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PubMed1995

Access to ambulatory care for American Indians and Alaska Natives; the relative importance of personal and community resources.

The debate on health care reform in the United States has been greatly influenced by various national studies showing a strong relationship between lack of public or private health care coverage and inadequate access to health services. There is also much concern about deficiencies in the availability and delivery of services to certain population groups--especially for those living in the most remote and sparsely populated areas of the country. However, national studies have generally not demonstrated that the use of health services is strongly associated with urban/rural residence or the supply of medical providers. In this study, we show that national studies can obscure the problems of certain population groups including American Indians and Alaska Natives. Using data from the 1987 National Medical Expenditure Survey, the findings show that the availability of medical providers as well as place of residence were strongly associated with the use of health care by American Indians and Alaska Natives. Although American Indians and Alaska Natives included in this study were eligible to receive health care free of charge from the Indian Health Service (IHS), financial factors were also significantly associated with use due to the use of services other than those provided or sponsored by IHS. Also, the results show that while geographic and supply factors have only modest effects on the average travel time to medical providers for the U.S. population as a whole, travel times are dramatically longer for American Indians and Alaska Natives living in rural areas and where there are few medical providers. In addition, there appear to be fewer hospitalizations in areas where there are IHS outpatient services. We conclude by discussing the need for health care reform to take into account the diversity of a large country such as the U.S., and the special needs of population groups that are usually not adequately represented in national studies.

Adult↗
PubMed2004

Capacity in Thai public hospitals and the production of care for poor and nonpoor patients.

OBJECTIVE: To assess the capacity of Thai public hospitals to proportionately expand services to both the poor and the nonpoor. This is accomplished by measuring the production of services provided to poor, relative to nonpoor, patients and the plant capacity of individual public hospitals to care for the patient load. STUDY SETTING: Thai public hospitals operating in 1999, following the economic crisis when public hospitals were required to treat all patients irrespective of ability to pay. STUDY DESIGN AND DATA COLLECTION: Input and output data for 68 hospitals were collected using databases and questionnaire surveys. A distinction was made between inpatient and outpatient services to both poor and nonpoor patients and the data were assessed statistically. DATA ANALYSIS: Congestion and capacity indices to measure poor/nonpoor service trade-offs and capacity utilization were estimated. The analysis was undertaken by data envelopment analysis (DEA), a nonparametric linear programming approach used to derive efficiency and productivity estimates. Principal Findings. Increases in the amount of services provided to poor patients did not reduce the amount of services to nonpoor patients. Overall, hospitals are producing services relatively close to their capacity given fixed inputs. Possible increases in capacity utilization amounted to 5 percent of capacity. CONCLUSIONS: Results suggest that some increased public hospital care can be accomplished by reallocation of resources to less highly utilized hospitals, given the budgetary constraints. However, further expansion and increase in access to health services will require plant investments. The study illustrates how DEA methodologies can be used in planning health services in data constrained settings.

Data Collection↗
PubMedDate not supplied

[Ambulatory anorectal surgery under local anesthesia: analysis of 351 procedures].

Three hundred and twenty-eight patients with anorectal diseases were submitted ambulatory surgery, under local anesthesia, in a three-year period. Three hundred and fifty one operations were performed in outpatient service. Local anesthesia by Hook-Needle Puncture technique was used in 37 operations and the rest of them by classical technique through infiltration of both lateral anal quadrants. Hemorrhoids, fistulas, fissures and pilonidal cysts were the most frequent diseases treated (71.6%). The incidence of early and late complications was 19.6% and 4.8%, respectively. The most common complication was severe pain (16.1%). Five patients (1.5%) required hospitalization due postoperative complications. The surgery on an outpatient basis was a well-accepted procedure for two hundred eighty-eight patients (88%). The main benefit reported by patients was the possibility of recovery at home, which is more comfortable. The ambulatory anorectal surgery under local anesthesia is a safe and effective method, with the additional advantage of the costs saved and increase of available beds for more complex surgery.

Adolescent↗
PubMed2000

Alcohol exposure and health services utilization in older veterans.

The objective of this study was to determine if increased alcohol exposure is associated with greater use of health services among older veterans. A total of 129 older veterans (> or =65 years old), receiving longitudinal care in a Veterans' Administration primary care clinic, were followed retrospectively for up to 42 months. Subjects were screened at baseline for problem drinking with the CAGE or the quantity-frequency questions from the Alcohol Use Disorders Identification Test (QF-AUDIT), and stratified by exposure into three categories: abstainers, social drinkers, and problem drinkers. Outcomes included total outpatient clinic visits, laboratory tests, radiologic and other technologic procedures, as well as acute care hospitalizations. For all subjects (N = 129), no association was found between alcohol exposure and use of any outpatient services. Among CAGE-screened (n = 62) abstainers, social drinkers, and problem drinkers, significant differences were found in the median number of laboratory tests (7.3 vs. 3.4 vs. 7.1, P = 0.004) and hospitalizations (0.3 vs. 0.0 vs. 0.3, P = 0.001) per patient year of follow-up. No exposure-outcome associations were present, however, among QF-AUDIT-screened subjects (n = 67). We were unable to demonstrate a consistent relationship between alcohol exposure and health services utilization. The effects of alcohol on older veterans' use of health services varied with the method used to measure alcohol exposure. Additional studies are needed to determine whether multiple, or possibly new, measures can more precisely define the health effects of alcohol in older populations.

Aged↗
PubMed1989

Sex differences in child psychiatric outpatients: cognitive, personality, and behavioral characteristics.

This paper describes sex differences in a clinically referred sample on direct measures of child competence and ratings of psychopathology. The sample comprised 117 6-12 year-old boys and 63 girls referred to a psychiatric outpatient service. The results indicated that although boys and girls did not differ in overall problems or on externalizing problems, girls had significantly more internalizing problems and were more impaired as measured by both individual and composite measures of competence.

Child↗
PubMed1986

The cost implications of academic group practice. A randomized controlled trial.

We evaluated the reorganization of a general medical clinic into several group practices, using equivalent groups of patients and physicians in a randomized controlled trial. The group practice, unlike the traditional clinic, provided decentralized registration, clinic coverage five days a week, and telephone coverage at night and on weekends. Residents worked in small groups with an attending physician, nurse practitioner, and receptionist. All financial activity involving a sample of 2299 patients was followed during the 11-month intervention. The total hospital charges per patient were 26 percent lower for the patients seen in the group practice than for those seen in the traditional clinic (P = 0.003). This difference was primarily attributable to inpatient charges, which were 27 percent lower per patient hospitalized (P = 0.004). The mean length of stay was 8.3 days among group-practice patients and 10.5 days among traditional-clinic patients (P = 0.011). We conclude that organizational changes to improve outpatient access and to integrate inpatient and outpatient services can decrease medical charges.

Academic Medical Centers↗
PubMed2005

A family support organiser for stroke patients and their carers: a randomised controlled trial.

BACKGROUND: Previous trials of interventions to support stroke survivors and their families in the community have had contradictory and inconclusive results. Using the MRC Framework for Complex Interventions we developed a family support organiser (FSO) service and refined outcome measures for evaluation. We tested the effects of the intervention in a randomised controlled trial. METHODS: From 1 March 1999 to 1 April 2001 all first-in-a-lifetime strokes (n = 513) were identified and 340 (96%) of eligible strokes randomised to receive FSO or usual care. Patients and their carers were followed up at 3 months and 1 year post-stroke. Outcomes included satisfaction (main outcome) with hospital staff and outpatient services, use of social services, reintegration to normal living (RNLI) and feelings about life after the stroke. RESULTS: The mean number of contacts with the FSO was 15 (SD = 9.8) per patient. More intervention than control patients received some social services and had increased patient and carer satisfaction in most aspects, particularly with information about recovery and feeling that someone had listened. There was little evidence at 3 or 12 months of differences in RNLI. CONCLUSIONS: A meta-analysis of trials in this area is now needed along with further trials of interventions in subgroups of the stroke population to fully identify any benefits of the FSO role.

Aged↗
PubMed1996

Panic disorder: relationship to high medical utilization, unexplained physical symptoms, and medical costs.

Epidemiologic surveys and retrospective studies in the primary care setting have demonstrated that panic disorder is a primary cause of morbidity and increased utilization of medical services. Half of all visits to a primary care provider are precipitated by the somatic symptoms that are often associated with this anxiety disorder, including chest pain, dyspnea, tachycardia, dizziness, and abdominal discomfort. Since many of these symptoms resemble those of clinical diseases, patients frequently undergo extensive and costly diagnostic procedures to rule out conditions such as coronary artery disease, inflammatory bowel disorder, and asthma. Persistent, unexplained medical symptoms not only place an undue financial burden on outpatient services and hospitals, but also have a negative impact on social and vocational function. The primary care physician is in a unique position to recognize patients who may be at risk for panic disorder and to initiate appropriate treatment, preventing prolonged functional impairment and unnecessary cost to the patient and the health care system.

Adult↗
PubMed1988

High users of outpatient mental health services, II: Implications for practice and policy.

Four assumptions underlie the stereotyped view of use of outpatient mental health services: 1) all use is alike, 2) any use leads to high use, 3) all high use is discretionary, and 4) insurance encourages excessive use. The authors refute the first three assumptions and suggest that different types of treatment episodes vary in their responsiveness to price. Diagnosis appears to be a poor indicator of inpatient needs; some coverage limits outpatient benefits according to type of treatment. The authors favor a combination of pricing strategies, as well as case management and clinical review for high users, which would not impede initial treatment but would limit excessive use of mental health services.

Ambulatory Care↗
PubMed1999

Reduced rehospitalizations and reintegration of persons with mental illness into community living: a holistic approach.

The goal of inpatient rehabilitation services should be directed towards returning persons with mental illness to the community by producing measurable gains in functioning that promote increased personal independence, self-direction, and care to prepare the patient to live in the least restrictive environment. Aftercare compliance was increased and the recidivism rate was cut in half when the aftercare nurse saw the person with mental illness before discharge and a specific appointment was scheduled with the aftercare nurse. The scope of community outpatient services that can be authorized is determined by the outcome of negotiating and communicating between the clinician and case manager.

Aftercare↗
PubMed1998

An analysis of program and family costs of case managed care for technology-dependent infants with bronchopulmonary dysplasia.

Caring for technology-dependent infants with bronchopulmonary dysplasia requires a wide range and intense level of services. Case management programs can offer comprehensive services to patients with complex needs. The Neonatal Pulmonary Program at Tulane University Medical Center is a case management program for infants with chronic pulmonary problems. The purpose of this study was to describe the costs of providing care for technology-dependent infants with bronchopulmonary dysplasia and to include the direct and indirect costs to families as well as the Program costs. The study population included 89 infants enrolled in the program from September 1987 through February 1992. Outpatient, inpatient, and professional staff costs were derived from hospital and clinic billing information; all other costs were determined through family interviews. Total costs for outpatient services were $59,627 (89), professional team members time $185,539 (89); inpatient services $1,144,930 (89), professional costs for inpatient services $88,946; direct health costs $32,543 (37) for home health care, equipment, medications, special diets; direct non-health costs $30,670 (37) for transportation, meals, child care, lodging during clinic visits and rehospitalizations and household expenses to accommodate equipment needs; and indirect costs $26,173 (37) for missed work days and employment changes.

Bronchopulmonary Dysplasia↗
PubMedDate not supplied

Use of non-antacid antiulcer agents in the treatment of heartburn and dyspepsia.

This study examined secondary-claims data to measure the cost of using non-antacid antiulcer agents to treat patients with heartburn or dyspepsia. Health care utilization data were obtained from the Pennsylvania Medicaid program. The study population comprised all enrollees with dyspepsia or heartburn, excluding those with a history of ulcers. The rate and cost of gastrointestinal-related outpatient services were examined for patients receiving antiulcer drug monotherapy. The mean age of the study population (n = 1830) was 39.1 years. Ranitidine patients (n = 856) received monotherapy for an average of 71.1 days. Cimetidine (n = 395) and famotidine (n = 255) patients received monotherapy for an average of 65.0 and 71.7 days, respectively. (Mean duration of monotherapy for the other four groups ranged from 58.0 to 112.6 days). On average, there were 0.83 prescriptions issued, 0.21 physician visits, and 0.23 outpatient hospital visits per patient-month across all treatment groups. The average cost to the Pennsylvania Medicaid program was approximately $68 monthly per patient. Drugs accounted for the majority of these costs ($51.04), followed by surgical/diagnostic procedures ($5.13), outpatient hospital visits ($4.89), and physician visits ($4.15).

Adult↗
PubMed1991

[Small hospitals--future tasks and functions].

We review the small municipal hospitals included in our study of hospitals serving less than 50,000 persons. We identified the following problems: These hospitals are resource-intensive to a greater degree than expected, measured in terms of beds, doctors, health services and per capita costs in the area served by the hospital. Moreover, their quality is questionable, due to problems of recruitment and lack of continuity, a weak infrastructure, and insufficient patients to maintain a high level of competence, especially in taking care of patients with complicated and acute conditions. We foresee, and recommend, a new and different future for small hospitals, emphasizing closer links with primary health care and closer collaboration with the larger county hospitals. Key words are: Outpatient services, including perhaps ambulatory specialist services from the larger hospitals, elective services in fields of special competence, possibly covering a larger area, rehabilitation services, municipal psychiatric services; and finally, the traditional acute services should be changed to a first-aid service, preferably as part of emergency care in the municipality.

Hospitals, Municipal↗
PubMed2006

Reduced 6-month resource use and costs associated with cilostazol in patients after successful coronary stent implantation: results from the Cilostazol for RESTenosis (CREST) trial.

BACKGROUND: The CREST trial demonstrated that after successful coronary stent implantation, the 6-month rate of target vessel revascularization (TVR) was similar (15.4% vs 16%, P = .90) for the 2 treatment groups, but restenosis rate was lower (22.0% vs 34.5%, P = .002) in cilostazol-treated patients. We sought to evaluate resource use, cost, and cost-effectiveness of cilostazol in CREST. METHODS: A total of 705 patients were randomized to cilostazol 100 mg twice daily (n = 354) versus placebo (n = 351) for 6 months. Resources included rehospitalizations, medications, and outpatient services. Costs were determined from the Medicare fee schedule. Cilostazol was priced at 1.64 dollars a day. Base-case cost and cost-effectiveness analysis was performed for the entire population using TVR as a measure of effectiveness. Sensitivity analysis was conducted among 526 patients because restenosis data were available only for this patient population. A bootstrap resample approach (5000 samples) was used to obtain confidence intervals for cost differences. RESULTS: For the entire population, costs of rehospitalizations, concomitant medications, outpatient tests, and physician or emergency department visits were lower during follow-up for cilostazol-treated patients. Overall, total 6-month follow-up costs remained 447 dollars lower for cilostazol (4178 dollars vs 4625 dollars), although this difference did not reach significance (95% CI -1458 dollars to 515 dollars). Cilostazol is likely a cost-saving strategy (similar rate of TVR and lower costs). Sensitivity analysis showed that cilostazol is likely a dominant strategy (lower restenosis rate and costs, 85% dominant, 88.9% <1000 dollars per restenosis averted). CONCLUSIONS: Treatment with cilostazol is likely a cost-saving or dominant strategy in patients with successful coronary bare metal stent implantation. Cilostazol may offer a low-cost alternative to restenosis prevention in patients who do not receive drug-eluting stents.

Adult↗
PubMed2003

Disasters and the public health safety net: Hurricane Floyd hits the North Carolina Medicaid program.

OBJECTIVES: We measured the effect of Hurricane Floyd on Medicaid enrollment and health services use in the most severely affected counties of North Carolina. METHODS: We used differences-in-differences models on balanced panels of Medicaid claims and enrollment data. RESULTS: Overall spending per enrollee showed little short-term effect but demonstrated a moderate increase 1 year after the storm. We found very modest short-term increases in Medicaid enrollment, a small long-term decrease in enrollment, and large increases in the long-term use of emergency room and outpatient services. CONCLUSIONS: Our findings suggest that hurricane victims experienced substantial changes in patterns of care that endured for much longer than the initial crisis period. These findings can have important implications for the management of disaster relief for this population.

Ambulatory Care↗
PubMedDate not supplied

Bringing geriatricians to the front lines: evaluation of a quality improvement intervention in primary care.

BACKGROUND: Frail elders often receive low-quality primary care, yet the optimal role of geriatricians in primary care settings remains uncertain. We evaluated the health utilization impacts of an innovative intervention emphasizing chronic disease self-management and physical activity promotion among frail elders in primary care. METHODS: The intervention was implemented within two primary care practices at a single clinic serving a large population of frail elders enrolled in a western Washington health plan. Subjects included older patients (age >or=65 years) with disproportionate baseline outpatient service use who attended two on-site visits with a geriatrician during which each received comprehensive assessment and a problem-solving intervention to enhance chronic disease self-management and promote physical activity (N = 146). Our evaluation had a retrospective matched cohort design. Controls receiving primary care at other health plan clinics were matched 3:1 to intervention subjects by sex and a propensity score (N = 437), which was computed using demographic, clinical, and health care utilization factors that were predictive of attending the intervention. Among intervention subjects and controls following the intervention, we compared relative rates of hospitalization, outpatient and specialty visits, nursing home admission, mortality, and prescription of selected high-risk medications, as well as total health care costs. RESULTS: From March 2002 to November 2003, the geriatrician evaluated 146 of 725 elderly subjects (20%) in the two primary care practices. During a mean follow-up of 1.3 years, intervention subjects had a reduced rate of hospitalization relative to matched controls (incidence rate ratio 0.57; 95% CI: 0.37 to 0.86; P < .01). Intervention and control subjects did not have significantly different rates of specialty visits, outpatient visits, nursing home admission, mortality, or high-risk prescriptions. Relative to matched controls during follow-up, total health care costs were 26.3% lower among intervention subjects (95% CI: 1.3%, 44.9%; P = .04). CONCLUSIONS: Outpatient geriatric interventions emphasizing collaboration between geriatricians and primary care physicians, chronic disease self-management, and physical activity may reduce hospitalization risk and total health care costs among vulnerable elders.

Aged↗
PubMedDate not supplied

[The quality of organization in cardiac rehabilitation--a comparison of inpatient and outpatient forms of service delivery].

Regarding the ongoing dispute on strengthening outpatient medical rehabilitation programmes, questions arise about the quality of different (organizational) forms of rehabilitation (inpatient and outpatient). The aim of this contribution is to draw a comparison between the structures and processes of inpatient and outpatient facilities for cardiac rehabilitation. Additional questions will be posed regarding the prerequisite factors for improving structures and processes in the quality assurance and management framework.

Ambulatory Care↗
PubMed2003

The economic burden of environmental tobacco smoke in the first year of life.

AIMS: To examine the population impact and economic costs associated with environmental tobacco smoke (ETS) in Chinese infants with non-smoking mothers. METHODS: Prospective, population based birth cohort study in Hong Kong, 1997-98. Main outcome measures were: doctor consultations and hospitalisations; adjusted odds ratios for higher utilisation by service type for each of the ETS exposure variables; corresponding population attributable risks (PARs); and associated extra health care costs. RESULTS: For the 1997 annual birth cohort, ETS exposure through the mother in utero was positively associated with higher consultation (adjusted odds ratio (OR) 1.26) and hospitalisation (OR 1.18) due to any illness. This translated into 7.4% of all inpatient episodes in the first year of life, representing an additional 1581 hospital attendances that cost over 2.1 million US dollars. The corresponding PAR for outpatient services was 7.7%, where the majority was due to respiratory or febrile illnesses, accounting for 0.44 million dollars in extra costs. Postnatal exposure to ETS at home was linked to higher rates of hospitalisations for any illness compared with non-exposed infants (OR 1.12), which led to 662 extra hospitalisations consuming 0.90 million dollars, where the associated PAR was 3.1%. CONCLUSIONS: Assuming that ETS was causally associated with health services use, about 9% of the total direct medical costs in the first year of life can be attributed to passive smoking. The community, as well as the private citizen, needs to be made aware of the costs foregone from exposure to tobacco smoke as well as the potential savings from a smoke-free society.

Cohort Studies↗