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PubMed1999

Sleep complaints among the elderly: results from a survey in a psychogeriatric outpatient clinic in Brazil.

BACKGROUND: Sleep complaints are frequent in old age. These difficulties are often associated with health-related problems, drug consumption, and the presence of mental disorders. Nonetheless, only sparse information is available on the clinical characteristics of elderly persons with insomnia. AIMS: (a) To evaluate the prevalence of sleep problems among the elderly assessed in a psychogeriatric outpatient clinic; (b) to evaluate the association between the use of sleep tablets and sleep difficulties in this sample of patients. METHODS: One hundred eighteen consecutive subjects were recruited from a psychogeriatric outpatient service in São Paulo, Brazil. Their sleep pattern was systematically assessed with the "sleep inventory," a questionnaire consisting of 31 items that evaluate a number of sleep-related features. Clinical diagnoses followed the ICD-10 clinical descriptions and diagnostic guidelines. The number of drugs consumed by patients was also recorded. RESULTS: Sleep complaints were highly prevalent (59.3%), with early-morning awakening and nightmares being more frequent among patients with a depressive disorder. The use of sleep tablets was reported by 37.3% of subjects, and was associated with subjective sleep difficulties (odds ratio [OR] = 7.13, p = .008), difficulties falling asleep (OR = 7.33, p = .021), and frequent awakening during the night (OR = 7.10, p = .040) in a logistic regression analysis. CONCLUSION: Sleep dissatisfaction is frequent among psychogeriatric outpatients. Subjects taking hypnotic drugs have more sleep-related complaints than those who do not. The clinical use of hypnotics may not be very effective for the treatment of sleep-related problems in the elderly. There is an urgent need for systematic prospective controlled studies to assess the efficacy and safety of the various forms of treatment of insomnia in old age.

Aged↗
PubMed1989

The effect of prospective payment on Medicare expenditures.

Medicare's prospective payment system was introduced in 1983 to slow the growth of expenditures for hospital care, which from the bulk of Medicare costs. Instead of reimbursing hospitals for the actual costs of patient care, the system pays them at fixed rates for each admission. In this study, we estimated the savings to Medicare from the use of prospective payment. We analyzed the expenditure projections published in 10 successive annual reports (1979 to 1988) by the trustees of the federal Hospital Insurance Trust Fund, which pays hospital bills for Medicare beneficiaries. To show the effect of prospective payment, these projections were adjusted to correct for the different assumptions about inflation and admissions made in each report. We also examined trends in expenditures from the Supplementary Medical Insurance Trust Fund, which pays for outpatient services, to see whether the savings in hospital expenses were offset by higher spending for out-of-hospital services. We found that prospective payment has reduced Medicare's hospital costs substantially. Expenditures from the Hospital Insurance Trust Fund for 1990 are expected to be +12 billion less in 1980 dollars, and +18 billion in 1990 dollars, than was expected shortly before prospective payment went into effect--the equivalent of a savings of approximately 20 percent. By contrast, the effect of prospective payment on the supplementary fund has not been great. We conclude that the prospective payment system is having a major impact on Medicare's hospital expenditures and that the savings is not offset by an increase in outpatient expenditures.

Ambulatory Care↗
PubMed1990

[Family physician: problems and realities].

The experience gained in the Soviet Union and abroad with family physician service is reviewed. The scope of his duties is outlined which are to be adjusted for specific conditions of rural and city health care. The family physician is to be neither a particular specialist nor an expert in all fields of medicine, rather a broad-minded and skilled internist informed about social and psychological matters and able to attend both adults and adolescents. The chief goal of his practice should be prophylaxis medicine, regular check-ups. Extensive experimental research is needed to adopt the system of family physician in this country as it necessitates revision of conventional principles of industrial, school, outpatient services, training of medical staff, etc.

Estonia↗
PubMed1987

Detection of chlamydial cervicitis with Papanicolaou-stained smears and cultures in a university student population.

Over a 34-month period, 12,647 Papanicolaou smears were obtained from a student health service outpatient gynecologic population at moderate risk of chlamydial infection. We found 287 (2.3%) to have cytologic features suggestive of chlamydial cervicitis. Chlamydia trachomatis was definitely isolated by endocervical culture in only 4.5% of these 287 subjects. Cytologic features suggestive of chlamydial cervicitis were found to be unreliable in diagnosing chlamydial infection.

Adult↗
PubMed2000

Cognitive rehabilitation: a pilot survey of therapeutic modalities used by Canadian occupational therapists with survivors of traumatic brain injury.

This pilot study used survey methodology to gather initial information from Canadian occupational therapists on 1) the delivery of cognitive rehabilitation services for survivors of traumatic brain injury and 2) the therapeutic approaches and modalities used currently to manage residual cognitive impairments. A questionnaire was developed, field-tested and mailed to 27 sample sites across Canada, selected non-randomly. Twenty returned questionnaires (74%) were included in the data pool. The findings revealed that a wide range of cognitive impairments were seen very often, with impairments in memory being most common. Respondents used both a cognitive remediation and compensatory approach and a combination of therapeutic modalities to address impairments of orientation, attention, and memory. There was an interesting and overlapping range of specific modalities identified. Inpatient and outpatient services were offered to survivors, primarily within the first year post-injury. These occupational therapists used various resources to develop expertise in cognitive rehabilitation. Possible implications of the pilot study findings for Canadian occupational therapists are high-lighted and discussed.

Adult↗
PubMed2003

Analysis model for planning chemical dependence treatment systems.

Statewide needs assessments commonly generate a single estimate of the number of persons needing chemical dependence treatment. The present analysis utilizes help-seeking behavior models and patient placement concepts to break a single statewide need estimate into operational units of services and costs that can be used for planning and resource allocation. The analyses are presented as allocation models for placements, service populations, service capacities, and costs. The guide was tested using state data for a target year and the results were compared to actual treatment admissions, which revealed a lack of convergence. Only 9% of persons were estimated to need intensive residential treatment whereas actual admissions to intensive residential treatment accounted for 29% of all admissions. The disparities may be accounted for by sampling bias of the needs estimate and by the likelihood that persons with more severe problems may be overrepresented when only a small proportion of treatment need is being met. These findings suggest that if resources become available to narrow the treatment gap, a larger proportion of outpatient services and less intensive services may be appropriate for the expanded clientele.

Health Planning↗
PubMed2004

Outpatient mental health services for children in foster care: a national perspective.

OBJECTIVE: To determine factors influencing the use of outpatient mental health services provided by mental health professionals (OMHS) for children in foster care using a national probability sample in the United States. METHOD: As part of the National Survey of Child and Adolescent Well-being, detailed survey data were collected on 462 children, ages 2-15, who had been in out-of-home care for approximately 12 months at the time of sampling. A multivariate logistic regression model was used to determine how clinical need, as measured by a Total Problem, Externalizing, or Internalizing Scale T-score of 64 or greater on the Achenbach Child Behavior Checklist (CBCL), and non-clinical factors affected OSMHS use. RESULTS: Over half of the children in the sample received at least one OMHS. Need, older age, and history of sexual abuse history all positively predicted OMHS. A history of physical neglect negatively predicted OSMHS. African-Americans used fewer services than children of Caucasian ancestry at all values on the CBCL. This finding was particularly salient at lower levels of CBCL scores; at higher levels, the discrepancy in the use of services diminished but the proportion of children receiving services remained lower for African-American children. CONCLUSIONS: This national study confirms previous findings regarding the use of mental health services based on regional data. Limitations in the use of services imposed by non-clinical factors, specifically, age, race/ethnicity and type of abuse, need to be examined in order to address implicit and explicit policies and practices that may result in inequitable distribution of services.

Adolescent↗
PubMed2004

Age-related modifiers of clinical presentation and health service use among veterans with bipolar disorder.

OBJECTIVE: This retrospective analysis of a large Department of Veterans Affairs (VA) database evaluated differences in clinical presentation, health service use, and use of psychotropic medications between older and younger adults with bipolar disorder. METHODS: The results presented in this article focus on veterans with bipolar disorder who were active in the VA's National Psychosis Registry in federal fiscal year 2001 (FY01). RESULTS: The registry listed 65,556 individuals as having bipolar disorder in FY01. In FY01, nearly 25 percent of veterans with bipolar disorder (more than 16,000 individuals) were aged 60 years or older, and more than 10 percent were aged 70 years or older. Elderly persons were hospitalized at similar or slightly lower rates than middle-aged persons but tended to have longer hospital stays. Use of outpatient services was also higher in older populations. Patterns of use of psychotropic medications indicated that valproate is the most commonly used mood-stabilizing agent in the VA, in use by 72.9 percent of patients who receive a mood stabilizer. Use of lithium is substantial as well, with more than 40 percent of patients taking this agent. In addition, just over 40 percent of all veterans with bipolar disorder receive antipsychotic medication. CONCLUSIONS: Bipolar disorder affects large numbers of veterans across the entire life span, and use of VA resources by this population becomes greater with advancing age. Data from this study provide new information about the unique treatment requirements and clinical presentations of older patients with bipolar disorder.

Age Factors↗
PubMed1997

Reciprocating gait orthosis powered with electrical muscle stimulation (RGO II). Part I: Performance evaluation of 70 paraplegic patients.

Seventy paraplegics were fitted with an improved Reciprocating Gait Orthosis powered with or without (low-level injury) electrical stimulation of the thigh muscles (RGO II) as a secondary rehabilitation phase after the acute period. The patients comprised a broad cross-section of the paraplegic population applying for medical services and varied in age from 16 to 55 years, time since injury ranging from less than 1 to 15 years, injury levels ranging from C-6/7 to T-11/12, and varying levels of spasticity, contractures, scoliosis and other related medical and physiologic problems. The success/failure ratio was dependent on the injury level, which was 1:1 for paraplegics with injury level at C-6/7; 1.67:1 for those with injury of T-1/3; and about 4:1 for paraplegics with injury level from T-3 to T-12. Lack of motivation and medical problems unrelated to the RGO II treatment were the primary reasons for failure. The duration of treatment (outpatient service three times per week) ranged from 2 to 48 weeks (mean: 16). Forty-one patients who completed the RGO II rehabilitation and were sent home with the orthosis for independent use (for at least 6 months and up to 3 years) were surveyed by a staff member for analysis of the meaning and impact of the RGO II on the patient's life and health, and potential problems. It was shown that 80.5% of the 41 patients were regular users and 19.5% were non-users. Thirty-eight of the 41 patients declined an offer to return the RGO II equipment for a full refund, while three patients were willing to return the orthosis. It was concluded that the RGO II is viable orthosis for restoring standing and limited walking in paraplegics while providing sufficient function, safety, and reliability. The most appropriate patients for the use of such an orthosis consist primarily of those with T-3 to T-12 injury level and good motivation, although highly selected patients with higher injury levels also can benefit from its use. Regular use of the RGO II, even for exercise only, had a general positive impact on the patients' health and outlook.

Adolescent↗
PubMed1999

Direct expenditures for the treatment of allergic rhinoconjunctivitis in 1996, including the contributions of related airway illnesses.

BACKGROUND: Previous estimates of the national economic burden of allergic rhinoconjunctivitis (AR/AC) have relied on data analyses in which AR/AC was the primary International Classification of Diseases-ninth revision-Clinical Modification (ICD-9-CM)-coded diagnosis. These studies ignore the costs when AR/AC was a secondary diagnosis to other disorders such as asthma and sinusitis. OBJECTIVE: We sought to determine the national direct cost of illness for AR/AC. METHODS: An expert panel used the Delphi technique to estimate the proportion of visits coded by other primary ICD-9-CM diagnoses in which AR/AC was a significant secondary comorbid condition. The costs of this proportion were deemed to be "attributable" to AR/AC and were added to the costs when allergic rhinitis and allergic conjunctivitis were the primary diagnoses. RESULTS: The cost when AR/AC was the primary diagnosis was $1.9 billion (in 1996 dollars). The cost when AR/AC was a secondary diagnosis was estimated at $4.0 billion, giving an estimate of $5.9 billion for the overall direct medical expenditures attributable to AR/AC. Outpatient services (63%, $3.7 billion), medications (25%, $1.5 billion), and inpatient services (12%, $0.7 billion) accounted for the expenditures. Children 12 years and younger accounted for $2.3 billion (38.0%). CONCLUSION: Upper airway allergy is an expensive disease process because of its readily apparent manifestations as AR/AC and its contribution to other airway disorders.

Adult↗
PubMed1982

An analysis of types and costs of health care services provided to an elderly inner-city population.

The challenge facing national policymakers is to provide health care that is comprehensive and cost-effective to our nation's growing population of elderly people. A solution worthy of consideration is the use of health maintenance organizations (HMOs) in this capacity. An analysis of the services provided by a multidisciplinary health care system to 150 inner-city elderly, many of whom were "homebound," reversal 1) this population is not homogeneous with respect to severity of disease and service utilization, and 2) a total mean cost per individual per year of $2,021.34 covers: physician, nursing, and social service home visits; visiting nurse, homemakers, home health aide, occupational therapy and physical therapy services; outpatient, laboratory and medication costs. These findings suggest that while costs for those over 65 are many times the per capita costs of younger enrollees, these costs may be significantly less than the costs of institutional care. Further investigation of the costs of maintaining low-income inner-city old, as well as other elderly populations, at home is vital to planning for future long-term care.

Aged↗
PubMed1989

Smoking, prevalence of disease and health service utilization among the Swiss population.

The data of the 1981-83 Swiss National Health Survey "SOMIPOPS", based on a randomly selected sample of 4,235 individuals aged 20 or over representative of the whole Swiss population, were used to investigate the relation between smoking, prevalence of disease and frequency of health care utilization. The risks of several conditions, including hypertension, myocardial infarction and other heart diseases, asthma, tuberculosis and kidney disease were elevated among ex-smokers. The diseases showing elevated risks among current smokers and significantly positive dose-risk trends included acute bronchitis (relative risk, RR = 3.2 for heavy cigarette smokers vs never smokers), chronic bronchitis or lung emphysema (RR = 2.0), gastro-duodenal ulcer (RR = 1.8) and bone fractures (RR = 1.6). For respiratory conditions, the risk of pipe or cigar smokers was comparable to that of moderate cigarette smokers, whereas for ulcer (RR = 4.1) or fractures (RR = 2.0) the point estimates were even higher than for heavy cigarette smokers. Smokers tended to consult more frequently general practitioners, used more other outpatients services, and were more frequently admitted to hospital during the year preceding the interview. These effects were consistent across strata of age, socio-economic indicators, and persisted after allowance for major identified potential distorting factors. Thus, the results of this survey confirm that smoking is an important cause of morbidity and a major contributory factor to the use of health services.

Adult↗
PubMed1990

The DRG hospital payment system, surgical readmissions and cost containment.

We analyzed all adult surgical patients requiring readmission to the surgical service of an acute care academic hospital for a four-year period (1/1/85-12/31/88). We stratified surgical readmissions by the number of times the patient was readmitted to surgery (from one to five times). For surgical patients 41.1 per cent of the readmission population was readmitted more than once, only 4.4 per cent were readmitted five or more times. Patients requiring three or more admissions generally had the greatest hospital resource utilization, financial risk under DRG payment, and mortality, compared with other surgical readmissions. This analysis suggests that within the surgical readmission population resource parameters may differ by the number of readmissions per patient. Factors were identified which corresponded to a greater likelihood of surgical readmission, and possibly allow the focus of outpatient services which may reduce hospital inpatient costs in the future.

Academic Medical Centers↗
PubMed1979

Hospital pharmacy purchases and inventories.

The results of the hospital pharmacy purchases and inventories portion of a 1978 national mail survey of pharmaceutical services in short-term hospitals are reported. A sample of 815 hospitals was selected randomly from among 5,200 U.S. short-term hospitals that employ a pharmacist on at least a part-time basis. The inventory question had a response rate of 67.7%, the purchasing question, 62.2%; inventory turnover was calculated based on a response rate of 60.5% to both questions. Inventories were inordinately large in small hospitals. Inventory turnover rates, which increased with hospital size, were somewhat less than optimal in small and medium hospitals. The Pacific region's inventory/bed and purchases/bed values were substantially greater than those of any other region. Large hospitals had a 20% higher annual purchases/bed figure than the smaller hospitals, perhaps because of their relatively greater volume of outpatient services. Based on their respective demand (as measured by adjusted inpatient days), the drug purchases of the New England and Mid-Atlantic regions were less than expected, while the Mountain and Pacific regions' drug purchases were much greater than expected. Total 1979 purchases of pharmaceuticals and related supplies by pharmacies in all short-term hospitals are estimated to reach $2,215 to $2,772 million.

Hospital Bed Capacity↗
PubMed2000

Trauma patient outcome in an army Deployable Medical Systems environment compared with a medical center.

William Beaumont Army Medical Center is the second busiest trauma center in the Army. Recent facility renovations there necessitated the use of a temporary field hospital to serve as the Emergency Department, which included the initial evaluation and resuscitation of trauma patients by the trauma team. Although designed for the battlefield, the use of field medical equipment during renovation of military medical facilities is not a new concept. The MUST (Medical Unit Self-contained Transportable) and DEPMEDS (Deployable Medical Systems) have been used successfully during fixed-facility renovations. Previously described functions included inpatient services, outpatient care, and operating room facilities. However, no published information directly compares the use of these temporary structures with standard fixed facilities in the initial management of trauma patients. Trauma patients often present with complex concerns, are highly resource intensive, and their survival is dependent on efficient, timely care. We compared several aspects of patient outcome in the DEPMEDS versus the medical center.

Adolescent↗
PubMedDate not supplied

Marketing telehealth to align with strategy.

Telehealth is a twenty-first century solution to an old problem-how to deliver quality health services with shrinking resources. Telehealth enables healthcare providers to interact with and monitor patients remotely, thus adding value to service delivery models. On occasion, telehealth can substitute for live encounters, saving time and resources. Furthermore, as the geriatric population increases, telehealth will support independent living by supplementing the existing network of care. To be used most effectively, however, telehealth services must be carefully planned and executed. This study investigated management practices used to promote telehealth services, focusing on strategic goals for adopting telehealth. Interviews with senior managers from 19 home health agencies identified three strategic goals for adopting telehealth: (1) clinical excellence, (2) technological preeminence, and (3) cost containment. Organizational documents were analyzed to determine the extent to which the telehealth program was featured in marketing materials. Documents included the organization's brochure, newspaper ads and articles, and each home health agency's web site. Results showed that marketing practices vary widely but are correlated with motivations to adopt telehealth. The organizations with the highest marketing scores emphasize clinical excellence as a major reason for using telehealth, whereas those with the lowest marketing scores tend to focus on cost containment. Although this study focused on management practices in home health agencies, results are applicable to hospital and outpatient services as well as to other community-based programs. Using a strategic management framework, the authors offer recommendations to help organizations develop effective marketing approaches for telehealth programs.

Guidelines as Topic↗
PubMed2002

A comparison of youth referred to psychiatric emergency services: police versus other sources.

Although the presentation of children and adolescents to psychiatric emergency services has been increasing, little is known about the characteristics of these persons, the circumstances surrounding their referral for treatment, or their disposition. This study compares patients referred by police with those referred by others, based on data from a study of 1,779 patients in the Bronx, New York. Logistic regression was used to develop propensity scores for selection of a matched sample of non-police referrals (n = 159) to compare with police referrals (n = 53). Caregivers in police-referred cases were rated as less capable of active treatment involvement, and domestic violence was more likely to occur in their homes. Police referrals had higher substance use in the past month than referrals from other sources, were rated as more symptomatic and dangerous to self and others, had exhibited more assaultive and destructive behavior, and were less likely to be referred to outpatient services.

Adolescent↗
PubMed1981

The detection of active pulmonary tuberculosis in Singapore.

A prospective study was carried out to identify the services which were responsible for detection of pulmonary tuberculosis in Singapore. It was found that the public health services were the sources of 58.8% of cases. Among them the Tuberculosis Control Department detected the largest proportion (25.8%) of cases. These formed the majority of the asymptomatic and a large proportion of the abacillary cases detected. It was suggested that this reflected the result of the Department's active case-finding programme. The private practitioners identified 30% of patients. More than half of them were bacillary cases and they were a significant proportion of all infectious cases detected. Thus while the Department of Tuberculosis Control detected most of the patients with early tuberculosis disease, the bulk of the infectious cases with extensive disease were diagnosed by the private practitioners. Both sectors complement each other in the detection of tuberculosis cases in the country. An improvement and expansion of the existing case detection programme among patients attending the clinics of private practitioners and the Outpatient Service Department's dispensaries was recommended. The way in which this could be done and some of the problems that might be encountered were discussed.

Bacteriological Techniques↗