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Biomedical subjects

Rajesh Balkrishnan

Publications and source records attributed to Rajesh Balkrishnan.

At least 91 records · Page 5Linked to original sources
PubMed2003

The importance of skin disease as assessed by "willingness-to-pay".

BACKGROUND: To achieve optimal resource allocation in health care, it is necessary to value competing resource uses according to the benefit derived from those uses. Skin disease makes as great an impact as other serious medical conditions when assessed by effects on health-related quality of life. OBJECTIVE: To confirm the high impact of skin disease by comparing patients' willingness to pay (WTP) to be cured or relieved from symptoms of skin and nonskin conditions. METHODS: We searched the published literature on WTP to compare the impact of dermatologic conditions with the impact of other medical conditions. A total of 46 articles were identified of which 10 included information on willingness to pay for cure reported on a monthly basis. RESULTS: WTP for skin diseases fell in the range of 125-260 dollars/month and was comparable or higher than all but one of the other identified conditions. CONCLUSION: Willingness to pay for relief from skin diseases is comparable to that for relief of other serious medical conditions. Skin diseases are associated with a significant adverse impact on patients' lives.

Cost-Benefit Analysis↗
PubMed2003

Predictors of medication adherence and associated health care costs in an older population with type 2 diabetes mellitus: a longitudinal cohort study.

BACKGROUND: The cost of treating diabetes mellitus and its complications is high (91.8 billion dollars in the United States in 2002). It is important to understand predictors of adherence to therapy with different antidiabetic medications and to determine the relationships between adherence and health care service utilization in older adults (aged >or=65 years) with type 2 diabetes mellitus. OBJECTIVE: The aim of this study was to examine the relationship between self-reported health status data, subsequent antidiabetic medication adherence, and health care service utilization in older adults with type 2 diabetes mellitus in a managed care setting. METHODS: This was a longitudinal cohort study of older adults in the south-eastern United States with type 2 diabetes mellitus who completed a health status assessment, used antidiabetic medications, and were enrolled in a health maintenance organization (HMO) continuously for 1 to 5 years. The baseline assessment included questions related to demographics, health care service utilization in the year before enrollment, lifestyle, and quality of life. Demographic, clinical, and utilization-related economic variables were also retrieved from the administrative claims data of the patients' HMO. Prescription refill patterns were used to measure adherence. Associations were examined with a sequential, mixed-model, regression approach. Model appropriateness was tested via sensitivity analyses with logged and unlogged dependent variables. RESULTS: A total of 775 patients were included. Increased comorbidity severity and an emergency room visit during the year prior to enrollment in a Medicare HMO were independently associated with decreased antidiabetic medication possession ratios (MPRs) after enrollment. After controlling for type of medication therapy and other variables, increased antidiabetic MPR remained the strongest predictor of decreased total annual health care costs (8.6% to 28.9% decrease in annual costs with every 10% increase in MPR; P < 0.001). Adherence to anti-diabetic medications was a greater driver of cost reduction than other concurrent medications (eg, statins) in this population. CONCLUSIONS: This study found strong associations between decreased anti-diabetic medication adherence and increased health care service utilization in older adults with type 2 diabetes mellitus in a managed care setting. Health status assessments completed at time of enrollment had the potential to identify enrollees with higher risk for both nonadherent behaviors and poor health-related outcomes.

Aged↗
PubMed2003

Factors associated with self-esteem in pre-adolescents and adolescents with cerebral palsy.

Predictors of self-esteem were examined in 50 pre-adolescents and adolescents with cerebral palsy. On average, self-esteem was high, although 30% scored below a cut-point for low self-esteem. Self-esteem was bivariately associated with female gender, better physician-assessed functional ability, greater perception of the impact of the disability, and higher perceived parent overprotectiveness. In a multivariate model, only perceived impact of the disability remained significant.

Adolescent↗
PubMed2003

Medication-related predictors of health-related quality of life in glaucoma patients enrolled in a medicare health maintenance organization.

BACKGROUND: Glaucoma is an important public health concern in the United States, particularly among older adults (aged >or=65 years). Pharmacologic therapy for glaucoma consists mainly of topical eye drops containing beta-blockers or prostaglandin analogs. OBJECTIVE: The goal of this study was to assess the associations between factors of topical medication use (self reported medication compliance, belief in benefit of medication use, usage difficulty, usage assistance, and complexity of medication regimen) and health-related quality of life (HRQOL) in a cross-sectional population of older patients with glaucoma. METHODS: A self-administered, 48-question survey soliciting information on medication-taking behaviors, treatmen-trelated factors, and HRQOL was mailed to members of a Medicare health maintenance organization who were aged >or=65 years and had primary open-angle glaucoma. Two mailings were conducted 4 months apart; the second was sent to members whose responses to the first mailing had not yet been received. The 12-Item Short-Form Health Survey (SF-12) and the 25-Item National Eye Institute Visual Function Questionnaire (VFQ-25) were used to assess HRQOL. Other questions addressed perceptions of eye drop use in these patients. Multiple regression techniques were used to analyze associations between medication-related factors and HRQOL in this population. RESULTS: The questionnaire was mailed to 589 patients; 375 responded (218 in the first mailing and 157 in the second mailing). A total of 358 responses were complete and analyzable (effective response rate, 62%). After controlling for the effects of other confounders, we found that self reported difficulty in using eye drops was strongly associated with decreased HRQOL (11.5% in VFQ-25 total score and 8.4% in SF-12 mental health score, P<0.05). Other medication-related factors that were examined were not significantly associated with changes in HRQOL. CONCLUSION: Based on our findings, patients aged >or=65 years with glaucoma were likely to have significant comorbidity, which affected both visual and general health and well-being perception. Additionally, a significant proportion of these patients reported difficulty with use of topical medication, which was independently associated with a significant decrease in HRQOL. Care of older patients with glaucoma should incorporate strategies to minimize the difficulty associated with medication use.

Administration, Topical↗
PubMed2003

Efficacy, safety, and cost of office-based surgery: a multidisciplinary perspective.

An increasing number of media reports on patient safety risks arising from office-based surgery procedures, as well as growing concerns about patient safety issues in general, have brought office-based surgery as well as its practitioners into focus and placed this very cost-effective medical practice in the eye of the media and regulators. Concerted efforts are now being made to understand the causes and true incidence of patient safety risk associated with office-based surgery and to find ways to minimize this risk.

Ambulatory Surgical Procedures↗
PubMed2003

Nonmelanoma skin cancer: an episode of care management approach.

BACKGROUND: The incidence of nonmelanoma skin cancers (NMSCs) was estimated at 1.3-million cases for the year 2000 and is on the rise. It is the most common form of cancer in the United States, more common than all other cancers combined. To determine the contributors to the cost of NMSC care, an episode of care of NMSC needed to be defined. OBJECTIVE: To define and validate an episode of NMSC care. DESIGN: Using survey and Medicare part A and part B claims data of the Medicare Current Beneficiary Survey (MCBS), 1992 to 1995, an algorithm was created to define an episode of care for the diagnosis and treatment of an NMSC. MCBS estimates of the number of episodes occurring in three service settings (physician's office, outpatient/ambulatory surgical center, or hospital) and demographics were compared to data from independent datasets, including the National Ambulatory Medical Care Survey (NAMCS, 1995), the National Survey of Ambulatory Surgery (NSAS, 1994 to 1996), and the National Hospital Discharge Survey (NHDS, 1992 to 1997). RESULTS: Pathology claims for NMSC diagnosis served as the indicator of NMSC episodes. The procedures, office visits, and tests that resulted in and from the pathology specimen were identified. The sum of the associated charges to Medicare or Medicare payments for all identified claims equaled the total cost of the episode of NMSC care. For example, these preliminary results demonstrated significant differences between medical and surgical subspecialties. CONCLUSION: This study defined and validated a model of an episode of NMSC care. This model's initial results serve as preliminary data for the design of further studies addressing the differences between specialties and settings. The use of this model will allow identification of factors that determine the cost of NMSC treatment and that are associated with higher cost of care.

Algorithms↗
PubMed2003

No smoking gun: findings from a national survey of office-based cosmetic surgery adverse event reporting.

BACKGROUND: Because of recent press reports of adverse outcomes, office-based cosmetic surgery has come under intense scrutiny and associated legislative regulatory action. OBJECTIVE: To assess the safety of office-based cosmetic surgery through a national survey of state agencies that collect information on adverse patient outcomes. METHODS: Medical boards or other responsible authorities were contacted in 48 states to obtain records on adverse outcomes from cosmetic surgery procedures performed in an office-based setting. RESULTS: Five states were able to provide complete information regarding 13 cases of adverse outcomes that resulted from office-based cosmetic surgery procedures. Thirteen states had incomplete information or were unable to provide information. The remaining states reported no adverse outcomes. Information collected by state agencies varies greatly and is inadequate to define the safety of office-based cosmetic surgery practice. CONCLUSIONS: The need to regulate physician office surgery on the basis of hospital privileges and office certification is not supported by current data. Mandatory reporting of adverse outcomes from office-based surgery is warranted to identify modifiable risk factors and to reduce the risk of adverse outcomes.

Ambulatory Surgical Procedures↗
PubMed2003

Electronic monitoring of medication adherence in skin disease: results of a pilot study.

BACKGROUND: Traditional medication adherence monitoring for topical medication use in dermatology relies heavily on measures of self-reporting and ointment tube weight, which are susceptible to various biases. METHODS: We first assessed the feasibility of using medication electronic monitoring system caps with cream, ointment, and gel formulations. We then performed a pilot study using 10 patients given a diagnosis of psoriasis with a weekly follow-up visit. Topical salicylic acid 6% was supplied to patients in medication jars with caps that recorded the opening and closing of the bottles, without patient knowledge. RESULTS: Medication electronic monitoring system cap monitors accurately recorded the opening and closing of bottles of topical agents. Patients overreported adherence in patient logs, and there was greater detection of missed doses using electronic monitors than self-reporting through patient log (relative risk = 6.2, 95% confidence interval: 1.13, 34.09). CONCLUSION: Electronic monitoring shows promise as a more accurate form of measuring treatment adherence to topical medication regimens.

Administration, Topical↗
PubMed2003

Patients with palmoplantar psoriasis have more physical disability and discomfort than patients with other forms of psoriasis: implications for clinical practice.

BACKGROUND: Psoriasis is a chronic, unpredictable, and incurable disease that has a negative impact on patients' quality of life. Palm and sole psoriasis can add to this negative impact as it directly affects activities of daily living. OBJECTIVE: We sought to estimate the prevalence of palmoplantar psoriasis in a patient population and to explore associations with patient outcomes. METHODS: In all, 317 individuals with psoriasis completed a comprehensive assessment battery. Patients with palmoplantar psoriasis (n = 124, 39%) were compared with patients without palmoplantar involvement with respect to functional disability, psychiatric symptoms, physical and social discomfort, self-reported psoriasis severity, and health-related quality of life. RESULTS: Patients with palmoplantar involvement reported significantly greater physical disability and physical discomfort than patients without palmoplantar involvement (both P <.01). There were no differences between the 2 groups with respect to psychosocial outcomes. CONCLUSION: Patients with palmoplantar psoriasis are affected to a greater degree by the physical aspects of the disease than patients without palmoplantar involvement.

Adult↗
PubMed2003

Trust and satisfaction with physicians, insurers, and the medical profession.

BACKGROUND: Conceptual or theoretical analysts of trust in medical settings distinguish among markedly different objects or types of trust. However, little is known about how similar or different these types of trust are in reality and the relationship of trust with satisfaction. OBJECTIVES: This exploratory study conducted a comparison among trust in one's personal physician, health insurer, and in the medical profession, and examined whether the relationship between trust and satisfaction differs according to the type of trust in question. RESEARCH DESIGN: Random national telephone survey using validated multi-item measures of trust and satisfaction. SUBJECTS: A total of 1117 individuals aged 20 years and older with health insurance and reporting 2 healthcare professional visits in the past 2 years. RESULTS: Rank-order correlation analyses find that both physician and insurer trust are sensitive to the amount of contact the patient has had and their adequacy of choice in selecting the physician or insurer. Trust in the medical profession stands out as being uniquely related to patients' desire to seek care and their preference for how much control physicians should have in making medical decisions. Adding satisfaction to the models reduced the number of significant predictors of insurance trust disproportionately. CONCLUSIONS: Consistent with theory, we found both substantial similarities and notable differences in the sets of factors that predict 3 different types of trust. Trust and satisfaction are much less distinct with respect to health insurers than with respect to physicians or the medical profession.

Adult↗
PubMed2003

Strategy to manage the treatment of severe psoriasis: considerations of efficacy, safety and cost.

Psoriasis is a common, unpredictable, chronic immune-mediated disease characterised by skin lesions and frequently associated with arthritis. Although rarely fatal, psoriasis has a tremendous impact on a patients' quality of life. Traditional therapies for severe psoriasis include phototherapy, methotrexate, oral retinoids and cyclosporin. New biological agents add to the treatment options for psoriasis; however, they raise the already considerable cost of managing the disease. In considering efficacy, safety and cost-effectiveness, ultraviolet Type B (UVB) phototherapy appears to be the best first-line agent for the control of psoriasis. Methotrexate, psoralen plus UVA, alefacept, etanercept and infliximab are appropriate second-line agents, the choice of which requires considerable patient input and physician judgement. Developing rational, effective and acceptable strategies to manage psoriasis treatments would encourage cost-effective psoriasis management.

