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PubMedDate not supplied

Multistrategy health education program to increase mammography use among women ages 65 and older.

Mammography use decreases with age although the risk of breast cancer increases with age. Medicare now provides biennial coverage for screening mammography. This study was designed to simulate the Medicare condition by subsidizing mammography among women in eight retirement communities in the metropolitan Philadelphia area. The study also measured the impact of health education interventions and the presence of a mobile mammography van on increased use of mammography. Retirement communities were assigned randomly to the control (cost subsidy alone) or experimental group (cost subsidy, mammography van, and tailored health education interventions). A total of 412 women ages 65 and older who had not had mammograms in the previous year were surveyed at baseline and 3 months later. Analytic techniques reflected the cluster nature of the randomization. Women in the experimental group were significantly more likely than the control group women to have obtained mammograms. Forty-five percent of the experimental group women compared with 12 percent of the control group women subsequently had mammograms in the 3 months after the baseline interview (P less than .001). Logistic regression analysis for mammography use indicated an odds ratio of 6.1 associated with being in the experimental group. For women in the experimental group, a separate logistic regression for mammography use showed an odds ratio of 7.8 associated with attendance at the educational presentation. The results suggest that Medicare coverage alone will not increase mammography use sufficiently to achieve year 2000 objectives. However, the addition of access enhancing and health education interventions boosts utilization dramatically.

Aged↗
PubMed2000

Treatment of acute myocardial infarction and 30-day mortality among women and men.

BACKGROUND: Previous studies have suggested that women with acute myocardial infarction receive less aggressive therapy than men. We used data from the Cooperative Cardiovascular Project to determine whether women and men who were ideal candidates for therapy after acute myocardial infarction were treated differently. METHODS: Information was abstracted from the charts of 138,956 Medicare beneficiaries (49 percent of them women) who had an acute myocardial infarction in 1994 or 1995. Multivariate analysis was used to assess differences between women and men in the medications administered, the procedures used, the assignment of do-not-resuscitate status, and 30-day mortality. RESULTS: Among ideal candidates for therapy, women in all age groups were less likely to undergo diagnostic catheterization than men. The difference was especially pronounced among older women; for a woman 85 years of age or older, the adjusted relative risk was 0.75 (95 percent confidence interval, 0.68 to 0.83). Women were somewhat less likely than men to receive thrombolytic therapy within 60 minutes (adjusted relative risk, 0.93; 95 percent confidence interval, 0.90 to 0.96) or to receive aspirin within 24 hours after arrival at the hospital (adjusted relative risk, 0.96; 95 percent confidence interval, 0.95 to 0.97), but they were equally likely to receive beta-blockers (adjusted relative risk, 0.99; 95 percent confidence interval, 0.95 to 1.03) and somewhat more likely to receive angiotensin-converting-enzyme inhibitors (adjusted relative risk, 1.05; 95 percent confidence interval, 1.02 to 1.08). Women were more likely than men to have a do-not-resuscitate order in their records (adjusted relative risk, 1.26; 95 percent confidence interval, 1.22 to 1.29). After adjustment, women and men had similar 30-day mortality rates (hazard ratio, 1.02; 95 percent confidence interval, 0.99 to 1.04). CONCLUSIONS: As compared with men, women receive somewhat less aggressive treatment during the early management of acute myocardial infarction. However, many of these differences are small, and there is no apparent effect on early mortality.

Adrenergic beta-Antagonists↗
PubMed1988

Accuracy of diagnostic coding for Medicare patients under the prospective-payment system.

Reimbursement of hospitals by Medicare under the prospective-payment system is based on patients' diagnoses as coded at discharge. During the period October 1984 through March 1985, we studied the accuracy of the coding for diagnosis-related groups (DRGs) in hospitals receiving Medicare reimbursement. We used a two-stage cluster method to sample 7050 medical records from 239 hospitals that were stratified according to size. Using blinded techniques with reliability checks, medical-record specialists reabstracted the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes to assign correct DRGs to discharged patients. The correct DRGs were then compared with those originally assigned by the physician and the hospital administration. The study revealed an error rate of 20.8 percent in DRG coding. Errors were distributed equally between physicians and hospitals. Small hospitals had significantly higher error rates. Previous studies had found that errors occurred randomly, so that half the errors benefited the hospital financially and half penalized the hospital. The present study found that a statistically significant 61.7 percent of coding errors favored the hospital. These errors caused the average hospital's case-mix index--a measure of the complexity of illness of the hospital's patients--to increase by 1.9 percent. As a result, hospitals received higher net reimbursement from Medicare than was supportable by the medical records. We conclude that "creep" does occur in the coding of DRGs, resulting in overpayment to hospitals for patients covered by Medicare.

Abstracting and Indexing↗
PubMed1994

Increased health care costs associated with ED overcrowding.

The overcrowding of emergency departments (EDs) with inpatients results in an increased average inpatient length of stay; therefore, overcrowded hospitals have increased costs per patient. All admissions through the ED to our institution for 1988, 1989, and 1990 were reviewed. These admissions were analyzed based on whether they had spent less than 1 day or more than 1 day in the ED, after they had been admitted to the hospital and were waiting for a bed assignment. Analyses were performed for the five medical diagnosis-related groups, with the highest volumes of admissions via the ED. All categories were reviewed on the basis of whether or not the payor was Medicare. This was a retrospective data analysis of 3 years worth of hospital and ED length of stay. There was no intervention. The total number of patients admitted via the ED for 1988, 1989, and 1990 was 26,020. In 1988, 19% of admissions via the ED spent more than 1 day in the ED. The total hospital length of stay for this 19% was 11% longer than for the group who reached an inpatient bed on the first hospital day. In 1989, 32% of admissions via the ED remained in the ED for more than 1 day and had a 13% increase in total hospital length of stay. In 1990, 25% of admissions via the ED spent more than 1 day in the ED and had a 10% increase in total hospital length of stay. Inpatients who remained in the ED after admission had a greater average length of stay than those who were promptly transferred to inpatient units.(ABSTRACT TRUNCATED AT 250 WORDS)

Connecticut↗
PubMed1995

Practice and malpractice expenses in maxillofacial prosthetics.

Recent changes in Medicare reimbursement methods have made the estimation of specific practice and malpractice expenses in maxillofacial prosthetics more important. New reimbursement models such as the resource-based relative value scale used by Medicare and an increasing number of private carriers require accurate and specialty-specific values for these parameters. The Health Care Financing Administration's estimates of practice expense values in all specialties of medicine are significantly lower than those suspected in maxillofacial prosthetics. There is concern that the assignment of erroneous values in maxillofacial prosthetics could lead to inadequate reimbursement. Because the American Dental Association provides only aggregate specialty values, a survey of the general membership of the Academy of Maxillofacial Prosthetics was undertaken to determine these values more accurately. Practice expense values were found to be significantly higher than those in medicine, whereas malpractice expense values were lower. In addition, practice expense values in the survey were found to be greater than the ADA's aggregate specialty calculations.

American Dental Association↗
PubMed2001

Making health care quality reports easier to use.

BACKGROUND: Although there is evidence that consumers want comparative quality information, most studies indicate that consumers make limited use of the data in decision making. The reasons for the limited use appear to be the complexity of the information and the difficulty of processing and using the amount of information in reports. The purpose of this investigation was to determine whether there are approaches to reporting comparative information that make it easier for consumers to comprehend the information. Further, the degree to which consumers who have a low level of skill can accurately use that information when it is presented in a format that is easier to use was examined. METHODS: The study used an experimental design to examine how different presentation approaches affect the use of information. Participants were randomly assigned to different conditions and were asked to review information and complete a decision task related to using comparative information and making health plan selections. Two separate convenience samples were used in the study: an elderly Medicare sample (N = 253), and a nonelderly sample (N = 239). RESULTS: The findings indicate that there are data presentation approaches that help consumers who have lower skills use information more accurately. Some of these presentation strategies (for example, relative stars) improve comprehension among the lower skilled, and other strategies (for example, evaluative labels) appear to aid those in the midrange of comprehension skill. CONCLUSIONS: Using these approaches in reporting would likely increase the use of the comparative information and increase the efficacy of reporting efforts.

Adolescent↗
PubMed2001

Inpatient costs of major cardiovascular events.

OBJECTIVE: Many trials of new therapies for cardiovascular disease include economic measures to assess the impact of treatment on healthcare costs, however, it is difficult to compare results between trials due to variation in methods for assigning costs. Therefore we developed a standard library of inpatient hospital costs for major cardiovascular events commonly reported in trials for new cardiovascular therapies. DESIGN: Mean and median hospital charges for each event were calculated from Medicare admissions selected by ICD-9-CM codes from the most recent Healthcare Cost and Utilisation Project (HCUP) Nationwide Inpatient Sample (NIS) database available. Charges were converted to costs using the cost-to-charge ratio from the most recent Medicare cost report data and updated to 1999 using a model derived from the Medicare Payment Advisory Commission (MedPAC) forecast to recommend annual updates to Medicare. RESULTS: Total hospital costs for medical events ranged from $US3654 (1999 values) to $US7833; total hospital costs for surgery and procedures ranged from $US7054 to $US46 317. The distribution of hospital costs is skewed with median costs and lengths of stay lower than mean values. Costs for patients who died in the hospital were generally higher than costs for patients who were discharged. CONCLUSIONS: The library of costs was calculated using a uniform method based on publicly available and easily accessible data and may be updated from year to year. This method provides standardised estimates of hospital costs that can be used in economic analyses of cardiovascular clinical trials.

Cardiovascular Diseases↗
PubMed1978

The scope and limits of equality as a normative guide to federal health care policy.

In American political culture, as in much of Western political thought, the proposition that men are and ought to be treated as equal in the eyes of polity, law, and society is highly valued. Whether traditional arguments for equality can be properly extrapolated from the political and social spheres to a third sphere--the distribution of resources and services under public welfare state policies--is another question, rarely explored with care. In one of these policy areas, health care, the notion that each citizen is entitled by right to equal access to medical care has grown very popular. Federal programs that equalize access among groups by means of biomedical research, hospital construction and renovation, and financial aid for the elderly and poor have dominated federal health care policy since the end of the Second World War. Empirical consideration of the nature of medical care services, the structure of the health care system, and the consequences of programs to equalize access suggests, however, that public expectations and federal policy may have placed more weight on the principle of equality than it can properly bear. In recent years policy analysts have begun to insist that the equal access issue be viewed in the context of the national cost of medical services relative to that of other social goods, the cost effectiveness of medical services, and the degree to which health and illness result from behavior in an individual's power to pursue or avoid. Attracted by the new revisionist thinking, but unwilling to follow its arguments to their logical policy implications, federal policy makers have institutionalized their ambivalence. The mainstream equalizing programs continue to receive strong support, but they are now challenged by another set of federal programs based largely on revisionist premises. This seemingly inconsistent policy solution is probably the most rational approach to preserving the claims of equality of medical care services, while assigning the principle of equality an appropriately delimited scope.

Federal Government↗
PubMed2005

Estimating patient time costs associated with colorectal cancer care.

BACKGROUND: Nonmedical costs of care, such as patient time associated with travel to, waiting for, and seeking medical care, are rarely measured systematically with population-based data. OBJECTIVES: The purpose of this study was to estimate patient time costs associated with colorectal cancer care. METHODS: We identified categories of key medical services for colorectal cancer care and then estimated patient time associated with each service category using data from national surveys. To estimate average service frequencies for each service category, we used a nested case control design and SEER-Medicare data. Estimates were calculated by phase of care for cases and controls, using data from 1995 to 1998. Average service frequencies were then combined with estimates of patient time for each category of service, and the value of patient time assigned. Net patient time costs were calculated for each service category, summarized by phase of care, and compared with previously reported net direct costs of colorectal cancer care. RESULTS: Net patient time costs for the 3 phases of colorectal cancer care averaged dollar 4592 (95% confidence interval [CI] dollar 4427-4757) over the 12 months of the initial phase, dollar 2788 (95% CI dollar 2614-2963) over the 12 months of the terminal phase, and dollar 25 (95% CI: dollar 23-26) per month in the continuing phase of care. Hospitalizations accounted for more than two thirds of these estimates. Patient time costs were 19.3% of direct medical costs in the initial phase, 15.8% in the continuing phase, and 36.8% in the terminal phase of care. CONCLUSIONS: Patient time costs are an important component of the costs of colorectal cancer care. Application of this method to other tumor sites and inclusion of other components of the costs of medical care will be important in delineating the economic burden of cancer in the United States.

Colorectal Neoplasms↗
PubMed1997

Physical activity in usual occupation and risk of breast cancer (United States).

We have used data from a large population-based case-control study in the United States to evaluate the effect of occupational physical activity on breast cancer risk. Women diagnosed with breast cancer identified from four state cancer registries, and controls randomly selected from lists of licensed drivers or Medicare beneficiaries, were interviewed by telephone for information on usual occupation and other factors. We classified usual occupation into one of four categories of physical activity. After excluding subjects for whom a strength rating could not be assigned, we had a final sample size of 4,863 cases and 6,783 controls. Using conditional logistic regression models, we calculated adjusted odds ratios (OR) and 95 percent confidence intervals (CI) for occupations having light, medium, and heavy activity compared with sedentary ones. Women with heavy-activity occupations had a lower risk of breast cancer than women with sedentary jobs (OR = 0.82, CI = 0.63-1.08), as did women with jobs with medium activity (OR = 0.86, CI = 0.77-0.97) or light activity (OR = 0.92, CI = 0.84-1.01). There was a significant decreasing trend in the ORs from sedentary to heavy work (P = 0.007). Although limited by exposure misclassification, these data are consistent with the hypothesis that physical activity reduces the risk of breast cancer.

Adult↗
PubMed2001

Managing up to maximize medicare reimbursement for outpatient care.

An example of managing up through participation in a multidisciplinary team tasked with maximizing reimbursement under the Medicare ambulatory patient classification (APC) system is described. Medicare's new system of payment for hospital outpatient services replaces the cost-based reimbursement model of the past with a technical payment based on the outpatient evaluation and management level. Individual institutions are responsible for developing criteria for defining technical visit levels. Managers at the New England Medical Center formed a team to develop these criteria. The team outlined components of the patient visit that qualified as technical costs, such as the use of space at a facility, medical and surgical supplies, and nonphysician professional services. Team members then contacted each of the center's clinics to identify specific services that met these criteria. After formulating the technical visit level criteria, the team determined who would assign the technical visit level, wrote policies and procedures, and trained staff. The APC team also assessed billing procedures, focusing particularly on the accuracy of the charge master and the use of proper codes and billing units for pass-through drugs. The team continues to monitor its results by reviewing payments received from Medicare and auditing high-risk areas. The APC team used the principles of managing up to maximize Medicare reimbursement for outpatient visits.

Ambulatory Care↗
PubMed1998

Functional outcomes of posthospital care for stroke and hip fracture patients under medicare.

BACKGROUND: Medicare's introduction of the Prospective Payment System for hospitals has led to tremendous growth in ways of providing posthospital care. Despite substantial differences in costs per episode of care, the type of posthospital care that produces the best results for specific types of patients is not clear. This study analyzed the outcomes of different types of posthospital care for a cohort of older Medicare patients (who had diagnoses associated with the use of a range of posthospital care modalities) for up to a year after hospital discharge. METHODS: Medicare patients hospitalized with strokes and hip fractures were enrolled consecutively just before discharge from 52 hospitals in three cities in 1988-1989. These diagnosis-related groups were chosen because patients were discharged to all three major types of Medicare-supported posthospital care. Patients were interviewed in-person before discharge and again at 6 weeks, 6 months, and 1 year after discharge. The functional outcomes of posthospital care were evaluated by the instrumental variables estimation approach to correct for selection bias caused by nonrandom treatment assignment. The impacts of discharge locations on the functional outcomes were examined by one-way analyses of variance (ANOVA). RESULTS: In general, the more disabled patients went to nursing homes and rehabilitation, but the overlap in distribution was sufficient to conduct the analyses. Stroke patients discharged to nursing homes had the highest mortality rate (P<.01). Stroke patients discharged to home health had the lowest rehospitalization rates (P<.05). Hip fracture discharged to home health care had the highest adjusted rehospitalization rate, whereas those discharged to nursing homes had the lowest adjusted rehospitalization rate (P<.05). For stroke patients, posthospital care in rehabilitation facilities or home health care was associated with significantly better functional improvement compared with stroke patients discharged elsewhere. However, functional outcomes deteriorated by 1 year posthospitalization among stroke patients who received their posthospital care at nursing homes or received no formal posthospital care. For hip fracture patients, all four types of posthospital care were associated with functional improvement, but patients discharged to rehabilitation facilities experienced the most functional improvement. CONCLUSIONS: The choice of posthospital care can influence the course of Medicare patients. Careful attention should be paid to how hospital discharge decisions are made and to the financial incentives for different types of posthospital care provided under the current payment system. The current supply of nursing homes is not well suited to the demands of posthospital care.

Activities of Daily Living↗
PubMed1995

Epidemiology of do-not-resuscitate orders. Disparity by age, diagnosis, gender, race, and functional impairment.

BACKGROUND: The relationship of do-not-resuscitate (DNR) orders to patient and hospital characteristics has not been well characterized. METHODS: This observational study of a nationally representative sample of 14,008 Medicare patients hospitalized with congestive heart failure, acute myocardial infarction, pneumonia, cerebrovascular accident, or hip fracture evaluated the relationship of DNR orders to patient sickness at admission, functional impairment, age, disease, race, gender, preadmission residence, insurance status, and hospital characteristics. RESULTS: Of the 14,008 patients, DNR orders were assigned to 11.6%. Patients with greater sickness at admission and functional impairment received more DNR orders (P < .001) but even among patients in the sickest quartile (with a 65% chance of death within 180 days), only 31% received DNR orders. The DNR orders were assigned more often to older patients after adjustment for sickness at admission and functional impairment (P < .001), and DNR order rates differed by diagnosis (P < .001). After adjustment for patient and hospital characteristics, DNR orders were assigned more often to women and patients with dementia or incontinence and were assigned less often to black patients, patients with Medicaid insurance, and patients in rural hospitals. CONCLUSIONS: Do-not-resuscitate orders are assigned more often to sicker patients but may be underused even among the most sick. Sickness at admission and functional impairment do not explain the increase in DNR orders with age or the disparity across diagnosis. Further evaluation is needed into whether variation in DNR order rates with age, diagnosis, race, gender, insurance status, and rural location represents differences in patient preferences or care compromising patient autonomy.

Age Distribution↗
PubMed1998

Managed care for congestive heart failure: influence of payer status on process of care, resource utilization, and short-term outcomes.

BACKGROUND: Although health maintenance organizations (HMO) are insuring an increasing number of Americans, there are concerns that cost-reduction strategies may limit access to medical care or jeopardize its quality. This study was conducted to examine the influence of insurance payer status on the process of care and resource utilization among patients hospitalized for congestive heart failure (CHF). METHODS AND RESULTS: Administrative information on all 1995 New York State hospital discharges assigned ICD-9-CM codes indicative of CHF in the principal diagnosis position were obtained from the Statewide Planning and Research Cooperative System database. The following were compared among patients with HMO, indemnity, Medicaid fee-for-service, and Medicare fee-for-service insurance coverage: demographics, comorbid illness, process of care, length of stay, hospital charges, mortality rate, and CHF readmission rate. A total of 43,157 patients were identified (HMO, 1322; indemnity, 4350; Medicaid, 3878; Medicare, 33 607). Noninvasive procedures were used with similar frequency, whereas greater use of invasive techniques was observed among HMO and indemnity patients. After adjustment for patient characteristics and hospital type and location, HMO care was associated with shorter length of stay and lower hospital charges, the latter partially explained by fewer hospital days. Medicaid patients had the longest length of stay, greatest hospital charges, and highest CHF readmission rate. The adjusted risk of death during the index hospitalization did not vary among insurance groups. CONCLUSIONS: Though insuring only a small proportion of New Yorkers hospitalized for CHF, managed care plans provide similar access to clinical services while generating fewer charges. Whether these observed differences in short-term outcomes derive from patient mix or quality of care is uncertain and deserves wider prospective study.

Adolescent↗
PubMed1988

Measuring the clinical appropriateness of the use of a procedure. Can we do it?

Increasing attention is being paid to data on geographic differences in population-based rates of use of medical and surgical procedures. To understand these differences and to determine what level of use is appropriate, a method is needed to judge the clinical appropriateness of services. We recently developed and tested such a method in two large, urban geographic areas. Eighty-one medical records from a randomly selected sample of 30 billing entities (46 physicians) who performed upper gastrointestinal endoscopy (UGIE) on Medicare patients were abstracted. Ninety-four percent of physicians who were asked agreed to participate. Reliability testing showed 99% agreement on items abstracted from a subset of records independently reviewed by two abstractors. Based on the abstractions, each patient could be assigned at least one (mean 2.2) specific clinical indication for which UGIE was performed. Using ratings derived from a previously held panel meeting, it was possible to evaluate the appropriateness of the indications for each UGIE.

Data Collection↗
PubMed1999

Effects of the Medicare Alzheimer's Disease Demonstration on the use of community-based services.

STUDY QUESTION: Did the Medicare Alzheimer's Disease Demonstration with its case management and community service waivers affect the use of community-based long-term care services among people with dementia and their primary caregivers? DATA SOURCES: Baseline and periodic caregiver interviews. Measures include client and caregiver attributes and self-reported service use. STUDY DESIGN: The demonstration randomly assigned voluntary applicants into treatment and control groups. Treatment group cases were eligible for case management and for up to $699 per month in community care benefits. The actual monthly entitlement varied among the eight demonstration communities due to regional cost and inflation adjustments over time. Analyses are for the year after enrollment. DATA COLLECTION: Analyses are of cases surviving six months or more in the community after enrollment (n = 5,209). Cases received baseline and semi-annual assessments. PRINCIPAL FINDINGS: The intervention of case management and community service reimbursement had a strong, consistent, and positive effect on the likelihood of using home care (including homemaker/chore services, personal care services, companion services) and adult day care. Treatment group clients were at least twice as likely as control group clients to be using any of the four community-based services. A similar, but less pervasive effect was achieved with caregiver training and support group participation. Reimbursement provided by the demonstration's Medicare waiver was generally not sufficient to exceed the level of control group service acquired through private payment. CONCLUSIONS: Reimbursement levels within the demonstration may have enabled more individuals to purchase some services, but they were not sufficient to increase the average level of use over those in the control group. No consistent differences between demonstration models were found in service use likelihood or average use among users.

Aged↗
PubMed1991

Medicare program; update of ambulatory surgical center payment rates and additions to and deletions from the current list of covered surgical procedures--HCFA. Notice with comment period.

This notice implements section 1833(i)(2)(A) of the Social Security Act, which requires that the payment rates for ambulatory surgical center (ASC) services be reviewed and updated annually, and responds to the public comment we received concerning the ambulatory surgical center payment rate update notice with comment period published on July 5, 1990 (55 FR 27690). It also implements section 1833(i)(1) of the Social Security Act, which requires, in part, that the list of covered ambulatory surgical center procedures be reviewed and updated at least every 2 years. This notice announces additions to and deletions from the list of surgical procedures for which facility services are covered when the procedures are performed in an ASC. This notice also announces the assignment of payment groups for each procedure and responds to public comments received in response to the notice proposing additions to and deletions from the list of covered surgical procedures that was published on December 7, 1990.

Abstracting and Indexing↗
PubMed1989

Incidence, costs, and DRG-based reimbursement for traumatic brain injured patients: a 3-year experience.

A 3-year prospective study was conducted to establish the incidence of traumatic brain injury (TBI) and related characteristics of age, sex, length of stay (LOS), intensive care unit LOS (ICU/LOS), direct hospital charges, and reimbursement using a prospective DRG-based reimbursement system. The study identified TBI patients using ICD-9-Codes. The mean LOS for the two groups of patients with intracranial injury differed (p less than 0.05). Those with such an injury accompanied by a fracture stayed 1.8 days less in the ICU and 6.0 days less overall. Direct hospital charges for all TBI patients were $14,138,036 (mean, $11,645). Using Medicare weights and hospital-specific rates/DRG, the DRG reimbursement was $6,689,293. Thirty-day outliers (those who stayed ten times the geometric mean length of stay) provided an additional $526,389 leaving a total non-reimbursable figure of $6,922,354, or 49% of total charges. Of the 71 DRGs assigned to the study population, 15 reimbursed more than the actual charges. The severity of TBI victims and the complexity of caring for them in a Level I trauma center generates hospital charges of which only half are reimbursed through an all-payor DRG system. Strategies to correct what could be a financial disincentive are: documenting the uniqueness of this population to justify additional reimbursement, calculating a more precise mean LOS for TBI-related DRGs to more accurately identify outliers, and calculating DRG rates for TBI diagnoses derived from a representative sample at varying severity levels and hospitalized in facilities with and without rehabilitation services.

Adolescent↗