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PubMedDate not supplied

Cost analysis of a managed care decentralized outpatient pharmacy anticoagulation service.

OBJECTIVES: To determine the per-patient-per-month (PPPM) cost of a decentralized outpatient pharmacy anticoagulation service (OPAS) in patients with chronic atrial fibrillation (AF) who were maintained on warfarin sodium therapy in a managed care setting, to compare the annual costs versus the risk for stroke, and to assess the quality of the anticoagulant management. METHODS: Data were collected retrospectively from clinical, research, and administrative claims databases. Patient demographic data were stratified to include age and risk factors for stroke. Inclusion criteria for the study were adult patients (>18 years) who were maintained on chronic warfarin therapy with a diagnosis of AF (diagnosis code 427.31) and continuously enrolled during calendar year 2000. The cost analysis included the personnel cost of clinical pharmacy specialists, direct and indirect cost of laboratory tests for international normalized ratios (INR), and anticoagulant (warfarin plus bridge therapy with a low molecular weight heparin) drug cost and dispensing fee. The percentage of INR values within or near target was used to evaluate the effectiveness of the service. RESULTS: A total of 97 patients on chronic warfarin therapy for AF were identified for cost analysis. The demographics for these patients included the following: 71% were male, with 32% of the patients over the age of 75 years, and 60% had 1 or more identifiable risk factors for stroke. Utilizing established criteria, 80.4% of the sample was considered to be at high risk for ischemic stroke. A majority of the patients (94.8%) had nonvalvular disease, with an INR goal in the range of 2 to 3 in 91.8% of the cases. The PPPM cost for the OPAS monitoring service was $51.25, distributed as $13.78 (27%) in personnel costs for monitoring pharmacists, $18.38 (36%) for lab tests, and $19.09 (37%) for anticoagulant drug costs. These costs did not significantly differ among patient groups with various risks for ischemic stroke. For nonvalvular AF patients, the percentage of INR values within each individual patient.s specific INR goal range was 60.4%; the percentage within or near goal was 74.6%. CONCLUSION: The average PPPM cost for pharmacist and laboratory monitoring as well as anticoagulant medication for CY 2000 was estimated to be $51.25. The annual costs were comparable among AF patients with different risks for ischemic stroke. The percentage of INR values within the individual patient.s stated target goal was 60.4%. Effective monitoring to maintain patients within their target INR goal is relatively inexpensive compared with the cost of complications such as ischemic stroke or intracranial bleeding.

Adult↗
PubMed2002

The costs of epilepsy in Italy: a prospective cost-of-illness study in referral patients with disease of different severity.

PURPOSE: [corrected] Epilepsy poses a considerable economic burden on society. However, information is insufficient on the comparative costs of different disease varieties. The purpose of this study was to compare the direct costs of epilepsy in referral patients with disease of different severity and duration. METHODS: Patients with newly diagnosed epilepsy (NDE), seizure remission (SR), occasional seizures (OS), frequent non-drug-resistant (NDR) and drug-resistant (DR) seizures, and surgical candidates (SC) from 14 epilepsy centers were the target population. All patients were followed prospectively for 12 months and all medical and paramedical contacts for diagnostic and therapeutic services were noted with details, using ad-hoc diaries and semistructured questionnaires. RESULTS: The study population comprised 525 consecutive children and adults with partial (68%), generalized (25%) and undetermined epilepsy (4%) as follows: NDE 70; SR 131; OS 108; NDR 101; DR 107; SC 8. Ambulatory visits (mean 2.8 per patient per year) were the leading service in all groups, followed by EEG recordings (1.8) and biochemical assays (1.1). At entry, the commonest drugs were carbamazepine (50%), valproate (37%), phenobarbital (21%), vigabatrin (14%) and lamotrigine (11%). New antiepileptic drugs (AED) were used increasingly with the severity of the disease. The total annual costs varied significantly across groups: 3945 Euro (SC), 2198 Euro (DR), 1626 Euro (NDR), 1002 Euro (NDE), 558 Euro (OS), 412 Euro (SR). The main item of expenditure was hospital stay (including day-hospital), followed by drug treatment and outpatient visits. The costs of outpatient services, hospital services and drugs varied significantly across groups. CONCLUSIONS: The direct costs of epilepsy vary significantly depending on the severity of the disease and the response to treatment. Hospital admissions and drugs are the commonest items of expenditure.

Adolescent↗
PubMed1992

A randomized trial to evaluate the effectiveness of a Medicaid HMO.

The value of health-care services used by AFDC Medicaid patients receiving care in a voluntary enrollment HMO is contrasted with that of health care services used by Medicaid patients receiving fee-for-service (FFS) care. The randomized assignment of Medicaid recipients to the HMO or to FFS allows the authors to conclude that the apparent lower use of HMO enrollees results from the HMO's selection of patients with lower needs for care rather than from technical efficiency. Patients had lower use while in the HMO, but disenrollees and those who refused enrollment had significantly higher use than FFS participants. In contrast to the effect of HMOs on non-Medicaid populations, the Medicaid HMO studied provided significantly fewer outpatient services, but the same level of inpatient services as the FFS sector. Overall, voluntary enrollment of Medicaid eligibles into the HMO resulted in higher state expenditures for Medicaid because of favorable selection.

Ambulatory Care↗
PubMed2005

Acute coronary syndromes: cardiac rehabilitation programmes and quality of life.

AIMS: This paper reports a study examining the quality of life of clients following hospital admission with acute coronary syndrome in Hong Kong and their use of cardiac rehabilitation. BACKGROUND: Coronary heart disease is a major source of mortality and morbidity in Hong Kong. Western studies have suggested that participation in cardiac rehabilitation improves the quality of life of clients with coronary heart disease yet the use of cardiac rehabilitation has been reported to be low. Better understanding is needed of the psychosocial status of these clients in Hong Kong and their use of cardiac rehabilitation services. METHODS: A prospective, pretest-post-test study was carried out, with data collected over a period of 6 months with convenience sample of 182 participants. Baseline data were obtained within one week after hospital admission for individuals experiencing ACS. The second phase of data collection commenced at 6 months after hospital discharge. Total period of data collection took over 12 months between 2002 and 2003. The Chinese version of the SF-36 was used to assess quality of life, and demographic data and the extent to which clients participated in the cardiac rehabilitation programme were assessed. RESULTS: Only 25% of the participants attended at least one session of the cardiac rehabilitation programme. Significant improvement occurred in all clients' perceived quality of life 6 months following initial hospital admission. No significant group differences in perceived quality of life were found according to whether or not clients used the cardiac rehabilitation services. CONCLUSION: Improvement in perceived health-related quality of life was evident over a 6-month period. Yet our findings suggested that participation in the cardiac rehabilitation programme did not have any apparent effects in subjects' perceived quality of life. Further studies using both generic and disease-specific health-related quality of life instruments, as well as the inclusion of control group, are recommended. Continual improvement in cardiac rehabilitation programmes, and consideration of alternative modes of delivery other than the traditional attendance at hospital outpatient services, are also recommended.

Aged↗
PubMed1996

Problem of antimicrobial resistance of fecal aerobic gram-negative bacilli in the elderly.

In this study, we assessed the magnitude of risk (odds ratio [OR]) of patients being colonized with fecal aerobic gram-negative bacilli in two geriatric hospitals compared with the community, and we associated the use of antimicrobial agents with bacterial resistance. One fecal sample was collected from each of 341 patients, aged 60 years or older, during the hospital stay or when visiting the outpatient service. Samples were collected in 1988 and 1993 to 1994. The aerobic gram-negative bacilli from all samples were examined for resistance to seven antimicrobials by a replica plating method. The long-term-hospitalized patients had a significantly higher risk of being colonized with bacilli resistant to ampicillin (OR, 14.3; 95% confidence interval [95% CI], 6.0 to 34.1), cefuroxime (OR, 7.5; 95% CI, 2.7 to 20.8), trimethoprim (ORs, 22.3; 95% CI, 8.6 to 57.8), and tetracycline (OR, 5.2; 95% CI, 2.4 to 10.9) than the outpatients. The respective ORs among the short-term-hospitalized patients compared with the outpatients were 4.0 (95% CI, 1.9 to 8.4), 7.5 (95% CI, 2.7 to 20.8), 5.5 (95% CI, 2 to 14), and 2.0 (95% CI, 1 to 4). In 1993 to 1994 compared with 1988, in both hospitals there was a significantly increased risk of colonization by bacilli resistant to ampicillin (OR, 3.1; 95% CI, 1.9 to 5.1), cefuroxime (OR, 3.8; 95% CI, 2.1 to 6.7), and tetracycline (OR, 1.6; 95% CI, 1.0 to 2.5). However, the total use of antimicrobial agents increased only among the patients of the short-term-care hospital.

Aged↗
PubMed2004

Mental health care system and mental health expenditures in the Czech Republic.

BACKGROUND: Although the mental health care is a substantial component of the health system in the Czech Republic, there is a lack of information and research on mental health expenditures. Determining the level and profile of mental health expenditures is the first step in achieving awareness of the cost of mental illness to society. AIMS OF THE STUDY: To describe the mental health care financing and delivery system in the Czech Republic and to estimate the mental health expenditures in 2001. The paper examines expenditures with regard to structure by type of service, relative share of total health expenditures, and relative share of the gross domestic product. It also makes international comparisons of mental health expenditures between the Czech Republic and other countries. METHODS: The data discussed in this study come from the Institute of Health Information and Statistics of the Czech Republic and from the General Health Insurance Fund of the Czech Republic. Mental health expenditures are defined as expenditures on services for patients with primary or first-listed diagnoses from Chapter V, Mental and Behavioural Disorders (F00-F99), of the Tenth Revision of International Classification of Diseases (ICD-10). Different methods of allocation are used for various types of services. In addition, expenditures of sickness insurance related to mental illness are also estimated. RESULTS: Mental illness is diagnosed and treated in about 4% of the population. The share of mental illness on the total morbidity in the population is approximately 2%. The share of mental health expenditures on both the total health expenditures (3.54%) and the gross domestic product (0.26%) is low when compared to levels in other developed countries. Psychiatric hospitals consume 35.6% of mental health expenditures; prescribed drugs and medical aid consume 33.2%; specialized outpatient services consume 17.4%; and shares of other services are relatively low. IMPLICATIONS FOR HEALTH CARE POLICY FORMULATION: First, if the amount of expenditures allocated to mental health can be interpreted as an indicator of the government's commitment to mental health, then, in comparison to other developed countries, mental health has a low priority in the Czech Republic. Second, the improved availability of data on morbidity and regular analyses of these data are needed and should yield fast and valuable results.

Czech Republic↗
PubMed1989

A survey of elderly new patients at a dermatology outpatient clinic.

A study of all new dermatitic out patients greater than 70 years of age, referred in the period January-June 1987 (257 patients), was undertaken to obtain information on the types of skin diseases and the dermatological outpatient services required in the case of the elderly. The group accounted for 14% of all new patients. The leading diagnoses were seborrheic keratosis (15.6%), basal cell carcinoma (13.6%), solar keratosis (13.2%), psoriasis (9.7%) and leg ulcer (9.3%). A skin biopsy was required in 27%, and surgical treatment in 31% of the group, compared with 12% and 16%, respectively, of all new patients during the same period. Consequently, the elderly group were more likely to require a follow-up appointment and tended to be more time-consuming outpatients.

Aged↗
PubMed2006

Assessing the effect of the 2001-06 Mexican health reform: an interim report card.

Since 2001, Mexico has been designing, legislating, and implementing a major health-system reform. A key component was the creation of Seguro Popular, which is intended to expand insurance coverage over 7 years to uninsured people, nearly half the total population at the start of 2001. The reform included five actions: legislation of entitlement per family affiliated which, with full implementation, will increase public spending on health by 0.8-1.0% of gross domestic product; creation of explicit benefits packages; allocation of monies to decentralised state ministries of health in proportion to number of families affiliated; division of federal resources flowing to states into separate funds for personal and non-personal health services; and creation of a fund to protect families against catastrophic health expenditures. Using the WHO health-systems framework, we used a wide range of datasets to assess the effect of this reform on different dimensions of the health system. Key findings include: affiliation is preferentially reaching the poor and the marginalised communities; federal non-social security expenditure in real per-head terms increased by 38% from 2000 to 2005; equity of public-health expenditure across states improved; Seguro Popular affiliates used more inpatient and outpatient services than uninsured people; effective coverage of 11 interventions has improved between 2000 and 2005-06; inequalities in effective coverage across states and wealth deciles has decreased over this period; catastrophic expenditures for Seguro Popular affiliates are lower than for uninsured people even though use of services has increased. We present some lessons for Mexico based on this interim evaluation and explore implications for other countries considering health reforms.

Delivery of Health Care↗
PubMed2002

Risk for respiratory events in a cohort of patients receiving inhaled zanamivir: a retrospective study.

BACKGROUND: Inhaled zanamivir is indicated for treatment of uncomplicated acute illness due to influenza A and B viruses in patients aged > or = 12 years who have been symptomatic for no more than 2 days. OBJECTIVE: The primary objective of this study was to estimate the incidence of adverse respiratory events among zanamivir-treated patients under conditions of usual care. METHODS: The Ingenix research database includes insurance claims for all dispensations, inpatient and outpatient services, and procedures including the associated diagnoses and costs for a subset of all enrolled UnitedHealthcare members. We identified all persons with a dispensation of zanamivir recorded between October 1, 1999, and April 30, 2000. We captured medical and pharmaceutical claims data for the 6 months before the dispensation to obtain information about comorbidities, overall health status, and respiratory events. Medical and hospital record abstraction and clinical review served to confirm inpatient/emergency department (ED) events. We also examined the records of an approximately 10% random sample of patients treated for a potential respiratory event in an outpatient/ physician office visit during the 10-day follow-up period. Respiratory events not sufficiently severe to result in medical care were not captured in this study. RESULTS: A total of 5498 eligible zanamivir dispensations contributed by 5450 patients (2911 females, 2539 males; mean age, 38.8 years), with 40 confirmed inpatient/ED respiratory events, were included in the study. Of these 40 events, 31 were pneumonia, bronchitis, or exacerbations of existing chronic respiratory disease; none required intubation or ventilation. No events occurred on the dispensation date. The overall risk for an inpatient/ ED respiratory event was 0.7 per 100 episodes (95% CI, 0.5-1.0). Seven events of wheezing or shortness of breath were not an obvious extension of the original influenza-like illness or of a complicating bronchitis (risk = 0.13 per 100 episodes; 95% CI, 0.06-0.26). CONCLUSIONS: No immediate or severe bronchoconstrictive responses occurred among 5498 zanamivir dispensations. The overall risk for any respiratory event was low, and none was sufficiently severe to suggest respiratory failure.

Administration, Inhalation↗
PubMed2000

[Effect of a geriatric psychiatric center on quality of care for elderly psychiatric patients].

The goal of this evaluation study is to analyze the effects of a new gerontopsychiatric institution, the gerontopsychiatric center (GC: a combination of a home-based outpatient service, a day-hospital and a consulting office for elderly with mental disorders) on the reorganization process of the treatment system from intramural toward extramural structures, as experts of the government of the FRG have been demanding for a long time. Based on data of cross-sectional and longitudinal studies two regional catchment areas--the city of Bielefeld (without GC, control region) and the district of Gütersloh (with GC)--are compared and analyzed, whether changes within the gerontopsychiatric system (subsystem A), the system of general medical treatment (subsystem B), or within the elderly care system (subsystem C) occurred. Concerning subsystem A the results are that the GC has a strong impact on the intended shift from intra- to extramural structures, without selecting patients by diagnosis nor by severity degrees of their mental disorders in extramural treatment facilities. The home-based outpatient treatment is especially successful for elderly with a functional psychic disorder. These patients had the highest scores in improvement of psychiatric symptoms as well as in reduction of their self-care deficits within one year. Effects of the GC on subsystem B were evident soon after its establishment, for example, by the increasing cooperation between the gerontopsychiatric health services and general hospitals in the region with GC, in which (hospitals) two fifths of all clinical gerontopsychiatric patients with a mental disorder as the main diagnosis (ICD-9) are treated. An effect of the GC on subsystem C is possibly the fact that in its region the rate of direct transfers of patients from the clinical gerontopsychiatric department into homes for the elderly is significantly lower than in the region without GC.

Aged↗
PubMed2005

Risk factors for ineffective therapy in patients with bloodstream infection.

BACKGROUND: Infections occurring among outpatients having recent contact with the health care system have been termed health care-associated infections. The objective of this study was to analyze the impact of health care-associated status on effectiveness of initial therapy in hospitalized patients with bloodstream infections. METHODS: Prospective cohort study of adults with bloodstream infections at 3 North Carolina hospitals. Bloodstream infection was defined as health care-associated if it occurred within the first 48 hours after hospitalization and if patients had 1 of the following characteristics: had received home health services, outpatient intravenous therapy, or outpatient renal dialysis in the 30 days prior to hospital admission; had been hospitalized within 90 days prior to admission; or lived in a long-term care facility. RESULTS: Of 466 bloodstream infections, 132 (28%) were community-acquired, 178 (38%) were health care-associated, and 156 (33%) were nosocomial. Multivariable logistic regression using community-acquired status as a reference identified health care-associated status (odds ratio, 3.1; 95% confidence interval, 1.6-6.1) and nosocomial status (odds ratio, 4.3; 95% confidence interval, 2.2-8.3) as independent predictors of ineffective initial antibiotic therapy. Among health care-associated characteristics, hospitalization in the 90 days prior to admission was independently associated with ineffective initial therapy (odds ratio, 2.4; 95% confidence interval, 1.4-4.2). CONCLUSIONS: Among patients treated in the hospital for bloodstream infection, health care-associated status was an independent predictor of ineffective initial antibiotic therapy. Hospitalization within 90 days prior to hospital admission was the component of health care-associated status most strongly associated with ineffective initial therapy.

Anti-Bacterial Agents↗
PubMed2007

Mental health care in Germany: current state and trends.

Germany turned towards community-based mental health care in the mid seventies, during a general climate of social and political reform. The continuing deinstitutionalisation process and the implementation of community mental health services was considerably affected by the reunification of East and West Germany in 1990, which required dramatic changes in the structure and quality of the mental health care system of the former German Democratic Republic (GDR). Overall, German mental health care is organised as a subsidiary system, where planning and regulating mental health care is the responsibility of the 16 federal states. So German mental health care provision is spread among many sectors and characterised by considerable regional differences. A key characteristic is the particularly wide gap between inpatient and outpatient services, which are funded separately and staffed by different teams. In 2003 the total number of psychiatric beds was a mere two thirds of the overall bed capacity in 1991, the first year as a re-unified Germany, when psychiatric beds in East and West Germany totalled 80,275. From 1970 onwards the number of psychiatric beds was cut by roughly half. So the momentum of the reform has been strong enough to assimilate the completely different mental health care system of the former German Democratic Republic and, in the course of a decade, to re-structure mental health services for an additional 17-18 million new inhabitants. In an ongoing struggle to adapt to changing administrative set-ups, legal frameworks, and financial constraints, psychiatry in Germany in currently facing specific problems and is seriously challenged to defend to considerable achievements of the past. A major obstacle to achieving this aim lies in the fragmented system of mental health care provision and mental health care funding.

Germany↗
PubMed1983

Medical care of asthma and wheezing illness in children: a community survey.

A survey was carried out to investigate the medical care of asthma and wheezing illness in a school population. Children with current wheezing illness were identified by a screening questionnaire to the parents of 5100 children in one school cohort from all schools in an outer London borough. Of the 89% who responded, 11.1% reported wheezing within the past 12 months. Parents of a sample of 284 wheezy children aged about 9 were interviewed at home about their child's illness and the related use of drugs and services. There was evidence of substantial underuse of services and this was not associated with social, family, or general practice factors. Considerable proportions of children were not having drug treatment, were receiving only non-antiasthmatic drugs, or were using antiasthmatic drugs incorrectly. The most important social and family factor associated with undertreatment was poor maternal mental health, and this factor appeared to explain the observed association of manual social class with undertreatment. Only about half of the most severe group were labelled as having "asthma," and those with this label were more likely to be receiving treatment and using outpatient services. The results show that the potential of modern treatment to prevent disability due to wheezing illness is not being realised despite the existence of a free and accessible health service.

Absenteeism↗
PubMed1995

Clinical audit of a specialist symptomatic breast clinic.

The efficient delivery of health care requires vigilant quality assurance. We describe the audit of our symptomatic breast clinic, which includes the option of a one-stop diagnostic service. A total of 134 new and 386 follow-up patients attended over four consecutive clinics. The majority of new referrals (68%) were seen by a consultant surgeon. Urgent referrals were seen significantly sooner than routine referrals (P < 0.001, chi 2-test), and the mean wait from designated appointment to seeing the surgeon was 37.6 (range-68 to 171) min. One-stop investigations were offered to 50 patients; of these, 36 women (72%) had a total wait of less than 2 h. For those not investigated at the same clinic, the mean time until investigations was 6.1 (range 0-36) days and mean recall was 2.7 (range 1-8) weeks. Patients undergoing definitive surgery for cancer (n = 5) were operated on average 14.2 (range 7-27) days after the decision was made in outpatients, while the mean waiting time for non-cancer operations was 49.7 (range 15-98) days. Objective audit on outpatient services is possible and can lead to improvement of services.

Adult↗
PubMed1996

Self-reported health and use of health services: a comparison of diabetic and nondiabetic persons from a national sample.

Population-based epidemiological and health service utilisation information on diabetes and other noncommunicable diseases is still scarce in Australia. Such information is needed by health economists, policy makers and service providers. Data from the 1989-90 National Health Survey conducted by the Australian Bureau of Statistics have been used to obtain estimates of the prevalence of cardiovascular morbidity, life-style factors, use of hospital and medical services, and self-assessed health and happiness for Australian persons with diabetes. Prevalences are compared with those for persons without diabetes. Those with diabetes had two to three times the prevalence of most cardiovascular conditions, similar levels of exercise (except for diabetic women over 40 years of age who exercised less than their nondiabetic counterparts), lower levels of alcohol consumption (except for younger men, who had a similar frequency of heavy drinking as their nondiabetic peers), similar levels of smoking, a higher prevalence of overweight, and significantly greater frequency of hospital admissions, use of outpatient services and general practitioner consultations. About half of the people with diabetes assessed their health as good or excellent but 90 per cent stated that they were happy or very happy. No differences between diabetic people living in capital cities and other areas were found. These results have implications for education and life-style behaviour modification programs for people with diabetes. Research into the prevention and more effective management of diabetes and its complications is required in order to contain the escalating health care burden associated with diabetes in Australia.

Adolescent↗
PubMed1986

Acceptance and use of patient-carried health records.

The ultimate goals of providing health records to patients are to improve continuity of care, to improve patient understanding of instructions, and to encourage patients to take a more active role in maintaining their health. In the current study, four types of patient-carried health records were evaluated in a hospital-based outpatient service to determine whether records would be accepted and used, to estimate the cost of the process, and to obtain patient and provider reactions. Records were provided at moderate cost and the primary determinants in record acceptance and use were physicians' support of the process, the type of record, and the employment status of the patient. A small record which could be carried in a wallet seemed suited to most patients; other more elaborate participatory records appeared to have benefits for selected patients. More extensive use of participatory records appears to require changes in the way health care would be delivered.

Attitude of Health Personnel↗
PubMed1980

Coping with outpatients who cannot cope : management of persistent complainers in an African country.

Some 15 to 20% of patients visiting general outpatient services in developing countries suffer from some emotional disorder although they present mainly with somatic complaints. Their contact with the services is generally a frustrating experience for themselves and for the health worker, resulting in undue medical attention to their problem. A series of five consecutive steps, of increasing psychiatric sophistication, to assist in the management of these cases is described, permitting the health worker to stop at a level not exceeding his competence.

Developing Countries↗
PubMed2006

Pathological gamblers: inpatients' versus outpatients' characteristics.

Several researchers and clinicians have questioned the advantages and disadvantages of inpatient and outpatient treatment for people suffering from pathological gambling. This study compares the characteristics of pathological gamblers seeking inpatient and outpatient treatment. A total of 233 pathological gamblers (inpatients = 134, outpatients = 99) participated in the study. Results show that inpatients have more severe gambling problems than those receiving outpatient services. Similar results were obtained on most other related variables such as anxiety, depression, alcohol consumption, and comorbidity. These results are discussed in terms of the costs and benefits of these two treatment modalities.

Adult↗