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Biomedical subjects

N Lurie

Publications and source records attributed to N Lurie.

At least 91 records · Page 5Linked to original sources
PubMed1990

Measuring health changes among severely ill patients. The floor phenomenon.

The interest in measuring health status with survey instruments has not been matched with an analysis of their performance characteristics in the field. We used the Medical Outcome Study Short Form (MOS-20) to assess health outcomes among patients who were hospitalized in one of two public hospitals. We mailed the MOS-20 and a series of transition questions, which asked about changes in health, to patients admitted in the previous year. We received 414 completed surveys from 480 patients at baseline and follow-up data on 90% of these patients six months later. Baseline MOS-20 scores for study patients were significantly lower, corresponding to worse health, than previously reported outpatient and general population cohorts. While the direction of change on serial applications of the MOS-20 paralleled the patients' perception of change reported on transition questions, many patients who reported their health had become worse also recorded the lowest possible score on the MOS-20 at baseline. These low baseline MOS-20 scores prohibited the recognition of larger declines in function during the follow-up period. This floor in the response range creates an instrument bias against documenting a decline in health among severely ill patients, the group in which it may be most important to detect such a change.

Acute Disease↗
PubMed1990

Do-not-resuscitate orders in an extended-care study group.

We examined the charts of 911 nursing home patients in Hennepin County, Minnesota, to determine the prevalence of written do-not-resuscitate (DNR) orders. Information regarding demographic characteristics, and whether a surrogate decisionmaker was available and participated in the decision, was also collected. Twenty-seven percent of patients had DNR orders. Ninety percent of all patients had potentially available surrogate decisionmakers. However, for 31% of patients with DNR orders, there was no documentation of patient or surrogate participation in the DNR decision. Univariate analysis identified female sex; increased age, level of care (skilled versus intermediate), presence of a potential surrogate decisionmaker, and increasing length of time since nursing home admission as factors associated with presence of DNR orders. When a logistic regression model was used, increased age, increased length of time since nursing home admission, skilled versus intermediate level of care, and presence of a surrogate decisionmaker were independently associated with presence of DNR status. Several variables are independently associated with written DNR orders; their relationship to the factors physicians use in decision making requires further study.

Age Factors↗
PubMed1990

Teaching status and resource use for patients with acute myocardial infarction: a new look at the indirect costs of graduate medical education.

To investigate whether the process of graduate medical education increases costs in teaching hospitals by causing longer lengths of stay and greater resource use, we compared lengths of stay, hospital charges, and the use of cardiovascular procedures for patients with acute myocardial infarction admitted to the teaching and nonteaching services of a university-affiliated community hospital. After adjusting for severity of illness and demographic characteristics, patients on the teaching services had a mean length of stay that was shorter by 0.6 days (p = 0.04) and mean charges that were $2,060 lower (p = 0.15) than for patients on the nonteaching service. Patients on the teaching service also had 15 percent (95% CI: -26, -4) fewer cardiac catheterizations and 9 percent (-18, 0) fewer procedures for myocardial revascularization (angioplasty or cardiac bypass surgery). These findings suggest that graduate medical education per se may not directly increase the use of health care resources and that the cost differences between teaching and nonteaching hospitals may be largely a consequence of other factors. These factors may include epiphenomena of teaching such as a specialized organizational structure, specialized patient care services, and continuing medical education for the nursing and medical staffs. They may also include factors not related to teaching such as differences in patients' severity of illness and sociodemographic characteristics.

Aged↗
PubMed1989

How do house officers spend their nights? A time study of internal medicine house staff on call.

Recommendations to limit the working hours of house staff are forcing directors of training programs to reevaluate how house officers spend their time. We studied how 35 house officers in internal medicine spent their on-call time in three teaching hospitals: an urban county hospital, a university hospital, and a regional Veterans Administration medical center. Trained observers accompanied each member of different on-call teams for five nights and quantified how their time was spent. Teams consisting of residents and interns admitted three new patients per night at the Veterans Administration hospital, six at the university hospital, and eight at the county hospital. Each house officer received 16 to 25 calls per night. Up to 12 percent of their time was spent doing procedures (such as inserting intravenous catheters or drawing blood specimens) most of which could have been done by nonphysicians. From 87 to 175 minutes of on-call time was spent in direct patient evaluation, and the mean time spent on each new-patient evaluation ranged from 17 to 31 minutes. The mean time before the evaluation was interrupted ranged from 7 to 11 minutes. In contrast, 66 to 197 minutes per night was spent documenting new-patient evaluations in the hospital record. The average sleep time ranged from 122 to 273 minutes; however, the mean time before sleep was interrupted ranged from 40 to 86 minutes. We conclude that while on call, house officers spend relatively little time in direct patient contact, but they spend considerable time charting. They are frequently interrupted while working and trying to sleep. These data may be useful in finding administrative ways to improve patient care and the experience of the house staff while on call and in evaluating the effect of reforms.

Data Collection↗
PubMed1989

Mainstreaming the mentally ill in HMOs.

Administratively complex and politically sensitive issues can arise when mentally ill persons who are public program beneficiaries are enrolled in existing HMOs. The experiences of a demonstration program undertaken in Minnesota illustrate these issues.

Contract Services↗
PubMed1989

Health care cost containment measures and mortality in Hennepin County's Medicaid elderly and all elderly.

In Minnesota, several health care cost containment measures occurred about the time Medicare's Prospective Payment System (PPS) was implemented. These included a moratorium on additional nursing home beds, preadmission screening of nursing home applicants, and rapid growth in HMO (health maintenance organization) enrollment by Medicare recipients. Hospital days per elderly Medicaid recipient decreased by 38 percent for those in nursing homes and by 35 percent for those not in nursing homes from 1982 to 1984. By 1986, hospital days per recipient had decreased 53 and 55 percent, respectively, from the 1982 level. Age-adjusted mortality rates for elderly Medicaid nursing home residents for the period 1977 through 1986 showed an increasing trend after 1982. Estimated age-adjusted mortality rates for the entire County population, which had decreased steadily from 1970 to 1982, rose significantly above the projected rate in 1984, 1985, 1986, and 1987. We conclude that, coincident with the institution of the PPS and other health care cost containment measures, use of hospital care has fallen for all elderly Medicaid recipients, age-adjusted mortality rates among those in nursing homes have increased, and the mortality rate trend for the total Hennepin County elderly population has stopped declining.

Aged↗
PubMed1989

How free care improved vision in the health insurance experiment.

We studied reasons for the improvement in the functional vision of enrollees receiving free care in the Rand Health Insurance Experiment. Among low income enrollees, 78 per cent on the free plan and 59 per cent on the cost-sharing plans had an eye examination; the proportions of those obtaining lenses were 30 per cent and 20 per cent, respectively. Visual acuity outcomes of low income vs non-poor enrollees were more adversely affected by enrollment in cost-sharing plans. Free care resulted in improved vision by increasing the frequency of eye examinations and lens purchases.

Adolescent↗
PubMed1989

Differences in inpatient resource use by type of health plan.

Approximately 50% of the annual increase in hospital costs comes from increased resource use per hospital admission. Health maintenance organizations (HMOs), given their fixed financial resources for patient care, have an incentive to constrain their enrollees' use of hospital resources. Our analysis investigates differences in length of stay, total charges, and the ancillary to total charge ratio for hospitalized patients in network HMOs, independent practice associations (IPAs), and fee-for-service (FFS) health plans in the Twin Cities from 1982 to 1984. Network HMO patients in several diagnostic categories are found to use significantly fewer resources, once hospitalized, than patients in either IPA or FFS plans. This difference may give network HMOs a competitive advantage in the market for health plans.

Group Practice↗
PubMed1988

Use of the hospital in a randomized trial of prepaid care.

Health maintenance organizations (HMOs) achieve their cost savings through lower rates of hospital admissions. To determine whether HMOs selectively avoid discretionary hospitalizations, medical records were reviewed from a randomized trial where families were assigned to either HMO or free-for-service care. Physicians who were blinded to system reviewed 244 medical records and judged the appropriateness both of the hospital setting and of the medical indications for hospitalization. The rate of discretionary surgery was lower in the HMO, while the rate of nondiscretionary surgery was equivalent in the two systems. For medical admissions, rates of discretionary and nondiscretionary admissions were lower in the HMO. There were no observable adverse effects on health from the lower rates of nondiscretionary hospitalization, either because the net effect on health was small or because the HMO substituted appropriate ambulatory services. We conclude that HMO reductions in hospitalization rates do not occur "across the board"; discretionary surgery is selectively avoided.

Adult↗
PubMed1987

Preventive care: do we practice what we preach?

We used insurance claims from enrollees in the Rand Health Insurance Experiment to determine the amount of selected components of preventive care received by a representative sample of the non-aged population in the United States and to determine whether insurance coverage was an important determinant of that amount. Only 45 percent of infants received timely immunization for DPT and polio; 93 per cent received some well child care by 18 months of age. In the three-year experimental period, only 4 per cent of adults had a tetanus shot, 66 per cent of women aged 17-44 and 57 per cent aged 45-65 received a Pap smear, and 2 per cent of women aged 45-65 had a mammogram. Cost sharing was associated with even less preventive care: 60 per cent of children on the free plan and 49 per cent on cost sharing plans received preventive care of any type. For adults, women on the free plan received more preventive care of several kinds, and those aged 45-65 received more Pap smears than those on cost-sharing plans. Even with free care, most enrollees did not receive adequate preventive care. Thus, free care alone, while significant, is not a sufficient incentive to providing recommended levels of preventive care. The average per person insurance charge for increasing the amount of preventive care to a level consistent with that recommended would be $22 for a complete set of immunizations by age 18 months, $9 for a Pap smear every three years, and $97 for a Pap test and mammogram every three years.

Adolescent↗
PubMed1979

Ten years' experience in general practice of dip-slide urine culture in children under five years old.

Of 567 children under five registered with an industrial general practice over a 10-year period, 559 presented with symptoms of ill health in the first five years of life, and of these, 158 (27.9 per cent of those registered) had urine cultured using the dip-slide method. Thirty-four (12.3 per cent) girls and 23 (7.9 per cent) boys had at least one episode of significant bacteriuria. Two boys and three girls were found to have radiological abnormalities of the genito-urinary tract, of which two were obstructive lesions requiring surgery.Symptoms usually ascribed to the urinary tract in older children and adults did not discriminate for infection in this age group and were not a reliable indicator of the presence, or of the absence, of significant bacteriuria.The incidence of significant bacteriuria was considerably above that recorded by surveys on asymptomatic children. Proteus infections were four times more common among boys than girls, and under the age of three the proportion of boys with bacteriuria exceeded that of girls.Dip-slide culture is a valuable tool in the diagnosis, management, and follow-up of urinary tract infection.

Bacteriological Techniques↗