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PubMed2003

Violence prevention in the ED: linkage of the ED to a social service agency.

Interpersonal violence continues to be a problem in the United States, most prominent in the inner-city minority young persons population. The medical approach of "treat 'em and street 'em" philosophy has led to foregoing the psychosocial needs of injured young persons. This study describes a program to link young persons who are victims of interpersonal violence to a healthcare system and a social service agency in an effort to meet their psychosocial needs. An unvalidated screening tool was developed by a team consisting of an EP, social worker, and public health scientist to determine the young victims' psychosocial needs. Patients aged 10 to 24 years who were victims of interpersonal violence (excluding child abuse, sexual assault, and domestic violence) were randomly assigned in the study. The control group was given a list of services and the treatment group received an assessment, case management, and referral to appropriate resources. The study site was a community, teaching level 1 trauma center. The study was approved by the institutional review board. Numbers of referrals in both groups were counted and compared using SPSS (version 10, Chicago, IL). One hundred eighty-eight victims of interpersonal violence were enrolled. A total of 82.5% were male, 65.4% were African American and 31.4% were Hispanic. At the end of 6 months, 78 of the 96 young persons (81.3%) in the treatment group made one or more contacts with their case manager and made use of social service, healthcare, and other referrals. Education (21.6%), job readiness (19.1%), and mental health (11.9%) were the most frequently used services. Nine of the 92 (9.8%) in the control group used services; most of these referrals were for social services (7 of 9 respondents) and the others were healthcare-related. The difference in utilization of services between the treatment and the control groups were found to be significant different (95% confidence interval, 1.41-1.55, significance =.00), and there was a strong positive correlation of using services and case management (Pearson coefficient = 0.728, significance =.00). The referral of young victims of violence from the ED to psychosocial services could be successful using a case management model and an alliance between a healthcare system and a social service agency.

Adolescent↗
PubMed1988

Immunization of the elderly. A vital part of routine healthcare.

The vaccines recommended for routine use in healthy elderly persons (influenza vaccine, pneumococcal vaccine, tetanus-diphtheria toxoid) have benefits far outweighing any risks, yet they are under-utilized. Every patient visit to a healthcare provider presents an opportunity for assessment of the patient's immune status, but preventive care for the elderly is often neglected. Elderly patients are willing to change their habits to maintain good health. The success of any program aimed at protecting this age-group is dependent on a change in habit by the physicians and institutions that provide their healthcare.

Adult↗
PubMed2004

Cost-utility analysis in evaluating prophylaxis in haemophilia.

Prophylaxis is an expensive form of management in haemophilia but has demonstrated many advantages with respect to decreasing joint bleeds and potentially preventing joint damage. The valuation of prophylaxis and how the costs and benefits of this intervention compare with other interventions in the management of haemophiliacs can be evaluated through cost-utility analysis (CUA). CUA is an economic method of analysis where the benefits of a healthcare intervention are expressed as an overall utility or preference, usually in the form of quality-adjusted life years (QALYs). This is a composite measure, which takes into consideration both an individual's lifespan and quality of life (QoL). The most difficult aspect of performing a CUA is the measurement of health-related QoL (HRQoL). Much work is ongoing into evaluating HRQoL in haemophiliacs. This paper addresses some of the ways in which this can be achieved and some of the problems with evaluating HRQoL. Ultimately CUA may provide a tool to allow societies to decide if prophylaxis is worth the cost and how the costs and benefits of prophylaxis compare to other healthcare interventions for other disease entities.

Child↗
PubMed2003

The arrival of consumer-centric healthcare.

Rising employer healthcare costs are driving the need for new cost-saving benefit programs. Consumer-driven health plans have the potential to create savings for employers and better care options for patients. Furthermore, three fundamental forces need to come together for these health plans to become a reality. First, employees need to view healthcare benefits as assets and be provided with the tools to manage those assets. Second, employees must have continuity in the management of their healthcare assets, which includes their medical utilization history. Finally, any savings accumulated in these plans must be employee owned and portable from job to job or available for retirement healthcare needs. Making consumers active participants in the next generation of health plans is a necessity. Making it happen, however, will be a challenge.

Consumer Behavior↗
PubMed2000

Cost-utility analysis of interferon beta-1b in secondary progressive multiple sclerosis.

OBJECTIVES: Interferon beta-1b has recently become available for the treatment of secondary progressive multiple sclerosis (SPMS). This study aims at estimating the cost-effectiveness of this new treatment that has been shown in a clinical trial to reduce the progression of the disease. Effectiveness is measured as the number of quality-adjusted life-years (QALYs) gained from the reduction in progression. Because the clinical trial period will only capture part of the treatment's effect in terms of QALYs gained, since benefits achieved during the trial will have an effect beyond it, the cost-effectiveness analysis involves modeling over the longer term using complementary data. METHODS: A Markov model with states based on disability expressed by EDSS scores was used. Transition probabilities were calculated directly from clinical trial data for the first 3 years and then extrapolated to 10 years. Mean costs and utilities for each Markov state were calculated from a population-based cross-sectional study in Sweden. RESULTS: The incremental cost per QALY is SEK 342,700 (US $39,250; US $1 = SEK 8.73, March 10, 2000) when all costs (direct, informal care, and indirect) are included (discounted 3%). When indirect costs are excluded, the cost per QALY is SEK 542,000 ($62,100). CONCLUSIONS: Cost-effectiveness analysis in SPMS requires that the effect of treatment beyond clinical trials be included. Also, analysis should be done from a societal perspective, since many of the costs occur outside the healthcare system. The cost-utility ratios estimated in this analysis are at or below the mean threshold value indicated in a recent survey of health economists ($60,000).

Adjuvants, Immunologic↗
PubMed2005

High rates of uninsured among HCV-positive individuals.

BACKGROUND AND GOALS: There are no published data on the health insurance status of Hepatitis C virus (HCV)-positive individuals. To address this issue, we analyzed data from the Third National Health and Nutrition Examination Survey (NHANES III). STUDY: Individuals 18 years of age and older who participated in NHANES III were included in the study. We determined the rates of health insurance coverage according to HCV status. We also determined healthcare status and health service utilization according to health insurance status among HCV-positive persons. RESULTS: HCV-positive individuals were more likely to be uninsured compared with those who were HCV-negative (29.6% vs. 12.2%, P = 0.0002). Among those with health insurance, HCV-positive individuals were more likely to have government insurance compared with those who were HCV-negative (42.9% vs. 27.6%, P < 0.005). Among HCV-positive individuals, being uninsured was associated with younger age, being unmarried, living in the South, Mexican-American race/ethnicity, and not graduating from high school. Additionally, the uninsured were less likely than their insured counterparts to identify a healthcare facility for sick or routine care, and less likely to have regular contact with a healthcare professional. CONCLUSIONS: A high proportion of HCV-positive individuals are uninsured, and many HCV-positive individuals with health insurance have publicly funded insurance. This finding may have implications for access to health care and for liver-related disease outcomes in HCV-positive persons.

Adolescent↗
PubMed2000

Utilization of specialty mental health care among persons with severe mental illness: the roles of demographics, need, insurance, and risk.

OBJECTIVE: To examine the sociodemographic, need, risk, and insurance characteristics of persons with severe mental illness and the importance of these characteristics for predicting specialty mental health utilization among this group. DATA SOURCE: The Healthcare for Communities survey, a national study that tracks alcohol, drug, and mental health services utilization. Data come from a telephone survey of adults from 60 communities across the United States, and from a supplemental geographically dispersed sample. STUDY DESIGN: Respondents were categorized as having a severe mental disorder, other mental disorder, or no measured mental disorder. Differences among groups in sociodemographics (gender, marital status, race, education, and income), insurance coverage, need for mental health care (symptoms and perceived need), and risk indicators (suicide ideation, criminal involvement, and aggressive behavior) are examined. Measures of service use for mental health care include emergency room, inpatient, and specialty outpatient care. The importance of sociodemographics, need, insurance status, and risk indicators for specialty mental health care utilization are examined through logistic regression. PRINCIPAL FINDINGS: The severely mentally ill in this study are disproportionately African American, unmarried, male, less educated, and have lower family incomes than those with other disorders and those with no measured mental disorders. In a 12-month period almost three-fifths of persons with severe mental illness did not receive specialty mental health care. One in five persons with severe mental illness are uninsured, and Medicare or Medicaid insures 37 percent. Persons covered by these public programs are over six times more likely to have access to specialty care than the uninsured are. Involvement in the criminal justice system also increases the probability that a person will receive care by a factor of about four, independent of level of need. The average number of outpatient visits for specialty care varies little across type of disorder, and the median number of visits (ten) is equivalent for those with a severe mental illness and those with other disorders. CONCLUSIONS: Persons with severe mental illness have a high level of economic and social disadvantage. Barriers to care, including lack of insurance, are substantial and many do not receive specialty care. Public insurance programs are the major points of leverage for improving access, and policy interventions should be targeted to these programs. Problems of adequate care for the severely mentally ill may be exacerbated by the managed care trend to reductions in intensity of treatment.

Acute Disease↗
PubMed2000

Analysis of patient profile in predicting home care resource utilization and outcomes.

OBJECTIVES: The study identifies patient profile variables that explain variation in resource utilization and outcomes for home healthcare. BACKGROUND: The healthcare reform and the demand for quality patient care have increased the need to identify key patient characteristics that can predict the use of resources and outcomes; however, home healthcare industry currently lacks adequate information collection to reflect these needs. This study explored both the resource use and care outcomes for nursing administrators in monitoring quality, resource distribution, and reimbursement policy decision making. METHOD: The conceptual framework is based on Donabedian's quality care elements (structure, process, and outcome) and Nursing Minimum Data Set. This is a retrospective descriptive study design in which 244 patient records and data were obtained from a home healthcare agency located in Washington, DC. A series of stepwise and discriminant analyses was conducted for data analysis. RESULTS: The findings indicated that the total number of nursing diagnoses and two specific nursing diagnoses (alteration in mobility and knowledge deficit in i.v. therapy) were strong predictors of overall resource use. Prognosis proved to be the strongest predictor of discharge outcomes. CONCLUSIONS/IMPLICATIONS: The results indicated that data related to nursing diagnoses and nursing interventions can provide valuable information in predicting resource use. Prognosis made by nursing judgment was also sensitive in predicting patient outcomes. These critical data elements should be included in describing home health patient characteristics and related resource utilization and care outcomes.

Adult↗
PubMedDate not supplied

Databases for outcomes research: what has 10 years of experience taught us?

This paper describes how the mission of the Agency for Healthcare Research and Quality (AHRQ) is being executed through the many programs that it has developed and implemented. The Evidence-based Practice Center program was developed to provide systematic reviews on common and expensive conditions and health technologies and to ensure that this information is used to improve health care outcomes and costs. The National Guidelines Clearinghouse provides an internet-based source of clinical practice guidelines that are produced by clinical specialty organizations for the primary purpose of improving health care delivery and outcomes. Relevant to this symposium on databases, AHRQ has supported the development of databases to track hospital utilization on a state-by-state basis. The Healthcare Cost and Utilization Project (HCUP) allows comparisons between states and within regions of individual states. New initiatives have been launched to evaluate interventions across systems rather than focusing on the individual patient (Translating Research into Practice--TRIP). The Centers for Education and Research on Therapeutics (CERTs) program was developed to conduct real world evaluations to better understand the benefits and risks of single and combined therapy. Both programs further the mission of the AHRQ to improve the outcomes and quality of health care, with additional focus on the cost-effectiveness, patient safety, and increasing access to care for all. Information on programs developed by the AHRQ is available in more detail at the Agency Web site http://www.ahrq.gov.

Databases as Topic↗
PubMed2001

Healthcare quality in an international setting.

This report discusses the process used by the Healthcare Quality Certification Board to internationalize its certification program. With some modifications this methodology can be utilized to define the role of any healthcare professional and to legitimize, create or restructure a certification program that assesses competency in a particular healthcare field. This process and the importance of quality management are related to today's cataclysmic healthcare environment which challenges efforts to confront cost and access.

Certification↗
PubMed1996

Program evaluation of an intervention approach for staff assaulted by patients: preliminary inquiry.

Crisis intervention procedures for emergency services personnel and healthcare providers are increasingly being utilized to address the psychological sequelae of acute stress during critical incidents. While anecdotal evidence suggests the efficacy of these approaches, more formal experimental inquiry has been limited. This brief report outlines one strategy for conducting program evaluation of a crisis intervention approach for staff who are assaulted by patients. This outcome design was implemented in multiple sites, even as the service was being delivered.

Crisis Intervention↗
PubMed2006

The association between psoriasis, diabetes mellitus, and atherosclerosis in Israel: a case-control study.

BACKGROUND: Previous reports demonstrated an association between psoriasis and other diseases including heart failure and diabetes mellitus. OBJECTIVES: Our aim was to describe the association between psoriasis, diabetes mellitus, and atherosclerosis in Israel. METHODS: A cross-sectional study was performed utilizing the database of Maccabi Healthcare Services (MHS), a large health provider organization in Israel. Case patients were defined as subjects who were diagnosed with psoriasis. Patients with diabetes and atherosclerosis were identified by using the MHS diabetes and cardiovascular registries, respectively. The control group included MHS enrollees without psoriasis. The proportion of diabetes and atherosclerosis among case and control groups was compared. Chi-square tests were used to compare categorical parameters. Logistic regression models were used for multivariate analyses. RESULTS: The study included 46,095 patients with psoriasis (case patients) and 1,579,037 subjects without psoriasis (control patients). The age-adjusted proportion of diabetes was significantly higher in psoriasis patients as compared with the control group (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.1-1.48). The age-adjusted proportion of atherosclerosis was significantly higher in psoriasis patients as compared with the control group (OR 1.28, 95% CI 1.04-1.59). In patients with psoriasis, a multivariate logistic regression model demonstrated an association between diabetes and the multiple use of very potent topical steroids (P < .05) or use of systemic medication for psoriasis (methotrexate, cyclosporine or acitretin) (P < .001). A similar model demonstrated an association between atherosclerosis and the use of phototherapy (P < .001). LIMITATIONS: Our study was based on a computerized database. The diagnosis of psoriasis was based on digitally transmitted data. Therefore overestimation (false-positive cases) and underestimation (false-negative cases) of psoriasis patients may exist, thereby being a source for information bias. A second limitation is selection bias that may occur due to the possibility that reporting of both psoriasis and associated illnesses is higher in individuals who are seeking medical care. A third limitation concerns the causal effect between occurrence of psoriasis and atherosclerosis or diabetes. The dataset of MHS records diagnoses only from 1997 and does not record the date of disease onset. CONCLUSIONS: Our study supports previous reports for an association between psoriasis and atherosclerosis and psoriasis and diabetes. Further study is needed to support this observation.

Adolescent↗
PubMed2005

Primary care physicians' awareness and adherence to cervical cancer screening guidelines in Texas.

BACKGROUND: Cervical cancer screening guidelines were created to help healthcare professionals in appropriate screening utilizing the PAP test. However, significant variation in cervical cancer screening among primary care physicians has been noted. Knowledge of the awareness of and adherence to cervical cancer screening guidelines by primary care physicians will help determine how best to disseminate and educate these physicians regarding the guidelines in hopes of reducing unnecessary screening and improving screening for under screened populations. METHODS: A cross-sectional, mailed survey involving Family Medicine (FP), Community Internal Medicine (CIM), and Obstetrics/Gynecology (OB) physicians practicing in a large University-affiliated, multi-specialty group practice associated with an 186,000-member HMO in Central Texas (n = 177) was conducted in 2001-2002. RESULTS: Most physicians performed PAP testing (50.4%). PAP screening was noted to vary significantly by specialty (P < 0.0001). All OBs were aware of at least one published guideline, compared to 96% of FPs and 91% of CIMs (P < 0.05). A wide variation was reported regarding adherence to published guidelines. In addition, there was significant intraspecialty variation regarding adherence to the physicians' own specialty's guidelines. CONCLUSIONS: While most physicians in the primary care setting perform PAP tests and are aware of published guidelines for PAP screening, adherence to the published guidelines varies considerably even in the same clinical setting.

Adult↗
PubMedDate not supplied

Bipolar disorder and diabetes mellitus: epidemiology, etiology, and treatment implications.

INTRODUCTION: Bipolar disorder (BD) is a highly prevalent and disabling condition with significant mortality risk from suicide and other unnatural causes. This ignominious description is alongside recent observations that the majority of excess deaths in BD are secondary to medical comorbidity. The medical burden in BD is associated with a clustering of risk factors (e.g., obesity, smoking, unhealthy dietary habits) and inadequate utilization of preventative and primary healthcare. Diabetes mellitus (DM) is also a prevalent multifactorial disease which imparts substantial illness burden. Preliminary investigations indicate that patients who suffer from BD with comorbid DM have a more severe course and outcome, lower quality of life, higher prevalence of medical comorbidity and higher cost of illness. METHODS: We conducted a MedLine search of all English-language articles 1966-2004 using the key words: bipolar disorder, major depressive disorder, diabetes mellitus, glucose metabolism, mortality, overweight, obesity, body mass index. The search was supplemented with manual review of relevant references. Priority was given to randomized controlled data, when unavailable; studies of sufficient sample size are presented. RESULTS: Subpopulations of BD patients should be considered at high risk for DM. The prevalence of DM in BD may be three times greater than in the general population. CONCLUSIONS: Bipolar disorder populations may be an at-risk group for glucose metabolic abnormalities. Opportunistic screening and vigilance for clinical presentations suggestive of DM is encouraged.

Adolescent↗
PubMedDate not supplied

Veterans Health Administration Office of Nursing Services exploration of positive patient care synergies fueled by consumer demand: care coordination, advanced clinic access, and patient self-management.

The consumers who utilize the Veterans Health Administration healthcare system are older, and most are learning to live with chronic diseases. Their desires and needs have driven changes within the Veterans Health Administration. Through patient satisfaction initiatives and other feedback sources, consumers have made it clear that they do not want to wait for their care, they want a say in what care is provided to them, and they want to remain as independent as possible. Two interdisciplinary processes/models of healthcare are being implemented on the national level to address these issues: advanced clinic access and care coordination. These programs have a synergistic relationship and are integrated with patient self-management initiatives. Positive outcomes of these programs also meet the needs of our staff. As these new processes and programs are implemented nationwide, skills of both patients and nursing staff who provide their care need to be enhanced to meet the challenges of providing nursing care now and into the 21st century. Veterans Health Administration Office of Nursing Services Strategic Planning Work Group is defining and implementing processes/programs to ensure nurses have the knowledge, information, and skills to meet these patient care demands at all levels within the organization.

Clinical Competence↗
PubMedDate not supplied

Focus on the COX-1 and COX-2 agents: renal events of nonsteroidal and anti-inflammatory drugs-NSAIDs.

This article will focus upon some of the cautions used in the process of prescribing NSAIDs with a focus upon renal events, pharmacokinetics of COX-2 agents, and phytopharmaceuticals that present co-prescribing hematologic challenges. Prescribing any pharmacotherapeutic agent presents the clinician with the cognitive challenge between providing a therapeutic balance weighing potential benefits to be achieved through prescribing against the potential liabilities of pharmacokinetic and pharmacodynamic iatrogenic events, and drug interactions. The following information is presented as a brief overview of the familiar arachidonic acid cascade followed by the renal events reported with non-COX-2-specific NSAIDs. The pharmacokinetics of the three currently available COX-2 NSAIDs are presented. Patient-specific risk assessments for renal function/dysfunction should be considered prior to or concurrent with initiation of any NSAID therapy coupled with periodic renal monitoring during treatment of those with patient risk factors. Phytopharmaceuticals, supplements, and over-the-counter agents should be discussed with the patient following patient disclosure of use and not omitted by the patient during presentation of their medication consumption with utilization history to their respective healthcare professionals.

Acute Kidney Injury↗
PubMed2004

Review article: uninvestigated dyspepsia and non-ulcer dyspepsia-the use of endoscopy and the roles of Helicobacter pylori eradication and antisecretory therapy.

Due to its prevalence, impact on quality-of-life and the associated significant health resource utilization, dyspepsia is a major healthcare concern. The available management strategies for uninvestigated dyspepsia include prompt endoscopy, the 'test-and-treat' strategy for Helicobacter pylori, and empiric antisecretory therapy. There is consensus that endoscopy should be reserved for patients with alarm features (e.g. symptom onset after 45 years of age, recurrent vomiting, weight loss, dysphagia, evidence of bleeding, anaemia), H. pylori-positive individuals who fail test-and-treat, and those with an inadequate response to empiric antisecretory therapy. Factors influencing the decision between test-and-treat and empiric antisecretory therapy in uninvestigated dyspepsia include the local prevalence of H. pylori and peptic ulcer disease and the proportion of ulcers attributable to H. pylori. For uninvestigated dyspepsia in patients without alarm features, test-and-treat is the preferred initial management method in Europe based on the relatively high prevalence of H. pylori/peptic ulcer disease whereas empiric antisecretory therapy is preferred in many parts of the United States, where the prevalence of H. pylori/peptic ulcer disease is relatively low. In patients with non-ulcer dyspepsia, H. pylori eradication and empiric antisecretory therapy result in comparable and small, but statistically significant, improvements in dyspepsia. Empiric antisecretory therapy is the preferred initial method of managing non-ulcer dyspepsia in Europe and the US. The test-and-treat approach would receive increased enthusiasm if H. pylori cure is shown to prevent development of gastric cancer in non-ulcer dyspepsia patients in a large Western trial.

Algorithms↗
PubMed2006

Utility and direct costs: ankylosing spondylitis compared with rheumatoid arthritis.

OBJECTIVES: To compare utility and disease-specific direct costs between patients with ankylosing spondylitis (AS) and patients with rheumatoid arthritis (RA) in the Netherlands. METHODS: Patients with AS and those with RA completed questions on disease characteristics, the EuroQol-5D (EQ-5D) to assess utility, and questionnaire resource utilisation. Resource utilisation was assessed prospectively in AS, but retrospectively in RA. True cost estimates (2003) were used to calculate the costs. Differences in disease characteristics between AS and RA were described, and determinants of EQ-5D utility and costs were explored by Cox proportional hazard regressions. RESULTS: 576 patients with RA and 132 with AS completed the questionnaires. EQ-5D utility (0.63 vs 0.7) was lower, and annual direct costs higher in RA (euro5167 vs euro2574). In multivariate Cox proportional hazard regressions, there was no difference in utility between the diagnostic groups, but patients with RA incurred higher direct costs after controlling for age, gender and disease duration. CONCLUSIONS: In patients with RA and patients with AS, who are under the care of a rheumatologist, utility is equally reduced, but healthcare costs are higher in RA after controlling for age, gender and disease duration. These data can be helpful to provide insights into the differences and similarities between the healthcare needs of both patient groups and to identify issues for further research and for policy in healthcare organisations.

Adult↗