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Biomedical subjects

A M Epstein

Publications and source records attributed to A M Epstein.

At least 91 records · Page 5Linked to original sources
PubMed1989

A comparison of length of stay and costs for health maintenance organization and fee-for-service patients.

Enrollees of health maintenance organizations (HMOs) are less frequently hospitalized than are patients cared for by fee-for-service physicians. To determine if care provided to HMO and fee-for-service patient is different once they are hospitalized, we compared length of stay, total costs, and severity of illness for 617 HMO and fee-for-service patients hospitalized during the period 1983 through 1985 at a major teaching hospital. Severity was gauged in the following two ways: the Severity of Illness Index developed by Horn, and ratings by two physicians who were given all records from the first day of each patient's hospitalization. Length of stay was shorter and total costs were less for HMO patients in 7 of 11 diagnosis related groups. Using regression analysis to adjust for age, sex, emergency ward admission, diagnosis related group, and severity, we found that overall length of stay was 14% shorter for HMO patients than for fee-for-service patients (6.2 vs 5.3 days, P less than .01), whereas total costs were only 4% less ($4251 vs $4090, P greater than .2). These findings indicate that while patterns of utilization may vary by diagnosis related groups, HMO patients had shorter lengths of stay but comparable overall costs. Whether shorter lengths of stay represent greater efficiency, substitution of outpatient for inpatient care, or diminution in the quality of care is not clear.

Boston↗
PubMed1989

Using proxies to evaluate quality of life. Can they provide valid information about patients' health status and satisfaction with medical care?

Instruments using interview data to measure health status have been increasingly used to measure patient outcomes. To assess the potential utility of proxy responses about health status when subjects are unable to respond, the authors compared the responses of 60 subject and proxy pairs on instruments measuring overall current health, functional status, social activity, emotional health, and satisfaction with medical care. Proxies were asked to respond as they thought the subject would. Subject and proxy responses were strongly correlated with each other for overall health, functional status, social activity, and emotional health (P less than .001), and moderately correlated for satisfaction (P less than .005). Proxies reported lower emotional health and satisfaction than did subjects (P less than .005). Proxy and subject mean responses were generally similar for overall health, functional status, and social activity. However, those proxies who spent more time per week helping the subject rated the subject's functional status and social activity as more impaired than did the subject (P less than .05). Subjects who had poorer overall health tended to rate their health relatively lower than did the proxies (P less than .05). These results suggest that use of proxies intermingled with subjects to measure health status through interview may lead to biased results.

Activities of Daily Living↗
PubMed1988

The association of patients' socioeconomic characteristics with the length of hospital stay and hospital charges within diagnosis-related groups.

To determine whether the hospital stays are longer and charges within a given diagnosis-related group (DRG) are higher for poor patients, we examined patterns of care for patients hospitalized at the Brigham and Women's Hospital for connective-tissue disorders (DRGs 240 and 241) from 1981 to 1985. The socioeconomic characteristics of 402 patients were determined through interviews, and the severity of their illness was measured by means of a standard scale of function--the Instrumental Activities of Daily Living (IADL) scale. After excluding outliers and adjusting for DRG, we found that hospital stays were significantly longer for subgroups of patients of lower socioeconomic status, whether this was defined by occupation, education, or income (P less than 0.05 for all three). Patients of low socioeconomic status also had higher total hospital charges, although the differences were not statistically significant. The differences between patients of low socioeconomic status and those of high socioeconomic status were as great as 25 percent for length of stay and 16 percent for charges. These trends persisted after we adjusted for patients' age and sex, the severity of illness, the year of discharge, the doctor's specialty, whether the patient had a regular doctor, and whether the patient lived alone. Our results suggest that for at least some conditions, hospital care for poor patients entails longer stays and probably requires the use of more resources.

Activities of Daily Living↗
PubMed1988

Changes in ambulatory testing for hypertensive patients 1971-1980.

To determine temporal changes in the outpatient use of diagnostic tests, the authors studied ambulatory testing for 208 patients diagnosed with uncomplicated hypertension, cared for by 15 private office internists in 1971 through 1980. Patients diagnosed and treated earlier in the decade tended to have significantly higher blood pressure. After adjustment for blood pressure, use of diagnostic tests in terms of total charges for testing per patient per year peaked between 1973-74 and thereafter remained fairly stable at a level slightly lower than that in 1973-74. Considering the decade as a whole, use of tests was generally greater for patients with higher blood pressure readings (P less than 0.05). These findings suggest that use of tests for hypertensive patients in outpatient settings is related to severity of disease. Although treatment of new patient groups may be one factor increasing medical costs, the use of tests per se may have stabilized for diseases in which the diagnostic technologies have remained stable.

Ambulatory Care↗
PubMed1988

Medical costs of ambulatory patients with AIDS-related complex (ARC) and/or generalized lymphadenopathy syndrome (GLS) related to HIV infection, 1984-85.

A cost-of-illness study July 1, 1984-June 30, 1985 evaluating 28 patients with AIDS-Related Complex (ARC) and/or Generalized Lymphadenopathy Syndrome (GLS) found the average cost to be $489 per patient per year. None of the ARC or GLS patients in our study was hospitalized during the one year period, and none progressed to AIDS. No AIDS-specific treatment such as AZT was available at the time this study was completed.

AIDS-Related Complex↗
PubMed1988

Capitation payment: using predictors for medical utilization to adjust rates.

The current adjusted average per capita cost methodology has been strongly criticized because the subgroup classifications explain minimal interpatient variation in utilization, therefore providing incentives for biased selection. In this article, we review previous investigations of predictors of medical utilization that might be included in the adjusted average per capita cost: perceived health status, functional health status, prior utilization, clinical descriptors, sociodemographic characteristics, and other miscellaneous patient characteristics. The existing data are analyzed to assess what is known about the relative strength of various predictors. Gaps in the available literature and the implications for future research and policy are discussed.

Aged↗
PubMed1987

Cost-effectiveness of antihyperlipemic therapy in the prevention of coronary heart disease. The case of cholestyramine.

Using cholestyramine as a model, we considered the cost-effectiveness of antihyperlipemic therapy in the primary prevention of coronary heart disease among men between 35 and 74 years of age with elevated levels of total plasma cholesterol. Our findings indicate that the cost-effectiveness of treatment varies substantially, ranging from about $36,000 to over $1 million per year of life saved. Cost-effectiveness was highest for younger patients, for those with additional coronary risk factors (eg, smoking or hypertension), and for those whose course of therapy is of less-than-lifelong duration. Conversely, it is lowest for older patients, for those with no additional coronary risk factors, and for those who are treated for a lifetime. Our results suggest that pharmacologic therapy may not be cost-effective for all patients with elevated cholesterol levels, especially those over 65 years of age. For many younger patients, however--those with additional coronary risk factors and more severe elevations in cholesterol levels--the cost-effectiveness of therapy may be comparable with other accepted medical practices.

Adult↗
PubMed1987

Differences in ambulatory test ordering in England and America. Role of doctors' beliefs and attitudes.

Forty-five American and English doctors were surveyed to determine whether differences in their beliefs about the incidence and morbidity of complications and the role of testing for patients with chronic hypertension could be contributing to the large cross-national differences previously demonstrated in ambulatory test use for such patients. For each of nine tests, the number the English doctors thought they "should order" was significantly less than that of the American group. English doctors also estimated a lower incidence for each of seven possible complications of hypertension, but there was no difference in perceived morbidity of the complications. Both groups thought results from testing would alter therapy for only a small proportion of patients; however, the English estimate was significantly smaller than the American (16 percent versus 27 percent: p less than 0.05). The reasons given for testing were very similar in the two countries except that American doctors ranked as more important the reason that patients used the quantity of test ordering as an indicator of quality care. These results suggest that differences in ambulatory test use are consistent with physicians' beliefs about the number of tests they should be ordering, disease incidence, the likelihood that testing will affect patient care, and patient expectations. Further study should be directed toward understanding the contributions that differences in physician beliefs about the natural histories of diseases and patient expectations make to variations in test ordering.

Ambulatory Care↗
PubMed1987

Variations in ambulatory test use: what do they mean?

This article discusses the meaning of variations in ambulatory test use with emphasis on practice setting, availability of testing services, financial incentives, and physician and patient characteristics.

Ambulatory Care↗
PubMed1987

The relation of body weight to length of stay and charges for hospital services for patients undergoing elective surgery: a study of two procedures.

We studied the relation of body weight to lengths of stay and total charges for all patients hospitalized at the Brigham and Women's Hospital for total knee replacement and total hip replacement during a 12-month period. Patients with moderate obesity (actual body weight 141-170 per cent of ideal) had lengths of stay and total charges similar to normal weight patients (body weight 100-110 per cent ideal). However, patients who were extremely overweight (body weight greater than or equal to 188 per cent ideal) had mean lengths of stay 35 per cent longer (28.9 days vs 21.5) and total charges 30 per cent higher ($25,692 vs $19,576) than patients with normal weight. Those who were extremely underweight (body weight less than or equal to 75 per cent ideal) had mean lengths of stay 40 per cent longer (30.1 days vs 21.5) and total charges 35 per cent higher ($26,447 vs $19,576).

Aged↗
PubMed1987

The emergence of geriatric assessment units. The "new technology of geriatrics".

Previous studies have suggested that geriatric assessment units may provide important benefits to the care of elderly persons. In early 1985 we surveyed personnel at 104 (91%) of the existing 114 geriatric assessment units associated with medical schools and Veterans Administration medical centers for information on the units' development and operation. Although almost 80% of the units were hospital based, most (61%) provided care for outpatients. Nearly half (47%) began operation in 1983 or later; of those in existence before 1983, two thirds have increased their capacity since then. The types of personnel and their training differed substantially among units. Fifty percent of the physicians had had no formal training in geriatrics. Of the 104 units, 99 (95%) did routine assessment. The estimated time spent per new patient in outpatient units was 2.7 +/- 2.1 (SD) hours. These data suggest that geriatric assessment units are proliferating rapidly, have differing structures, and consume substantial resources. Further efforts are needed to define their optimal structure, targets, and function.

Geriatrics↗
PubMed1987

Outpatient geriatric assessment in a Health Maintenance Organization. Its structure, practice, and clinical implications.

The authors review their experience with the implementation of a geriatric assessment unit (GAU) within the Rhode Island Group Health Association, a Health Maintenance Organization (HMO). Included is a historical background of the involvement of HMOs with care of Medicare patients, a description of the structure of an outpatient GAU, and the authors' experience to date with this population of patients. This article concludes with a discussion of the future role of GAUs and HMOs in the care of older patients.

Aged↗
PubMed1986

Medical care costs of AIDS in Massachusetts.

Previous investigation has suggested that the direct cost of medical care for the 24,011 reported patients with acquired immunodeficiency syndrome (AIDS) may be as high as $147,000 per patient. To evaluate the use and cost of medical services for patients with AIDS in Massachusetts, we performed a one-year cost of illness study of 45 AIDS patients. Sociodemographic and clinical data as well as information on medical utilization were obtained from review of outpatient and hospital records. Patients with AIDS required a mean of 3.3 (+/- 3.2) hospitalizations per year and 18.4 (+/- 21.8) ambulatory visits per year. Overall, medical costs averaged $46,505 +/- $38,720 per patient per year, with 91% of these expenditures related to use of inpatient services. These results suggest that the cost of medical care for AIDS patients may be substantially less than previously estimated.

Acquired Immunodeficiency Syndrome↗
PubMed1986

The use of ambulatory testing in prepaid and fee-for-service group practices. Relation to perceived profitability.

To examine the influence of method of payment on ambulatory testing by internists, we compared the rate at which patients with uncomplicated hypertension were tested by 10 doctors practicing in large fee-for-service groups with that by 17 doctors in large prepaid groups. We examined the use of individual tests and asked the doctors in the fee-for-service groups what they believed about the profitability and costs of tests. After correcting for the patient's age, sex, duration of disease, and severity of disease as measured by pretreatment blood pressure, and for the doctor's year of medical school graduation, we found that 50 percent more electrocardiograms were obtained among patients in fee-for-service practices (0.69 per patient per year vs. 0.45, P = 0.006), and 40 percent more chest radiographs (0.49 vs. 0.35, P = 0.11). Fee-for-service doctors believed that both tests were associated with high profit and costs. These results suggest that the use of certain high-profit, high-cost tests is higher in large fee-for-service groups than in large prepaid groups. Although the generalizability of conclusions based on this limited study must be considered tentative, the findings suggest that it may be appropriate to consider changing the payments for tests as part of a more general reform of the fee schedules.

Ambulatory Care↗
PubMed1986

Relationship of beliefs and behavior in test ordering.

Understanding the reasons physicians order diagnostic tests may be useful in designing strategies to promote cost-effective practice and helpful in developing appropriate endpoints for evaluations of new diagnostic technologies. Testing by 27 private office physicians for 324 hypertensive patients was examined and the doctors were surveyed for their beliefs about appropriate levels of use for common tests, how they compared with other doctors in frequency of use, and their reasons for ordering tests. Beliefs about appropriate levels of testing were correlated with actual use (0.45 to 0.63, Pearson). Usage also correlated with beliefs about relative ordering patterns. Annual testing charges incurred by physicians who believed they ordered tests "more frequently" than average were higher than those who believed they ordered tests "less frequently" than average ($122 +/- $46 versus $51 +/- $15, p less than 0.05). Reasons for ordering tests were (in order of importance): establishing a baseline, assessing prognosis, reassuring patients, and helping with treatment decisions. These results suggest that "high usage" physicians may know who they are; and therefore strategies of feedback to modify behavior should be designed to do more than educate physicians about their own utilization. Second, evaluations of technology must consider more than contributions to immediate treatment decisions.

Attitude of Health Personnel↗
PubMed1986

Primary prevention and coronary heart disease: the economic benefits of lowering serum cholesterol.

We examined the expected economic benefits of cholesterol lowering for adult men with significant elevations of total serum cholesterol (above 260 mg/dl), incorporating estimates of direct benefits from anticipated reductions in lifetime expenditures for medical care, and estimates of indirect benefits related to extension of work-life secondary to reductions in morbidity and premature mortality. Our findings yield discounted lifetime direct benefits of a 15 per cent reduction in total serum cholesterol of $3 to $208 per person, and discounted lifetime indirect benefits of $1 to $8,946. Benefits increase with an individual's initial cholesterol level and decrease with the age at which an intervention is initiated. Economic benefits increase approximately twofold in the presence of other coronary risk factors, such as cigarette smoking and hypertension. Results suggest that cholesterol-lowering interventions, no matter what their cost, are unlikely to result in substantial direct savings to the health care system. However, the indirect benefits of intervention are quite high for young and middle-aged adults, as well as for those with severe elevations of cholesterol or with additional coronary risk factors.

Adult↗