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Biomedical subjects

A M Epstein

Publications and source records attributed to A M Epstein.

At least 55 records · Page 3Linked to original sources
PubMed1994

Changes in insurance status and access to care for persons with AIDS in the Boston Health Study.

The purpose of this study was to measure unmet needs and changes in insurance status for persons with acquired immunodeficiency syndrome (AIDS). Thirty-six percent of the study's Boston-area respondents (n = 305) had a change in insurance coverage between AIDS diagnosis and interview. Medicaid coverage increased from 14% to 41%. Pneumocystis carinii pneumonia prophylaxis was nearly universal. Only 5% did not receive zidovudine, and intravenous drug users were at higher risk. Approximately 14% to 15% of patients reported problems in obtaining medical and dental services; Blacks, homeless persons, and those who were not high school graduates were at higher risk. Use of selected treatments for which there were clear clinical guidelines was adequate, yet disadvantaged groups were more likely than other persons with AIDS to face obstacles to other services.

Acquired Immunodeficiency Syndrome↗
PubMed1994

The impact of patient socioeconomic status and other social factors on readmission: a prospective study in four Massachusetts hospitals.

Readmissions to hospitals may serve as markers for morbidity, high costs, and potentially poor quality of care, yet little is known about the relation of socioeconomic factors to the likelihood of readmission. In this article, we used logistic regression models to examine the readmission experience of nearly 12,000 patients, adjusting for age, gender, hospital, severity of illness, and the overall probability of readmission within each diagnosis related group (DRG). After adjustment, patients were more likely to be readmitted within 60 days if they were poor (OR = 1.25, p < .05), worked in unskilled or semiskilled occupations (OR = 1.25, p < .05), or rented their homes (OR = 1.23, p < .01). Nonwhites (OR = .76, p < .01) and uninsured patients (OR = .48, p < .01) were less likely to be readmitted. Within a 7-day period, patients who rented their homes were more likely to be readmitted (OR = 1.32), while patients were less likely to be readmitted if they were uninsured (OR = .36) or nonwhite (OR = .72) (all p < .05). Social support factors including marital status, living situation, and availability of help at home were not associated significantly with the risk of readmission. Our results suggest that patients in lower socioeconomic positions have higher readmission rates, at least for readmissions within longer time periods. Providers designing interventions to reduce the risk of readmission may want to target the groups identified by our study.

Demography↗
PubMed1993

The relation between health insurance coverage and clinical outcomes among women with breast cancer.

BACKGROUND: Women without private health insurance are less likely than privately insured women to be screened for breast cancer, and their treatment may differ after cancer is diagnosed. In this study we addressed two related questions: Do uninsured patients and those covered by Medicaid have more advanced breast cancer than privately insured patients when the disease is initially diagnosed? And, for each stage of disease, do uninsured patients and patients covered by Medicaid die sooner after breast cancer is diagnosed than privately insured patients? METHODS: We studied 4675 women, 35 to 64 years of age, in whom invasive breast cancer was diagnosed from 1985 through 1987, by linking New Jersey State Cancer Registry records to hospital-discharge data. We compared the stage of disease and stage-specific survival among women with private insurance, no insurance, and Medicaid coverage through June 1992. We also estimated the adjusted risk of death for these groups, using proportional-hazards regression analysis to control for age, race, marital status, household income, coexisting diagnoses, and disease stage. RESULTS: Uninsured patients and those covered by Medicaid presented with more advanced disease than did privately insured patients (P < 0.001 and P = 0.01, respectively). Survival was worse for uninsured patients and those with Medicaid coverage than for privately insured patients with local disease (P < 0.001 for both comparisons) and regional disease (P < 0.001 for both comparisons), but not distant metastases. The adjusted risk of death was 49 percent higher (95 percent confidence interval, 20 to 84 percent) for uninsured patients and 40 percent higher (95 percent confidence interval, 4 to 89 percent) for Medicaid patients than for privately insured patients during the 54 to 89 months after diagnosis. CONCLUSIONS: The more frequent adverse outcomes of breast cancer among women without private health insurance suggest that such women would benefit from improved access to screening and optimal therapy.

Adult↗
PubMed1993

The effect of health coverage for uninsured pregnant women on maternal health and the use of cesarean section.

OBJECTIVES: Although there has been substantial policy interest in interventions to improve the neonatal outcomes of disadvantaged women, little attention has been paid to the health status of pregnant women themselves. We therefore examined whether the provision of health coverage to uninsured low-income pregnant women affects maternal health status or the use of cesarean section. DESIGN: Natural experiment in Massachusetts. PATIENTS: All in-hospital, single-gestation births in 1984 (N = 57,257) and 1987 (N = 64,346). INTERVENTION: Healthy Start is a statewide health coverage program for uninsured pregnant women. In 1985, it covered women with incomes below 185% of the federal poverty level. MAIN OUTCOME MEASURES: Rates of adverse maternal outcome (severe pregnancy-related hypertension, placental abruption, and a length of stay at least 1 day longer than infants' stay) and cesarean section for uninsured women, and for two concurrent control groups, women with Medicaid and women with private insurance. We calculated the difference in rates between the uninsured and each concurrent control. We then examined the change in these interpayer differences in rates between 1984 and 1987 to measure the effect of Healthy Start. MAIN RESULTS: In 1984, uninsured women had higher rates of adverse maternal health outcome than privately insured women (5.5% vs 5.1%, respectively; interpayer difference, 0.4%) and received fewer cesarean sections (17.2% vs 23.0%; interpayer difference, -5.8%). Between 1984 and 1987 there was no statistically significant change in the interpayer difference in adverse outcome relative to women with private insurance. However, the interpayer difference in cesarean sections between the uninsured and the privately insured was reduced by 2.3% (95% confidence interval [CI], +0.4% to +4.2%), although the uninsured continued to undergo fewer cesarean sections (22.4% vs 25.9%). Similar results were observed when the uninsured women were compared with women with Medicaid. CONCLUSIONS: The provision of health insurance alone to low-income pregnant women may not be associated with an improvement in maternal health. Expanded coverage was associated, however, with an increase in the rate of cesarean section.

Adult↗
PubMed1993

Racial differences in the use of revascularization procedures after coronary angiography.

OBJECTIVE: To assess whether rates of coronary revascularization procedures differ between blacks and whites after coronary angiography is performed and to assess the relationship of these rates to hospital characteristics. DESIGN: A retrospective cohort study using 1987 and 1988 data on hospital claims and characteristics from the Health Care Financing Administration. SETTING: One thousand four hundred twenty-nine acute care hospitals that provide coronary angiography in the United States. PATIENTS: A national sample of 27,485 Medicare Part A enrollees, aged 65 to 74 years, who underwent inpatient angiography for coronary heart disease in 1987. MAIN OUTCOME MEASURE: The adjusted odds of revascularization with either coronary angioplasty or bypass graft surgery within 90 days of angiography for whites relative to blacks, controlling for age, sex, region, Medicaid eligibility, principal diagnosis, comorbid diagnoses, and hospital characteristics of ownership, teaching status, urban/suburban or rural location, and availability of revascularization procedures. RESULTS: White men and women were significantly more likely than black men and women, respectively, to receive a revascularization procedure after coronary angiography (57% and 50% vs 40% and 34%, both P < .001). The adjusted odds of receiving a revascularization procedure after coronary angiography were 78% higher for whites than blacks (95% confidence interval for odds ratio, 1.56 to 2.03). Statistically significant racial differences in the adjusted odds of receiving a revascularization procedure were present in all types of hospitals except rural hospitals, and these differences did not vary significantly by any of the four hospital characteristics (all P > .20 for interaction terms). CONCLUSIONS: Among Medicare enrollees, whites are more likely than blacks to receive revascularization procedures after coronary angiography. Racial differences of similar magnitude occur in all types of hospitals. These differences may reflect overuse in whites or underuse in blacks, but they are unlikely to reflect access to cardiologists or hospitals that perform revascularization procedures. Potential explanations include unmeasured clinical or socioeconomic factors, differing patient preferences, and racial bias at the hospitals performing angiography.

Black or African American↗
PubMed1993

Discussion of preferences for life-sustaining care by persons with AIDS. Predictors of failure in patient-physician communication.

OBJECTIVES: To assess the determinants of communication about resuscitation between persons with acquired immunodeficiency syndrome (AIDS) and their physician. DESIGN AND SETTING: Structured patient interview at a staff-model health maintenance organization (HMO), an internal medicine group practice at a private teaching hospital, and an AIDS clinic at a public hospital. PATIENTS: 289 persons with AIDS. MAIN RESULTS: Only 38% of patients had discussed their preferences for resuscitation with their physician. Using logistic regression, we found that patients were less likely to have discussed resuscitation with their physician if they were nonwhite (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.24 to 0.99), had never been hospitalized (OR, 0.52; 95% CI, 0.27 to 0.99), or were cared for in the HMO (OR, 0.44 relative to the private teaching hospital; 95% CI, 0.23 to 0.82). Patients were more likely to have discussed their preferences if they were not currently taking zidovudine (OR, 1.76; 95% CI, 1.02 to 3.03) and if they had decided to defer life-sustaining therapy (OR, 2.30; 95% CI, 1.35 to 3.91). Among nonwhites, those with a nonwhite physician were more likely to have discussed resuscitation (OR, 4.38; 95% CI, 1.13 to 16.93). Of patients who had not discussed their preferences for life-sustaining care, 72% wanted to do so. Patient desire for discussion of this issue did not vary by race, severity of illness, hospitalization status, use of zidovudine, or site of care. CONCLUSIONS: A majority of persons with AIDS in this study had not discussed their preferences for life-sustaining care with their physician, despite the desire to do so. Interventions to improve patient-physician communication about resuscitation for nonwhites and other groups at risk of inadequate discussion might lead to clinical decisions that are more consistent with patient preferences.

Acquired Immunodeficiency Syndrome↗
PubMed1993

The effect of providing health coverage to poor uninsured pregnant women in Massachusetts.

OBJECTIVES: There has been substantial policy interest in whether the provision of health coverage to poor uninsured pregnant women affects access to prenatal care and birth outcomes. We therefore examined whether the statewide provision of health coverage to uninsured low-income pregnant women affects access to prenatal care and infant birth outcomes. DESIGN: Natural experiment. PATIENTS: All in-hospital, single-gestation live births in 1984 (N = 57,257) and 1987 (N = 64,346). INTERVENTION: In 1985, Massachusetts instituted Healthy Start, a program providing health coverage to uninsured pregnant women with incomes below 185% of the federal poverty level. MAIN OUTCOME MEASURES: Rates of satisfactory prenatal care, care initiated before the third trimester, and adverse infant outcome for uninsured women and for two concurrent control groups, women with Medicaid, and women with private insurance. We calculated the difference in rates between the uninsured and each concurrent control. To assess the effect of the program, we examined the change in these interpayer differences in rates between 1984 and 1987. MAIN RESULTS: Between 1984 and 1987, the rate of satisfactory prenatal care declined from 96.4% to 93.8% for all women in Massachusetts (P < .001). There was no statewide change in the overall incidence of adverse birth outcome (6.6% in both years). In 1984, uninsured women were less likely than privately insured women to receive satisfactory prenatal care (90.5% and 98.1%, respectively; interpayer difference, -7.6%) and to initiate care before the third trimester (94.2% and 99.1%; interpayer difference, -4.9%), and were more likely to suffer an adverse birth outcome (7.1% and 5.8%; interpayer difference, 1.3%). Between 1984 and 1987, there were no statistically significant changes in the interpayer differences in rates for any of the outcome measures relative to either control group. CONCLUSIONS: Our findings suggest that access to prenatal care may have declined for all women in Massachusetts between 1984 and 1987. In the setting of this statewide decline in access, the expansion of health coverage to uninsured low-income pregnant women was not associated with an improvement in access to prenatal care or birth outcomes.

Female↗
PubMed1993

Physicians' liking for their patients: more evidence for the role of affect in medical care.

Correlates of physicians' liking for their patients were examined among 17 internists at a health maintenance organization and 530 of their patients 70 years of age and older. Analyses were conducted for the entire sample as well as for individual physicians, whose results were combined by meta-analysis. Both kinds of analysis showed that patients were more liked when they were in better health (based on psychometric measures of social, emotional, functional, and overall self-rated health) and when they were more satisfied with their care. In addition, male patients were liked more than female patients, and physicians who were female and less experienced liked their patients more.

Adult↗
PubMed1993

A causal model of health status and satisfaction with medical care.

Patients with better health status have often been shown to be more satisfied with their medical care, but the causal factors in this relation have not been determined. In this study, a longitudinal assessment of these two constructs was undertaken in which older patients in a health maintenance organization were interviewed at baseline (N = 590) and again 1 year later (N = 526) about their health status and satisfaction with their medical care. Structural equation modeling using LISREL procedures revealed that the predominant direction of causation went from earlier self-perceived overall health and functional ability to later levels of satisfaction. There was no evidence for causal paths going from satisfaction to later health. In addition, a test of spuriousness indicated that for self-perceived overall health, the significant longitudinal path was unlikely to be explained by unmeasured confounding variables.

Activities of Daily Living↗
PubMed1993

The effects of intravenous drug use and gender on the cost of hospitalization for patients with AIDS.

At present limited data exist describing the hospital use patterns of intravenous drug users (IVDUs) and women with AIDS. Our objective was to determine if frequency of hospitalization, length of stay (LOS), and cost per hospitalization varied by risk status and gender, controlling for a variety of confounders, including severity of illness as measured by the Turner-Kelly-Ball and Justice AIDS severity of illness systems. We performed a population-based cohort study that compared all women (n = 69) and male IVDUs (n = 74) with AIDS diagnosed in Massachusetts in 1987 with a random sample of all male, nonintravenous drug-using patients diagnosed in that year (n = 148). Frequency of hospitalization, LOS, and cost of hospital care were obtained from hospital billing records for 1987 and 1988. Regression analysis showed 42% longer lengths of stay (p < or = 0.001) and 38% higher cost (p < or = 0.001) per hospitalization for IVDUs with AIDS compared with non-IVDU homosexual AIDS patients. No statistically significant differences by gender were observed. Our results suggest that hospital care for IVDUs is likely to be more expensive. Policymakers should incorporate these data when planning for AIDS care. In addition, instruments to assess severity of illness should incorporate information on intravenous drug use.

Acquired Immunodeficiency Syndrome↗
PubMed1993

Physician payment reform: past and future.

Medicare's decision to compensate physicians using a fee schedule based on the relative value of their services was an attempt to rationalize fee-for-service payment of physicians. Reformers hoped also to control the costs of care, improve its quality, and protect access to health services among Medicare beneficiaries. A close examination of the system's provisions indicates, however, that the reform does not address many fundamental problems that have plagued physician payment under Medicare in the past. In the cost area, for example, the new fee schedule does not affect such factors as the basic incentives built into fee-for-service medicine and the explosion of new medical technologies. The failure of the program to achieve its goals in cost containment and other areas could result in abandonment of fee-for-service compensation of physicians under Medicare.

Cost Control↗
PubMed1992

The relation between hospital experience and mortality for patients with AIDS.

OBJECTIVE: To determine whether there is an association between mortality and hospital acquired immune deficiency syndrome (AIDS) experience for all AIDS-related diagnoses, and to determine whether the association is explained by differences in severity of illness, earlier discharge of terminally ill patients, or differences in resource use. DESIGN AND SETTING: Population-based statewide cohort study. All hospitalizations identified for a cohort of AIDS patients diagnosed during 1987 in 40 Massachusetts hospitals were included. PATIENTS: All women and all male intravenous drug users (n = 151), and a random sample of all male non-intravenous drug users diagnosed with AIDS during 1987 in Massachusetts (n = 149). MAIN OUTCOME MEASURES: Primary end points studied were (1) inpatient mortality and (2) 30-day mortality. Length of stay, cost, and intensive care unit use were also examined. RESULTS: In 806 hospitalizations at 40 hospitals inpatient mortality was 13.2%. Relative risk of mortality at low AIDS experience hospitals was 2.16 (95% confidence interval, 1.43 to 3.26) compared with high AIDS experience hospitals. When logistic regression was used to control for age, sex, race, human immunodeficiency virus transmission mode, severity, payer, admission type, hospital ownership, and teaching status, low hospital experience with AIDS remained a significant predictor of inpatient mortality (relative risk, 2.92; 95% confidence interval, 1.37 to 6.22). Comparisons of 30-day mortality by hospital AIDS experience yielded similar results. Length of stay and intensive care unit use were also significantly higher at low-experience hospitals after controlling for severity of illness (P < .05). CONCLUSIONS: We conclude that mortality of AIDS patients is higher at hospitals with less AIDS experience. This finding is not because of greater severity of illness, differences in discharge patterns of the terminally ill, or less intensive use of resources.

Acquired Immunodeficiency Syndrome↗
PubMed1992

Acute myocardial infarction in the Medicare population. Process of care and clinical outcomes.

OBJECTIVE: To describe the process of care and clinical outcomes associated with acute myocardial infarction (AMI) in the Medicare population, and to examine differences in process of care and outcome of care as a function of patient age, gender, and race. DESIGN: Retrospective cohort study using a longitudinal database created from Medicare utilization and administrative files. PATIENT POPULATIONS: A cohort of AMI patients covered by Medicare in 1987 and a random sample of Medicare patients without AMI. MAIN PROCESS AND OUTCOME MEASUREMENTS: (1) The use of coronary angiography, coronary artery bypass graft surgery, and percutaneous transluminal coronary angioplasty during the first 90 days after a new AMI; (2) mortality at 30 days, 1 year, and 2 years; (3) reinfarction rates; and (4) reoperation rates for coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty. MAIN RESULTS: Mortality rates were high: 26% at 30 days, 40% at 1 year, and 47% at 2 years. They varied greatly by age, less so by gender and race, and were high even among patients who survived the first 30 days. Compared with mortality, reinfarction was uncommon, occurring in 7.3% of patients. During the first 90 days, 23% of all patients underwent angiography and 13% underwent coronary revascularization (coronary artery bypass graft surgery, 8%; percutaneous transluminal coronary angioplasty, 5%). The use of all three procedures decreased with age and was less common among women and blacks than among men and whites. Differential use by age and race was greater for angiography than for revascularization procedures. CONCLUSIONS: The prognosis following AMI in patients aged 65 years and above is much worse than is commonly realized. Procedure use in these patients varies as a function of gender and race, even though mortality does not. Further research is needed to reduce the mortality of elderly patients with AMI and to understand the significance of differences in procedure use on the basis of sociodemographic characteristics.

Aged↗
PubMed1992

Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland.

OBJECTIVE: To determine whether uninsured and Medicaid patients have higher rates of avoidable hospitalizations than do insured patients. DESIGN: We used 1987 computerized hospital discharge data to select a cross-sectional sample of hospitalized patients. Population estimates from the Current Population Survey were used to estimate rates of admission, standardized for age and sex. SETTING: Nonfederal acute care hospitals in Massachusetts and Maryland. PATIENTS: All patients under 65 years of age who were uninsured, privately insured, or insured by Medicaid. Hospitalizations for obstetric and psychiatric conditions were excluded. MAIN OUTCOME MEASURES: Relative risk of admission for 12 avoidable hospital conditions (AHCs) identified by a physician panel. RESULTS: Uninsured and Medicaid patients were more likely than insured patients to be hospitalized for AHCs. Rates for uninsured patients were significantly greater than for privately insured patients in Massachusetts for 10 of 12 individual AHCs, and in Maryland for five of 12 AHCs. After adjustment for baseline utilization, the results were statistically significant for 10 of 12 AHCs in Massachusetts and seven of 12 AHCs in Maryland. For Medicaid patients, rates were significantly greater than for privately insured patients for all AHCs in each state before adjustment, and for nine of 12 and seven of 12 AHCs in each state, respectively, after adjustment for baseline utilization. CONCLUSION: Our findings suggest that patients who are uninsured or who have Medicaid coverage have higher rates of hospitalization for conditions that can often be treated out of hospital or avoided altogether. Our approach is potentially useful for routine monitoring of access and quality of care for selected groups of patients.

Adult↗
PubMed1992

Cost-effectiveness and cost-benefit analyses in the medical literature. Are the methods being used correctly?

OBJECTIVE: To determine whether published cost-effectiveness and cost-benefit analyses have adhered to basic analytic principles. DESIGN: Structured methodologic review of published articles. STUDY SAMPLE: Seventy-seven articles published either from 1978 to 1980 or from 1985 to 1987 in general medical, general surgical, and medical subspecialty journals. MAIN OUTCOME MEASUREMENTS: Articles were reviewed to assess the use and reporting of six fundamental principles of analysis. These principles were derived by reviewing widely cited textbooks and articles describing the methods for performing economic analyses and by selecting the methods universally recommended. MAIN RESULTS: Overall performance was only fair. Three articles adhered to all six principles, and the median number of principles to which articles adhered was three. Among the problems noted were failure to make underlying assumptions explicit and, therefore, verifiable, and failure to test assumptions with sensitivity analyses. No improvement in performance was observed between 1978 and 1987. Articles in general medical journals, however, were more likely to use analytic methods appropriately than articles in the general surgical or medical subspecialty literature. CONCLUSIONS: Greater attention should be devoted to ensuring the appropriate use of analytic methods for economic analyses, and readers should make note of the methods used when interpreting the results of economic analyses.

Cost-Benefit Analysis↗