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PubMed2005

Bipolar disorder--costs and comorbidity.

Not only is bipolar disorder a chronic, severe psychiatric disorder, it is also expensive to treat and expensive to society. An estimate of the total cost of bipolar disorder made more than a decade ago was as high as 45 billion dollars per year. Most of this cost is accounted for by indirect costs related to reduced functional capacity and lost work. Patients with bipolar disorder have higher rates of utilization of healthcare resources compared with the general population and compared with patients with other types of psychiatric conditions. Comorbidity contributes to the heavy burden that bipolar disorder imposes on society. Bipolar disorder frequently occurs together with other psychiatric disorders, especially anxiety disorders and substance abuse. In addition, bipolar disorder has been associated with a variety of general medical conditions, which further complicate management of the psychiatric disorder.

Bipolar Disorder↗

PubMed2006

The impact and prevalence of chronic insomnia and other sleep disturbances associated with chronic illness.

Chronic insomnia may coexist with chronic physical and psychiatric conditions, and its prevalence is often higher among patients with these conditions than in the general population. Evidence suggests that insomnia as a feature of chronic disease tends to be more severe and persistent than insomnia that does not occur in the context of chronic illness. Furthermore, comorbid insomnia can have a profound negative impact on patients' quality of life and overall functioning, and may be associated with greater healthcare resource utilization. In some cases, treatment of the underlying disorder may improve sleep, whereas in other cases, treatment of the sleep symptoms may actually improve the underlying disorder. In addition, chronic insomnia may be a precursor to certain psychiatric comorbidities. Further research is needed not only to clarify the efficacy and safety of specific therapeutic approaches but also to further investigate the possibility that successful treatment of sleep disturbances may improve objective and subjective parameters of the disorders themselves. This article reviews the specific associations between chronic insomnia and a wide range of chronic physical and psychiatric disorders.

Chronic Disease↗

PubMed2006

The economic impact of insomnia in managed care: a clearer picture emerges.

An important question for managed care organizations is whether insomnia is associated with increased consumption of healthcare resources. Even though a large number of adults complain of insomnia, few actually receive a diagnostic code for the condition. Consequently, it has been challenging to consistently measure both direct medical costs and indirect costs attributable to insomnia. Recent data have provided a clearer picture showing that insomnia is a costly medical condition. This paper summarizes current understanding of the prevalence of insomnia and explores its impact on health-related quality of life, workplace productivity, and healthcare resource utilization.

Efficiency↗

PubMed2001

The prevalence of urinary incontinence.

Urinary incontinence is a significant health problem with considerable social and economic impact. It is important to distinguish between prevalence and incidence with regard to incontinence, and prevalence-the probability of having incontinence within a defined population at a defined point in time-is the more important when considering its impact and the utilization of healthcare resources. There are large variations in the severity and impact of incontinence, and its severity, frequency, and predictability all need to be considered when evaluating its effects on patients, The degree of bother is particularly significant when determining who will need treatment. Incontinence may be a result of bladder dysfunction, sphincter dysfunction, or a combination of both, but large-scale studies are not designed to determine the etiology. In young women, the prevalence of incontinence is usually low, but prevalence peaks around menopause, with a steady rise there-after into later life. Although the prevalence of stress and mixed (stress and urge) incontinence is higher than urge incontinence, the latter is more likely to require treatment. In women, moderate and severe bother have a prevalence ranging from about 3% to 17%. Severe incontinence has a low prevalence in young women, but rapidly increases at ages 70 through 80. In men, the prevalence of incontinence is much lower than in women, about 3% to 11% overall, with urge incontinence accounting for 40% to 80% of all male patients. Stress incontinence accounts for less than 10% of cases and is attributable to prostate surgery, trauma, or neurological injury. Incontinence in men also increases with age, but severe incontinence in 70- to 80-year-old men is about half of that in women. The most effective therapy for incontinence will rely on targeting the correct populations to be treated, which depends on how data is collected on prevalence and severity.

Journal Article↗

PubMed2006

Health outcomes beyond glucose control.

Direct and indirect costs for diabetes mellitus place a large economic burden on the US healthcare system. Diabetes and cardiovascular disease (CVD) are closely interrelated, and it is estimated that much of the burden of CVD too is attributable to diabetes. Insulin resistance may be the common link between diabetes and CVD, often manifested clinically as the metabolic syndrome. The thiazolidinediones (TZDs) reduce insulin resistance and have favorable effects on lipids, blood pressure, and other cardiovascular risk factors. Large clinical trials have shown that early, aggressive intervention with lifestyle changes and pharmacotherapy with TZDs and other agents may slow progression to overt diabetes in high-risk patients and reduce the risk of cardiovascular and other complications; this could reduce healthcare resource utilization and costs.

Cardiovascular Diseases↗

PubMed1993

Geriatric assessment teams in nursing homes: do they work?

Several studies have examined the effectiveness of geriatric assessment teams in outpatient and acute care settings. This project compared medical records of 69 consecutive nursing home patients randomly assigned on arrival to team (n = 33) and nonteam (standard care, n = 36) conditions. Quality-of-care indices and healthcare service utilization were compared over a 12-month postadmission period. Team patients had a significantly greater number of diagnoses and ancillary services combined with nonsignificant trends toward decreased mortality, fewer emergency department visits, and fewer drugs prescribed. The team approach improves quality of care. Additional clinical studies evaluating the effectiveness of geriatric assessment teams should be made in other nursing homes.

Aged↗

PubMed1997

Pressure ulcers: collaboration in wound care. Is there a reasonable approach?

Pressure ulcers represent a significant impact on utilization of healthcare beds, cost for the insurer, and adverse emotional impact for the family. With this in mind, one must address in an effective fashion a method of objective assessment using the current methodology to deal with risk factors in mobility, disease states, and nutrition, as well as give significant attention to prevention protocols. One should adhere to a schedule of turning the patient, sleep surfaces, and appropriate skin care while recognizing the impact of each. Finally, treatment modalities should be undertaken, not only with cost-effective issues in mind, but with ease and convenience for the healthcare provider and the least discomfort for the patient as well. One can focus on debridement by way of enzymatic, autolytic, or surgical methods, recognizing surgery as the least effective for our goals in the management of this patient. Assessment and, finally, reassessment using the available scales will allow us to provide effective healthcare in a therapeutic fashion.

Beds↗

PubMed1997

Can medical school-affiliated hospitals compete with private hospitals in the age of managed care? An 11-state, population-based analysis of 351,201 patients undergoing cholecystectomy.

BACKGROUND: The purpose of this study was to use an 11-state, population-based hospital discharge database to assess the charges for care of patients undergoing cholecystectomy at both medical school affiliated hospitals (MSAHs) and private hospitals (nonMSAHs). It was our hypothesis that MSAHs could indeed provide efficient, competitively priced patient care. STUDY DESIGN: Data were obtained from the Healthcare Cost Utilization Project of the Agency for Health Care and Policy Research. The database tracks information on all hospitalized patients from 11 states for the years 1988-1992. RESULTS: Represented in the study were 849 nonMSAHs (82%) and 191 MSAHs (18%). During the 5 years of the study, 351,201 patients underwent cholecystectomy. The mean charges and the lengths of stay were similar in the two diagnosis related groups (DRGs) studied (197,198). The analysis demonstrated that during this same period, MSAHs led in both the adoption of laparoscopic cholecystectomy and decreased use of intraoperative cholangiography. CONCLUSIONS: Others have reported that MSAHs cannot compete with nonMSAHs in providing competitively priced care. The present study shows that for cholecystectomy, charges and length of hospital stay are comparable in MSAHs and nonMSAHs. This study supports the hypothesis that the leadership provided at United States medical schools may also extend to the area of cost-efficient care and hints at further areas of improvement.

Cholangiography↗

PubMedDate not supplied

Incorporating digital imaging into dental hygiene practice.

The objective of this paper is to describe digital imaging technology: available modalities, scientific imaging process, advantages and limitations, and applications to dental hygiene practice. Advances in technology have created innovative imaging modalities for intraoral radiography that eliminate film as the traditional image receptor. Digital imaging generates instantaneous radiographic images on a display monitor following exposure. Advantages include lower patient exposure per image and elimination of film processing. Digital imaging enhances diagnostic capabilities and, therefore, treatment decisions by the oral healthcare provider. Utilization of digital imaging technology for intraoral radiography will advance the practice of dental hygiene. Although spatial resolution is inferior to conventional film, digital imaging provides adequate resolution to diagnose oral diseases. Dental hygienists must evaluate new technologies in radiography to continue providing quality care while reducing patient exposure to ionizing radiation.

Dental Hygienists↗

PubMed2006

Secondary healthcare contacts after multiphasic preventive health screening: a randomized trial.

AIM: To analyze the consequence of preventive health screenings and discussions on the utilization of secondary healthcare. METHODS: All 30- to 49-year-old residents registered with a general practitioner in the district of Ebeltoft, Denmark, were included (n = 3,464) in a randomized controlled trial with eight years' follow-up. A random sample of 2,030 subjects was selected for invitation (Invited). The remaining 1,434 persons were never contacted and served as external control group (Non-Invited). Persons accepting participation were randomly divided into one internal control group (Questionnaire) and two intervention groups. One intervention group was offered three health screenings (Health Screening) during the five years. The other intervention group were in addition offered a yearly health discussion with their general practitioner (Health Screening and Discussion). RESULTS: The rate ratio for hospital admissions was 0.97 (95% confidence interval 0.80 to 1.18) in the Invited group compared with the Non-Invited. The annual admission rates showed a significant trend (p = 0.0003) with a decrease four and five years after intervention launch for the Invited group compared with the Non-Invited. A similar trend was found when comparing the internal control group with intervention groups (p = 0.0016). CONCLUSIONS: A 30- to 49-year-old general population's utilization of secondary healthcare did not increase in response to a general health promotion offer. During the observation period a significant decline in annual hospital admission rates was seen.

Adult↗

PubMed1998

Chinese medicine users in the United States. Part II: Preferred aspects of care.

OBJECTIVES: While a limited amount of data describe who seeks Chinese medicine care and for what conditions, there have been few attempts to explain what users think the care does for them, or why they value and "like" the care. This article presents such data via an analysis of a sample of 460 handwritten stories collected as part of a mixed quantitative qualitative survey of 6 acupuncture clinics in 5 states. RESULTS: Quantitative data collected in this survey (Part I) showed that respondents were highly satisfied with their Chinese medicine care. The qualitative analysis found that respondents valued relief of presenting complaints as well as expanded effects of care including improvements in physiological and psychosocial adaptivity. In addition, respondents reported enjoying a close relationship with their Chinese medicine practitioner, learning new things, and feeling more able to guide their own lives and care for themselves. While these factors mesh well with Chinese medicine theory, respondents did not reveal familiarity with that theory. Instead, their language and experiences indicate familiarity with an holistic model of healthcare--and they seem to have experienced Chinese medicine care as holistic care. CONCLUSIONS: This finding matters because it shows that respondents are not seeking an 'exotic' kind of healthcare, but are utilizing a homegrown, if nonmainstream, model of healthcare. The finding also matters because it shows that an holistic health delivery model is not only feasible, but currently exists in the United States: how Chinese medicine practitioners are trained, and how they subsequently deliver their care, could serve as a model for American healthcare reform.

Complementary Therapies↗

PubMed2001

Are rural residents less likely to obtain recommended preventive healthcare services?

BACKGROUND: This study examined rural-urban differences in utilization of preventive healthcare services and assessed the impact of rural residence, demographic factors, health insurance status, and health system characteristics on the likelihood of obtaining each service. METHODS: National data from the 1997 Behavioral Risk Factor Surveillance System (BRFSS) and the 1999 Area Resource File were used to evaluate the adequacy of preventive services obtained by rural and urban women and men, using three sets of nationally accepted preventive services guidelines from the American Cancer Society, U.S. Preventive Services Task Force, and Healthy People 2010. Logistic regression models were developed to control for the effect of demographic factors, health insurance status, and health system characteristics. RESULTS: Rural residents are less likely than urban residents to obtain certain preventive health services and are further behind urban residents in meeting Healthy People 2010 objectives. CONCLUSIONS: Efforts to increase rural preventive services utilization need to build on federal, state, and community-based initiatives and to recognize the special challenges that rural areas present.

Adolescent↗

PubMed2002

"My patients are sicker:" using the Pra risk survey for case finding and examining primary care site utilization patterns in a medicare-risk MCO.

BACKGROUND: The probability of repeat admissions (Pra) survey is a case-finding tool designed to identify elderly persons at risk for hospitalization. Little is known about the ability of the Pra to assess utilization patterns in a managed care setting. OBJECTIVES: To assess the ability of the Pra survey to identify elders at risk for increased healthcare costs and to determine the utility of this tool in predicting mean per member per year (PMPY) claims among primary care sites in a managed care setting. STUDY DESIGN: Mean PMPY paid claims, inpatient admissions, and inpatient days were compared for survey respondents with high, medium, and low Pra scores. Linear regression was used to examine the correlation (R2) between the mean Pra score for respondents and the percentage of high Pra score respondents at each primary care site in the HMO and the sites' mean PMPY paid claims. METHODS: From a single Medicare-risk health maintenance organization (HMO) with approximately 25,000 members and 234 primary care sites in northeastern and central Pennsylvania, we contacted 24,947 enrollees about the Pra survey. A total of 17,484 (70.1%) patients in 159 of 234 (67.9%) primary care sites responded to the survey. Of these, 17,469 (99%) surveys could be scored. RESULTS: The mean Pra score in this population was 0.27 (standard deviation = 0.108). Pra scores were stratified as follows: 4.5%, 24.1%, and 71.4% of respondents scored high (20.5), moderate (> or = 0.3 and <0.5), and low (<0.3), respectively. Patients with high Pra scores had a mean of $12,611 in PMPY claims, versus $6944 and $3038 for moderate and low scores respectively (P < .0001). The R2 between the mean Pra score for respondents at each primary care site and the sites' mean PMPY Medicare-risk claims was 0.042. If survey respondents assigned to 6 specialty care sites (hematology, oncology, rheumatology, endocrinology, nephrology, and pulmonary medicine) are included, the R2 increased to 0.176. The R2 between the percentage of high-risk individuals with a Pra score of 0.5 or higher at each primary care site and the sites' mean PMPY Medicare-risk claims was 0.0005. CONCLUSIONS: In this Medicare-risk HMO population, the Pra survey successfully performed 2 functions: (1) the prospective identification of enrollees at risk for increased healthcare utilization and (2) identification of patient factors that accounted for as much as 17.6% of the variation in utilization between primary sites.

Aged↗

PubMedDate not supplied

Burden of illness for children and where we stand in measuring the quality of this health care.

CONTEXT: Measures of health care quality for children are not as well developed as those for adults. It is also unclear the extent to which the current pool of measures address common causes of illness and health care utilization for children. OBJECTIVE: The goal of this study was to create lists of high-priority conditions for children based on different vantage points for defining burden relative to both inpatient and outpatient care for children. These high-priority conditions were then cross-tabulated with all known existing quality measures for pediatric health care. DATA: High-prevalence conditions for children were identified by using the 2000 National Ambulatory Medical Care Survey, 2000 National Hospital Ambulatory Medical Care Survey, 1999 Medical Expenditure Panel Survey, 2000 Healthcare Cost and Utilization Project's State Inpatient Databases, and 2000 Healthcare Cost and Utilization Project's State Ambulatory Surgery Databases. Burden assessments were done using frequencies of visits, charges, in-hospital deaths. Existing quality measures for children were identified from a recent compendium of such measures and a search of the National Quality Measures Clearinghouse. RESULTS: There are numerous and large gaps in existing quality-of-care measures for children relative to high-burden conditions in both the inpatient and outpatient setting. With the ever increasing efforts to measure and even publicly report on health care, efforts for children need to include focus on building a representative repertoire of quality measures for the high-burden conditions children experience.

Adolescent↗

PubMed2004

Managed care and preventable hospitalization among Medicaid adults.

OBJECTIVE: The study examines the association between managed care enrollment and preventable hospitalization patterns of adult Medicaid enrollees hospitalized in four states. DATA SOURCES/STUDY SETTING: Hospital discharge data from the Healthcare Cost and Utilization Project (HCUP) database of the Agency for Healthcare Research and Quality (AHRQ) for New York (NY), Pennsylvania (PA), Wisconsin (WI), and Tennessee (TN) residents in the age group 20-64 hospitalized in those states, linked to the Area Resource File (ARF) and American Hospital Association (AHA) survey files for 1997. STUDY DESIGN: The study uses separate logistic models for each state comparing preventable admissions with marker admissions (urgent, insensitive to primary care). The model controls for socioeconomic and demographic variables, and severity of illness. PRINCIPAL FINDINGS: Consistently in different states, private health maintenance organization (HMO) enrollment was associated with fewer preventable admissions than marker admissions, compared to private fee-for-service (FFS). However, Medicaid managed care enrollment was not associated with a reduction in preventable admissions, compared to Medicaid FFS. CONCLUSIONS: Our analysis suggests that the preventable hospitalization pattern for private HMO enrollees differs significantly from that for commercial FFS enrollees. However, little difference is found between Medicaid HMO enrollees and Medicaid FFS patients. The findings did not vary by the level of Medicaid managed care penetration in the study states.

Adult↗

PubMedDate not supplied

Prevalence of radioactive signals from surveillance of an emergency department.

INTRODUCTION: Since the 11 September 2001 terrorist attacks in the United States, concerns have been raised regarding the threat of a radiological terrorist weapon. Although the probability of the employment of a nuclear device is remote, the potential of a radiological dispersal device (RDD) or "dirty bomb" is of concern. While it is unlikely that such a device would produce massive numbers of casualties, it is far more likely that it would result in public panic and perhaps even disable the local healthcare system. The utility of surveillance with radiation detectors in the healthcare setting has not been fully evaluated. OBJECTIVE: The objective of this study was to characterize the prevalence of radioactive sources entering an urban emergency department (ED). METHODS: A retrospective review of data obtained from a radiation detector positioned to detect radioactive people entering an ED of an urban academic hospital that serves 45,000 patients/year was performed. Graphical outputs of radioactivity were recorded in Microsoft Excel (Microsoft, Redmond, WA, US) spreadsheets in microREM/hour. Data were collected continuously from 22 December 2003 to 22 January 2004. An event was defined as any elevation in radiation levels >95% confidence interval from the mean level of background radiation over 72 hours (h). RESULTS: A total of 215 events were observed over a 28-day period, with a mean value of 7.7 events/day, and a maximum of 15 events/day. During the 28-day period, the baseline mean level of background radiation was 2-4 microREM/h. Readings ranged from 2,148.28-17,292.25 microREM/h with a maximum sustained detector exposure of 684.37 microREM. Distinct signal patterns were seen at both detectors including tonic, phasic, dual, and short duration spikes. CONCLUSION: The number of radioactive signals detected from persons entering the ED was much higher than expected. While the vast majority of these signals pose no health threat, they may make routine screening for a radiological terrorist event difficult. Further study is needed to determine this correlation.

Air Pollution, Radioactive↗

PubMedDate not supplied

Differences in hospital length-of-stay, charges, and mortality in congestive heart failure patients.

The aim of this study was to demonstrate differences in hospitalization outcomes including length-of-stay (LOS), charges, and mortality in congestive heart failure patients using the Healthcare Cost and Utilization Project dataset. Hospitalizations with International Classification of Diseases, Ninth Revision, clinical modification (ICD-9-CM) codes for congestive heart failure were extracted from a 10% random Healthcare Cost and Utilization Project sample to yield 19,693 hospitalizations between January 1 and December 31, 1997. Mean hospital charges were $11,688 and mean LOS was 5.83 days. The overall in-hospital mortality rate was 4.7%. Both LOS and hospital charges were higher in urban compared with rural hospitals (p< or =0.05). LOS and charges also increased with hospital size (p< or =0.05). Among patient characteristics, patient health status significantly affected LOS, charges, and mortality. Privately insured/health maintenance organization patients had 9% shorter LOS than Medicare patients, and Medicaid patients had 6.6% lower charges and 42% lower mortality than Medicare patients (p< or =0.05). Other significant predictors of study outcome variables included age, gender, race, hospital region, and hospital experience.

Aged↗

PubMed2005

A multistate comparison of patient characteristics, outcomes, and treatment practices in acute myocardial infarction.

The primary purpose of this study was to examine variations in patient characteristics, outcomes, and treatment practices in acute myocardial infarction (AMI) across 11 states. Data from 11 states were extracted from the Healthcare Cost and Utilization Project State Inpatient Dataset. Patients who had a primary diagnosis of AMI (International Classification of Diseases, Ninth Revision, Clinical Modification, code 410.x1) from 11 states were extracted from the Healthcare Cost and Utilization Project 1999 dataset. Bivariate comparisons were conducted to examine the characteristics, treatment practices, and outcomes of patients who had AMI. Multivariate regression models were used to examine the association between geographic location (and other factors) and the likelihood of in-hospital mortality, undergoing coronary artery bypass grafting (CABG), or percutaneous coronary interventions (PCIs). Results revealed considerable variations across states in practice patterns and treatment outcomes. New York had the highest average length of stay (8.2 days, p <0.01), rate of patients who had AMI being transferred (20.7%, p <0.01), and in-hospital case fatality rate (10.7%, p <0.01) and the lowest rate of alive discharges being routine (65.6%, p <0.01). PCI was performed 2 times as often as CABG for patients who had AMI (23.9% vs 11.3%, p <0.01), with patients who underwent CABG being transferred more often. Multivariate analyses showed that state of residence, age, female gender, transfer status, and number of co-morbidities were predictors of in-hospital mortality and the likelihood of undergoing CABG or PCI. In conclusion, large differences in practice patterns and treatment outcomes exist across states.

Age Distribution↗