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Biomedical subjects

J M Swint

Publications and source records attributed to J M Swint.

At least 19 recordsLinked to original sources
PubMed2006

A retrospective study to determine the impact of medical- and lifestyle-based contraindications to a prescribed HAART regimen on clinical outcomes and adherence.

OBJECTIVE: To determine whether patients who are prescribed a highly active antiretroviral therapy regimen, that minimizes medical and lifestyle contraindications, will be better able to adhere to their drug regimens and will have better clinical outcomes, than patients who do not have such a regimen. METHODS: A retrospective chart review of patients' prescription renewals and changes in viral load and CD4(+) count and a comparison of these changes with patients' self-identified contraindications. Contraindications were identified by a questionnaire with 35 questions relating to medical history/concurrently prescribed medication and 16 questions on lifestyle. Main outcome measures are adherence assessed by prescription renewals, change in plasma HIV-1 RNA viral loads, and change in CD4(+) T-lymphocyte counts. Logistic and linear regression and student t-test were used to identify associations between outcome measurements and number of contraindications. RESULTS: A total of 203 patients (72% male, 74% African-American, 7% Hispanic) completed the questionnaire. Seventy-four per cent of the patients had at least one medical/drug contraindication and 78% had at least one lifestyle contraindication. Increases in CD4 counts were reduced by an average of 13 cells/mm(3) (P = 0.033) for each medical/drug contraindication and viral load decreases was significant even with one medical contraindication vs. none (P = 0.042). Patients with fewer lifestyle contraindications were more likely to have at least a 1 log drop in viral load (P = 0.036). For each increase in the number of contraindications, there was a corresponding 2% decrease in the rate of adherence (P = 0.048). CONCLUSIONS: The results suggest that using a patient administered questionnaire it is possible to identify contraindications in prescribed regimens that impact on adherence and on treatment effects on viral load and CD4 counts.

Acquired Immunodeficiency Syndrome↗
PubMed1999

Technology evolution: the technology spectrum and its application to orthopedic technologies.

The evolution of clinical technologies presents potential adopters with considerations in planning for clinical program development that include the stage and the rate of a technology's evolution. This paper presents a conceptual framework for these considerations and applies the framework to orthopedic technologies. Eight orthopedic surgeons were asked to assess 14 orthopedic technologies and position each of them along a spectrum of research, clinical, and adopted technologies. The distribution of responses for each technology-year combination is presented, and estimates of central tendency, dispersion, and variances provide measures of the change in the distribution of responses over time for each technology and the change in the degree of rater consensus over time for each technology. While orthopedic trauma was chosen to illustrate the technology spectrum model, the model and assessment methodology is applicable to other medical specialties as well. Adoption of this framework in a hospital setting should enable more systematic and effective clinical program development.

Diffusion of Innovation↗
PubMed1997

Health care's double standard: the prevention dilemma.

Curative services often have been judged by their perceived value, while preventive services have been held to a more rigorous standard of documentation. The dilemma for preventive services is not driven by evidence of their cost-ineffectiveness relative to curative services, but by the paucity of evidence of any type. The issues are whether preventive services of different types are perceived as having value, by what criteria these perceptions are measured, and by whom they are determined. We examine five key constituencies, the measures by which the value of prevention is judged, and the implications for the funding of prevention activities.

Attitude to Health↗
PubMed1997

Have Medicaid reimbursements been a credible measure of the cost of pediatric care?

OBJECTIVE: Despite uncertain validity as a measure of cost, Medicaid reimbursements may be used to compare the costs of different pediatric interventions. We explored the credibility of Medicaid reimbursements as a measure of the costs of inpatient care associated with two different approaches to follow-up care for high-risk indigent infants. DESIGN: Analysis of Medicaid reimbursements within a randomized trial of primary follow-up care. PATIENTS: Infants </=1500 g at birth in a large county hospital (Parkland Memorial Hospital). INTERVENTION: Conventional care after nursery discharge (with well-baby care and care for chronic illnesses provided in our follow-up clinic) or primary care (with care for acute illnesses also provided in the follow-up clinic). Measures to prevent a lapse in Medicaid coverage were included in all clinic visits. OUTCOME MEASURES: The completeness, comparability, and plausibility of Medicaid reimbursements for inpatient care of the two groups between nursery discharge and 1 year adjusted age. RESULTS: A high percentage (90% to 91%) of both groups were enrolled in Medicaid. However, with fewer clinic visits in the conventional care group, Medicaid coverage often lapsed in this group, particularly among the highest risk infants. As a result, the proportion of hospital days reimbursed by Medicaid was substantially lower for conventional care than primary care infants (53% [92/174] vs 96% [298/310]). An even larger disparity was observed for pediatric intensive care days (10% [6/61] vs 100% [33/33]). Implausible Medicaid reimbursements included a lower reimbursement rate per day in the pediatric intensive care unit than on the pediatric floor (1 infant), a lower reimbursement rate per day for hospital care than home care (1 infant), and a mean reimbursement rate per day for our private pediatric teaching hospital ($1244/day) that did not exceed that for the private nonteaching pediatric hospital ($1268/day). The reimbursement rate for our public teaching hospital was particularly low ($507/day) despite a high acuity of illness (21% of hospital days in the pediatric intensive care unit). CONCLUSIONS: Without proper validation, reimbursements from Medicaid (or any program that replaces it) should not be assumed to provide an unbiased or acceptably accurate measure of the relative or absolute cost of pediatric health care interventions.

Continuity of Patient Care↗
PubMed1992

Screening for patients with alcohol problems: severity of patients identified by the CAGE.

Primary care physicians are well situated to identify patients with substance abuse problems and motivate them to seek appropriate assistance, but active programs are the exception. A study in a community setting was undertaken to assess the CAGE (the first letters of key words in a series of four questions about drinking: cut down; annoyed; guilty; and eye-opener), instrument in the routine screening for alcohol problems in both new and established patients. The screening process identified subjects for a pilot evaluation of a motivational interview designed to encourage problem-solving behavior. This article focuses on the screening results and the use of the CAGE instrument. During June and July of 1990, 687 patients of two primary care physicians belonging to a large group practice were asked to complete a health questionnaire that included the CAGE. Those who responded affirmatively to at least two of the four CAGE questions were requested to participate in follow-up assessment of problems associated with alcohol and health. The type and severity of alcohol problems experienced by patients who scored positive on the CAGE are described. Prevalence of a positive score on the CAGE was 8.6 percent with males, smokers, and blue collar and unemployed persons being more likely to score positive. The positive predictive value was .68. Primarily, persons with moderate alcohol problems were identified. Results show that the CAGE instrument is a useful screening device for identifying those with mild to moderate substance abuse problems, increasing the opportunity for intervention prior to serious medical complications. The instrument is easily administered, and has demonstrated relatively high levels of sensitivity and specificity. When combined with assessment and motivational interviews, the CAGE shows promise in the secondary prevention of substance abuse and related health problems.

Adult↗
PubMed1989

Patterns and economic effects of drug overdose mortality in Texas: 1980-1986.

Drug overdose mortality and its economic consequences are explored for ten different drug categories in this article. Data on drug overdose mortality in Texas for the years 1980-1986 are examined and a cost of mortality analysis is presented using the human capital methodology. In addition, mortality rates per 100,000 population are presented for each drug category. The results indicate that the cost of drug overdose mortality has more than doubled over the six-year period. The greatest growth in mortality cost has been for narcotics and cocaine, with commonly prescribed psychoactive drugs remaining fairly constant. The results suggest that men are at far greater risk of drug overdose than women with respect to illicit drugs. Women, however, appear to be at greater risk for overdose from commonly prescribed drugs.

Adult↗
PubMed1988

Maternal serum alpha-fetoprotein screening for Down syndrome: economic considerations.

The economic consequences of using an index of maternal age and maternal serum alpha-fetoprotein (MSAFP) screening to indicate risk of Down syndrome (DS) are examined. If DS screening indicated solely by a given maternal age is economically justifiable, then amniocentesis indicated by a DS risk equivalent to that maternal age cutoff, but based on an index of maternal age (for ages below the cutoff) and low MSAFP results, is also economically justifiable. It is concluded that the extant use of MSAFP screening for DS is a move toward the cost-effective use of scarce resources that can be made available with coordinated planning. However, increased professional and public awareness may result in significant increases in aggregate demand for these services. While MSAFP screening for DS is economically justifiable, there exists some potential for bottlenecks at the aggregate level, and these should be considered in conjunction with recommendations that the technology be adopted on a widespread basis.

Adult↗
PubMed1988

Economic considerations in technology assessment: the case of genetic disease.

This paper describes economic issues pertinent to health care technology assessment. Of interest are the allocation of resources between health and other sectors of the economy, between alternative services within the health sectors, and the costs of producing the services that are selected. These issues are discussed and then illustrated by reference to a specific area of health care technology: screening for and intervention against genetic diseases. It is concluded that investments in screening programs for Tay Sachs disease and Down Syndrome are allocatively efficient. Indications are that such investments are also efficient for interventions against Neural Tube Defects; however, there are complex ethical issues involved. There are many genetic diseases for which screening tests have yet to be developed. As such tests become available, each will have to be evaluated on its own merits relative to alternative health sector investments.

Cost-Benefit Analysis↗
PubMed1985

Forecasting staffing needs for productivity management in hospital laboratories.

Daily and weekly prediction models are developed to help forecast hospital laboratory work load for the entire laboratory and individual sections of the laboratory. The models are tested using historical data obtained from hospital census and laboratory log books of a 90-bed southwestern hospital. The results indicate that the predictor variables account for 50%, 81%, 56%, and 82% of the daily work load variation for chemistry, hematology, and microbiology sections, and for the entire laboratory, respectively. Equivalent results for the weekly model are 53%, 72%, 12%, and 78% for the same respective sections. On the basis of the predicted work load, staffing assessment is made and a productivity monitoring system constructed. The purpose of such a system is to assist laboratory management in efforts to utilize laboratory manpower in a more efficient and cost-effective manner.

Efficiency↗
PubMed1985

Economic evaluation of occupation-based programs: conflicting criteria and the case for government subsidy.

Differences in the economic criteria for evaluating the efficiency of occupation-based intervention programs vs public (nonprofit) rehabilitation programs are highlighted and the consequences of these differences are discussed. It is shown that if the development of such programs is determined strictly by the employer's criteria, they will not produce the full benefits for society that they are capable of. The incentive therefore exists for government to encourage the development and proliferation of quality programs. It is proposed that this can be accomplished by altering the employer's incentives (through subsidies or tax credits), thus making the private and public economic criteria for program evaluation more consistent.

Alcoholism↗
PubMed1980

Do-not-admit versus inpatient surgery in an HMO: determinants of choice and the implications for medical care costs.

We develop a model for investigating the implications of policies that have encouraged a shift from inpatient to do-not-admit (DNA) surgery. We use discriminant function analysis on date for two surgical procedures from the Kaiser Permanente Medical Care Program of Portland, Oregon. Case attributes found to be significantly associated with the choice of surgery mode are surgeons' rate of inpatient surgery, number of chronic conditions per patient, time in surgery, number of procedures performed, and type of anesthesia used. Our estimates of cost savings provide support on economic grounds for the use of DNA surgery, for the types of surgery investigated. Our results also suggest that simple evaluation methods, based on the mean length of stay and on extrapolation of proportion of DNA cases from the base year to the current year, may overestimate the cost savings derived from the shift to DNA surgery.

Ambulatory Surgical Procedures↗
PubMed1979

Prospective economic evaluation of lead poisoning prevention programs.

This paper illustrates an economic methodology for the prospective evaluation of individual lead poisoning screening and prevention programs. A method is presented for prospectively estimating the prevalence and expected health consequences of lead poisoning in an urban population. The economic costs of these consequences are calculated and cost-benefit analysis is used to complete the evaluation. A case study is developed to illustrate the potential utility of the model as a framework for the prospective evaluation of programs under funding consideration.

Child, Preschool↗
PubMed1979

Estimates of preventive versus nonpreventive medical care demand in an HMO.

Multiple regression analysis is used to investigate whether medical services in a large HMO are distributed primarily on the basis of need and predisposing factors (such as health status, age and sex) or according to enabling characteristics (such as coinsurance and income) of the population. Equations are formulated to estimate the likelihood and volume of preventive visit demand, nonpreventive visit demand and hospital admissions for a sample of 3,892 individuals enrolled in the Kaiser Foundation Health Plan of Portland, Oregon. The results indicate that predisposing and need factors are the main determinants of nonpreventive visits and hospital utilization, while enabling characteristics are important determinants (along with age and education) of preventive utilization. There are marked differences in the impact of explanatory factors on utilization by dependents (children) versus nondependents (adults).

Adult↗
PubMed1978

A multivariate analysis of the likelihood and volume of preventive visit demand in a prepaid group practice.

An economic framework for the investigation of the demand for preventive medical care services is suggested and empirical models for the likelihood and volume of preventive physician visits are specified. These are tested using data on 3,892 individuals enrolled in the Kaiser Foundation Prepaid Health Plan of Portland, Oregon. Preventive visits, delineated by the Kaiser Clinical Behavioral Classification System, included general medical examinations, eye examinations, well-child care and immunization services. Multiple regression is used to estimate the likelihood of preventive visits for all persons and the volume of preventive visits for users. Income and coinsurance were the most significant economic variables in the likelihood equation, possessing the expected positive and negative signs, respectively. The usual findings of a positive education effect and negative family size effect were supported by the results. The economic variables were less significant in the volume equations than in the likelihood equations, suggesting that system and physician effects may neutralize these factors. Females were more likely to make a preventive visit than were males and the relatively young and old were the heaviest age-group users of preventive care. Perceived helath status did not appear to significantly affect preventive care demand.

Adult↗