ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.Hip replacement is the preferred treatment for displaced femoral neck fractures, whereas other less expensive procedures are preferred for nondisplaced fractures. The authors determined whether there was geographic variation in the use of hip replacement to treat displaced and nondisplaced fractures.Methods.The authors studied 332 patients, age 65 years or older, hospitalized with a femoral neck fracture in three cities.Results.The population was 55% over age 80, 80% female, and lived in Houston (17%), Pittsburgh (29%), and Minneapolis (54%). Rates of hip replacement varied by city (Houston-84%, Pittsburgh-77%, Minneapolis-63%;P= 0.002), with great variability among patients with nondisplaced fractures (Houston-88%, Pittsburgh-77%, and Minneapolis-56%;P= 0.0001), and no variation among those with displaced fractures (P= 0.72). Other factors associated with hip replacement are history of hip fracture (P= 0.003) and cerebrovascular disease (P≤ 0.10), APACHE II-APS score (P= 0.09), and impacted fracture (P= 0.001). Sociodemographic and functional status (perceived health; activities of daily living and instrumental activities of daily living dependencies) were not associated with hip replacement (P> 0.10). In a logistic model controlling for prior history, APACHE II-APS, and fracture characteristics, city remained a significant predictor of hip replacement (P < 0.001).Conclusions.Despite an absence of evidence supporting its appropriateness and a much higher cost, hip replacement is used to treat nondisplaced fractures much more frequently in Houston and Pittsburgh than in Minneapolis.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.Information on lifetime nursing home use is needed to design and evaluate long-term care financing reforms. Whereas a number of studies have estimated mean lifetime use or its distribution, very little is known about variation in use among subgroups of the population, the timing of use, the number of distinct episodes of care experienced by nursing home users, and the risk and expected use at ages other than age 65. The purpose of the study was to fill these gaps in knowledge.Methods.The study used a data base constructed to represent decedents who used nursing homes. The sample was derived from the sample of discharges collected as part of the 1985 National Nursing Home Survey. Weights were constructed for the purpose of making projections of remaining lifetime nursing home use at selected ages in 1995.Results.There was considerable variation in lifetime use among demographic groups. Overall, estimates of the amount of use remaining at selected ages tended to be relatively constant at approximately 1 year. Mean years until nursing home admission, however, decreased sharply from almost 40 years at age 45 to approximately 5 years at age 85.Conclusions.The distribution of lifetime use was highly skewed, providing support for efforts to spread risk through public or private insurance. With roughly one quarter of all use occurring after 5 years of nursing home residence, however, a substantial share of use would exceed benefit maximums that are part of many proposals for public financing of long-term care as well as private insurance policies.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.Despite substantial evidence of socioeconomic differences in the use of breast and cervical cancer screening, the mechanisms explaining these differences, and therefore their policy implications are not well understood. We investigated the way that education and income influence rural women's use of mammograms and Pap tests, including financial barriers to medical care, knowledge and attitudinal barriers, and nonfinancial factors related to health-care access.Methods.Data were from a population-based telephone survey of 2,346 rural Wisconsin women aged 40 years and older. Logistic regression analyses and simulation exercises were conducted.Results.The strongest barriers to screening in this rural population were nonfinancial impediments to access. Removing economic barriers did not lead to significant increases in screening when other types of barriers were present.Conclusions.Policies and interventions that focus on the most visible differences that exist between rural women of differing socioeconomic levels (ie, differences in the ability to afford health services) and do not simultaneously address knowledge, attitudinal, and health-care access barriers will fall short of their goal to increase breast and cervical cancer screening.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.A hierarchical classification for avoidable morbidity in infants was developed based on a conceptual model for causes of morbidity. Experts rated the impact of risk factors and health services on diseases coded according to the International Classification of Diseases, 9th Revision, Classification Modification (ICD-9-CM). An etiologic framework was chosen for the classification because knowledge of etiology often suggests strategies for prevention. Causes of morbidity that cluster on the basis of similar risk factors might be avoided using similar strategies.Methods.Diseases (346 different diagnoses) were rated by 16 general pediatricians; 12 attributes were considered, including the impact on disease occurrence and on severity of five risk factors, preventive health services, and medical treatment. Raters evaluated the impact of health services, constitutional risk factors, and environmental risk factors without regard for service site (eg, inpatient, emergency department, primary care office). Environmental risk factor categories, including family, social, and physical environments, were rated separately. The impact of health services was rated on prevention, treatment, and complications of care.Results.Only ratings indicating that the impact of a risk factor category was substantial were used for the final classification of 275 diagnoses. Consistent with the multifactorial etiology of many diseases, many diagnoses had ratings indicating substantial impact of multiple risk factors. Five mutually exclusive clusters were derived from the 12 ratings based on factor analysis and recognized strategies for prevention. Ordered by level of avoidability, these clusters were termed vaccine-preventable, health-care quality indicators, environmental, environmental/constitutional, and constitutional.Conclusions.The usefulness of this classification for policy-oriented epidemiologic and health services research is grounded in the premise that prevention is the cardinal objective of child health policy. Cluster-specific hospitalization rates, ie, rates aggregated for all diagnoses falling in a cluster, might be used for allocating resources to interventions directed at environmental or health service determinants of morbidity. Widespread use of ICD-9-CM codes in hospital discharge and ambulatory databases suggests many potential applications for this classification of morbidity burden in population groups.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.Blacks and poor persons share a greater burden of oral disease and are less likely to seek dental care on a regular basis. The role of dental attitudes and knowledge of services on this circumstance is unclear. The authors quantified group differences in dental attitudes and knowledge of services and related them to regularity of dental care use.Methods.As part of the baseline phase ofThe Florida Dental Care Study,a longitudinal study of oral health, 873 respondents who had at least one tooth and who were 45 years or older participated for an interview and a clinical dental examination. Dental care use, seven dental attitudinal constructs, and knowledge of dental services were queried.Results.Forty-five percent of respondents reported going to a dentist only when they have a problem, and 17% of respondents had not seen a dentist in more than 5 years. Ten percent of respondents reported that they had at least one permanent tooth removed by someone other than a dentist (typically, the respondent himself). Blacks and poor persons had more negative attitudes toward dental care and dental health and were less knowledgeable of dental services. Multivariate analyses suggested that dental attitudes were important to understanding the use of dental care services for this diverse group of adults, and that race and poverty contributed independently to dental care use even with dental attitudes taken into account.Conclusions.Dental attitudes contribute to race and poverty differences in dental care use among adults. The persistence of race and poverty effects with attitudes taken into account suggests that additional explanatory factors contribute as well. These differences may contribute to more prevalent and severe oral health decrements among the same adults who also are more likely to suffer from other health decrements.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.Using the public reports of the Pennsylvania Health Care Cost Containment Council on coronary artery bypass graft surgery for 1990 to 1992 as a case study, the authors assess the sensitivity of results to the choice of data and statistical methodology.Methods.Using the Council's public-release data, surgical mortality and utilization were reanalyzed by standard linear models, empirical Bayes methods, Monte Carlo simulations, and hierarchical statistical models.Results.Statistical power calculations demonstrate that the annual volume of bypass surgery for many hospitals and for most surgeons is too small for meaningful mortality comparisons. The number of hospitals and physicians designated as mortality "outliers" in the Council's reports results in part from a failure to adjust criticalPvalues for multiple comparisons. Hierarchical statistical models implemented by mixed effects logistic regression, by contrast, can detect true differences in performance without producing false outliers. Mortality analyses are sensitive to the choice of comorbidities used for severity adjustment of a mortality model. Small-area analyses indicate large differences in the rates of bypass surgery across Pennsylvania, with lower population-based rates of surgery associated with higher population-based inpatient mortality.Conclusions.Analyses of mortality by operative procedure, rather than by patient diagnosis, should consider the potential for selection bias caused by the decision to elect surgery. The clinical and statistical issues of operative mortality are sufficiently complex to merit review by independent experts before public release of hospital and physician performance measures.

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

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