ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.Few studies have estimated the economic costs and benefits of brief physician advice in managed care settings.Objective.To conduct a benefit-cost analysis of brief physician advice regarding problem drinking.Design.Patient and health care costs associated with brief advice were compared with economic benefits associated with changes in health care utilization, legal events, and motor vehicle accidents using 6- and 12-month follow-up data from Project TrEAT (Trial for Early Alcohol Treatment), a randomized controlled clinical trial.Subjects.482 men and 292 women who reported drinking above a threshold limit were randomized into control (n= 382) or intervention (n= 392) groups.Measures.Outcomes included alcohol use, emergency department visits, hospital days, legal events, and motor vehicle accidents.Results.No significant differences between control and intervention subjects were present for baseline alcohol use, age, socioeconomic status, smoking, depression or anxiety, conduct disorders, drug use, crimes, motor vehicle accidents, or health care utilization. The total economic benefit of the brief intervention was $423,519 (95% CI: $35,947, $884,848), composed of $195,448 (95% CI: $36,734, $389,160) in savings in emergency department and hospital use and $228,071 (95% CI: −$191,419, $757,303) in avoided costs of crime and motor vehicle accidents. The average (per subject) benefit was $1,151 (95% CI: $92, $2,257). The estimated total economic cost of the intervention was $80,210, or $205 per subject. The benefit-cost ratio was 5.6:1 (95% CI: 0.4, 11.0), or $56,263 in total benefit for every $10,000 invested.Conclusions.These results offer the first quantitative evidence that implementation of a brief intervention for problem drinkers can generate positive net benefit for patients, the health care system, and society.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.Quantified measures of unmet health care needs can be used to evaluate health care interventions, assess the impact of managed care, monitor health status trends in populations, or assess equity of access to medical care across population subgroups. Such a measure needs to be simple, relatively easy to obtain, inexpensive, and appropriately targeted to the population of interest.Objective.To develop a measure of unmet health care needs that is specifically targeted to a pediatric population.Subjects.Study participants consisted of children, aged 1 to 5 years (n= 1,031), and adolescent mothers, aged 13 to 19 years (n= 172), predominantly from poor, minority families in New York City.Research Design.Based on a measure, the symptoms-response ratio, developed for all age groups, this study replicated Taylor's procedures specifically for children and adolescents. Respondents were asked if they had experienced a set of physical symptoms and if they saw a doctor in response. A panel of pediatricians rated the same symptoms as to whether health care should be sought.Results.The measure achieved adequate inter-rater reliability and good construct validity. The children's overall use of health services did not differ from the pediatric panel's expectations, but with differing degrees of unmet needs by symptom. Adolescents sought care less often than the expert panel members believed they should.Conclusions.The symptoms-response ratio provides a good balance of a simple and inexpensive measure while yielding a fair estimate of unmet needs for primary care. This analysis created a pediatric measure targeted to the needs of young children and adolescent females.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective.To assess the association between race and insurance and Cesarean delivery rates after adjusting for clinical risk factors that increase the likelihood of cesarean delivery.Design.Retrospective cohort study in 21 hospitals in northeast Ohio.Subjects.25,697 women without prior cesarean deliveries admitted for labor and delivery January 1993 through June 1995.Methods.Demographic and clinical data were abstracted from patients' medical records. The risk of cesarean delivery was adjusted for 39 maternal and neonatal risk factors that were included in a previously developed risk-adjustment model using nested logistic regression analysis.Main Outcome Measures.Odds ratios for cesarean delivery in nonwhite patients relative to whites and for patients with government insurance or who were uninsured relative to patients with commercial insurance.Results.The overall rate of cesarean delivery was similar in white and nonwhite patients (15.8% and 16.1%, respectively), but rates varied (P< 0.001) according to insurance (17.0%, 14.2%, 10.7% in patients with commercial insurance, government insurance, and without insurance, respectively). However, after adjusting for clinical factors, the adjusted odds ratio (OR) of cesarean delivery was higher in nonwhite patients (OR = 1.34; 95% CI: 1.14-1.57;P< 0.001), but similar for patients with government insurance (OR = 1.01; 95% CI: 0.90-1.14;P= 0.84) and lower for uninsured patients (OR = 0.65; 95% CI, 0.41, 1.03;P= 0.067), albeit not statistically significant. In analyses stratified according to quintiles of predicted risk of cesarean delivery, racial differences were largely limited to patients in the lower risk quintiles. However, differences in odds ratios for uninsured patients were seen across the risk quintiles, although odds ratios were not statistically significant.Conclusion.After adjusting for clinical factors, race and insurance status may independently influence the use of cesarean delivery. The higher rates in nonwhites and lower rates in the uninsured may reflect differences in patient preferences or expectations, differences in physician practice, or unmeasured risk factors. The lower odds of cesarean delivery in uninsured women, particularly women at high risk, may raise the issue of underutilization of services and warrants further study.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.In a highly competitive health care environment, even microgeographic differences in availability of tertiary services might affect access to care.Objectives.To study the impact of (1) geographic distance from patient's residence to cardiac revascularization services and (2) the availability of cardiac revascularization services at the hospital nearest the patient's residence on utilization of these services in a geographically small, densely populated area.Methods.Historical cohort study of 55,659 New Jersey residents hospitalized between 1992 and 1996 with primary diagnosis of acute myocardial infarction (AMI).Main Study Outcomes.Use of percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft surgery (CABG) within 90 days of initial hospitalization for AMI and in-hospital mortality. Distance from patient's residence to nearest hospital with cardiac revascularization services (PTCA and CABG) was a straight-line distance in miles, categorized as 0 to <2, 2 to <5, 5 to <10, 10 to <15, 15 to <20, 20 to <25, ≥25 miles. Adjusted odds of PTCA or CABG use at each distance category were compared with odds at ≥25 miles.Results.A strong linear decline in adjusted odds ratios for PTCA use was found with increasing distance of this service from the patient's residence (p<0.05). Adjusted odds of PTCA use were 2.4, 2.1, 1.8, 1.5, 1.3, and 1.0 times higher for each increasing distance category in comparison with ≥25 for patients aged <65 and 3.1, 2.7, 2.2, 1.9, 1.7, and 1.1 for patients aged ≥65. Use of CABG was also higher for patients residing closer to cardiac revascularization services. The availability of these services at the hospital nearest to the patient's residence also increased utilization. In-hospital mortality was not associated with distance from services.Conclusion.Even across a relatively small geographic area, shorter distance to services and availability of services at the nearest hospital were strongly related to increased utilization of cardiac revascularization services.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.Previous research has indicated that the needs of persons infected with human immunodeficiency virus (HIV) for supportive services often go unmet. Although case management has been advocated as a method of decreasing unmet needs for supportive services, its effectiveness is poorly understood.Objectives.To assess the prevalence of need and unmet need for supportive services and the impact of case managers on unmet need among HIV-infected persons.Research Design.National probability sample.Participants.A total of 2,832 HIV-infected adults receiving care.Measures.Need and unmet need for benefits advocacy, housing, home health, emotional counseling, and substance abuse treatment services.Results.Sixty-seven percent of the sample had a need for at least one supportive service, and 26.6% had an unmet need for at least one service in the previous 6 months. Contingent unmet need (unmet need among persons who needed the service) was greatest for benefits advocacy (34.6%) and substance abuse treatment (27.6%). Fifty-seven percent of the sample had had contact with their case manager in the previous 6 months. In multiple logistic regression analysis, with adjustment for covariates, having a case manager was associated with decreased unmet need for home health care (OR = 0.39; 95% CI = 0.25-0.60), emotional counseling (OR = 0.54; 95% CI = 0.38-0.78), and any unmet need (OR = 0.70; 95% CI = 0.54-0.91). An increased number of contacts with a case manager was significantly associated with lower unmet need for home health care, emotional counseling, and any unmet need.Conclusions.Need and unmet need for supportive services among HIV-infected persons is high. Case management programs appear to lower unmet need for supportive services.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objective.This study examined differences in the odds of receiving health promotion/disease prevention services recommended by the US Preventive Services Task Force among three subgroups of patients. It tested the hypotheses that those most uninvolved in their own health (as exemplified by the lack of knowledge of blood pressure and cholesterol levels despite having been tested) would receive the least other health promotion services, and those being treated for both high blood pressure and hyperlipidemia would receive the most additional services.Methods.A mail survey was sent to a random sample of 68,422 veterans who had obtained primary care from any of the 153 Veterans Health Administration facilities in 1996. The adjusted response rate was 68%. Subgroup analyses were performed on three subgroups who reported having been tested for both hypertension and hyperlipidemia in the previous year (n= 5,113).Results.Both hypotheses were supported. Uninvolved patients were the least likely subgroup to report obtaining other recommended health promotion services, and the dually treated were most likely. The uninvolved subgroup was significantly more likely to report being female, physically inactive, current smokers, and heavy alcohol drinkers, and to report having a problem with alcohol, and significantly less likely to report being ≥50 years of age and overweight, to almost always wear seat belts, and to obtain at least 90% of their health care at the Veterans Health Administration.Conclusions.Clinicians need to encourage all patients to receive health promotion services, but in particular they should be aware that those who do not know their last hypertension and cholesterol levels despite having been tested are particularly in need of attention.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Background.The inadequacy of quality of care in nursing homes has been and continues to be a focus of public concerns. Understanding the relationship between quality and costs can offer guidance to policies designed to encourage high quality.Objectives.To investigate the relationship between costs and quality of care in nursing homes, and to test the hypothesis that higher quality may be associated with lower costs.Research Design.Statistical regression techniques were used to estimate nursing home variable-cost functions that included three risk-adjusted outcome measures of quality. Quality measures were based on decline in functional status, worsening pressure ulcers, and mortality. The study hypothesis was tested by an F test for the exclusion of nonlinear quality variables in the cost functions.Subjects.The study included 525 free-standing private and public nursing homes in New York State, or 84% of all nursing homes in the state during 1991.Results.F tests rejected the hypotheses that the three quality measures could be excluded from the cost function and that the association between costs and quality was linear. An inverted U-shaped relationship between quality and costs suggests that there are quality regimens in which higher quality is associated with lower costs.Conclusions.Policies that encourage research to identify care protocols and management strategies leading to better outcomes and lower costs, as well as policies that encourage dissemination of such practices, may prevent decline in quality despite the continued financial constraints faced by nursing homes.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Objectives.Both the Medicare and Medicaid programs have experienced considerable growth in spending on home care in recent years. As policymakers adopt measures (such as those legislated in the Balanced Budget Act of 1997) to curb the rate of spending growth on home care services, it is important to understand interactions between the Medicare and Medicaid home care programs in serving the dually enrolled population. This study examines the potential effects of the Medicaid home care program on Medicare home health utilization using multivariate models.Methods.The study relied on data from the Health Care Financing Administration's Medicare Current Beneficiary Survey (MCBS), a longitudinal survey of Medicare enrollees. The primary MCBS file used was from Round 1 of the survey, which was fielded between September and December 1991. The unit of analysis was individuals. The authors used descriptive and multivariate methods to explore the relationship between Medicare coverage and state home care program characteristics. Included were variables that have been found to be significant determinants of Medicare home health utilization in other studies as well as variables to indicate the availability and generosity of Medicaid home care services in each state represented in the survey.Results.The findings were consistent with those of previous studies, in that dual enrollees were disproportionate users of Medicare home health services, accounting for only 16% of enrollees but receiving 40% of all visits. In addition, lower levels of Medicare home health use were observed in states with relatively higher Medicaid spending on home health and personal care services, but this relationship appeared to be heavily dominated by the inclusion of enrollees living in New York State. When individuals from New York were excluded from the analysis, we found a negative but statistically significant relationship between Medicaid outlays on home health and personal care services and Medicare home health utilization.Conclusions.Because the Medicare and Medicaid programs are interconnected through the sizable dual enrollee population, changes in one program are likely to have ramifications for the other. This study presents another step in exploring how the two programs interact and emphasizes the fact that costs can be shifted between the two programs as policy changes are made to control the rate of home care spending growth.

ISSN:0025-7079    

出版商:OVID    

年代:2000

数据来源: OVID