Biomedical subjects

Robert L Kane

Publications and source records attributed to Robert L Kane.

At least 37 records · Page 2Linked to original sources

PubMed2005

Potential cost-effective use of spine radiographs to detect vertebral deformity and select osteopenic post-menopausal women for amino-bisphosphonate therapy.

Prevalent vertebral deformities are predictive of future clinical fractures independent of bone density. We used a Markov model with eight health states to estimate from the societal perspective the cost-effectiveness of using spine radiographs to identify postmenopausal women age 60 or older with one or more vertebral deformities and then treat them with anti-resorptive drug therapy to prevent fractures. We compared three strategies: 5 years of amino-bisphosphonate (alendronate) therapy for all, 5 years of alendronate therapy for only those with prevalent a radiographic vertebral deformity or no initial alendronate treatment. Lifetime direct medical and indirect costs, quality adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) were tracked. For women with one or more prevalent vertebral deformities, the costs per QALY gained ranged from 5,084 dollars (for an 80 year old with a T-score of -2.4) to 61,192 dollars (for a 60 year old with a T-score of -1.0). For women without prevalent vertebral deformity, the costs per QALY gained ranged from 41,897 dollars (for a 60 year old with a T-score of -2.4) to 166,219 dollars (for an 80 year old with a T-score of -1.0). These results were modestly sensitive to reasonable changes in fracture rates, disutility, discount rates and assumptions about the accuracy of spinal radiographs for detecting vertebral deformity. Assuming a societal willingness to pay per QALY gained of 50,000 dollars, the strategy of performing spine radiographs in post-menopausal osteopenic women with T-scores at or below -1.5 and treating those with 1 or more prevalent vertebral deformities is likely to be cost-effective. However, further research on the accuracy of vertebral deformity ascertainment from routine clinical radiographs and on the efficacy of amino-bisphosphonate drugs for reducing the risk of non-vertebral fractures in osteopenic women is needed to define more precisely the subset of osteopenic post-menopausal women in whom use of spinal radiographs is most cost-effective.

Aged↗

PubMed2005

Prostate-specific antigen, digital rectal examination and transrectal ultrasonography: a meta-analysis for this diagnostic triad of prostate cancer in symptomatic korean men.

We conducted a meta-analysis using results from the Korean literature to determine whether prostate-specific antigen (PSA) or digital rectal examination (DRE) or transrectal ultrasonography (TRUS) provides a better diagnostic outcome for possible prostate cancer patients. An extensive literature search of MedRIC database et al. (1980 to 2003) was performed using the medical subject headings "PSA", "DRE", "TRUS" and "prostate cancer". Of the 108 articles that we retrieved, 13 studies (2,029 subjects) were selected for this meta-analysis. The criteria for quality evaluation were as follows: the study subjects must have been compared clinically for suspected prostate cancer, and the articles must have included individual data about sensitivity and specificity for this diagnostic triad based on the biopsy results as a reference standard. For the quantitative meta-analysis process the Hasselblad method was utilized. The pooled sensitivity and specificity for a PSA level greater than 4ng/mL were 91.3 % and 35.9 %, respectively; and those for a PSA level greater than 10ng/mL were 77.3 % and 67.5 %, respectively; and those for DRE were 68.4 % and 71.5 %, respectively; and those for TRUS were 73.6 % and 61.3 %, respectively. According to the results in a fixed effect model for PSA criteria, the estimates of d for PSA4 and PSA10 were 0.8517 [95 % confidence interval (CI): 0.6694, 1.0340] and 1.0996 (95 % CI: 0.9459, 1.2534), respectively. Also, according to the results using a random effect model for both DRE and TRUS criteria, the estimates of d for DRE and TRUS were 0.8398 (95 % CI: 0.7169, 0.9627) and 0.8002 (95 % CI: 0.6714, 0.9289), respectively. The detection rate for combination testing of PSA, DRE and TRUS for the diagnosis of prostate cancer jumped further to 68.3 % or to 76.8 %. In conclusion, this study suggests that this diagnostic triad for prostate cancer was noneffective when they were used separately. Therefore, we recommend that the urologists should use PSA together with DRE and TRUS for the primary diagnosis of prostate cancer in men with lower urological symptoms.

Humans↗

PubMed2005

Cost-effectiveness of alendronate therapy for osteopenic postmenopausal women.

BACKGROUND: Treatment guidelines recommend drug treatment to prevent fractures for some postmenopausal women who have low bone mass (osteopenia) but do not have osteoporosis or a history of clinical fractures. OBJECTIVE: To estimate the societal costs and health benefits of alendronate drug treatment to prevent fractures in postmenopausal women with osteopenia. DESIGN: Markov model with 8 health states: no fracture, post-distal forearm fracture, post-clinical vertebral fracture, post-radiographic (but clinically inapparent) vertebral fracture, post-hip fracture, post-hip and vertebral fractures, post-other fracture, and death. DATA SOURCES: Population-based studies of age-specific fracture rates and costs, prospectively measured estimates of disutility after fractures, and the Fracture Intervention Trial of alendronate versus placebo to prevent fracture. TARGET POPULATION: Postmenopausal women 55 to 75 years of age with femoral neck T-scores between -1.5 and -2.4. TIME HORIZON: Lifetime. PERSPECTIVE: Societal. INTERVENTIONS: Five years of alendronate therapy or no drug treatment. OUTCOME MEASURES: Costs, quality-adjusted life-years, and incremental cost-effectiveness ratios. RESULTS OF BASE-CASE ANALYSIS: For women with no additional fracture risk factors, the cost per quality-adjusted life-year gained ranged from 70,000 dollars to 332,000 dollars, depending on age and femoral neck bone density. RESULTS OF SENSITIVITY ANALYSES: Results were sensitive to changes in fracture risk reduction attributable to alendronate and alendronate cost. LIMITATIONS: Results apply only to postmenopausal white women residing in the United States. CONCLUSION: Alendronate therapy for postmenopausal women with femoral neck T-scores better than -2.5 and no history of clinical fractures or other bone mineral density-independent risk factors for fracture is not cost-effective, assuming U.S. costs of alendronate and currently available estimates of alendronate efficacy in osteopenic women.

Aged↗

PubMed2005

Estimating the patient care costs of teaching in a teaching hospital.

PURPOSE: Because leaders at medical schools and teaching hospitals need current data to estimate the clinical costs of graduate medical education, the authors developed a new methodology to estimate the hospital costs associated with the presence of teaching physicians for the year 2002. METHOD: A hospital accounting system was used to determine the case mix-adjusted direct variable costs for 41,522 inpatient admissions associated with or without a teaching physician. RESULTS: Prior to adjustment, teaching cases had greater median costs than non-teaching cases. After severity adjustment, teaching cases in aggregate were associated with an additional 4.4% of the total direct variable cost of inpatient admissions, or US 3.6 million dollars. The size of the teaching effect varied by service, ranging from -5.7% for medical services to 13 percent for behavioral services. The effect of teaching on cost centers such as laboratory, pharmacy, and radiology varied by specialty service. Teaching was associated with a negligible 0.7% relative difference in length of stay. CONCLUSION: The incremental effects of teaching on hospital patient care costs are modest. These analyses can be repeated annually to detect changes in teaching costs and to target areas of excessive cost for interventions that improve efficiency. Our results and methods for identifying hospital costs associated with teaching services may prove useful in negotiations between academic health centers and affiliated teaching hospitals.

Education, Medical, Graduate↗

PubMed2005

Visual Analog Scale pain reporting was standardized.

BACKGROUND AND OBJECTIVE: Whereas pain is frequently measured using a visual analog scale (VAS) that can examine change over short time intervals in the same subject, such ratings are not useful in analyzing differences across subjects. We created a method for normalizing VAS pain reporting to control for the variation between different populations due to the differences in subjective perception or objective evaluation of pain. METHODS: A list of 226 pains was gathered from a convenience sample of persons on the street and patients waiting at medical and orthopedic clinics. These pains were ranked according to severity by health professionals and 19 pains with the most stable rankings were selected. These 19 pains were then rated by a sample of community-dwelling persons and a method of VAS standardization was developed, based on six selected pains. RESULTS: Individual variations in pain ratings were found to be independent of respondent age and gender, but were correlated with experience of the event or behavior and with self-reported health status. A new scoring method that takes into account these correlations is proposed. CONCLUSION: It is possible to standardize VAS pain ratings to compare pain between different populations.

Age Factors↗

PubMed2005

The longitudinal effects of early behavior problems in the dementia caregiving career.

Using multiregional, 3-year data from early career dementia caregivers, this study determines how behavior problems that occur early in the caregiving career influence time to nursing home placement and change in burden and depression over time. A Cox proportional hazards model indicated that caregivers who managed frequent behavior problems earlier are more likely to institutionalize. After controlling for important time-varying covariates in a series of growth-curve models, caregivers who were faced with severe, early behavior problems reported greater increases in burden and depression over the 3-year study period. The findings suggest the need to consider experiences early in the dementia caregiving career when accounting for key longitudinal outcomes and also emphasize the importance of attrition when attempting to model the health implications of informal long-term care over time.

Aged↗

PubMed2005

Use of proxy respondents and accuracy of minimum data set assessments of activities of daily living.

BACKGROUND: Although the Minimum Data Set (MDS) presents a wide range of opportunities for policy makers and practitioners interested in outcomes of nursing home care for frail elderly persons, researchers have debated the validity and reliability of measurements in the MDS from the outset. To investigate this issue, the authors studied the accuracy of functional assessments by comparing the MDS and interview data collected in two evaluation studies. METHODS: Activities of daily living (ADL) assessment data from 3385 nursing home residents were collected from interviews with nursing home residents (n = 1200), family members (n = 1070), and nursing home staff (n = 1115). The MDS data for these nursing home residents were obtained and matched with the interview data. The agreement in ADL assessments between interview data and the MDS was assessed using Kappa statistics and multinomial logit regression for each of the three data sources. RESULTS: The agreement on ADL assessments between MDS and interview data was low to moderate (Kappa = 0.25 to 0.52), regardless of the sources of data. Interview data from staff and family proxies agreed to a greater degree with the MDS than did data collected from nursing home residents. The MDS reported fewer ADL difficulties than did staff proxies and more ADL difficulties than did nursing home residents. These findings held even after adjustment for other confounding factors using multinomial logit regression. CONCLUSIONS: The substantial discrepancy between MDS and interview data can be attributed to both bias and error. The ADL assessments based on residents' and family or staff reports differ, but the size of these differences depends on the proxy type and the method of data collection.

Activities of Daily Living↗

PubMed2005

Proxy sources for information on nursing home residents' quality of life.

OBJECTIVES: This study explores how well staff and family proxies' reports on selected quality-of-life (QOL) domains (comfort, dignity, functional competence, privacy, meaningful activity, food enjoyment, relationships, security, and autonomy) correspond to residents' own reports. METHODS: We compared QOL domain scores for nursing home residents and 1,326 staff proxies and 989 family proxies at the individual and facility level using means, Pearson correlation statistics, and intraclass correlations. Regression models adjusted for residents' age, gender, length of stay, ability to perform activities of daily living, and cognition. RESULTS: For each domain in more than half the cases, proxy means were within 1 SD of the resident means. Resident and family proxy individual reports for selected domains were correlated at 0.14 to 0.46 (all p <.000). Resident and staff proxy individual reports were correlated at 0.13 to 0.37 (all p <.000). Correlation of mean levels by facility for staff proxies was 0.26 to 0.64 (generally p <.05) and for family proxies 0.13 to 0.61 (p <.01 except for one domain). DISCUSSION: Although staff and family proxy domain scores are significantly correlated with resident scores, the level of correlation suggests they cannot simply be substituted for resident reports of QOL. Determining how proxy reports can be used for residents who cannot be interviewed at all remains an unresolved challenge.

Activities of Daily Living↗

PubMed2005

The effects of duration of caregiving on institutionalization.

PURPOSE: Our objective in this analysis was to determine how the duration of caregiving interacts with key care demands (i.e., severity of problem behaviors) to influence the institutionalization of individuals suffering from dementia. METHODS: We utilized multiregional data from 4,761 caregivers of individuals with dementia over a 3-year period. We conducted multinomial logistic and Cox proportional hazards analyses to determine the moderating effects of duration on behavior problems when institutionalization was predicted. Baseline covariates included the context of care, primary objective stressors, primary subjective stressors, resources, and global outcomes. RESULTS: The Duration of care x Behavior problems interaction term was not significant in the multinomial regression or Cox hazards models. However, main effects models demonstrated that more recent caregivers were more likely to institutionalize individuals with dementia than respondents in different stages of the caregiving career. IMPLICATIONS: The results emphasize the need to (a) broaden scientific conceptualizations to consider duration of care as integral; (b) refine targeting when interventions are administered early in the dementia caregiving process; and (c) understand patterns of attrition when caregiver adaptation is modeled over time.

Dementia↗

PubMed2005

Future development of nursing home quality indicators.

Nursing home quality indicators have been developed over the past 10 years to quantify nursing home quality and to draw systematic comparisons between facilities. Although these indicators have been applied widely for nursing home regulation, quality improvement, and public reporting, researchers and stakeholders have raised concerns about their accuracy and usefulness. We critically evaluate nursing home quality indicators from the standpoint of theory, measurement, and application, and we recommend strategies to make the indicators more valuable as quality assessment tools. We recommend that (a) more comprehensive quality indicators should be developed in conjunction with the new Minimum Data Set 3.0; (b) the validity and reliability of the indicators should be evaluated thoroughly with respect to both measurement and application; (c) statistical criteria should be incorporated explicitly into quality indicator scoring and outlier targeting; (d) the dimensionality and theoretical structure of the quality indicators should be carefully examined; (e) risk adjustment methods should be refined and broadened; and (f) quality indicator reporting systems should be strengthened and tailored to stakeholders' needs.

Nursing Homes↗

PubMed2005

Early community-based service utilization and its effects on institutionalization in dementia caregiving.

PURPOSE: The present study attempts to determine whether utilizing community-based long-term-care services early in the dementia caregiving career delays time to nursing home placement (adjusting for severity of dementia). DESIGN AND METHODS: With a reliance on data from 4,761 dementia caregivers recruited from eight catchment areas in the United States and followed over a 3-year period, a Cox proportional hazards model was conducted that considered key components of the stress process (e.g., context of care, primary objective and subjective stressors, and resources), duration, and community-based long-term-care use. RESULTS: An analysis of interaction terms in the Cox regression model found that those individuals who utilized in-home help services earlier in their dementia caregiving careers were more likely to delay institutionalization. IMPLICATIONS: The findings suggest the practical importance and cost-effectiveness implications of early community-based service use, and they emphasize the role of timing when one is conceptualizing the proliferation of stress in the dementia caregiving career.

Catchment Area, Health↗

PubMed2005

The quality of care under a managed-care program for dual eligibles.

PURPOSE: Our objective in this study was to compare the quality of care provided under the Minnesota Senior Health Options (MSHO), a special program designed to serve dually eligible older persons, to care provided to controls who received fee-for-service Medicare and Medicaid managed care. DESIGN AND METHODS: Two control groups were used; one was drawn from nonenrollees living in the same area (Control-In) and another from comparable individuals living in another urban area where the program was not available (Control-Out). Cohorts living in the community and in nursing homes were included. Quality measures for both groups included mortality rates, preventable hospital admissions, and preventable emergency room (ER) visits. For the community group, nursing home admission rates were also tracked. For nursing home residents, quality measures included quality indicators derived from the Minimum Data Set. RESULTS: There were no differences in mortality rates for either cohort. MSHO had fewer short-stay nursing home admissions but no difference for stays 90 days or longer. MSHO community and nursing home residents had fewer preventable hospital and ER visits compared to Control-In. There were no major differences in nursing home quality indicator rates. IMPLICATIONS: The cost of changing the model of care for dual eligibles from a mixture of fee-for-service and managed care to a merged managed-care approach cannot be readily justified by the improvements in quality observed.

Aged↗

PubMed2005

Outcomes and reimbursement of inpatient rehabilitation facilities and subacute rehabilitation programs for Medicare beneficiaries with hip fracture.

OBJECTIVE: We sought to assess whether outcomes and reimbursement differ for Medicare beneficiaries with hip fracture when treated in an inpatient rehabilitation facility (IRF) compared with a skilled nursing facility (SNF) subacute rehabilitation program. PARTICIPANTS: Clinical data were linked with Medicare claims for 29,793 Medicare fee-for-service beneficiaries with a recent hip fracture who completed treatment in 1996 or 1997 in rehabilitation facilities that subscribed to the Uniform Data System for Medical Rehabilitation. OUTCOME MEASURES: We measured discharge destination, change in motor FIM rating, and Medicare Part A reimbursement. RESULTS: For patients with moderate-to-severe and severe disabilities, case mix groups (CMGs) 704 and 705, the percentage of patients discharged to the community from IRFs was lower than for patients treated in subacute rehabilitation SNFs, after controlling for covariates. Adjusted odds ratios were 0.71 (95% confidence interval 0.55-0.92) for CMG 704 and 0.72 (95% confidence interval 0.63-0.83) for CMG 705. For patients in the 3 other CMGs, no significant differences were detected. Improvement in motor functional status was roughly equivalent for patients treated in IRFs and those treated in the subacute rehabilitation programs across all 5 CMGs, after controlling for covariates. Medicare Part A payments for IRFs were significantly higher than SNF payments across all CMGs. CONCLUSION: SNF-based subacute rehabilitation was less costly and outcomes were in most, but not all, instances similar or better than IRF-based rehabilitation for Medicare fee-for-service beneficiaries who had a recent hip fracture.

Aged↗

PubMed2005

The causes of racial and ethnic differences in influenza vaccination rates among elderly Medicare beneficiaries.

OBJECTIVE: To explore three potential causes of racial/ethnic differences in influenza vaccination rates in the elderly: (1) resistant attitudes and beliefs regarding vaccination by African-American and Hispanic Medicare beneficiaries, (2) poor access to care during influenza vaccination weeks, and (3) discriminatory behavior by providers. DATA SOURCES: Medicare beneficiaries who responded to both the 1995 and 1996 Medicare Current Beneficiary Survey (MCBS) (n=6,746). STUDY DESIGN: We combined survey information from the MCBS with Medicare claims. We measured resistance to vaccination by self-reported reasons for not receiving vaccination, access to care by claims submitted during vaccination weeks, and discrimination by racial differences in vaccinations among beneficiaries who visited the same providers during vaccination weeks. PRINCIPAL FINDINGS: White beneficiaries (66.6 percent) were more likely to self-report having received vaccination than were African Americans (43.3 percent) or Hispanics (52.5 percent). Resistance to vaccination plays a role in low vaccination rates of African-American (-11.8 percentage points), but not Hispanic beneficiaries. Unequal access accounts for <2 percent of the disparity. Minority beneficiaries remained unvaccinated despite having medical encounters with their usual providers on days when those same providers were administering vaccinations to white beneficiaries. This disparity is attributable not to provider discrimination but to a 1.6-5 x higher likelihood of white beneficiaries initiating encounters for the purpose of receiving vaccination. CONCLUSION: Disparities in access to care and provider discrimination play little role in explaining racial/ethnic disparities in influenza vaccination. Eliminating missed opportunities for vaccination in 1995 would have raised vaccination rates in three racial/ethnic groups to the Healthy People 2000 goal of 60 percent vaccination.

Black or African American↗

PubMed2005

Rating the importance of nursing home residents' quality of life.

OBJECTIVES: To assess how various stakeholders involved with nursing home care rate the importance of various quality-of-life (QoL) items for hypothetical residents with varying types of impairment. DESIGN: A community-based exploratory description of a convenience sample. SETTING: Eleven nursing homes in Florida, New Jersey, and Minnesota. PARTICIPANTS: Samples of registered and licensed nurses (RNs and LPNs), certified nursing assistants (CNAs), activities personnel, social workers, physicians, residents, and family members. MEASUREMENTS: Using a magnitude estimation approach, 17 QoL items were rated in order of importance on each of three hypothetical types of nursing home residents. RESULTS: Overall, there was little variation in the ratings for individual items. Ratings for persons with cognitive impairment were consistently lower. RNs'/LPNs' and CNAs' ratings were generally higher than the others, and physicians' ratings were generally lower. Residents' and families' ratings were generally lower than nurses' ratings. CONCLUSION: All stakeholders considered QoL to be important and felt that it deserves more attention in practice and regulation. A summary QoL score need not be weighted. Respondents (who were not cognitively impaired) considered QoL less important for residents with cognitive impairment. Value differences between those involved in nursing home care deserve more exploration.

Aged↗

PubMed2005

Unmet care needs and key outcomes in dementia.

OBJECTIVES: To determine how unmet needs for activity of daily living tasks influenced nursing home placement, death, or loss to follow-up in dementia. DESIGN: An 18-month longitudinal design, with interviews administered every 6 months. SETTING: Eight catchment areas in the United States. PARTICIPANTS: Five thousand eight hundred thirty-one dementia patients and their caregivers were included at baseline. MEASUREMENTS: Measures of sociodemographic context of care; functional, cognitive, and behavioral status of care recipients; caregiver stress and well-being; and formal and informal resources served as covariates. The independent variables of interest were unweighted unmet care need scores and unmet need scores weighted by importance and severity in a prior sample of older consumers of long-term care. Outcomes included nursing home placement, death, and loss to follow-up. RESULTS: Cox regression models suggested that greater unmet need was predictive of nursing home placement, death, and loss to follow-up. These results were apparent when the unweighted and the weighted scores for unmet need with activity of daily living dependencies were used. CONCLUSION: Unmet need may be useful in identifying dementia care recipients at risk for nursing home placement and death. Further study of unmet need is needed to effectively assess and target intervention protocols during the course of dementia.

Activities of Daily Living↗

PubMed2005

Universal bone densitometry screening combined with alendronate therapy for those diagnosed with osteoporosis is highly cost-effective for elderly women.

OBJECTIVES: To investigate the cost-effectiveness of universal bone densitometry in women aged 65 and older combined with alendronate treatment for those diagnosed with osteoporosis (femoral neck T-score < or = -2.5). DESIGN: A Markov model with a lifetime time horizon and eight health states (no fracture, distal forearm fracture, radiographic (but clinically inapparent) vertebral fracture, clinical vertebral fracture, hip fracture, hip and vertebral fracture, and other fractures), using the societal perspective. SETTING: Women living independently and those in nursing homes. PARTICIPANTS: Caucasian women aged 65, 75, 85, or 95. INTERVENTION: Bone densitometry of the hip, with 5 years of alendronate therapy for those found to have osteoporosis versus no intervention (densitometry or drug therapy). MEASUREMENTS: Lifetime accumulated quality adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios. RESULTS: The cost per QALY gained for the screen-and-treat strategy was 43,000 dollars per QALY gained for 65-year-old women and 5,600 dollars per QALY gained for 75-year-old women. For 85- and 95-year-old women, the screen-and-treat strategy was cost saving. Sensitivity analyses showed that the screen-and-treat strategy was cost-effective even under assumptions of reduced adherence to drug therapy, reduced fracture reduction benefit from alendronate therapy, or reduced QALYs saved by preventing fracture. CONCLUSION: Universal bone densitometry combined with alendronate therapy for those found to have osteoporosis is highly cost-effective for women aged 65 and older and may be cost saving for ambulatory women aged 85 and older (whether independently living or residing in nursing homes).

Absorptiometry, Photon↗

PubMed2005

Explaining trends in hospitalizations for pneumonia and influenza in the elderly.

From 1987-99, influenza and pneumococcal vaccination rates among elderly Medicare beneficiaries increased by 300 percent and 500 percent, respectively. Despite these gains, annual rates of hospitalizations for pneumonia and influenza (P&I) have not decreased; rather, they have increased steadily. The authors investigate whether this paradoxical increase in hospitalization rates reflects an increasing burden of P&I or the effects of a changing healthcare environment. They find that from 1987-99, P&I hospitalizations per one thousand beneficiaries increased from 15.1 to 23.4. Of this increase, 23 percent was due to an aging Medicare population, 2.4 percent was due to increased rates of rehospitalization, and at most 5 percent was due to upcoding. There was no evidence that physicians were increasingly admitting patients with less complicated cases of P&I. The changing healthcare environment only partially explained the paradoxical increase in P&I hospitalizations. P&I appears to be an increasing burden to the elderly, despite increased vaccination rates.

Aged↗