摘要:

Legal factors related to the malpractice liability insurance purchased by general dentists in the United States were investigated using a comprehensive multivariate model that assessed the contribution of legal provisions affecting the probability of a malpractice claim, the probability of a payment, and the average size of the payment. General practice dentists in the United States were selected randomly, and 3,048 dentists were studied by mail survey. A number of legal statutes (periodic payment allowed, percentage fault liability informed consent limits, limits onres ipsa loquitor, attorney fee control, some statute of limitations provisions) had the intended effect of reducing the malpractice insurance sought by dentists. Other provisions, such as binding arbitration, may have unintended cost-raising effects. Previous malpractice claims were associated with purchasing greater amounts of insurance. These findings have implications for future changes in the legal system as part of health care reform.

ISSN:0025-7079    

出版商:OVID    

年代:1995

数据来源: OVID

ISSN:0025-7079    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

Patients often want considerable information about their conditions, and enhanced patient participation might reduce unwanted practice variation and improve medical decisions. The authors assessed how men with benign prostatic hyperplasia reacted to an educational program designed to facilitate participation in decisionmaking, and how strongly ratings of their symptom state and the prospect of complications predicted their treatment choice. A prospective cohort study was conducted in three hospital-based urology practices: two in prepaid group practices, and one Veterans Administration clinic. Four hundred twenty-one men with symptomatic benign prostatic hyperplasia without prior prostatectomy or benign prostatic hyperplasia complications were enrolled, and 373 provided usable ratings. Subjects participated in an interactive videodisc-based shared decisionmaking program about benign prostatic hyperplasia and its treatment options, prostatectomy, and “watchful waiting.” They rated the length, clarity, balance, and value of the program and were followed for 3 months to determine if they underwent surgery. Patients rated the program as generally clear, informative, and balanced. Across all three sites, 77% of patients were very positive and 16% were generally positive about the program's usefulness in making a treatment decision. Logistic models predicting choice of surgical treatment documented the independent importance of negative ratings of the current symptom state (odds ratio 7.0, 95% confidence interval 2.9–16.6), as well as the prospect of postoperative sexual dysfunction (odds ratio 0.20, 95% confidence interval 0.08–0.48) in decisionmaking. Patients rated the Shared Decisionmaking Program very positively and made decisions consistent with their assessed preferences. These results suggest that patients can be helped to participate in treatment decisions, and support a randomized trial of the Shared Decisionmaking Program.

ISSN:0025-7079    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

Different types of medication prescribed during a 6-month period for the treatment and management of chronic conditions were utilized in the refinement and validation of a chronic disease score. Prescription data, in addition to age and sex, were utilized to develop a chronic disease score based on empirically derived weights for each of three outcomes: total cost, outpatient cost, and primary care visits. The ability of the revised chronic disease score to predict health care utilization, costs, hospitalization, and mortality was compared to an earlier version of the chronic disease score (original) that was derived through clinical judgments of disease severity. The predictive validity of the chronic disease score is also compared to ambulatory care groups, which utilize outpatient diagnoses to form mutually exclusive diagnostic categories. Models based on a concurrent 6-month period and a 6-month prospective period (ie, the 6-month period after the chronic disease score or ambulatory care group derivation period) were estimated using a random one half sample of 250,000 managed-care enrollees aged 18 and older. The remaining one half of the enrollee population was used as a validation sample. The revised chronic disease score showed improved estimation and prediction over the original chronic disease score. The difference in variance explained prospectively by the revised chronic disease score versus the ambulatory care groups, conversely, was small. The revised chronic disease score was a better predictor of mortality than the ambulatory care groups. The combination of revised chronic disease score and ambulatory care groups showed only marginally greater predictive power than either one alone. These results suggest that the revised chronic disease score and ambulatory care groups with empirically derived weights provide improved prediction of health care utilization and costs, as well as hospitalization and mortality, over age and sex alone. We recommend the revised chronic disease score with total cost weights for general use as a severity measure because of its relative advantage in predicting mortality compared to the outpatient cost and primary care visit weights.

ISSN:0025-7079    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

This article verifies if the increase in the percentage of women in the medical profession led to the convergence of male and female physicians'hours of work as well as income. Active physicians in Quebec in 1978 were compared to the ones in 1988. Data were obtained from the computerized files of the Quebec Corporation of Physicians and the Régie d'assurance-maladie du Quebec. Despite the increasing representation of women in the medical profession, gender differences in hours worked and income remained. However, results also showed a tendency toward a convergence in total hours of work, more behavioral variation among women physicians and some behavioral change among men. The experience of the past should thus not be used as the basis for projections of future physician productivity or for medical manpower planning purposes without a careful analysis of trends in behavioral changes.

ISSN:0025-7079    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

Diagnosis-related groups have been revised through more refined uses of secondary diagnoses. Under the refined diagnosis-related groups, patients are distinguished with respect to classes of secondary diagnoses that are disease- and procedure-specific. Each class represents a different level of utilization for a given principal diagnosis or surgical procedure. The refined system was evaluated with national data from the Medicare program. Estimates of hospital costs and utilization based on refined diagnosis-related groups were more precise than those based on unrefined diagnosis-related groups. This approach to diagnosis-related group refinement does not represent a radical departure from the current diagnosis-related group framework and does not require new data collection efforts. Moreover, a payment system based on the refined model is less affected by the ordering of the diagnoses than under the existing diagnosis-related group system. How the refined diagnosis-related group framework can accommodate future refinements at all levels of the classification scheme is also discussed.

