ISSN:0025-7079    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

The authors compare the appropriateness ratings and mutual influence of panelists from different specialties rating a comprehensive set of indications for six surgical procedures. Nine-member panels rated each procedure: abdominal aortic aneurysm surgery, carotid endarterectomy, cataract surgery, coronary angiography, and coronary artery bypass graft surgery/percutaneous transluminal coronary angioplasty (common panel).Panelists individually rated the appropriateness of indications at home and then discussed and re-rated the indications during a 2-day meeting. Subsequently, they rated the necessity of those indications scored by the group as appropriate. There were 45 panelists, including specialists (either performers of the procedure or members of a related specialty) and primary care providers, all drawn from nominations by their respective specialty societies.Main outcome measures included: individual panelists' mean ratings over all indications, mean change and conformity scores between rounds of ratings, and the percentage of audited actual procedures rated appropriate or necessary. Performers had the highest mean ratings, followed by physicians in related specialties, trailed by primary care providers. One fifth of all actual procedures were for indications rated appropriate by performers and less than appropriate by primary care providers. At the panel meetings, primary care providers and related specialists showed no greater tendency to be influenced by other panelists than did performers. Multispecialty panels provide more divergent viewpoints than panels composed entirely of performers. This divergence means that fewer actual procedures are deemed performed for appropriate or necessary indications.

ISSN:0025-7079    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

The study examines the extent to which the effect of full-time employment on informal caregiving has changed over time. Such a change could be expected because women, who constitute the majority of unpaid caregivers, have been increasing their commitment to career employment. Full-time market work by an increasing proportion of successive cohorts of women means that proportionally fewer will be available to provide the amount of assistance needed by persons with disabilities that require the constant presence of a caregiver.This study is based on the National Informal Caregiver Surveys that are linked to the National Long-Term Care Surveys of 1982 and 1989. To achieve comparability between the 1982 and 1989 data, the analysis is based on primary caregivers whose care-recipients were disabled in performing the activities of daily living (ADLs): 1,489 in 1982 and 597 in 1989. A simultaneous-equations model estimates the number of weekly hours of unpaid help and the probability of full-time work for pay.The principal finding is that, compared with nonemployment, full-time employment reduced caregiving by 25 hours a week in 1982 and by 22 hours a week in 1989, but the difference of 3 hours is not statistically significant. The proportion of primary caregivers engaged in market work full time increased from 15.8% in 1982 to 19.3% in 1989, but this difference is not statistically significant. These findings suggest that full-time employment reduces caregiving time substantially but that the effect of full-time employment on informal caregiving by primary caregivers of ADL-disabled elderly did not change during the 1980s. Primary caregivers with full-time jobs were more likely to assist individuals disabled in bathing and dressing, two activities that do not require the constant presence of a caregiver. The primary caregivers of individuals with more than two ADL disabilities frequently were the spouses of the care-recipients, themselves elderly persons who were not expected to be engaged in market work.The data from the 1980s appear to be reassuring in the sense that full-time employment by primary caregivers of ADL-disabled elderly did not further reduce the amount of time that they devoted to caregiving. In 1989, only about one fifth of these caregivers were engaged in market work full time. But this proportion is likely to increase in the future. As these future increases materialize, proportionally fewer caregivers will be available to provide the amount of help needed by persons with ADL disabilities that require the constant presence of a caregiver.

ISSN:0025-7079    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

The authors assess the factorial validity of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) for use in a clinical sample of disadvantaged, older adults with significant comorbidities. Confirmatory factor analysis was performed using LISREL VIII on data obtained from baseline face-to-face interviews with a clinical sample of 1,051 patients who were at risk for acute deterioration of their clinical condition due either to their age alone (75 years or older), or to their age (50 to 74 years old) and major comorbid conditions.An acceptable eight-factor measurement model reflecting the original specification (ie, subscales) of the SF-36 was obtained (chi-square to degrees of freedom ratio = 2.14; root mean squared residual =.055; adjusted goodness of fit index =.90). That model, however, required relaxing the assumptions associated with seven correlated error terms. Moreover, an alternative nine-factor model that allowed the ”getting sick” and ”getting worse” items to form their own factor, labeled ”health optimism,” fit the data significantly better (8 degrees of freedom chi-square improvement = 61;P< 0.0001).Although continued use of the SF-36 in older, disadvantaged, clinical samples is appropriate, further assessment of the underlying measurement model in other samples using confirmatory factor analytic techniques is needed to resolve the issue of correlated error structures and the existence of the health optimism factor.

ISSN:0025-7079    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

As part of a move toward a more market-oriented health-care system, major changes have been implemented in the Dutch social health insurance system. The competing sickness funds now receive risk-adjusted capitation payments, currently based on the age-sex distribution of the insurance portfolios. These very crude health indicators do not reflect expected costs accurately. The authors examine whether the incorporation of inpatient diagnostic information over a multiyear period can increase the accuracy of the capitation model.Using a panel data set (n ≅ 50,000) comprising annual costs and diagnostic information for 5 successive years, the authors compare demographic and diagnostic models in their ability to predict future health care costs. The predictive accuracy of an age-sex-based capitation formula improves substantially when diagnostic information from an individual's prior hospitalizations is used as an additional risk-adjuster. The longer the period over which diagnostic information is available, the better is the predictive accuracy. The expected loss in 1992 for insured persons with the highest costs in 1988 decreases from 88% (demographic model) to 62% (1-year diagnostic model) and to 43% (3-year diagnostic model).The use of diagnostic information from prior hospitalizations is a promising option for improving the capitation formulae. The authors' results are relevant not only for situations where competing insurers are capitated, as in the Netherlands, but also when providers (United Kingdom) or health maintenance organizations (United States) are capitated.

ISSN:0025-7079    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

The question of whether the full range of possible health states is measured by the Medical Outcomes Study (MOS) 20-Item Short-Form Health Survey (SF-20) in human immunodeficiency virus (HIV)-seropositive individuals is examined in this article. Ninety-five HIV-seropositive men (37 with asymptomatic infection, 58 with symptomatic infection) from two primary care practices were enrolled. Patients completed the SF-20 evaluating six dimensions of health status. Asymptomatic patients reveal substantial skew in score distributions for the dimensions of physical (-1.60), role (-1.19), and social (-1.13) functioning; no substantial skew is exhibited by symptomatic patients. Both subgroups reveal ceiling effects for physical, role, and social functioning, and pain dimensions; asymptomatic patients' ceiling effects are higher (physical functioning: 65% versus 31%; role functioning: 73% versus 41%; social functioning: 54% versus 43%; and pain: 41% versus 24%). Patients from both subgroups reveal floor effects for the role functioning dimension (asymptomatic patients, 22%; symptomatic patients, 34%). When looking at items rather than scales, asymptomatic patients' item distributions for the physical, role, and social functioning, and pain dimensions reveal clustering toward positive health states in most items; distributions of symptomatic patients are similar. Because this HIV-seropositive sample exhibits substantial ceiling effects in four of six SF-20 dimensions, effects that particularly are notable for asymptomatic patients, these dimensions should be revised for use in HIV-seropositive individuals or a disease-specific quality of life instrument should be constructed.

ISSN:0025-7079    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

By understanding the range of approaches implicit in modern record linkage, epidemiologists and health services researchers can better decide its suitability for their needs. The authors discuss a small record linkage project, providing a sense of where mistakes were made. The research first uses existing identification numbers as a gold standard for linking hospital abstracts and physician claims to investigate whether or not coronary angiography was performed on a given individual. Even if identification numbers are not available, a successful linkage (with more than 95% of the cases matched) may be possible under some circumstances. The linkage process highlights problems with the consistent recording of coronary angiography in inpatient and outpatient hospital abstracts. Our approach should prove useful when the same procedure is recorded in more than one place on a single file and when validating a procedure (or other event) across files is important. Given the growing number of health care databases and ongoing changes in the delivery of care, record linkage often can provide quality control and expand research opportunities in a timely fashion.

ISSN:0025-7079    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Flexible spending accounts (FSA) represent a current health care financing tool that may become an important component of incremental health care reform. Because FSAs require employees to make financial contributions based on anticipated health care needs, contribution decisions are likely to be subject to many of the errors made in other insurance decisions. The authors analyzed the benefits selections, benefits forms completion, and FSA contribution levels of approximately 9,500 employees of the University of Pennsylvania from 1987 to 1992. Default and repeat choice trends characterize the completion of benefits forms and the reselection of health insurance options by employees. Despite the economic benefits of contributing to an FSA, only 14% of employees contributed in any one year and 73% never made a contribution. Multivariate models of these contributions fail to demonstrate the importance of what ought to be relevant influences in contribution decisions (for example, age, income, family status, or underlying health insurance). Whereas most FSA decisions are characterized by default contributions of $0, employees who contribute in one year are most likely to contribute exactly the same amount the next year, even when other circumstances change. The pervasiveness of these patterns raises concerns that health care reform plans that rely on financial incentives at the consumer level—for example, proposed medical savings accounts—will be inefficient.

ISSN:0025-7079    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Hospitalization rates for chronic medical conditions vary across small areas and are associated inversely with community income. The authors studied whether variation in hospitalization rates can be attributed to differences in physician practice style. Using census and hospital discharge data, hospitalization rates were calculated for asthma, congestive heart failure, and diabetes in 40 medical service areas in California. The authors surveyed a random sample of 1,530 emergency physicians, general internists, and family and general practitioners in these areas, and measured clinical admission threshold by asking physicians whether they would hospitalize patients presented in 15 vignettes of graded severity. The authors measured social admission predisposition by asking how physicians' admission decisions would be influenced by social characteristics that increase patients' vulnerability to illness, including homelessness and drug use; 1,090 physicians responded (71%). There was significant variation across areas in both the clinical (P< 0.0001) and social (P< 0.001) admission scores. Variation in hospitalization rates correlated with physicians' clinical (r =.34,P= 0.03) and social (r =.36,P= 0.02) admission scores. However, in a multiple linear regression analysis that included community sociodemographic factors, physician practice style was not associated significantly with hospitalization rates. Physician practice style varies across areas, but does not explain variation in admission rates for chronic medical conditions after adjusting for community sociodemographic factors. Using methods such as practice guidelines or utilization review to re-set physicians' threshold for admission may not be effective in reducing hospitalizations for chronic medical conditions.

ISSN:0025-7079    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

To help clinicians better assess and treat functional disabilities in persons with acquired immunodeficiency syndrome (AIDS), the authors estimate empirical relations among biologic and physiologic variables, symptoms, and physical functioning in persons with AIDS. The sample of 305 persons with AIDS for this cross-sectional analysis came from three sites in Boston, Massachusetts: a hospital-based group practice, a human immunodeficiency virus clinic at a city hospital, and a staff-model health maintenance organization. Physical functioning, 10 AIDS-specific symptoms, and mental health were assessed by interview. Clinical diagnoses, comorbidities, health habits such as smoking, laboratory results, and selected medication use were assessed by chart review. Significant predictors of physical functioning (P< 0.01, R2=.58) in a multivariable regression model included energy/fatigue, neurologic symptoms, fever symptoms, a lower hemoglobin level, and current non-pneumonia bacterial infection. Ninety-six percent of the explained variance in physical functioning was accounted for by three symptom complexes: energy/fatigue, neurologic symptoms, and fever symptoms. Significant predictors of energy/fatigue in multivariable models included poorer mental health, lower white blood cell count, longer time since diagnosis, and weight loss (P< 0.01, R2=.36). Significant predictors of neurologic symptoms included poorer mental health, weight loss, and no zidovudine use (P< 0.001, R2=.30). Predictors of fever symptoms included poorer mental health, no zidovudine use, weight loss, and history of asthma or chronic obstructive pulmonary disease (P< 0.05, R2=.25). In conclusion, symptom reports were strong predictors of physical functioning. Poorer mental health and weight loss were correlated consistently with worse symptoms, and not using zidovudine was correlated with worse neurologic and fever symptoms. These variables, and the others the authors identified, may represent mutable determinants of physical functioning in persons with AIDS, and potential targets for specific clinical interventions.

ISSN:0025-7079    

出版商:OVID    

年代:1996

数据来源: OVID