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Biomedical subjects

N R Powe

Publications and source records attributed to N R Powe.

At least 19 recordsLinked to original sources
PubMed1996

The review process used by US health care plans to evaluate new medical technology for coverage.

OBJECTIVE: To examine the process and information used by medical directors (MDs) of private health plans to make medical coverage determinations for new medical technologies, and to assess the influence of plan characteristics on the process. DESIGN: Cross-sectional national survey. PARTICIPANTS: Two hundred thirty-one MDs at private health plans representing 66% and 72% of the US population covered by HMOs and indemnity plans, respectively. MEASUREMENTS: Actual and optimal review process, final decision authority, sources, and evidence used for technology coverage decisions. RESULTS: In 96% of plans, MDs take part in the medical policy review process for new technology. However, MDs have final authority over coverage decisions in only 27% of plans. Indemnity plans are more likely to assert that MDs should be responsible for final decisions, odds ration (OR) = 3.3 (95% confidence interval [95% CI] 1.4, 10). Optimal sources of information of new technology were journals, medical society statements or practice guidelines, and opinions of national experts. Actual sources of information used differed from optimal ones; local experts were used more often than is considered optimal (p < .001). For-profit plans were more likely than nonprofit plans to use national experts, OR 2.5 (95% CI 1.3, 5.0), and practice guidelines, OR 5.0 (95% CI 2.5, 10). Randomized trials (94% of MDs) meta-analyses (61%), and reviews (42%) were considered the best evidence for making coverage decisions. Barriers to making optimal decisions were lack of timely evidence on effectiveness and cost-effectiveness, not legal or regulatory issues; HMO, small, and nonprofit plans were two or three times more likely to list lack of cost-effectiveness data than their counterparts (p < .05). CONCLUSIONS: Although MDs are nearly always involved in the technology evaluation process, a minority of MDs retain final authority over coverage decisions. Evidence from strong scientific research designs is the most frequently cited basis for decisions, but there is need for more timely, rigorous scientific evidence on medical interventions. How a health plan evaluates a new medical technology for coverage varies with identifiable plan characteristics.

Cross-Sectional Studies↗
PubMed1996

The role of perspective in defining economic measures for the evaluation of medical technology.

Perspectives in an economic analysis of medical technology reflect who makes decisions about the use of or payment for medical resources. Commonly used perspectives include those of providers, insurers, the individual, and society. Perspective is a critical determinant of study design, affecting the time horizon, types of resources considered, and economic cost measures assigned to those resources. Individuals involved in technology assessment for either research or policy-making purposes should be aware of the complexities of defining costs from different perspectives.

Costs and Cost Analysis↗
PubMed1996

Awareness of providers' use of new medical technology among private health care plans in the United States.

In a national survey of medical directors at 231 U.S. private health care plans that cover over two thirds of the privately insured population, we studied whether medical directors are aware when a new technology, such as laser therapy, is being used in procedures for which claims are submitted, the factors alerting them to such use, and the factors prompting them to make a specific coverage decision for the technology. We also examined possible associations between health plans' characteristics (HMO versus indemnity, size, profit status, and time in operation) and their medical directors' awareness of the use of technologies, factors alerting medical directors to their use, and factors prompting specific coverage decisions. The majority of plans were generally not aware that laser technology was being used when it was billed under a general billing code, raising the possibility that less effective or less safe technologies could be introduced rapidly into the treatment of insured populations. Nonprofit and older plans were less likely to be aware that lasers were used in some procedures than for-profit and younger plans.

Analysis of Variance↗
PubMed1996

Quality assessment: is the focus on providers or on patients?

Most studies of ambulatory care quality are based on chart reviews of episodes of care in single settings, rather than on care received by a patient over time and across settings. The purpose of this study was to compare ambulatory care quality scores based on information from the usual source of care to scores based on information from all providers seen during a year. The quality of well child care for 55 two-year-olds and asthma care for 70 children and adults continuously enrolled in the Maryland Medicaid program throughout 1988 was assessed. Combining data from multiple providers changed quality scores in both directions. For well child care, quality scores generally improved because of an increased opportunity to perform desirable actions, such as lead screening. However, quality scores for asthma care generally decreased because undesirable clinician actions, such as the failure to document follow-up plans, increased as more problems were uncovered. Thus, the findings of quality assessments differ according to whether the focus is on care delivered by individual providers or on care received by patients. The direction of the difference will depend upon whether the indicators of quality represent omission of recommended care or commission of improper care.

Adult↗
PubMed1996

Systemwide provider performance in a Medicaid program. Profiling the care of patients with chronic illnesses.

OBJECTIVES: This study illustrates how claims data can be applied to examine cost and clinical performance of providers in the Medicaid program. METHODS: The authors conducted a cross-sectional analysis of Medicaid beneficiaries in Maryland with diabetes mellitus, hypertension, and asthma treated on an ambulatory basis by hospital-based outpatient departments, physician office-based providers, and community health centers. The study year was July 1987 to June 1988. The authors defined the cost performance (high, medium, or low) of providers in the management of each of the three chronic illnesses, both before and after casemix adjustment, using a classification system based on ambulatory diagnoses (ambulatory care groups). The authors constructed claims-based clinical performance indicators for each of the three conditions. These included the number of patients admitted to acute-care hospitals for any and specific (diabetes mellitus, hypertension, and asthma) causes, the number of patients without a follow-up visit within 30 days of being discharged from the hospital, and the number of patients with consecutive emergency room visits during the study period. RESULTS: The ambulatory care group casemix classification system explained 23%, 33%, and 36% of the variation in total payments for patients with hypertension, diabetes, and asthma, respectively. Without adjustment for casemix, 35% to 50% of providers would be misclassified regarding their cost performance. Forty-one (19.4%) of 211 providers who treated all three illnesses were in the same cost group for all three illnesses and 95 (43%) of 223 providers who treated two of the three illnesses were in the same cost group for both illnesses. Among office-based physicians, for all three chronic illnesses, high-cost providers had more admissions (P < 0.01) for ambulatory care-sensitive conditions than low-cost providers. Among hospital outpatient departments, only high-cost providers of asthma had more admissions (P < 0.05) for asthma than low-cost providers. There was no statistically significant (P > 0.05) difference in the clinical performance indicators between high-cost and low-cost hospital outpatient department providers of primary care for hypertensive and diabetic Medicaid beneficiaries. For the other clinical performance indicators, the results were not consistent across the three illnesses or across the different types of providers. CONCLUSIONS: Without adjustments for casemix, a large number of providers are misclassified regarding to cost performance. In addition, most providers are not equally efficient in managing different chronic illnesses. Provider cost performance is not associated consistently with clinical performance, although severity differences not captured by the casemix adjustment may account for these observations. These measurement methods and relationships between provider performance measures may be useful to state Medicaid programs that seek to contain costs, enhance coordination of care, and improve health.

Aged↗
PubMed1996

Measuring effectiveness and outcomes of interventions for renal disease.

Effectiveness research, often called patient outcome research, is an evolving research discipline that attempts to provide information about the appropriate use of medical practices. This field of research uses epidemiological methods (observational and randomized controlled trials), analyses of variation and outcomes in medical practices, formal literature reviews and meta-analyses, quality of life measurement, decision analysis, patient preference assessment, patient satisfaction assessment, and economic and cost-effectiveness analysis. Several recent studies have applied a variety of these methods to provide data that will assist health professionals in the field of nephrology to make more informed clinical decisions. More of these studies are needed as new interventions are developed and tested in an environment where policy makers are asking how much value these interventions add and at what cost.

Cost-Benefit Analysis↗
PubMed1996

Ambulatory care practice variation within a Medicaid program.

STUDY QUESTIONS: What is the extent of variation in patterns of ambulatory care practice across one state's Medicaid program once case mix is controlled for? How much of this variation in resource consumption is explained by factors linked to the provider, patient, and geographic subarea? DATA SOURCES/STUDY SETTING: Practices of all providers delivering care to persons who were continuously enrolled in the Maryland Medicaid program during FY 1988 were studied. A computerized summary of all services received during this year for 134,725 persons was developed using claims data. We also obtained data from the state's beneficiary and provider files and the American Medical Association's masterfile. Each patient was assigned a "usual source of care" (primary provider) based on the actual patterns of service. The Ambulatory Care Group (ACG) measure was used to help control for case mix. STUDY DESIGN: This was a cross-sectional study based on the universe of continuously enrolled Medicaid enrollees in one state. PRINCIPAL FINDINGS: After controlling for case mix, the variation in patient resource use by type of primary provider was 19 percent for ambulatory visits, 46 percent for ancillary testing, 61 percent for prescriptions, and 81 percent for hospitalizations. Across Maryland counties, comparing the low- to high-use jurisdiction, there was 41 percent variation in case mix-adjusted visit rates, 72 percent variation in pharmacy use, and 325 percent variation in hospital days. At the individual practice level, physician characteristics explain up to 17 percent of ambulatory resource use and geographic area explains only a few percent, while patient characteristics explain up to 60 percent of variation. CONCLUSIONS: Since a large proportion of variation was explained by patient case mix, it is evident that risk adjustment is essential for these types of analyses. However, even after adjustment, resource use varies considerably across types of ambulatory care provider and region, with consequent implications for efficiency of health services delivery.

Ambulatory Care↗
PubMed1995

Economic impact of immunization against rotavirus gastroenteritis. Evidence from a clinical trial.

OBJECTIVE: To estimate the economic impact of immunization against rotavirus gastroenteritis in an infant population in the United States. DESIGN: Cost identification and break-even analyses from the perspective of society, nested within a phase 3, randomized, double-blind, placebo-controlled trial. PATIENTS: Infants (N = 1278), aged 6 to 22 weeks, enrolled during the summer and fall of 1991 and followed up until July 1, 1992. INTERVENTION: Immunization schedule of three doses of orally administered tetravalent or serotype 1 rhesus rotavirus vaccine, or placebo. MAIN OUTCOME MEASURES: Incidence of rotavirus gastroenteritis, total direct medical costs, direct nonmedical costs, and indirect costs of rotavirus and nonrotavirus gastroenteritis for the duration of the study and of any illness during 5 days after each dose. The cost of the vaccine was not included. RESULTS: Median total cost per infant among the 1187 infants who completed the immunization schedule was $9 in the tetravalent vaccine group, $9 in the serotype 1 vaccine group, and $49 in the placebo group (P = .01). Rotavirus gastroenteritis occurred in 195 infants (16%): 13% (51/398) in the tetravalent group, 12% (47/404) in the serotype 1 group, and 25% (97/385) in the placebo group (P < .0001). Of infants with an episode of rotavirus gastroenteritis, the proportion who incurred cost during the episode and the median cost during the episode did not differ by treatment group. The baseline net cost savings for treatment of rotavirus gastroenteritis and break-even cost of immunization were $11 per infant for the tetravalent vaccine and $12 for the serotype 1 vaccine. In sensitivity analysis, savings ranged from $40 to -$6, because of a large variance in the costs of rotavirus gastroenteritis. CONCLUSION: The results of the baseline analysis suggest that society should be willing to pay between $11 and $12 for immunization against rotavirus. It might be willing to pay an additional amount for the intangible benefits of reduced parental inconvenience or anxiety associated with this illness in infants.

Cost Savings↗
PubMed1995

The clinical-economic trial: promise, problems, and challenges.

The clinical-economic trial is a study design that is appearing with greater frequency in medical and public health literature. Some experienced investigators view these trials with skepticism; to policy makers they represent a promising step in the control of rising health care costs. The success of clinical-economic trials in meeting the important goal of more rational and efficient use of health care resources will depend on the strengths and limitations of the research method. As part of a report to the Office of Technology Assessment of the U.S. Congress on new health care assessment techniques, we describe the reasons why economic data collection and analysis are being considered in clinical trials, identify and discuss various designs and methods for gathering economic trial data, and evaluate the strengths and limitations of different methods for providing sound data for decision making on appropriate use of health care interventions. Because of the potential significance and increasing visibility of such research, experts in research methods should give more attention to methodological research for clinical-economic trials. Future efforts should be directed at comparing different techniques for collecting data, examining the incremental value of precision in economic measurements and ensuring appropriate interpretation of data from clinical-economic trials.

Clinical Trials as Topic↗
PubMed1995

Small area variations in health care delivery in Maryland.

OBJECTIVE: Our purpose is a descriptive analysis of variations in hospital use among small areas of Maryland. DATA SOURCE: The data are Maryland patient discharge records from acute care hospitals for 1985-1987 and small area population estimates by age, gender, race, and income. FINDINGS: The common finding was excess geographic variability among Maryland's 115 areas. The hypothesis of uniform rates was rejected for most DRGs, including low-variation mastectomy and hernia repair. Clustering of high-use rates occurred in neighboring areas for orthopedic, vascular, and elective procedures. Admission rates for most nondiscretionary procedures and medical DRGs were reduced in affluent areas while discretionary surgery increased with income level. Elective procedures had extreme variation and were related to income. Coronary artery disease rates declined with income while coronary artery procedure rates increased, indicating that access and patient selection were factors in the use of coronary bypass and angioplasty. CONCLUSIONS: The issue is not the ubiquitous variation among small areas but its extent and identification of geographic patterns. Hospital use is related to demography, morbidity, medical resources, access, selection for care, and physician practice patterns. Heterogeneity of these factors ensures that uniform delivery of health care rarely holds. There is little evidence that incidence of surgical disease is the main source of variation in use of discretionary surgery. Rather, variations reflect differing medical opinion on appropriate use. Without evaluation, excessive use cannot be distinguished from underservice. Morbidity explains the variability of nondiscretionary surgery and conditions related to lifestyle. Access plays an important role for discretionary surgery. Geographic analysis can identify variation and relate incidence to socioeconomic and specific local effects. Hospital data do not permit direct assessment of appropriate care. Understanding the reasons for variation requires information beyond incidence data. The challenge is to identify and explain small area variations or to fix them.

Catchment Area, Health↗
PubMed1995

A survey of current problems in meta-analysis. Discussion from the Agency for Health Care Policy and Research inter-PORT Work Group on Literature Review/Meta-Analysis.

The United States Agency for Health Care Policy and Research brought together representatives from each of the Patient Outcomes Research Teams (PORTs) as the Inter-PORT Meta-Analysis Work Group. The purpose of the meeting was to discuss a wide range of problems the panel had encountered in the area of meta-analysis. Several actual problems were presented, and tentative solutions to those problems were given. The PORTs had to consider issues such as quality assessment, survival analysis, rare events, sensitivity and specificity, and random effects models. The solutions presented represent the methods used by several researchers who are active in the area of meta-analysis.

Evaluation Studies as Topic↗
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

Rigor of research methods in studies of the effectiveness and safety of cataract extraction with intraocular lens implantation. Cataract Patient Outcome Research Team.

OBJECTIVE: To assess the rigor of research methods reported in studies of the safety or effectiveness of contemporary cataract surgery. DESIGN: Formal systematic identification of pertinent studies and critical appraisal of each study's research methods. SUBJECTS: From 6113 unique, potentially relevant citations that we identified, 90 original studies published between 1979 and 1991 that addressed visual acuity or complications following standard extracapsular cataract extraction with posterior chamber intraocular lens implantation, phacoemulsification with posterior chamber intraocular lens implantation, or intracapsular cataract extraction with flexible anterior chamber intraocular lens implantation. MAIN OUTCOME MEASURES: Strength of study design, performance, and reporting in 11 methodologic areas assessed with a standardized abstraction form by two reviewers masked to authors, their institutions, and the journal of publication. Results of reviews were tallied to produce an overall quality score (measure of rigor in research methods) for each study. RESULTS: The mean (+/- SD) quality score was 43.1 +/- 20.1 out of a maximum possible score of 100. Studies received intermediate scores on description of baseline ocular disease and low scores on descriptions of other characteristics of enrolled patients, standardization of outcome assessment and follow-up duration, and handling of patient attrition. Eighty-three studies (92%) lacked a comparison group. The rigor of research methods in studies varied by the journal of publication, did not improve over time, and was no greater for studies with larger vs smaller sample sizes. CONCLUSIONS: The rigor of research methods in studies of cataract surgery can be improved if more attention is paid to fundamental principles of study design, data analysis, and reporting.

Cataract Extraction↗
PubMed1994

Synthesis of the literature on visual acuity and complications following cataract extraction with intraocular lens implantation. Cataract Patient Outcome Research Team.

OBJECTIVE: To better define the effectiveness and risks of modern cataract surgery. DESIGN: Meta-analysis (formal systematic identification, selection, review, and synthesis) of published literature. PATIENTS: Patients described in 90 studies published between 1979 and 1991 that addressed visual acuity (n = 17,390 eyes) or complications (n = 68,316 eyes) following standard extracapsular cataract extraction with posterior chamber intraocular lens implantation, phaco-emulsification with posterior chamber intraocular lens implantation, or intracapsular cataract extraction with flexible anterior chamber intraocular lens implantation. MAIN OUTCOME MEASURES: The proportion of eyes with postoperative Snellen visual acuity of 20/40 or better and the proportion of eyes with each of 18 complications. RESULTS: The pooled percentage of eyes (weighted by sample size) with postoperative visual acuity of 20/40 or better was 95.5% (95% confidence interval [CI], 95.1% to 95.9%) among eyes without preexisting ocular comorbidity and 89.7% (95% CI, 89.3% to 90.2%) for all eyes. The pooled percentage of eyes experiencing complications (weighted by sample size and, when pertinent, by quality score of the individual studies but not adjusted for variation in duration of follow-up) ranged from 0.13% for endophthalmitis to 19.7% for posterior capsule opacification. Pooled proportions of eyes with other complications were as follows: bullous keratopathy, 0.3%; intraocular lens malposition/dislocation, 1.1%; clinically apparent cystoid macular edema, 1.5%; and retinal detachment, 0.7%. Pooled results for postoperative Snellen visual acuity and most complications were similar for surgery performed via phacoemulsification vs standard extracapsular cataract extraction, although comparisons of the outcomes between these procedures should be interpreted with caution. CONCLUSIONS: The published literature indicates that modern cataract surgery yields excellent visual acuity and, although not free of complications, is a very safe procedure regardless of the extraction technique used.

Aged↗
PubMed1994

Early adoption of cyclosporine and recombinant human erythropoietin: clinical, economic, and policy issues with emergence of high-cost drugs.

The discovery of new drugs and their introduction into US markets will become an intense area of focus should health care reform result in Medicare insurance coverage for prescription drugs. Particular attention will be focused on high-cost drugs. Two high-cost drugs, cyclosporine and recombinant human erythropoietin (rHuEPO), introduced into the clinical management of patients with kidney disease during the past decade, provide some experience concerning the forces affecting the use of expensive drugs in a cost-conscious health care system. The decision to prescribe a drug will depend on provider's judgements of the drug's clinical benefits and costs compared with those of other possible therapies. It may also depend on payment policy. Both cyclosporine and rHuEPO were adopted rapidly and extensively by providers of end-stage renal disease care following US Food and Drug Administration approval, despite their high costs. Both drugs were remarkably effective, relatively safe, and able to be administered without great difficulty compared with the therapies they have replaced. There was no additional payment to hospitals for the initial use of cyclosporine, which was introduced in 1983 at the time when Medicare's prospective payment was established, since choice of immunosuppressive agent did not affect the fixed, per-admission payment determined by the diagnosis-related group for kidney transplantation. Medicare coverage for continuing outpatient use of cyclosporine was not initially provided, in contrast to rHuEPO, which was introduced in 1989 with Medicare outpatient coverage and payment of 80% of the allowed charge. Despite their high costs and different methods of insurance payment both drugs achieved a rather quick and high penetration rate into their respective populations.(ABSTRACT TRUNCATED AT 250 WORDS)

Cyclosporine↗
PubMed1994

Measuring, managing, and improving quality in the end-stage renal disease treatment setting: committee statement.

The Institute of Medicine (IOM) committee that organized the conference reported in this issue of the journal on assessing quality of care and quality of life, wishes to emphasize that it regards the task of measuring quality as one that can be approached systematically, albeit with caution. Outcomes of end-stage renal disease (ESRD) care by dialysis and transplantation (and variations of outcomes among treatment units) and related processes of care need to be measured in ways useful to clinicians. In addition to clinical measures of outcome, the committee also favored giving greater attention to functional outcomes and health-related quality of life. The interest in maintaining and improving quality in the treatment setting reflects an underlying need to encourage its systematic assessment on a sustained basis, with appropriate weight devoted to practical issues.

Humans↗
PubMed1994

The relationship of provider organizational status and erythropoietin dosing in end stage renal disease patients.

Controversy exists as to whether provider organizational characteristics such as profit status and setting are associated with the content of medical care or efficiency with which care is rendered. Following FDA approval of human recombinant erythropoietin (EPO) for use in clinical practice, Medicare approved coverage for beneficiaries in its end stage renal disease program and established a fixed payment per dose. Because cost of EPO administration varied positively with dose, providers could realize larger profit with prescription of smaller doses. We used Medicare claims data to assess EPO use by renal dialysis providers one year after FDA approval (June 1990) as a function of provider ownership (for-profit, not-for-profit, government agency) and setting (hospital-based, free-standing). Mean dose of EPO was 236 units greater (P = 0.0001) for not-for-profit freestanding facilities, 593 units greater (P = 0.0001) for government facilities, and 555 units greater for not-for-profit hospitals (P = 0.0001) than among for-profit freestanding providers. With fixed payment per dose of EPO, for-profit, freestanding providers prescribed EPO more often and administered smaller doses than not-for-profit or government providers, behavior that is consistent with profit maximization.

Ambulatory Care Facilities↗