ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Each province in Canada independently assesses drugs for their reimbursement eligibility. Publicly funded access to specific drugs is therefore dependent on province of residence.Objective.Evaluate the variability of access and its determinants for publicly available prescription drugs across Canada, and discuss the feasibility of implementing a national plan.Methods.For a sample of 58 drugs receiving Health Protection Branch approval in Canada between 01/01/1996 and 12/31/1997, all provinces were surveyed about their formulary inclusion/exclusion decision. Kappa values were estimated to measure concordance between provincial coverage decisions. Logistic analysis using Generalized Estimating Equations was used to assess the impact of key features of provincial plans on the decision.Results.Among the 58 drugs, 5 (9%) were included in all 10 and 14 (24%) by at least 8 provincial formularies. None were e-cluded by all the provinces. Concordance rates among provinces were low (overall &kgr;-like statistic = 0.20 and range of pairwise &kgr; = -0.11 to 0.64). Logistic regression showed that therapeutic category, price ratio to comparator, the integration of public with private coverage, and the e-istence of ability-to-pay criteria were significant determinants of the inclusion decision.Conclusions.Findings show that public access to the same prescription medications differs widely across provinces. If Canada were to adopt a “National” plan without disrupting current individual prescriptions, all currently funded drugs in each province would have to be “grandfathered” and included in the new National formulary. Such an all-inclusive list would also make such a plan unaffordable.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Approximately 2.5 million Americans are admitted to the hospital after traumatic physical injury each year. Few investigations have elicited patients’ perspectives regarding posttraumatic outcomes.Objective.To identify and categorize physically injured trauma survivors’ posttraumatic concerns.Research Design.Prospective longitudinal investigation; trauma survivors were interviewed during the post-injury hospitalization and again 1, 4, and 12 months after the trauma.Subjects.Ninety-seven, randomly selected, English speaking, hospitalized survivors of motor vehicle-crashes or assaults.Measures.At the end of each interview patients were asked, “Of all the things that have happened to you since you were injured, what concerns you the most?” Using an iterative process and working by consensus, investigators categorized patient concerns in content domains. Concern domains were then compared with established measures of posttraumatic stress disorder (PTSD) symptoms and limitations in physical functioning.Results.Seven categories of posttraumatic concerns were identified. During the course of the year, 73% of patients e-pressed physical health concerns, 58% psychological concerns, 53% work and finance concerns, 40% social concerns, 10% legal concerns, 10% medical concerns, and 20% uncodable concerns. Rater agreement on concern categorization was substantial (&kgr; = 0.72). The mean number of concerns e-pressed per patient gradually decreased over time (1 month mean = 1.51; 12 month mean = 1.26) and resembled the trajectories of PTSD symptoms and functional limitations.Conclusions.The concerns of physically injured trauma survivors are readily elicited and followed up during the course of the year after injury. Open-ended inquiry regarding posttraumatic concerns may complement standardized outcome assessments by identifying and contextualizing the outcomes of greatest importance to patients.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Millions of doses of influenza vaccine are administered each year in the United States at nontraditional sites and by nontraditional vaccine providers. Pharmacists are increasingly becoming vaccine providers.Objectives.To measure association between availability of pharmacist-immunizers and immunization delivery to adult prescription recipients, and the relative contributions of various types of vaccine providers.Research Design.Mailed survey in spring 1999, contrasting adults in urban Washington State, where pharmacists administer vaccines, to adults in urban Oregon, where pharmacists did not.Subjects.Cluster sample based on October 1998 prescription records suggesting need for influenza vaccine, derived from 24 community pharmacies belonging to one pharmacy chain.Measures.Vaccination status and choice of vaccine provider.Results.Influenza vaccination rates among respondents 65 years or older increased 4.7% more in Washington than in Oregon between 1997 and 1998 (P= 0.20). The net increase in influenza vaccination rate among younger respondents taking indicator medications for chronic diseases for which influenza vaccination is recommended was 10.6% (P= 0.05). Among respondents unvaccinated against influenza in 1997, the 1998 influenza vaccination rate was 34.7% in Washington, compared with 23.9% in Oregon (P= 0.01).Conclusions.Vaccine delivery by pharmacists is associated with higher rates of vaccination among those younger than 65 taking indicator medications medications for chronic diseases, as well as prescription recipients unvaccinated against influenza in the previous year.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.The interpersonal patient-provider relationship (PPR) is an essential part of health care quality, particularly for patients with depression, yet little is known neither about how to measure this relationship nor about its association with quality of care.Objectives.To evaluate properties of patient rating measures, understand the relation between 2 types of ratings, and determine the association of ratings with quality depression care.Setting and Participants.1,104 patients with current depressive symptoms and lifetime or 12-month disorder identified through screening 27,332 consecutive primary care visitors in 6 managed care organizations participating in Partners in Care (PIC).Design.Cross-sectional analysis of 18-month data (collected in 1998) after the start of PIC depression quality improvement (QI) interventions (in which clinics were randomized to 1 of 2 QI interventions or usual care).Measures.Patient ratings of the interpersonal relationship with the primary care provider and satisfaction with health care, and quality of depression care indicators.Analysis.Factor analysis and multitrait scaling to evaluate the psychometric properties of multiitem constructs and analysis of covariance to evaluate associations between patient ratings and quality.Results.Patient ratings had high internal consistency and met criteria for discriminant validity tapping unique aspects of care. Patients receiving quality care, especially for medication use, had significantly higher ratings of the interpersonal relationship (by 22% to 27% of a SD) and were more satisfied (by 26% to 34% of a SD) than patients who did not receive quality care.Conclusions.Ratings of the interpersonal relationship and satisfaction measure distinct aspects of care and are positively associated with quality care for depression.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Despite limited evidence of its effectiveness, most guidelines recommend colorectal cancer survivors undergo posttreatment surveillance care. This article describes the posttreatment use of colon e-aminations, carcinoembryonic antigen (CEA) testing, and metastatic disease testing among a managed care population.Methods.Two hundred fifty-one patients with colorectal cancer enrolled in a managed care organization at diagnosis (1/1/90–12/31/95) and treated with curative intent. Patients were identified via a Cancer Registry maintained by a large group practice. Cumulative incidences of service receipt were estimated using actuarial (Kaplan-Meier) survival analyses. Co- Proportional Hazard Models were used to evaluate the relation of patient sociodemographic and clinical characteristics to service receipt. Average 8-year medical care e-penditures were calculated.Results.Within 18 months of treatment, 55% of the cohort received a colon examination, 71% received CEA testing, and 59% received metastatic disease testing. Whites were more likely than minorities to receive CEA testing (RR = 1.47,P= 0.04) and tended to be more likely to receive a colon examination (RR = 1.43,P= 0.09). As the median household income of a patient’s zip code of residence increased, so too did the likelihood of colon examination and metastatic disease testing receipt (RR = 1.09,P= 0.03 and RR = 1.12,P<0.01, respectively). Average 8-year medical care expenditures among the cohort were $30,247.Conclusions.Among a population with financial access to care, differences were found in the receipt of colorectal cancer surveillance care by race and income. Additional investigations are needed to understand why minorities and those residing in low-income areas are less likely to receive surveillance care.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Empirical evidence on the economic impact of cancer clinical trials is in short supply, but it is widely assumed that clinical trials add at least 10% to overall costs.Objectives.To estimate how much, if at all, trial enrollment increases the use of scarce resources in treating breast, lung, lymphoma, and ovarian cancer patients.Research Design.A profile of the cumulative charges for all inpatient and outpatient hospital care received by a sample of patients over an observation period beginning at diagnosis and continuing for upwards of 44 months postdiagnosis. Patients are classified by whether they were enrolled on an IRB-sanctioned research protocol and, if so, by the type of protocol. Both univariate and multivariate statistical tests are conducted to appraise whether cumulative charges differ between patients who were enrolled on key types of protocols and those who were not.Subjects.Approximately 1,900 breast, lung, lymphoma, and ovarian cancer patients treated at a single center.Measures.Clinical endpoints and demographic, disease, and therapy characteristics of patients that drive treatment costs.Results.Controlling for demographic and disease characteristics, initial therapy, and key endpoints, the net effect of trial participation on cumulative charges for hospital inpatient and outpatient care is never significantly positive at conventional confidence limits. This result is found for each of the four patient groups and three types of protocols encompassed by this analysis.Conclusions.Support for clinical trials by health care payers does not necessarily risk adding significantly to the cost of cancer care.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Objective.To provide a population-based description of current practice in the use of hormonal management of prostate cancer.Desing,Setting & Participants.All men in Ontario, Canada, age 65 and older, with confirmed prostate cancer starting maintained hormonal therapy, from July 1992 through December 1998 (11,435 patients). Data sources included the provincial drug benefit plan, hospital services data, and Ontario Cancer Registry.Outcome Measures.Rates and trends in the use of: surgical or medical castration; total androgen blockade (TAB); and monotherapies based on steroidal or nonsteroidal antiandrogens.Results.In 5.5 years, use of ‘standard’ therapy based on surgical or medical castration alone dropped from 36% to 26% of patients, while the use of TAB doubled from 22% to 41%. Approximately 15% of patients received nonsteroidal antiandrogens without evidence of therapy aimed at central androgen blockade. Marked regional differences were observed and not explained by patient age or practitioner specialty.Conclusions.New hormonal therapies for prostate cancer have implications in terms of disease control, patient survival, side effects, and costs. Rapid growth in prescribing of antiandrogens may represent an unnecessary expense for public or private payers, and observed regional differences likely reflect lack of consensus on the relative merit of TAB. Patients and practitioners must have current information on the advantages and disadvantages of different therapeutic options, and quality-of life, particularly with respect to emerging drug therapies.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Although the patient experiences the symptoms, only symptoms that providers recognize and report “count” in most clinical and research settings. Reliance upon provider-report has been justified by the claim that providers report only “clinically important” symptoms.Objective.To determine whether provider-reported symptoms constitute a more “clinically important” subset of patient-reported symptoms in HIV infection.Design.Secondary analyses of AIDS Clinical Trials 175 (ACTG 175), a randomized controlled trial of combination antiviral therapy among patients with moderate HIV disease.Setting.Large, multicenter study.Patients.1,262 patients who participated in the health-related quality of life (HRQOL) sub-study and for whom providers completed symptom forms.Measurements.Patient- and provider-reported symptoms, HRQOL, risk of recent hospitalization, survival, CD4 cell count, and plasma HIV-1 RNA levels.Results.On average, providers reported 3-fold fewer symptoms than patients did, but the degree of under report varied by symptom. When patient-reports were used as a gold standard, provider-reports demonstrated poor sensitivity (mean 0.25) and good specificity (mean 0.96). Agreement beyond chance was fair (mean &kgr; 0.35) and did not improve when weighted by symptom severity. Site specific variation was greater for provider than for patient-reported symptoms (R2: 0.15 and 0.05 respectively). Patient-reported symptoms were substantially more strongly associated with the physical health scale and all HRQOL subscales than provider-reported symptoms (P<0.0001). Patient-reported symptoms were equally strongly associated with survival (P>0.50) and recent hospitalization as provider-reported symptoms (P>0.48). Of note, patient-reported symptoms were independently associated with survival and recent hospitalization after adjustment for CD4 cell count and plasma HIV-1 RNA levels (P<0.05).Conclusions.Provider-reported symptoms are not a more clinically important subset of patient-reported symptoms. Patient-reported symptom checklists are likely to be more complete and more strongly associated with HRQOL. Further, patient-reported symptoms are as related to recent hospitalization and survival as provider-reported symptoms. An HIV specific, patient-completed symptom checklist might substantially improve symptom reporting for adverse drug event monitoring, clinical management and medical research.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID