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PubMed2006

Ankylosing spondylitis: a dual perspective of current issues and challenges.

This series of articles on ankylosing spondylitis (AS) provides insight into the burden of disease and focuses on early diagnosis and effective management. AS leads to progressive functional impairment over time and has tremendous impact on society at large in terms of economic costs and indirect costs associated with physical impairment and loss of employment. Early diagnosis is crucial now that we have more effective therapy with tumor necrosis factor (TNF) antagonists, which suppress disease activity and improve the functional ability of patients whose disease is refractory to conventional drug therapy. Early identification of variables that help predict severe disease with bad functional prognosis is needed. If biological therapy with TNF inhibitors is proven to retard disease progression and prevent or delay functional limitations, insight into such prognosticators will help us offer the correct treatment to the correct patient at the correct time. There is also a need to demonstrate longterm benefits of such a therapy as well as a favorable cost/benefit ratio to help convince healthcare authorities, insurance companies, and others of the utility of these drugs for treating patients with AS refractory to conventional drug therapy.

Humans↗

PubMedDate not supplied

Clinical evaluation: outcomes, benchmarking, introspection, and quality improvement.

Transforming the current event-driven reimbursement system into a quality powered marketplace will require clinical evaluation of how care is delivered. The managed care marketplace is evolving in three stages, from an event-driven, cost-avoidance model, to which the concepts of "value" and "quality" are added, with the final addition of a more "public health" focus. Clinical evaluation is a scientific process of outcomes assessment, clinical guidelines, and benchmarking. This process was applied to a hospital-based outpatient wound clinic, leading to a determination that the overall clinic Kaplan-Meier median time to healing could be improved. Two groups of patients were studied, 141 retrospectively from 1993 to 1994 and 57 prospectively in 1995. While there was no significant difference in the percentage healed between the groups, a significant difference in the median times to healing was revealed, which was linked to antibiotic use. Even when antibiotics were used prophylactically, the median times for healing were elevated from those without infections. Introspection led to fewer patients receiving preventive antibiotics. The overall lower median time to healing curve in 1995 can be explained by this change in clinical practice. This quality improvement demonstrates the utility of the clinical evaluation process as the healthcare marketplace evolves.

Benchmarking↗

PubMed2003

Determinants of the use of maternal health services in rural Bangladesh.

Utilization of health services is a complex behavioral phenomenon. Empirical studies of preventive and curative services have often found that use of health services is related to the availability, quality and cost of services, as well as to social structure, health beliefs and personal characteristics of the users. In this paper an attempt is made to examine the factors associated with the use of maternal health care services in Bangladesh on the basis of data from a survey of maternal morbidity in Bangladesh, conducted by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERHT). The results from both the bivariate and multivariate analyses confirmed the importance of mother's education in explaining the utilization of health care services. Female education retains a net effect on maternal health service use, independent of other women's background characteristics, household's socioeconomic status and access to healthcare services. The strong influence of mother's education on the utilization of health care services is consistent with findings from other studies. Women whose husbands are involved in business/services also positively influenced the utilization of modern health care services. However, the study results are inconclusive with respect to the influence of other predisposing and enabling factors, such as women's age, number of previous pregnancies and access to health facilities. Multivariate logistic regression estimates do not show any significant impact of these factors on the use of maternal health care. The influence of severity of disease condition in explaining the utilization of maternal health care appears to be significant. Multivariate analysis indicate that women having had a life-threatening condition are little over two times more likely to seek care from a doctor or nurse to treat their maternal morbidities.

Adolescent↗

PubMed2004

Institutionalizing interdisciplinary health professions programs in higher education: the implications of one story and two laws.

The interdisciplinary education of health professionals in the USA has increasingly been tied to renewed efforts directed toward quality improvement in the healthcare system, where problems with communication, collaboration, and cooperation are seen as endemic. Many of the published reports and recommendations on interdisciplinary programming, however, have omitted or downplayed the difficulties and challenges of developing and sustaining efforts in this area. Through the presentation of a detailed case study and the exploration of two laws of interdisciplinary programming proposed from it, this paper explores the fundamental difficulties of developing and, more importantly, sustaining interdisciplinary health professions programs in higher educational settings. The utilization of strategies based on emerging forces in the healthcare system and in higher education itself is suggested for initiating interdisciplinary projects, and structural and procedural factors are explored as critical in guaranteeing the long-term sustainability of such programs. Recommendations for the successful development and implementation of interdisciplinary programs in higher educational contexts are suggested, focusing particularly on the role of an advocate in the top down and bottom up development and maintenance of the resources needed for the success of such programs.

Curriculum↗

PubMedDate not supplied

Combining utilization management and discharge planning.

Utilization management and discharge planning are two essential functions for all healthcare facilities. In many hospitals, these two jobs are performed by personnel from two separate departments. This article describes the methodology and benefits of a project that combined the functions of utilization management and discharge planning.

Education, Continuing↗

PubMed2007

Quality of life and relative importance: a comparison of time trade-off and conjoint analysis methods in patients with age-related macular degeneration.

AIM: To investigate the relative priorities in quality of life (QoL) in patients with age-related macular degeneration (AMD). METHODS: Measures of visual function, QoL and utility associated with visual loss were obtained from 122 patients with AMD classified according to macular morphology. The two methods of utility assessment were time trade-off (TTO) and conjoint analysis (CA), which have been recommended by the UK's National Institute of Clinical Excellence as techniques for the assessment of healthcare priorities. RESULTS: Results show that the two methods for assessing utility are poorly related: TTO relates moderately to visual function and disease severity but CA does not. CA identified two different subgroups of patients: one with outdoor mobility and the other with reading as their main priority. CONCLUSION: Further work is needed and caution required in interpreting data obtained using these methodologies for determining their relative importance in vision-related QoL studies.

Activities of Daily Living↗

PubMed1998

The role of clinical practice guidelines in disease management.

UNLABELLED: This activity is designed for medical directors, pharmacy directors, quality assurance managers, and all members of disease management or quality improvement teams. GOAL: To review the guideline literature and help healthcare organizations plan guideline development and implementation strategies. OBJECTIVES: 1. Clarify the terminology used in practice policy development. 2. Explain how guideline implementation is related to disease management. 3. Discuss interventions utilized to enhance guideline adoption. 4. Provide a stepwise plan for healthcare organizations to follow.

Algorithms↗

PubMed2006

Co-occurrence and comorbidities in patients with immune-mediated inflammatory disorders: an exploration using US healthcare claims data, 2001-2002.

OBJECTIVE: Research in immune-mediated inflammatory disorders (IMIDs) suggests that several diseases share disruptions in key cytokines. A common pathogenesis may present as similar patterns of disease co-occurrence and comorbidity, which could be observed through the analysis of healthcare claims datasets. METHODS: Adult patients continuously enrolled from 2001-2002 were identified in two US healthcare datasets containing medical and drug claims from health plans and self-insured employers. Patients with treatment records indicating an IMID were selected (e.g., rheumatoid arthritis, psoriasis, Crohn's disease); controls for each disorder were matched 3:1 based on age, gender, region, and previous insurance coverage. IMID cohorts and comorbidities were identified using International Classification of Diseases, 9th revision codes. Prevalence relative risk was used to assess co-occurrence and comorbidity rates in IMID cohorts and controls. Medical and drug utilization patterns were also explored. RESULTS: Findings were similar across the two datasets. IMID patients represented about 4% of the population; specific IMID prevalence matched the epidemiology literature. Patients with at least one IMID had a higher risk for another IMID when compared to controls. The risk for infectious, renal, liver, and ulcerative comorbidities was also elevated. Selected drug utilization patterns confirmed comorbidity findings. IMID patients used more healthcare resources compared to controls; findings were robust under sensitivity analyses. CONCLUSIONS: IMID patients were generally more likely than controls to have another IMID, supporting the concept that the diseases are related. These patients also had higher comorbidity rates. Findings may be limited by the nature of claims datasets and the confounding effect of current treatments. Prospective studies are needed to determine whether IMIDs have a common pathogenesis.

Adult↗

PubMed2004

Assessment of possible impact of a health promotion program in Korea from health risk trends in a longitudinally observed cohort.

BACKGROUND: Longitudinally observed cohort data can be utilized to assess the potential for health promotion and healthcare planning by comparing the estimated risk factor trends of non-intervened with that of intervened. The paper seeks (1) to estimate a natural transition (patterns of movement between states) of health risk state from a Korean cohort data using a Markov model, (2) to derive an effective and necessary health promotion strategy for the population, and (3) to project a possible impact of an intervention program on health status. METHODS: The observed transition of health risk states in a Korean employee cohort was utilized to estimate the natural flow of aggregated health risk states from eight health risk measures using Markov chain models. In addition, a reinforced transition was simulated, given that a health promotion program was implemented for the cohort, to project a possible impact on improvement of health status. An intervened risk transition was obtained based on age, gender, and baseline risk state, adjusted to match with the Korean cohort, from a simulated random sample of a US employee population, where a health intervention was in place. RESULTS: The estimated natural flow (non-intervened), following Markov chain order 2, showed a decrease in low risk state by 3.1 percentage points in the Korean population while the simulated reinforced transition (intervened) projected an increase in low risk state by 7.5 percentage points. Estimated transitions of risk states demonstrated the necessity of not only the risk reduction but also low risk maintenance. CONCLUSIONS: The frame work of Markov chain efficiently estimated the trend, and captured the tendency in the natural flow. Given only a minimally intense health promotion program, potential risk reduction and low risk maintenance was projected.

Journal Article↗

PubMed2006

Case study: factors in defining the nurse informatics specialist role.

Healthcare organizations, consultant groups, vendor companies, and academic institutions feel the challenge to enhance user experiences with information systems. To meet this challenge, organizations and companies are looking to better understand and utilize a variety of informatics roles to further marketing, business, or healthcare goals. Nursing is one practice area that can support the successful integration of information systems development, implementation, support, and user experience. However, the definition and development of such a role or position has met with mixed success. This article explores some of the issues and influences related to the role's development. The issues, impacts, and influences have been identified based on healthcare business assessment, job description analysis, employment and project evaluations, and professional standards set by the American Nurses Association.

Humans↗

PubMed2001

Perceptions of primary healthcare services among persons with physical disabilities - part 2: quality issues.

BACKGROUND: The ability of persons with disabilities to access quality primary care in Canada is not well documented. This article reports on the perceived quality of primary care received by persons with disabilities by looking at utilization of elements of the health maintenance examination, referrals, health promotion, healthcare provider role clarification, and satisfaction. METHODS: A sample of convenience was undertaken whereby an anonymous self-report questionnaire, which included the Short Form-36 Health Survey, was mailed to members of several Canadian disability organizations and persons discharged within the last 2 years from a rehabilitation hospital. The Statistical Package for the Social Sciences was used to analyze the data. RESULTS: A total of 201 individuals (20% response rate) completed and returned the surveys, 61.2% of whom were women. Some elements of the health maintenance examination, including Pap tests, mammogram referral, and measurement of blood pressure (BP), were not markedly different from population census data. Inquiry around health promotion was low, as 61.7% of our sample did not receive a functional assessment, 58.2% were not asked about emotions, and only 10% were asked about physical or sexual violence. Diet, exercise, smoking, pain, sleep, alcohol, sex, sexually transmitted diseases (STDs), and reproductive choices were discussed in varying degrees. INTERPRETATION: Among respondents in our survey, disabled women were able to access important screening tests. Health promotion services, however, were often not offered. The particular healthcare needs of disabled women and men -- eg, having a condition that may be progressive, being at increased risk of secondary disability and the added effects of aging -- may be addressed more effectively by including health promotion. It is proposed that functional assessment, emotional inquiry, and role clarification could improve the delivery of health promotion and the perceived quality of care received.

Adolescent↗

PubMed1995

Utilization of a clinical pathway in the care of the ambulatory cataract surgical patient.

Rapid changes are occurring in healthcare today. Both customers and consumers of healthcare are demanding a change in the way business is being conducted. According to Smith (1993), healthcare organizations are being prompted to explore and implement systems which will enhance quality care as well as promote cost effective resource utilization. A notable change in recent years is the shift of ophthalmic surgical patients from inpatient to an ambulatory setting. This paper will focus on the implementation of a case management model for ophthalmic patients utilizing clinical pathways on an ambulatory unit. Emphasis will be on the provision of quality care resulting in positive patient outcomes.

Ambulatory Surgical Procedures↗

PubMed2004

Prolonged enoxaparin therapy to prevent venous thromboembolism after primary hip or knee replacement. A cost-utility analysis.

BACKGROUND: Among patients undergoing elective total hip or knee replacement, prolonged prophylaxis with low-molecular-weight heparin significantly reduces the risk of symptomatic venous thromboembolism. Whether implementing routine prolonged prophylaxis is cost-effective remains uncertain. METHODS: We performed an economic modeling study to compare the costs and health outcomes of standard (12 days) with prolonged (42 days) enoxaparin prophylaxis against venous thromboembolism after elective total hip and knee replacement. The primary economic perspective was that of a societal healthcare payer, taking Belgium as a case country. We used cost-utility analysis, a form of cost effectiveness analysis in which costs are reported in monetary terms (euros) and health outcomes are converted into quality-adjusted life years (QALYs) gained, thereby incorporating a measure of quality of life (utility) into the health outcomes. Costs for diagnosis and treatment of proximal and distal deep vein thrombosis, pulmonary embolism, postphlebitic syndrome, and major bleeding were obtained from a Delphi panel (orthopaedic surgeons) and the official reimbursement rates (Federal Ministry of Health). QALYs for these health outcomes were based on utility scores as reported in the literature. The main outcome measure was the incremental cost-utility ratio, reported as the incremental cost per quality-adjusted life year gained (euros/QALY). The incremental cost-utility ratio refers to the amount of money needed to produce one additional QALY. We also performed sensitivity analyses on clinical and economic parameters to identify important model uncertainties. RESULTS: In the base-case analysis, incremental costs of prolonged prophylaxis amounted to 58 euros and 114 euros per patient, with an additional gain in QALY of 0.0083 and 0.0018 after total hip and knee replacement, respectively. Thus, a strategy of prolonged enoxaparin prophylaxis was associated with a cost-utility ratio of 6,964 euros/QALY and 64,907 euros/QALY after total hip and knee replacement, respectively. This tenfold difference in incremental cost-utility ratios between hip and knee replacement might have important practical implications. According to recent European guidelines, an intervention costing less than 20,000 euros per QALY is said to exhibit strong evidence for adoption, whereas one costing 20,000-100,000 euros exhibits moderate evidence for adoption. By current European guidelines, the cost of 6,964 euros and 64,907 euros per QALY gained would give strong evidence for adoption of prolonged enoxaparin prophylaxis among total hip replacement patients, but moderate evidence for adoption among total knee replacement patients. Sensitivity analyses using 20% changes from the base-case analysis showed this outcome to be robust. CONCLUSIONS: Our findings indicate that, among patients undergoing elective total hip or knee replacement, prolonged enoxaparin prophylaxis leads to increased health benefits at increased cost. Given the additional costs that healthcare decision makers in Europe are usually prepared to pay for a gain in utility, prolonged prophylaxis with enoxaparin is cost-effective after elective total hip replacement, and our data provide strong evidence for adoption of prolonged enoxaparin prophylaxis after elective total hip replacement.

Anticoagulants↗

PubMed2000

Measuring costs in cost-utility analyses. Variations in the literature.

OBJECTIVES: Although cost-utility analysis (CUA) has been recommended by some experts as the preferred technique for economic evaluation, there is controversy regarding what costs should be included and how they should be measured. The purpose of this study was to: a) identify the cost components that have been included in published CUAs; b) catalogue the sources of valuation used; c) examine the methods employed for estimating costs; and d) explore whether methods have changed over time. METHODS: We conducted a comprehensive search of the published literature and systematically collected data on the cost estimation of CUAs. We audited the cost estimates in 228 CUAs. RESULTS: In most studies (99%), analysts included some direct healthcare costs. However, the inclusion of direct non-healthcare and time costs (17%) was generally lacking, as was productivity costs (8%). Only 6% of studies considered future costs in added life-years. In general, we found little evidence of change in methods over time. The most frequently used source for valuation of healthcare services was published estimates (73%). Few studies obtained utilization data from RCTs (10%) or relied on other primary data (23%). About two-thirds of studies conducted sensitivity analyses on cost estimates. CONCLUSIONS: We found wide variations in the estimation of costs in published CUAs. The study underscores the need for more uniformity and transparency in the field, and continued vigilance over cost estimates in CUAs on the part of analysts, reviewers, and journal editors.

Cost-Benefit Analysis↗

PubMed2004

Resource utilization in postmenopausal osteoporosis without incident fractures.

OBJECTIVE: To evaluate the annual utilization and cost incurred by postmenopausal women with osteoporosis in a public tertiary healthcare facility. METHODS: One hundred consecutive patients with postmenopausal osteoporosis were selected from the Universidade Federal de São Paulo (UNIFESP), Brazil. The socioeconomic and clinical characteristics, quality of life, and resource utilization and costs in the last year were assessed using 3 questionnaires. Each resource used had its unitary cost based on the Public Healthcare System Table of Fees (1998). RESULTS: The mean age was 66 years and the monthly family income was 456 US dollars (1998). There was a mean of 7 visits/patient/year. Seventy-seven percent of the patients used calcium and 38% used estrogens. There were no incident fractures during the study. The mean total annual cost for osteoporosis treatment, considering the societal perspective, was 775 US dollars (1998) per patient/year. CONCLUSION: The costs of all treatment drugs related and not related to osteoporosis represented 9% of the monthly household income. Among some drugs used, many are lacking evidence of effectiveness, such as shark cartilage. The costs related to transportation were significant, representing 21% of the total directly spent by the patients. Further studies are necessary to rationally drive treatment, based on the best cost-effectiveness strategies of osteoporosis management.

Adult↗

PubMed1995

Administrative issues for use of nurse practitioners.

As nurse administrators increasingly use nurse practitioners in healthcare delivery systems to provide high-quality, more cost-effective care, they must recognize and take action on key practice issues--autonomy, title protection, admitting privileges, physician back-up, and reimbursement. Careful attention and action directed to enhancing nurse practitioner usefulness will increase the flexibility of nurse practitioner utilization within specific institutions and across a diverse network of healthcare delivery sites structured to provide continuity of care.

Delivery of Health Care↗

PubMedDate not supplied

Community-based VHA clinics: effect on patient satisfaction and resource utilization.

This study was conducted to determine whether enrollment in a Veterans Healthcare Administration (VHA) Access Point (AP) community-based clinic would reduce hospital admissions and unplanned urgent care visits while maintaining patient satisfaction with medical care. Through use of a survey and a review of medical records, data were gathered on the following three patient groups: veterans receiving care at a VHA hospital-based clinic, veterans receiving care at an AP, and veterans receiving care from non-VHA sources. Results showed that the number of unplanned hospital admissions and urgent care visits decreased in the two groups receiving care at VHA facilities.

Adult↗

PubMed2001

Utilization of public and private dental services in Sibu, Sarawak: a sociodemographic appraisal and types of treatment received.

This study investigated the sociodemographic profiles of patients attending public and private dental clinics and the types of treatment received. Patients (n=454) were interviewed using a structured questionnaire at two public and four private clinics in Sibu District, Sarawak. Generally, Chinese (74.7%), females (60.0%) and urban dwellers (83.7%) were more likely to visit the dentist. Both clinics had more females and more Chinese but private clinics had a lower percentage of female attendees (53.1% versus 67.0%) but a higher percentage of Chinese (85.0% versus 64.5%). Private attendees were younger (mean age of 31.0 years compared to 41.0 years) and from higher income households (median value of MR 2,000 versus MR 900) than public attendees. Treatments were mostly curative and a third of the visits were associated with painful conditions. Age (p=0.006), gender (p=0.003), ethnicity (p<0.001) and household income (p<0.001) were associated with the type of clinic visited. Choice of clinic was not related to having painful conditions (p=0.970). To ensure a more affordable and equitable distribution of oral healthcare, health planners need to identify disparities in the utilization of services and differences between public and private attendees.

Adolescent↗