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PubMed2002

Patient and caregiver characteristics and nursing home placement in patients with dementia.

CONTEXT: The decision to institutionalize a patient with dementia is complex and is based on patient and caregiver characteristics and the sociocultural context of patients and caregivers. Most studies have determined predictors of nursing home placement primarily according to patient or caregiver characteristics alone. OBJECTIVE: To develop and validate a prognostic model to determine the comprehensive predictors of placement among an ethnically diverse population of patients with dementia. DESIGN, SETTING, AND PARTICIPANTS: The Medicare Alzheimer's Disease Demonstration and Evaluation study, a prospective study at 8 sites in the United States, with enrollment between December 1989 and December 1994 of 5788 community-living persons with advanced dementia. MAIN OUTCOME MEASURES: Time to nursing home placement throughout a 36-month follow-up period, assessed by interview and review of Medicare records, and its association with patient and caregiver characteristics, obtained by interview at enrollment. RESULTS: Patients were divided into a development (n = 3859) and validation (n = 1929) cohort. In the development cohort, the Kaplan-Meier estimates of nursing home placement throughout 1, 2, and 3 years were 22%, 40%, and 52%, respectively. After multivariate adjustment, patient characteristics that were associated with nursing home placement were as follows: black ethnicity (hazard ratio, 0.60; 95% confidence interval [CI], 0.48-0.74), Hispanic ethnicity (HR, 0.40; 95% CI, 0.28-0.56) (both ethnicities were inversely associated with placement), living alone (HR, 1.74; 95% CI, 1.49-2.02), 1 or more dependencies in activities of daily living (HR, 1.38; 95% CI, 1.20-1.60), high cognitive impairment (for Mini-Mental Status Examination score < or =20: HR, 1.52; 95% CI, 1.33-1.73), and 1 or more difficult behaviors (HR, 1.30; 95% CI, 1.11-1.52). Caregiver characteristics associated with patient placement were age 65 to 74 years (HR, 1.17; 95% CI, 1.01-1.37), age 75 years or older (HR, 1.55; 95% CI, 1.31-1.84), and high Zarit Burden Scale score (for highest quartile: HR, 1.73; 95% CI, 1.49-2.00). Patients were assigned to quartiles of risk based on this model. In the development cohort, patients in the first, second, third, and fourth quartile had a 25%, 42%, 64%, and 91% rate of nursing home placement at 3 years, respectively. In the validation cohort, the respective rates were 21%, 50%, 64%, and 89%. The C statistic for 3-year nursing home placement was 0.66 in the development cohort and 0.63 in the validation cohort. CONCLUSIONS: Patient and caregiver characteristics are both important determinants of long-term care placement for patients with dementia. Interventions directed at delaying placement, such as reduction of caregiver burden or difficult patient behaviors, need to take into account the patient and caregiver as a unit.

Aged↗
PubMedDate not supplied

Excess mortality in small dialysis centers. The result of dialyzing high-risk patients.

End Stage Renal Disease Network 12 regularly collects information describing the Medicare dialysis population within its boundaries (Iowa, Nebraska, Missouri, and Kansas). Hoping to foster a regional quality improvement program, Network 12 began calculating provider specific mortality rates in 1988. These rates were extremely variable, but small dialysis units (< or = 30 patients) generally had higher mortality rates than their larger counterparts. To determine why mortality rates were inversely proportional to the number of patients treated within the center, we undertook a more intensive statistical review of patient mortality rate within the network. Actual and expected mortality rates were derived for each Network 12 dialysis center. Forty-eight percent of dialysis centers served 30 or fewer patients (small centers), and 40% had an expected mortality rate < or = 5 deaths per year. In 1989 and 1990, the crude mortality rate for dialysis centers enrolling 30 or fewer patients exceeded that of larger dialysis centers (p = 0.02). When Standardized Mortality Ratios were analyzed, this relationship disappeared (p = 0.83). Statistical review of dialysis providers is a complex process. Adjusting mortality rates for patient characteristics known to influence survival obviated the relation of dialysis unit size to patient mortality rate within Network 12. This suggests that patients were not randomly assigned to dialysis units and that small providers enrolled a disproportionate number of high risk patients. Adjusting mortality rates for endemic patient characteristics did not reduce the extreme variability noted in small mortality rates. This uncertainty, embedded in probability theory, cannot be eliminated from the statistical analysis of small samples.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemodialysis Units, Hospital↗
PubMed2004

Rural GPs' ratings of initiatives designed to improve rural medical workforce recruitment and retention.

INTRODUCTION: Since the early 1990s, Australian governments have recognised the problems of rural medical workforce recruitment and retention and have implemented a range of programs and incentives designed to improve the supply of, and access to, doctors in rural and remote areas. Some incentives involve differential payments according to degree of rurality or remoteness. Since these programs involve considerable costs to governments, some assessment of their impact on recruitment or retention is warranted. The objective of this study is to examine the effectiveness of different recruitment and retention incentives from the perspective of the rural GP. Doctors practising in rural and remote communities were, therefore, asked to rank the relative importance of different interventions in terms of their impact on recruitment to and retention of GPs in their communities. METHODS: Six possible interventions were selected to cover the major objectives underpinning rural workforce programs most relevant to doctors currently in rural practice. Respondents assigned a rank to indicate the relative importance of each item with respect to each of the two questions: "What would help most to attract more GPs to this community?" and "What would help most to retain GPs in this community?" The data were collected as part of a national study into the viability of rural general practice undertaken jointly by the Rural Doctors Association of Australia and Monash University School of Rural Health Bendigo. The Rural, Remote and Metropolitan Areas (RRMA) classification was used as the rurality indicator. Analysis involved the calculation of mean ranks for each item. Item means were then ranked to indicate most to least important items in total, and within each RRMA category. RESULTS: Thirty-five percent of all GPs practising in rural and remote Australia responded to the national survey, representing 53% of all practices in those areas. Of these, 1050 doctors who nominated themselves as a principal, partner or associate in their practice were eligible for inclusion in this analysis. The results showed a high degree of agreement in the responses to both questions, with the possible interventions being ranked in the same overall order. 'Better remuneration for Medicare consultations' and 'Improved after-hours and on-call arrangements' were ranked as the most important interventions for both attracting and retaining GPs, whereas 'Better education and professional support activity' and 'Improved availability of allied health professional services' were ranked as least important of the options presented. 'Better locum availability' and 'Capital funding to improve practice infrastructure/enable GPs to set up practice' ranked in between. Results within each RRMA category were very similar to the overall rankings, confirming the significance of the improved remuneration and workload arrangements, regardless of geographical location. CONCLUSIONS: Ensuring professional support, workforce supply, income and infrastructure support are all relevant to the recruitment and retention of GPs in rural and remote areas. However, from the perspective of GPs practising in such areas, specific initiatives that increase the core income of rural practices, and which address those medical workforce supply issues which impact most on workload, are considered those which are most likely to assist in the recruitment and retention of GPs to Australia's rural and remote communities.

Journal Article↗
PubMedDate not supplied

The effects of a low-cost intervention program on hospital costs.

OBJECTIVE: To assess the impact of a low-cost education and feedback intervention designed to change physicians' utilization behavior on general medicine services. DESIGN: Prospective, nonequivalent control group study of 1,432 admissions on four general medicine services over 12 months. Two services were randomly selected to receive the intervention. The other two served as controls. Admissions alternated between control and intervention services each day. Results were casemix-adjusted using diagnosis-related groups (DRGs). Three internists blinded to patient study group assignment assessed quality of care using a structured implicit instrument. SETTING: Four general medicine services at a university hospital. INTERVENTIONS: A brief orientation, a pamphlet of cost strategies and common charges, detailed interim bills, and information about projected length of stay and usual hospital reimbursement for each patient. PATIENTS/PARTICIPANTS: Each service was staffed by a full-time internal medicine faculty member, one third-year and two first-year internal medicine houseofficers, three medical students, and a clinical pharmacist. Physicians were assigned to services for one-month periods by a physician unaware of the study design. To prevent crossover, houseofficers assigned to a service returned to the same service for all subsequent general medical inpatient assignments. MEASUREMENTS AND MAIN RESULTS: Geometric mean length of stay was 0.44 days (7.8%) shorter for the intervention services than for the control services (p less than 0.01), and geometric mean charges were $341 (7.1%) less (p less than 0.01). Effects persisted despite using a more precise cost estimate or casemix adjustment. Intervention houseofficers demonstrated superior cost-related attitudes but no difference in knowledge of charges. Audits of quality of care detected no significant difference between groups. CONCLUSION: This low-intensity intervention reduced length of stay and charges, even under the cost-constrained context of the prospective payment system.

Cost Control↗
PubMed1985

Medicaid program; third party liability for medical assistance; FFP rates for skilled professional medical personnel and supporting staff; and sources of state share of financial participation--HCFA. Final regulations.

These final regulations--(1) Broaden the scope of services for which a State must collect from third parties the cost of medical assistance furnished to Medicaid recipients, revise the methods of paying claims involving third party liability, and make conforming changes to incorporate a statutory provision that requires the assignment of medical support rights and other third part payments and cooperation in establishing paternity and obtaining support as a condition of eligibility for Medicaid; (2) Revise and clarify criteria used in determining whether skilled professional medical personnel and directly supporting staff involved in the administration of the Medicaid program qualify for 75 percent Federal matching; and (3) Clarify policy to permit public and private donations to be used as a State's share of financial participation in the entire Medicaid program, instead of only for training expenditures. These amendments are a combination of steps to remove unnecessary requirements in our regulations and to include provisions that will improve the administration of the Medicaid program. They also conform the Medicaid regulations to certain provisions of the Deficit Reduction Act of 1984 (Pub. L. 98-369).

Allied Health Personnel↗
PubMed1999

Clinical correlates of the initial and long-term cost of coronary bypass surgery and coronary angioplasty.

BACKGROUND: Medical costs vary substantially among patients. Understanding the baseline factors that predict subsequent cost may allow better selection of therapy for individual patients. Understanding the postprocedure events that increase cost should help to improve efficiency and effectiveness of coronary revascularization. METHODS: Data on 4-year costs were collected from patients randomly assigned to coronary angioplasty or bypass surgery as part of the BARI (Bypass Angioplasty Revascularization Investigation) trial. Regression models first examined factors known at the time of randomization that prospectively predicted initial procedure cost and long-term cost. Subsequent models tested the value of postrandomization events as explanatory variables for cost. RESULTS: The independent baseline predictors of higher initial percutaneous transluminal coronary angioplasty cost included 3-vessel disease (+12%) and acute presentations (+22%), whereas the independent predictors of higher initial coronary artery bypass grafting cost included the number of comorbid conditions (+5% per condition) and female sex (+7%). The independent baseline predictors of 4-year cost included heart failure (+26%), diabetes (+22%), comorbidity (+10%), and angioplasty assignment in patients with 2-vessel disease (-15%). Postrandomization models showed higher initial and long-term costs were strongly correlated with the number of repeat revascularization procedures (+30% to +128%) and the occurrence of clinical complications (+8% to +131%). CONCLUSIONS: Two-vessel disease identifies patients likely to have lower costs after angioplasty, whereas heart failure, comorbid conditions, and diabetes identify patients likely to accrue higher costs after either angioplasty or bypass surgery. Long-term costs can be potentially reduced by interventions that decrease procedural complications or reduce the need for repeat revascularization.

Aged↗
PubMed1989

Development and evaluation of a survey-based type of benefit classification for the Social Security program.

This attempt to classify Social Security beneficiaries by type of benefit using the new Survey of Income and Program Participation (SIPP) has yielded promising results. Evaluations of the classification algorithm based on comparison of the estimated number of beneficiaries in each of the several categories to independent estimates of the number of beneficiaries indicate that in most instances a high percentage of each category has been identified. For the most part, age and monthly benefit amount size distributions seem reasonable. Furthermore, very few persons in the sample who were identified as Social Security beneficiaries could not be assigned to one or another of the benefit groups. The classification procedure also represents a marked improvement over earlier efforts to classify type of beneficiary that relied on data from the March Supplement to the Current Population Survey (CPS). Most importantly, the benefit classification scheme based on SIPP data appears to provide reasonably reliable distinctions between retired-worker and widow benefits for widowed women and permits the identification of retired-worker benefits for those women dually entitled to retired-worker and spouse benefits. In addition, the distinction between disabled- and retired-worker benefits for recipients aged 62-64 appears to be reasonably reliable, and for women under age 65, the classification procedure distinguishes between disabled-worker benefits on the one hand and widow and widowed mother benefits on the other. Finally, SIPP procedures for identifying minor child beneficiaries yield markedly better estimates than those available from the Current Population Survey. These improvements in the SIPP context are due entirely to the presence of information not collected in the CPS. The enhancement of the SIPP data set in turn resulted directly from an assessment of earlier work carried out by Projector and Bretz in the CPS context and on extensive research into the nature of Social Security reporting errors in the CPS. The superiority of the SIPP data set is linked principally to the presence of three pieces of information: the Medicare BIC, the direct question on reasons for benefit receipt asked of persons under age 65, and the direct measurement of recipiency and amount of benefits for minor children. Other items of some import include self-reported work disability, retirement status (ever retired from a job), previous marital status for currently married women, age first prevented from working due to a health condition, and Supplemental Security Income misreporting items.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed2003

An economic analysis of the Atorvastatin Comparative Cholesterol Efficacy and Safety Study (ACCESS).

INTRODUCTION: The objective of the Atorvastatin Comparative Cholesterol Efficacy and Safety Study (ACCESS) was to compare the efficacy and safety of the five 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors in a randomised, controlled, yet large-scale study. ACCESS also produced data that permitted comparative analysis of the cost to achieve National Cholesterol Education Panel (NCEP) II low density lipoprotein-cholesterol (LDL-C) targets. STUDY DESIGN: A 54-week, multicentre, open-label, randomised, parallel-arm, active-control study in men and women with or without documented coronary heart disease or peripheral vascular disease. Data included medication use, clinic visits, adverse events, LDL-C and other laboratory measures. Analyses of resource use and cost are reported from a third-party payer perspective. METHODS: Patients were randomly assigned to receive one of the following treatments: atorvastatin (10-80 mg/day); fluvastatin (20-40 mg/day, or 40 mg twice daily); lovastatin (20-40 mg/day, or 40 mg twice daily); pravastatin (10-40 mg/day); or simvastatin (10-40 mg/day). Patients were started at the lowest available dose and titrated to higher doses at 6-week intervals until they achieved the NCEP II LDL-C target or reached the highest available dose of medication. PATIENTS: A total of 153 centres enrolled 3887 patients: atorvastatin (n = 1944); fluvastatin (n = 493); lovastatin (n = 494); pravastatin (n = 478); and simvastatin (n = 478). Inclusion criteria included LDL-C >or= 30 mg/dL higher than NCEP II LDL-C target (stratified by risk factors), fasting triglyceride values < 400 mg/dL, and a confirmed negative serum pregnancy test. Known hypersensitivity to statins, use of prohibited medications, uncontrolled diabetes, acute liver disease and age > 80 years or < 18 years were among the exclusion criteria. RESULTS: Mean total treatment costs to reach LDL-C targets for patients receiving atorvastatin (US dollars 683.37 in 2001) were significantly less than mean total treatment costs for patients receiving fluvastatin (difference = US dollars 211.35, p < 0.01), lovastatin (US dollars 607.96, p < 0.01), pravastatin (US dollars 424.60, p < 0.01) and simvastatin (US dollars 95.74, p < 0.01). Results were robust to sensitivity analyses using alternative definitions of the patient population (randomised, intent-to-treat, completers) and cost measures (50th percentile charges, 95th percentile charges, Medicare prices). CONCLUSIONS: Compared with the other statins studied, atorvastatin was associated with the lowest resource use and costs when used to treat patients to their NCEP II LDL-C targets. Atorvastatin was also associated with the highest percentage of patients achieving their desired clinical outcomes. Therefore, in cost-effectiveness terms, it dominated the four other statins.

Adult↗
PubMed2003

Emergency department visits for ambulatory care sensitive conditions: insights into preventable hospitalizations.

OBJECTIVES: To explore whether differences in disease prevalence, disease severity, or emergency department (ED) admission thresholds explain why black persons, Medicaid, and uninsured patients have higher hospitalization rates for ambulatory care sensitive (ACS) conditions. MATERIALS AND METHODS: The National Hospital Ambulatory Care Survey was used to analyze the ED utilization, disease severity (assessed by triage category), hospitalization rates, and follow-up plans for adults with five chronic ACS conditions (asthma, chronic obstructive lung disease, congestive heart failure, diabetes mellitus, and hypertension). The National Health Interview Survey was used to estimate the prevalence of these conditions in similarly aged US adults. RESULTS: Black persons, Medicaid, and uninsured patients make up a disproportionate share of ED visits for these chronic ACS conditions. Cumulative prevalence of these conditions was higher in black persons (33%) compared with white persons (27%) and Hispanic persons (22%), but did not differ among the payment groups. All race or payment groups were assigned to similar triage categories and similar percentages of their ED visits resulted in hospitalization. Black persons and Hispanic persons (odds ratios for both = 0.7), were less likely than white persons, whereas Medicaid and uninsured patients (odds ratios for both = 0.8), were less likely than private patients to have follow-up with the physician who referred them to the ED. CONCLUSIONS: The disproportionate ED utilization for chronic ACS conditions by black persons and Medicaid patients does not appear to be explained by either differences in disease prevalence or disease severity. Follow-up arrangements for black persons, Medicaid, and uninsured patients suggest that they are less likely to have ongoing primary care. Barriers to primary care appear to contribute to the higher ED and hospital utilization rates seen in these groups.

Adolescent↗
PubMed2004

Integrating case management and palliative care.

Most seriously ill Americans live at home under the care of their primary physician and with the support of family caregivers. To reduce costs while simultaneously improving the quality of patient care, insurers have increasingly turned to the concept of case management. While case management is targeted to individuals with life-threatening illnesses, palliative care assessment and interventions are typically not included in the management protocols. An academic/care management/health plan partnership between Mount Sinai School of Medicine, Franklin Health, a care management organization, and South Carolina Blue Cross Blue Shield, was formed in 1998 to test the utility of integration of case management with formal palliative care assessment, feedback and recommendations to treating physicians, and ongoing support for implementation of a palliative care plan. The goal of the project was to ensure identification and optimal care of seriously ill patients' complex needs, while facilitating doctor-patient continuity, improving patient/family/physician communication, providing assistance with decision-making, ensuring quality care at home, and promoting efficient use of health care resources. Care management nurses were randomly assigned to a control (usual care) group or to the intervention (palliative care) group. Intervention nurses were trained in formal palliative care assessment and interventions, supported by treatment protocols and communication strategies with treating physicians. Measurements included symptom burden, prescribing practices, advance care planning status, satisfaction, and health care utilization. These results are pending completion of study run-out and analysis. Preliminary programmatic results indicate that combining palliative care with the case management approach is a logical, feasible, and effective strategy to improve the care of seriously ill patients living in the community. Franklin Health has offered the program to their entire client base because they feel that the integration of palliative care into their case management program improved the standard of patient care. Blue Cross Blue Shield of South Carolina has also chosen to sustain this enhanced model of care management for seriously ill patients.

Case Management↗
PubMed2003

Waiting for scheduled services in Canada: development of priority-setting scoring systems.

RATIONALE, AIMS AND OBJECTIVES: An Achilles' heel of Canadian Medicare is long waits for elective services. The Western Canada Waiting List (WCWL) project is a collaboration of 19 partner organizations committed to addressing this issue and influencing the way waiting lists are structured and managed. The focus of the WCWL project has been to develop and refine practical tools for prioritizing patients on scheduled waiting lists. METHODS: Scoring tools for priority setting were developed through extensive clinical input and highly iterative exchange by clinical panels constituted in five clinical areas: cataract surgery; general surgery procedures; hip and knee replacement; magnetic resonance imaging (MRI) scanning, and children's mental health. Several stages of empirical work were conducted to formulate and refine criteria and to assess and improve their reliability and validity. To assess the acceptability and usability of the priority-setting tools and to identify issues pertaining to implementation, key personnel in the seven regional health authorities (RHAs) participated in structured interviews. Public opinion focus groups were conducted in the seven western cities. RESULTS: Point-count scoring systems were constructed in each of the clinical areas. Participating clinicians confirmed that the tools offered face validity and that the scoring systems appeared practical for implementation and use in clinical settings. Reliability was strongest for the general surgery and hip and knee criteria, and weakest for the diagnostic MRI criteria. Public opinion focus groups endorsed wholeheartedly the application of point-count priority measures. Regional health authorities were generally supportive, though cautiously optimistic towards implementation. CONCLUSIONS: While the WCWL project has not 'solved' the problem of waiting lists and times, having a standardized, reliable means of assigning priority for services is an important step towards improved management in Canada and elsewhere.

Canada↗
PubMed2001

CPT coding by interventional radiologists: accuracy and implications.

PURPOSE: To evaluate the accuracy of Current Procedural Terminology (CPT) coding for interventional radiology services when coding is performed by the operating physician. MATERIALS AND METHODS: Coding data for 1,174 interventional radiology encounters in 736 patients were analyzed for appropriate use of CPT codes. Physician operators initially assigned provisional codes. Formal coding for billing purposes was performed at a later date by one of two experienced interventional radiology physician coders. Initial operator coding errors and associated relative value unit (RVU) impact were analyzed. The coding patterns of experienced physician coders were compared with those of the other interventionalists. RESULTS: Only 82% of encounters were initially coded correctly, with a small net tendency toward undercoding. The overall net RVU impact of errors was only -1.2%, with the effects of undercoding outweighing those of overcoding. More complex cases (> or =4 CPT codes) were much more likely to be coded erroneously than less complex cases (24% vs 14%, P <.001). Experienced physician coders committed significantly fewer errors than other physicians (10% vs 25%, P <.001), but there was a similar minimal net RVU impact of errors (-1.1% vs -1.4%, P =.198). CONCLUSION: Although initial physician coding errors for interventional radiology procedures are common, the net RVU impact is minimal. The accuracy of experienced physician coders is significantly higher than that for other interventionalists. Because of the regulatory consequences of coding inaccuracies, practices should establish quality improvement systems to minimize errors and use the skills of experienced individuals in their coding processes.

Forms and Records Control↗
PubMed2004

Use of newer antiretroviral treatments among HIV-infected medicaid beneficiaries with serious mental illness.

OBJECTIVES: The study compares rates of protease inhibitor (PI) use during the 3 years following the introduction of these newer treatments among human immunodeficiency virus (HIV)-infected individuals with and without serious mental illness and examines persistence of use of these therapies across these subgroups. METHOD: We used merged autoimmune deficiency syndrome (AIDS)/HIV surveillance and Medicaid claims data to examine use of PIs and non-nucleoside reverse transcriptase inhibitors (NNRTIs) among New Jersey Medicaid beneficiaries with AIDS between 1996 and 1998. Based on the ICD-9-CM diagnoses assigned by a high-credibility source in 1 inpatient or 2 outpatient claims, we identified patients with schizophrenia (ICD-9-CM code 295) and those with severe affective disorder (combining patients with recurrent major depressive disorder [ICD-9-CM code 296.3] or bipolar disorder [296.4, 296.5, 296.6, 296.7, or 296.8]). These groups were compared with those patients with no serious mental illness. RESULTS: In this sample, patients with schizophrenia (68.3%) and those with severe affective disorder (75.6%) were more likely to have initiated new antiretroviral therapy than were those without serious mental illness (64.3%). Patients with severe affective disorder, but not those with schizophrenia, were significantly less persistent (p <.01) in their use of PI/NNRTI therapy than those without serious mental illness. CONCLUSIONS: No evidence was found that the presence of a serious mental illness discourages physicians from initiating new antiretroviral therapy, perhaps reflecting a comparatively high level of integration of these patients into the health care system. Patients with schizophrenia are as persistent in their use of PI/NNRTI therapy as those without a serious mental illness. Lower rates of medication compliance by those with severe affective disorder justify increased efforts to support optimal adherence.

Acquired Immunodeficiency Syndrome↗
PubMed1992

Assigning appropriateness ratings for diagnostic upper gastrointestinal endoscopy using two different approaches.

Methods that combine information in the medical literature with expert clinical judgment are needed to determine the appropriateness of use of a procedure. The purpose of this study is to better understand the reliability and construct validity of this process by comparing ratings of appropriateness for diagnostic upper gastrointestinal endoscopy that were developed using different approaches by two independent groups. Both the RAND/UCLA Health Services Utilization Study (HSUS) and the American Society for Gastrointestinal Endoscopy (ASGE) combined scientific data with expert physician judgment to rate the appropriateness of specific clinical indications for the use of upper gastrointestinal endoscopy. This study applies the ratings developed by each group to a nationally representative sample of 1,585 endoscopies performed on people 65 years of age and older in 1981. HSUS developed indications that could be used to rate all 1,585 procedures; ASGE indications were less comprehensive and applied to 70% (n = 1,115) of procedures. Of those rated by both groups, appropriateness category ratings agreed for 94% of the procedures. However, the procedures not rated by ASGE were unevenly distributed across HSUS appropriateness ratings. Twelve percent of procedures rated as appropriate by HSUS were not rated by ASGE, but 80% of procedures rated as equivocal by HSUS and 73% rated as inappropriate by HSUS were not rated by ASGE, for those procedures rated by both approaches there was good agreement; however, a more explicit and comprehensive method may be required if equivocal and inappropriate use of a procedure is to be identified.

Aged↗
PubMed1995

A rational process for the reform of the physician payment system.

UNLABELLED: Analysis of the resource-based relative value scale (RBRVS) for physician payment indicates that in 1996, hourly reimbursement rates will be unrelated to the intensity of work and income will be unrelated to hours worked. A "consensus method" of payment is proposed as an alternative to the RBRVS. METHOD: As with the method of the RBRVS study, a pilot survey asked a specialty-representative cohort of physicians to assign dimensionless numbers to the relative value of work in 15 specialties using the Hsiao et al. definition of work intensity as "time modified by, a) mental effort, b) clinical judgment, c) technical skill, and d) physical effort under stress." The consensus method is similar to that of the Hsaio method, except there is no mathematical transformation of the raw data to establish specialty work values once the data are collected. A comparative analysis was then made of work hours, reimbursement rates, and annual income with 1) the customary prevailing and reasonable system (CPR, pre-1992), 2) the RBRVS system (1996), and 3) the proposed consensus system. RESULTS: The RBRVS intends that physicians be reimbursed on the basis of time and intensity of work. Neither the CPR nor the RBRVS systems accomplish this objective when the data and computational methods of the Physician Payment Review Commission are used with independently determined work intensity to compute hourly reimbursement rates in the specialties. The consensus method shows the desired direct linear correlation of income with both length of the physician's work week and intensity of effort. It rates the primary care specialties as a group more highly than the RBRVS. CONCLUSION: The proposed consensus method meets the original intent of the RBRVS to reimburse physicians on the basis of the resource input of time as modified by the criteria of Hsiao et al.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1998

Validation of relative value scale for congenital heart operations.

BACKGROUND: To determine the validity of the newly assigned work relative value unit (RVU) scale for surgical procedures for congenital heart disease, we measured its relationship to length of hospital stay, total hospital charges, and mortality. METHODS: We identified cases by the presence of ICD-9-CM codes in nine statewide, administrative hospital discharge abstract databases for 1992. Computer algorithms were generated to assign RVUs to individual cases. Spearman correlation coefficients between work and practice expense RVUs and median length of hospital stay, total hospital charges, and in-hospital mortality were determined, as well as parameter estimates from linear and logistic regression. RESULTS: Using data from 5,192 cases involving 34 surgical procedures for congenital heart disease, higher work RVUs were associated with longer lengths of hospital stay (rs = 0.72, p < 0.0001), higher total hospital charges (rs = 0.81, p < 0.0001), and higher in-hospital mortality (rs = 0.45, p = 0.01). A 5-point increase in the relative value scale was associated with an increase in the length of stay by a multiplicative factor of 1.3 (p < 0.0001); total hospital charges by 1.5 (p < 0.0001); and the odds of in-hospital death by 1.9 (p < 0.0001). Findings were similar for practice expense RVUs, as work and practice expense RVUs were highly correlated (rs = 0.93, p < 0.0001). CONCLUSIONS: The group of work RVUs for surgical procedures for congenital heart defects are reasonable relative measures, on average, of physician work for these procedures, thus supporting the use of this scale to determine physician reimbursement. Practice expense RVUs may not be an independent measure for these procedures.

Cardiac Surgical Procedures↗