditional behavioral model did not capture the intermediacy of having a usual source of care in linking predisposing, enabling, and need factors to service use. More importantly, many previous studies ignored the fact that the choice of a usual source of care was correlated with the error term in a regression of service use, controlling for observable consumer characteristics. Figure 1 illustrates a modified structure of the behavioral model.

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