Biomedical subjects

Edward Alan Miller

Publications and source records attributed to Edward Alan Miller.

11 recordsLinked to original sources

PubMed2006

Solving the disjuncture between research and practice: telehealth trends in the 21st century.

Despite the great promise that telehealth holds for improving cost, quality and access, there is currently a disjunction between what we know about telehealth and system growth and performance. To better understand the relationship between these two facets of telehealth development, this paper examines trends in telehealth, both as an intellectual endeavor and as a practical means of providing health services. Although there are promising avenues for government intervention in the way of coordination, funding, and regulatory practice, lack of knowledge regarding what works and what does not work has served as a major impediment to further progress in this area. In the absence of solid empirical evidence, key decision makers entertain doubts about telehealth's effectiveness, which, in turn, limits public leadership, private investment, and the long-term integration of telehealth into the health and technological mainstream. Solving the disjuncture between research and practice will require additional clinical trials and evaluation studies that examine the efficacy of various technologies, both relative to each other and to conventional in person medical encounters. At the same time, it will require more even distribution of research across applications, service locations, regions, and nations. But the generation of additional high-quality empirical data on process, benefits, costs, and effects is only the beginning. That data must in turn be used to effectuate change. This will require researchers to take a more proactive stance in promoting use of their findings, both instrumentally, to adjust, modify or improve particular programs or policies, and conceptually, to influence how key stakeholders think about telehealth more generally.

Diffusion of Innovation↗

PubMed2006

Risk of nursing home admission in association with mental illness nationally in the Department of Veterans Affairs.

OBJECTIVE: We sought to determine whether patients with mental health diagnoses in the Department of Veterans Affairs (VA) are more likely to be admitted to nursing homes and to identify sociodemographic, utilization, and clinical characteristics, especially indicators of mental illness severity, associated with nursing home admission among mentally ill patients. METHODS: Patients receiving treatment in the VA system nationally during FY 2000 and having no evidence of nursing home utilization during FY 1999 or FY 2000 were followed through FY 2003 using administrative claims data. Three-year incidence rates and unadjusted odds ratios were estimated for each diagnosis. Logistic regression was used to examine the correlates of admission among mentally patients, including analyses stratified by age. RESULTS: Of 3,952,229 VA patients with no prior nursing home use, 15.2% received a mental health diagnosis, of which, 4.6% were eventually admitted to a nursing home. Among mentally ill patients, risk of admission was highest for those with any inpatient medical/surgical days (odds ratio [OR] = 2.28), followed by 3+ outpatient medical visits (OR = 1.48), inpatient mental health days (OR = 1.31), and outpatient mental health visits (OR = 1.09). Patients diagnosed with dementia were 58% more likely to be admitted. Patients diagnosed schizophrenia (OR = 1.26), other psychosis (OR = 1.15), and personality disorder (OR = 1.14) had the next highest probabilities. Elderly patients with bipolar disorder (OR = 1.28) were also more likely to enter. CONCLUSION: Although factors leading to nursing home entry among the mentally ill are similar to those driving entry in the general population, those with more severe mental health problems are still more likely to be admitted.

Adult↗

PubMed2006

Bureaucratic policy making on trial: medicaid nursing facility reimbursement, 1988-1998.

Few systematically assess the determinants of Medicaid nursing facility reimbursement. Consequently, this article examines what factors influence program administrators'decisions regarding nursing facility cost report data-the basic information states use to establish payment. Whereas elected officials focus primarily on how much is spent on nursing homes, state Medicaid officials assume primary responsibility for the esoteric and highly technical dimensions that help make spending goals a reality. Findings indicate that the federal government influenced state policy by enabling provider litigation under the Boren Amendment. They also indicate that program administrators responded rationally to fiscal and economic concerns, and that states with stronger administrative capacity were better able to overcome obstacles to sustaining desired policies. Although results reveal that states with more powerful nursing home lobbies tended to implement more generous systems, they fail to reveal significant associations between cost report year and lobbying activity on behalf of the elderly.

Health Care Costs↗

PubMed2006

The digital divide in public e-health: barriers to accessibility and privacy in state health department websites.

State health departments have placed a tremendous amount of information, data, and services online in recent years. With the significant increase in online resources at official health sites, though, have come questions concerning equity of access and the confidentiality of electronic medical materials. This paper reports on an examination of public health department websites maintained by the 50 state governments. Using a content analysis of health department sites undertaken each year from 2000 to 2005, we investigate several dimensions of accessibility and privacy: readability levels, disability access, non-English accessibility, and the presence of privacy and security statements. We argue that although progress has been made at improving the accessibility and confidentiality of health department electronic resources, there remains much work to be done to ensure quality access for all Americans in the area of public e-health.

Communication Barriers↗

PubMed2005

Modifying the Roter Interaction Analysis System to study provider-patient communication in telemedicine: promises, pitfalls, insights, and recommendations.

This paper suggests modifications to the Roter Interaction Analysis System (RIAS)--the most widely used measure for assessing provider-patient communication during conventional face-to-face consultations--for use in telemedicine. The RIAS, which describes and categorizes communication behaviors, is used to quantify communication events, which may then be correlated with patient, provider, and system attributes and health outcomes. Most of the changes suggested here add new coding subcategories to characterize technology-related utterances and to provide opportunities for global assessments of the overall technology environment within which provider-patient interactions took place. There are also general issues raised that interaction analysis researchers should consider when studying provider-patient communication in a telemedicine context. These relate to nonverbal behavior, multiple participants, missing information, and validity and reliability. In addition to comparing telemedicine to in person consultations, a modified RIAS could be used to compare televideo consultations to each other, across different specialties and technical specifications. A modified RIAS would accommodate not only differences in the current technology environment, but also changes in the way providers and patients communicate over time. The more we know about what interaction patterns lead to best outcomes, the more emphasis can be placed on developing training programs and other interventions to enhance patient-provider interactions in telemedicine.

Humans↗

PubMed2005

Incidence of new-onset diabetes mellitus among patients receiving atypical neuroleptics in the treatment of mental illness: evidence from a privately insured population.

The purpose of this study is to determine sociodemographic, clinical, and pharmacotherapeutic characteristics, especially use of atypical antipsychotics, associated with incident diabetes mellitus in a population of privately insured patients with mental health diagnoses. Patients with a mental health diagnosis stably medicated for a 3-month period during January 1999 through October 2000 and having no diabetes were followed through December 2000. Cox proportional hazards models were developed to identify antipsychotic medications associated with newly diagnosed diabetes. Of the 7381 patients identified, 339 developed diabetes, representing an annual incidence rate of 4.7%. Diabetes risk among the entire sample was lowest for risperidone (hazard ratio [HR] = 0.69; p < 0.05), while quetiapine (HR = 0.74), olanzapine (HR = 0.95), and clozapine (HR = 1.22) were not significantly different from first-generation antipsychotics. Diabetes risk was significantly lower among males receiving risperidone (HR = 0.49; p < 0.01) or quetiapine (HR = 0.50; p < 0.10), while diabetes risk among females did not differ significantly from first-generation antipsychotics for any atypical examined. These findings are substantially different from other reports.

Adult↗

PubMed2005

Medicaid nursing facility reimbursement in flux: effects of federal regulatory changes and prevailing fiscal conditions, 1978-1998.

Basic concepts and trends are examined in Medicaid nursing facility reimbursements between 1978 and 1998, because Medicaid payment reform is a common budget reduction strategy pursued by state officials. Non-incremental changes in state rate-setting methods, as well as incremental changes in per diem rates and expenditures per recipient, are analyzed. In addition to substantial cross-state variation, results reveal clear trends in reimbursement policy characteristics over time. Not only do these track closely with changes in the federal regulatory environment, but they also track closely with prevailing fiscal and economic conditions. Given the serious ramifications reimbursement policy changes can have for nursing home residents and providers, it is imperative that the impact of federal disengagement from this policy area be understood.

Diagnosis-Related Groups↗

PubMed2003

Strategies for integrating Medicare and Medicaid: design features and incentives.

In a typical third-party payer situation--representative of most U.S. health care delivery--the payer is likely to have interests that are at odds with the patient and provider. The separation and overlap between Medicare and Medicaid for individuals eligible for both programs introduces an additional level of complexity: multiple masters over plans, providers, and patients. This creates opportunities for shifting costs and administrative burdens between states and the federal government, providers and governments, and patients and everyone else. Program designers who wish to minimize unwanted consequences must find ways to structure their programs to produce financial incentives that encourage the pursuit of societal goals, including appropriately shared intergovernmental responsibilities and appropriate plan, provider, and patient behavior. Here the authors review nine federal and state initiatives that use varying strategies to integrate Medicare and Medicaid services for vulnerable populations. For each initiative, the authors examine and critique program design features in three areas: (1) eligibility determination, (2) finance and administration, and (3) service delivery. They find a few strengths and many weaknesses in design. Future efforts would be well served by carefully considering the incentive structures designed into these initiatives and working to improve them in the next generation of Medicare-Medicaid integration efforts.

Acute Disease↗

PubMed2003

The technical and interpersonal aspects of telemedicine: effects on doctor-patient communication.

The influence of telemedicine on the nature and content of doctor-patient communication stems from both its technical and its interpersonal aspects. While the technical aspects are concerned with the communication technologies used and the clinical processes enabled by those technologies, the interpersonal aspects are concerned with relationships between system personnel, providers and patients, and the way in which those relationships are organized. On the one hand, this paper posits that the influence of the technical environment stems from depersonalization of the doctor-patient relationship, participatory enhancements and impediments, and sensory and non-verbal limitations. On the other hand, it posits that the influence of the interpersonal environment stems from third-party participation, social and professional distancing, and underdeveloped norms and standards. A combined positivist and interpretivist evaluation strategy would enable researchers to make better-informed connections between telemedicine, medical encounter behaviour and health outcomes.

Communication↗

PubMed2003

Models, measures, and methods: variability in aging research.

The purpose of this paper is to review the models and measurement strategies used in studies evaluating the predictors of nursing home placement, hospitalization, functional impairment and mortality. To do so we examine 167 multivariate equations abstracted from 78 longitudinal studies published between 1985 and 1998 that assess the risk factors of one or more adverse outcomes. We find that both comparatively straightforward concepts such as age and income and widely used scales such as activities of daily living and the short-portable mental status questionnaire display considerable variability in operationalization and coding. We also find that few researchers employ explicit conceptual models to assist with variable choice, while some predictors-demographics, physical and cognitive functioning-were studied much more frequently than others-service, market, and policy characteristics. Variability in measurement highlights the lack of standardization in this area of aging research and leaves room for improvements in validity and reliability. Limited use of conceptual models has led researchers to include some predictors in their analyses to the exclusion of others.

Activities of Daily Living↗

PubMed2002

Telemedicine and doctor-patient communication: a theoretical framework for evaluation.

The literature on doctor-patient communication demonstrates that patient, provider and contextual characteristics influence behaviour within medical encounters, which in turn is an important determinant of health outcomes. This paper introduces a conceptual model which posits that telemedicine affects health outcomes through changes in the way doctors and patients communicate with one another. It also proposes that this process depends on the medium through which the consultation takes place, whether in person, over the telephone, via fax or email, or through two-way interactive video. Since participants in two-way interactive video-consultations rarely meet in person, it is particularly important that the effect of substituting video for face-to-face consultations be delineated.

Attitude of Health Personnel↗