ISSN:0025-7079    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objectives.To evaluate the validity of patient report, pharmacy dispensing records, and pill counts as measures of antihypertensive adherence using electronic monitoring as the validation standard.Methods.The study was conducted among 286 members of Harvard Pilgrim Health Care, a managed care organization, who were at least 18 years of age, on monotherapy for hypertension, and had prescription drug coverage. Prescription refill adherence during the 12 months before enrollment was determined from their automated pharmacy dispensing records. Participants were interviewed about their medication adherence before and after a 3-month electronic monitoring period during which pill counts were also performed. Adherence to both recommended number and timing of doses was estimated from electronic monitoring data. Data analysis was based on statistical correlation and analysis of variance.Results.Electronic adherence monitoring revealed that the proportion of prescribed doses consumed was higher (0.92) than the proportion of doses taken on time (0.63). The correlation between adherence to quantity and timing of doses was 0.32. Concurrent pill counts and earlier refilling patterns were moderately correlated with electronic monitoring (pill count:r= .52 with quantity andr= .17 with timing; refill adherencer= .32 with quantity andr= .22 with timing). There was considerable misclassification of adherence reported by patients, although nonadherence was generally accurately reported.Conclusions.Deviation from recommended timing of doses appears to be greater than from prescribed number of doses. Pharmacy dispensing records demonstrate predictive validity as measures of cumulative exposure and gaps in medication supply. Adherence levels determined from pill counts and pharmacy dispensing records correlate more closely with quantity than with timing of doses. Nonadherence reported by patients can serve as a qualitative indicator and predictor of reduced adherence.

ISSN:0025-7079    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Background.Little is known about the impact of marital dissolution and/or marital harmony on health service use.Objectives.To examine the ways in which marital dissolution and/or marital quality influence health and health service use.Research Design.The americans' Changing Lives (ACL) survey was designed to provide a longitudinal study of successful aging. The ACL contains a nationally representative sample of people over age 24, with an oversampling of individuals age 60 and above.Subjects.Nine hundred and twenty seven female subjects who were married at baseline (1986); 101 (10.9%) of those were no longer married at follow up (1989).Measures.Health status and health service use at follow up.Results.Marital dissolution, alone and together with marital quality, was associated with worsened mental and physical health and increased mental health service use. Marital harmony was associated with better sleep and fewer depressive symptoms and physician visits. Widowhood was associated with worsened health, but not with greater health service use. Separated women and women divorced from a discordant marriage were not more depressed but used more mental health services. Women separated from a marriage they had rated as harmonious increased their alcohol consumption.Conclusions.Marital dissolution increases the risk for mental and physical health problems, some of which emerge only among women who had harmonious marriages. Marital harmony appears protective against physician visits. Widows should be encouraged to seek help for their health difficulties. Separated women should be counseled that they are at heightened risk for increased alcohol consumption. Divorced and separated women appear to seek help for emotional problems, over and above depressive symptoms.

ISSN:0025-7079    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Background.Although risk assessment models for specific adult populations such as the elderly have been developed, little work has focused on developing pediatric-specific models. The lack of pediatric models may result in incorrect estimates of relative disease severity among children, in reduced reimbursement for health plans and providers, and in inadequate health care for chronically ill children.Objectives.To develop and to evaluate a pediatric risk assessment model using automated pharmacy data.Design.Retrospective, case-cohort study using automated data.Subjects.All children continuously enrolled in Group Health Cooperative of Puget Sound during 1992 and 1993.Measures.The Pediatric Chronic Disease Score (PCDS), an algorithm that classified children into chronic disease categories by prescription drug fills, was compared with the ICD-9-CM-based Ambulatory Care Groups (ACG) model and a demographic model for prediction of total, ambulatory, or primary care costs and primary care visits. Forecast models were estimated using linear regression and they were evaluated with R2, mean prediction error, mean squared prediction error, and Mincer-Zarnowitz tests.Results.The pharmacy-based PCDS performed significantly better on each of the four forecasting accuracy tests than did a demographic model (eg, R2s averaging fourfold higher). Compared with the ACG model, the PCDS model performed similarly on mean squared prediction error tests; however, the ACG generally had higher validation R2values.Conclusions.A pharmacy-based pediatric risk assessment model performs better than a demographic model and represents a viable alternative to ICD-9-CM-based models. Further research is necessary to determine if children must be considered separately from adults when conducting population-based risk assessments.

ISSN:0025-7079    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objectives.For depression, this research measures the impact of travel time on visit frequency and the probability of receiving treatment in concordance with AHCPR guidelines.Methods.The medical, insurance, and pharmacy records of a community-based sample of 435 subjects with current depression were abstracted to identify those treated for depression, to determine the number of depression visits made over a 6-month period, and to ascertain whether treatment was provided in concordance with AHCPR guidelines. A Geographic Information System was used to calculate the travel time from each patient to their preferred provider. Poisson and logistic regression analyses were used to estimate the impact of travel time on visit frequency and guideline-concordance, controlling for patient casemix.Results.In the community-based sample, 106 subjects were treated for depression by 105 different preferred providers. About one-third (30.7%) were treated by a mental health specialist. One average, patients made 2.8 depression visits over the 6-month period. One-third (28.9%) of the patients received guideline-concordant treatment for depression. The average number of visits for those receiving guideline-concordant care was significantly greater than for those not receiving guideline-concordant care (P< 0.01). Travel time to the preferred provider was significantly associated with making fewer visits (P< 0.0001) and having a lower likelihood of receiving guideline-concordant care (P< 0.05).Discussion.For depression, both pharmacotherapy and psychotherapy treatment regimens require frequent provider contact to be effective. This study suggests that travel barriers may prevent rural patients from making a sufficient number of visits to receive effective guideline-concordant treatment.

ISSN:0025-7079    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objectives.This study examined data on case management clients who are homeless and have a severe mental illness to determine how those contacted through street outreach differ in their socio-demographic characteristics, service needs, and outcomes from those clients contacted in shelters and other health and social service agencies.Methods.As part of the Center for Mental Health Services' Access to Community Care and Effective Services and Supports (ACCESS) program, data were obtained from potential clients over the first 3 years of the program at the time of the first outreach contact (n= 11,857), at the time of enrollment in the case management program (n= 5,431), and 3 months after enrollment (n= 4,587).Results.Clients contacted at outreach on the street, as opposed to being contacted in shelters and service agencies, were generally worse off. They were more likely to be male, to be older, to spend more nights literally homeless before the contact, to have psychotic disorders, and took longer to engage in case management. They expressed less interest in treatment and were less likely to enroll in the case management phase of the project. Subjects contacted on the street who did enroll were more impaired than their street counterparts who did not enroll. Three month outcome data showed that enrolled clients contacted through street outreach showed improvement that was equivalent to those enrolled clients contacted in shelters and other service agencies on nearly all outcome measures.Conclusion.Street outreach to homeless persons with serious mental illness is justified as these clients are more severely impaired, have more basic service needs, are less motivated to seek treatment, and take longer to engage than those contacted in other settings. Street outreach is further justified as it engages the most severely impaired among the street population. Street outreach also appears to be effective as the clients reached in this way showed improvement equal to that of other clients in most outcome domains when baseline differences were taken into account.

ISSN:0025-7079    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Objectives.Test the reliability and validity of 5 translations of the 34-item version of the MOS HIV for use in multinational clinical trials.Research Design.Investigators in five countries followed a standardized protocol and recruited HIV+ patients stratified by disease stage: asymptomatic; symptomatic; and AIDS. During routine clinic visits, patients completed the MOS HIV and a checklist of HIV-related symptoms. Clinicians reported patients' demographics, most recent CD4+ count and disease stage.Subjects.Three hundred and sixty three HIV+ outpatients attending AIDS clinics in The Netherlands, France, Germany, Italy, and England.Measures.Dutch, French, German, Italian, and UK English translations of the MOS HIV CD4+ cell count and the SCL-57.Results.All translations recruited roughly equal proportions of each disease stage, although the number of patients recruited differed by translation (n:German = 92, French = 86; Italian = 88; UK English = 72; and Dutch = 25). Internal consistency reliability was similar across translations and adequate (alpha >.70) for all scales except for Mental Health in the French sample. Multi-trait analyses supported structural validity of the MOS HIV scales in each translation. Principal component analysis of scale scores identified 2 dimensions for all translations except German. For all translations, scores were significantly correlated with symptom severity scores but were uncorrelated with CD4+ cell counts.Conclusions.In general, the 5 translations of the MOS HIV had similar psychometric properties to those reported in the validation study for the original US English version of the MOS HIV. With some revision, these translations promise to provide useful quality of life data from HIV+ subjects in clinical trials.

ISSN:0025-7079    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Background.Although most of the elderly are covered by Medicare, they potentially face large out-of-pocket costs for their health care because of excluded services. Aside from nursing home care, the exclusion of prescription drugs is one of the most significant. Several earlier policy initiatives have proposed adding prescription drug coverage to the Medicare program. To determine the effects of such an expansion, one must account for the potential increase in the demand for prescription drugs from providing insurance coverage.Methods.The study uses a new data source, theRAND Elderly Health Supplement to the 1990 Panel Study of Income Dynamics (PSID).The endogenity of insurance coverage is tested using instruments that exploit the longitudinal nature of the data. Equations are estimated on 910 persons (≥ 66 years) using a two-part model.Results.Insurance coverage for prescription drugs significantly increases the probability of use, but not of total expenditures, among those who use prescription drugs. However, insurance coverage significantly lowers out-of-pocket expenditures, thereby decreasing the financial burden on elderly households associated with prescription drug use. Medicaid coverage has effects that are smaller than those for private insurance, but the magnitude is less precisely estimated.These findings imply that if prescription drug coverage were added to Medicare, expected expenditures on drugs would rise by on average $83 for each elderly Medicare beneficiary (in 1990 dollars), although this increase is significant only at the 90% level. If the benefit had been included under Medicare, expected spending on prescription drugs by the elderly would have risen by approximately 20%, or $2.6 billion in 1990.

ISSN:0025-7079    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Background.Assess the reproducibility of methods to measure overuse of cataract surgery.Objectives.The objectives of this study are: (1) To determine the extent of agreement about clinical scenarios among, between, and within three physician panels; (2) to apply ratings of clinical scenarios from three panels to actual surgeries; and (3) to assess reproducibility of rates of appropriate use and overuse.Methods.Three physician panels scored 2,894 clinical scenarios for the appropriate use of cataract surgery. One thousand and twenty charts were abstracted and assigned to the clinical scenario that best corresponded to the patient's clinical situation. Two hundred and fifty nine clinical scenarios were required to assign the cases. Weighted kappa values, confidence intervals, and percentages of agreement were used to measure agreement among, between, and within panels.Results.The all ophthalmologist panel (OP) and the convened multispecialty panel (CM) each rate 92% of the cases as appropriate use, compared with 70% by the mail-in multispecialty panel (MM). The MM have higher uncertain (26% vs. 8% and 7%) and higher inappropriate use (3.5% vs. 0.1% and 1.9%). For the clinical scenarios, the CM and the MM have similar percentages of overuse (6.6%, 7.3%), in contrast to the OP (0.4%). The weighted kappa value for the overall level of agreement about the clinical scenarios among the three panels is 0.53, consistent with moderate agreement.Conclusions.Study results demonstrate reproducibility for assessment of appropriate use of surgery between the OP and CM. However, both multispecialty panels rate more clinical scenarios as inappropriate use than the ophthalmologist panel. Thus, reproducibility between the CM and the OP may be attributable to the low percentage of overuse of cataract surgery in the study population. The overall level of agreement about the clinical scenarios among the panels is moderate.

ISSN:0025-7079    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Background.Explanations for regional variation in the use of many medical and surgical treatments is controversial.Objectives.To identify factors that might be amenable to intervention, we investigated the determinants of regional variation in the use of knee replacement surgery.Research Design.We examined the effect of the following factors: characteristics and opinions of surgeons; family physicians and rheumatologists; patients' severity of disease before knee replacement; access to knee-replacement surgery; surgeons' use of other surgical treatment; and county population characteristics.Outcomes Measure.County utilization rates of knee replacement in Ontario, Canada.Results.Counties that had higher rates of knee replacement had older patients (P= 0.0001), higher percentage of medical school affiliated hospital beds (P= 0.04), with more male (P= 0.02) non-North American trained referring physicians (P=0.002) and orthopedic surgeons who had higher propensities to operate and better perceptions of outcome (P= 0.0001).Conclusions.After controlling for population characteristics and access to care (including the number of hospital beds, and the density of orthopaedic and referring physicians), orthopaedic surgeons' opinions or enthusiasm for the procedure was the dominant modifiable determinant of area variation. Thus, research needs to focus on the opinions of surgeons which may be important in reducing regional variation for knee replacement.

ISSN:0025-7079    

出版商:OVID    

年代:1999

数据来源: OVID