ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.Decisions to refer patients to other physicians for care or consultation are an important component of the provision of appropriate care for cancer patients. However, little is known about the referral process between specialists.Objectives.To examine the referral patterns of specialists to specialists and to understand why only some breast cancer patients receive a consultation with a medical oncologist.Research Design.This study was conducted in a large metropolitan region from 1993 to 1995 using a 2-staged population-based sampling strategy. One hundred seven physicians discussed 244 patient cases and their own knowledge, attitudes, and practices toward treatment and referral.Results.Of the 244 patients, 87.7% were referred to an oncologist, and 10.2% were actually prescribed tamoxifen by their surgeons before they saw the oncologist. Surgeons who were less involved in making decisions about the type of adjuvant therapy the patients were to receive and who preferred the use of chemotherapy were significantly more likely to refer patients to oncologists. Patients who were older, unemployed, node negative, and had a better prognosis or preferred not to see an oncologist were significantly less likely to be referred. These 7 factors explained a total of 55% of the variation in surgeons' decisions to refer patients to an oncologist.Conclusions.Extramedical factors, such as surgeon and patient preferences and communication factors, play a strong role in the referral process. In this sample, most patients were referred to an oncologist. However, older, unemployed patients and patients whose medical features indicated a better long-term prognosis were most likely to be among the nonreferred group.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.The current climate of anger and frustration with managed care has heightened interest in the quality of health care provided by managed-care plans, particularly health maintenance organizations (HMOs). This breast cancer outcomes study, investigating relationships of health insurance and delivery systems to stage at diagnosis, treatment selected, and survival, is based in a heavily penetrated, highly competitive HMO market.Methods.Data for 1,788 residents of northern California younger than 65 years of age at diagnosis (1987-1993) were provided by a population-based cancer registry. Patient insurance included fee-for-service (FFS), group-model HMO, nongroup HMO, publicly insured, and uninsured. Diagnosis and treatment occurred in 73 hospitals (large, medium/moderately small, or very small community, rural, teaching, or HMO-owned hospitals). Regression models examined relationships of insurance and hospital type to 3 outcomes (stage, treatment, and survival), controlling for age, ethnicity, education, neighborhood occupational class, and time period.Results.Early diagnosis was as likely for group-model and nongroup-model HMO-insured patients as for the private FFS-insured patients. In 1987-1990, HMO-owned hospitals were leaders in treating 46% of early-stage breast cancers with breast-conserving surgery plus radiation (BCS+); by 1991-1993, the most significant increases in BCS+ use occurred at teaching and large community hospitals. Survival of group-model HMO, nongroup-model HMO, and FFS patients was not significantly different. Publicly insured/uninsured patients had more stage III/IV disease (OR=2.01,P= 0.006) and greater all-cause mortality (risk ratio 1.46,P= 0.015).Conclusions.Group-model and nongroup-model HMO patients are similar to FFS-insured patients in stage at diagnosis and survival outcomes. Treatment selection is related to hospital type rather than insurance coverage.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.Although a number of studies have used Medicare claims data to study trends and variations in breast cancer treatment, the accuracy and completeness of information on surgical treatment for breast cancer in the Medicare data have not been validated.Objectives.This study assessed the accuracy and completeness of Medicare claims data for breast cancer surgery to determine whether Medicare claims can serve as a source of data to augment information collected by cancer registries.Methods.We used the Surveillance, Epidemiology and End Results (SEER) Cancer Registry-Medicare data and compared Medicare claims on surgery with the surgery recorded by the SEER registries for 23,709 women diagnosed with breast cancer at ≥65 years of age from 1991 through 1993.Results.More than 95% of women having mastectomies according to the Medicare data were confirmed by SEER. For breast-conserving surgery, 91% of cases were confirmed by SEER. The Medicare physician services claims and inpatient claims were approximately equal in accuracy on type of surgery. The Medicare outpatient claims were less accurate for breast-conserving surgery. In terms of completeness, when the 3 claims sources were combined, 94% of patients receiving breast cancer surgery according to SEER were identified by Medicare.Conclusions.The combined Medicare claims database, which includes the inpatient, outpatient, and physician service claims, provides valid information on surgical treatment among women known to have breast cancer. The claims are a rich source of data to augment the information collected by tumor registries and provide information that can be used to follow long-term outcomes of Medicare beneficiaries.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background and objectives.The number of US residents with limited English proficiency (LEP) is 14 million and rising. The goal of this study was to estimate the effects of LEP on physician time and resource use.Design.This was a prospective, observational study.Setting and Subjects.The study included 285 Medicaid patients speaking English (n = 112), Spanish (n = 62), or Russian (n = 111) visiting the General Medicine and Family Practice Clinics at the UC Davis Medical Center in 1996-1997 (participation rate, 85%). Bilingual research assistants administered patient questionnaires, abstracted the medical record, and conducted detailed time and motion studies.Main outcome measures.We used seemingly unrelated regression models to evaluate the effect of language on visit time, controlling for patient demographics and health status, physician specialty, visit type, and resident involvement in care. We also estimated the effect of LEP on cross-sectional utilization of health care resources and adherence to follow-up with referral and testing appointments.Results.The 3 language groups differed significantly by age, education, and reason for visit but not gender, number of active medical conditions, physical functioning, or mental health. Physician visit time averaged 38±20 minutes (mean±SD). Compared with English-speaking patients and after multivariate adjustment, Spanish and Russian speakers averaged 9.1 and 5.6 additional minutes of physician time, respectively (P<0.05). The language effect was confined largely to follow-up visits with resident physicians (house staff). Compared with English speakers, Russian speakers had more referrals (P= 0.003) and Spanish speakers were less likely to follow-up with recommended laboratory studies (P= 0.031).Conclusions.In these academic primary care clinics, some groups of patients using interpreters required more physician time than those proficient in English. Additional reimbursement may be needed to ensure continued access and high-quality care for this special population.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective.Health care has variable features, specific determinants, and consequences on people's health that should be investigated in a population perspective. We present a population-based analytical approach to assessing patterns, determinants, and outcomes of health care.Methods.The approach uses standard epidemiological methods for sample selection and analysis, as well as statistical methods concerning model fitting and validation strategy. It also uses psychometric methods allowing pattern identification: factor analysis, cluster analysis, and polytomous logistic regression to investigate the factors associated with identified patterns of care. The approach is illustrated with an application to ectopic pregnancy (EP).Results.EP diagnostic and therapeutic procedures appeared to be closely related, suggesting 3 differentiated patterns of care. Predictors of these patterns were not only the clinical features and the woman's prior gynecological history but also center characteristics and location. These patterns were found to influence immediate and middle-term outcomes and risk of recurrence of EP.Conclusions.We illustrate the feasibility and profitability of a population-based analytical approach to identify patterns, determinants, and consequences of care. This approach could be used to analyze other pathological conditions and health care systems.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objectives.The objectives of this study were (1) to estimate the prevalence, bothersomeness, and variation of HIV-related symptoms in a nationally representative sample of HIV-infected adults receiving medical care and (2) to evaluate new aggregate measures of symptom frequency and bothersomeness.Methods.Beginning in January 1996, 76% of a multistage national probability sample of 4,042 HIV-infected adults receiving medical care were interviewed. Participants endorsed the presence and degree of bothersomeness of 14 HIV-related symptoms during the preceding 6 months. Sex-standardized symptom number and bothersomeness indices were constructed. After sampling weights were incorporated, symptom distributions were compared according to selected characteristics by analysis of variance and multiple linear regression modeling.Results.Prevalence of specific symptoms in the reference population was as follows: fever/night sweats, 51.1%; diarrhea, 51%; nausea/anorexia, 49.8%; dysesthesias, 48.9%; severe headache, 39.3%; weight loss, 37.1%; vaginal symptoms, 35.6% of women; sinus symptoms, 34.8%; eye trouble, 32.4%; cough/dyspnea, 30.4%; thrush, 27.3%; rash, 24.3%; oral pain, 24.1%; and Kaposi's sarcoma, 4%. Aggregate measures were reliable (Cronbach's alpha ≥0.75) and demonstrated construct validity when compared with other measures of disease severity. After adjustment for CD4 count, both symptom number and bothersomeness varied significantly (P< 0.05) by teaching status of care setting, exposure/risk group, educational achievement, sex, annual income, employment, and insurance category. However, the magnitude of variation was small. Symptoms were greatest in women and injection drug users, as well as in persons with lower educational levels, lower income, and Medicare enrollment or those who were followed up at teaching hospitals.Conclusions.The prevalence and bothersomeness of HIV-related symptoms are substantial and vary by setting of care and patient characteristics.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.Utilities for health conditions, including major depressive disorder, have a theoretical relationship to health-related quality of life (HRQOL). Because of the complexity of utility measurement and the existence of large numbers of completed studies with HRQOL data but not utility data, it would be desirable to be able to estimate utilities from measurements of HRQOL.Objective.The objective of this study was to estimate utility for remission in major depression by use of information on associated variation in Short Form 12 (SF-12) scores.Design.A mapping function for SF-12 scores (based on a 6-health-state model with patient-weighted preferences) was applied to longitudinal data from a large naturalistic study to estimate changes in utilities.Subjects.Preference ratings for states were performed in a convenience sample of depressed primary care patients (n = 140). Outcomes were evaluated in patients in the Course of Depression Study (n=295) with a DSM III diagnosis of depression at the onset of the study.Measures.From clinical interview data, differences in utilities and global physical and mental health-related quality of life at 1- and 2-year follow-up were compared for patients who did and did not experience remission as determined by the Course of Depression Interview.Results.Remission of depression resulted in health status improvement, as measured by the SF-12, equivalent to a gain of 0.11 quality-adjusted life-years over 2 years.Conclusions.Utilities for changes in health status, associated with a clinical change in depression, can be modeled from the SF-12 scales, which results in utilities within the range of estimates described in the literature.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.Methods to select physicians most likely to benefit from educational interventions to improve the outcome of depression have not been adequately developed.Objective.The purpose of this study was to identify a combination of primary care provider (PCP) self-report questions to improve the precision of PCP estimates of actual anti-depressant prescribing as a potential tool for PCP selection.Methods.The total number of new and refill antidepressant prescriptions written by 124 PCPs and actually filled at pharmacies over a 2-year period were matched with telephone survey results of these PCPs completed before the 2-year period. Multiple regression techniques were used to identify a set of variables that improved upon PCPs' self-report of prescriptions.Results.The mean for PCP-reported antidepressant prescriptions written in the last week was 7.8 (±11.2). The average weekly prescriptions actually filled was 6.72 (±5.65). Most survey variables were significantly correlated with antidepressant prescriptions. The final model included 6 variables that explained 52% of the variance in prescriptions. In addition to PCP-reported number of antidepressants prescribed, average number of primary care patients seen per week and number of patients covered by managed care were directly related to the volume of prescriptions. PCP age, percentage of patients referred immediately without treatment, and mental health services being too far away were inversely related.Conclusions.PCP self-reports on antidepressant prescribing are reasonably accurate proxies of actual prescribing. The precision of estimates of actual prescribing can be improved by considering practice structural and financial characteristics.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID