S/HMOs, the second generation: building on the experience of the first Social Health Maintenance Organization demonstrations.
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Geriatrics↗
Biomedical subjects
R L Kane
Publications and source records attributed to R L Kane.
State variations in Medicare expenditures.
OBJECTIVES: This study examined variations in Medicare expenditures across states. METHODS: 1992 data on average Medicare expenditures per enrollee, users of services per 1000 enrollees, service use per user, and payment per unit of service were compared across states for various services. Weighted least squares regression analysis was employed to examine total Medicare expenditures per enrollee by state. RESULTS: Variation in Medicare expenditures across states is driven more by average number of service users per 1000 enrollees and average service units per user than by average payment per service unit. Medicare expenditures per enrollee by state are primarily a function of Medicare HMO penetration rate (P = .000), urban area (P = .001), hospital bed supply (P = .005), elderly mortality rate (P = .012), Medicare physician assignment rate (P = .026), percentage of primary care practitioners (P = .042), and interactions between urban elderly and percentage of primary care physicians (P = .005) and Black elderly and nursing home bed supply (P = .012). CONCLUSIONS: Before sweeping Medicare cuts are undertaken or excessive reliance on managed care occurs, attention should be focused on the current disproportionate distribution of expenditures across states.
Aged↗
Consumer and professional ratings of the importance of functional status components.
As the population ages and chronic disease becomes the more dominant form of illness, measures of functional loss and disability assume greater importance in the assessment of both quality of life and the cost-effectiveness of care. The authors studied the responses of consumers and health care professionals regarding the impact on dependency of various levels of disability. Striking differences in perception were noted, raising concerns about the ability of those providing care to assume that the recipients share their values about what is important. This study makes clear the need for more research on functional outcome measurements that incorporate the values of consumers.
Activities of Daily Living↗
Improving hospital discharge planning for elderly patients.
Hospital discharge planning has become increasingly important in an era of prospective payment and managed care. Given the changes in tasks, decisions, and environments involved, it is important to identify how to move such planning from an art to an empirically based decisionmaking process. The authors use a decision-sciences framework to review the state-of-the-art of hospital discharge planning and to suggest methods for improvement.
Activities of Daily Living↗
Neuropsychological and psychological functioning in chronic fatigue syndrome.
Although patients with chronic fatigue syndrome (CFS) typically present subjective complaints of cognitive and psychological difficulties, studies to date have provided mixed objective support for the existence of specific cognitive deficits. The present study was designed to examine differences in performance between individuals diagnosed with CFS and matched controls with respect to sustained attention, processing efficiency, learning, and memory. Subjects included 17 patients meeting Centers for Disease Control research criteria for CFS and 17 control subjects. Subjects were administered six measures assessing attention, memory, and word-finding ability and two measures assessing psychological distress. For the most part, the two groups did not differ on measures of neurocognitive functioning. Significant group differences were found on a single measure of attention and incidental memory. However, CFS patients differed markedly from controls with respect to reported psychological distress. The results support previous findings of notable levels of psychological distress among CFS patients. They also suggest the need for alternative research paradigms to assess the cognitive abilities of CFS patients.
Adult↗
Which outcomes matter in Alzheimer disease and who should define them?
The identification of salient outcomes depends on the conceptual map of the disease and its consequences. Early attention focuses on cognition. Cognitive losses can lead to behavioral problems, which may be exacerbated by treatment. Behavioral problems can create a need for supervision. Client functioning can require another form of supervision, cuing. Because Alzheimer disease affects families as much as patients, many outcomes are directed at measures of caregiver burden and stress. A therapeutic model of chronic care management, which aims at producing results at least as good as might be reasonably expected (i.e., slowing decline), creates a different mind set from a compensatory model of care, which seeks primarily to meet dependency needs. In the latter, good care is equivalent to meeting needs without incurring adverse events. Outcomes and locus of decision-making intersect around issues of quality of life. Assumptions about the ability of a patient with Alzheimer disease to express positive feelings or to indicate preferences for care need to be explored carefully. Although the use of agents or proxies may be necessary when making decisions about care, proxies serve poorly to convey information about another person's quality of life.
Alzheimer Disease↗
Neurocognitive functioning in chronic fatigue syndrome.
Although substantial research has been conducted on chronic fatigue syndrome (CFS) over the past decade, the syndrome remains poorly understood. The most recent case definition describes CFS as being characterized both by disabling fatigue and by subjective reports of difficulty with concentration and "short-term" memory. However, research into the neurocognitive and psychological functioning of individuals with CFS has provided mixed objective results. The current paper reviews studies that have examined the neurocognitive and/or psychological functioning of individuals with CFS. Changes in research design and instruments employed to study individuals with CFS are suggested.
Attention↗
Use of post-hospital care by Medicare patients.
BACKGROUND: Medicare's introduction of the Prospective Payment System for hospitals has shortened hospital stays and, as a consequence, has increased the use of post-hospital care. Medicare coverage provides for various types of post-hospital care. This paper examines the characteristics of patients, cities, and hospitals associated with discharge to these different types of post-hospital care. METHODS: A Total of 2248 consecutive Medicare patients having one of five diagnosis related groups (DRGs), who were about to be discharged from 52 hospitals in three cities in 1988-1989, were enrolled in the study. These DRGs comprised approximately one-eighth of all Medicare hospital discharges and 40% of all Medicare-paid post-hospital care. Patients were interviewed in person before discharge and again 6 weeks after discharge. Clinical severity measures were developed from information abstracted from each patient's medical record. For each DRG, multinomial logit regression equations were developed to identify factors associated with the choice of one of four possible discharge locations: home with no formal care, home health care, nursing home care, or rehabilitation. RESULTS: Discharge location could be predicted correctly in 52 to 71% of cases, depending on the DRG. This level of predictive accuracy was significantly greater than relying on the modal discharge location, which accounted for 33 to 62% of cases. Most of the predictive power came from information gathered at the discharge interview. The variables associated significantly with the discharge location varied with the DRG and location examined. Living alone and functional dependency at discharge were the significant predictors found most often. CONCLUSIONS: Rather than assuming that everyone is discharged to the modal location, patient discharge location can be predicted. Much of the explanation can be traced to a few variables such as functional status and living situation. The lack of greater accuracy suggests that factors other than those identified as important by clinical panels are involved in discharge planning for Medicare patients.
Activities of Daily Living↗
Do rehabilitative nursing homes improve the outcomes of care?
OBJECTIVES: To compare the differences in outcomes of Medicare patients discharged from hospital to two types of nursing homes, rehabilitative and regular, and to rehabilitative facilities. DESIGN: Criteria for distinguishing rehabilitative nursing homes (RNHs) from ordinary nursing homes (NH), based on staffing criteria, were developed by an expert panel and validated on a national sample of nursing homes. Those criteria that significantly discriminated the two types of NHs were then applied to a sample of nursing homes from a study of the outcomes of care for more than 2500 Medicare patients to classify the nursing homes in which patients were discharged. Actual discharge outcomes were compared with optimal outcomes based of predictive equations for different types of treatment (ordinary NH care, RNH care, and formal rehabilitative care). PARTICIPANTS: Medicare patients with strokes an hip fractures discharged from 52 hospitals in three cities. MEASUREMENTS: A disability scale that weights components of ADL measures was used as the primary outcome indicator. Nursing homes were classified as rehabilitative on the basis of the extent of staffing in rehabilitative areas. RESULTS: Patients discharged to various types of care varied on several parameters. After adjusting for these differences, stroke patients fared better when treated in rehabilitative facilities; there was no substantial benefit for RNH care over NH care. Healthier hip fracture patients who received RNH care fared better, but functional change for sicker hip fracture patients was not different among the three groups. CONCLUSIONS: The study suggests that at least a preliminary distinction among NHs can be made on the basis of staffing patterns and that the benefits of the additional staffing may vary with the problem under consideration. More work is needed to establish just what sorts of patients are most likely to benefit from the higher level of NH care.
APACHE↗
Decreasing disability in the 21st century: the future effects of controlling six fatal and nonfatal conditions.
OBJECTIVES: This study assessed the effects of reducing fatal and nonfatal health conditions on the number of functionally limited older Americans in the coming decades. METHODS: Data from the 1990 census and the Longitudinal Study of Aging were used to project the number of functionally limited older Americans from 2001 to 2049, assuming 1% biennial reductions in five conditions that shorten life expectancy (coronary artery disease, stroke, cancer, diabetes, and confusion) and one condition that decreases functional ability (arthritis). RESULTS: Decreasing the prevalence of arthritis by 1% every 2 years would lead to a much greater reduction in functional limitation between 2001 and 2049 (4 million person-years) than would decreasing any of the other conditions by the same amount. Decreases in two fatal conditions (cancer and coronary artery disease) would lead to increases in functional limitation (0.9 and 0.1 million person-years, respectively). CONCLUSIONS: Advances against common nonfatal disabling conditions would be more effective than advances against fatal conditions in blunting the large increase in the functionally limited older population anticipated in the 21st century.
Aged↗
Long-term care.
Long-term care has come to include both an acute component and the more traditional chronic component. The growth in subacute care has occurred under private prepaid auspices but has also been stimulated by changes in Medicare funding for hospitals. Quality improvement techniques, such as critical pathways, have been applied to long-term care.
Health Care Reform↗
Improving the quality of long-term care.
Quality of long-term care can be improved by changing the strategies used to monitor it. Nursing home care has been the subject of intensive regulations, while it has been neglected by physicians. Newer forms of long-term care are coming under stricter oversight, which may stifle the innovations they offer. Greater but different attention is needed: more creativity can be fostered with better accountability by emphasizing long-term care outcomes. It is unrealistic to require that long-term care patients will improve; good outcomes are defined as doing as well as or better than expected. The Minimum Data Set for nursing homes offers a mechanism to generate data on many pertinent outcomes. An outcomes focus would encourage more collective action by the various parties involved in providing long-term care, including physicians. Clinicians are reluctant to assume responsibility for outcomes they feel unable to strongly influence, but they must recognize that part of their role is to engender cooperation from the myriad participants in long-term care, including patients and their families. Better-quality long-term care may cost more, but it may be possible to use less expensive personnel more creatively if current regulations are modified. Managed care arrangements offer one vehicle for reorganizing care and could provide the appropriate incentives to make positive changes. However, they could also lead to minimalist strategies. Accountability for realistic outcomes can provide the needed countervailing regulatory pressure.
Aged↗
Developing a measure of health outcomes in survivors of childhood cancer: a review of the issues.
The success of treatment for childhood cancer has prompted greater attention to issues of quality of life for the survivors. Work on health-related quality of life has proceeded faster for adults than for children. This paper reviews the results of such work for adults and points to the potential for applications in children. Specific problems in adapting measures and in interpreting the results in the context of a child's development are discussed. An approach to the assessment of the health-related quality of life for survivors of childhood cancer is proposed.
Adolescent↗
Who cares? The size, scope, and composition of the caregiver support system.
The informal care networks of 242 impaired older people were examined in terms of the primary caregiver and secondary helpers. Most primary caregivers had at least one secondary helper; 88% identified helpers who provided hands-on help, 19% reported that helpers contributed financially, and 44% had helpers involved in care decisions. The size of the network was larger for direct care compared to financial or decision-making assistance. Almost half of primary caregivers reported that their spouse helped. It was expected that after controlling for characteristics of the primary caregiver and of the older person, that characteristics of the secondary caregiver network would influence the amount and type of primary caregiver assistance and formal care used by the older person. However, both hours and type of care by the primary caregiver were independent of size, scope, and composition of the secondary helper network. This independence suggests that efforts to alter the secondary caregiver network may have limited effects on the primary caregiver.
Aged↗
Effect on physical functioning of care in adult foster homes and nursing homes.
This study tested the effects on physical functioning of substituting adult foster care (AFC) for nursing home care. Secondary data from Oregon's Medicaid agency were used to compare change in ADL functioning of 1,032 nursing home and 279 AFC residents. Maximum likelihood estimation was used to analyze selection of long-term care setting and change in functioning. One-third of surviving AFC residents would have been better off in a nursing home, whereas almost all nursing home residents were placed appropriately. Further research on outcomes that clients value most along with efforts to support functioning are needed.
Activities of Daily Living↗
Developing a new metric for ADLs.
BACKGROUND: Most ADL summary measures add up the number of dependencies. They assume an equal weighting among items and require an arbitrary definition of dependency. METHODS: A panel of experts in geriatrics was asked to rate a set of ADL and IADL components in terms of the contribution of each to overall dependency using a magnitude estimation (ME) technique. The ratings were done for both domains and for levels of function within each domain. The resultant scores were compared with the usual dependency count approach. RESULTS: The distribution of weighted items appears to have face validity. The pattern of dependency traced by the ME model was intermediate between those created by simple counts with two different definitions of dependency. The ME approach has stronger statistical properties than the ordinal scoring approach. CONCLUSIONS: The ME approach appears to be a reasonable and workable method for creating a measure that permits meaningful statements about the mean value of functional dependencies. This result can be used for any comparison of means, such as across individuals, across aggregates of individuals, or across time.
Activities of Daily Living↗