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PubMed2003

[The access to care of underserved populations: a research among free clinics patients in the Paris area].

BACKGROUND: Over the last decade, the increasing number of people experiencing difficult social conditions--especially in urban areas--has led to the implementation of free (health and social care) clinics for uninsured and/or poor people. METHODS: In this paper, we give some results of multidisciplinary (sociological and epidemiological) research conducted among patients attending five of these free clinics in the Paris area. RESULTS: The statistical and qualitative analyses revealed the diversity of the studied population, as well as the conditions in which these consultants attended such clinics, what kind of services and help they used and, furthermore, what kind of social ties were strengthened. CONCLUSION: These results lead us to discuss our present knowledge of the determinants of the utilization of the healthcare system, not only among vulnerable people, but perhaps also amongst the general population.

Adult↗
PubMed2006

Renewed growth in hospital inpatient cost since 1998: variation across metropolitan areas and leading clinical conditions.

OBJECTIVE: To use disaggregated data about metropolitan statistical areas (MSAs) and clinical conditions to better describe the variation in cost increases and explore some of the hypothesized influences. STUDY DESIGN: The study uses the state inpatient databases from the Healthcare Cost and Utilization Project, containing all discharges from hospitals in 172 MSAs in 1998 and 2001. The discharge summary information was combined with standardized hospital accounting files, surveys of managed care plans, MSA demographics, and state data pertaining to caps on medical malpractice awards. METHODS: The analysis used descriptive comparisons and multivariate regressions of admission rate and cost per case in 9 leading disease categories across the MSAs. The increase in hospital input prices and changes in severity of illness were controlled. RESULTS AND CONCLUSION: Metropolitan statistical areas with higher HMO market penetration continued to show lower admission rates, no less so in 2001 than in 1998. A cap on malpractice awards appeared to restrain admissions, but the net effect on hospital cost per adult eroded for those states with the most experience with award caps. Higher admission rates and increase in cost were found in several disease categories.

Cost of Illness↗
PubMed2006

[Contingent valuation for health care services. Review of domestic studies and outline of foreign investigations].

Contingent valuation method (CVM) can be applied to measure benefits of healthcare services. It is a technique for estimating subjects' willingness to pay (WTP) for a service under the scenario describing a virtual market with a questionnaire. In the present research, we outlined foreign studies and reviewed domestic studies on healthcare contingent valuation. A total of 14 papers from domestic literature (five English and nine Japanese articles) identified with mechanical search engines were verified for the following eight items: the method of the questionnaire; the information included in the virtual scenario; the question form for the willingness to pay; bias problems specific to CVM; validity/reliability, ex post/ex ante valuation, altruistic WTP, and non-health value. The following conclusions were drawn from the domestic studies: (1) several studies were short of sufficient information regarding the virtual scenario; (2) no research proved the existence of bias and the ways of coping with it; (3) tests for reliability were not carried out, although some kind of validity was verified; (4) all involved ex post user based evaluation; (5) neither altruistic WTP nor non-health value was examined. Taken the advantages of CVM into consideration, it should become a useful tool, complementing other economic evaluation techniques. Since its application has just begun in Japan, more emphasis needs to be given to practical issues so that healthcare workers will utilize CVM in a way that domestic studies in health economics will be activated.

Attitude to Health↗
PubMed1994

Can SNOMED International represent patients' perceptions of health-related problems for the computer-based patient record?

As the United States moves towards a computer-based patient record, there is much discussion related to the contents of such a record and the manner in which the data elements will be represented. Recent health care reform has emphasized the need for increased patient involvement in health care decision making, however, there has been little discussion about including the patient perspective in the computer-based patient record. Using an existing data set of 201 patients who were hospitalized for Pneumocystis carinii pneumonia, this study examined the ability of SNOMED International to represent patients' perceptions of health-related problems. The majority of concepts used by patients to describe health-related problems could be matched with existing SNOMED terms. The addition of the social context module as an adjunct to existing terminologies of medical diagnoses, NANDA diagnoses, and signs/symptoms provided additional matching terms. Patient goals did not match existing SNOMED terms. The findings of this study suggest that SNOMED International has the potential to adequately represent patients' perceptions of health-related problems for the computer-based patient record. Additional studies are needed that will examine the extent to which patients' perceptions of health-related problems are already documented in the patient record by healthcare providers. The utility of patients' perceptions of health-related problems in the prediction of patient outcomes must also be analyzed.

Attitude to Health↗
PubMed1993

Healthcare reform: the role of coordinated critical care.

OBJECTIVE: To evaluate and editorialize the evolving role of the discipline of critical care as a healthcare delivery system in the process of healthcare reform. DATA SOURCES: The sources included material from the Federal Office of Management and Budget, Health Care Financing Review, President Bush's Office, Association of American Medical Colleges, and publications of the Society of Critical Care Medicine. STUDY SELECTION: Data were selected that the author felt was relevant to the healthcare reform process and its implications for the discipline of critical care. DATA EXTRACTION: The data were extracted by the author to illustrate the forces behind healthcare reform, the implications for the practice of critical care, and role of critical care as a coordinated (managed) care system in the process of healthcare reform. DATA SYNTHESIS: Healthcare reform has been initiated because of a number of considerations that arise in evaluating the current healthcare delivery system: access, financing, cost, dissatisfactions with the mechanisms of delivery, and political issues. The reform process will occur with or without the involvement of critical care practitioners. Reforms may greatly alter the delivery of critical care services, education, training, and research in critical care. Critical care has evolved into a healthcare delivery system that provides services to patients who need and request them and provides these services in a coordinated (managed) care model. CONCLUSIONS: Critical care practitioners must become involved in the healthcare reform process, and critical care services that are effective must be preserved, as must the education, training, and research programs. Critical care as a healthcare delivery system utilizing a coordinated (managed) care model has the potential to provide services to all patients who need them and to deliver them in a manner that is cost effective and recognized as providing added value.

Critical Care↗
PubMedDate not supplied

Patterns of decline among inpatient procedures.

This paper explores how the new financial incentives and organizational structures that prevail in the hospital industry have affected the mix of services provided by hospitals. Using data from the Agency for Health Care Policy and Research's Healthcare Cost and Utilization Project, the authors studied the 150 procedures that were most frequently performed on inpatients in 1980. They found that (a) 37 of the 150 procedures declined in use more than 40 percent by 1987, (b) patients that continued to receive one of the 37 procedures in 1987 on an inpatient basis tended to be more severely ill than in 1980, and (c) rates of decline were disproportionately large for Medicaid recipients. Three main factors have contributed to the decline in inpatient use of these procedures. Most important has been the shift from inpatient to outpatient settings, a result of new technologies and pressures from reimbursement mechanisms and utilization review policies. Some procedures have been replaced by less invasive, more effective approaches. Other procedures are now considered ineffective by the medical community and have been largely abandoned as a result.

Ambulatory Surgical Procedures↗
PubMed1999

Antibiotic therapy of Helicobacter pylori infection reduces healthcare expenditures related to duodenal ulcer.

OBJECTIVE: To test whether eradication of Helicobacter pylori saves costs in the treatment of duodenal ulcer disease, compared with conventional antisecretory therapy. STUDY DESIGN: A prospective, double-blind clinical trial was conducted at 132 sites in the United States. PATIENTS AND METHODS: Adult patients with active duodenal ulcer and confirmed H pylori infection were randomized to receive treatment with clarithromycin plus omeprazole, omeprazole alone, or ranitidine alone. Utilization of ulcer-related healthcare resources was documented during 1 year following therapy. Costs were calculated by multiplying the number of health resources utilized by the cost of each resource. Resource costs were obtained from a database containing actual average costs spent by managed care organizations on outpatient and inpatient treatment. RESULTS: Of the 819 patients enrolled, 727 completed the study: 243 received clarithromycin plus omeprazole, 248 omeprazole alone, and 236 ranitidine alone. Ulcer-related health resource utilization and total ulcer-related healthcare costs were decreased after treatment with clarithromycin plus omeprazole, compared to treatment with omeprazole or ranitidine alone. In multivariate linear regression analyses, type of treatment was found to be a significant predictor of total costs. Specific costs associated with endoscopic examinations, clinic visits, and medications were also significantly reduced by treatment with clarithromycin plus omeprazole as compared to other treatment forms. CONCLUSIONS: In a managed care environment, therapy with clarithromycin and omeprazole to eradicate H pylori in patients with duodenal ulcer disease would result in significant cost savings secondary to a reduction in the utilization of healthcare resources.

Adolescent↗
PubMed2006

Relationships among childhood maltreatment, PTSD, and health in female veterans in primary care.

OBJECTIVE: Women with histories of childhood maltreatment (CM) have higher rates of physical health problems and greater medical utilization compared to women without abuse histories. This study examined whether current post-traumatic stress disorder (PTSD) symptoms mediate the relationship between CM and indicators of physical health and medical utilization in female veterans. METHOD: Respondents were 221 female veterans (56% of the potential sample), who received medical care from the San Diego VA Healthcare System during a 12-month period. Respondents provided self-report information about CM, PTSD symptoms, use of pain medication, and physical symptoms and functioning. Additional information about medical utilization was extracted from respondents' medical charts. Regression-based models were conducted to test whether PTSD symptoms mediate the relationships between CM and physical symptoms and between CM and medical utilization. RESULTS: Emotional abuse was associated with poorer role-physical functioning, increased bodily pain and greater odds of using pain medication in the past 6 months. Physical abuse was associated with poorer general health. Contrary to prediction, emotional neglect was associated with better role-physical functioning, and CM was not associated with increased healthcare utilization. PTSD was shown to mediate the relationship between emotional and physical abuse and health outcomes. CONCLUSIONS: PTSD, or psychopathology more generally, appears to be an important factor in the negative health impact of CM. Given that several empirically supported interventions are available for PTSD, there may be physical health benefits in early identification and treatment of psychopathology related to CM.

California↗
PubMed2004

Pap screening in a U.S. health plan.

The U.S. Preventive Services Task Force recommends cervical cancer screening begin with the onset of sexual activity and be repeated at least every 3 years until age 65. Previous studies examining the annual utilization and frequency of Pap screening have relied on patient self-report, found to be less reliable than medical records and administrative data. We estimate the age-specific rate and frequency of Pap screening in a U.S. health plan using 1998-2002 administrative data on 150,052 female enrollees within the Kaiser Permanente Northwest health plan, Portland, OR. We analyze the age-specific rate of cervical and vaginal Pap screening and age-specific proportion of routinely screened women receiving cervical screening at various yearly intervals. Of the enrolled women, 31.2% received a Pap smear in 1998, with utilization highest for ages 25-29 (62.4%). Among routinely screened women, 36% were estimated to receive annual cervical smears, versus 22% biennial, 13% triennial, and 29% less frequent screening. Less frequent screening was observed with increasing age. These are the first age-specific estimates of Pap screening frequency and annual utilization in a general healthcare setting, derived from administrative data, rather than self-report. Overall Pap utilization was lower than found in national surveys based on self-report. Despite limited evidence of benefit from more frequent screening, a substantially higher proportion of women was found to receive annual rather than either biennial or triennial screening. Sporadic screening was also more prevalent than expected based on prior self-reported data. Further opportunities exist for improving screening adherence, even within traditionally less vulnerable populations.

Adult↗
PubMed2006

The association of comorbidities, utilization and costs for patients identified with low back pain.

BACKGROUND: Existing studies have examined the high prevalence of LBP along with the high treatment costs of patients with low back pain (LBP). Various factors have been shown to be correlated or predictive of chronic or episodic LBP including the characteristics of the initial episode, pain, comorbid conditions, psychosocial issues, and opiate use. This study replicates and extends earlier studies by examining the association of patient characteristics including baseline comorbidities with patterns of healthcare service use and cost. METHODS: This is a retrospective analysis of measures of comorbidities, healthcare use, and cost for patients identified with LBP, stratified by the number of LBP episodes. Administrative data associated with outpatient and hospital based care for the years 1996 through 2001, were used to identify adult patients with LBP. LBP patients continuously enrolled for 12 months prior and 24 months after their initial LBP event were included in the study. A LBP episode was identified as the number of 30-day periods where a patient had one or more healthcare events with a diagnosis consistent with LBP. Chi-square and multivariate regression analyses were employed to estimate the variation in utilization and costs. RESULTS: Of 16,567 patients enrolled, 67% were identified with only one LBP episode and 4.5% had > or =6. The prevalence of comorbidities, analgesic use, and healthcare service use, varied by the number of back pain episodes. Diabetes, rheumatoid arthritis, anxiety, psychotic illness, depression, use of opiates and NSAIDs were associated with significant incremental increases in costs (P < .003). CONCLUSION: Physical and mental health co-morbidities and measures of analgesic use were associated with chronicity, healthcare utilization and costs. Given the association of comorbidities and cost for patients with LBP, management approaches that are effective across chronic illnesses may prove to be beneficial for high cost patients identified with LBP.

Adult↗
PubMed2004

Functional status and radiographic joint damage are associated with health economic outcomes in patients with rheumatoid arthritis.

OBJECTIVE: This analysis examines the relationship between the functional and radiographic measures of disease activity and the employment status in patients with rheumatoid arthritis (RA). We also assessed the influence of improvement in physical function on employability, healthcare costs, and quality of life, utilizing data collected in the ATTRACT trial. METHODS: During the ATTRACT trial, the Health Assessment Questionnaire (HAQ) disability index, radiographic damage measured by the van der Heijde modified Sharp (vdH-Sharp) score, employment status, healthcare resource utilization, and quality of life measured by Medical Outcomes Survey Short Form-36 were assessed at baseline and again periodically through Week 54. Clinically important improvement was defined as an improvement in the HAQ of > or = 0.25 from baseline to Week 54. RESULTS: There was a significant association at baseline between functional status and the percentages of patients employed. Increased radiographic joint damage was associated with lower full-time employment rate, with patients in the 2 highest quartiles (vdH-Sharp score > 51.5) of radiographic damage having lower rates of full-time employment than those with less damage. During the ATTRACT trial, patients who achieved a clinically important improvement in HAQ scores had a significant improvement in their employability (21% vs 3%; p < 0.001), in their time lost from work (7 vs 30 days; p = 0.012), in their total/direct medical costs (7093/6791 US dollars vs 11,712/10,039 US dollars; p < 0.001), and in their quality of life (p < 0.001) compared with those who did not demonstrate this improvement. CONCLUSION: Functional disability and radiographic joint damage are correlated with employment in patients with RA. Clinically important improvement in HAQ scores is associated with substantial health economic and quality of life benefits for patients with RA.

Arthritis, Rheumatoid↗
PubMed2006

Using the addiction severity index to predict mental and medical health service utilization.

This study assessed the utility of adding the Addiction Severity Index (ASI) to demographic and clinical diagnostic information for the purpose of predicting subsequent substance use disorder service use, and use of other healthcare services by 260 veterans admitted for outpatient substance use disorder treatment. Data collected included demographics, clinical diagnoses, assessment data from the ASI, as well as measures of six-month health service utilization (e.g., substance use disorder services, other mental health services, outpatient medical visits, urgent care visits, inpatient psychiatric and medical). Multivariate analysis using Tobit regression models showed six out of seven ASI scales were significant predictors, and that combining ASI data with demographics and clinical data significantly improved prediction of health care services. It also was found that certain psychiatric and medical diagnoses were related to service use measures, and that a diagnosis of depression was related to overall healthcare utilization.

Adult↗
PubMedDate not supplied

Use of electronic networking for the enhancement of mental health services.

In the Behavioral Informatics Tomorrow column of our November/December, 1994, issue, we presented an introduction to the basic concepts and techniques of electronic communication via the Internet, as well some resources for behavioral healthcare professionals who already utilize electronic bulletin board services (BBS). Now we offer this more detailed article for those interested in utilizing archies, gophers, browsers and chats to gain access to the rapidly growing body of behavioral healthcare informational resources residing in Cyberspace. The authors present dozens of mental health BBs, conferences and networks--with instructions on how to get there.

Computer Communication Networks↗
PubMed2003

[The development of certificates criteria and curriculum in home healthcare nurse specialist program].

PURPOSE: To make a contribution to raising the quality of nursing and home healthcare services through reviewing the present state of home healthcare nurse specialist training institutions and education programs and creating concrete measures to establish high-quality education courses. METHOD: International comparative study of accreditation criteria and curriculum in home healthcare nurse specialist program. RESULT: The Authorization Standards of home healthcare nurse training institutions consists of 8 items, 23 evaluation criteria and 72 evaluation indexes. Proposal to develop a specialist training program: Curriculum. Modify and complement a present homecare nurse education program. Curriculum 1. Designate two forms of certification. The first certification has been granted the authority to serve as a manager and open a home healthcare agency to nurses having masters degrees and clinical experience for five years. The second certification is allowed to perform general home healthcare after having completed a short term training course. Currculum 2. To meet increasing demands, granting a certification to perform home healthcare to registered nurses having clinical experience of more than three years. CONCLUSION: These results can be utilized in the home healthcare educational program for raising the quality of nurses and home healthcare services.

English Abstract↗
PubMed2006

The effectiveness of a care coordination home telehealth program for veterans with diabetes mellitus: a 2-year follow-up.

OBJECTIVES: To assess healthcare use among veterans with diabetes mellitus (DM) enrolled in a Department of Veterans Affairs (VA) Care Coordination Home Telehealth (CCHT) program during 24 months and to contrast this utilization with the service use of a comparison group of veterans with DM not enrolled in the program. STUDY DESIGN: Two-year, retrospective, concurrent matched cohort study design. METHODS: The VA CCHT program included older veterans with type 2 DM at high risk for multiple VA inpatient and outpatient visits. Healthcare utilization (hospitalizations, length of stay, and outpatient visits by type) was assessed at baseline and at 24 months after intervention for the treatment (n = 400) and comparison (n = 400) groups. Propensity scores were used to improve the balance between the treatment and comparison groups. A difference-in-differences approach was used to control for selection bias and for intervening time factors. RESULTS: Two years after enrollment, the treatment group exhibited a statistically significant reduction in the likelihood of all-cause and DM-related hospitalizations. In a subgroup analysis in which we controlled for patients' baseline glycosylated hemoglobin levels, the treatment group had a lower likelihood of having any care coordinator-initiated primary care clinic visits (in which the care coordinator initiated referral to primary care based on health information received from patients' CCHT technology). CONCLUSION: After controlling for selection bias and for intervening time factors, the VA CCHT program reduced avoidable healthcare services for DM (such as hospitalizations) and reduced care coordinator-initiated primary care clinic visits.

Aged↗
PubMed1990

Position paper on the appropriate use of emergency air medical services. Association of Air Medical Services.

Hospitals must document effective use of their resources every three years for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) through a utilization review program. Air medical services remain a large expense for healthcare institutions, so the board of directors of the Association of Air Medical Services (AAMS) directed the Medical Advisory Committee to develop a document on the appropriate utilization of air medical services. The purpose of the paper was to suggest broad guidelines for the use of air medical services and to thereby help ensure the proper allocation of available resources. This project generated substantial interest among program directors and medical directors. Early drafts were sent out by regional representatives, and a large response resulted. Many revisions were made before the Medical Advisory Committee met to decide the details of the final draft. When completed in May 1990, the document was sent out to all program directors and medical directors for their approval. The response was overwhelmingly positive. In July 1990, the AAMS Board of Directors gave its unanimous approval for the document published here.

Aircraft↗
PubMed1997

Succeeding under managed care using strategic cost reduction.

Under managed care, healthcare providers experience drops in utilization and the prices they can charge for services. Therefore, healthcare providers that achieve lower costs increase their chances for success. Operational improvements to control costs include reducing unit costs, reducing capacity, accelerating operational decision making, and developing new performance measures. Strategies to control costs include managing costs along the continuum of care, continuously managing costs, and refining assets. Specific cost-reduction strategies include building primary-care-driven networks, undertaking patient-focused care initiatives, reengineering patient flow, implementing managed variable costing, and developing a tight primary care operating environment.

Cost Control↗
PubMedDate not supplied

When should managed care firms terminate private benefits for chronically mentally ill patients?

Corporate America's healthcare cost crisis and the country's budget deficit are forcing limits on the resources used to finance healthcare, including mental healthcare. At the same time, the 1990 Americans with Disabilities Act bars discrimination against patients with chronic illnesses, including chronic mental illness. Therefore, corporate benefits managers need guidance on how to ethically and rationally allocate scarce clinical resources to those high-morbidity insureds who utilize disproportionate amounts of these resources. In particular, how should we define the public/private interface: When do patients who repeatedly fail to respond to treatment fall out of the private sector's responsibility? The author, medical director for a leading behavioral healthcare utilization management company, offers the following guidelines recommending reasonable and practical limitations on trials of treatment for seven common categories of difficult psychiatric patients.

Chronic Disease↗