Miscoding of mental health diagnoses and stigmatization.
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Alcoholism↗
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Functional vs cosmetic ophthalmologic defects.
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Blepharoptosis↗
The content and cost of cataract surgery.
Although more than 1 million cataract surgeries are performed annually in the United States, little is known about the frequency of use or cost of various services provided in connection with this procedure. To assess the frequency with which various ophthalmic, optometric, anesthesia, and medical services are provided in conjunction with cataract surgery and to estimate the cost to Medicare associated with those services, we analyzed 1985 through 1988 Medicare claims records of a nationally representative 5% sample of Medicare beneficiaries. The experience of 57,103 Medicare beneficiaries who underwent extracapsular cataract surgery in 1986 or 1987 that was not combined with another ophthalmologic procedure formed the basis of our analysis. Projections for current costs were performed using 1991 charges allowed by Medicare for physician services. We estimate that the median charge allowed by Medicare for a "typical" episode of cataract surgery in 1991 was approximately $2500. In addition to the $3.4 billion that Medicare spent in 1991 on such "typical" episodes, Medicare spent more than $39 million on miscellaneous "atypical" preoperative ophthalmologic tests, such as specular microscopy (14% of cases) and potential acuity testing (8% of cases), more than $7 million on postoperative ophthalmologic diagnostic tests, such as fluorescein angiography (3% of cases), and more than $18 million on perioperative medical services (most commonly electrocardiography and chest roentgenography). The major determinants of the cost to Medicare associated with cataract surgery are the rate of performance of cataract surgery and neodymium-YAG laser capsulotomy and the charges allowed for these procedures.(ABSTRACT TRUNCATED AT 250 WORDS)
Cataract Extraction↗
Ophthalmic malpractice lawsuits with large monetary awards.
Malpractice claims against ophthalmologists that were closed with patient indemnification of at least $250,000(18% of all eye claims closed with payments to patients) were analyzed for risk prevention. The incident of alleged malpractice occurred within 1 month of the initial physician-patient encounter in 43% of claims and on the initial encounter in 17%. Cataract was the most frequent problem for which these patients sought treatment. Eighty-four percent of these patients sustained injuries resulting in legal blindness or worse. The most frequent complication of treatment (25%) was failure or delay in diagnosis of detached retina, or negligent treatment resulting in a retinal detachment. The most frequent factors influencing the decision to seek a settlement included altered records, poor documentation, informed consent problems, failure to see the patient promptly, and failure to obtain or follow the advice of a consultant.
Adolescent↗
Compensation for birth-related injury: no-fault programs compared with tort system.
OBJECTIVE: To compare compensation systems for birth-related injuries. DESIGN: Retrospective cohort study. SETTING: Florida. PARTICIPANTS: Parents of children with birth-related injuries who filed claims that closed before August 1, 1995, with Florida's no-fault program (Neurological Injury Compensation Act [NICA]) or who filed tort claims that closed from January 1, 1986, to August 1, 1995. MAIN OUTCOME MEASURES: Compensation for medical and income losses due to birth-related injuries. RESULTS: Families who received tort settlements were overcompensated for the injury, considering all sources of compensation. By contrast, NICA recipients broke even. Those who did not receive tort or NICA compensation lost nearly $75000 in the first 5 years following the birth. In the subsample of families of children with cerebral palsy, overcompensation by tort claim was even greater, whereas NICA recipients were undercompensated. The cost of care for cerebral palsy in both groups was the same. The difference between tort and NICA compensation levels was attributable to payment for income loss. Overall, NICA recipients were satisfied with compensation received. CONCLUSIONS: Medical expenses were adequately covered under NICA, but not income loss. A universal health insurance program for children would not cover income losses. Similar costs incurred in NICA and tort systems suggests no rationing of care by NICA. Finally, absent some sort of targeted compensation, the losses experienced by families of children with birth-related injuries were substantial.
Adult↗
Changing patterns of conditions among children receiving Supplemental Security Income disability benefits.
