ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Objectives.To explore whether differences in disease prevalence, disease severity, or emergency department (ED) admission thresholds explain why black persons, Medicaid, and uninsured patients have higher hospitalization rates for ambulatory care sensitive (ACS) conditions.Materials and methods.The National Hospital Ambulatory Care Survey was used to analyze the ED utilization, disease severity (assessed by triage category), hospitalization rates, and follow-up plans for adults with five chronic ACS conditions (asthma, chronic obstructive lung disease, congestive heart failure, diabetes mellitus, and hypertension). The National Health Interview Survey was used to estimate the prevalence of these conditions in similarly aged US adults.Results.Black persons, Medicaid, and uninsured patients make up a disproportionate share of ED visits for these chronic ACS conditions. Cumulative prevalence of these conditions was higher in black persons (33%) compared with white persons (27%) and Hispanic persons (22%), but did not differ among the payment groups. All race or payment groups were assigned to similar triage categories and similar percentages of their ED visits resulted in hospitalization. Black persons and Hispanic persons (odds ratios for both = 0.7), were less likely than white persons, whereas Medicaid and uninsured patients (odds ratios for both = 0.8), were less likely than private patients to have follow-up with the physician who referred them to the ED.Conclusions.The disproportionate ED utilization for chronic ACS conditions by black persons and Medicaid patients does not appear to be explained by either differences in disease prevalence or disease severity. Follow-up arrangements for black persons, Medicaid, and uninsured patients suggest that they are less likely to have ongoing primary care. Barriers to primary care appear to contribute to the higher ED and hospital utilization rates seen in these groups.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Objective.The purpose of this study was to compare the sensitivity of four generic effectiveness measures with clinically meaningful symptom improvement in persons with schizophrenia.Method.Baseline and 6-month interviews were conducted with 134 subjects diagnosed with schizophrenia or schizoaffective disorder. The design was observational. The four generic effectiveness measures included the Quality of Well-Being scale (QWB), a quality-adjusted index score based on the SF-36 VAS, Veterans SF-36 mental health component summary score (MCS), and the World Health Organization Disablement Assessment Schedule (WHO-DAS). Symptom measures included the Positive and Negative Syndrome Scale (PANSS) and Calgary Depression Scale (CDS). The side effect measure was the Extrapyramidal Symptom Rating Scale (ESRS). Data analysis included correlations between symptom, side effect, and generic effectiveness change scores; and an effect size calculation to detect a clinically significant improvement in the total PANSS.Results.All four effectiveness measures were correlated with changes in side effects. All but the SG-36 VAS were correlated with changes in depression. Only the QWB was correlated with changes in PANSS scores. The QWB required at least three times fewer subjects (n = 61) to detect a clinically significant improvement in total PANSS compared with the other effectiveness measures (n = 201–324).Conclusions.It is recommended that clinicians and researchers use the QWB to demonstrate the effectiveness and cost-effectiveness of schizophrenia interventions. The QWB allows for direct comparison of the effectiveness and cost-effectiveness of schizophrenia interventions with other mental and physical health interventions and may contribute to a greater recognition of the value of mental health interventions.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Objectives.The relative performance of three widely used generic health status measures (EQ-5D, a modified HUI3 [mHUI3], and SF-12) was compared within a general population sample.Materials and methods.Data were taken from a cohort of persons identified from the patient list of a large general practice in York, UK. Two-way comparisons were made between EQ-5D and mHUI3 and EQ-5D and SF-12. The measures were assessed in terms of their practical viability, coverage, and discrimination. Practical viability was evaluated in terms of the extent of missing responses and the proportion indicating difficulty with a measure. Coverage examined the range of responses across the items in the measures. Discrimination examined the capacity of the measures to discriminate between persons according to their self-reported morbidity and socioeconomic status.Results.One thousand one hundred twenty-six persons completed a postal questionnaire containing EQ-5D and either mHUI3 (n = 593) or SF-12 (n = 533). Missing responses were low across all three instruments. SF-12 showed a broad distribution of responses across its items however, responses on the mHUI3 hearing, speech and dexterity dimensions and the EQ-5D self-care dimension were highly skewed, with few persons reporting problems. In terms of summary scores, mHUI3 identified more mild health states than EQ-5D. EQ-5D and mHUI3 showed slightly better discrimination than SF-12.Conclusions.Despite the inherent differences in their descriptive systems and scoring functions, no one instrument performed better or worse than the other with respect to the criteria applied in this study. Some of the issues to be considered when choosing a population health measure are discussed.