摘要:

Objectives.In the face of escalating medical costs for injured workers, the Washington State Department of Labor and Industries (L&I), which pays for most workers' compensation costs in the state, established guidelines for elective Iumbar fusion as part of its inpatient utilization review program. The guidelines were tied to reimbursement strictures. The authors attempt to assess the effects of these guidelines, which were introduced in November 1988, upon subsequent L&I fusion procedures.Methods.Discharge data from the Comprehensive Hospital Abstract Reporting System and algorithms using International Classification of Diseases, Version 9, Clinical Modification diagnosis and procedure codes were used to identify lumbar surgical cases. Population estimates were from the 1990 US Census Bureau.Results.During the period of years 1987 through 1992, the lumbar fusion rate for the state showed a 26% decline compared with a 3% decrease for all lumbar operations. After November 1988, when the guidelines went into effect, the state fusion rate declined 33%, whereas rates for nonfusion operations essentially were unchanged. The sharpest decline corresponded in time to implementation of the guidelines. Prior to the initiation of L&I guidelines, the proportion of fusions among L&I patients was higher than among non-L&I patients. The opposite was true by the end of 1992, and the L&I proportion decreased more rapidly than the non-L&I proportion. Time series analysis revealed that both the decline in Washington state lumbar fusion rates and the decline in the proportion of lumbar fusion among L&I patients were statistically significant.Conclusions.The data suggest that the L&I lumbar fusion surgery criteria and reimbursement standards implemented in 1988 contributed to a decline in rates of performing that procedure. The utilization review aspect of the guidelines as well as the process of involving surgeons in the preparation and dissemination of guidelines also may have been contributory.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.In 1990, the state of Florida implemented an acquired immunodeficiency syndrome (AIDS)-specific Medicaid waiver program to provide home and community-based services to AIDS patients as an alternative to institutional care. The program is available to Medicaid beneficiaries with AIDS who are at risk of institutionalization. This study examines whether the waiver option was effective in reducing Medicaid expenditures per beneficiary during its first 2 years of operation.Methods.The authors used Medicaid claims data and county information on the availability of health services to model the selection of the waiver option by AIDS patients and then to estimate the effect of the waiver on expenditures controlling for nonrandom program selection.Results.The results indicate that the selection model is highly significant, but that the influence of nonrandom selection on the estimation of the program effects is negligible. More importantly, the regression results indicate that persons with AIDS who use waiver services incur monthly Medicaid expenditures that are on average 22% to 27% lower than otherwise similar nonparticipants.Conclusions.These results, based on the first 2 years that Project AIDS Care was operational, suggest that home and community-based care for AIDS patients results in lower expenditures per beneficiary.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.The aim of this 2-year research project was to develop an instrument specifically designed to assess the quality of life of people with diabetes.Methods.The project was divided into two phases. In the first phase, information from a detailed literature review, from existing quality-of-life instruments, and from interviews with health professionals and people with diabetes was used to develop an initial instrument of 92 items considered to address important aspects of patients' lives. This questionnaire was mailed to 1,000 people with diabetes, and data from the 516 respondents were used to select the most important and useful items. Fifty items were excluded, leaving 42 items that constituted the pilot instrument.During phase 2, the pilot instrument was used to assess the quality of life of 427 diabetic patients who completed the revised questionnaire. After analyzing this data, three additional items were dropped. The final instrument consists of 39 items and covers five dimensions of patients' lives: Energy and Mobility, Diabetes Control, Anxiety and Worry, Social Burden, and Sexual Functioning.Results.The results of validity and reliability tests conducted to date testify to the relevance of the 39-item questionnaire (Diabetes-39) as a valid discriminative instrument, one which shows significant correlations with an overall quality-of-life assessment, the pattern of diabetes severity, and comorbidity. Further, the results from Diabetes-39 correlate well with the results from the established generic quality-of-life instrument, the Medical Outcomes Study 36-Item Short-Form Health Survey.Conclusions.Validation of a quality-of-life instrument, however, is an ongoing process. Further research is required to corroborate these early findings and to ensure that this is an instrument that can capture data of greatest relevance to the diabetic patient and that is responsive to change in quality of life.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.The authors determine whether prevention influences the use of health services. Fluoridation's effect on restorative dental demand among 972 Washington state employees and spouses, aged 20 to 34 years, in two fluoridated communities and a nonfluoridated community was examined.Methods.At baseline, adults were interviewed by telephone, and oral assessments were conducted to measure personal characteristics, lifetime exposure to fluoridated water, oral disease, and the quality of restorations. Adults were followed for 2 years to measure dental demand from dental claims. Each adult's baseline and claims data were linked with provider and practice variables collected from the dentist who provided treatment.Results.Relative to adults with no lifetime exposure to fluoridated water, adults drinking fluoridated water for half or more of their lives had less disease at baseline and a lower but nonsignificant probability of receiving a restoration in the follow-up period. In the 2-year follow-up period, however, more than half of the restorations were performed to replace fillings of satisfactory or ideal quality at baseline. When only teeth with decay and unsatisfactory fillings at baseline were considered, adults with high fluoridation exposure had a lower probability of receiving a restoration than adults with no exposure. Market effects also were detected in demand equations; relative to adults in the nonfluoridated community, adults residing in the fluoridated community with a large dentist supply received a greater number of restorations, suggesting potential supplier-induced demand from less disease and fewer patients.Conclusions.Among adults aged 20 to 34 years with private dental insurance, fluoridation reduces oral disease but may or may not reduce use of restorative services, depending on dentists' clinical decisions.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.Decisions made by private health care plans as to whether to cover new medical technology have a significant impact on access, diffusion, and costs. This study describes the variation in health plan coverage of different laser technologies and the types of considerations used in making coverage decisions for them.Methods.In a cross-sectional national survey of medical directors at private plans, medical directors indicated current coverage of 15 different laser therapies, and then ranked the top five considerations both in favor and against recommending coverage for three of the laser therapies (angioplasty, discectomy, and photodynamic therapy). The influence of explicit clinical information and/or plan characteristics on coverage and the importance of considerations was examined through multivariate analyses (multiple logistic or linear regression analysis).Results.Overall, 231 medical directors responded from plans representing 66% and 72% of persons in US health maintenance organization and indemnity plans, respectively. Current coverage for 13 of the 15 laser therapies varied between 20% and 90%. For-profit and indemnity plans covered approximately two more of the different laser technologies than nonprofit plans and health maintenance organizations. Considerations most frequently listed in favor of and against recommending coverage across the three laser technologies were clinical, economic, and regulatory. Legal, competitive, and compassionate concerns were listed less frequently. Considerations were not uniform across laser therapies; they reflected the specifics of the technology under review. Plan characteristics influenced the ranking of considerations as well. For instance, health maintenance organizations were two to three times more likely than indemnity plans to list potential for decreased cost in favor of recommending coverage.Conclusions.These findings demonstrate that there is substantial variation in coverage of new technologies, indicating that a large proportion of the population covered by private health plans are ineligible for treatments that are routinely available to others. A greater range of medical therapy may be available for persons enrolled in indemnity and for-profit plans should their physicians choose to prescribe it. Clinical and economic considerations, including cost-effectiveness, predominate in coverage decisions for new technologies. The importance of considerations appears sensitive not only to specific clinical information, however, but also to characteristics of health plans.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.The use of self-report questionnaires for the assessment of health-related quality of life (HRQOL) is increasingly common in clinical research. This method of data collection may be less suitable for patient groups who suffer from cognitive impairment, however, such as patients with brain cancer. In such cases, one can consider employing the patients' significant others as proxy raters of the patients' health-related quality of life. The authors examined the response agreement between patients with brain cancer and their significant others on a health-related quality of life instrument commonly used in cancer clinical trials, the EORTC QLQ-C30, and on a brain cancer-specific questionnaire module, the QLQ-BCM.Methods.The study sample consisted of 103 pairs of patients, with either recently diagnosed or recurrent brain cancer, and their significant others (75% spouses, 22% relatives, and 3% friends). Patients and proxies independently completed the EORTC QLQ-C30 and the QLQ-BCM at three different times.Results.Approximately 60% of the patient and proxy scores were in exact agreement, with more than 90% of scores being within one response category of each other. For most HRQOL dimensions assessed, moderate to good agreement was found. Statistically significant differences in mean scores were noted for several dimensions, with proxies tending to rate the patients as having a lower quality of life than the patients themselves. With the exception of fatigue ratings, this response bias was of a limited magnitude. Less agreement and a more pronounced response bias was observed for the more impaired patients, and particularly for patients exhibiting mental confusion. This finding was confirmed by longitudinal analyses, which indicated lower levels of patient-proxy agreement at follow-up for those patients whose physical or neurologic condition had deteriorated over time.Conclusions.In general, patients and their significant others provide similar ratings of the patients' quality of life. Lower levels of agreement and more biased ratings can be expected among those patients for whom the need for proxies is most salient. It is argued, however, that discrepancies between patient-proxy ratings should not be interpreted, a priori, as evidence of the inaccuracy or biased nature of proxy-generated data. Future studies are needed to examine the relative validity and reliability of patient- versus proxy-generated health-related quality of life scores.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.Parental and maternity leave policies are a popular fringe benefit among childbearing employed women and a benefit employers frequently are required to offer. However, few rigorous evaluations of the effect of maternal leave on maternal health exist.Methods.Using a hybrid of the household and health production theories of Becker and Grossman and a sample of women identified from state vital statistics records, a nonlinear relationship between maternal postpartum health and time off work after childbirth was estimated.Results.For women taking more than 12 weeks leave, time off work had a positive effect on vitality. With more than 15 weeks leave, time off work had a positive effect on maternal mental health, and with more than 20 weeks leave, time off work had a positive effect on role function. Subjects' mental health scores were comparable and vitality scores slightly lower than ageand gender-specific norms; 70% of women studied reported role function limitations.Conclusions.Findings suggest employed women experience problems in well-being at approximately seven months postpartum. Variables associated with improved health include: longer maternity leaves, fewer prenatal mental health symptoms, fewer concurrent physical symptoms, more sleep, increased social support, increased job satisfaction, less physical exertion on the job, fewer infant symptoms, and less difficulty arranging child care.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.An empirical, head-to-head comparison of the performance characteristics of four generic health status measures.Methods.The Nottingham Health Profile, the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36), the COOP/WONCA charts, and the EuroQol instrument were simultaneously employed in a controlled survey measuring the impact of migraine on health status. The feasibility (number of missing cases per item), internal consistency (Cronbach's α), construct validity (correlation patterns and common factor analysis), and discriminative ability (Receiver Operating Characteristic analyses) of the four measures were investigated.Results.The Nottingham Health Profile produced the lowest missing value rate. The internal consistency of the Nottingham Health Profile scales was lower than the scales of the SF-36. Combined factor analyses with data of the four instruments together resulted in two-factor solutions with a physical and a mental factor, explaining approximately 50% of variance. The SF-36 exhibited the best ability to discriminate between groups. Test-retest reliability and sensitivity to change over time could not be tested because of the cross-sectional character of the study.Conclusions.None of the instruments performed uniformly as "best" or "worst." Purely on the basis of the results of the psychometric analyses, the SF-36 appeared to be the most suitable measure of health status in this relatively healthy population. In general, the choice of the most suitable instrument for generic health status assessment in a particular study should be guided by the special features of each candidate instrument under consideration.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID