The revision of government-sponsored health care.
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Health Care Reform↗
Biomedical subjects
S M Retchin
Publications and source records attributed to S M Retchin.
Access and outcomes of elderly patients enrolled in managed care.
OBJECTIVE: To determine differences in access to care and medical outcomes for Medicare patients with an acute or a chronic symptom who were enrolled in health maintenance organizations (HMOs) compared with similar fee-for-service (FFS) nonenrollees. DESIGN: A 1990 household telephone survey of Medicare beneficiaries who reported joint pain or chest pain during the previous 12 months. SAMPLE: Stratified random sample of HMO enrollees (n = 6476) and comparable sample of FFS Medicare beneficiaries (n = 6381). ACCESS AND OUTCOME MEASURES: Care-seeking behavior, physician visits, diagnostic procedures performed, therapeutic interventions prescribed, follow-up recommended by a physician, and symptom response to treatment. RESULTS: After controlling for demographic factors, health and functional status, and health behavior characteristics, HMO enrollees with joint pain (n = 2243) were more likely than nonenrollees (n = 2009) to have a physician visit (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.03 to 1.38) and medication prescribed (OR, 1.35; 95% CI, 1.14 to 1.60). Patients with chest pain who were enrolled in HMOs (n = 556) were less likely than nonenrollees (n = 524) to have a physician visit (OR, 0.50; 95% CI, 0.30 to 0.82). For both joint and chest pain, HMO enrollees were less likely to see a specialist for care, have follow-up recommended, or have their progress monitored. There were no differences in complete elimination of symptoms, but HMO enrollees with continued joint pain reported less symptomatic improvement than nonenrollees (OR, 0.72; 95% CI, 0.59 to 0.86). CONCLUSIONS: Reduced utilization of services for patients with specific ambulatory conditions was observed in HMOs with Medicare risk contracts, with less symptomatic improvement in one of the four outcomes studied.
Activities of Daily Living↗
Faculty practice plans: caring for the underserved?
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Academic Medical Centers↗
Should the elderly receive chemotherapy for node-negative breast cancer? A cost-effectiveness analysis examining total and active life-expectancy outcomes.
PURPOSE: This study determines the survival benefit and cost-effectiveness of adjuvant chemotherapy in elderly women with breast cancer. In addition, the analysis measures the impact of substituting active life expectancy for survival in the clinical decision. PATIENTS AND METHODS: Two cohorts of women with estrogen receptor (ER)-negative, stage I breast cancer from age 60 to 80 years were monitored using a Markov process. One group received standard chemotherapy following primary therapy, and the other had no postoperative treatment. Data were derived from recently published clinical trials and a major meta-analysis. Outcome included the average survival, active life-expectancy, and incremental cost/quality-adjusted life-year (cost/QALY). RESULTS: Adjuvant chemotherapy prolongs survival in older women, but to a lesser extent compared with younger women. The average gain in quality-adjusted months was 1.8 months in a 75-year-old cohort at a cost/QALY of $4,400. These small benefits were not substantially altered when univariate changes were made in toxicity, recurrence risk, or effectiveness of chemotherapy. When active life expectancy replaced survival as an end point, the benefit for 75-year-old women decreased to 2 weeks at a cost of more than $96,000/QALY. CONCLUSION: There is a small survival benefit for adjuvant chemotherapy in elderly patients. The cost of this benefit is high, but within the range of commonly reimbursed procedures until a point between 75 and 80 years old. The use of active life expectancy as the primary outcome reduces the benefit and adds to the cost. If physicians and policymakers agree that active life expectancy is a relevant outcome, withholding chemotherapy for patients > or = 70 years old is a reasonable approach.
Age Factors↗
Do health maintenance organizations work for Medicare?
Since 1985, the Health Care Financing Administration (HCFA) has encouraged health maintenance organizations (HMOs) to provide Medicare coverage to enrolled beneficiaries for fixed prepaid premiums. Our evaluation shows that the risk program achieves some of its goals while not fulfilling others. We find that HMOs provide care of comparable quality to that delivered by free-for-service (FFS) providers using fewer health care resources. Enrollees experience substantially reduced out-of-pocket costs and greater coverage. However, because the capitation system does not account for the better health of those who enroll, the program does not save money for Medicare.
Capitation Fee↗
An overview of the older driver.
Although MVC rates are not substantially higher among older drivers after adjusting for mileage and may even be lower, the crash risk of the elderly driver remains a matter of increasing public concern. In part this is due to media attention over isolated cases of fatal MVCs involving older drivers, occasionally with a demented driver. This media attention has led to growing apprehension over the issue of elderly drivers. Physicians are likely to be involved increasingly in the evaluation of older drivers, whether they want to or not. The physician's quandary is the competing interests of the patient's well-being (i.e., continued independence), and the public's welfare (i.e., protection from impaired drivers). Unfortunately, there are no certain guidelines to protect the physician from liability for either of these conflicting duties. At issue is the foreseeability of harm from an elderly driver, either to self or to others. What degree of impairment is necessary before a physician is bound to report a patient to authorities? Although there are no clear answers, the best advice is to follow clinical judgment. One suggestion is to consider the diagnosis as suitable evidence. Thus, if the patient has a dementing illness of sufficient severity to warrant documentation in the medical record as a diagnosis, then perhaps the physician should consider advising the patient not to drive; reporting the patient to the appropriate authorities would be left to the physician's discretion after consultation with the patient's family. This might have the added benefit of obliging physicians to think twice before mislabeling patients with benign forgetfullness as demented, an all-too-frequent phenomenon. In this weighty ethical decision, it is critical for physicians to consider the consequences of removal of driving privileges from their elderly patients as well as their duty to protect the public health. Neither should be taken lightly. Above all else, physicians should not forsake their responsibility for advising either patients or the public regarding the driving privilege. To do so would simply relinquish the decision-making to those without clinical training or evaluative skills relevant to driving tasks. The physician's role in the evaluation of the elderly driver should be regarded as a pivotal challenge in the complicated management of the health of the elderly population.
Accidents, Traffic↗
Reported home health agency referrals by internists and family physicians.
OBJECTIVE: To evaluate the frequency of home health agency referrals (HHRs) by internists and family physicians. DESIGN: Telephone survey of a randomly selected, nationally representative, stratified physician sample. PARTICIPANTS AND SETTING: One thousand one hundred sixty-one interviews with 576 family physicians and 585 internists selected from the American Medical Association Physician Masterfile. MAIN RESULTS: Most respondents (88%) reported making HHRs (mean for those making HHRs = 43/year). Physicians with > or = 48 annual HHRs (n = 315) reported a mean of 2.6 hours/week in home care telephone management and 2.1 hours/week on related paperwork. Rural internists and family physicians (n = 230) reported less availability of several types of non-physician home health services than non-rural respondents (n = 931), yet rural physicians were more likely to refer patients to home health agencies. Using multivariate linear regression, the reported frequency of HHRs was significantly related to rural practice location, number of home-bound patients, proportion of geriatric patients, number of house calls, graduation from a U.S. or Canadian medical school, physician knowledge of community resources, and physician experience either as a medical director, a member of the board of directors, or a consultant for a home health agency. CONCLUSIONS: Internists and family physicians who work at least 10 hours per week in ambulatory care report making approximately three home health agency referrals per month and spending substantial amounts of time coordinating home health agency care. Despite reporting less availability of many home health agency services, rural physicians report greater involvement than non-rural physicians in the delivery of home care.
Attitude of Health Personnel↗
A geriatric and gerontologic perspective on the effects of medical conditions on older drivers: discussion of Waller.
In discussing Waller's paper, we build on his review of medical conditions and the risk of motor vehicle accidents (MVAs) using principles derived from geriatrics, gerontology, and health services research. Three approaches are suggested. The medical model uses discrete diseases as risk factors, but despite its utility and appeal, this model does not sufficiently characterize health and functional status to be the sole approach, and future investigative efforts should at least consider severity of illness concepts. The functional status model emphasizes a functional and physiological approach to health status, but despite its successful application in geriatric assessment and its investigative promise, functional status can be difficult to measure and has not been validated in relation to MVA risk. Finally we consider a behavioral model and within that framework discuss the relation of depressive and other emotional illnesses as well as social vitality to driving patterns and MVA occurrence.
Accidents, Traffic↗
How the elderly fare in HMOs: outcomes from the Medicare competition demonstrations.
Because of concern about the effects of prepaid care on outcomes for elderly enrollees in health maintenance organizations (HMOs), a prospective study of access to care and functional outcomes was performed. HMOs with Medicare risk contracts in January 1985 (N = 17) were selected from ten communities and were matched for comparison with ten similar communities where no Medicare HMOs were in operation. Random samples of HMO enrollees (N = 2,098) and fee-for-service (FFS) nonenrollees (N = 1,059) were assessed at baseline and at follow-up one year later (HMO = 1,873, FFS = 916) to observe access to care and functional outcomes. At baseline, nonenrollees had more bed days and poorer functional status than HMO enrollees. While fewer HMO enrollees experienced declines in functional status between baseline and follow-up (e.g., patient's ability to function declined in one or more activities of daily living: HMOs at 5.3 percent versus FFS at 8.5 percent, p < .01), after controlling for other factors with logistic regression, enrollment status was not significantly associated with functional decline. Self-rated health, history of hospitalization, age of 80 or older and baseline functional status were predictive of decline in function. After controlling for baseline differences, HMO disenrollees also experienced similar functional declines at follow-up compared to continuously enrolled beneficiaries. These findings suggest that Medicare beneficiaries who belong to HMOs experience comparable rates of functional decline to those experienced by beneficiaries in the FFS sector with similar initial levels of function and health status. Together with results showing no significant difference in medical visits according to various symptoms, we conclude that access and quality of care delivered by HMOs is comparable to that provided in FFS settings.
Activities of Daily Living↗
The management of geriatric hypertension in health maintenance organizations.
OBJECTIVE: To evaluate the quality of medical care received by Medicare enrollees with hypertension in health maintenance organizations (HMOs) compared to that received by a similar group of elderly hypertensives in a fee-for-service (FFS) setting. DESIGN: A quasi-experimental design was used to study an historical cohort of newly evaluated hypertensive patients over a 2-year period. SETTING: Medicare HMO and FFS practice settings. PARTICIPANTS: Eight Medicare HMOs and 87 FFS primary care physicians in the same communities were selected. A sample of 685 elderly hypertensive patients was studied, 336 in FFS settings and 349 in HMOs. MEASUREMENTS AND MAIN RESULTS: An expert panel of physicians selected standards of care for the management of geriatric hypertension, and medical records were reviewed. The results showed significant differences (P less than 0.01) in recording medications (94.5% HMO versus 88% FFS) and smoking histories (75.8% HMO versus 64.7% FFS), checking orthostatic blood pressures (9.5% HMO versus 3.3% FFS), performing funduscopy (44.4% HMO versus 27% FFS), completing cardiac examinations (90.8% HMO versus 79.8% FFS), and obtaining chest x-rays (72.8% HMO versus 64.3% FFS, P less than 0.05). Treatment and follow-up were similar between the two groups, except that FFS hypertensives were more likely to have medications adjusted and electrolytes ordered. CONCLUSIONS: The results suggest that elderly hypertensives in HMOs received equal or better quality of care for most criteria compared to elderly hypertensives in FFS settings.
Aged↗
Effects of cost containment on the care of elderly diabetics.
OBJECTIVE: Because of rising costs in the Medicare program, the elderly have been encouraged to enroll in health maintenance organizations (HMOs). To evaluate the quality of care in these HMOs, detailed criteria on the treatment of elderly diabetics were established by an expert panel. DESIGN: Approximately 20 months of care for elderly diabetics was reviewed by medical record abstractions with a historical cohort design. SETTING: The care of elderly diabetics in eight HMOs was compared with the care received in fee-for-service (FFS) settings located in similar geographic areas. PATIENTS: Elderly diabetics enrolled in HMOs (n = 158) were compared with similar diabetics (n = 134) in FFS settings. RESULTS: Diabetic HMO enrollees were more likely to have funduscopic examinations (48% in HMOs vs 30% FFS) and urinalyses (89% in HMOs vs 74% FFS) performed. Enrollees with poor diabetic control were also more likely than FFS diabetics to be referred to an ophthalmologist (45% in HMOs vs 11% FFS). However, influenza vaccinations were administered to diabetics more often in FFS settings than to diabetic enrollees (19% in HMOs vs 62% FFS). One fifth of diabetics in both groups were treated with insulin and two thirds were treated with oral hypoglycemic agents, though HMO enrollees were more likely to have medication changes. CONCLUSION: We conclude that most aspects of the quality of diabetic care were similar in HMO and FFS settings and were unaffected by this effort at cost containment.
Aged↗
Elderly patients with congestive heart failure under prepaid care.
PURPOSE: Because of concern about the quality of care received by Medicare patients in health maintenance organizations (HMOs), the care of patients with congestive heart failure (CHF) in eight HMOs was compared with the care of fee-for-service (FFS) Medicare cases. PATIENTS AND METHODS: We compared the care of 170 patients with CHF enrolled in one of eight Medicare HMOs with the care of 191 similar FFS patients. Panels of expert physicians developed criteria for evaluating quality of care, and specially trained nurse clinicians abstracted medical records. RESULTS: Outpatient evaluation and management were similar in both settings, although HMO patients were significantly more likely to be advised to restrict salt intake. However, FFS patients with uncontrolled hypertension were more likely to have their medication regimens changed (62% versus 36%, p less than 0.01). Ejection fractions were obtained equally as often, and inpatient management was similar for both groups. Nonetheless, HMO providers scheduled follow-up visits within 1 week of hospital discharge more often (42% versus 27%, p less than 0.01). CONCLUSIONS: This study suggests that financial incentives of prepaid care are not detrimental to most aspects of care for CHF patients. More rapid follow-up after hospital discharge for patients with CHF suggests that HMOs may be more effective in delivering continuity of care for patients with chronic illness.
Aged↗
The quality of ambulatory care in Medicare health maintenance organizations.
The quality of ambulatory care received by Medicare recipients who enrolled in health maintenance organizations (HMOs) was compared to the care received by fee-for-service (FFS) Medicare recipients, in a quasi-experimental, non-randomized design. Both samples were drawn from the four major geographic areas in the country, and included two types of HMO practices: staff/group models, and independent practice associations (IPAs). A panel of expert physicians developed criteria for evaluating ambulatory care, and medical record abstractions using these criteria were performed on 1,590 outpatient records: 777 FFS and 813 HMO (441 staff/group, 372 IPA). While individual items of medical histories and physical examinations were performed most often for staff/group HMO patients and least often in FFS patients, odds ratios (OR) for performance in staff/group HMO patients were particularly large for health maintenance items: tonometry (OR = 8.4), mammography (OR = 2.7), pelvic examination (OR = 5.3), rectal examination (OR = 2.9), fecal occult blood test (OR = 3.3). The results suggest that recommended elements of routine and preventive care are more likely to be performed for Medicare enrollees in staff/group HMOs than in FFS settings.
Aged↗
The influence of physician specialty on housecalls.
Despite growing numbers of frail elderly, physicians make housecalls infrequently. We surveyed 1000 primary care physicians from Virginia regarding their attitudes and knowledge about housecalls, and 389 completed questionnaires (response rate, 52%): 185 family physicians, 36 general practitioners, 101 general internists, and 63 subspecialists. Despite similar proportions of homebound patients and practice demographics, family physicians (69%) and general practitioners (63%) were significantly more likely than either internists (53%) or subspecialists (37%) to make routine housecalls. Although all four groups thought the fee was rarely a motivation, internists and subspecialists suggested larger increases. Also, internists and subspecialists were less likely than family physicians or general practitioners to increase housecalls with increased payment. Internists and subspecialists also were more likely than family physicians or general practitioners to report that housecalls were often unnecessary, not "enjoyable," "inefficient," and unimportant. While improved reimbursement may lead to increased housecalls by family physicians, future strategies should include efforts to change internists' attitudes.
Aged↗
The role of aging and chronic disease in sexual dysfunction.
Sexual dysfunction is so highly prevalent in elderly males that it is often considered an inevitable consequence of "normal aging." To determine if other factors are related to an age-associated decline in sexual function, we surveyed two groups of elderly male veterans in a geriatric ambulatory care clinic: aged 65 to 75 years ("young-old") and aged over 75 ("old-old"). We compared their survey responses with responses from a general medical clinic for unstable medical patients, aged under 65 ("old-young"). Of 347 subjects surveyed, 225 completed a health and sexual function questionnaire (response rate = 65%). Absent libido was reported by 30% of old-young, 31% of young-old, and 47% of old-old. Erectile dysfunction was reported in 26% of old-young, 27% of young-old, and 50% of old-old (P less than .01). We used ordinal logistic regression and found overall sexual dysfunction to be significantly related to subjective poor health, diabetes mellitus, and incontinence (P less than .05), while controlling for age. These data suggest that, although sexual dysfunction is more common in the aged, it is often related more to comorbid illness than aging alone.
Aged↗
Performance-based measurements among elderly drivers and nondrivers.
Although driving is an important ability for maintaining independence in the later years, clinical factors that determine driving status are unknown. Aged male veterans (mean age, 70 years) were recruited from an outpatient clinic (N = 143), including 77 frequent drivers, 41 infrequent drivers, and 25 who drove rarely or not at all. There were 116 (84%) who completed a comprehensive performance-based assessment. There were no significant differences between the three groups in age, formal cognitive testing, or prevalence of stroke history. However, there were significant differences in grip strength, reaction time, static visual acuity, dynamic visual acuity, and peripheral vision. Using stepwise ordinal logistic regression, dynamic visual acuity, nondominant hand grip strength, and total horizontal peripheral visual field were significantly associated with driving frequency (P less than .05), and together explained approximately 45% of the variance. Subtle motor and visual deficits that can be detected by a performance-based assessment may play an important role in determining driving frequency in the elderly.
Activities of Daily Living↗
The impact of echocardiographic results on treatment decisions for patients suspected of mitral valve prolapse.
Although echocardiography is frequently ordered in ambulatory settings for patients suspected of mitral valve prolapse (MVP), its impact on their subsequent management is unknown. We studied the relationship between the results of echocardiography for outpatients suspected of MVP, and two frequent medical decisions: treatment with beta blockers and the recommendation of antibiotic prophylaxis to prevent bacterial endocarditis. A medical record audit was performed on 274 outpatients referred to a university medical center echocardiography laboratory to rule out MVP. Although echocardiographic evidence for MVP significantly influenced the decision to recommend antibiotic prophylaxis (P less than 0.001), symptoms were more likely to be used as indications for beta-blocker therapy in patients suspected of the condition. We conclude that echocardiographic results are used for recommending antibiotic prophylaxis to outpatients suspected of MVP, but not for beta-blocker therapy.
Adrenergic beta-Antagonists↗
Mitral valve prolapse. Disease or illness?
Mitral valve prolapse (MVP) is a common condition that is believed to be responsible for numerous symptoms and potentially serious complications. To determine whether symptoms and functional impairment are related to MVP itself, we studied 274 outpatients referred to an echocardiography laboratory for suspicion of MVP. The age, sex, and symptoms at the time of echocardiography were similar among patients with and without evidence of MVP. After 14 to 36 months, 158 patients were interviewed. There was a high rate of dysfunction, but echocardiographic evidence of MVP was not associated with disability, health care utilization, or reported symptoms. The results of this study suggest that symptoms and dysfunction are not related to the presence of MVP by echocardiography. The functional impairment that is seen in patients suspected of MVP may be caused by other factors.
Adult↗