ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.Recent work has highlighted a negative correlation between proprietary status and nursing home quality of care. This relationship might be explained by the context in which proprietary homes operate. However, another possible explanation is that some proprietary homes take excessive profit to the detriment of care quality.Objective.To examine the relationship between profit levels and quality in proprietary and nonproprietary nursing homes (NHs), accounting for resident and market characteristics.Methods.Data on 1098 free-standing NHs were taken from the California Office of Statewide Health Planning and Development, the On-line Survey Certification and Reporting System, and California licensing and statistical reports for 1998 and 1999. Tobit multivariate techniques were used to examine the relationship between deficiency citations and a range of explanatory variables, including profit.Results.Proprietary homes in California had significantly lower quality of care than nonproprietary homes. A stratified analysis revealed that, controlling for resident, facility, and market characteristics, profits located within the highest 14% of the proprietary sector’s profit distribution were associated with significantly more total deficiencies and serious deficiencies. This relationship was not found in nonproprietary facilities. Other factors related to deficiencies included the ethnic mix of residents and facility size.Conclusions.Within the context in which proprietary homes operate, profit above a given threshold is associated with a higher number of deficiencies. Given this and the role of the proprietary sector in NH care, careful monitoring of profit levels in this sector appears warranted.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Objectives.This study uses variance cost analysis and regression analysis as tools for investigating the initial effects of Taiwan’s outpatient prescription drug copayment program in the elderly. Under its new National Health Insurance program, Taiwan implemented a prescription drug cost-sharing program August 1, 1999. We compare an elderly population’s prescription drug use after the policy was implemented with an elderly population’s prescription drug use before the policy change to describe initial and general consequences of the drug cost-sharing program.Methods.Approximately 240,000 patients aged 65 and over representing 1,600,000 outpatient prescriptions were drawn from 21 hospitals in the Taipei area for the study using a stratified random sampling method. Variance analysis, as used primarily in accounting, was applied to decompose overall cost variance of the policy into the sum of variances of several specific factors that are important to policymakers. The cost variances of each specific factor can be further decomposed into sublevels of analyses. Regression analysis is then applied to better understand covariates that might influence drug cost variances of significant magnitude.Results.The initial effects of the policy change did not reverse the trend of drug cost increases. Instead, there was a significant increase in total prescription drug costs in the cost-sharing group (approximately 12.86%) and an even higher increase rate in the non-cost-sharing group (approximately 51.42%). The main reason for the drug cost increase for the cost-sharing group was attributed to an increase in average drug costs per prescription (explaining 69.20% of the variance). We found physicians seemed to prescribe more expensive drugs and extend prescription duration, especially when drug costs exceed the upper bound of the cost-sharing schedule. By contrast, the main factor contributing to the increase in drug costs for the non-cost-sharing group was an increase in average prescription duration (explaining 64.98% of the variance). The increase mainly results from the effect of extended prescriptions for chronic diseases that were designed to reduce unnecessary visits for refills.Discussion.The significant increase in average drug price per prescription indicates that many prescriptions could move above the upper bound of the cost-sharing schedule. The results suggest that the Bureau of National Health Insurance should increase the upper bound. We do not think these effects are unique to Taiwan. Rather, these effects should be considered as countries change their outpatient drug benefit programs. We also found a decrease in utilization of essential drugs with an increase in utilization of nonessential drugs for patients subject to copayments. The results suggest potential adverse effects on patients’ health outcome.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.Patient satisfaction surveys are increasingly used by hospitals. Many questionnaires are available, but little evidence exists to guide the choice of the most suitable instrument.Objective.To compare the acceptability and patient perceptions of 4 patient satisfaction questionnaires.Research Design.Randomized trial of 4 satisfaction questionnaires: Picker, Patient Judgment System (PJS), Sequs, and a locally developed Lausanne questionnaire.Subjects.Patients discharged from 2 Swiss teaching hospitals (n = 2850).Measures.Response rates, missing data, completion time, and patient ratings of the questionnaire (5-point agree–disagree scale).Results.Response rates were similar across instruments (Picker: 70%, PJS: 71%, Sequs: 68%, Lausanne: 73%;P= 0.27). The Picker questionnaire had the most missing responses (mean per item: Picker: 3.1%, PJS: 1.9%, Sequs: 1.6%, Lausanne: 1.1%;P<0.001) and took the longest to complete (minutes: Picker: 19.3, PJS: 12.5, Sequs: 13.4, Lausanne: 13.1;P<0.001), but the fewest patients indicated that the questionnaire failed to address at least 1 important aspect of the hospital stay (Picker: 28.2%, PJS: 38.8%, Sequs: 39.1%, Lausanne: 28.9%;P<0.001). Patient evaluations of the questionnaires were generally similar; the most favorable assessment was chosen by approximately half of the respondents (average of 10 items: Picker: 46.5%, PJS: 46.2%, Sequs: 47.4%, Lausanne: 48.2%;P= 0.60). Key survey results differed considerably by questionnaire.Conclusions.No questionnaire emerged as uniformly better than the others in terms of acceptability and patient evaluations. All 4 could be used for patient satisfaction surveys.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.Practice guidelines for breast cancer emphasize the importance of establishing an accurate diagnosis using a minimum number of procedures and selecting optimal treatment regimens. Understanding the determinants of waiting time is essential to develop optimum interventions to reduce delay.Objectives.The purpose of this study is to estimate the extent to which variability in 1) the number of procedures before surgery and 2) waiting time from initial procedure to surgery are explainable by factors related to the woman, to the provider, and to the care setting.Research Design.Records of physicians’ fee-for-service claims were obtained for 23,370 women undergoing breast cancer surgery in Quebec between 1992 and 1997. Multilevel logistic regression was used to determine predictors of having multiple procedures before surgery. Hierarchical linear regression models were used to identify predictors of waiting time, separately for women with lymph node involvement and without this involvement.Results.Overall, 23% of the women had 3 or more procedures before surgery with significant variation found across hospitals and surgeons. Number of procedures was a strong predictor of waiting time. Waiting time also varied by stage, age, comorbidity, a history of benign disease, surgical setting, calendar time, month of initial procedure, and hospital teaching status.Conclusion.Although variability in waiting time was more strongly influenced by the characteristics of the women rather than by physician- or hospital-related factors, most variation remained unexplained by the factors included in this study. To reduce overall waiting time, strategies would need to be systemically applied.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Objective.To describe the impact of arthritis and other rheumatic conditions on hospitals by describing the magnitude and characteristics of these hospitalizations.Methods.Data from the 1997 National Hospital Discharge Survey were used to examine this impact. Arthritis was defined using International Classification of Diseases, 9th Revision, Clinical Modification, codes specified by the National Arthritis Data Workgroup. Arthritis-related hospitalizations were analyzed by principal diagnosis of arthritis and by any-listed arthritis diagnosis.Results.In 1997, there were an estimated 744,000 hospitalizations with a principal arthritis diagnosis (3% of hospitalizations). Compared with nonarthritis hospitalizations, persons hospitalized with a principal arthritis diagnosis were older, had fewer comorbidities, had shorter hospital stays, were more likely to undergo a procedure, and were more likely to be discharged to short- and long-term care facilities. The most common diagnoses and procedures related to osteoarthritis. This profile was consistent with a healthier-than-average hospital population electively admitted for specific procedures and subsequent rehabilitation. There were an estimated 2.5 million hospitalizations with an any-listed arthritis diagnosis (>9% of hospitalizations). Persons hospitalized with an any-listed arthritis diagnosis were older, had more comorbidities, and had longer hospital stays than those with principal arthritis or nonarthritis hospitalizations. This profile was consistent with a sicker-than-average hospital population nonelectively admitted for reasons other than their arthritis, especially cardiovascular disease.Conclusion.Arthritis has a sizable impact on the hospital care system. As our population ages, this impact, in both human and economic terms, is likely to increase.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.Clinical practice guidelines quickly become outdated. One reason they might not be updated as often as needed is the expense of collecting expert judgment regarding the evidence. The RAND-UCLA Appropriateness Method is one commonly used method for collecting expert opinion. We tested whether a less expensive, mail-only process could substitute for the standard in-person process normally used.Methods.We performed a 4-way replication of the appropriateness panel process for coronary revascularization and hysterectomy, conducting 3 panels using the conventional in-person method and 1 panel entirely by mail. All indications were classified as inappropriate or not (to evaluate overuse), and coronary revascularization indications were classified as necessary or not (to evaluate underuse). Kappa statistics were calculated for the comparison in ratings from the 2 methods.Results.Agreement beyond chance between the 2 panel methods ranged from moderate to substantial. The kappa statistic to detect overuse was 0.57 for coronary revascularization and 0.70 for hysterectomy. The kappa statistic to detect coronary revascularization underuse was 0.76. There were no cases in which coronary revascularization was considered inappropriate by 1 method, but necessary or appropriate by the other. Three of 636 (0.5%) hysterectomy cases were categorized as inappropriate by 1 method but appropriate by the other.Conclusions.The reproducibility of the overuse and underuse assessments from the mail-only compared with the conventional in-person conduct of expert panels in this application was similar to the underlying reproducibility of the process. This suggests a potential role for updating guidelines using an expert judgment process conducted entirely through the mail.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.A U.S. Food and Drug Administration advisory committee deemed the second-generation antihistamines (SGA) safe for over-the-counter use against the preliminary opposition of the manufacturers. As a result, loratadine is now available over-the-counter. First-generation antihistamines (FGA) are associated with an increased risk of unintentional injuries, fatalities, and reduced productivity. Access to SGA over-the-counter could result in decreased use of FGA, thereby reducing deleterious outcomes. The societal impact of transitioning this class of medications from prescription to over-the-counter status has important policy implications.Objective.To examine the cost-effectiveness of transitioning SGA to over-the-counter status from a societal perspective.Research Design.A simulation model of the decision to transition SGA to over-the-counter status was compared with retaining prescription-only status for a hypothetical cohort of individuals with allergic rhinitis in the United States. Estimates of costs and effectiveness were obtained from the medical literature and national surveys. Sensitivity analysis was performed using a second-order Monte Carlo simulation.Main Outcome Measures.Discounted, quality-adjusted life-years saved as a result of amelioration of allergic rhinitis symptoms and avoidance of motor vehicle, occupational, public and home injuries and fatalities; discounted direct and indirect costs.Results.Availability of SGA over-the-counter was associated with annual savings of $4 billion ($2.4–5.3 billion) or $100 ($64–137) per allergic rhinitis sufferer and 135,061 time-discounted quality-adjusted life years (84,913–191,802). The sensitivity analysis provides evidence in support of these results.Conclusion.Making SGA available over-the-counter is both cost-saving and more effective for society, largely as a result of reduced adverse outcomes associated with FGA-induced sedation. Further study is needed to determine the differential impact on specific vulnerable populations.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Objectives.To document the extent to which physician organizations, defined as medical groups and independent practice associations, are providing support for smoking cessation interventions and to identify external incentives and organizational characteristics associated with this support.Methods.This research uses data from the National Study of Physician Organizations and the Management of Chronic Illness, conducted by the University of California at Berkeley, to document the extent to which physician organizations provide support for smoking cessation interventions. Of 1587 physician organizations nationally with 20 or more physicians, 1104 participated, for a response rate of 70%.Results.Overall, 70% of physician organizations offered some support for smoking cessation interventions. Specifically, 17% require physicians to provide interventions, 15% evaluate interventions, 39% of physician organizations offer smoking health promotion programs, 25% provide nicotine replacement therapy starter kits, and materials are provided on pharmacotherapy (39%), counseling (37%), and self-help (58%). Factors positively associated with organizational support include income or public recognition for quality measures, financial incentives to promote smoking cessation interventions, requirements to report HEDIS (Health Plan Employer Data and Information Set) scores, awareness of the 1996 Clinical Practice Guideline on Smoking Cessation, being a medical group, organizational size, percentage of primary care physicians, and hospital/HMO ownership of the organization.Conclusion.Physician organizations are providing support for smoking cessation interventions, yet the level of support might be improved with more extensive use of external incentives. Financial incentives targeted specifically at promoting smoking cessation interventions need to be explored further. Additionally, emphasis on quality measures should continue, including an expansion of HEDIS smoking cessation measures.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID