Date of Award

Winter 1999

Document Type


Degree Name

Doctor of Philosophy (PhD)


Urban Services--Health Services

Committee Director

Brenda Nichols

Committee Member

Betty Alexy

Committee Member

Christine B. Philput


The study examined the ability of the Health Enrollment Assessment Review (HEAR) survey instrument to classify participants into one of two groups according to utilization of health resources anticipated in the following year. Developed by the U.S. Air Force, the HEAR survey is used worldwide by the Department of Defense for enrollees in TRICARE Prime, the military's adaptation of the HMO model of managed care. Individual HEAR reports are prepared for survey participants and their primary care providers in TRICARE Prime. Although it is currently administered worldwide to a majority of the 8.4 million health care beneficiaries of the Department of Defense, the developers expected the health resource utilization (HRU) measure scored from HEAR survey data to be validated in the future when suitable criterion data became available.

This study estimated the reliability and validity of the original HRU model. Further, an alternate HRU model was derived with optimal use of the data available from the HEAR survey. The original HRU model was based on the Pareto principle, which states that “in any population that contributes to a common effect, a relative few of the contributors account for the bulk of the effect” (Juran, 1992, p. 57). Alternatively, it is sometimes stated as the 80/20 rule: 20% of the contributors account for about 80% of the common effect (Caldwell, 1994).

The target population for the study was adult active duty family members continuously enrolled in TRICARE Prime in the Hampton Roads metropolitan area of Southeastern Virginia in 1997. The survey was mailed to a random sample that yielded 391 usable surveys. A Pareto analysis revealed that 21.2% of participants utilized 50.4% of the primary care visits. Attempting to identify those participants, the sensitivity (true positive rate) of the original HRU model was 25.3% and the specificity (true negative rate) was 90.9%. The reliability coefficient was .619 and the validity coefficient was .200. The sensitivity of the derived HRU model was 34.9% and the specificity rate was 84.1%. It had a reliability coefficient of .816 and a validity coefficient of .195. Neither model was deemed sufficient to classify members into utilization groups.