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PubMed1993

Medicare payment policy and recombinant erythropoietin prescribing for dialysis patients.

The Medicare payment policy for recombinant human erythropoietin (rHuEPO) treatment for dialysis patients changed in January 1991 from a relatively fixed payment per treatment (allowed charge of $40 per < or = 10,000 units injected) to a more variable payment based on the amount of rHuEPO administered with each treatment (allowed charge of $11 per 1,000 units injected). This change provided an opportunity to examine how payment policy can effect the use, cost, and health outcome of a biotechnology product used in the dialysis population. In cross-sectional (n = 71,880 Medicare-entitled dialysis patients) and longitudinal (n = 29,088 Medicare-entitled dialysis patients) study designs, we used Medicare end-stage renal disease program and claims data in bivariate and multivariate analyses to examine the effect of the change in payment policy for rHuEPO on access to the biotechnology, dosing, costs, and hematocrit, including the prescribing patterns at for-profit versus not-for-profit providers. The observation period included several months before (July 1989 to December 1990) and 6 months after (January to June 1991) the change in Medicare payment policy. The mean dose per treatment during the initial and fourth month of therapy was low (2,742 [95% confidence interval, 2,703 to 2,781] units and 2,632 [95% confidence interval, 2,598 to 2,667] units, respectively, in June 1990) and increased 3.4% and 5.0%, respectively, in the next 6 months prior to the change in Medicare payment policy compared with 14.6% and 14.8%, respectively, in the 6 months following the change in payment policy. The average monthly allowed charge for rHuEPO per dialysis patient receiving rHuEPO decreased from $455 before the policy change to $349 immediately following the policy change, because the allowed charge per unit of rHuEPO was lower when payment became more dependent on the amount of rHuEPO administered with each treatment than when the payment was fixed at $40 per treatment. The average monthly allowed charge for rHuEPO increased to $375 in the sixth month following the change in payment policy as a result of the increase in dose and the new variable payment. The unadjusted and adjusted changes in mean hematocrit 6 months after the payment change were positive but clinically very small (0.3 and 0.2 percentage points, respectively).(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1984

Bayesian comparison of cost-effectiveness of different clinical approaches to diagnose coronary artery disease.

The objective of this study was to compare the cost-effectiveness of four clinical policies (policies I to IV) in the diagnosis of the presence or absence of coronary artery disease. A model based on Bayes' theorem and published clinical data was constructed to make these comparisons. Effectiveness was defined as either the number of patients with coronary disease diagnosed or as the number of quality-adjusted life years extended by therapy after the diagnosis of coronary disease. The following conclusions arise strictly from analysis of the model and may not necessarily be applicable to all situations. As prevalence of coronary disease in the population increased, it caused a linear increase in cost per patient tested, but a hyperbolic decrease in cost per effect, that is, increased cost-effectiveness. Thus, cost-effectiveness of all policies (I to IV) was poor in populations with a prevalence of disease below 10%, for example, asymptomatic people with no risk factors. Analysis of the model also indicates that at prevalences less than 80%, exercise thallium scintigraphy alone as a first test (policy II) is a more cost-effective initial test than is exercise electrocardiography alone as a first test (policy I) or exercise electrocardiography first combined with thallium imaging as a second test (policy IV). Exercise electrocardiography before thallium imaging (policy IV) is more cost-effective than exercise electrocardiography alone (policy I) at prevalences less than 80%. 4) Noninvasive exercise testing before angiography (policies I, II and IV) is more cost-effective than using coronary angiography as the first and only test (policy III) at prevalences less than 80%. 5) Above a threshold value of prevalence of 80% (for example patients with typical angina), proceeding to angiography as the first test (policy III) was more cost-effective than initial noninvasive exercise tests (policies I, II and IV). One advantage of this quantitative model is that it estimates a threshold value of prevalence (80%) at which the rank order of policies changes. The model also allows substitution of different values for any variable as a way of accounting for the uncertainty inherent in the data. In conclusion, it is essential to consider the prevalence of disease when selecting the most cost-effective clinical approach to making a diagnosis.

Angiography↗
PubMed1989

The relationship between alcohol consumption and social status in Stockholm. Has the social pattern of alcohol consumption changed?

