ISSN:0025-7079    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objective.To use detailed pre-discharge follow-up data to predict readmissions within 3 months after Coronary Artery Bypass Grafting (CABG).Settings and Design.A prospective nationwide study (ISCAB) of 4,835 patients undergoing isolated CABG in Israel in 1994. Survivors of the initial hospitalization were candidates for the readmission study.Methods.Patient information was prospectively collected from preoperative interviews and hospital follow-up. Readmissions' data were obtained from the National Hospital Admission Registry. Logistic and multinomial models were constructed for total and cause-specific readmissions, respectively.Results.Of CABG survivors, 1,094 (24.1%) were rehospitalized within 3 months of the original surgery. Significant multivariate predictors of total readmissions included the following: preoperative co-morbidities; operative factors; immediate post-operative complications and socio-demographic characteristics as well as provider characteristics. However, the logistic model had low predictive power (c-statistic = 0.65). The heterogeneous reasons for readmissions were classified into specific serious cardiac diagnoses (19.0%), other cardiac reasons (35.4%), specific infections at the site of the operation (10.2%), other infections (7.3%), and various other reasons (23.0%). The multinomial model for cause-specific readmissions caused by either serious cardiac reasons or wound infection had a higher predictive value (c-statistics of 0.75, 0.72, respectively).Conclusions.Total readmissions after CABG in Israel were difficult to predict, even with an extensive pre-discharge follow-up data. We propose that reasons for readmission vary from true emergencies to nonspecific causes, with the latter related to a lack of support services in the community. We suggest that cause-specific rehospitalizations could be a better outcome for evaluating quality of care.

ISSN:0025-7079    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Background.The Composite International Diagnostic Interview (CIDI) has been developed as a state-of-the-art, structured diagnostic instrument, designed to diagnose psychiatric disorders across cultures and languages. Partly because it has been validated in a number of countries and cultural settings, the CIDI has become widely accepted as a diagnostic instrument in epidemiologic and clinical research.Objectives.As part of a larger study of psychiatric disorders in a multi-ethnic, primary care setting, we tried to clarify the limitations of the CIDI in diagnosing somatoform symptoms among Latino patients.Design.Relevant sections of the CIDI were administered in English or Spanish to new patients seeking primary care services at an inner-city, university-affiliated community clinic. Interviews were tape recorded and pertinent passages were transcribed for qualitative analysis.Subjects.One thousand, four hundred and fifty six new patients, comprising 4 ethnic groups: Central American; Mexican; Chicano; and non-Latino White.Measures.The CIDI's diagnostic algorithms for somatization were examined in relation to the transcriptions of interviews for Latino patients whom the CIDI diagnosed as somatizers.Results.The CIDI led to the inaccurate identification of somatoform symptoms resulting from such issues as financial barriers to health-care access, cultural syndromes that were not recognized by Western medicine, and language differences between patients and physicians. Like other structured instruments, the CIDI also forced a range of complex experience into a fixed-choice interview format.Conclusions.Despite the advantages of such structured instruments as the CIDI, their capacity to reach accurate psychiatric diagnoses in some cultural groups and clinical settings requires clarification. These findings also call into question the relatively high rates of somatization among Latino patients reported in previous studies that have used structured psychiatric diagnostic instruments.

ISSN:0025-7079    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objectives.In a randomized study, the authors examine how data can be collected at the point of care. Specifically, examining to what extent handheld computer data collection systems introduce bias or increase respondent difficulty.Methods.Volunteers were randomized to 1 of 2 survey methods: the hand-held computer or a paper and pencil form of similar content. Differences between group scale scores were compared using the Wilcoxon (rank sum) test.Results.The hand-held computer system produced comparable scores to paper and pencil surveys. However, there was evidence of lower internal consistency reliability with the handheld computer.Conclusions.This study demonstrated the comparability of the hand-held computer methodology to the paper and pencil methodology in obtaining survey information in an ambulatory clinic. The hand-held computer method of survey data collection offers an alternative to paper methods when point-of-care administration is acceptable. Preliminary evidence shows that this method produces comparable results to paper forms.

ISSN:0025-7079    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objectives.To estimate costs for the prevention and treatment of cervical cancer based on resource utilization and to compare those costs to published estimates and to local charges and reimbursements.Design.Cost estimates for cervical cancer prevention services were based on clinic staff time, use of specialized equipment and supplies, laboratory costs, and clinic overhead. Cost estimates for cervical cancer treatment were based on HMO expenditures for cervical cancer patients and control patients. These costs were adjusted for stage distribution and survival rates. Published cost estimates were obtained from a systematic review of the medical literature between 1990 and 1996.Setting.Three family planning clinics (for prevention costs) and a staff-model HMO (for treatment costs).Patients.For treatment costs: 98 cervical cancer patients and 133,058 female control patients, matched by age and chronic disease score.Main Outcome Measures.Estimated costs for prevention and treatment of cervical cancer. Cost-to-charge and cost-to-reimbursement ratios.Results.Costs of cervical cancer prevention and treatment services have been determined using a variety of methods. We found substantial variation in these estimates, even for studies with similar methodologies. Detailed resource-based estimation suggests that prevention costs are generally lower than those previously published in the literature, whereas the costs of cervical cancer treatment are generally higher.Conclusions.It is practical and desirable to employ resource use-based estimates of medical costs in cost-effectiveness analyses. Failure to do so for cervical cancer may affect policy recommendations by understating the relative benefits of prevention programs.

ISSN:0025-7079    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Background.Understanding older adults' volume and patterns of health service use is fundamental to efforts to improve the quality and efficiency of services.Objective.To analyze the accuracy of older adults' self report of health services use and to determine the proportion of care obtained outside a defined urban academic health care system.Research Design.Telephone survey of self-reports validated against data routinely archived in an electronic medical record system.Subjects.Stratified random sample of 422 patients (≥ 60 years) who had contact with the health care system at least once in the previous 3 months.Measures.Self reports of hospitalizations, emergency room visits, physicians visits, extended care visits, and home care visits over the past 12 months, health status, physical activity, and sociodemographics factors.Results.The sample population was more likely to report health services use and functional disability than was a community-based sample of older adults; 67% of the sample were women, 53.9% were African American, 71% were age 65 and over, 38.7% lived alone, and 24.6% reported poor financial resources. Based on data from the electronic medical record, 27.9% of the sample were hospitalized at least once in the prior 12 months, 54.6% had at least one emergency room visit, and the mean number of ambulatory visits was 8.1. Comparing self-report data to the electronic record data, 24.1% of older adults with a hospitalization in the prior 12 months failed to report the episode; 28.1% of those with an emergency room visit failed to report the episode as did 5.2% of those with an ambulatory care visit. The accuracy of the self reports of volume of these services were also substantially under reported. We were unable to identify any patient characteristics that were highly correlated with inaccuracy. We estimate that approximately 9.5% of health care costs are accrued outside this urban health care system.Conclusions.These older adults substantially under-report health services use, including hospital episodes over a 12-month period. Reliance on self-reported use data over the prior year to model patterns of health care use among older adults is not supported by these data.

ISSN:0025-7079    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Background."Feeling thermometers" and category rating scales (CRS) can be used to measure self-rated health, though the interpretation of scores on the feeling thermometer may be problematic.Objectives.To analyze correspondence between scores of self-rated health on the EuroQol-5D "feeling thermometer" and a five-Point CRS. To determine the influence of sociodemographic variables on correspondence.Research Design.Correspondence between EQ-5D "thermometer" scores and CRS categories was determined in a within-subjects design using data from a large-scale health survey.Subjects.Twelve thousand, two hundred and forty-five members of the Spanish general population interviewed in the Catalan Health Interview Survey.Measures.Instruments used were the EQ-5D "feeling thermometer" and a five-Point CRS with categories from "excellent" to "poor."Results.Median scores on the thermometer corresponding to CRS categories were as follows: poor = 40; fair = 53; good = 76; and very good = 80; excellent = 90; differences were statistically significant (P< 0.05). Ranges in thermometer scores covered by CRS categories varied from 23.5 points for the category "poor" to 13 points for the category "very good" (range, 25-75 percentiles), with considerable overlap between categories at the upper end of the scale. Median thermometer scores corresponding to the categories "good," "fair," and "poor" were lower in older respondents and in those with a lower educational level.Conclusions.Determining correspondence between CRS and thermometer scores is useful in interpreting and categorizing thermometer scores. The age and level of education in particular affect the interpretation of CRS categories, and should be taken into account when analyzing results obtained with such instruments.

ISSN:0025-7079    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Schizophrenia leads to impairments in mental, social, and physical functioning, which should be included in evaluations of treatment.Objectives.This study was designed to determine the reliability and validity of the Medical Outcomes Study Short Form Health Survey (SF-36) for schizophrenic patients, to characterize perceived functioning and well being and to compare short-term change in SF-36 scores for patients treated witholanzapineorhaloperidol.Research Design.Data were obtained from a randomized, double-blind trial comparing these agents for safety, efficacy, and cost effectiveness. A 6-week acute treatment portion preceded a 46-week "responder extension" phase.Subjects.A subsample (n= 1,155) completing a pre-treatment SF-36 provided data for this study.Measures.Psychometric analyses were conducted, and perceived level of functioning was compared with that for the US adult population. Change from baseline to 6 weeks was examined by treatment group.Results.Clear evidence was obtained for the instrument's reliability and validity for these patients. There were marked deficits inGeneral health, Vitality, Mental health, Social functioning,and inRole limitationsresulting from both physical and emotional problems. Olanzapine-treated patients improved in 5 of 8 domains to a significantly greater degree than did haloperidol patients.Conclusions.The SF-36 can be a reliable and valid measure of perceived functioning and well being for schizophrenic patients. The perceptions of functioning can be valuable indices of disease burden and can help to demonstrate the effectiveness of newer anti-psychotic medications such as olanzapine.

ISSN:0025-7079    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objectives.To assess the likely effects of the 1996 Health Insurance Portability and Accessibility Act (HIPAA), based on small firms' experiences under state small group insurance reforms that were similar in design to HIPAA.Methods.Data on 17,818 small businesses (range, 2-50 employees) nationwide from the 1994 National Employer Health Insurance Survey were analyzed to examine the effects of state small group reforms on the following: (1) employers' provision of coverage; (2) the percentage of workers in insured firms who were covered by plans; and (3) insurer practices of "enrollee exclusion." Logistic regression models were estimated and used to quantify the marginal effects of state small-group reform. Reform effects were examined for all small firms, for small firms by size category, and for small firms in redlined industries.Results.Under full reform for at least 3 years (full reform includes guaranteed issue and renewal, portability, limits on pre-existing condition waits, and rating restrictions), employers were slightly more likely to sponsor health plans; however, employee participation in employer plans was no higher and the prevalence of enrollee-exclusion provisions was unchanged. Businesses in redlined industries clearly benefitted from all types of small group reform. For other subgroups of businesses, however, there were advantages and disadvantages associated with reforms, which varied with the scope of the measures and time since their implementation.Conclusion.Widespread small group reform may eventually help raise the proportion of small firms that sponsor health benefits, but not by much.

ISSN:0025-7079    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Background.The validity of using claims data for measuring tumor stage, one of the most important determinants of choice of therapy and long-term survival, is unknown.Objectives.To determine the relative accuracy of both inpatient and hospital Outpatient Medicare claims for measuring the stage of disease of six commonly diagnosed cancers.Research Design.Analysis of a database linking Surveillance, Epidemiology, and End Results (SEER) registry data and Medicare claims in patients aged 65 years with cancer.Subjects.Three hundred twenty thousand, six hundred and thirty seven cases of invasive breast, colorectal, endometrial, lung, pancreatic, and prostate cancers diagnosed between 1984 and 1993.Measures.Using SEER files as the "gold standard," concordance with Medicare claims, as well as sensitivity and positive predictive value of coding for each stage was measured.Results.Although Medicare data correctly categorized local, regional, and distant stage tumors in 97%, 33%, and 65%, respectively, the data substantially overestimated the proportion of localized tumors and underestimated the rate of regional stage disease. The highest concordance was observed for breast and colorectal cancer. However, the sensitivity and positive predictive values were never simultaneously 80% within one stage of a specific cancer. The accuracy of coding for stage in Outpatient files was inferior to inpatient data.Conclusions.With few exceptions, Medicare claims have limited utility as a measure of cancer stage. If tumor registry data are not available, investigators should consider the trade offs in sensitivity and predictive value when considering a study that will use claims data.

ISSN:0025-7079    

出版商:OVID    

年代:1999

数据来源: OVID