ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.Population-based cancer registries represent a potentially valuable tool to evaluate treatment; however, information on the completeness of registry treatment data is sparse.Objective.To evaluate the completeness of registry treatment data for patients with colorectal cancer and to identify predictors of complete reporting.Research Design.We surveyed physicians or reviewed office records of 1956 northern California patients diagnosed with colorectal cancer during 1996 to 1997 to assess the completeness of registry data regarding use of adjuvant chemotherapy and radiation therapy.Results.For patients with a record of receipt of chemotherapy in either the registry or physician survey, information was in the original registry records for 82.0%. In the multivariate analysis, completeness of chemotherapy reporting was lower for patients aged 65 to 74, those with colon cancer, and those treated in teaching hospitals; and higher for patients treated in hospitals that are part of a large health maintenance organization (HMO). For patients with a record of receipt of radiation therapy, information was in the original registry records for 90.2%. In the multivariate analysis, completeness of radiation therapy reporting was higher for patients aged 18 to 54 and those treated in HMO hospitals.Conclusions.Because the completeness of the registry treatment data varied by patient and hospital characteristics, use of registry data without supplementation could bias estimates of the proportion of patients treated, and of the patient and provider characteristics associated with treatment. Enhanced cancer registry data could be a valuable component of population-based cancer data systems for assessing quality of cancer care.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Objectives.To investigate the impact of implementing service line organization on the delivery of mental health services.Methods.Survey data on the implementation of service lines and facility-level administrative data on the delivery of mental health services at 139 Department of Veterans Affairs medical centers (VAMCs), over a 6-year period, were used to examine the relationship between service line implementation and subsequent performance in 4 areas: 1) continuity of care (COC), 2) readmission after inpatient discharge, 3) emphasis on community-based mental health care (as contrasted with inpatient care), and 4) maintenance of proportionate funding for mental health care. Models were analyzed using hierarchical linear modeling techniques to control for potential autocorrelation.Results.Of 6 COC measures, 1 strongly improved in all years following service line implementation, and 3 of the 5 other measures demonstrated improvement in the first year. One of 2 readmission measures showed a decline in the first year after service line implementation. Service line implementation was associated with only 1 indicator of increased emphasis on community-based mental health care (and only in the first year), whereas 3 of the 4 other measures suggested a decline in such emphasis. Lastly, although there were increases in per capita mental health expenditures 3 or more years after service line implementation, 2 related measures indicated that service line implementation was associated with a decline in mental health expenditures relative to nonmental health services.Conclusion.Service line implementation was associated with significant, although predominantly short-term, improvement in patient level variables such as continuity of care and hospital readmission, but less so with regard to institutional measures addressing emphasis on outpatient care and maintaining proportionate funding of mental health services.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Statement of Problem.Many healthcare decisions are difficult because they are complex and have important consequences such as the impact on survival or quality-of-life of individuals and on allocation of limited resources. The present state-of-the-art in healthcare decision modeling is often inadequate to properly assess these decisions.Methods.Based on a literature search and the experience of the authors, typical methodologies used in healthcare decision analysis modeling are explored and compared with methods used in other practices. An example of hormonal therapy decisions is used.Results.Useful methods that have been developed in other fields are presented. These include methods targeted toward appropriate assessment and representation of the complexity of decisions, assessment of uncertainty, use of nonexpected value decision analysis, and use of multi-attribute decision criteria.Conclusion.The state-of-the-art in healthcare decision modeling can be improved through learning from other practices.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.Assessment of the performance of primary care physicians requires multiple, reliable measures. This article explores the appropriateness of selected Health Plan Employer Data and Information Set (HEDIS) measures, developed to assess health plans, to assess individual physician performance.Objectives.To determine the consistency and reliability of 4 measures of primary care physician performance measures: cancer screening, diabetic management, patient satisfaction, and ambulatory costs.Methods.The study population consisted of all 194 family practitioners and general internists providing ambulatory services in 1998 to a defined patient panel of 320,000 adult health maintenance organization members. Administrative data on physician practice and performance were assessed with multiple regression and analysis of variance.Results.Each performance measure was significantly related to 1 or 2 of the other measures: high cancer screening rates with good diabetic management and high patient satisfaction, good diabetic management with high cancer screening rates, high patient satisfaction with high cancer screening rates and high ambulatory costs, or high ambulatory costs with higher patient satisfaction. Although 76% of the physicians ranked in the highest third for at least 1 measure, 81% of these high performers ranked in the lower third for at least 1 other measure. Three percent of physicians ranked exclusively in the top or bottom third on all measures.Conclusions.Care should be taken in assessing physicians based on narrow performance measures. Assessments of individual physicians with current performance measures might identify areas in which improvement is needed and to provide feedback to improve performance quality and efficiency. However, assumptions should not be made from one measure of performance to another.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.It has not been demonstrated that the implementation of computerized quality improvement strategies can improve client-centered outcomes in public community based, long-term care (CBLTC) programs.Objectives.To test and evaluate 2 innovative computer-assisted, client-centered quality improvement strategies for public community-based, long-term care. The first strategy, the Normative Treatment Planning (NTP) program, assesses needs, prescribes services, and evaluates outcomes. The second strategy, the Client Feedback System (CFS) program, provides service vendors with feedback on client perceptions of services.Research Design.A 2 × 2 factorial design with the 2 strategies using cluster randomization.Subjects.A total of 2222 clients (86% of eligible program clients) enrolled in Indiana’s state case management program and/or the Medicaid home and community-based services waiver program for the aged and disabled as of January 1, 1995.Measures.Outcomes of needs met and client satisfaction were measured through telephone surveys every 6 months for 2 years.Results.A total of 1006 participants (45%) completed the 2-year evaluation study. For the group using only the NTP program, perception of needs met and client satisfaction were significantly better than the control group over the 2 years. During this period, the group using only the CFS program had significantly better client satisfaction than the control group. However, the effect sizes of the significant differences were small, and no statistically significant effects were found for the group using both programs.Conclusions.Client-centered quality improvement strategies can be implemented to enable public CBLTC programs to meet client needs better and increase client satisfaction.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.Conceptual or theoretical analysts of trust in medical settings distinguish among markedly different objects or types of trust. However, little is known about how similar or different these types of trust are in reality and the relationship of trust with satisfaction.Objectives.This exploratory study conducted a comparison among trust in one’s personal physician, health insurer, and in the medical profession, and examined whether the relationship between trust and satisfaction differs according to the type of trust in question.Research Design.Random national telephone survey using validated multi-item measures of trust and satisfaction.Subjects.A total of 1117 individuals aged 20 years and older with health insurance and reporting 2 healthcare professional visits in the past 2 years.Results.Rank-order correlation analyses find that both physician and insurer trust are sensitive to the amount of contact the patient has had and their adequacy of choice in selecting the physician or insurer. Trust in the medical profession stands out as being uniquely related to patients’ desire to seek care and their preference for how much control physicians should have in making medical decisions. Adding satisfaction to the models reduced the number of significant predictors of insurance trust disproportionately.Conclusions.Consistent with theory, we found both substantial similarities and notable differences in the sets of factors that predict 3 different types of trust. Trust and satisfaction are much less distinct with respect to health insurers than with respect to physicians or the medical profession.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.Commonly used measures such as the Physical Component Scale of the Short Form 36-item health survey (PCS) are undefined at death, limiting longitudinal analyses to survivors, a healthier cohort that cannot be identified prospectively, and that might have had little change in health. One proposed approach is to transform the PCS into the Physical Component Transformed, with Deaths included (PCTD), which is the probability of being healthy 1 year later and for which deaths logically have a value of zero. Data missing for other reasons than death have not been considered.Objective.To examine the performance of the PCTD, to determine the influence of including deaths, the additional effects of imputing missing values and adjusting for covariates, and the calibration of the PCTD in different populations.Methods.We imputed missing values of the PCTD, calling the new variable the PCTDI. We compared the distributions of the PCS, PCTD, and PCTDI cross-sectionally and over time. In 3 different populations, we determined whether the PCTD accurately predicted the probability of being healthy 1 year later.Results.The patients who died did not have extreme values on the PCTD. The experience of the cohort was best described by the PCTDI. The calibration of the PCTD was surprisingly good in all the populations examined. Results were similar for the physical function index.Conclusion.The PCTDI is an improvement over the PCS, in which patients who had died have no influence, and over the PCTD, where they might have too much influence. We recommend the PCTDI for longitudinal analyses of physical health when deaths occur, for primary or secondary analysis.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.We have previously used an evidence-based, epidemiologic approach to estimate the proportion of incident cases that should be treated with radiotherapy (RT) for lung cancer. The first objective of the present study was to compare this evidence-based estimate of the appropriate rate of use of RT with the rates observed in selected “benchmark” communities where there are no barriers to the appropriate use of RT and no incentives to the unnecessary use of RT. The second objective of the study was to compare the rates of use of RT in the general populations in the United States and Canada with the estimated appropriate rate.Methods.We established benchmark rates for the use of RT for lung cancer in Ontario, Canada, where: 1) residents make no direct payments for RT; 2) all RT is provided by site-specialized radiation oncologists in multidisciplinary cancer centers, and 3) radiation oncologists receive a salary in lieu of technical fees. Communities located close to cancer centers without long waiting lists for RT were selected to serve as benchmarks. Prospectively gathered electronic treatment records from all RT cancer centers were linked to the provincial cancer registry to describe the rate of use of RT in Ontario. The public use file of Surveillance, Epidemiology and End Results Registries (SEER) was used to describe the use of RT in the United States.Results.Overall, 41.3% (95% confidence interval [CI], 39.9%, 42.7%) of incident cases of lung cancer received RT as part of their initial management in the benchmark communities compared with the evidence-based estimate of 41.6% (95% CI, 39.2%, 44.1%). The rate of use of RT in the initial management of nonsmall cell lung cancer (NSCLC) in the benchmark communities was 49.3% (95% CI, 47.5%, 51.1%) compared with the evidence-based estimate of 45.9% (95% CI, 41.6%, 50.2%). The use of RT in the initial management of small-cell lung cancer (SCLC) in the benchmark communities was 47.0% (95% CI, 43.3%, 50.7%) compared with the evidence-based estimate of 45.4% (95% CI, 42.4%, 48.4%). In many counties of Ontario, the observed rates of RT use in the initial management of lung cancer were significantly lower than either the benchmark rate or the evidence-based estimate of the appropriate rate. In contrast, rates of use of RT in most counties in the SEER regions of the United States were close to, or higher than, the estimated appropriate rate.Conclusions.The observed benchmark rate converged on the evidence-based estimate of the appropriate rate of use of RT for lung cancer, suggesting that either measure might reasonably be used as a “standard” against which to compare rates observed in similar populations elsewhere.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.Access to health care, reflected by an ability to meet one’s health needs, is influenced by individual characteristics and the environment. Although managed care activity influences healthcare prices and overall utilization, its relationship to access and its broader effects across different insurance categories has not been well studied.Objective.To examine the association between managed care activity and individuals’ access to care, and to assess differences in this relationship by insurance status.Research Design.Cross-sectional survey of households conducted in 1998.Subjects.A sample of 15,613 adult Ohio residents.Measures.Self-reported difficulties in obtaining health care, medications, supplies, or medical equipment in the past year.Results.A total of 1248 (8.0%) identified an access problem. In bivariate analyses, these problems were more common among continuously and intermittently uninsured individuals compared with those who were continuously insured during the previous 12 months (P<0.001) and also among those living in areas with more managed care (P= 0.01). After accounting for other individual and environmental characteristics in hierarchical analyses, individuals residing in areas with more managed care had 28% higher odds of reporting problems obtaining care than those elsewhere (multivariate odds ratio, 1.28; 95% confidence interval, 1.04–1.58];P= 0.02). No significant interaction between managed care penetration and insurance status was observed.Conclusions.Greater managed care activity is associated with unfavorable patterns of healthcare access despite an individual’s insurance status, suggesting more pervasive effects. Unintended effects should be carefully evaluated when formulating future programs that seek to address disparities in access to care.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID