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Biomedical subjects

E C Norton

Publications and source records attributed to E C Norton.

31 records · Page 2Linked to original sources
PubMed1998

The effect of hospital volume on the in-hospital complication rate in knee replacement patients.

OBJECTIVE: To examine the effect of hospital volume on in-hospital surgical outcomes for knee replacement using six years of Medicare claims data. DATA SOURCES/STUDY SETTING: The data include inpatient claims for a 100 percent sample of Medicare patients who underwent primary knee replacement during 1985-1990. We supplemented these data with information from HCFA's denominator files, the Area Resource File, and the American Hospital Association survey files. STUDY DESIGN: We estimated the probability that a patient has an in-hospital complication in the initial hospitalization for the first primary knee replacement, using a Logit model, for three definitions of complication. The models controlled for hospital volume, other hospital characteristics, patient demographics, and patient health status. We tested for the endogeneity of hospital volume. DATA COLLECTION/EXTRACTION METHODS: A panel of two orthopaedic surgeons and two internists reviewed diagnosis codes to determine whether a complication was likely, possible, or due to anemia. After removing the few observations with bad or missing data, the final population has 295,473 observations. PRINCIPAL FINDINGS: The probability of a likely in-hospital complication declines rapidly from 53 through 107 operations per year, then levels off. Statistical tests imply that hospital volume is exogenous in this patient-level data. Complication rates increased steadily through the study period. Although obesity appeared to lower the probability of a complication, a counterintuitive result, further investigation revealed this to be an artifact of the claims data limit of listing no more than five diagnoses. Controlling for this restriction reversed the effect of obesity. CONCLUSIONS: Rather than uncontrolled expansion of knee surgery to small hospitals, decentralization to regional centers where at least about 50, and preferably about 100, operations per year are assured appears to be the optimal policy to reduce in-hospital complications.

Arthroplasty, Replacement, Knee↗
PubMed1997

Cost shifting in a mental health carve-out for the AFDC population.

This study tests whether the managed care vendor shifted costs to Medicaid-reimbursed medical care after the start of the mental health carve-out for the Aid to Families with Dependent Children (AFDC) population in Massachusetts. We used claims data over a 4-year period to estimate expenditures for four types of health services, two of which were paid for by the managed care vendor and two by Medicaid. Total per person public expenditures declined by only about 3 percent. Inpatient psychiatric services were replaced by outpatient psychiatric services and some pharmaceuticals, but overall there was little or no evidence of cost shifting to the medical sector. These results are in contrast to what was found in a sample of Medicaid beneficiaries eligible due to a mental health disability.

Adolescent↗
PubMed1997

Impact of Medicare SELECT on cost and utilization in 11 states.

In this article, the authors evaluate the cost and utilization effects of the SELECT implementations in 11 States. In particular they compare the before-and-after enrollment experiences of Medicare beneficiaries newly enrolled in SELECT plans with the experiences of those newly enrolled in traditional medigap plans. Using Medicare claims data for 1991 through 1994, the authors find that Medicare SELECT increased costs in five States, decreased costs in three States, and had no effect in three States. Cost increases were generally related to Part B utilization.

Aged↗
PubMed1997

School and neighborhood characteristics associated with school rates of alcohol, cigarette, and marijuana use.

Previous research has noted that schools vary in substance use prevalence rates, but explanations for school differences have received little empirical attention. We assess variability across elementary schools (N = 36) in rates of early adolescent alcohol, cigarette, and marijuana use. Characteristics of neighborhoods and schools potentially related to school prevalence rates are examined, as well as whether these characteristics have independent effects or whether neighborhood characteristics are mediated by school characteristics. Neighborhood and school characteristics were measured using student, parent, and archival data. The findings show substantial variation across schools in substance use. Attributes of neighborhoods and schools are statistically significantly related to school rates of lifetime alcohol use, lifetime cigarette use, and current cigarette use. Contrary to expectations, lifetime alcohol and cigarette use rates are higher in schools located in neighborhoods having greater social advantages as indicated by the perceptions of residents and archival data. Neighborhood effects are expressed both directly and indirectly through school characteristics. The findings are discussed in light of contagion and social disorganization theories.

Adolescent↗
PubMed1996

Managing the care of schizophrenia. Lessons from a 4-year Massachusetts Medicaid study.

BACKGROUND: In 1992, Massachusetts launched a state-wide managed care plan for all Medicaid beneficiaries. METHODS: This retrospective, multi-year, cross-sectional study used administrative data from the Massachusetts Division of Medical Assistance and Department of Mental Health, consisting of claims for 16,400 disabled adult patients insured by Medicaid in Massachusetts between July 1, 1990, and June 30, 1994. The main outcome measures include annual rates of hospitalization, emergency department utilization, and follow-up care 30 days after discharge; length of inpatient stay; and per-person inpatient and outpatient expenditures. RESULTS: Between 1991 and 1994, the likelihood of an inpatient admission decreased from 29% to 24% and was accompanied by a slight reduction in length of stay (median number of bed-days per admission dropped by 3.3 days). There was a slight decrease in the number of patients who sought care in general hospital emergency department utilization. However, there was a small increase in the fraction of patients readmitted within 30 days of discharge. Medicaid and Department of Mental Health expenditures for mental health per treated beneficiary decreased slightly, from $11,060 to $10,640, during the 4-year study period. CONCLUSION: Although per-person expenditures dropped and most patient patterns of care remained the same, longer-term study is recommended to asses whether the trends can be maintained.

Adolescent↗
PubMed1996

Analysis of prevention program effectiveness with clustered data using generalized estimating equations.

Experimental studies of prevention programs often randomize clusters of individuals rather than individuals to treatment conditions. When the correlation among individuals within clusters is not accounted for in statistical analysis, the standard errors are biased, potentially resulting in misleading conclusions about the significance of treatment effects. This study demonstrates the generalized estimating equations (GEE) method, focusing specifically on the GEE-independent method, to control for within-cluster correlation in regression models with either continuous or binary outcomes. The GEE-independent method yields consistent and robust variance estimates. Data from project DARE, a youth substance abuse prevention program, are used for illustration.

Adolescent↗
PubMed1996

The effect of maternal substance abuse on the cost of neonatal care.

This study addresses the effect of maternal substance abuse on the cost of neonatal care in a sample of all singleton live births in Maryland in 1991. Most other cost studies have analyzed data from only one hospital; we analyzed data from 54 hospitals and therefore can control for individual hospital effects and correlation of observations within hospitals. We find that maternal drug abuse has a significant positive effect on total hospital charges, length of stay, and average daily charges, with the increase in length of stay being proportionally greater than the increase in average daily charges. Maternal alcohol abuse also has a positive effect on hospital charges and length of stay, but the effects are not statistically significant. About half the effect of drug abuse on total charges works indirectly through premature birth and other comorbidities.

Comorbidity↗
PubMed1994

How hospital ownership affects access to care for the uninsured.

This article addresses the effect of hospital ownership on the delivery of service to uninsured patients. It compares the volume of uninsured patients treated in for-profit and nonprofit hospitals by regarding hospital ownership and service as endogenous. Instrumental variable estimates are used to predict the percentage of patients who are uninsured, controlling for hospital ownership and service. The study shows that when for-profit and nonprofit hospitals are located in the same area, they serve an equivalent number of uninsured patients, but for-profit hospitals indirectly avoid the uninsured by locating more often in better-insured areas.

Chi-Square Distribution↗
PubMed1992

Incentive regulation of nursing homes.

A social experiment was conducted in San Diego to test the effectiveness of monetary incentives in improving the health of nursing home residents and lowering Medicaid expenditures. Use of a Markov model to represent the resulting health changes of nursing home residents shows that the monetary incentives had beneficial effects on both the quality and the cost of nursing home care. Moreover, the nursing homes admitted more people with severe disabilities, and the average length of their stays was shortened. If implemented, this kind of incentive program would save Medicaid substantial amounts of money, but not through lowering nursing home payments. Instead, the more efficient use of nursing homes would transfer more people out of hospitals and thereby save unnecessary hospital reimbursement.

Aged↗
PubMedDate not supplied

How managed care organizations develop selective contracting networks for psychiatric inpatient care: a Massachusetts case study.

Medicaid agencies recently have adopted selective contracting to control use and costs of publicly financed behavioral health care. This case study describes formation of an inpatient network for serving psychiatrically disabled Medicaid beneficiaries in Massachusetts. Network formation is seen as a two-stage process: hospitals first decide to bid for a contract, and form a pool from which the managed care organization chooses hospitals. We used logit models to predict how hospital experience with Medicaid patients, competition, prior reimbursement rates, and geographic distribution affected these two stages. Hospitals are more likely to bid if they have treated more psychiatric inpatients and more disabled Medicaid inpatients receiving Supplemental Security Income. Managed care organizations take into account hospitals' experience with Medicaid patients and geographic dispersion, but not prior reimbursement rates.

Competitive Bidding↗
PubMedDate not supplied

How managed care plans contribute to public health practice.

Growth in managed care enrollment potentially creates incentives for health plans to become involved in public health activities, such as health promotion and disease prevention interventions, and care for vulnerable populations. Using cross-sectional data from 60 diverse markets, this study explores the extent to which health maintenance organizations (HMOs) form cooperative alliances with local public health agencies to perform such activities. Results from multivariate models suggest that the incentives for cooperation vary substantially with health plan ownership and market structure. In view of recent HMO industry trends, these findings raise questions about the ability of alliances to integrate the practice of public health and medicine on a broad national scale, as some proponents suggest they do.

Cooperative Behavior↗