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Objective.Examine disparity in health services and outcomes for adults with a hip fracture or lower extremity joint replacement.Materials and methods.This study examined 28,522 patient records including 12,328 (mean age 76.6 years) with hip fracture and 16,194 (mean age 71.8 years) with joint replacement.Results.Non-Hispanic white and black patients were significantly (P<0.05) more likely to be discharged home alone and responsible for their own care than were Asian or Hispanic patients. Sixty-four percent of Hispanic patients received inpatient rehabilitation after hip fracture and 36% after hip or knee arthroplasty. In contrast, 58% of non-Hispanic white persons, 67% of black persons, and 56% of Asian persons received inpatient medical rehabilitation after hip or knee joint replacement.Conclusion.Disparity in outcomes appeared to be related to family structure and social support.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Objectives.The specialty referral process is one of the chief targets of managed care constraints on ambulatory medical decision-making. This study examines the influence of gatekeeping arrangements and capitated primary care physician (PCP) payment on the specialty referral process in primary care settings.Research Design.Primary care practice-based study of referred and nonreferred office visits.Subjects.The study comprised 14,709 visits made by privately insured, nonelderly patients who were seen by 139 primary care physicians in 80 practices located in 31 states.Measures.Visits were grouped by health plan type: gatekeeping with capitated PCP payment; gatekeeping with fee-for-service PCP payment; no gatekeeping. Dependent measures included the proportion of visits referred, characteristics of referrals, and physician coordination activities.Results.The percentages of office visits resulting in a referral were similar between the two gatekeeping groups and higher than the no gatekeeping group. Patients in plans with capitated PCP payment were more likely to be referred for discretionary indications than those in nongatekeeping plans (15.5% v 9.9%,P<0.05). The frequency of referring physician coordination activities did not vary by health plan type. The proportion of patients in gatekeeping health plans within a practice was directly related to employing staff as referral coordinators, allowing nurses to refer without physician consultation, and permitting patients to request referrals by leaving recorded telephone messages.Conclusion.The specialty referral process for privately insured nonelderly patients enrolled in managed health plans is generally similar, regardless of the presence of gatekeeping arrangements and capitated PCP payment. An increase in the number of discretionary referrals among patients in plans with capitated PCP payment provides support for exploring strategies that encourage PCPs to manage in their entirety conditions that straddle the boundaries between primary and specialty care. In response to increasing numbers of patients enrolled in managed health plans with gatekeeping arrangements, physicians appear to modify the structure of their practices to facilitate access to and coordination of referrals.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.The present study examined the structure and reliability of the Dutch version of the Patient Satisfaction Questionnaire III (PSQ III). The PSQ III was designed to measure technical competence, interpersonal manner, communication, time spent with doctor, financial aspects, and access to care. In the Dutch version, the financial items were left aside because these are not appropriate for the Dutch socialized system.Objectives.The main objectives were to assess response bias, the number of dimensions needed to describe the PSQ III items, and the reliability of the scales. In addition, distribution characteristics were examined and norm scores to interpret satisfaction scores in an oncological setting were presented.Research Design.A cross-sectional survey study.Subjects.The study was comprised of 1594 cancer patients from eight hospitals.Measures.The Dutch version of the PSQ III.Results.Approximately 14% of the respondents were found to demonstrate considerable response bias. Confirmative factor analyses were performed to test three theoretical models with a varying number of dimensions among those participants who did not demonstrate response bias. The original structure did not fit the data well, but support was found for a three-factor model (with interpersonal manner, communication, and time spent with doctor loading on one factor instead of separate factors) and a one-dimensional model.Conclusions.The PSQ III seems to be an appropriate measure of cancer patients’ satisfaction, with the note that the number of dimensions may vary for different patient groups and/or care settings and that it is important to be aware of response bias.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.Public sector mental health treatment has been transformed in recent years by the advent of managed care, but investigators of managed care policy have not yet focused on ethnic minority children, especially those involved with the child welfare system. Because of an overrepresentation of high-need minority children, foster care in particular is important to consider.Objectives.The present study examined children placed in foster care and documented differences between minority children and youth (black persons, Hispanic persons, and white persons) in use of mental health services. The primary concern of the study was to consider whether there were differences in access to services or service use among the groups in the transition to capitated managed care.Materials and methods.Medicaid claims and encounter data for two experimental managed care sites and one comparison fee-for-service site are used in a “difference-in-difference” analysis to estimate a changes in inpatient, outpatient, and residential treatment center (RTC) utilization, controlling for patient characteristics.Results.The study finds persistent declines in inpatient and outpatient use for all ethnic groups, persistent under-representation of Hispanic persons and black persons in treatment regardless of managed care, and greater use of RTCs by black persons and Hispanic persons that is attributable in part to managed care.Conclusions.Black and Hispanic children received more rather than less mental health care under capitated managed care. The significance of this shift, largely increased in use of RTCs, however, cannot be determined at present, as the effectiveness of treatment delivered in RTCs is not known.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background and Objectives.This study used the Behavioral Model for Vulnerable Populations16to identify determinants of receipt of outpatient medical care within 6 months of initial contact with a national homeless veterans outreach program.Research Design.Prospective study.Subjects.Homeless veterans contacted through the program in 1999 (n = 26,926).Measures.Data from structured interviews conducted at the time of program intake were merged with Veterans Affairs administrative data to determine subsequent medical service use. Logistic regression modeling was used to identify predisposing, enabling, and need factors from traditional and vulnerable domains predictive of receiving medical care.Results.Overall, 41.8% of subjects received at least one medical visit in the 6 months after program intake; of these, 48.7% had three or more visits. In multivariate analyses, the likelihood of receiving medical care was, among other things, positively associated with age, female gender, and placement in residential treatment and negatively associated with duration of homelessness and being contacted through outreach versus referred or self-referred into the homeless program. Mental illness did not appear to be an additional barrier to initiating medical care; however, a diagnosis of substance abuse or schizophrenia was associated with a decreased likelihood of receiving three or more visits.Conclusion.A majority of homeless veterans contacted through a national outreach program failed to receive medical services within 6 months of program entry. Vulnerable-domain factors were important supplements to traditional variables in predicting use of medical services in the homeless population. Greater efforts are needed to ensure that mentally ill homeless persons are successfully linked with and engaged in medical treatment.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background.Although joint replacement can restore function for arthritis patients with severe joint disease, this procedure has not been used equally across racial groups. Differences in joint replacement use are assessed from a national sample.Objective.This study evaluates the role of health conditions and economic access to explain differences in joint replacement among older black and Hispanic minorities relative to white persons.Design.Longitudinal (1993–1995) Asset and Health Dynamics Among the Oldest Old (AHEAD) study.Setting.National probability sample of US community-dwelling older adults.Patient Population.AHEAD participants (n = 6159) aged 69 to 103 years.Measurements.The outcome is subject-reported 2-year use of any arthritis-related joint-replacement. Independent variables are demographics, health needs (arthritis, other medical conditions, functional health), and economic access (income, assets, education, and health insurance).Results.Older minorities reported arthritis-related joint replacements (black: 0.98%; Hispanic: 0.97%, annually) less frequently compared with white persons (1.48% annually). Older minorities were significantly less likely to use joint replacement compared with white persons (OR, 0.37; 95% CI, 0.20, 0.71) controlling for demographics, and arthritis and other health needs. Disparities remained significant (OR, 0.46; 95% CI, 0.22, 0.98) after additionally controlling for economic medical access. Use was lower among people who depended solely on Medicare compared with those with supplemental health insurance (OR, 0.46; 95% CI, 0.22, 0.95).Conclusions.These national data document low rates of arthritis-related joint replacement among older Hispanic persons comparable to black persons. Less use among older minorities compared with white persons is not explained by differences in health needs or economic access. Other cultural and attitudinal factors merit investigation to explain disparities.

ISSN:0025-7079    

出版商:OVID    

年代:2003

数据来源: OVID