ISSN:0025-7079    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

Although extensive resources go to cancer care, national population-based data on the costs of such care at the patient level have been unavailable. Medicare payments subsequent to diagnosis of cancer for elderly enrollees with five common cancers were estimated using tumor registry data from the Surveillance, Epidemiology, and End Results Program linked to Medicare claims from 1984 to 1990. The time between diagnosis and death was divided into four phases corresponding to the clinical course of solid tumors, average payments for each phase were estimated (including payments for services not related to cancer), then phase-specific payment data were aggregated.Average payments by phase varied among cancer sites, especially in the initial care phase, where payments were highest for lung and colorectal cancers ($17,500 in 1990 dollars) and lowest for female breast cancer ($8,913). Total Medicare payments from diagnosis to death were highest for persons with bladder cancer ($57,629) and lowest for those with lung cancer ($29,184). Low payments for persons with lung cancer corresponded to brief survival times. Persons diagnosed at earlier stages incurred higher total payments between diagnosis and death than those diagnosed at later stages, reflecting their longer survival. This implies that early detection may increase total Medicare expenditures by extending beneficiaries' lives. However, Medicare payments per year of survival were lower for earlier stages.Data on Medicare payments subsequent to diagnosis of cancer are useful for identifying the cost implications of differences in treatment patterns by demographic characteristics, geography, and delivery systems; comparing the financial impact of alternative therapies; evaluating the long-term cost impacts of screening and prevention programs; and risk-adjusting payments to health plans.

ISSN:0025-7079    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

Back pain is a common illness and chiropractors provide a large proportion of back pain care in the United States. This is the first study to systematically compare chiropractic patients with those who saw other providers for back pain. The authors analyzed data from the RAND Health Insurance Experiment, a community-based study of the use of health services. Insurance claims forms were examined for all visits specified by the patient as occurring for back pain. Visits were grouped into episodes using decision rules and clinical judgment. The primary provider of back pain care was defined as the provider who delivered most of the services. Sociodemographic and health status and attitudes variables of patients were examined for association with the choice of chiropractor. Multivariate logistic regression models were constructed to calculate adjusted odds ratios for independent predictors. There were 1020 episodes of back pain care made by 686 different persons and encompassing 8825 visits. Results indicated that chiropractors were the primary provider for 40% of episodes, and retained as primary provider a greater percentage of their patients (92%) who had a second episode of back pain care than did medical doctors. Health insurance experiment site, white race, male sex, and high school education were independent predictors of choosing a chiropractor. Conclusions suggested that chiropractors were the choice of one third of all patients who sought back pain care, and provided care for 40% of all episodes of care. Geographic site, education, gender, and income were independent patient factors predicting chiropractic use.

ISSN:0025-7079    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

This article investigates the way in which the presence of censored cost data in clinical trials should dictate the inferential tests adopted when comparing treatment and nontreatment groups for the purpose of economic evaluation. The authors argue that the techniques of survival analysis are appropriate where censoring is present, and that bias will be imparted if cruder methods are used to analyze cost data, even if that data is drawn from a relevant population. The first section of the article discusses the problem of censoring and survival analysis, while the second examines three methods of dealing with censored cost data and possible biases resulting from them. The third section presents results from actual trial data using the three methods described in the preceding section. Conclusions are presented in section four, where it is argued that these methodological issues are likely to become more important as economists are called upon to evaluate the treatment of chronic conditions using data from clinical trials with finite end points.

ISSN:0025-7079    

出版商:OVID    

年代:1995

数据来源: OVID

摘要:

Numerous studies have demonstrated the importance of race, payor, and gender in determining the use of cardiac services, including revascularization procedures (bypass surgery and angioplasty). However, there has been less investigation into where and when in the process of care differences in utilization arise. In this report, the authors examined the sequence of events leading to the use of revascularization procedures, identifying four phases of care (prehospital, intrahospital, interhospital, and posthospital). Following a cohort of 5857 patients admitted to California hospitals with acute myocardial infarction in 1991, the authors found differences in treatment probabilities during nearly every phase for different racial and payor groups. For example, compared with patients who are uninsured, patients with private insurance were more likely to be admitted initially to a hospital offering revascularization (adjusted odds ratio [OR] = 1.40, 95% confidence interval [CI] 1.30 to 1.51). Moreover, once admitted to such a hospital, private patients were more likely to undergo revascularization (adjusted OR = 2.30; 95% CI 1.80 to 2.94). They were also more likely to undergo transfer to receive revascularization (adjusted OR = 1.22; 95% CI 1.03 to 1.45), and to be readmitted for revascularization (adjusted OR = 1.60; 95% CI 1.13 to 2.27) Previously reported discrepancies in service use represent the cumulative effects of multiple phases during which different racial and payor groups experience different processes of care.

ISSN:0025-7079    

出版商:OVID    

年代:1995

数据来源: OVID