摘要:

Objectives.Previous studies have found that health-status measures may be unable to detect clinically important changes for patients whose baseline health is poor (the "floor phenomenon"). It is not known whether this inability to detect change is confined to patients in very poor baseline health or whether the sensitivity of health-status instruments varies across the entire range of health states. The goals of this study were to see how changes in physical health, mental health, and overall health (1) depend on baseline (usual) health and (2) compare with patients' global assessment of changes in their health.Methods.Stable, ambulatory patients presenting to the emergency department of a public hospital retrospectively rated their usual physical health (eight items), mental health (three items), and overall health (one item); their health on the day of study entry using these same items; and their global assessment of the change in their health compared with baseline. Complete information on these items was available for 1,005 patients. Baseline scores on the physical and mental health subscales and the overall health item were divided into five categories: 81 to 100 (best), 61 to 80, 41 to 60, 21 to 40, and 0 to 20 (worst).Results.The mean difference in health from baseline to emergency department presentation decreased as the baseline health category worsened, as follows: physical health, −26.0, −35.9, −15.1, −9.5, +1.0; mental health, −23.0, −16.1, −9.6, 0.0, 6.6; overall health −64.0, −45.3, −28.4, −8.4, 10.4, respectively. However, patients' global assessment of health change showed the opposite trend; the proportion of patients rating their health as "much worse" than baseline increased as baseline health worsened. When only patients whose physical health score declined less than 10 points were analyzed, 14% of those in the best baseline health said their health was "much worse," whereas 74% of those with the worst baseline physical health said their health was "much worse" than baseline.Conclusions.These findings suggest that the sensitivity of health-status measures to change and the meaning of an incremental change in physical health or mental health vary depending on baseline health. This may result from noninterval properties of response options or from patients being at the lowest health state (the "floor") of individual questions. If health-status measures similar to this are to be used to compare the outcomes of treatment across diseases and for patients in a wide variety of baseline health states, weighting schemes may be needed to account for these effects.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.Use of antepartum tests of fetal well-being is widespread even though effectiveness in preventing fetal damage or stillbirth has not been established. The study objective was to examine whether aggressive use of these tests might contribute to increased rates of other birth outcomes, including low birth weight (LBW).Methods.A total of 3,235 low-income women receiving care from 28 clinic sites were studied. All women were eligible for Medi-Cal benefits. Clinic sites were classified as aggressive, moderate, or low users of antepartum tests. The relations between patient risk factors, clinic testing style, LBW, and other pregnancy outcomes were examined using multiple logistic regression.Results.After adjustment for risk factors, patients seen by aggressive testers had a risk of LBW higher than patients receiving care from moderate testers (odds ratio = 1.65;P<0.01). Rates of LBW within patients receiving care from moderate and low testers did not differ (P= 0.22). Patients seen by aggressive testers also had higher rates of preterm delivery, cesarean delivery, and provided more expensive care.Conclusions.Although antepartum testing is intended to prevent fetal distress, extremely aggressive use of antepartum testing may have unfavorable effects on LBW and other pregnancy outcomes. More attention should be paid to variation in obstetric practices in evaluations of the costs and effectiveness of public prenatal care programs.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.The authors assess the costs associated with treatment of dyspepsia with histamine2antagonists versus without availability of over-the-counter (OTC).Methods.A cost analysis was performed using a decision-analysis model. Patients with an initial episode of dyspepsia were studied. The model includes costs associated with consumption of OTC and prescription (Rx) medications for dyspepsia, physician visits and associated diagnostic testing, time spent for physician visits and diagnostic tests, and hospitalization costs.Results.The model is sensitive to the relative cost of histamine2antagonists when purchased Rx or OTC, as well as to the efficacy of these drugs in relieving dyspeptic symptoms. For patients with nonulcer dyspepsia (the largest group of likely consumers), the model demonstrates a cost savings if the OTC cost of the medication is slightly less than one third the Rx cost. Costs are similar whether or not histamine2antagonists are available OTC. If the symptom relief efficacies of histamine2antagonists are equivalent whether purchased by prescription only or OTC, then the health-care expenditures for a typical patient with dyspepsia are $204 for OTC availability and $203 for Rx-only use. Viewing costs from the perspective of a managed-care organization, expenditures for an episode of dyspepsia are $149 regardless of whether or not histamine2antagonists are available OTC. Restricting the analysis to patients with underlying nonulcer dyspepsia yields similar results. Variation of numerous assumptions and probabilities other than histamine antagonist cost and efficacy, including costs associated with physician visits and diagnostic tests, and the likelihood of seeking medical care, do not substantially affect the results of the model.Conclusions.Health-care costs associated with initial treatment of dyspepsia are similar regardless of the availability of histamine2antagonists OTC. This is due largely to the similar efficacy of these drugs compared with antacids and the predicted increase in diagnostic testing that may result if a patient visits a physician after failure to achieve symptom relief with OTC use of histamine2antagonists.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.The purpose of this study was to determine whether performing coronary artery bypass surgery on high-risk patients adversely affects the risk-adjusted mortality rates for patients of surgeons and hospitals in New York State compared with the impact of performing surgery on more routine patients.Methods.Risk-adjusted mortality rates were calculated for 31 hospitals and 87 surgeons for high-risk (a predicted mortality rate of at least 7.5%) and low-risk patients during the time period 1990 to 1992.Results.The risk-adjusted mortality for all high-risk patients was lower (2.94%) than the risk-adjusted mortality for other patients (3.02%). Fifteen of the 31 hospitals had a lower risk-adjusted mortality for all patients than they did for low-risk patients only, and no differences in either direction were statistically significant. Forty-one of 87 surgeons (47%) had risk-adjusted mortality for all patients that was at least as low as the risk-adjusted mortality for low-risk patients. In general, hospitals and surgeons with the lowest risk-adjusted mortality for all cases also had the lowest risk-adjusted mortality for high-risk cases.Conclusions.The authors conclude that there is no systematic bias against operating on high-risk coronary artery bypass graft patients in the risk-adjusted performance system in New York.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

The authors present an approximate but simple approach to comparing age-gender standardized rates of low-incidence events (mortality or morbidity) rates across several geographic areas. The presented method will be useful particularly when a person-level database, one that includes unique person identifiers, is not available. We specify conditions under which comparisons can be made without calculating empirical standard errors and worrying unduly about recurrent events. To compare indirectly standardized rates, only information on the size, the crude rate, and the standardized rate of the areas are needed. For comparing directly standardized rates, which requires stratum-specific rates, the method also requires stratum-specific total numbers of events and individuals but does not require person-level information. The proposed approach builds on previous work comparing rates using person-level data.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Objectives.Obtaining accurate and representative patient-centered data may be difficult among poor, inner-city patients because of changing addresses, variable access to telephones, and a higher prevalence of illitercy than in the populations in which many survey instruments were developed and tested. Assumptions about the usefulness of mailed surveys versus telephone interviews may not hold for the urban poor. Therefore, identifying the most efficient mode of survey administration in this population becomes an important methodological question.Methods.We conducted a randomized trial of patients discharged from the inpatient medicine service of an urban teaching hospital to compare telephone interview with mailed self-administration of a detailed instrument for measuring patients' experiences with hospital care. Our primary outcomes were response rate, missing data, and data collection costs. Patients were excluded if they were not discharged to home or were mentally or physically unable to complete mailed or telephone interviews. The research assistant contacted eligible patients while hospitalized, informed them of the postdischarge survey, and obtained current phone numbers an daddresses. Patients then were randomized to receive a 116-item satisfaction survey via one of two survey methods: mail-first (mailed surveys with follow-up on nonrespondents by telephone) or telephone-first (telephone interviews with follow-up of nonrespondents by mail).Results.Of the 252 patients enrolled, 130 were randomized to the mail-first and 122 to the telephone-first method. Responsse rates were higher with the telephone-first (73%) compared with the mail-first method (50%;P< 0.0001). Surveys obtained by the telephone-first method had fewer missing data (0.7 ± 2.39) for those items not involved in skip patterns compared with the mail-first method (7.1 ± 12.3;P<0.001) and were 42% less expensive per completed survey ($26.32 versus $37.35;P<0.0001).Conclusions.In this survey of patients served by an urban teaching hospital, a strategy of telephone interviews with mail follow-up proved less expensive and yielded a higher response rate with more complete data than using a method where mailed surveys were followed by back-up telephone interviews. In addition, we believe that the improved response rate for telephone interviews compared with those reported in the literature for similar populations is the result of informing inpatients of the survey and obtaining telephone numbers and addresses in the hospital.

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID

ISSN:0025-7079    

出版商:OVID    

年代:1997

数据来源: OVID