ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Area variation in the use of surgical interventions such as arthroplasty is viewed as concerning and inappropriate.Objectives.To determine whether area arthroplasty rates reflect patient-related demand factors, we estimated the need for and the willingness to undergo arthroplasty in a high- and a low-use area of Ontario, Canada.Research Design.Population-based mail and telephone survey.Subjects.All adults aged ≥55 years in a high (n = 21,925) and low (n = 26,293) arthroplasty use area.Measures.We determined arthritis severity and comorbidity with questionnaires, established the presence of arthritis with examination and radiographs, and evaluated willingness to have arthroplasty with interviews. Potential arthroplasty need was defined as severe arthritis, no absolute contraindication for surgery, and evidence of arthritis on examination and radiographs. Estimates of need were then adjusted for patients’ willingness to undergo arthroplasty.Results.Response rates were 72.0% for questionnaires and interviews. The potential need for arthroplasty was 36.3/1,000 respondents in the high-rate area compared with 28.5/1,000 in the low-rate area (P<0.0001). Among individuals with potential need, only 14.9% in the high-rate area and 8.5% in the low-rate area were definitely willing to undergo arthroplasty (P= 0.03), yielding adjusted estimates of need of 5.4/1,000 and 2.4/1,000 in the high- and low-rate areas, respectively.Conclusions.Demonstrable need and willingness were greater in the high-rate area, suggesting these factors explain in part the observed geographic rate variations for this procedure. Among those with severe arthritis, no more than 15% were definitely willing to undergo arthroplasty, emphasizing the importance of considering both patients’ preferences and surgical indications when evaluating need and appropriateness of rates for surgery.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background and Objectives.Despite evidence to the contrary, a common assumption in the area of health status measurement is that the state “dead” is the worst possible health state and by definition should be assigned a value of 0. However, the value of the state “dead” and the notion of states worse than “dead” have never been fully addressed as a research topic. This article demonstrates the e-tent of the variation in the value given to the state “dead” by individuals and the effects of transformation on individual and aggregate values using data elicited with 2 methods (visual analog scale rating and ranking) that place no constraint on the value given to the state “dead.”Research Design.Face-to-face interviews were conducted with 253 adults in North Yorkshire, UK, in 1998. Each participant performed ranking and visual analog scale rating e-ercises for 19 EuroQol EQ-5D health states.Conclusions and Results.Data showed that there is a small group of individuals who, when given the option, choose to place relatively high value on the state “dead” compared with other health states. This did not appear to be due to artifact. Evidence also suggested that the usual assumptions underlying the transformation of health state values, for which the distance between full health and “dead” is used to define the denominator, may not hold for these individuals and may distort aggregate preference structures. The authors stress the need for more systematic inquiry in this field.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Few measures exist to assess physicians’ practice style, and there are few data on physicians’ practice styles and patterns of care.Objectives.To use clinical vignettes to measure surgeons’ “propensity” for local treatments for early-stage breast cancer and to describe factors associated with propensity.Research Design and Subjects.A cross-sectional mailed survey with telephone follow-up of a random sample of 1,000 surgeons treating Medicare beneficiaries in fee-for-service settings.Measures.Outcome measures include treatment propensity, self-reported practice, and actual treatment received by the surgeons’ patients.Results.Propensities were significantly associated with actual treatment, controlling for covariates. Area Medicare fees were the strongest predictor of propensity, followed by region, attitudes, volume, and gender. For instance, after other factors were considered, surgeons practicing in areas with the highest breast-conserving surgery (BCS) fees were 8.61 (95% CI 2.26–32.73) times more likely to have a BCS propensity than surgeons in areas with the lowest fees. Surgeons with the strongest beliefs in patient participation in treatment decisions were nearly 6 times (95% CI 1.67–20.84) more likely to have a BCS propensity than surgeons with the lowest such beliefs, controlling for covariates. Male surgeons were also independently more likely to have a mastectomy propensity than female surgeons.Conclusions.Surgeons’ propensities explain some of the observed variations in breast cancer treatment patterns among older women. Standardized scenarios provide a practical method to measure practice style and could be used to evaluate physician contributions to shared decision making, practice patterns, costs and outcomes, and adherence to guidelines.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Quality-of-life outcomes are an important consideration for patients evaluating therapeutic options for localized prostate cancer.Objectives.The objective of this study was to describe the effect of treatment choice on change in health-related quality of life (HRQOL) among men with clinically localized prostate cancer.Research Design.This was a prospective observational study.Subjects.The study subjects were 122 men with clinically localized adenocarcinoma of the prostate. Forty-two subjects (34%) underwent radical prostatectomy, 51 (42%) underwent radiation therapy, and 29 (24%) were followed with e-pectant management.Measures.The University of California at Los Angeles Prostate Cancer Quality of Life Inde- and the Medical Outcomes Study Short Form-36 were administered before and 3 and 12 months after initial treatment. The study used an analysis of covariance model adjusted for baseline differences in clinical and demographic factors.Results.Men who underwent radical prostatectomy e-perienced significant declines in urinary and se-ual function and bother that persisted at 12 months after treatment. Men treated with radiation therapy e-perienced smaller but significant declines in se-ual function and a decline in social function. E-pectant management patients did not have a significant change in disease-targeted or generic HRQOL domains. Differential rates of change in urinary and se-ual function between treatment groups persisted after adjustment for differences in pretreatment clinical and demographic factors.Conclusions.Men undergoing radical prostatectomy have substantial declines in urinary and se-ual function, and men undergoing radiotherapy have declines in se-ual function. Men undergoing e-pectant management have no change in disease-specific or general HRQOL in the first year after treatment.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.With the growth of managed care, there are increasing concerns but inconclusive evidence regarding deterioration in the quality of medical care.Objectives.To assess physicians’ perceptions of their ability to provide high-quality care and explore what factors, including managed care, affect these perceptions.Research Design.Bivariate and multivariate analyses of the Community Tracking Study Physician Survey, a cross-sectional, nationally representative telephone survey of 12,385 patient-care physicians conducted in 1996/1997. The response rate was 65%.Participants.Physicians who provide direct patient care for ≥20 h/wk, excluding federal employees and those in selected specialties.Measures.Level of agreement with 4 statements: 1 regarding overall ability to provide high-quality care and 3 regarding aspects of care delivery associated with quality.Results.Between 21% and 31% of physicians disagreed with the quality statements. Specialists were generally 50% more likely than primary care physicians to express concerns about their ability to provide quality care. Generally, the number of managed care contracts, but not the percent of practice revenue from managed care, was negatively associated with perceived quality. Market-level managed care penetration independently affected physicians’ perceptions. Practice setting affected perceptions of quality, with physicians in group settings less likely to express concerns than physicians in solo and 2-physician practices. Specific financial incentives and care management tools had limited positive or negative associations with perceived quality.Conclusions.Managed care involvement is only modestly associated with reduced perceptions of quality among physicians, with some specific tools enhancing perceived quality. Physicians may be able to moderate some negative effects of managed care by altering their practice arrangements.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.A self-report questionnaire is the most widely used method to assess (in)patients’ satisfaction with (hospital) care. However, problems like nonresponse, missing values, and skewed score distributions may threaten the representativeness, validity, and reliability of results. We investigated which of alternative item-response formats maximizes desired outcomes.Design.Five formats were compared on the basis of sample characteristics, psychometric properties at the scale and item levels, and patients’ opinions of the questionnaire.Subjects.Consecutively discharged patients (n=784) were sampled, of which a representative (sex, age, length of hospital stay) subsample of 514 (65%) responded.Measures.A 54-item satisfaction questionnaire addressing 12 aspects of care was used. Patients responded using either a 10-step evaluation scale ranging from “very poor” to “excellent” (E10), a 5-step evaluation scale ranging from “poor” to “excellent” (E5), or a 5-step satisfaction scale ranging from “dissatisfied” to “very satisfied” (S5). The 5-step scales were administered with response options presented as either boxed scale steps to be marked or words to be circled.Results.E5 scales yielded lower means than S5 scales. However, at the item level, the S5 scale showed better construct validity, more variability, and less peaked score distributions. Circling words yielded fewer missing item scores than marking boxes. The E5 scale showed more desirable score distributions than the E10 scale, but construct validity and reliability were lower.Conclusions.No large differences among formats were found. However, if individual items are important carriers of information, a (5-step) satisfaction response scale, with response options presented in words next to each item, appears to be the optimal format.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.An episode of substance abuse treatment is an opportunity to link substance-abusing patients to medical care at a time when management of medical problems might stabilize recovery and long-term health. However, little is known about the ability of organizational linkage mechanisms to facilitate the delivery of medical care to this population.Objectives.The goal of this study was to e-amine whether organizational linkage mechanisms facilitate medical service utilization in drug abuse treatment programs.Research Design.This was a prospective secondary analysis of the Drug Abuse Treatment Outcome Study, a national longitudinal study of drug abuse treatment programs and their patients from 1991 to 1993. Hierarchical linear models evaluated the effect of on-site delivery, formal and informal referral, case management emphasis, and transportation on the log-transformed number of medical visits at the 1-month in-treatment patient interview.Measures.Program directors’ surveys provided organizational information, including the linkage mechanism used to deliver medical care. Patients reported the number of medical visits during the first month of drug abuse treatment.Results.E-clusive on-site delivery increased medical utilization during the first month of drug abuse treatment (&bgr; estimate, 0.22; standard error [SE], 0.06;P<0.001). Transportation services also increased 1-month medical utilization (&bgr; estimate, 0.13; SE, 0.03;P<0.001).Conclusions.E-clusive on-site delivery of medical services increased drug abuse treatment patients’ utilization of medical services in the first month of treatment. Transportation assistance warrants strong policy consideration as a facilitator of medical service delivery. Future research should clarify whether program-level linkage to medical services improves the patient-level outcomes of drug abuse treatment.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Having annual dollar limits in prescription coverage is a type of benefit design unique to Medicare beneficiaries. This type of coverage is found predominantly within private Medigap policies and Medicare+Choice plans offering prescription coverage.Objectives.The purpose of this study was to determine the impact of capped prescription benefits on efforts to reduce out-of-pocket prescription e-penses by beneficiaries at risk for reaching their cap.Research Design.This design was quasi-e-perimental, with data obtained from self-administered questionnaires mailed to 600 Medicare HMO risk enrollees with capped prescription benefits.Results.Data were collected on 378 Medicare enrollees for a 63% response rate. Appro-imately half of all respondents participated in ≥1 strategy to reduce their out-of-pocket prescription e-penses. Participation in selected strategies included obtaining samples from physicians (39.2%), taking less than prescribed amounts (23.6%), and discontinuing prescribed medications (16.3%). Additionally, 15% of respondents indicated going without necessities, and 12% indicated borrowing money to pay for their prescriptions. Those who reached their prescription cap were more likely to participant in any one behavior (odds ratio [OR], 2.18), more likely to take less medication than prescribed (OR, 2.83), more likely to discontinue a medication (OR, 3.36), and more likely to obtain samples from their physician (OR, 2.02) compared with those who had not reached their prescription cap.Conclusions.Beneficiaries at risk for reaching their prescription cap are taking steps to reduce their out-of-pocket prescription costs. Although some behaviors would be considered prudent, other behaviors may be placing beneficiaries at risk for drug-related morbidity and mortality.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Although clinical trials evaluate pharmacotherapeutic interventions under highly controlled conditions, there remains a need to evaluate medication use in actual practice.Methods.Patients prescribed atypical antipsychotic medications in the VA system during a 4-month period in 1999 (n = 73,981) were classified into 32 groups on the basis of clinical diagnosis and recent level of inpatient use. Variation was e-amined across groups in drug costs, agents, dosages, and duration of use. The potential impact of these medications on VA costs was estimated by calculating medication costs and subtracting estimated inpatient savings.Results.A majority of patients were diagnosed with schizophrenia (57.2%), but substantial off-label use of these medications to treat other psychiatric illnesses was also evident (42.8%). Compared with published trials reporting average annual costs from $3,000 to $7,000, average annualized pharmacy costs were only $1,395 per patient because of a 58.5% VA price discount; relatively low dosing, especially for people with diagnoses other than schizophrenia; and medication prescription coverage for only 75% of the days in the study period. The sample averaged only 6.96 inpatient days; as a result, potential inpatient savings were limited. Assuming 0% to 18% inpatient savings, annual net drug costs are estimated to range from $500 to $1,152 per patient.Conclusions.Medication costs in actual practice can be substantially lower than in clinical trials. Atypical antipsychotic medications in actual VA practice incur net costs estimated at $500 to $1,152 per patient per year with substantial variation across clinical subgroups.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID