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PubMedDate not supplied

Low back pain in older adults: are we utilizing healthcare resources wisely?

OBJECTIVES: 1) To examine recent change in prevalence and Medicare-associated charges for non-invasive/minimally invasive evaluation and treatment of nonspecific low back pain (LBP); and 2) to examine magnetic resonance imaging (MRI) utilization appropriateness in older adults with chronic low back pain (CLBP). DESIGN: Two cross-sectional surveys of 1) national (1991-2002) and Pennsylvania (2000-2002) Medicare data; and 2) patients aged >or= 65 years with CLBP. SETTING: Outpatient data. PARTICIPANTS: Patients aged >or= 65 years with LBP. MEASUREMENTS: Study 1: Outpatient national and Pennsylvania Part A Medicare data were examined for number of patients and charges for all patients, and for those with nonspecific LBP. Total number of visits and charges for imaging studies, physical therapy (PT), and spinal injections was also examined for Pennsylvania. Study 2: 111 older adults with CLBP were interviewed regarding presence of red flags necessitating imaging and history of having a lumbar MRI, neurogenic claudication (NC), and back surgery. RESULTS: Study 1: Between 1991 and 2002, there was a 42.5% increase in total Medicare patients, 131.7% increase in LBP patients, 310% increase in total charges, and 387.2% increase in LBP charges. In Pennsylvania (2000-2002), there was a 5.5% increase in LBP patients and 33.2% increase in charges (0.2% for PT, 59.4% for injections, 41.9% for MRI/CT, and 19.3% for X rays). Study 2: None of the 111 participants had red flags and 61% had undergone MRIs (29% with NC, 24% with failed back surgery syndrome). CONCLUSION: LBP documentation and diagnostic studies are increasing in Medicare beneficiaries, and evidence suggests that MRIs may often be ordered unnecessarily. Injection procedures appear to account for a significant proportion of LBP-associated costs. More studies are needed to examine the appropriateness with which imaging procedures and non-invasive/minimally invasive treatments are utilized, and their effect on patient outcomes.

Age Distribution↗
PubMed2002

Blood pressure destabilization and related healthcare utilization among hypertensive patients using nonspecific NSAIDs and COX-2-specific inhibitors.

OBJECTIVE: To determine the incremental cost of blood pressure (BP) destabilization among patients with stable hypertension who newly initiate therapy with celecoxib, rofecoxib, or 3 commonly used nonspecific nonsteroidal anti-inflammatory drugs (NSAIDs), ibuprofen, diclofenac, or naproxen, based on incidence rates of BP destabilization and costs of BP destabilization events obtained from a single observational data source. METHODS: Historical cohort observational analysis was performed based on real-life practice data that are contained in the LifeLink Integrated Claims Solutions employer claims databases. Patients with stable hypertension who had newly initiated therapy with rofecoxib, celecoxib, ibuprofen, diclofenac, or naproxen between January 1, 1999, and September 30, 2000, were identified from the database. The study consists of 3 components. First, the incidence rate of BP destabilization, based on patients' time of exposure to studied drugs, was estimated. Then, the cost of a BP destabilization event was determined by matching all BP destabilization cases with non-BP destabilization cases and following them for 90 days. The differences in the total costs between cases and controls were considered an estimate of the costs associated with managing the BP destabilization event. Last, the drug-specific incremental costs of BP destabilization of using each treatment were estimated in comparison with celecoxib. Incremental costs of BP destabilization were determined by multiplying the specific excess incidence rate of BP destabilization for each of the specific drugs, relative to celecoxib, by the cost of a BP destabilization event. RESULTS: The adjusted incidence rate of outpatient BP destabilization for celecoxib was 2.27 per 1000 patient-days vs 2.66 for rofecoxib (P < .001) or 2.65 for nonspecific NSAIDs (P < .001). The incremental cost of BP destabilization per patient per day of drug utilization for the study drugs compared with celecoxib were $0.18 for rofecoxib and $0.17 for nonspecific NSAIDs. The higher costs of BP destabilization relative to celecoxib were due to the higher incidence of outpatient BP destabilization associated with the other study drugs. The average incremental healthcare cost for an outpatient BP destabilization event within the first 90 days of the event was $459. The incidence of inpatient BP destabilization among rofecoxib users was significantly higher than among celecoxib users (risk rate = 4.17; 95% Cl, 1.86-9.26; P< .001). Incremental cost was not estimated for inpatient BP destabilization because the sample size was too small to provide a stable result. CONCLUSION: The costs of managing BP destabilization were significantly lower for celecoxib compared with rofecoxib and nonspecific NSAIDs. The observed differences among these anti-inflammatory drugs in the costs of BP destabilization will have a significant impact on the total cost of therapy in patients with stable hypertension. In addition to the monetary cost of BP destabilization, the physical cost to the patient regarding development or exacerbation of this serious medical condition should be considered when choosing cyclooxygenase-2-specific inhibitor and nonspecific NSAID therapies.

Aged↗
PubMed2006

Predictors of healthcare utilization among older Mexican Americans.

OBJECTIVE: To examine the effects of predisposing, enabling, and need factors on physician and hospital use among older Mexican Americans. DESIGN: A two-year prospective cohort study. SETTING: Five Southwestern states: Texas, New Mexico, Colorado, Arizona, and California. PARTICIPANTS: A population-based sample of 1987 non-institutionalized Mexican American men and women age > or =65 years. MAIN OUTCOMES MEASURES: Physician and hospital utilization. Predictor variables included predisposing, enabling, and need factors. Ordinary least square and logistic regression analysis were used to model the effects of predictor factors specified in the Andersen model of health service use on physician and hospital use. RESULTS: After two years of follow-up, predisposing and enabling factors accounted for <5% of the variance in physician and hospital use. Need factors explained 21% of the variance in physician use and 7% of the variance in hospital use. Older age; being female; insurance coverage; having arthritis, diabetes, heart attack, hypertension, stroke, or cancer; and number of medications were factors associated with higher physician utilization. Subjects with arthritis, diabetes, hip fracture, high depressive symptoms, activities of daily living (ADL) disability, or high number of medications increased the odds of having any hospitalization. Subjects with diabetes, heart attack, hip fracture, ADL disabled, and high number of medications had a greater number of hospital nights than their counterparts. CONCLUSIONS: Older age, female sex, insurance coverage, and prevalent medical conditions are determinants of healthcare use among older Mexican Americans.

Aged↗
PubMedDate not supplied

Effect of group therapy for breast cancer on healthcare utilization.

PURPOSE: The purpose of this study was to determine whether participation in a group psychosocial intervention by patients with breast cancer would result in an improvement in psychological measures and in reduced billings in general medical expenses. DESCRIPTION OF STUDY: Eligible women who had completed treatment for stage 0, I, or II primary breast cancer were prospectively and randomly assigned to either the intervention (n=46) or control (n=43) group. Both groups received the usual psychosocial care; however, the intervention group also participated in six weekly cognitive/behavioral psychosocial meetings. All were assessed on psychiatric symptoms, mood, depression, and coping strategies at four time periods: pre-intervention, post-intervention, 1-year follow-up, and 2-year follow-up. Alberta Healthcare billing records were obtained covering the 2-year follow-up period to determine the amount billed per person over the course of the study. RESULTS: Women in the intervention group had less depression, less overall mood disturbance, better overall quality of life, and fewer psychiatric symptoms than those in the control group, beginning immediately post-intervention and remaining so at 2 years post-intervention. Billing in the intervention group was an average of $147 less than in the control group, a 23.5% reduction. CLINICAL IMPLICATIONS: This is the first study to show that a psychosocial intervention can reduce direct healthcare billings in a sample of patients with cancer. Importantly, these findings help to justify the routine availability of such programs in cancer treatment facilities worldwide.

Alberta↗
PubMed2006

Factors associated with healthcare utilization costs for statin therapy--a pilot study in Hong Kong.

BACKGROUND: Socio-economic status, comorbidities and adherence to statin therapy might affect the cost-effectiveness of statin therapy in hyperlipidemia. OBJECTIVE: To examine the effects size of demographic factors, clinical factors and adherence to statin therapy on the direct medical costs for Chinese patients at high risk of coronary heart disease (CHD). METHODS: This was a prospective, observational cohort study conducted in the outpatient departments of a public teaching hospital in Hong Kong. Patients at high risk of CHD who had been on statin monotherapy for < 12 months were recruited. Baseline demographic and clinical data were obtained. Statin adherence was monitored prospectively over 6 months using the Medication Event Monitoring System. Total direct medical costs per member per month (cPMPM), including cost for clinic visits, statin medication, laboratory tests on lipids and management of CHD events if any, were calculated from the perspective of a public healthcare organization. RESULTS: 83 patients completed the study. Median cPMPM in 80 patients (96% of 83 patients) without a new CHD event (USD 42) and for 3 (4%) patients who experienced CHD events (USD 444) were significantly different (p = 0.003). History of congestive heart failure (beta = 1,957, 95% CI = 1,006 - 2,909), male gender (beta = 584, 95% CI = 215 - 952), coronary atherosclerosis (beta = 1,436, 95% CI = 538 - 2,334) and diabetes mellitus (beta = 604, 95% CI = 136 - 1,07 1) were positive predictors for cPMPM. CONCLUSION: In this pilot study male gender, diabetes mellitus, congestive heart failure and coronary atherosclerosis appear to be significantly associated with higher costs for Chinese patients at high risk of CHD.

Cohort Studies↗
PubMed2006

Healthcare utilization and outcomes after bariatric surgery.

OBJECTIVE: Bariatric surgery is one of the fastest growing hospital procedures. Our objective is to examine the safety outcomes and utilization of resources in the 6 months after bariatric surgery using a nationwide, population-based sample. DATA/DESIGN: We examine insurance claims for 2522 bariatric surgeries, at 308 hospitals, among a population of 5.6 million nonelderly people covered by large employers in the 2001-2002 MarketScan data. Outcomes and costs were risk-adjusted using multivariate regression methods. PRINCIPAL FINDINGS: Although the complication rate was 21.9% during the initial surgical stay, the rate increased by 81% (P < 0.01) to 39.6% (95% confidence interval, 37.7-41.5%) over the 180 days after discharge. A total of 10.8% of the patients without 30-day complications developed a complication between 30 days and 180 days. Overall, 18.2% of the patients had some type of postoperative visit to the hospital with a complication (through readmission, outpatient hospital visit, or emergency room visit) within 180 days. Although there was no difference between men and women, the near-elderly had a 26% (P < 0.01) higher risk-adjusted complication rate than those age 18 to 39 years. Total 6-month risk-adjusted healthcare payments were $65,031 for those with 180-day readmissions compared with $27,125 for those without readmissions (P < 0.01). CONCLUSION: In contrast to current bariatric studies, which report a 20% in-hospital complication rate, we find a significantly higher complication rate over the 6 months after surgery, resulting in costly readmissions and emergency room visits. Thus, a clear way to reduce the costs and improve outcomes of bariatric surgery is to address the high rate of postoperative complications.

Adolescent↗
PubMed2002

Evaluation of healthcare utilization and health status of patients with Parkinson's disease treated with deep brain stimulation of the subthalamic nucleus.

OBJECTIVE: To assess the effects on motor functioning, health status and direct medical costs of high-frequency stimulation of the subthalamic nucleus (DBS-STN) in patients with idiopathic Parkinson's disease (PD). In addition, the cost-effectiveness of DBS-STN vs. drug treatment was investigated. METHODS: 16 consecutive patients with PD from two centers (Düsseldorf/Cologne; Kiel) treated by DBS-STN were prospectively evaluated. Clinical evaluations were done at baseline and 1, 3, 6, 12 months following surgery by means of the Unified Parkinson's disease Rating Scale (UPDRS). Health status of PD patients was assessed using the Sickness Impact Profile (SIP) at baseline and 6 months following surgery. Relevant economic data were taken from the medical records and costs (1999) were derived from different German medical economic resources. Costs were determined from the perspective of the health care provider. RESULTS: Following DBS-STN UPDRS scores (subscores and sum score) as well as health status improved considerably in PD patients. The overall SIP score and the physical dimension score (p < 0.009) were significantly different (p < 0.01) six month after surgery compared with baseline values. Mean costs of DM 40,020 (US dollars 20,810, EURO 20,410, GB pounds 12,810) per patient were spent during the 12 month observation period for in-patient and out-patient care. These expenses included already the costs for the electronic device for bilateral stimulation. Following DBS-STN medication was considerably reduced. Mean daily drug costs at baseline were DM 46.7+/-21.8 (US dollars 24, EURO 24, GB pounds 15) and DM 18.3+/-17.7 (US dollars 10, EURO 9, GB pounds 6) at 12 months following DBS-STN. Accounting for the decreased drug consumption, total annual costs amounted to DM 31,400 (US dollars 16,330, EURO 16,010, GB pounds 10,050). Further, we estimated the incremental cost effectiveness as DBS-STN had higher costs but was more effective than baseline treatment. The incremental total cost-effectiveness ratio for DBS-STN was DM 1.800 (US dollars 940, EURO 920, GB pounds 580) for one point decrease of the UPDRS. CONCLUSION: DBS-STN is an effective treatment that considerably alleviates the severity of signs and symptoms and improves the health status of patients with PD. Compared with drug treatment, however, the expenditures associated with DBS-STN are increased when only direct medical costs are considered in a one year horizon. However, on a long-term basis costs will decrease considerably because of the reduction of the drug expenditure and improved functioning in all activities of daily living. To adequately evaluate the cost-effectiveness of DBS-STN compared with standard drug regimen for PD it is necessary to include direct, indirect and intangible costs on a long-term basis and under standardized circumstances.

Aged↗
PubMed2001

Healthcare utilization and costs in managed care patients with Alzheimer's disease during the last few years of life.

OBJECTIVES: To learn whether managed care patients with Alzheimer's disease (AD) are more or less costly to care for than patients with other forms of dementia or patients without dementia during the last few years of life. DESIGN: Case control study. SETTING: A health maintenance organization base population. PARTICIPANTS: Three groups of subjects (mean age 85) who were deceased members of a dementia registry obtained from a health maintenance organization base population: 263 subjects with clinically diagnosed probable AD, 133 subjects with other forms of dementia, and 100 cognitively intact controls. MEASUREMENTS: Utilization records were examined for the 3 years preceding death. RESULTS: In all subcategories and in aggregate, utilization and costs of care were either similar or lower for patients with AD than for the other groups, even after controlling for age, gender, and comorbidity. CONCLUSIONS: Persons with AD do not incur higher costs than persons with other types of dementia or age-matched persons without dementia in a mature health maintenance organization during the last few years of life, when utilization is likely to be highest.

Aged↗
PubMed2000

Prior healthcare utilization as a predictor of survival for medical intensive care unit patients.

OBJECTIVE: To determine whether measures of inpatient care utilization from the year preceding admission to a medical intensive care unit (MICU) improve physiology-based predictions of hospital and 1-yr survival. DESIGN: Inception cohort study with a validation cohort. SETTING: The MICU in university-affiliated Department of Veterans Affairs Medical Center. PATIENTS: A total of 1,200 consecutive patients admitted to the MICU. MEASUREMENTS AND MAIN RESULTS: Increased use of inpatient health care before MICU admission was associated with increased mortality. However, inpatient utilization data failed to improve physiology-based logistic models for hospital and 1-yr survival (p > .15 for improvement in the area under the receiver operating characteristic curve for both end points in the validation cohort), whereas physiologic data improved models derived from measures of inpatient care (p < .001 for both end points). Empirically derived inpatient care models used only information from the few days preceding MICU admission, despite the availability of a full year of data. CONCLUSIONS: Chronic illness, as gauged by a need for frequent inpatient care in the year before MICU admission, is not independently predictive of poor short- or long-term survival. Clinicians should not attempt to predict survival of prospective MICU patients by the extent of previous inpatient care.

APACHE↗
PubMed2006

Descriptive epidemiology and prior healthcare utilization of patients in the Spine Patient Outcomes Research Trial's (SPORT) three observational cohorts: disc herniation, spinal stenosis, and degenerative spondylolisthesis.

STUDY DESIGN: Prospective observational cohorts. OBJECTIVE: To describe sociodemographic and clinical features, and nonoperative (medical) resource utilization before enrollment, in patients who are candidates for surgical intervention for intervertebral disc herniation (IDH), spinal stenosis (SpS), and degenerative spondylolisthesis (DS) according to SPORT criteria. SUMMARY OF BACKGROUND DATA: Intervertebral disc herniation, spinal stenosis, and degenerative spondylolisthesis with stenosis are the three most common diagnoses of low back and leg symptoms for which surgery is performed. There is a paucity of descriptive literature examining large patient cohorts for the relationships among baseline characteristics and medical resource utilization with these three diagnoses. METHODS: The Spine Patient Outcomes Research Trial (SPORT) conducts three randomized and three observational cohort studies of surgical and nonsurgical treatments for patients with IDH, SpS, and DS. Baseline data include demographic information, prior treatments received, and functional status measured by SF-36 and the Oswestry Disability Index (ODI-AAOS/Modems version). The data presented represent all 1,411 patients (743 IDH, 365 SpS, 303 DS) enrolled in the SPORT observational cohorts. Multiple logistic regression was used to generate independent predictors of utilization adjusted for sociodemographic variables, diagnosis, and duration of symptoms. RESULTS: The average age was 41 years for the IDH group, 64 years for the SpS group, and 66 years for the DS group. At enrollment, IDH patients presented with the most pain as reported on the SF-36 (BP 26.3 vs. 33.2 SpS and 33.8 DS) and were the most impaired (ODI 51 vs. 42.3 SpS and 41.5 DS). IDH patients used more chiropractic treatment (42% vs. 33% SpS and 26% DS), had more Emergency Department (ED) visits (21% vs. 7% SpS and 4% DS), and used more opiate analgesics (49% vs. 29% SpS and 27% DS). After adjusting for age, gender, diagnosis, education, race, duration of symptoms, and compensation, Medicaid patients used significantly more opiate analgesics (58% Medicaid vs. 41% no insurance, 42% employer, 33% Medicare, and 32% private) and had more ED visits compared with other insurance types (31% Medicaid vs. 22% no insurance, 16% employer, 3% Medicare, and 11% private). CONCLUSION: IDH patients appear to have differences in sociodemographics, resource utilization, and functional impairment when compared with the SpS/DS patients. In addition, the differences in resource utilization for Medicaid patients may reflect differences in access to care. The data provided from these observational cohorts will serve as an important comparison to the SPORT randomized cohorts in the future.

Adult↗
PubMed2003

Somatic healthcare utilization among adults with serious mental illness who are receiving community psychiatric services.

BACKGROUND/OBJECTIVE: Somatic health care utilization was studied among individuals with serious mental illness who were receiving community-based psychiatric services. RESEARCH DESIGN: Cross-sectional study. SUBJECTS: A total of 200 outpatients, 100 with schizophrenia and 100 with affective disorder, were recruited from randomly selected samples receiving care at two psychiatric centers. MEASURES: Patients were interviewed using questions from national health surveys. Multiple logistic regression analyses were used to compare responses from each sample to those of matched subsets of individuals from the general population. RESULTS: The psychiatric samples were more likely to report receiving some medical care services in the past year than were individuals in the general population including having visited a general medical doctor (Odds ratio, schizophrenia sample = 2.04; Odds ratio, affective disorder sample = 2.37) and having a complete physical examination (Odds ratio, schizophrenia sample = 2.69; Odds ratio, affective disorder sample = 1.74). However, our samples were less likely to receive routine dental care (Odds ratio, schizophrenia sample = 0.46; Odds ratio, affective disorder sample = 0.60). Perceived barriers to receiving medical care were reported significantly more often by the patient groups than the comparison groups (Odds ratios > 3). CONCLUSIONS: General health services are widely utilized by individuals with serious mental illness who are in outpatient psychiatric care. Dental services remain underutilized, however, and there is a high rate of perceived barriers to receiving medical care in this population.

Adolescent↗
PubMed2006

Associations between alcohol use and homelessness with healthcare utilization among human immunodeficiency virus-infected veterans.

BACKGROUND: Alcohol use is a frequent root cause of homelessness, and both homelessness and alcohol use influence the quality and quantity of interactions with health care providers. OBJECTIVE: The objectives of this study are to compare rates of homelessness and alcohol use in a cohort of human immunodeficiency virus (HIV)-infected persons and to evaluate the influence of homelessness and alcohol use on utilization of health services. RESEARCH DESIGN AND MEASURES: Data were obtained from the Veterans Aging Cohort 3-Site Study, a cohort study of 881 HIV-infected veterans at 3 VA hospitals. In a baseline survey, we assessed current and past history of homelessness and levels of alcohol consumption. Health care service utilization (ambulatory visits, emergency room visits, and hospital admissions) for the preceding 6 months was determined by self-report and VA administrative records. Logistic regression was used to assess whether homelessness and drinking variables were associated with health care visits in the past 6 months. RESULTS: Among HIV-infected veterans with complete data (n = 839), 62 (7%) were currently homeless, and 212 (25.3%) had a past, but not current, history of homelessness. Among the currently homeless, 36% reported alcohol consumption, 34% were hazardous drinkers, 46% were binge drinkers, and 26% had a diagnosis of alcohol abuse. When adjusting for age, severity of HIV disease, and use of illicit drugs, hazardous drinking (adjusted odds ratio [AOR] 0.68, 95% confidence interval [CI] 0.49-0.93) and current homelessness (AOR 0.56, 95% CI 0.32-0.97) were associated with less than 2 outpatient clinic visits. HIV-infected veterans who were homeless in the past were more likely to be hospitalized in the prior 6 months than those never homeless (AOR 1.51, 95% CI 1.07-2.11). CONCLUSIONS: Although homeless HIV-infected veterans tend to use inpatient services more than nonhomeless HIV infected veterans, they were less likely to achieve optimum outpatient care. Alcohol use complicates the effect of homelessness on adherence to outpatient care and is associated with increased inpatient utilization among HIV-infected veterans.

Adult↗
PubMed2005

Predicting mortality and healthcare utilization with a single question.

OBJECTIVE: We compared single- and multi-item measures of general self-rated health (GSRH) to predict mortality and clinical events a large population of veteran patients. DATA SOURCE/STUDY SETTING: We analyzed prospective cohort data collected from 21,732 patients as part of the Veterans Affairs Ambulatory Care Quality Improvement Project (ACQUIP), a randomized controlled trial investigating quality-of-care interventions. STUDY DESIGN: We created an age-adjusted, logistic regression model for each predictor and outcome combination, and estimated the odds of events by response category of the GSRH question and compared the discriminative ability of the predictors by developing receiver operator characteristic curves and comparing the associated area under the curve (AUC)/c-statistic for the single- and multi-item measures. DATA COLLECTION/EXTRACTION METHODS: All patients were sent a baseline assessment that included a multi-item measure of general health, the 36-item Medical Outcomes Study Short Form (SF-36), and an inventory of comorbid conditions. We compared the predictive and discriminative ability of the GSRH to the SF-36 physical component score (PCS), the mental component score (MCS), and the Seattle index of comorbidity (SIC). The GSRH is an item included in the SF-36, with the wording: "In general, would you say your health is: Excellent, Very Good, Good, Fair, Poor?" PRINCIPAL FINDINGS: The GSRH, PCS, and SIC had comparable AUC for predicting mortality (AUC 0.74, 0.73, and 0.73, respectively); hospitalization (AUC 0.63, 0.64, and 0.60, respectively); and high outpatient use (AUC 0.61, 0.61, and 0.60, respectively). The MCS had statistically poorer discriminatory performance for mortality and hospitalization than any other other predictors (p<.001). CONCLUSIONS: The GSRH response categories can be used to stratify patients with varying risks for adverse outcomes. Patients reporting "poor" health are at significantly greater odds of dying or requiring health care resources compared with their peers. The GSRH, collectable at the point of care, is comparable with longer instruments.

Ambulatory Care↗
PubMed1995

Feasibility and accuracy of a postcard diary system for tracking healthcare utilization of community-dwelling older persons.

OBJECTIVE: To test the feasibility of and to validate a self-report weekly postcard diary of health care utilization. DESIGN: Case-series and validation study. SETTING: Community-based sample of fee-for-service and health maintenance organization (HMO) patients. PARTICIPANTS: A convenience sample of 24 community-dwelling older persons who had failed a self-administered screen and were eligible for a study of outpatient comprehensive geriatric assessment consultation. MEASUREMENTS: Subjects completed and mailed in a weekly postcard diary documenting medical, counseling, or rehabilitation therapy visits. If a subject did not respond within 10 days after the end of the week, a telephone call was placed to gather the information. For a subset of 10 subjects who were HMO enrollees, all records were reviewed to determine accuracy of the postcard diaries. RESULTS: Of the 24 subjects enrolled, one HMO enrollee dropped out following hip surgery after 4 weeks of completing diaries. The remaining 23 subjects (96% of total entered) provided complete information for 12 weeks. Telephone follow-up to either obtain or clarify utilization information was required for 22% of subjects. For the subset of 10 HMO subjects, seven underreporting, two overreporting, and one incorrect day errors were detected-a total of 10 errors representing 9% of diaries and 1.3% of patient-days. Kappa as a measure of agreement between the two methods (self-report and chart review) was 0.82 (P < .0001). Compared with chart review, the diary report was 75.0% sensitive and 99.8% specific. Positive and negative predictive values were 91.3% and 99.2%, respectively. CONCLUSION: These findings suggest that a postcard diary system with telephone follow-up is both a feasible and reasonably accurate method of tracking health care utilization by community-dwelling older persons, although a small percentage will be unable to adhere to this method.

Aged↗