OBJECTIVE: To determine the relative growth of types of chronic health conditions among children and adolescents receiving Supplemental Security Income (SSI) benefits before and after major SSI program changes, including changes in definitions of childhood disability and outreach to identify eligible children. DESIGN: Retrospective analysis of Medicaid claims from California, Georgia, Michigan, and Tennessee. PARTICIPANTS: All children (aged < or = 21 years) newly enrolled in SSI programs in these states from July 1989 (n=21 222) to June 1992 (n=38 789). METHODS: Medicaid data indicate eligibility status and diagnoses for services rendered. For children newly enrolled before (time 1, July 1989 to June 1990), during (time 2, July 1990 to June 1991), and after (time 3, July 1991 to June 1992) the program changes, we used claims for the first 6 months of enrollment to determine rates of chronic conditions in general and rates of asthma, attention-deficit/hyperactivity disorder (ADHD), and mental retardation specifically. We also followed up time 1 enrollees during the study period to determine the likelihood of a chronic condition claim at any time. MAIN OUTCOME MEASURE: Presence of claims for chronic conditions. RESULTS: New SSI enrollees almost doubled during the study period. Increasing numbers of new enrollees had chronic condition claims in their first 6 months (from 29% to 36%); 58% of time 1 enrollees had such claims during any study month. Rates of chronic physical conditions other than asthma increased 14% (time 1 to time 3); asthma rates increased 73%. Rates of mental health conditions other than mental retardation and ADHD increased 63%; rates of mental retardation decreased 29%, while rates of ADHD increased almost 3-fold. CONCLUSIONS: The number of children with chronic conditions receiving SSI benefits experienced rapid growth from 1989 to 1992. Growth was particularly marked for children with diagnoses of asthma and ADHD.
Adolescent↗
Cost-effectiveness of systematic depression treatment for high utilizers of general medical care.
BACKGROUND: Expanding access to high-quality depression treatment will depend on the balance of incremental benefits and costs. We examine the incremental cost-effectiveness of an organized depression management program for high utilizers of medical care. METHODS: Computerized records at 3 health maintenance organizations were used to identify adult patients with outpatient medical visit rates above the 85th percentile for 2 consecutive years. A 2-step screening process identified patients with current depressive disorders, who were not in active treatment. Eligible patients were randomly assigned to continued usual care (n = 189) or to an organized depression management program (n = 218). The program included patient education, antidepressant pharmacotherapy initiated in primary care (when appropriate), systematic telephone monitoring of adherence and outcomes, and psychiatric consultation as needed. Clinical outcomes (assessed using the Hamilton Depression Rating Scale on 4 occasions throughout 12 months) were converted to measures of "depression-free days." Health services utilization and costs were estimated using health plan-standardized claims. RESULTS: The intervention program led to an adjusted increase of 47.7 depression-free days throughout 12 months (95% confidence interval [CI], 28.2-67.8 days). Estimated cost increases were $1008 per year (95% CI, $534-$1383) for outpatient health services, $1974 per year for total health services costs (95% CI, $848-$3171), and $2475 for health services plus time-in-treatment costs (95% CI, $880-$4138). Including total health services and time-in-treatment costs, estimated incremental cost per depression-free day was $51.84 (95% CI, $17.37-$108.47). CONCLUSIONS: Among high utilizers of medical care, systematic identification and treatment of depression produce significant and sustained improvements in clinical outcomes as well as significant increases in health services costs.
Ambulatory Care↗
Assessing heterogeneity and correlation of paired failure times with the bivariate frailty model.
We consider bivariate survival times for heterogeneous populations, where heterogeneity induces deviations in an individual's risk of an event as well as associations between survival times. The heterogeneity is characterized by a bivariate frailty model. We measure the heterogeneity effects through deviations associated with hazard functions and an association function defined through the conditional hazard functions: the cross-ratio function proposed by Oakes. We show how the deviation and association measures are determined by the frailty distribution. A Gibbs sampling method is developed for Bayesian inferences on regression coefficients, frailty parameters and the heterogeneity measures. The method is applied to a mental health care data set.
Algorithms↗
Assessment of the relationship between isocyanate exposure levels and occupational asthma.
As part of a previous study, we identified Ontario cases of isocyanate-induced occupational asthma (OA) and the companies at which they worked. The Ontario Ministry of Labour maintained a computerized database including isocyanate air sampling determinations conducted by the Ministry. Within this database, we compared levels of isocyanate concentrations measured at 20 case companies [with compensated isocyanate asthma (OA) claims] with 203 noncase companies, based on air samples collected during the same 4-year period during which the OA claims arose. The proportion of case companies that were ever recorded as having a measured ambient isocyanate concentration of > or = 0.005 ppm was greater than that for noncase companies, for TDI users (43% vs 22%), and for MDI users (40% vs 27%). This reached conventional significance when combined across companies and isocyanate types (50% vs 25%; P < 0.05). This provides some evidence that facilities having OA claims have higher isocyanate exposures than do those without claims.
Air Pollutants↗
Design of a state-based workers' compensation information system.
BACKGROUND: California policy makers have long been hampered by a lack of credible information for use in making legislative or administrative changes to address serious problems in the workers' compensation system. In 1993, the legislature directed the California Division of Workers' Compensation to develop a Workers' Compensation Information System (WCIS). METHODS: An advisory committee developed key questions and identified data sources regarding injury/illness incidence, costs, promptness of benefit delivery, adequacy of benefits, satisfaction with services, and other outcomes. RESULTS: Key data elements were identified, mostly from existing mandated reporting forms for employers and physicians, and from standardized medical billings. Data collection will be carried out using: 1) rapid electronic data interchange (EDI) for a minimum number of data elements; 2) electronic collection of data on medical services for a sample of claims; and 3) surveys to address adequacy of benefits, satisfaction with services, return to work, and other outcomes. A state-based repository will analyze data and provide de-identified public use data files. CONCLUSIONS: The proposed WCIS will provide information to improve the performance and to increase the accountability of all the participants in California's Workers' Compensation system. More importantly, it will provide information which will allow improved quality in the provision of mandated benefits to injured workers.
Benchmarking↗
Analysis of construction injury burden by type of work.
BACKGROUND: To lay groundwork for identifying patterns of injury etiology, we sought to describe injury experience associated with types of work performed at construction sites by examining workers' compensation (WC) claims for the 32,081 construction workers who built Denver International Airport (DIA). METHODS: Injury rates and WC payment rates were calculated for 25 types of work based on claims and payroll data reported to DIA's owner-controlled insurance program according to National Council on Compensation Insurance job classifications. By linking DIA claims with corresponding lost-work-time (LWT) claims filed with Colorado's Workers' Compensation Division, we were also able to obtain and examine both total and median lost days for each type of work. RESULTS: Injury experience varied widely among the types of construction work. Workers building elevators and conduits and installing glass, metal, or steel were at particularly high risk of both LWT and non-LWT injury. Median days lost by injured workers was highest (202 days) for driving/trucking. Median days lost for most types of work was much greater than previously reported for construction: 40 days or more for 18 of the 25 types of work analyzed. WC payment rates reflect both number and severity of injuries and were generally not significantly different from expected losses. They were, however, significantly higher than expected for driving/trucking, metal/steel installation, inspection/analysis, and elevator construction. CONCLUSIONS: Analysis of injury data by type of work allows targeting of safety resources to high risk construction work and would be useful in prospective surveillance at large construction sites with centrally administered workers' compensation plans.
Absenteeism↗
Low back pain disability: relative costs by antecedent and industry group.
BACKGROUND: Previous studies of workers' compensation claims for low back pain (LBP) have revealed that the preponderance of disability is borne by a fraction of cases. However, less is known regarding the influence of occupational factors on these extreme conditions. METHODS: Workers' compensation claims (n=107,867) for LBP reported to a large, national insurer in 1992 were examined by antecedent event and industry class. In addition to summaries of the frequency and cost distribution, each factor was examined at two points on its cost distribution: one more representative of the typical case and one more representative of the case with long disability. These alternative disability indicators were introduced to explore a different perspective of LBP disability. RESULTS: The information provided by the alternative indicators was distinct from the information provided by the traditional aggregate indicators (claim frequency and claim cost frequency). In particular, this method identified increased severity for claims in the construction and services sectors, as well as for claims arising from falls and motor vehicle crashes. CONCLUSIONS: The results suggest that the construction and service sectors confront unique challenges to prevention and management of LBP disability. LBP related to discrete antecedents such as falls and motor vehicle crashes merits consideration on the basis of exceptionally severe disability.
Accidental Falls↗
MMPI-2 profiles of worker's compensation claimants who present with complaints of harassment.
This study intended to differentiate among worker's compensation claimants with psychological problems who presented with work-related harassment and non-harassment complaints on the basis of their MMPI-2 profiles. Analysis of MMPI-2 mean scores revealed that the Harassment group scored significantly higher than the Non-harassment group on scale 6 of the MMPI-2. This was interpreted to mean that the Harassment group was more oversensitive, suspicious, and angry than the other group. There was no evidence that the Harassment group was more likely to exaggerate or malinger than the Non-harassment group. The profile pattern for both groups was otherwise very similar to those found in previous studies that have used MMPI worker's compensation claimants who present with psychological problems.
Adult↗
Workplace health and safety regulations: Impact of enforcement and consultation on workers' compensation claims rates in Washington State.
BACKGROUND: There has been considerable debate in the public policy arena about the appropriate mix of regulatory enforcement and consultation in achieving desired health and safety behavior across industries. Recently there has been a shift in federal policy toward voluntary approaches and constraining the scope of enforcement programs, although there is little evidence that this might improve health and safety outcomes. To address this, we examined changes in lost time workers compensation claims rates for Washington State employers who had (1) no OSHA State Plan (WISHA) activity, (2) enforcement, (3) consultation, and (4) both types of visits. METHODS: Compensable claims rates, hours, and WISHA activity were determined for each employer account with a single business location that had payroll hours reported for every quarter from 1997-2000 and more than 10 employees. We used a generalized estimating equations (GEE) approach to Poisson regression to model the association between WISHA activity and claims rate controlling for other external factors. RESULTS: Controlling for previous claims rate and average size, claims rates for employers with WISHA enforcement activity declined 22.5% in fixed site industry SIC codes compared to 7% among employers with no WISHA activity (P < 0.05), and in non-fixed site SICs (e.g., construction) claims rates declined 12.8% for employers with enforcement activity compared to a 7.4% decline for those with no WISHA activity (P > 0.10). WISHA consultation activity was not associated with a greater decline in compensable claims rates (-2.3% for fixed sites and +3.5% for non-fixed sites). WISHA activity did not adversely affect worksite survivability through the study period. CONCLUSIONS: Enforcement inspections are significantly associated with decreasing compensable workers compensation claims rates especially for fixed site employers. We were unable to identify an association between consultation activities and decreasing claims rates.
Government Regulation↗
Non-fatal injuries in the West Virginia logging industry: using workers' compensation claims to assess risk from 1995 through 2001.
BACKGROUND: The logging industry has a high rate of both fatal and non-fatal injuries in comparison to other industries, and plays a vital role in WV's economy. METHODS: Workers' compensation (WC) injury claims and employment data were summarized to examine patterns and rates of non-fatal logging injuries in WV from 1995 through 2001. RESULTS: The average annual rate of injury claims was 16.0 per 100 workers per year with rates remaining relatively steady over the 7-year study period. The highest rates of injury were a result of being struck by an object, typically trees, snags, or logs. CONCLUSIONS: WV loggers most often file injury claims as a result of being struck by trees and tree parts, snags, and logs. Assessment of risk is a critical component in helping regulators, researchers, and the logging industry develop viable prevention strategies to reduce the incidence and severity of logging-related injuries.
Accidents, Occupational↗
Work-related carpal tunnel syndrome (WR-CTS) in Massachusetts, 1992-1997: source of WR-CTS, outcomes, and employer intervention practices.
BACKGROUND: The Massachusetts Sentinel Event Notification System for Occupational Risks (MASS SENSOR) receives reports of work-related carpal tunnel syndrome (WR-CTS) cases from (1) workers' compensation (WC) disability claims for 5 or more lost work days; and (2) physician reports (PR). METHODS: From 1992 through 1997, 1,330 WC cases and 571 PR cases completed follow-back surveys to provide information on industry, occupation, attributed source of WR-CTS, outcomes, and employer intervention practices. RESULTS: Sixty-four percent of the respondents had bilateral CTS and 61% had surgery, both of which were proportionally more frequent among WC cases. Office and business machinery was the leading source of WR-CTS (42% of classifiable sources) in every economic sector except construction, followed by hand tools (20%). Managers and professional specialty workers were the most likely to report employers' interventions and were up to four times more likely to report equipment or work environment changes than higher risk groups. CONCLUSIONS: State-based surveillance data on the source of WR-CTS provided valuable information on how and where to implement interventions. New occurrences of WR-CTS are likely, especially in the highest risk industries where very few cases reported primary prevention measures (e.g., changes to equipment or work environment) implemented by their employers.
Absenteeism↗
More evidence of the need for an ergonomic standard.
BACKGROUND: In 1999, the Occupational Safety and Health Administration (OSHA) proposed regulations designed to reduce work related inquiries by limiting worker exposure to "ergonomic risk factors." Congress subsequently overturned the regulations. We provide additional evidence on earnings losses attributable to musculoskeletal disorders (MSDs), and thus on the need for an ergonomic standard. METHODS: Regression techniques are used to analyze data from a survey of injured workers that has been matched to employer-reported earnings data covering pre- and post-injury periods, and to workers' compensation claims records. RESULTS: MSDs lead to large and persistent earnings losses. Cost estimates used by OSHA to justify the 1999 EPS are corroborated. Losses are greatest among workers who file workers compensation claims, but nonclaimants also have losses. CONCLUSIONS: Earnings losses and lost productivity associated with work-related MSDs are substantial and an ergonomic standard could be cost effective.
Cost of Illness↗
An assessment of the effects of increased regulatory enforcement and legislative reform on occupational hearing loss workers' compensation claims: Oregon 1984-1998.
BACKGROUND: Hearing loss from occupational exposures is a serious and widespread problem. This study measured the outcomes that increased enforcement of regulations and legislative interventions had on hearing loss workers' compensation claims. METHODS: Workers' compensation claim data from Oregon was analyzed for the period of 1984-1998 to examine trends and severity of hearing loss claims. In 1987 and 1990, Oregon enacted legislative reforms to improve enforcement and promulgation of safety standards in the state. This study examined hearing loss claims between the periods of pre- and post-legislative reforms. RESULTS: It was found that hearing loss claims decreased significantly following the legislative reforms, although the average cost per claim increased. Age and tenure effects, and evidence of moral hazard were also discovered. CONCLUSIONS: Increased enforcement of regulations and legislative interventions by Oregon improved working conditions leading to occupational hearing loss. Nevertheless, hearing loss remains problematic, and continued efforts are required to improve worker safety.
Adult↗