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Biomedical subjects

D Steinwachs

Publications and source records attributed to D Steinwachs.

At least 19 recordsLinked to original sources
PubMed2001

Quality of care and outcomes of adults with asthma treated by specialists and generalists in managed care.

BACKGROUND: The growth of managed health care in the United States has been accompanied by controls on access to specialty physician services. We examined the relationship of physician specialty to treatment and outcomes of patients with asthma in managed care plans. METHODS: We conducted a mail survey of adult asthma patients who were enrolled in 12 managed care organizations and had at least 2 contacts for asthma (International Classification of Diseases, Ninth Revision, Clinical Modification code 493.x) during the previous 24 months; we also surveyed their treating physicians. This report concerns 1954 patients and their 1078 corresponding physicians. Treatment indicators included use of corticosteroid inhalers, use of peak flow meters, allergy evaluation, discussion of triggers, and patient self-management knowledge. Outcome measures included canceled activities, hospitalization or emergency department visits, asthma attacks, workdays lost, asthma symptoms, physical and mental health, overall satisfaction with asthma care, and satisfaction with communication with physicians and nurses. RESULTS: Significant differences were noted for patients of specialists and experienced generalists compared with those of generalist physicians. Peak flow meter possession was reported by 41.9% of patients of generalists, 51.7% of patients of experienced generalists, and 53.8% of patients of pulmonologists or allergists. Compared with patients of generalists, outcomes were significantly better for patients of allergists with regard to canceled activities, hospitalizations and emergency department visits for asthma, quality of care ratings, and physical functioning. Patients of pulmonologists were more likely to rate improvement in symptoms as very good or excellent. CONCLUSIONS: In a managed health care setting, physicians' specialty training and self-reported expertise in treating asthma were related to better patient-reported care and outcomes.

Adolescent↗
PubMed2001

Race and sex differences in consistency of care with national asthma guidelines in managed care organizations.

BACKGROUND: In the United States, morbidity from asthma disproportionately affects African Americans and women. Although inadequate care contributes to overall asthma morbidity, less is known about differences in asthma care by race and sex. SUBJECTS AND METHODS: To examine the relationships of race and sex with asthma care, we analyzed responses to questionnaires administered to adults enrolled in 16 managed care organizations participating in the Outcomes Management System Asthma Study between September and December 1993. Indicators of care consistent with National Asthma Education and Prevention Program (1991) recommendations were assessed. Of a random sample of 8640 patients asked to participate, 6612 (77%) completed the survey. This study focused on 5062 (14% African American, 72% women) patients with at least moderate asthma symptom severity. RESULTS: Fewer African Americans than whites reported care consistent with recommendations for medication use (eg, daily inhaled corticosteroid use, 34.9% vs 54.4%; P =.001), self-management education (eg, action plan, 42.0% vs 53.8%; P =.001), avoiding triggers (37.6% vs 53.6%; P =.001), and specialist care (28.3% vs 41.0%; P =.001). Differences in asthma care by sex were smaller and tended to favor women except for daily inhaled corticosteroid use (women vs men: 49.6% vs 58.3%; P =.001) and having specialist care (37.7% vs 43.1%; P =.001). Similar race and sex differences were observed after adjusting for age, education, employment, and symptom frequency. CONCLUSIONS: Even among patients with health insurance, disparities in asthma care for African Americans compared with whites exist and may contribute to race disparities in outcomes. Women generally reported better asthma care but may benefit from greater use of inhaled corticosteroids.

Adrenal Cortex Hormones↗
PubMed2000

Benchmarking treatment of schizophrenia: a comparison of service delivery by the national government and by state and local providers.

This study compared treatment of schizophrenia in two types of organization: a national, government-operated health care system, the Department of Veterans Affairs (VA), and in hospitals and clinics operated by state and local providers. Between 1994 and 1996, 746 male patients with a clinical diagnosis of schizophrenia residing in two states in the Southeast and Midwest were surveyed: 192 VA inpatients were compared with 96 non-VA inpatients, and 274 VA outpatients were compared with 184 non-VA outpatients. VA patients were older and had higher incomes than non-VA patients but did not differ significantly on measures of clinical status, satisfaction with providers, or community adjustment. VA outpatients were more likely to have been hospitalized during the previous year than non-VA outpatients and were less likely to have received services from a day hospital, from a case manager or social worker, or to have received crisis intervention services. On 5 of 26 Schizophrenic Patient Outcomes Research Team treatment recommendations, a smaller proportion of VA than non-VA patients adhered to standards. Four of these reflected reduced access among VA patients to psychosocial services such as work therapy, job training, or case management services. Cross-sectional surveys can be used to compare quality of care across service systems. VA care was associated with similar satisfaction and clinical outcomes but greater reliance on hospital treatment and less use of community-based psychosocial services.

Adult↗
PubMed1999

Home hospital program: a pilot study.

OBJECTIVE: To evaluate the basic safety and feasibility of hospital care at home (Home Hospital (HH)) for treating acutely ill older persons requiring hospitalization. DESIGN: Prospective case series SETTINGS AND PARTICIPANTS: Community-dwelling persons aged 65 and older requiring acute hospital admission for community-acquired pneumonia, chronic heart failure, chronic obstructive airways disease, or cellulitis. RESULTS: Seventeen subjects were treated in HH. One hundred twenty-two could not be enrolled because they presented for admission at times when HH was not operational. Six patients refused to enroll in HH. Subjects treated in HH had comparable clinical outcomes to those treated in the acute hospital and were highly satisfied with HH. Charges for HH care were 60% of those for the acute hospital care. CONCLUSIONS: In this pilot study, HH was safe, feasible, highly satisfactory, and cost-effective for certain acutely ill older persons who required acute hospitalization.

Acute Disease↗
PubMed1997

Prospective evaluation of clinical criteria to select older persons with acute medical illness for care in a hypothetical home hospital.

OBJECTIVE: To evaluate criteria to select older persons who need hospitalization for common acute medical illnesses for care in a hypothetical home hospital. DESIGN: Prospective record review. SETTING AND PARTICIPANTS: Patients aged 65 and older admitted to the general medical service of a community-based university hospital. MEASUREMENTS: We developed illness-specific selection criteria to identify older persons with certain acute medical conditions for treatment in a hypothetical home hospital. The selection criteria were reviewed prospectively against all community-dwelling older patients admitted to the general medical service of a community-based university hospital over a 2-month period. We determined eligibility for home hospital admission based on information available at the time of admission and then tracked the patient's hospital course. RESULTS: One hundred fifty-seven admissions of 143 patients were reviewed. The selection criteria identified 33% of patients admitted to the acute hospital with one of the three target diagnoses as eligible for a home hospital model of care had it been available. Eligible patients experienced shorter lengths of stay (3.7 vs 5.4 days, P = .012), fewer mean number of procedures performed (0.98 vs 1.70, P = .001), fewer mean number of complications (0.17 vs 0.56, P = .010), and fewer events that could be handled only in the acute hospital setting (P = .036). In addition, in logistic regression analysis, three criteria for home hospital ineligibility, pulmonary congestion associated with ischemic chest pain (odds ratio 6.85, 95% CI 2.64, 17.81), the presence of an acute coexisting illness requiring hospitalization independent of the target conditions (odds ratio 2.66, 95% CI 1.11, 6.41), and significant pulmonary congestion after initial treatment (odds ratio 14.4, 95% CI 1.77, 117.41) were significantly associated with items difficult to accomplish at home. CONCLUSIONS: Criteria can be delineated that identify older persons with acute medical illnesses who may be suitable for treatment in a home hospital.

Acute Disease↗
PubMed1995

Variation in ophthalmic testing prior to cataract surgery. Results of a national survey of optometrists. Cataract Patient Outcome Research Team.

OBJECTIVE: To assess variation in optometrists' use of ophthalmic tests in the evaluation of patients being considered for cataract surgery who have no history of other eye disease. DESIGN/PARTICIPANTS: National survey of a systematic sample of practicing members of the American Optometric Association (St Louis, Mo), who had referred at least one patient to an ophthalmologist for consideration of cataract surgery in 1991. RESULTS: Ninety-two of 130 eligible responding optometrists reported that they routinely performed preoperative testing on patients being considered for cataract surgery. Of these 92 optometrists, 91 (99%) frequently or always performed refraction, and 82 (89%) frequently or always performed a dilated fundus examination in their evaluation of patients being considered for cataract surgery who had no history of other eye disease. None of these 92 optometrists reported using B-scan ultrasonography or electroretinograms frequently or always, and few used A-scan ultrasonography or visual evoked responses frequently or always. A substantial percentage frequently or always used formal visual field testing (47%), formal color vision testing (40%), fundus photography (24%), potential acuity measurement (25%), glare testing (23%), contrast sensitivity testing (19%), and specular microscopy (14%), while 11% to 81% of optometrists never performed these tests on such patients. More recent graduation from optometry school was associated with a decreased frequency of use of potential acuity measurement and contrast sensitivity testing and with an increased use of dilated fundus examinations. CONCLUSION: There is a substantial variation in optometrists self-reported use of a number of ophthalmic tests in the preoperative evaluation of patients being considered for cataract surgery who have no history of other eye disease.

Adult↗
PubMed1995

Improving Medicaid pediatric care.

This article uses Medicaid claims data to examine the adequacy of well-child care provided by different ambulatory care providers for selected children enrolled in Maryland Medicaid. Considerable provider variation was observed. The majority of the nearly one-quarter of the children with no well-child visits during the year appeared to have had no regular primary care source. Results contributed to the development of a managed care program designed to increase care accessibility and continuity and improve provider practices. Advantages and disadvantages of using claims data to investigate this public health issue care discussed.

Child Health Services↗
PubMed1994

Costs vs quality in different types of primary care settings.

OBJECTIVE: To determine the relationship between efficiency in use of resources and quality of care provided by physicians serving as the usual source of care for patients in a state Medicaid program. DESIGN: Retrospective quality-of-care review of 2024 outpatient medical records of 135 providers sampled from system-wide Medicaid claims data in Maryland. SUBJECTS: Providers in three types of practice settings (hospital outpatient clinic, community health center, and physician's office) were stratified into three case mix-adjusted resource use groups (high, medium, and low). A sample of patients with the diagnoses of diabetes, hypertension, asthma, well-child care, or otitis media were identified from Medicaid claims forms from visits during 1988. Case mix was controlled by the application of the ambulatory care groups, a method that characterizes populations according to their burden of morbidity. MAIN OUTCOME MEASURES: Nurses from the local peer review organization audited medical records using explicit criteria for quality of care in several categories: evidence of impaired access, evidence of compromised technical quality, evidence of inappropriate care, outcome of care, and several generic indicators of quality. Well-adult care was assessed for patients with the adult diagnoses. RESULTS: Although there were some systematic differences by type of facility in some aspects of quality of care (more access problems for patients in hospital clinics and more technical quality problems for patients in office-based practice), there were no consistent differences in quality of care overall for patients in different types of settings and no consistent relationships between cost-efficiency and quality of care. However, patients in medium-cost community health centers had the best or second best scores for most of the 21 comparisons of type of quality assessed. CONCLUSIONS: Quality of care provided for common conditions in primary care is not associated with costs generated by providers. Policies directed toward the choice of low-cost vs high-cost providers will not necessarily lead to a deterioration in the quality of care. States can both improve quality and lower costs by consistent monitoring of programs over time. The finding of generally higher quality of care for patients in medium-cost community health centers deserves further study.

Adult↗
PubMed1994

Variation in ophthalmic testing before cataract surgery. Results of a national survey of ophthalmologists.

Little information is available either for the clinical value of many ophthalmic tests performed preoperatively in the evaluation of patients for cataract surgery or for variation in ophthalmologists' use of such tests. To assess variation in ophthalmologists' use of ophthalmic tests, we conducted a national survey of American Academy of Ophthalmology members. Thirty-three percent, 17%, 37%, and 19% of the respondents reported that they "frequently" or "always" perform glare testing, contrast sensitivity testing, potential acuity measurement, and specular microscopy, respectively, in patients being considered for cataract surgery who have no history of eye disease other than cataract. In contrast, 27%, 54%, 24%, and 48% of respondents reported that they never perform each of these four tests in such patients. Two ophthalmologist characteristics--a surgical volume of greater than 200 cataract extractions per year and performance of surgery in an ambulatory surgical center or private office (as opposed to a hospital)--were independently associated with an increased probability of performing each of these four tests frequently or always. Ten percent or less of the respondents reported that they frequently or always perform electroretinography, visual evoked response testing, photography of fundus or anterior segment, B-scan ultrasonography, formal color vision testing, and formal visual field testing in such patients. Thus, there is considerable variation in ophthalmologists' use of glare testing, contrast sensitivity testing, potential acuity measurement, and specular microscopy. A small percentage of ophthalmologists may be overusing several other tests in the evaluation of patients being considered for cataract surgery.

Adult↗
PubMed1991

Ambulatory care groups: a categorization of diagnoses for research and management.

This article describes a case-mix measure for application in ambulatory populations. The method is based primarily on categorization of diagnoses according to their likelihood of persistence. Fifty-one combinations (the ambulatory care groups or ACGs) result from applying multivariate techniques to maximize variance explained in use of services and ambulatory care charges. The method is tested in four different HMOs and a large Medicaid population. The percentage of the population in each of the 51 categories is similar across the HMOs; the Medicaid population has higher burdens of morbidity as measured by more numerous types of diagnoses. Mean visit rates for individuals within each of the 51 morbidity categories are generally similar across the five facilities, but these visit rates vary markedly from one category to another, even within groupings that are similar in the number of types of diagnoses within them. Visit rates for individuals who stay in the same ACG were similar from one year to the next. The ACG system is found useful in predicting both concurrent and subsequent ambulatory care use and charges as well as subsequent morbidity. It provides a way to specify case mix in enrolled populations for research as well as administration and reimbursement for ambulatory care.

Adolescent↗
PubMed1990

Ambulatory practice variation in Maryland: implications for Medicaid cost management.

Simulation modeling with data from the Maryland Medicaid Management Information System has provided an opportunity to examine policy options and assess their likely impact on savings before program decisions were made. Analysis of a large sample of the Maryland Aid to Families with Dependent Children (AFDC) Medicaid subpopulation confirms that a significant difference in utilization and cost to Medicaid exists between usual sources of care for AFDC clients even after controlling for patient demographics and case-mix differences. Findings indicate that savings from reduced use of hospital outpatient departments may offset increases of as much as 40-50 percent in physician fees under certain assumptions.

Adolescent↗
PubMed1985

Utilization and morbidity: random or tandem?

Earlier studies have shown that one in eight children persist in being high users of health care services over long periods of time and, conversely, about the same proportion of children are consistently low users. As these studies failed to discover reasons for these persistent deviations from average, this study explored three possible explanations: persistent morbidity, mental health problem, and familial patterns of use. Although all three phenomena were associated with both persistence of high utilization of services as well as an overall large number of visits, the number of types of morbidity was the most significant correlate of high use. Children who were constantly low users of services were much more likely to have only a few types of morbidity whereas children who were constantly high users were much more likely to experience a wide variety of types of problems. These findings suggest that an understanding of the demand for health services requires an understanding of the interrelationships of illnesses within individuals rather than a focus on particular illnesses or particular types of illnesses.

Acute Disease↗
PubMed1984

Morbidity in childhood--a longitudinal view.

We examined all the morbidity experienced in a six-year period by a total of 2591 children who were continuously enrolled in a prepaid medical plan. The children had received 19,291 diagnoses, each of which was assigned to one of 14 types of morbidity, and the frequency of each type was determined. Although the typical child had at least one problem in 5 of the 14 types of morbidity in the six-year period, over 20 per cent of children had at least 8 different types of problems during that time. Children with a greater variety of acute problems and more frequent acute problems were also more likely to have nonacute problems during the six-year period. Conversely, children with nonacute problems had more acute problems than other children. Our findings indicate that morbidity, like use of health services, occurred in clusters in this population of children. Therefore, an understanding of the cause and projected outcome of morbidity among children will be incomplete if the focus is only on specific diseases or specific types of illnesses.

Adolescent↗
PubMed1984

Preventive care and overall use of services. Are they related?

The relationship between the use of services of children constantly enrolled in a prepaid group practice medical plan for six years and the completeness of their preventive care were examined. Children who were consistently low users of services were more likely to be lacking one or more components of standard preventive care, particularly general health assessments in older children and vision, hearing, and tuberculosis screening in younger children. Teenage children who were low users were at some risk of not receiving their tetanus-diphtheria immunization on time. The relationship between low use of services and incomplete preventive care persisted after controlling for the severity of morbidity, although children with more severe morbidity were somewhat less likely to be missing preventive care. Health facilities and practitioners should pay special attention to assessing the need for standard preventive care in children who are infrequent users of services.

Adolescent↗
PubMed1979

Patient-doctor agreement about problems needing follow-up visit.

In this study in an urban prepaid group practice, patients and practitioners agreed less than half the time as to what problems required follow-up at a subsequent visit. Problems that were mentioned by both practitioner and patient were much more likely to be followed up subsequently by the practitioner than problems initially mentioned only by the practitioner or only by the patient. Patients reported much more improvement of problems at follow-up when both practitioner and patient mentioned the problem as requiring follow-up than when they had been mentioned only by the patient. The involvement of patients in the process of care may be augmented by a variety of mechanisms. We believe greater patient participation in the processes of care should result in better follow-up of problems and better results, at least as perceived by patients.

Adult↗