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PubMed2006

The Soterion Rapid Triage System: evaluation of inter-rater reliability and validity.

The Soterion Rapid Triage System is a new, computerized, five-level triage acuity system. The purpose of this study was to evaluate the system's inter-rater reliability and validity for stratifying patient acuity. The study was comprised of two components. A prospective evaluation of inter-rater reliability was conducted by the blinded, paired simultaneous triage of 423 patients. A retrospective evaluation of validity consisted of the analysis of 33,850 patients triaged with the system over an 8-month period. The system's validity was measured by in-hospital admission rate, Emergency Department (ED) length-of-stay, hospital charges and Current Procedural Terminology (CPT) Codes 99281-99285. Evaluation of inter-rater reliability demonstrated a weighted kappa of 0.87 (95% confidence interval 0.84, 0.91). The in-hospital admission rates for patients triaged as Level 1 Immediate-Level 5 Non-Urgent were 43%, 30%, 13%, 3% and 1%, respectively (p < 0.0001). Similarly, there were significant differences in the means for all hospital charges, ED lengths-of-stay, and CPT Codes. In conclusion, the Soterion Rapid Triage System possesses high inter-rater reliability and validity. The system's reliability and validity, and the availability of the system's electronically archived data are characteristics beneficial to the development of a national standardized five-level triage acuity system.

Algorithms↗
PubMed2006

The use of the Soterion Rapid Triage System in children presenting to the Emergency Department.

There has been a recent move toward the adoption of five-level triage systems in the United States. However, there have been no studies in this country that have critically evaluated the use of these systems in children. The purpose of this study was to evaluate the reliability and validity of a new five-level triage system, the Soterion Rapid Triage System, for stratifying acuity levels in children under the age of 13 years. The study was conducted in a 389-bed Level II mixed adult and pediatric Trauma Center that experiences approximately 12,000 patient visits/year of children under the age of 13 years. We performed a prospective evaluation of the system's reliability using the weighted kappa statistical method (n = 117) and a retrospective evaluation of the system's validity through an analysis of all patients under the age of 13 years triaged with the system over an 8-month period (n = 7077). The system's validity was measured by in-hospital admission rate, Emergency Department length of stay, hospital charges, and Current Procedural Terminology (CPT) Codes 99281-99285. The inter-rater reliability as measured by the weighted kappa was 0.90 (95% confidence interval 0.83-0.96), with 92% exact agreement between nurses in the triage level assigned. The in-hospital admission rates for patients triaged as Level 1 Immediate-Level 5 Non-Urgent were 38%, 18%, 9%, 1.5% and 0.4%, respectively (p < 0.0001). The mean total hospital charges for each of the five triage levels were $2673, $1563, $1112, $477, and $258, respectively (p < 0.0001). Similarly, there were significant differences in the means for laboratory and pharmacy charges, Emergency Department lengths of stay, and CPT Codes. This report represents the first study in this country on the effectiveness of a five-level triage system in children. We have demonstrated that the Soterion Rapid Triage System possesses high inter-rater reliability and validity when used to triage children younger than 13 years of age.

Algorithms↗
PubMed2004

Understanding work-related injuries in children: a perspective in West Virginia using the state-managed workers' compensation system.

BACKGROUND/PURPOSE: Little data exist that defines the consequences of occupational injuries in children. Traditional assessment of work-related injury is coupled with disability payments based on salary, which give little insight into etiology and severity. The authors hypothesize that the risk and pattern of occupational injuries in young workers are different then adults. METHODS: Claims from 1996 through 2000 were analyzed from the West Virginia Bureau of Workers Compensation. To define the significance of an injury, child and adult groups were subdivided into injuries that required surgery (ie, serious injuries). Current Procedural Terminology (CPT) codes for anesthesia and surgical procedures were cross referenced with the claims to ensure group designation. Relative risks (RR) were used to compare groups. RESULTS: Between 1996 and 2000, 364,063 claims were submitted, 14,093 in workers < or =19 years of age. Two hundred seventy claims in children required surgery. Serious injuries in children occur more often in boys 2.2x mainly in the (16 to 24 hours) evening (48% v 23.13%; P <.05) and in July/August (26.5 v 18.4; P <.001). Falls were the main mechanism of injury. Proportionately fingers (1.70x) and hands (1.64x, 1.6 to 1.7) were injured in children. Lacerations (3.4x), fractures (1.4x), and amputations (3.75x) frequently resulted in general anesthetic procedures, and the RR of these injuries were increased versus adults. Service, manufacturing, construction, and agriculture were the main injury-related occupations in children. CONCLUSIONS: For any job category, injuries in children have unique features, tend to be more serious, and require a surgical intervention proportionately more frequently than adults.

Accidental Falls↗
PubMed2006

Extracorporeal membrane oxygenation for support of children after hematopoietic stem cell transplantation: the Extracorporeal Life Support Organization experience.

PURPOSE: Extracorporeal membrane oxygenation (ECMO) is a means of respiratory and hemodynamic support for patients failing conventional therapies. Children requiring hematopoietic stem cell transplantation who develop complications during therapy may require ECMO. Such patients pose medical and ethical challenges for clinicians considering initiation of ECMO. The authors review the outcomes of these patients and propose recommendations. METHODS: The Extracorporeal Life Support Organization Registry was queried for all patients younger than 18 years with an International Classification of Diseases, Ninth Revision, or Current Procedural Terminology code related to bone or stem cell transplant. RESULTS: Nineteen children in the registry met inclusion criteria. The median age was 9.6 years (7 months to 17.5 years). Initiation of ECMO was for pulmonary support (n = 17), cardiac support (n = 1), or cardiopulmonary resuscitation (n = 1). The median duration of ECMO support was 5.1 days (range, 30 hours to 42 days). Pulmonary infections included 3 parainfluenza, 2 Pneumocystis carinii, 1 influenza A, and 1 respiratory syncytial virus. Overall, 15 (79%) died during their ECMO run, whereas only 4 (21%) survived to come off ECMO. Furthermore, of those who survived their ECMO run, only one patient survived to discharge from the hospital. Risk factors for death on ECMO include development of renal complications and development of multiorgan dysfunction. CONCLUSION: Patients who require ECMO for cardiopulmonary support after hematopoietic stem cell transplantation have a poor prognosis. Clinicians must be cautious in presenting this option to parents and present them with appropriate expectations in this high-risk population.

Adolescent↗
PubMed2006

The effects of the type of anesthesia on outcomes of lower extremity infrainguinal bypass.

OBJECTIVE: Three main types of anesthesia are used for infrainguinal bypass: general endotracheal anesthesia (GETA), spinal anesthesia (SA), and epidural anesthesia (EA). We analyzed a large clinical database to determine whether the type of anesthesia had any effect on clinical outcomes in lower extremity bypass. METHODS: This study is an analysis of a prospectively collected database by the National Surgical Quality Improvement Program (NSQIP) of the Veterans Affairs Medical Centers. All patients from 1995 to 2003 in the NSQIP database who underwent infrainguinal arterial bypass were identified via Current Procedural Terminology codes. The 30-day morbidity and mortality outcomes for various types of anesthesia were compared by using univariate analysis and multivariate logistic regression to control for confounders. RESULTS: The NSQIP database identified 14,788 patients (GETA, 9757 patients; SA, 2848 patients; EA, 2183 patients) who underwent a lower extremity infrainguinal arterial bypass during the study period. Almost all patients (99%) were men, and the mean age was 65.8 years. The type of anesthesia significantly affected graft failure at 30 days. Compared with SA, the odds of graft failure were higher for GETA (odds ratio, 1.43; 95% confidence interval [CI], 1.16-1.77; P = .001). There was no statistically significant difference in 30-day graft failure between EA and SA. Regarding cardiac events, defined as postoperative myocardial infarction or cardiac arrest, patients with normal functional status (activities of daily living independence) and no history of congestive heart failure or stroke did worse with GETA than with SA (odds ratio, 1.8; 95% CI, 1.32-2.48; P < .0001). There was no statistically significant difference between EA and SA in the incidence of cardiac events. GETA, when compared with SA and EA, was associated with more cases of postoperative pneumonia (odds ratio: 2.2 [95% CI, 1.1-4.4; P = .034]. There was no significant difference between EA and SA with regard to postoperative pneumonia. Compared with SA, GETA was associated with an increased odds of returning to the operating room (odds ratio, 1.40; 95% CI, 1.20-1.64; P < .001), as was EA (odds ratio, 1.17; 95% CI, 1.05-1.31; P = .005). GETA was associated with a longer surgical length of stay on univariate analysis, but not after controlling for confounders. There was no significant difference in 30-day mortality among the three groups with univariate or multivariate analyses. CONCLUSIONS: Although GETA is the most common type of anesthesia used in infrainguinal bypasses, our results suggest that it is not the best strategy, because it is associated with significantly worse morbidity than regional techniques.

Aged↗
PubMed2002

Position of the American Dietetic Association: nutrition services in managed care.

It is the position of the American Dietetic Association that medical nutrition therapy is an essential component of disease management and healthcare provided by managed care organizations, and that such care must be provided by qualified nutrition professionals. Compared with traditional fee-for-service reimbursement systems, managed care presents new opportunities for dietetics professionals. Until recently, the lack of billing infrastructure has handicapped nutrition providers who wish to bill for their services and has made it difficult to track the outcomes of nutrition care. With the publication of current procedure terminology codes for medical nutrition therapy (MNT) and the implementation of MNT benefits in Medicare part B for diabetes and nondialysis kidney disease, commercial payers, including managed care organizations (MCOs) are likely to implement or expand their coverage of MNT. A large body of evidence supports the efficacy and cost-effectiveness of MNT coverage within managed care plans. This evidence includes cost analyses of conditions treated by MNT, and clinical trial data confirming the efficacy of MNT in improving patient outcomes. MNT is also an important part of national standards of care for many chronic disease conditions. Based on evidence supporting the role of MNT in improving patient outcomes, the Institute of Medicine (IOM) recommended that MNT services be reimbursed by Medicare when patients are referred by a physician. Provision of appropriate MNT can also help MCOs meet accreditation and quality standards established by entities such as the National Committee for Quality Assurance and the Joint Commission for the Accreditation of Health Care Organizations. Much of the work required to secure a place for MNT in MCOs will be done at the practitioner level, by nutrition professionals themselves. Registered dietitians must market MNT to their customers in managed care by addressing the needs of each player. By emphasizing the importance of MNT and other cost-effective forms of preventive care and disease management, MCOs will be well positioned to improve population health at modest cost.

Cost-Benefit Analysis↗
PubMed1997

A community collaborative practice experience between Med/Peds and family practice.

PURPOSE: The medical literature has followed educational outcomes of Medicine-Pediatric (Med/Peds) physicians, but limited studies exist as to clinical outcomes for these combined specialty physicians. Although a variety of practice environments are available for a growing number of Med/Peds physicians, a collaborative practice setting with family physicians may optimize the Med/Peds practice potential. This study investigates clinical practice outcomes and utilization efficiencies of collaborative Med/Peds family practice physicians within a community, which should provide an effective model in a growing managed care environment. PATIENTS AND METHODS: Two collaborative practice settings in a moderate size Midwest community were analyzed with respect to patient demographics and utilization scores provided by a practice management group and a nationally based health care network. Current Procedural Terminology (CPT) coding was used to follow demographic trends for over 45,000 patient visits for 1 year. Efficiency ratings (Z-scores) were used over the same year for over 6,000 health care network patient visits to 10 collaborative practice-based physicians, which were then compared to 141,101 community family practice patient encounters, 26,617 general internist patient encounters, and 29,995 patient encounters to pediatricians for utilization trends. RESULTS: Med/Peds and Family Practice patient care data reflected nearly identical patient demographics between specialties with only a few exceptions. Med/Peds physicians cared for three times the total number of children less than 2 years old. Med/Peds physicians experienced a higher complexity of illness, in part due to a 40% increase in internal referrals from family practice colleagues in the ambulatory care setting, while maintaining a third of the proportion of outpatient referrals. Cost-effective interoffice utilization was still maintained, supported by a more optimal efficiency rating for Med/Peds physicians compared to collaborative family practice colleagues. Inpatient efficiency was demonstrated for Med/Peds specialists even though a threefold increase in hospitalizations was observed, in part resulting from physicians within these collaborative practices arranging all newborn nursery and pediatric admissions be covered by Med/Peds physicians. Both collaborative primary care specialists demonstrated more cost-effective overall practice utilization scores when compared to community-based primary care specialists. CONCLUSIONS: Med/Peds physicians in this study have been trained to provide cost-effective patient care in both outpatient and inpatient settings. Decreased outside referrals by collaborative family practice physicians through utilization of Med/Peds colleagues serves to optimize practice economy by eliminating the threat of competition that exists among community-based generalists. Such a model helps to control an overused referral system to subspecialists.

Community Health Services↗
PubMed2000

Office-based wire-guided open breast biopsy under local anesthesia is accurate and cost effective.

BACKGROUND: Mammographic abnormalities found to be malignant by stereotactic biopsy still require a wire-guided biopsy (WGB) in most cases. We have previously described a simplified method of WGB that allows the procedure to be done with a minimum of dissection and under local anesthesia in the office setting. We hypothesized that this procedure can be used to produce cost-effective, office-based breast preservation therapy (BPT). METHODS: We reviewed our recent experience with this WGB method to determine applicability and accuracy in the office setting. A cost-effectiveness analysis was also performed to determine potential charge reductions when this method is used to avoid operating room (OR) usage for either lumpectomy or lumpectomy plus sentinel lymph node biopsy (SLNB). RESULTS: Of the 164 biopsies reviewed, 114 (70%) were performed in the office setting under local anesthesia and 50 (30%) were performed in the OR. The most common reasons for choosing the OR setting included performance of biopsy during an unrelated procedure requiring the OR (16 cases), patient preference (12), deep lesions (6), and the inability of the patient to cooperate with local anesthesia (5). The complication rates were similar between the two settings (7% for office-based and 4% for OR; P = 0.697), and in neither setting were any lesions missed. A cost-effectiveness analysis using our Current Procedure Terminology (CPT)-based charges revealed a potential per-case charge reduction of $4,632 for office-based lumpectomy and $4306 for office-based lumpectomy/SLNB, using our method of WGB and local anesthesia, compared with the OR setting. CONCLUSIONS: Office-based WGB using our previously described method is accurate and can be applied to at least 70% of patients. Based on the favorable results of our cost analysis and rising support for SLNB, we anticipate increased utilization of the clinic setting and local anesthesia for BPT in the future.

Adult↗
PubMed1999

Prognostic models of thirty-day mortality and morbidity after major pulmonary resection.

BACKGROUND: A part of the prospective, multi-institutional National Veterans Affairs Surgical Quality Improvement Program was developed to predict 30-day mortality and morbidity for patients undergoing a major pulmonary resection. METHODS: Perioperative data were acquired from 194,319 noncardiac surgical operations at 123 Veterans Affairs Medical Centers between October 1, 1991, and August 31, 1995. Current Procedural Terminology code-based analysis was undertaken for major pulmonary resections (lobectomy and pneumonectomy). Preoperative, intraoperative, and outcome variables were collected. The 30-day mortality and morbidity models were developed by means of multivariable stepwise logistic regression with the preoperative and intraoperative variables used as independent predictors of outcome. RESULTS: A total of 3516 patients (mean age 64 9 years) underwent either lobectomy (n = 2949) or pneumonectomy (n = 567). Thirty-day mortality was 4.0% for lobectomy (119/2949) and 11.5% for pneumonectomy (65/567). The preoperative predictors of 30-day mortality were albumin, do not resuscitate status, transfusion of more than 4 units, age, disseminated cancer, impaired sensorium, prothrombin time more than 12 seconds, type of operation, and dyspnea. When the intraoperative variables were considered, intraoperative blood loss was added to the preoperative model. In the presence of these intraoperative variables in the model, do not resuscitate status and prothrombin time more than 12 seconds were only marginally significant. Thirty-day morbidity, defined as the presence of 1 or more of the 21 predefined complications, was 23.8% for lobectomy (703/2949) and 25.7% for pneumonectomy (146/567). In multivariable models, independent preoperative predictors (P <.05) of 30-day morbidity were age, weight loss greater than 10% in the 6 months before surgery, history of chronic obstructive pulmonary disease, transfusion of more than 4 units, albumin, hemiplegia, smoking, and dyspnea. When intraoperative variables were added to the preoperative model, the duration of operation time and intraoperative transfusions were included in the model and albumin became marginally significant. CONCLUSIONS: This analysis identifies independent patient risk factors that are associated with 30-day mortality and morbidity for patients undergoing a major pulmonary resection. This series provides an initial risk-adjustment model for major pulmonary resections. Future refinements will allow comparative assessment of surgical outcomes and quality of care at many institutions.

Adult↗
PubMed1999

Practice management in obstetrics and gynecology residency curriculum.

OBJECTIVE: To establish the current level of instruction in practice management in obstetrics and gynecology residency programs; review recommendations of medical school practice management executives and current and former residents on design of practice management instruction programs; and develop recommendations for future management instruction by residency programs in obstetrics and gynecology. METHODS: A questionnaire was sent to 101 practice plan executives of obstetrics and gynecology departments at medical schools in the United States and Canada. A modified version was sent to 44 current obstetrics and gynecology residents and 72 former residents from the University of Tennessee, Memphis. RESULTS: The response rates were 71% (practice executives), 93% (current residents), and 81% (former residents). There were no formal management programs at 87% of responding institutions, although most respondents (62%) thought there should be mandatory participation in management programs, probably given by organizations outside the university. Potential subjects that received high ratings were current procedural terminology and diagnosis coding, managed care, billing procedures, contractual agreements between medical doctors, patient record management, and practice economics. CONCLUSION: Residency programs should establish formal practice management instruction programs and make participation mandatory. Funding should come from the medical school and university. Instructional help should come from extradepartmental organizations and individuals.

Canada↗
PubMed2003

Routine use of postoperative ICU care for elective craniotomy: a cost-benefit analysis.

OBJECTIVE: Postoperative monitoring in an intensive care unit (ICU) setting following elective craniotomy is routine at many institutions, as it is believed that this reduces the incidence and potential seriousness of early postoperative complications. This is unproven, however, and ICU resources are scarce and costly. At our institution, one surgeon began to routinely transfer elective craniotomy patients directly to the floor following an uneventful postanesthesia care unit (PACU) recovery. This study was undertaken to see whether that practice was safe and cost-effective. METHODS: A retrospective cohort of 430 consecutive, elective adult craniotomies, from February, 2000 to September, 2001 were analyzed. Variables were divided into 12 major groups: attending surgeon, age, sex, diagnosis, Current Procedural Terminology (CPT) code, length of stay, preoperative deficit, medical co-morbidities, postop floor, medical complications, neurological complications, and total hospitalization cost. RESULTS: Patients admitted to the surgical intensive care unit (SICU) did not have fewer complications than patients transferred directly to the floor. Patients admitted to the SICU did not have more preoperative neurological deficits or medical co-morbidities. Age was not a significant predictor of either medical or neurological complications. In patients without initial postop complications, only length of stay and postop floor assignment correlated with cost (p < 0.001). Immediate transfer to the floor decreased average hospitalization length by 3 days, and provided cost savings of $4,026 per patient. CONCLUSIONS: Selective, rather than routine use of postoperative ICU care in elective craniotomy patients is safe, resulting in no greater incidence of medical or neurological complications, and may provide significant reductions in average hospitalization length and cost.

Adult↗
PubMed1988

The Wilmer Information System. A classification and retrieval system for information on diagnosis and therapy in ophthalmology.

The Wilmer Information System is a computerized medical information system used for the storage and retrieval of data pertaining to patient demographics, diagnosis, and therapy. The heart of the system is an expandable, hierarchical code based on International Classification of Diseases, 9th Revision (ICD-9) diagnosis codes and Physicians' Current Procedural Terminology procedure codes. Customized coding sheets containing highly specific diagnosis and procedure codes have been designed for each subspecialty area in ophthalmology. Interactive database management software facilitates data entry and retrieval. The system can be used to search for patients who meet very specific criteria, or to produce cumulative visit reports and summary statistics.

Computers↗
PubMed1998

Factors associated with elevated rates of adverse outcomes after cyclodestructive procedures versus drainage device procedures.

OBJECTIVE: To identify factors associated with an increased risk of adverse outcomes after cyclodestructive or drainage device procedures. DESIGN: Retrospective, cohort analysis. PARTICIPANTS: A total of 5570 Medicare patients who were older than 65 years of age and who underwent cyclodestructive or drainage device procedures in 1994 participated. INTERVENTION: The authors identified cyclodestructive and drainage device procedures from claims to the Health Care Finance Administration (HCFA) by International Classification of Diseases (ICD-9) procedure codes, Current Procedural Terminology procedure codes, and HCFA Common Procedural Classification System codes. The authors analyzed adverse outcome rates using hierarchical logistic regression. Race, age group, gender, length of observed follow-up, state in which surgery took place, ocular procedures performed before and at the same time as the index surgery, and ocular diagnosis were included as covariates in the model. MAIN OUTCOME MEASURES: The authors defined an adverse outcome as the occurrence after the index surgery of at least one of the following: repeat cyclodestructive or drainage device procedure, retinal hole-tear repair, retinal detachment repair, surgery for endophthalmitis, vitrectomy, enucleation, evisceration, surgery for ocular hypotony, and/or extrusion or revision of drainage device. Adverse outcomes were also defined without the inclusion of repeat cyclodestructive or drainage device procedures. RESULTS: When repeat cyclodestructive or drainage device procedures were not included in the definition of an adverse outcome, eyes with a drainage device procedure were 3.8 times more likely to have an adverse outcome than eyes with a cyclodestructive procedure (odds ratio [OR], 3.8; 95% confidence interval [CI], 3.07, 4.67). Subjects with concurrent corneal transplant had increased odds of an adverse outcome compared to subjects without a concurrent corneal transplant (OR, 2.00; 95% CI, 1.27, 3.15). When the definition of an adverse outcome included repeat cyclodestructive or drainage device procedures, the odds of an adverse outcome were similar for both cyclodestructive and drainage device procedures (OR, 0.94; 95% CI, 0.79, 1.13). CONCLUSIONS: Cyclodestructive procedures need to be repeated more frequently than drainage device procedures. However, if the patient has a drainage device procedure, then that patient is more likely to have other types of adverse ophthalmic events than if he or she had a cyclodestructive procedure. Because the average follow-up of subjects in this study is 5 months (range, 0-12 months), outcomes that might take longer to manifest themselves would be excluded from this study.

Aged↗
PubMed2000

Effect of a state definition of an "emergency medical condition" legislation on medicaid managed care organization reimbursement.

STUDY OBJECTIVE: The state of Michigan passed Public Act 136 of 1997 requiring Medicaid managed care organizations (MMCOs) to pay for emergency services whenever presenting symptoms constituted an "emergency medical condition." The objective of this study was to evaluate MMCO reimbursement before and after enactment of this state law. METHODS: We conducted a retrospective comparison of reimbursement for lacerations needing repair (identified using Current Procedural Terminology codes from computerized billing data) for 2 time periods (before the state law was applicable [January through March 1998] and after the state law was applicable [April through June 1998]) from MMCO enrollees in 7 different MMCOs presenting to 4 urban emergency departments. Three months after billing submission was allowed for payment. Only refusal of reimbursement was evaluated. Data were analyzed using chi(2) and Fisher's exact test (values of P <.05 were considered significant). RESULTS: The total number of MMCO patients evaluated/total number of ED patients evaluated for the 2 periods was 1,769/32,646 and 3, 376/30,901, respectively (P <.05). The number of MMCO lacerations with no reimbursement/total number of MMCO lacerations for the 2 periods was 4/135 (3%) and 78/196 (40%), respectively (P <.001). CONCLUSION: Reimbursement by MMCOs for a procedure chosen to reflect a state-defined "emergency medical condition" is inadequate and significantly decreased during the 2 periods, with a significant increase in MMCO patients evaluated.

Chi-Square Distribution↗
PubMed2000

Reimbursement impact of medicaid managed care organizations replacing standard medicaid.

STUDY OBJECTIVE: To evaluate the reimbursement difference for Medicaid managed care organization (MMCO) enrollees compared with Medicaid enrollees for emergency department patients with disease conditions that appear to meet the "prudent layperson" definition of an emergency medical condition. METHODS: This study used a retrospective reimbursement review of computerized billing data of reimbursement denials for 4 procedures (using Current Procedural Terminology codes for endotracheal intubation, cardiopulmonary resuscitation, central line placement, and lumbar puncture) and 1 International Classification of Diseases, ninth revision condition (chest pain) on MMCO patients from 7 MMCOs compared with standard Medicaid patients presenting to 4 EDs during a 6-month period (January through June 1998). Exclusion criteria were late bills that did not allow at least 90 days for payment and bills submitted on behalf of patients that were not covered at the time of service by Medicaid or MMCO. Data were analyzed using Fisher's exact test. RESULTS: The total number of MMCO and Medicaid patients evaluated/total ED patients evaluated was 5,153/63,552 and 6,020/63, 552, respectively. The number of nonreimbursed procedures/total number of procedures performed on MMCO and Medicaid patients was 35/93 and 14/88, respectively (P <.05). The number of nonreimbursed chest pain patients/total chest pain patients evaluated for MMCO and Medicaid enrollees was 65/277 and 12/199, respectively (P <.05). CONCLUSION: MMCOs reimburse significantly less than Medicaid does for ED patients with conditions that a prudent layperson would consider an emergency.

Confidence Intervals↗
PubMed2001

Can costs be measured and predicted by modeling within a cooperative clinical trials group? Economic methodologic pilot studies of the radiation therapy oncology group (RTOG) studies 90-03 and 91-04.

PURPOSE: To (1) measure radiation therapy costs for patients in randomized controlled clinical trials, (2) compare measured costs to modeling predictions, (3) examine cost distributions, and (4) assess feasibility of collecting economic data within a cooperative group. METHODS: The Radiation Therapy Oncology Group conducted economic pilot studies for two Phase III studies that compared fractionation patterns. Expected quantities of Current Procedural Terminology (CPT) codes and relative value units (RVU) were modeled. Institutions retrospectively provided procedure codes, quantities, and components, which were converted to RVUs used for Medicare payments. Cases were included if the radiation therapy quality control review judged them to have been treated per protocol or with minor variation. Cases were excluded if economic quality review found incomplete economic data. RESULTS: The median and mean RVUs were within the range predicted by the model for all arms of one study and above the predicted range for the other study. CONCLUSION: The model predicted resource use well for patients who completed treatment per protocol. Actual economic data can be collected for critical cost items. Some institutions experienced difficulty collecting retrospective data, and prospective collection of data is likely to allow wider participation in future Radiation Therapy Oncology Group economic studies.

Brain Neoplasms↗
PubMed1999

The use of automated data to identify complications and comorbidities of diabetes: a validation study.

We evaluated the accuracy of administrative data for identifying complications and comorbidities of diabetes using International Classification of Diseases, 9th edition, Clinical Modification and Current Procedural Terminology codes. The records of 471 randomly selected diabetic patients were reviewed for complications from January 1, 1993 to December 31, 1995; chart data served to validate automated data. The complications with the highest sensitivity determined by a diagnosis in the medical records identified within +/-60 days of the database date were myocardial infarction (95.2%); amputation (94.4%); ischemic heart disease (90.3%); stroke (91.2%); osteomyelitis (79.2%); and retinal detachment, vitreous hemorrhage, and vitrectomy (73.5%). With the exception of amputation (82.9%), positive predictive value was low when based on a diagnosis identified within +/-60 days of the database date but increased with relaxation of the time constraints to include confirmation of the condition at any time during 1993-1995: ulcers (88.5%); amputation (85.4%); and retinal detachment, vitreous hemorrhage and vitrectomy (79.8%). Automated data are useful for ascertaining potential cases of some diabetic complications but require confirmatory evidence when they are to be used for research purposes.

Adolescent↗
PubMed2002

Alzheimer's disease or other dementia and medical care utilization.

PURPOSE: Recent findings on medical care utilization among people with Alzheimer's disease (AD) or other dementia (OD) are conflicting. A population-based case-control study was designed to determine if patients with clinically diagnosed AD or OD have different medical care utilization patterns before and after diagnosis compared to age-matched controls. METHODS: All community dwelling incident cases of AD (n = 240) or OD (n = 208) diagnosed between July 1, 1992 and June 30, 1997, and age-matched controls (n = 363) living in an enumerated population, were included. Medical care services, defined by Physicians' Current Procedural Terminology Codes, were assessed the year prior to diagnosis and up to five years after diagnosis of AD/OD. RESULTS: Prior to diagnosis, AD/OD cases had a significantly greater age-adjusted average number of medical services per year, 33 and 29, respectively, compared to 20 for controls (p = 0.0001 and p = 0.0002, respectively). These differences were significant after adjusting for age, gender, follow-back time, comorbidities, and insurance status. After diagnosis, AD/OD cases still had significantly greater age-adjusted average number of medical services per year (34 services and 37 services, respectively) compared to controls with 27 services (p = 0.0064 and p = 0.0006, respectively). After adjusting for confounding variables (particularly comorbid conditions), these differences were no longer significant. CONCLUSIONS: This research demonstrates that higher medical care utilization by patients with AD/OD after diagnosis is not due to dementia per se, but explained by their poorer physical health compared to controls. Greater utilization prior to diagnosis of AD/OD is most likely due to the search for a diagnosis for the person developing dementia.

Aged↗