ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.An objective of pharmaceutical care is for pharmacists to improve patients’ health-related quality of life (HRQOL) by optimizing medication therapy.Objectives.The objective of this study was to determine whether ambulatory care clinical pharmacists could affect HRQOL in veterans who were likely to experience a drug-related problem.Research Design.This was a 9-site, randomized, controlled trial involving Veterans Affairs Medical Centers (VAMCs). Patients were eligible if they met ≥3 criteria for being at high risk for drug-related problems. Enrolled patients were randomized to either usual medical care or usual medical care plus clinical pharmacist interventions. HRQOL was measured with the SF-36 questionnaire administered at baseline and at 6 and 12 months.Results.In total, 1,054 patients were enrolled; 523 were randomized to intervention, and 531 to control. After patient age, site, and chronic disease score were controlled for, the only domain that was significantly different between groups over time was the bodily pain scale, which converged to similar values at the end of the study. Patients’ rating of the change in health status in the past 12 months was statistically different between groups, intervention patients declining less (−2.4 units) than control subjects (−6.3 units) (P<0.004). This difference was not considered clinically meaningful. However, a dose-response relationship was observed for general health perceptions (P= 0.004), vitality (P= 0.006), and change in health over the past year (P= 0.007).Conclusions.These results suggest that clinical pharmacists had no significant impact on HRQOL as measured by the SF-36 for veterans at high risk for medication-related problems.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Patients have longer lengths of hospital stay (LOS) in VA medical centers than in the general health care system.Objective.The objective of this study was to determine whether resource use and outcome differences between VA and non-VA inpatient rehabilitation facilities remain after controlling for patient and medical care delivery differences.Design.This analysis involved 60 VA inpatient rehabilitation units and 467 non-VA rehabilitation hospitals and units. Multivariate adjusted resource use and patient outcome differences were compared across setting within patients grouped by severity of disability at admission through assignment to the Function Related Group (FRG) patient classification system.Subjects.The study included 55,438 stroke patients.Measures.Study measures were LOS, functional status at discharge, and community discharge.Results.The VA serves a higher proportion of patients who are single, separated, or divorced; are unemployed or retired as a result of disability, and are not white (P<0.0001). These traits tended to be associated with longer LOS, lower functional outcomes, and reduced rates of community discharge. After adjusting for these and other differences, depending on FRG, average LOS remained from 30% to 200% longer in the VA centers (P<0.05); average functional outcomes were significantly higher in 8 and lower in 2 FRGs (P<0.05); and community discharge rates were lower in 12 FRGs (P<0.05).Conclusions.While certain variables accounted for some of the observed differences in resource use and outcomes, differences remained after adjustment. Fewer incentives for cost containment and less support in patients’ home environments may be among the most important unmeasured determinants of VA differences.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Health care reorganizations, with a change in focus from inpatient to outpatient care, are becoming increasingly frequent. Little is known regarding how reorganizations may affect risk-adjusted outcomes for those programs, usually inpatient, that lose resources as a result of the change in organizational focus.Objectives.To determine changes in risk-adjusted rates of pressure ulcer development over an 8-year period, the final 3 of which were characterized by a significant reorganization of the health care system.Design.This was an observational study that used an existing database.Subjects.Subjects were residents of Department of Veterans Affairs long-term care units between 1990 and 1997 who were without a pressure ulcer at an index assessment.Measures.The study examined risk-adjusted rates of pressure ulcer development, and proportions of new ulcers that were severe (stages 3 or 4) were calculated for successive 6-month periods.Results.Between 1990 and 1994, risk-adjusted rates of pressure ulcer development declined significantly, by 27%. However, beginning in 1995, rates began to increase, and in 1997 they were similar to those in 1990. The proportion of new ulcers that were severe increased significantly over time (P= 0.01).Conclusions.The reorganization of the VA that began in 1995, with its emphasis on outpatient care, was associated with an increase in rates of pressure ulcer development. This highlights the need to carefully monitor the quality of care in programs that may be losing resources as a result of the reorganization.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Objective.Public e-penditures for home health care grew rapidly in the 1990s, but it remains unclear to whom the additional services were targeted. This study tests whether the rapidly increasing e-penditures were targeted to the elderly with high levels of disability and low levels of social support, 2 groups that have historically been higher users of paid home health and nursing home services.Methods.The Asset and Health Dynamics Study, a nationally representative, longitudinal survey of people ≥70 years of age (n = 7,443), was used to determine the association of level of disability and level of social support with the use of paid home care services in both 1993 and 1995. Multivariable regression models were used to adjust for sociodemographics, recent hospital or nursing home admissions, chronic medical conditions, and receipt of informal care from family members.Results.Those with higher levels of disability received more adjusted weekly hours of paid home care in both 1993 and 1995. In 1993, users of paid home care with the least social support (unmarried living alone) received more adjusted weekly hours of care than the unmarried elderly living with others (24 versus 13 hours,P<0.01) and the married (24 versus 18 hours,P= 0.06). However, by 1995, those who were unmarried and living with others were receiving the most paid home care: 40 versus 26 hours for the unmarried living alone (P<0.05) and 24 hours for the married (P<0.05).Conclusions.The recent large increase in formal home care services went disproportionately to those with greater social support. Home care policy changes in the early 1990s resulted in a shift in the distribution of home care services toward the elderly living with their children.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Objectives.The objective of the study was to evaluate the effectiveness of 2 educational strategies aimed at improving prescribing standards in primary care.Methods.A pragmatic controlled trial was designed; the study population included general and family practitioners in Galicia (northwestern Spain) divided into 3 study groups: a one-to-one education group (n = 98), a by-group education group (n = 92), and a control group (n = 405). The educational intervention included explicit recommendations for selecting nonsteroidal anti-inflammatory drugs (NSAIDs) for inflammation signs. Some of the subjects were given reminders. Mixed-effect linear models were applied to data analysis. Analyses were done by intention-to-treat. The dependent variable is a rate with a numerator that is the number of prescribed units of the NSAIDs recommended during intervention; the denominator is the total number of prescribed units of the NSAID total.Results.One-to-one education obtained an average prescribing behavior improvement of 6.5% (P<0.001) in the 9 months after intervention. In the education group, the average improvement was 2.4% (P<0.05) for the same period. Statistically significant differences were observed between the group intervention and one-to-one groups. The reminder increased significantly the effectiveness of the one-to-one intervention.Conclusions.A single, short educational session to primary care doctors can improve their prescribing standards during long periods of ≥9 months. Of the 2 strategies followed in the trial, one-to-one education has shown to be the most effective. Results also show that the effectiveness of these interventions increases when presented together with written material.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.There have been major reductions in the availability of inpatient psychiatric care in the United States in recent years.Objective.The objective of this study was to evaluate the clinical impact of cost-cutting changes in the delivery of inpatient psychiatric care.Design.This was a nonequivalent control group pre/post design.Subjects.Outcome data on 6,397 veterans treated between 1993 and 2000 at 35 specialized VA inpatient and residential programs for posttraumatic stress disorder (PTSD) were used to compare changes in effectiveness (measured as patient improvement from admission to 4 months after discharge) at programs that either shortened their average length of stay or converted from a hospital-based program to a low-cost residential rehabilitation program. For comparison, outcome data are also presented over the same years from both inpatient PTSD programs and residential PTSD programs that did not experience program change.Measures.Measures addressed baseline characteristics and 4-month postdischarge outcome measures of PTSD symptoms, substance abuse, violent behavior, and employment.Results.Analyses of covariance showed no significant change in outcomes at inpatient programs that either reduced their length of stay or did not change at all. However, effectiveness declined on some measures at inpatient programs that converted to residential treatment during this period but improved at residential treatment programs that had been established before this period of change.Conclusions.Although there was no deterioration in effectiveness related to reduced length of inpatient stay, programs that converted to a residential model showed decreased effectiveness.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Although most health-related quality of life questionnaires are self-administered by means of paper and pencil, new technologies for automated computer administration are becoming more readily available. Novel methods of instrument administration must be assessed for score equivalence in addition to consistency in reliability and validity.Objectives.The present study compared the psychometric characteristics (score equivalence and structure, internal consistency, and reproducibility reliability and construct validity) of the Quality of Life in Reflux And Dyspepsia (QOLRAD) questionnaire when self-administered by means of paper and pencil versus touch-screen computer. The influence of age, education, and prior experience with computers on score equivalence was also examined.Research Design.This crossover trial randomized 134 patients with gastroesophageal reflux disease to 1 of 2 groups: paper-and-pencil questionnaire administration followed by computer administration or computer administration followed by use of paper and pencil. To minimize learning effects and respondent fatigue, administrations were scheduled 3 days apart. A random sample of 32 patients participated in a 1-week reproducibility evaluation of the computer-administered QOLRAD.Results.QOLRAD scores were equivalent across the 2 methods of administration regardless of subject age, education, and prior computer use. Internal consistency levels were very high (&agr; = 0.93–0.99). Interscale correlations were strong and generally consistent across methods (r= 0.75–0.87). Correlations between the QOLRAD and Short Form 36 (SF-36) were high, with no significant differences by method. Test-retest reliability of the computer-administered QOLRAD was also very high (ICC = 0.93–0.96).Conclusions.Results of the present study suggest that the QOLRAD is reliable and valid when self-administered by means of computer touch-screen or paper and pencil.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Objectives.The objective of this study was to ascertain the extent to which demographic and health-related variables are related to visits to a complementary or alternative medicine (CAM) practitioner.Methods.This study reports a secondary analysis of visits to CAM practitioners during the year before the 1996 Medical E-penditure Panel Survey (n = 16,038).Results.Overall visits to CAM providers (9%) were lower than reported in widely cited surveys but quite consistent with a previous Robert Wood Johnson study that used a similar sampling procedure. Gender, education, age, geographic location, and race (Hispanics and African Americans proved to be less likely to visit CAM providers than whites) were statistically significant predictors of visits to CAM providers. Individuals in poorer health and those suffering from mental, musculoskeletal, and metabolic disorders also tended to be more likely to have visited a CAM provider.Conclusions.Although the choice of alternative versus orthodo- treatment appears to be a comple- phenomenon, these data suggest that the heaviest users of CAM therapies tend to be individuals with comorbid, non–life-threatening health problems. This finding may help to ameliorate concerns that this type of care is being used in lieu of therapies with more definitive efficacy evidence.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Mail surveys of physicians have been characterized by lower response rates than general population surveys, raising concerns about nonresponse bias. Although monetary incentives have routinely been used to improve survey response among physicians, questions remain regarding how much of an incentive is most cost-effective. The present study seeks to further examine the effects of incentive size on response rates to a national mail survey of physicians.Methods.This study used a random sample of 873 physicians practicing in the United States; the response rate was 65% (n = 563). Respondents were randomly assigned to receive a $5, $10, or $20 cash incentive in the initial mailing. Except for the magnitude of the incentive, the procedures for each condition were identical, with each respondent receiving up to 3 follow-up mailings and 2 telephone calls.Results.Overall response rates ranged from 60.3% for the $5 incentive category to 68.0% for the $10 incentive category. Differences in overall response rates across the incentive categories, however, were not significant. Higher levels of incentives also did not significantly reduce the number of mail and/or telephone interventions required to reach the target response rate of 60.0%. As expected, aggregate costs (excluding labor) were lowest for the $5 incentive group.Conclusions.Our findings suggest that changes in the magnitude of incentive do not automatically result in increases in survey response among physicians. Possible reasons for this lack of effect as well as alternatives to monetary incentives are addressed.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID