ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Objective.To estimate the episodic costs of surgical treatments for breast cancer.Methods.The surgical treatment period as the 6 weeks following diagnosis is defined. Using a sample of 205 women aged 65 and older and their Medicare claim files, the cost of treatment is estimated and the progression from first to subsequent surgical procedures during the 6-week interval is demonstrated with a decision tree. Two equations are then estimated: the probability of mastectomy versus breast conserving surgery (BCS) as first surgery using Probit regression and the log of total charges using a generalized linear regression model.Results.It was found that only stage predicts the probability of mastectomy versus BCS and that 54% of women receiving BCS undergo a second surgery. Once all treatments in the initial surgical period are accounted, the difference between the adjusted cost of mastectomy alone and BCS followed by a second surgery was not statistically significant. Only a successful first BCS is statistically significantly (P<0.05) less costly than a mastectomy alone ($4,955 vs. $9,049).Conclusions.By defining a 6-week surgical treatment episode it is shown that BCS followed by subsequent surgeries is the more costly option for initial treatment. Given the high prevalence of second surgeries, previous work may have underestimated the costs of surgical interventions for breast cancer.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Objectives.We conducted a theoretically guided study of access to inpatient or residential treatment among a probability sample of homeless adults with alcohol or drug use disorders in Houston, Texas.Methods.This study used a cross-sectional, retrospective design with data collected from a multistage random sample of 797 homeless adults age 18 or older who were living in Houston shelters and streets in 1996. Structured, face-to-face interviews produced screening diagnoses for alcohol and drug use disorders, treatment use data, and candidate predictors of treatment use. Logistic and linear regression analyses were performed on the subset of 326 homeless persons with either alcohol or drug use disorder.Results.27.5% of persons with substance use disorder had accessed inpatient or residential treatment during the past year. Controlling for additional need factors such as comorbidity, persons having public health insurance and a history of treatment for substance problems had greater odds of receiving at least one night of treatment. Contrary to expectation, contact with other service sectors was not predictive of treatment access. Schizophrenia and having a partner appeared to hinder access. Greater need for treatment was associated with fewer nights of treatment, suggesting retention difficulties.Conclusions.This study adds to previous findings on access to health care among homeless persons and highlights a pattern of disparities in substance abuse treatment access. Health insurance is important, but enhancing access to care involves more than economic considerations if homeless persons are to receive the treatment they need. Referral relationships across different service sectors may require strengthening.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Utilization risk assessment is potentially useful for allocation of health care resources, but precise measurement is difficult.Objective.Test the hypotheses that health-related quality of life (HRQOL), severity of illness, and diagnoses at a single primary care visit are comparable case-mix predictors of future 1-year charges in all clinical settings within a large health system, and that these predictors are more accurate in combination than alone.Research Design.Longitudinal observational study in which subjects’ characteristics were measured at baseline, and their outpatient clinic visits and charges and their inpatient hospital days and charges were tracked for 1 year.Subjects.Adult primary care patients.Measures.Duke Health Profile for HRQOL, Duke Severity of Illness Checklist for severity of illness, and Johns Hopkins Ambulatory Care Groups for diagnostic groups classification.Results.Of 1,202 patients, 84.4% had follow up in the primary care clinic, 63.2% in subspecialty clinics, 14.8% in the emergency room, and 9.6% in the hospital. Of $6,290,775 total charges, $779,037 (12.2%) was for follow-up primary care. The highest accuracy was found for predicting primary care charges, where R2for predictors ranged from 0.083 for medical record auditor-reported severity of illness to 0.107 for HRQOL. When predictors were combined, the highest R2of 0.125 was found for the combination of HRQOL and diagnostic groups.Conclusions.Baseline HRQOL, severity of illness, and diagnoses were comparable predictors of 1-year health services charges in all clinical sites but most predictive for primary care charges, and were more accurate in combination than alone.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Referral to specialized physicians or institutions often is deemed necessary in clinical medicine, but no method exists to assess the clinical benefit of such referrals.Objectives.To describe a method, which is shared patient analysis, to measure the expected improvement in clinical management associated with referrals and to apply that method in the field of abdominal and pelvic oncological radiology.Subjects.All patients referred, during a 4-year period, to surgical oncologists at four academic centers (the referral providers, or RPs) with radiographs performed before referral at a community site (the initial providers, or IPs). Patients (n = 396) for whom both the IP interpretation and a final diagnosis was available were eligible. All IP and RP readings were placed in random order and presented to surgical oncologists, who then recommended a treatment course.Measurements.Diagnostic accuracy of the IP and RP readings and the proportion of patients who were assigned to an appropriate treatment by the oncologist were determined.Results.When the indication for imaging was primary diagnosis or staging, the kappa for presence of cancer was 0.70. When the indication was cancer follow-up, the kappa for presence of recurrent/progressing cancer was 0.66. There were disagreements between the IP and RP radiologists over the interpretation of 162 films, with the RP radiologists being correct in 153 (94%). Had the patients been treated using IP readings, there would have been 19 more inappropriate surgeries and 19 more admissions (bothP<0.05) than if the oncologists had based their recommendations on RP readings.Conclusions.The technique of shared patient analysis permits assessment of the clinical benefits associated with referrals.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Risk adjustment models typically use diagnoses from claims or encounter records to assess illness severity. However, concerns about the availability and reliability of diagnostic data raise the potential for alternative methods of risk adjustment. Here, we explore the use of pharmacy data as an alternative or complement to diagnostic data in risk adjustment.Objectives.To develop and test a pharmacy-based risk adjustment model for SSI and TANF Medicaid populations.Research Design.Pharmacological review combined with empirical evaluation. We developed the Medicaid Rxmodel, a system that classifies a subset of the National Drug Codes into categories that can be used for risk-assessment and risk-adjusted payment.Subjects.Subjects consisted of 362,370 persons with disability and 1.5 million AFDC and TANF beneficiaries in California, Colorado, Georgia, and Tennessee during 1990–1999.Measures.We compare pharmacy and diagnostic classification for three chronic diseases. We also compare R2statistics and use simulated health plans to evaluate the performance of alternative models.Results.Pharmacy and diagnostic classification vary in their ability to identify specific chronic disease. Using simulated plans, diagnostic models are better at predicting expenditures than are pharmacy-based models for disabled Medicaid beneficiaries, although the models perform similarly for TANF Medicaid beneficiaries. Models that combine diagnostic and pharmacy data have superior overall performance.Conclusions.The performance of risk adjustment models using a combination of pharmacy and diagnostic data are superior to that of models using either data source alone, particularly among TANF beneficiaries. Concerns regarding variations in prescribing patterns and the incentives that may follow from linking payment to pharmacy use warrant further research.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Incorporation of patient preferences into treatment decisions is an essential component of medical care. Conjoint analysis is an established method of eliciting consumer preferences in market research and is being increasingly used to study patient preferences for health care.Objective.To examine the value of Adaptive Conjoint Analysis (ACA), a unique method of performing conjoint analysis, and to evaluate patient treatment preferences.Research Design.Interactive computer survey.Subjects.Consecutive women (n = 103) with lupus followed in three community rheumatology practices.Measures.ACA was used to assess patients’ relative preferences for specific cytotoxic medication characteristics, and to estimate the percentage of women preferring cyclophosphamide over azathioprine for different risk-benefit scenarios.Results.All participants were able to complete the conjoint task in 14 ±5 minutes. Of the nine medication characteristics studied, efficacy and risk for infection had the greatest impact on preference (each accounting for 20% of the variation in preferences), suggesting that patients consider differences in the risk for infection equally as important as differences in the probability of renal survival. Premenopausal women wanting more children were less likely to choose cyclophosphamide compared with their counterparts (56% vs. 80%,P= 0.04). Modest changes in the probability of renal survival or risk for major toxicity lowered the percentage of women preferring cyclophosphamide by more than 20%, irrespective of their desire for more children.Conclusions.ACA is a feasible method of assessing how patients consider specific medication characteristics and predicting treatment preferences under different risk-benefit scenarios. ACA may be a valuable tool to incorporate patient preferences into medical decision-making.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Objectives.To assess the 1- and 2-year health status, health care utilization and self-efficacy outcomes for the Chronic Disease Self-Management Program (CDSMP). The major hypothesis is that during the 2-year period CDSMP participants will experience improvements or less deterioration than expected in health status and reductions in health care utilization.Design.Longitudinal design as follow-up to a randomized trial.Setting.Community.Participants.Eight hundred thirty-one participants 40 years and older with heart disease, lung disease, stroke, or arthritis participated in the CDSMP. At 1- and 2-year intervals respectively 82% and 76% of eligible participants completed data.Main Outcome Measures.Health status (self-rated health, disability, social/role activities limitations, energy/fatigue, and health distress), health care utilization (ER/outpatient visits, times hospitalized, and days in hospital), and perceived self-efficacy were measured.Main Results.Compared with baseline for each of the 2 years, ER/outpatient visits and health distress were reduced (P<0.05). Self-efficacy improved (P<0.05). The rate of increase is that which is expected in 1 year. There were no other significant changes.Conclusions.A low-cost program for promoting health self-management can improve elements of health status while reducing health care costs in populations with diverse chronic diseases.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Stage at diagnosis has been used to compare the quality of cancer screening services by health insurance type, using membership at diagnosis or treatment. This study evaluates breast cancer stage among women on Medi-Cal, California’s Medicaid program, in relation to duration of coverage to assess the impact of including women with recently acquired benefits in the Medi-Cal group.Methods.Breast cancers diagnosed in 1993 among women ages 30 to 64 were obtained from the statewide, population-based cancer registry and linked to Medi-Cal enrollment files. Women on Medi-Cal when diagnosed were categorized based on months covered during the 12 months preceding diagnosis (12, 1–11, or none), and compared with all other women with breast cancer. Logistic regression models measured the effect of duration of Medi-Cal coverage on the odds of late-stage disease, controlling for demographic, socioeconomic, health access, and tumor characteristics.Results.Among women with Medi-Cal benefits when diagnosed, 18% were not covered during the year preceding diagnosis, and late-stage disease was common among these women. The odds ratio for late-stage disease among all women on Medi-Cal was 1.67 (95% CI 1.41, 1.97), but was reduced by 42% to 1.39 (95% CI 1.15, 1.67) when women without benefits before diagnosis were excluded from the Medi-Cal group.Conclusions.Women with Medi-Cal benefits before diagnosis were more likely to be diagnosed with late-stage disease than other women with breast cancer. However, the practice of assigning health insurance status based on enrollment at diagnosis underestimates the effect of access to breast cancer screening through Medicaid.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.The high cost of caring for patients with congestive heart failure (CHF) results primarily from frequent hospital readmissions for exacerbations. Home nurse visits after discharge can reduce readmissions, but the intervention costs are high.Objectives.To compare the effectiveness of three hospital discharge care models for reducing CHF-related readmission charges: 1) home telecare delivered via a 2-way video-conference device with an integrated electronic stethoscope; 2) nurse telephone calls; and 3) usual outpatient care.Research Design.One-year randomized trial.Subjects.English-speaking patients 40 years of age and older with a primary hospital admission diagnosis of CHF.Measures.Our primary outcome was CHF-related readmission charges during a 6-month period after randomization. Secondary outcomes included all-cause readmissions, emergency department (ED) visits, and associated charges.Results.Thirty-seven subjects were randomized: 13 to home telecare, 12 each telephone care and 12 to usual care. Mean CHF-related readmission charges were 86% lower in the telecare group ($5850, SD $21,094) and 84% lower in the telephone group ($7320, SD $24,440) than in the usual care group ($44,479, SD $121,214). However, the between-group difference was not statistically significant. Both intervention groups had significantly fewer CHF-related ED visits (P= 0.0342) and charges (P= 0.0487) than the usual care group. Trends favoring both interventions were noted for all other utilization outcomes.Conclusions.Substantial reductions in hospital readmissions, emergency visits, and cost of care for patients with CHF might be achieved by widespread deployment of distance technologies to provide posthospitalization monitoring. Home telecare may not offer incremental benefit beyond telephone follow-up and is more expensive.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID