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PubMed2006

Health policy considerations for our sexual minority patients.

Homosexuality and transsexuality are still widely viewed by lay individuals as morally negative and deserving of legal proscription. Peer-reviewed data confirm that experiences of legal discrimination are associated with stress-related health problems, reduced utilization of health care, and financial and legal challenges for individuals and families, especially those with children. In the last 3 years, the American Psychiatric Association, American Psychological Association, and American Psychoanalytic Association have each reviewed the research on sexual orientation and identity, and each has confirmed that sexual orientation and gender identity do not correlate with mental illness or immorality. They have each endorsed laws that confer equality to sexual minorities, including nondiscrimination in employment, medical insurance coverage, adoption, and access to civil marriage. The American College of Obstetricians and Gynecologists (ACOG), by virtue of its history of advocacy for women's health, is in a position to promote policy and make similar recommendations, recognizing that sexual minority women's health and their family issues are an integral component of taking care of all women. The College should review the policies of America's premier mental health associations and consider including sexual orientation and gender identity in its own nondiscrimination policy, and ACOG should issue a policy statement in support of laws to provide safety from violence and discrimination, equal employment opportunities, equal health insurance coverage, and equal access to civil marriage.

Evidence-Based Medicine↗
PubMed2003

Determinants for hospitalization in " low-risk" community acquired pneumonia.

BACKGROUND: A variable decision in managing community acquired pneumonia (CAP) is the initial site of care; in-patient versus outpatient. These variations persist despite comprehensive practice guidelines. Patients with a Pneumonia Severity Index (PSI) score lower than seventy have low risk for complications and outpatient antibiotic management is recommended in this group. These patients are generally below the age of fifty years, non-nursing home residents, HIV negative and have no major cardiac, hepatic, renal or malignant diseases. METHODS: A retrospective analysis of 296 low-risk CAP patients evaluated within a year one period at St. Agnes Hospital, Baltimore, Maryland was undertaken. All patients were assigned a PSI score. 208 (70%) were evaluated and discharged from the emergency department (E.D.) to complete outpatient antibiotic therapy, while 88 (30%) were hospitalized. Patients were sub-stratified into classes I-V according to PSI. A comparison of demographic, clinical, social and financial parameters was made between the E.D. discharged and hospitalized groups. RESULTS: Statistically significant differences in favor of the hospitalized group were noted for female gender (CI: 1.46-5.89, p= 0.0018), African Americans (CI: 0.31-0.73, p= 0.004), insurance coverage (CI: 0.19-0.63, p= 0.0034), temperature (CI: 0.04-0.09, p= 0.0001) and pulse rate (CI: 0.03-0.14, p= 0.0001). No statistically significant differences were observed between the two groups for altered mental status, hypotension, tachypnea, laboratory/radiological parameters and social indicators (p>0.05). The average length of stay for in-patients was 3.5 days at about eight time's higher cost than outpatient management. There was no difference in mortality or treatment failures between the two groups. The documentation rate and justifications for hospitalizing low risk CAP patients by admitting physicians was less than optimal. CONCLUSIONS: High fever, tachycardia, female gender, African- American race and medical insurance coverage are determinants for hospitalization among low risk CAP patients in our study. The average length of stay for in-patients was 3.5 days (3 to 5 days). The cost of in-patient care was about eight times higher than outpatient management. This study supports the recommendation of using the PSI for E.D evaluation of patients in appropriate social settings.

Adolescent↗
PubMedDate not supplied

Referral of patients to specialists: factors affecting choice of specialist by primary care physicians.

BACKGROUND: We wanted to determine the importance of factors in primary care physicians' choice of specialist when referring patients and to compare importance ratings by physicians' race and sex. METHODS: Using a cross-sectional study design, we surveyed a stratified national sample of 1,252 primary care physicians serving adults to include equal numbers of black women, white women, black men, and white men. We assessed the percentage of physicians rating each of 17 items to be of major importance in choosing a specialist and compared importance ratings by physicians' race and sex. RESULTS: The response rate was 59.1%. Medical skill, appointment timeliness, insurance coverage, previous experience with the specialist, quality of specialist communication, specialist efforts to return patient to primary physician for care, and the likelihood of good patient-specialist rapport were of major importance to most respondents. Compared with black physicians, white physicians were more likely to rate previous experience with the specialist (65% vs 55%, P = .05) and board certification (41% vs 29%, P < .05) to be of major importance. White physicians were somewhat less likely than black physicians (17% vs 26%, P = .06) to rate patient convenience to be of major importance. Compared with male physicians, female physicians were more likely to rate the patient's insurance status to be of major importance (60% vs 44%, P < .01). CONCLUSIONS: Primary care physicians serving adults consider several factors to be of major importance when choosing a specialist. The importance of patient convenience, previous experience with the specialist, specialist board certification, and insurance coverage accepted by specialist varied by physicians' race and sex. A better understanding of factors important to a diverse physician workforce may help to improve the referral process.

Adult↗
PubMed1993

The use of ambulatory health care services by American Indians with disabilities.

Although most American Indians and Alaska Natives have access to health care through the Indian Health Service (IHS), it is uncertain whether IHS is able to provide all necessary health services to those with disabilities. Although IHS eligibles can use health services other than those provided or sponsored by IHS, this may be precluded by high rates of poverty, low rates of other health insurance coverage, and the lack of private providers in many areas inhabited by this population. Using data from the 1987 Survey of American Indians and Alaska Natives--the only nationally representative health care survey of persons eligible for IHS--this study examines the use of ambulatory health care for IHS eligibles with disabilities. Comparisons with the total US population showed similar rates of ambulatory care use for most categories of disability, but a higher frequency of use for the total US population. Findings also show that IHS provides most of the health care for its eligible population, although non-IHS care is also used. After controlling for the effects of sociodemographic characteristics and health insurance coverage, variables indicating disabilities due to health problems were found to have statistically significant effects on the likelihood of using non-IHS care. Furthermore, persons with activity limitations had a higher than average likelihood of using most of their health care at non-IHS providers. These findings suggest that for some persons with disabilities, it is necessary to supplement IHS care with services from other providers.

Adolescent↗
PubMed1997

The Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191).

The purpose of this article is to provide a general overview and reference source for the Health Insurance Portability and Accountability Act, which was signed into law by President Clinton last August. The focus of the article is on Title I--Improved Availability and Portability of Health Insurance Coverage, and on Title III--Tax-Related Health Provisions. The author points out that due to the trend towards an incremental approach to health care legislation, this act must be viewed as one of a series of initiatives being taken by the federal government intended to impact the cost of the U.S. health care delivery system.

Career Mobility↗
PubMedDate not supplied

Race, ethnicity, and insurance as determinants of epidural use: analysis of a national sample survey.

Despite widespread availability of pain interventions in childbirth, for most women, childbirth is associated with labor pain that exceeds expectations. Although epidural is superior to other medical interventions, the choice to use epidural still remains a matter of patient and doctor preference. Whether racial or ethnic characteristics influence preference of physician use or interact with insurance coverage is still unknown. This study used a large national sample of women to measure significant determinants of epidural use in order to discuss disparities in pain management. The findings suggest the need for nurse leaders to foster health policies that are sensitive to diversity and economics.

Adult↗
PubMed1993

Thirty-month evaluation of a popular very-low-calorie diet program.

OBJECTIVE: To analyze weight maintenance, cost, and predictors of weight maintenance in a formula-based very-low-calorie diet program. DESIGN AND SETTING: Consecutive sample of patients evaluated at 30 months after program entry at a community hospital in Orange Park, Fla. PATIENTS: Consecutive sample of 306 patients who entered a very-low-calorie diet program. Of these, 255 met inclusion criteria. INTERVENTION: Patients entered a 26-week very-low-calorie diet program. At 30 months after program entry, questionnaires were mailed. Data were collected via telephone interview, as needed. MAIN OUTCOME MEASURES: Initial and maintained weight loss, and association of weight loss to the following factors: insurance coverage, continued exercising, weeks attended, exit weight in relation to ideal weight, and cost per kilogram of weight loss. RESULTS: Medically significant weight loss of 10% was initially achieved by 90% of patients and maintained by 33%. The average initial weight loss was 21.4 kg and the maintained weight loss was 6.5 kg for all patients. For those who remained in the program 19 weeks (61%), the initial weight loss was 25.6 kg and the maintained weight loss was 9.2 kg. Exercisers maintained more than twice as much weight loss as nonexercisers. Men lost a larger percentage of weight (22% vs 19%) and maintained more of that loss (29.5% vs 8.3%). Maintenance was not associated with insurance coverage and at how close patients came to achieving ideal weight. The cost was $396 per kilogram of weight loss maintained. An improved sense of well-being was expressed by 71% of patients. CONCLUSIONS: Very-low-calorie diet programs can be effective in maintaining a medically significant weight loss in some patients at 30 months after program entry. Longer attendance and regular exercise help weight maintenance. The high costs and rate of weight regain indicate the need to find a more affordable and effective strategy for weight loss and maintenance.

Adult↗
PubMed2000

Physicians' attitudes about prescribing and knowledge of the costs of common medications.

BACKGROUND: Compliance with medical therapy is often compromised because patients cannot afford to pay for medications. Inadequate physician knowledge of drug costs may unwittingly contribute to this problem. OBJECTIVE: To measure attitudes about prescribing and knowledge of medication costs and compare differences among attending physicians and residents. DESIGN/PARTICIPANTS: Written survey of internal medicine house staff and general medicine attending physicians in an urban hospital-based primary care center. RESULTS: One hundred thirty-four of 189 physicians responded (71% response rate). Seventy percent of respondents were house officers and 30% were attending physicians. Eighty-eight percent of physicians felt the cost of medicines was an important consideration in the prescribing decision, and 71% were willing to sacrifice some degree of efficacy to make drugs more affordable for their patients. However, 80% often felt unaware of the actual costs. Only 33% had easy access to drug cost data, and only 13% had been formally educated about drug costs. Regarding insurance coverage, 94% of physicians gave strong consideration to the cost of medications when patients were self-paying, 68% when patients had Medicare, and 30% when patients had Medicaid or were participants in a health maintenance organization with a prescription plan. Physicians' estimates of the cost of a month's supply of 33 commonly used medications were accurate in 45% of cases, too low for 40%, and too high for 15%. The costs of brand-name and expensive drugs were most likely to be underestimated. House officers were less cost-conscious than attending physicians. CONCLUSIONS: Physicians were predisposed to being cost-conscious in their prescribing habits, but lacked accurate knowledge about actual costs and insurance coverage of drugs. Interventions are needed to educate physicians about drug costs and provide them with reliable, easily accessible cost information in real-world practice.

Adult↗
PubMed1998

Are health-based payments a feasible tool for addressing risk segmentation?

As they attempt to increase health insurance coverage and improve the efficiency of the market, researchers, policymakers, and health plan representatives have been addressing the issue of risk segmentation. Many risk assessment tools and risk-adjusted payment methodologies have been developed and demonstrated for a variety of populations and payers experiencing various market constraints. The evidence shows that risk-adjusted payments are feasible for most populations receiving acute care, while technical obstacles, political issues, and some research gaps remain.

Health Care Sector↗
PubMedDate not supplied

Reimbursement and patient assistance programs for oral chemotherapy agents.

Oncology nurses increasingly are being asked about medication insurance coverage for oral chemotherapy agents and other medications. In small clinic and office settings, nurses often are key providers of this information. Nurses need to be informed about Medicare's medication reimbursement guidelines and able to identify resources for patients. Resources may include pharmaceutical manufacturers, patient medication assistance programs, and medication discount programs. This article reviews these resources and provides tips to use them optimally in busy oncology practices.

Administration, Oral↗
PubMed2004

Adolescents in mid-sized and rural communities: foregone care, perceived barriers, and risk factors.

PURPOSE: To investigate the perceived health care needs, foregone care, barriers to care, and associated risk factors in a non-urban population of adolescents. METHODS: Tenth-grade students attending school and 15-17-year-old youth not attending school in a Midwestern county were surveyed or interviewed. Eighty-six percent provided usable data (n = 1948, 134 of whom were not in school). Nine focus groups (71 participants; 28 were not in school) were conducted in follow-up. Quantitative analysis included descriptive statistics, factor analysis, and logistic regression. Qualitative analysis of taped focus groups identified themes and interpreted findings. RESULTS: Although 91% had seen a physician in the past 2 years, 44% reported foregoing needed care in the last year. Barriers for specific health needs were: cost of care and lack of insurance coverage for injuries and illnesses; lack of knowledge, distrust, and stigma for depression; embarrassment and transportation for birth control and sexually transmitted infections (STIs); and not knowing where or how to access care for drug and alcohol use. Youth most likely to have foregone care included those involved with dangerous activities under peer pressure (1.8, CI: 1.44-2.13), sexual intercourse (1.4, CI: 1.25-1.67), marijuana use (1.4, CI: 1.17-1.67), anticipating parenthood before age 20 years (1.2, CI: 1.04-1.33), male gender (2.5, CI: 1.89-2.86) and perceiving good health (1.7, CI: 1.45-1.85). CONCLUSIONS: Nearly half of this non-urban population (both in and out of school) reported foregoing needed care in the last year. The barriers to care include lack of information, lack of access, poor insurance coverage, parenting issues, and concern about confidentiality.

Adolescent↗
PubMed2000

The trends in health care delivery for women: challenges for medical education.

The author discusses four key trends in the U.S. health care delivery system that affect how women's health care is delivered: the restructuring of primary care, particularly in the context of managed care organizations; initiatives in quality assessment; changes in patterns of health insurance coverage; and threats to the health care safety net. She concludes that medical educators need to link training to these changes in the health care delivery system to prepare physicians to work effectively for women's health in the changing system and to help bring about appropriate, needed transformations of the institutions in which women's health care is provided. Specific recommendations for medical educators are given after the discussion of each trend.

Delivery of Health Care↗
PubMed2003

Summary health statistics for U.S. children: National Health Interview Survey, 2001.

OBJECTIVES: This report presents statistics from the 2001 National Health Interview Survey (NHIS) on selected health measures for children under 18 years of age, classified by sex, age, race, Hispanic origin, family structure, parent's education, family income, poverty status, health insurance coverage, residence, region, and health status. The topics covered are asthma, allergies, learning disability, Attention Deficit Hyperactivity Disorder (ADHD), prescription medication, respondent-assessed health status, school-loss days, usual place of health care, time since last contact with a health care professional, unmet dental need, time since last dental contact, and selected measures of health care access. SOURCE OF DATA: The NHIS is a multistage probability sample survey conducted annually by interviewers of the U.S. Census Bureau for the Centers for Disease Control and Prevention, National Center for Health Statistics, and is representative of the civilian noninstitutionalized population of the United States. Data are collected during face-to-face interviews with adults present at the interview. Information about children is collected for one randomly selected child per family in face-to-face interviews with an adult proxy respondent familiar with the child's health. SELECTED HIGHLIGHTS: In 2001, most U.S. children under 18 years of age enjoyed excellent or very good health (84%). However, 10% had no health insurance coverage, and 5% had no usual place of health care. Thirteen percent of children had ever been diagnosed with asthma. Eight percent of children 3-17 years of age had a learning disability, and 6% of children had ADHD. Lastly, 11% of children in single-mother families had two or more visits to an emergency room in the past year compared with 6% of children in two-parent families.

Adolescent↗
PubMed2005

Health planning that magnifies the community's voice: allies against asthma.

Allies Against Asthma, a working group of the Consortium for Infant and Child Health (CINCH), conducted a comprehensive asthma needs assessment in Hampton Roads, Virginia, in 2001. Results from extant data and parent surveys indicated that asthma prevalence was high (15% to 18%), 45% to 50% of children received primary care for asthma in the emergency department, 30% had been recently hospitalized, and most children were not adequately medicated. Focus groups revealed inadequate asthma education, low income, lack of resources and consistent care, disparities in insurance coverage, and noncompliance with national asthma guidelines. An integrated community asthma action plan was developed and funded. Members were satisfied with the planning process--88% felt the plan reflected the needs assessment, and 86% agreed the plan would effectively improve asthma management. Interventions commenced in January 2002. The inclusive process that led to these interventions will ensure that the project is successful and sustainable.

Adult↗
PubMed2006

Explaining racial and ethnic disparities in health care.

OBJECTIVES: The substantial racial and ethnic disparities in access to and use of health services are well documented. A number of studies highlight factors such as health insurance coverage and socioeconomic differences that explain some of the differences between groups, but much remains unexplained. We build on this previous research by incorporating additional factors such as attitudes about health care and neighborhood characteristics, as well as separately analyzing different Hispanic subgroups. METHODS: We use the Oaxaca-Blinder regression-based method to decompose differences among racial and ethnic groups in 3 measures related to access, quantifying the portion explained by each of a number of underlying characteristics and the differences that remain unexplained. We use data from the 2000 and 2001 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the noninstitutionalized U.S. population. We link these data to detailed neighborhood characteristics from the Census Bureau and local provider supply data from the Health Services Resource Administration (HRSA). RESULTS: Consistent with earlier studies, we find insurance status and socioeconomic differences explain a significant part of the disparities. Additionally, neighborhood racial and ethnic composition account for a large portion of disparities in access, and language differences help explain observed disparities in the use-based access measure. However, much of the differences between racial and ethnic groups remain unexplained. We also found substantial variation in the level of disparities among different groups of Hispanics. CONCLUSIONS: Researchers and policymakers may need to broaden the scope of factors they consider as barriers to access if the goal of eliminating disparities in health care is to be achieved.

Adult↗
PubMed2002

Barriers to screening for colorectal cancer.

Rapidly growing interest in colon cancer screening is a crucial first step to identifying and reducing many of the barriers that impede population screening for this common disease. Promoting screening demands health care policy change to increase the percentage of Americans with insurance coverage that includes a colon cancer screening benefit. A systematic approach to screening with invitations that come from a clinician are likely to be the most effective way to prompt more individuals to be screened. Awareness campaigns and patient educational aids, including decision tools, implemented in multiple sites, such as worksites, community centers, health care systems, and physician offices, increase the percent of eligible Americans who understand their personal risk, the need for screening, and the options available to them.

Barium Sulfate↗
PubMedDate not supplied

Doughnut-hole economics.

Both the recently enacted Medicare prescription drug benefit and a new cohort of consumer-directed health benefit models offer doughnut-shaped insurance coverage with large deductibles that begin around the mean annual spending for enrollees. These policies leave enrollees to bear more risk than policies with equal expected payouts that rely on first-dollar deductibles. This risk to enrollees is substantial, given the skewed distribution of health care spending and the placement of the typical deductible. I consider alternative explanations for this new benefit design trend and conclude that the desire to distribute tangible benefits to the largest number of constituents is most plausible.

Deductibles and Coinsurance↗
PubMed2003

Summary health statistics for U.S. adults: National Health Interview Survey, 1999.

OBJECTIVES: This report presents health statistics from the 1999 National Health Interview Survey (NHIS) for the civilian, noninstitutionalized adult population, classified by sex, age, race and Hispanic origin, poverty status, and region of residence for chronic condition prevalence, health status and limitations in activity, health care access and utilization, health behaviors, and attitudes toward Acquired Immune Deficiency Syndrome (AIDS). Also, health statistics by education, income, health insurance coverage, marital status, and place of residence are presented for health status and limitations in activity, health care access and utilization, health behaviors, and knowledge and attitudes toward AIDS. SOURCE OF DATA: The NHIS is a multistage probability sample survey conducted annually by interviewers of the U.S. Census Bureau for the National Center for Health Statistics, Centers for Disease Control and Prevention, and is representative of the civilian noninstitutionalized U.S. population. Data are collected during face-to-face interviews with adults present at the time of the interview. The self-reported health information for adults in this report was obtained from one randomly-selected adult per family. HIGHLIGHTS: In 1999, 65% of adults 18 years of age or over reported excellent or very good health. However, 17% of adults less than 65 years of age had no health insurance coverage, and 16% of adults did not have a usual place of medical care. Eleven percent of adults had ever been told by a doctor or health professional that they had heart disease and 19% had been told on two or more visits that they had hypertension. Nearly a quarter of adults were current smokers, while 23% were former smokers. Sixty-one percent did not engage in any leisure-time vigorous physical activity, and, based on estimates of body mass index, 35% were overweight and 21% were obese.

Adolescent↗