Data from the Stockholm Health of the Population Study in 1984 (n = 6217) show small differences in mean alcohol consumption and in the prevalence of high consumers in various socioeconomic and educational categories of both sexes. Among young people mean consumption was higher in those who had low formal education, equal to 18.8 g 100% ethanol among men aged 18-24 years and 5.9 g for those with public elementary school education, while the corresponding figures for young women were 16.7 and 1.8 g respectively. Those reporting a high alcohol consumption (greater than or equal to 35 g 100% ethanol/day among men and greater than or equal to 25 g among women) had a relative risk over 7 of having been inpatients with alcohol-related diseases during 1980-1984. Our results, together with other recent Swedish survey data, indicate a change in the socioeconomic distribution of alcohol consumption over time. This change is analysed in relation to Swedish alcohol policy, changes in various socioeconomic categories, and the increase in information about alcohol.

Adolescent↗
PubMed1996

Preoperative fasting time: is the traditional policy changing? Results of a national survey.

Several papers in the 1980s questioned the wisdom of withholding clear liquids for more than 3 h before elective surgery. Furthermore, recent papers have suggested relaxing the current NPO after midnight (Latin: Nulla per os; or "nothing by mouth") practice in children and adults. To see whether the policy and practice regarding NPO status before elective surgery have changed in the United States, we performed a national survey. In November 1992, 300 questionnaires were mailed to the chairpersons of 114 university anesthesiology programs and the medical directors of 186 randomly selected, free-standing ambulatory surgery centers. Seventeen simple questions were asked regarding their NPO policy and practice guidelines before elective operations. Replies were tabulated, and the data were descriptively analyzed via frequency distribution. We received 191 replies, 85 from the university programs and 106 from the free-standing units (75% and 57% response rates, respectively) from all six time zones of the United States. Fifty-seven percent of the responders stated that they had revised their NPO policy during the last 3 yr, whereas 39% reported that they had not changed their NPO policy. One hundred percent of the respondents who allowed clear liquids considered water to be acceptable for adults, whereas 94% considered water acceptable in the pediatric population. Eighty-one percent of the responders denied the use of routine prophylaxis for acid aspiration. None of the responders reported an adverse outcome which could be attributable to the recent change in the NPO guidelines. On a related question, 16% of all the respondents stated that they would cancel the operation if a patient arrived for an elective outpatient surgical procedure after consuming coffee with cream 2 h before operation. In conclusion, our survey revealed that 69% of anesthesiologists in the United States have either changed their NPO policy or are flexible in their practice in allowing clear liquids before elective operation in children and 41% have done so for adult patients. The most frequently allowed clear liquids in the adult and pediatric population were water and apple juice. None of the respondents reported any medical adverse event associated with the institution of a flexible NPO policy.

Adult↗
PubMed1998

Communicating with the public: community-based nursing research and practice.

This paper presents examples of community-based nursing research in relation to selected health care trends that affect practice and considers ways the media can help community health nurses be more effective communicators with the public. Research provides evidence that community-based nursing practice includes quality services that can control costs; a focus on disease prevention and health promotion; the organization of services where people live, work, and learn; partnerships and coalitions; service to people across the life span; services to culturally diverse populations; access to services for at-risk populations; development of the community's capacity for health; work with policy makers for policy change; and efforts to make the environment healthier. Two approaches to communication with the public through the media, social marketing and media advocacy, are compared. It is recognized that community health nurses are well prepared and suited for media advocacy. Media advocacy can be used to not only communicate the effectiveness of community-based nursing practice but also to support the community's voice for public health.

Communication↗
PubMed1991

Geriatric dentistry and prevention: research and public policy.

Changing demographics, including the increase in life expectancy and the growing numbers of elderly, has focused attention on the need for dental research activities to be expanded for geriatric dentistry. The elderly are at greater risk for oral disease, since gains in longevity result in more medically compromising conditions or systemic disease with oral manifestations. Also, as edentulism decreases and as more teeth are retained by the elderly, the pattern of oral diseases and the treatment of dental conditions will be altered. Barriers to self-care and professional care must be removed, and prevention and early intervention strategies must be formulated to reduce the risk of oral disease. Risk factors for oral diseases in the elderly can be reduced by personal home-care regimens, professionally provided preventive, diagnostic, and therapeutic care, changes in high-risk behavior, and a supportive environment. Generating new information about the prevention of oral diseases and conditions that have an impact on the elderly requires a substantial research effort. A research agenda for the elderly should include: epidemiologic studies of relevant oral diseases and related risk factors; investigations of patient and provider attitudes and behavior related to oral health; studies of the relationship between general health and oral health; development and testing of preventive and treatment strategies for conditions such as xerostomia, root caries, secondary caries, and gingival recession; and studies for the evaluation of the impact of the aging population on the dental delivery system. Public policy options to support geriatric oral health care and research are limited by the Government's pre-occupation with cost containment and the lack of visibility for dental programs.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1984

The women's movement and older women's health: issues and policy implications.

Since women are an increasing proportion of the older population, the health issues that affect older Americans must be regarded in large part as women's issues. Women experience aging differently from men. The advantage in life expectancy of women over men is not always a boon. Older women have substantially lower incomes and higher poverty rates, are more likely to be widowed and living alone, and depend more on entitlement and social service programs. This paper traces the evolution of the women's movement and identifies some of the health care problems of older women in terms of psychological, socio-cultural, and economic factors. The role of the medical establishment and federal regulations that affect older women are examined. The White House Conference on Aging (1981) is seen as a prelude to the current policies of the Administration that affect older women. Necessary policy changes on the Federal and local levels are discussed as well as the need for redirection in the women's health movement.

Aged↗
PubMed1997

The social construction of target populations and the transformation of prison-based AIDS policy: a descriptive case study.

When interpreting policy changes, it is important to understand the social construction of those whom the policy affects. Policy Design Perspective by Schneider and Ingram (1993) concentrates on the construction of "agents" and "targets" in an attempt to comprehend policy formation and transformation. The following descriptive case study uses this design to assess the evolution of one prison's AIDS policy. This institution's HIV/AIDS policy originally was quite restrictive in nature, but the changing perceptions of the agents and targets allowed a more humanistic approach to emerge in the handling of HIV-positive inmates.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

Children's health insurance, access to care, and health status: new findings.

Despite various policy initiatives, a substantial number of children in the United States remain uninsured, have problems with access to health care, or are in fair or poor health. These difficulties are not evenly distributed across the population. Hispanic children, those whose parents have little education, and those who live in families without an employed parent are at disproportionately high risk of encountering these problems. Although multivariate analyses would be required to disentangle the complex relationships among these factors, these descriptive data reveal the segments of the population to which new health-related programs, such as CHIP-funded state plans, might most productively be directed. Issues concerning children's health are likely to remain on the national policy agenda for some time to come. Because MEPS is a continuing data collection effort, it will enable researchers and policymakers to follow trends in these issues over time. For example, MEPS data will support evaluations at the national level to determine whether children who lack health insurance or a usual source of care will actually face fewer barriers after CHIP-funded programs are implemented. This paper provides a baseline against which to evaluate the impact of CHIP and other policy changes on the health and well-being of America's children.

Adolescent↗
PubMed1997

Geographic distribution of pediatricians in the United States: an analysis of the fifty states and Washington, DC.

OBJECTIVES: To determine current geographic distribution of pediatricians in the United States, to assess the changes in the geographic distribution of pediatricians between 1982 and 1992, and to identify factors associated with the distribution of pediatricians among the 50 states. METHODS: A data set was constructed using several published data sources including the American Medical Association Physician Masterfile as the principal source for physician information. The pediatrician-to-child population ratio (PCPR, the number of pediatricians per 100 000 people under 18 years of age) was calculated to compare the distribution of pediatricians among states and the distributional changes between 1982 and 1992. Lorenz curves and Gini indices were used to describe distributions and to compare distributions across time periods. Linear regression analysis was performed to assess the relationship between PCPR (dependent variable) with 9 predictor variables. RESULTS: Between 1982 and 1992, there was a 5.4% increase in the United States (US) child population and a 46.1% increase in the number of pediatricians in patient care. During that time period, the PCPR increased by 38.6% from 35.1 per 100 000 to 48.6 per 100 000. There was a more than 4-fold difference in the PCPRs of the highest state (Maryland, 84.3) and the lowest state (Idaho, 18.5) in 1992. The PCPR increased in all 50 states, but varied from a 4.1% increase in Wyoming to a 63.4% increase in Massachusetts. The Lorenz curve showed that pediatricians were less evenly distributed than all physicians, but more evenly distributed than pediatric cardiologists. Between 1982 to 1992 the Gini index decreased 9.8% for all physicians and 10.2% for pediatric cardiologists, but only 1. 9% for pediatricians. Since a decrease in the Gini index signifies better overall distribution, these changes are relatively modest for pediatricians as a whole, especially when compared to other physicians. Regression analysis showed that a higher PCPR was associated with a greater number of residency positions per 100 000 children and with the per capita income of the state (R = .93). CONCLUSIONS: The distribution of pediatricians does not parallel the distribution of the child population in the US, nor has this distribution changed substantially in spite of a 38.6% increase in the PCPR. Pediatricians tend to concentrate in states with high per capita income and in states with a larger number of residency training positions. The failure of market forces to improve the geographic distribution may require manpower policy changes designed to improve distribution in underrepresented states. The uncertain impact of market changes due to increased use of managed care could affect distributional requirements of pediatricians in the future.

Cardiology↗
PubMedDate not supplied

Antimalarial drug resistance: surveillance and molecular methods for national malaria control programmes.

National malaria control programmes have the responsibility to develop a policy for malaria disease management based on a set of defined criteria as efficacy, side effects, costs and compliance. These will fluctuate over time and national guidelines will require periodic re-assessment and revision. Changing a drug policy is a major undertaking that can take several years before being fully operational. The standard methods on which a decision can be taken are the in vivo and the in vitro tests. The latter allow a quantitative measurement of the drug response and the assessment of several drugs at once. However, in terms of drug policy change its results might be difficult to interpret although they may be used as an early warning system for 2nd or 3rd line drugs. The new WHO 14-days in vivo test addresses mainly the problem of treatment failure and of haematological parameters changes in sick children. It gives valuable information on whether a drug still 'works'. None of these methods are well suited for large-scale studies. Molecular methods based on detection of mutations in parasite molecules targeted by antimalarial drugs could be attractive tools for surveillance. However, their relationship with in vivo test results needs to be established.

Animals↗
PubMed1998

Metropolitan governance, residential segregation, and mortality among African Americans.

OBJECTIVES: This study tested the hypothesis that the degree to which local government is metropolitanized is associated with mortality rates for African Americans and with residential segregation, which has itself previously been shown to be positively associated with mortality among African Americans. METHODS: One hundred fourteen US standard metropolitan statistical areas were examined. The primary dependent variable was the age-adjusted, race- and sex-specific all-cause mortality rate, averaged for 1990 and 1991. The 2 primary independent variables were residential segregation, as measured by the index of dissimilarity, and metropolitanization of government, as measured by the central city's elasticity score. RESULTS: Mortality rates for male and female African Americans were lower in metropolitan statistical areas with more metropolitanized local governments and lower levels of residential segregation. Mortality for male and female Whites was not associated in either direction with residential segregation. White male mortality showed no association with level of metropolitanization, but lower White female mortality rates were associated with less metropolitanization. CONCLUSIONS: This study suggests the need for further research into whether policy changes in areas not traditionally thought of as "health policy" areas can improve the health of urban minorities.

Black or African American↗
PubMed1998

Psychiatry in transition: outcomes of mental health policy shift in Italy.

OBJECTIVE: To assess the outcomes of changes in mental health policy introduced in Italy in 1978. METHODS: Data on psychiatric services, before and after the policy change, are presented. Effects of change are evaluated through indicators related to four issues: transfer of care, criminalisation of the mentally ill, suicides, and homelessness. RESULTS: Admissions of new patients to mental hospitals have been stopped and the size of the mental hospital population is now very low (26 per 100,000 population). Psychiatric care has been shifted to community services including general hospital psychiatric units. There has been an overall reduction of psychiatric hospitalisation. However, the provision of residential facilities is inadequate and community services are unevenly distributed across the country. Few negative effects of changing patterns of care have been reported, although the low quality of data limits the validity of such a conclusion. Outcome of care in areas where the full range of community services is available has been rated as satisfactory. CONCLUSIONS: Although care of the mentally ill has been shifted to community services, we lack hard data on the social and clinical outcome of community care at the nation-wide level. Long-term monitoring and evaluation of community services is a high priority in Italy.

Deinstitutionalization↗
PubMedDate not supplied

Fertility intentions and subsequent behavior: a longitudinal study in rural India.

This report compares fertility and family planning intentions of rural Indian women in 1975 with actual outcomes in 1987. Ninety-four of 103 respondents who had fewer children than they wanted in 1975 and had stated definite intentions with respect to future fertility and contraceptive use were reinterviewed in 1987. Overall, women had fewer children than desired and stopped childbearing when they reached or closely approximated their ideal number of sons. Since sons were clearly the determinant of "reproductive success," it is argued that only a significant change in the status of rural women can bring about widespread compliance with the official family planning program's two-child norm.

Adolescent↗
PubMed1986

The assessment of health policy changes using the time-reversed crossover design.

The time-reversed crossover design is a quasi-experimental design which can be applied to evaluate the impact of a change in health policy on a large population. This design makes use of separate sampling and analysis strategies to improve the validity of conclusions drawn from such an evaluation. The properties of the time-reversed crossover design are presented including the use of stratification on outcome in the sampling stage, which is intended to improve external validity. It is demonstrated that, although this feature of the design introduces internal validity threats due to regression toward the mean in extreme-outcome strata, these effects can be measured and eliminated from the test of significance of treatment effects. Methods for within- and across-stratum estimation and hypothesis-testing are presented which are similar to those which have been developed for the traditional two-period crossover design widely used in clinical trials. The procedures are illustrated using data derived from a study conducted by the United Mine Workers of America Health and Retirement Funds to measure the impact of cost-sharing on health care utilization among members of its health plan.

Costs and Cost Analysis↗
PubMedDate not supplied

Changing health policy in the post-Mao era.

A shift away from Mao Zedong's concept of equality in the delivery of medical care is now taking place in The People's Republic of China. This change is evident in the emphasis now placed upon high technology, basic research, and hospital care. All of these changes are occurring against the backdrop of extremely scarce medical resources. Medicine seemingly is viewed as one of many material incentives to be provided high productivity and leadership groups; the "modernization" of medicine is seen as one visible manifestation of the success of the broader modernization effort itself. As well, population policy has become more stringent, with rewards being given to one-child families and sanctions being applied against couples having three or more children. Although these policy changes offer bright prospects for Sino-American cooperation in the biomedical field, foreigners must remain sensitive to the controversial nature of these alterations in the Chinese political setting.

China↗
PubMed1995

Assessing the outcome of making it easier for patients to change general practitioner: practice characteristics associated with patient movements.

BACKGROUND: The government white paper, Promoting better health, suggested that primary health care services should be made more responsive to patient needs and that competition, brought about by the freer movement of patients between practices, could act as a mechanism for improving the quality of the services provided. Policy changes reflecting these aims were introduced with the 1990 contract for general practitioners. AIM: A study was carried out to estimate the volume of patient movement between practices not attributable to a patient's change of address or to a major change in the practice they had left, and to investigate which practice characteristics patients moved towards and which they moved away from when changing general practitioner. METHOD: Data on 2617 patient movements during June 1991 were collected from five family health services authorities. These patient movements were analysed in relation to data on practice characteristics obtained from family health services authority records. RESULTS: The estimated volume of movement of patients between practices was small (1.6% of the registered population per year). The majority of movements were between group practices; a quarter of the movements recorded were to single-handed general practitioners. However, the ratio of the number of movements from group practices to single-handed general practitioners compared with those from single-handed general practitioners to group practices was 1.37 (95% confidence interval 1.19 to 1.57). In choosing single-handed general practitioners these patients were willing to forgo access to a woman general practitioner, extended services and greater hours of general practitioner availability. Among the subset of movements between group practices, patients were more likely to gain access to a practice nurse, longer surgery hours and a woman general practitioner as a consequence of their move. CONCLUSION: The scale of patient movement observed did not indicate any substantial mechanism by which the new policy of encouraging consumerist behaviour on the part of primary care users could effect desired changes in primary care practice. Among the patient movements observed, the evidence suggests that when choosing a practice potential patients were not deterred by the fact that a practice was single-handed. The public's perception of the factors contributing to a high quality of service may conflict with the official characterization of good practice and high quality services in primary health care.

Adolescent↗