Combined Modality Therapy↗
PubMed2003

Spasticity associated with cerebral palsy in children: guidelines for the use of botulinum A toxin.

Botulinum A toxin produces selective and reversible chemodenervation that can be employed to balance muscle forces across joints in children with cerebral palsy (CP). Currently, there are two commercially available botulinum A toxin formulations (BOTOX) and Dysport). The amount of botulinum A toxin required depends upon the number of muscles that are targeted, and the size of the patient. In order to achieve adequate chemodenervation with botulinum A toxin, the following conditions must be met: (i) a sufficient number of units of toxin must be injected in order to neutralize neuromuscular junction (NMJ) activity; (ii) an appropriate drug volume is required in order to optimize the delivery of the toxin to the NMJs; and (iii) localization of the injecting needle through the fascia of the target muscle is necessary. Localization of the injection may be facilitated by active electromyography, ultrasonography, palpation of the muscle belly, and/or use of anatomic landmarks. Botulinum A toxin injections are indicated for use in pediatric patients with CP to: (i) improve motor function by balancing muscle forces across joints; (ii) improve health-related quality of life by decreasing spasticity and/or decreasing caregiver burden; (iii) decrease pain from spasticity; (iv) enhance self-esteem by diminishing inappropriate motor responses; and (v) provide a presurgical diagnostic tool. Following intramuscular injections of botulinum A toxin, short-term benefits of reduced spasticity are observed in approximately 70-82% of children. The intermediate term (1-2 years) efficacy rate is approximately 50%. The most common deformity treated with toxin injections in pediatric patients with CP is equinus foot deformity. However, efficacy of toxin injections for the management of crouched gait, pelvic flexion contracture, cervical spasticity, seating difficulties, and upper extremity deformity also has been documented. In addition, toxin injections have been shown to manage painful muscle spasticity associated with surgery or application of casts and painful cervical spasticity with or without dystonia. Toxin injections can also be used as a diagnostic tool to determine the appropriateness of other interventions by observing the muscle response to the injection in order to gain additional information for the development of a treatment plan. Botulinum A toxin, when used in appropriate doses, is well tolerated.

Botulinum Toxins↗
PubMed2003

Analysis of factors associated with increased prescription illegibility: results from the National Ambulatory Medical Care Survey, 1990-1998.

OBJECTIVE: To estimate the incidence of, and the variables affecting, illegible drug prescriptions in the United States. METHODS: Illegible notations of medications (ie, drug mentions) on the patient record form used for data collection in the National Ambulatory Medical Care Survey from 1990 to 1998 were used as a proxy for the incidence of illegible prescriptions in the United States. RESULTS: The average incidence of illegible mentions was 1.44%. Increased age of patient, female sex, urban practice setting, increased number of diagnoses and prescriptions written during the visit and seeing a family physician or internist were associated with an increased probability of at least 1 illegible drug mention. CONCLUSION: Distinct characteristics are associated with a higher incidence of illegible prescriptions. Multiple diagnoses and an increased number of prescriptions, both of which contribute to the complexity of a patient visit, are especially likely to be associated with at least 1 illegible prescription per visit. Physicians need to recognize factors contributing to illegible prescriptions to maintain high standards of care.

Adolescent↗
PubMed2002

Relation between use of angiotensin-converting enzyme inhibitors and muscle strength and physical function in older women: an observational study.

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors prevent decline in physical function in patients with congestive heart failure (CHF). We aimed to see whether ACE inhibitors also prevent reduction in physical performance and in muscle strength in older women who do not have CHF. METHODS: We assessed 3-year rates of decline in both knee extensor muscle strength and walking speed in 641 women with hypertension who had participated in the Women's Health and Aging Study. Women were stratified into four groups according to type and duration of antihypertensive drug treatment. 61 had used ACE inhibitors continuously, 133 intermittently, 146 never, and 301 had used other hypertensive drugs either continuously or intermittently. FINDINGS: Participants who had taken ACE inhibitors continuously had a lower mean 3-year decline in muscle strength of -1.0 kg (SE 1.1) compared with -3.7 (0.5) kg in continuous/intermittent users of other antihypertensive drugs (p=0.016) and with -3.9 kg in those who had never used antihypertensives (p=0.026). Muscle strength fell by 3.0 kg in 3 years in both continuous and intermittent users of ACE inhibitors (p=0.096). Mean 3-year decline in walking speed in continuous ACE inhibitor users was -1.7 cm/s compared with -13.6 cm/s in intermittent users of ACE inhibitors (p=0.015), -15.7 cm/s in continuous/intermittent users of other antihypertensive drugs (p=0.002), and -17.9 cm/s in never users of antihypertensive drugs (p=0.001). INTERPRETATION: ACE inhibitor treatment may halt or slow decline in muscle strength in elderly women with hypertension and without CHF.

Aged↗
PubMed2002

Self-reported health status, prophylactic medication use, and healthcare costs in older adults with asthma.

OBJECTIVES: To examine the relationship between self-reported health status, prophylactic medication use, and healthcare service use in older adults with asthma. DESIGN: A prospective longitudinal cohort study was conducted over a 2-year postenrollment period in a population of asthmatic older adults enrolled in managed care. Patients completed a comprehensive health-risk screen at time of enrollment in the plan. SETTING: A Medicare health maintenance organization (HMO) in the southeastern United States with prescription benefit. PARTICIPANTS: One hundred twenty-nine older adults with asthma using inhaled corticosteroid therapy as prophylaxis and enrolled in a Medicare HMO were available for complete follow-up. MEASUREMENTS: We measured self-reported health perception, falls, lifestyle, depressive symptomatology, and pre-enrollment healthcare service use using a comprehensive risk screen. We used the Med-Total index and total annual healthcare charges as measures of postenrollment inhaled corticosteroid and healthcare service use. RESULTS: After adjusting for the effects of other variables, we found that depressive symptomatology at baseline and increased comorbidity severity (using the Charlson comorbidity index) were associated with significant reductions in prophylactic medication possession (27% with depressive symptomatology and 6% with unit increase in Charlson's index, P <.05). Additionally, after adjusting for the effects of baseline health status, we found that a 10% increase in prophylactic medication possession was associated with a nearly 5% decrease in total annual healthcare charges in this population (P <.01). CONCLUSION: There are strong but not fully explained associations between depressive symptoms at time of enrollment, decreased postenrollment prophylactic medication use and increased postenrollment healthcare service use in older adults with asthma.

Administration, Inhalation↗
PubMed2002

Trust in the medical profession: conceptual and measurement issues.

OBJECTIVE: To develop and test a multi-item measure for general trust in physicians, in contrast with trust in a specific physician. DATA SOURCES: Random national telephone survey of 502 adult subjects with a regular physician and source of payment. STUDY DESIGN: Based on a multidimensional conceptual model, a large pool of candidate items was generated, tested, and revised using focus groups, expert reviewers, and pilot testing. The scale was analyzed for its factor structure, internal consistency, construct validity, and other psychometric properties. PRINCIPAL FINDINGS: The resulting 11-item scale measuring trust in physicians generally is consistent with most aspects of the conceptual model except that it does not include the dimension of confidentiality. This scale has a single-factor structure, good internal consistency (alpha = .89), and good response variability (range = 11-54; mean = 33.5; SD = 6.9). This scale is related to satisfaction with care, trust in one's physician, following doctors' recommendations, having no prior disputes with physicians, not having sought second opinions, and not having changed doctors. No association was found with race/ethnicity. While general trust and interpersonal trust are qualitatively similar, they are only moderately correlated with each other and general trust is substantially lower. CONCLUSIONS: Emerging research on patients' trust has focused on interpersonal trust in a specific, known physician. Trust in physicians in general is also important and differs significantly from interpersonal physician trust. General physician trust potentially has a strong influence on important behaviors and attitudes, and on the formation of interpersonal physician trust.

Adult↗
PubMed2002

Measuring patients' trust in their primary care providers.

Existing scales to measure trust in physicians have differing content and limited testing. To improve on these measures, a detailed conceptual model was constructed and a large item pool (n = 78) was generated following a detailed conceptual model and expert review. After pilot testing, the best-performing items were validated with a random national sample (n = 959) and a regional sample of HMO members (n =1,199). Various psychometric tests produced a 10-item unidimensional scale consistent with most aspects of the conceptual model. Compared with previous scales, the Wake Forest physician trust scale has a somewhat improved combination of internal consistency, variability, and discriminability. The scale is more strongly correlated with satisfaction, desire to remain with a physician, willingness to recommend to friends, and not seeking second opinions; it is less correlated with insurer trust, membership in managed care, and choice of physician. Correlations are equivalent with lack of disputes, length of relationship, and number of visits [corrected].

Clinical Competence↗