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PubMedDate not supplied

Evidence, appropriateness, and technology assessment in cardiology: a case study of computed tomography.

As the volume, complexity, and cost of new medical technology increase, the need for evaluating benefits and risks becomes increasingly important. Once the formal requirements for Food and Drug Administration approval and insurance coverage are met, however, few systematic criteria are applied to ensure patient benefit. A more systematic policy approach regarding new technologies is needed, with input from balanced groups reviewing evidence of clinical outcomes data to determine patient benefit. This paper examines cardiac computed tomography angiography as a case study; it proposes procedures designed to ensure that the benefits of new technologies justify their costs.

Angiography↗
PubMed2003

Veterans' system-of-care preferences for percutaneous transluminal coronary angioplasty in a rural setting.

CONTEXT: In the Veterans Health Administration (VHA), regionalization of high-technology health care services may influence veterans who live far from referral centers to obtain care locally, through the private sector. PURPOSE: To understand veterans' system-of-care preferences for a high-technology regionalized service. METHODS: The charts of 142 veterans who were referred for percutaneous transluminal coronary angioplasty (PTCA) by their VHA cardiologists were reviewed. FINDINGS: Fifty-two percent of these veterans obtained the procedure outside the VHA system. Insurance coverage and out-of-pocket costs were strongly associated with veterans' obtaining PTCA outside of the VHA system; travel distance was not. CONCLUSIONS: As the VHA begins to understand veterans' use of multiple systems of care, it will be important to understand the relationship between out-of-pocket costs and the system of care used for high-technology health care services.

Angioplasty, Balloon↗
PubMed1998

A comparison of women and men with spinal cord injury.

While research on spinal cord injury (SCI) is abundant, few studies focus on women. This population-based study investigates differences in the prevalence of secondary conditions between 128 women and 522 men. Case managers retrospectively interviewed 650 persons regarding medical and psychological conditions secondary to SCI, as well as other life issues. Overall, males and females show more similarities than differences in the ways in which they manage life with SCI. Differences were found, though, regarding etiology of initial injury, insurance coverage, caregiver use, transportation use, medication use, and in other medical and behavioral areas. Females are significantly involved in more automobile crashes than males, while males are involved in more galls than females. Females are more reliant on Medicaid, while males report more Medicare and Worker's Compensation coverage. Females are more likely to have a paid attendant as a caregiver while males are more likely to have their spouse or parents assist. Males report more independence in their use of transportation than females. Males and females also report significant differences in the use of medication. Females are more likely to use medication any time it is a treatment option. Males are more active, use tobacco more and have more arm fractures postinjury than females.

Accidental Falls↗
PubMed2004

Tough trade-offs: medical bills, family finances and access to care.

About 20 million American families-representing 43 million people-reported problems paying medical bills in 2003, according to a new study by the Center for Studying Health System Change (HSC). While uninsured families are more likely to have medical bill problems, two-thirds of families with problems paying medical bills have health insurance coverage. Of all families with medical bill problems, almost two-thirds reported difficulty paying for other basic necessities-rent, mortgage payments, transportation or food-as a result of medical debt. People in families with medical bill problems also reported much greater trouble getting care because of cost concerns-one in three did not get a prescription drug, one in four delayed care and one in eight went without needed care.

Bankruptcy↗
PubMed2004

The role of social marketing in understanding access to primary health care services: perceptions and experiences.

Using the concept of social marketing, this study examined the determinants of access to primary health care services in order to better understand the perceived access problems and unmet service needs of an entire city in Northeastern Pennsylvania. Consistent with previous research, lack of access to health insurance coverage represents an important financial barrier to access to health care services in this community. This study also highlights the role of perceived need in explaining the presence or absence of a physician consultation.While increased attention to access issues at the national level is important, there also needs to be more emphasis on collecting local data for local decision-making regarding access issues.

Adult↗
PubMed2002

Trends in mental health insurance benefits and out-of-pocket spending.

BACKGROUND: Insurance benefits can have a large effect on whether one is able to access health care services. Mental health and substance abuse (MHSA) insurance coverage has typically been less generous than that of general health services. AIMS OF THE STUDY: This paper examines trends in the generosity of private insurance benefits for mental health (MH) services in the United States from 1987 to 1996. The paper estimates the benefit-induced change in insurance payments for MH services that would have been made by typical health plans between 1987 and 1996 holding constant utilization of individuals at the 1987 level so that the changes in effective benefits could be isolated. METHODS: Trends in mental health benefits were measured using two nationally representative household surveys of the U.S. civilian non-institutionalized population, the 1987 National Medical Expenditure Survey (NMES) and the 1996 Medical Expenditure Panel Survey (MEPS). Data on utilization and expenditures from the NMES/MEPS were used to simulate what the average person would have paid out-of-pocket under typical insurance plans in 1987 and in 1996. RESULTS: The study finds that limits on MH coverage, such as limits on reimbursed days of care, became more prevalent from 1987 to 1996, but that consumer cost-sharing rates declined. The simulations indicate that private insurance would have paid for a lower proportion of total spending in 1996 (60.1 percent) as compared to 1987 (65.8 percent). DISCUSSION: Despite the fact that limits on mental health services became more prevalent over the time-period evaluated, out-of-pocket expenditures did not increase as significantly because there was a corresponding increase in coinsurance covered by health plans. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Trends in plan design negatively affected those with high costs who are likely to surpass their limits and positively affected coverage for those with minimal use due to lower cost-sharing. These trends also indicate that persons in the most need, those with high utilization, particularly of inpatient care, experienced a decline in coverage while those with less intensive needs may have experienced a slight increase. IMPLICATIONS FOR HEALTH POLICIES: Out-of-pocket spending in both years of the study was substantial suggesting that improved health care coverage, such as that mandated in parity legislation, could improve access to care for persons needing mental health treatment. IMPLICATION FOR FURTHER RESEARCH: Additional research is needed to understand how trends in out-of-pocket spending and insurance benefits have influenced access to care.

Adolescent↗
PubMed1997

Should health insurance cover IVF? Issues and options.

An emotional debate has attended the question of whether health insurance should cover the cost of in vitro fertilization (IVF) for infertile couples. Some private health plans have opted to cover IVF, although most have not. Ten states have mandated that it be included or offered as a standard benefit for private health insurance plans. This article analyzes several key issues in the debate: the impact of insurance coverage; the cost-effectiveness of IVF; valuing the benefit of IVF; and adoption as an alternative. It recommends policy action in several areas: more efficiently allocating resources for IVF (by giving priority to couples with better chances of success, and by making more extensive use of facilities with higher success rates); ensuring that clear and reliable information about the effectiveness of IVF is available; and leveling the playing field between IVF and adoption.

Adoption↗
PubMedDate not supplied

Evidence based? Caveat emptor!

Medical practices, clinical practice guidelines, clinical performance measures and measurements, and a variety of health care-related administrative decisions, such as insurance coverage decisions, are claiming to be "evidence based" with increasing frequency. In this paper we examine the "evidence based" label; discuss how evidence ought to have been assembled, evaluated, and synthesized; and when evidence is sufficient for the "evidence-based" moniker to rightfully apply. We also highlight several considerations other than the strength of evidence that are relevant to several common types of health care-related administrative decisions and that influence the extent to which the resulting decisions are truly evidence based.

Evidence-Based Medicine↗
PubMed2002

The health of adolescent girls: does the law support it?

The law provides protection and creates many policy options that could and do support the health of adolescent girls. Current legal protection pertains to consent for care, confidentiality of information, and insurance coverage; gaps in protection and policy options also exist. The extent to which the protection and options will remain in place and the gaps will be filled is uncertain. Additional issues of current interest and debate include financing treatment for increasingly pressing health concerns, such as eating disorders, obesity, and depression; new challenges concerning statutory rape reporting and enforcement of the laws related to it; and girls' access to emergency contraception.

Adolescent↗
PubMedDate not supplied

Can we trust population surveys to count Medicaid enrollees and the uninsured?

Health foundations, such as the Robert Wood Johnson Foundation (RWJF), make multimillion-dollar investments in programs to expand insurance coverage. These efforts are driven largely by estimates of the number of uninsured people derived from population surveys, which might overestimate the number of uninsured people if they under-count people enrolled in Medicaid. This paper reports the results of the RWJF-funded California Medicaid Undercount Experiment (CMUE) to estimate the extent of underreporting of Medicaid in the California Health Interview Survey (CHIS) and its effect on estimates of uninsurance. Although some over- and underreporting occurs, overall CHIS Medicaid estimates match administrative counts for adults.

Adolescent↗
PubMed1999

Maternal minimum-stay legislation: cost and policy implications.

OBJECTIVES: Recently, most state legislatures and Congress have passed laws mandating insurance coverage for a minimum period of inpatient care following delivery. This study analyzed the likely cost implications of one state's law. METHODS: Hospital discharge records for Illinois women who gave birth (n = 167,769) and infants born (n = 164,905) during a 12-month period predating the law were analyzed. RESULTS: As a percentage of total spending on birth-related admissions and readmissions, the net effect of the law ranges from a savings of 0.1% to a cost of 20.2%. CONCLUSIONS: There may be large cost implications to this legislation, even with savings from avoided re-admissions.

Adult↗
PubMed2003

A comparison of national estimates from the National Health Interview Survey and the Behavioral Risk Factor Surveillance System.

OBJECTIVES: The purpose of this study was to compare national estimates from the National Health Interview Survey (NHIS) and the Behavioral Risk Factor Surveillance System (BRFSS). METHODS: The authors compared data from the 2 surveys on smoking, height, weight, body mass index, diabetes, hypertension, immunization, lack of insurance coverage, cost as a barrier to medical care, and health status. RESULTS: Overall national estimates were similar for 13 of the 14 measures examined. Small differences according to demographic characteristics were found for height and body mass index, with larger differences for health status. CONCLUSIONS: Although estimates differed within subgroups, the BRFSS provided national estimates comparable to those of the NHIS. BRFSS national data could provide rapidly available information to guide national policy and program decisions.

Adolescent↗
PubMed2004

Implementation of evidence-based tobacco use cessation guidelines in managed care organizations.

BACKGROUND: Although managed care organizations (MCOs) may be optimal settings for implementing tobacco use cessation clinical guidelines, such guidelines remain poorly implemented in many MCO settings. PURPOSE: We examined issues related to the implementation of guidelines in MCOs, to provide examples of studies that have addressed issues related to guideline implementation and to suggest ways behavioral medicine researchers can play a role in examining issues of how guidelines can be better implemented. METHODS: Surveys of clinical guideline implementation, studies from the Robert Wood Johnson Foundation addressing tobacco use cessation in a managed care database, selected to illustrate issues related to system-wide implementation. RESULTS: Surveys show that effective tobacco use cessation interventions remain underutilized in MCOs. A few studies have evaluated and shown the benefit of insurance coverage for tobacco use and dependence treatments, clinician reimbursement and leadership incentives, practice feedback, and leveraging administrative data to create tobacco use tracking systems. The studies also point to the need for large-scale, multidisciplinary, methodologically rigorous studies that allow one to isolate the effects of promising strategies as well as to explore synergistic effects as different system changes are combined. CONCLUSIONS: Tobacco use cessation guidelines need to be better implemented in MCOs. Behavioral medicine research needs to move beyond treatment efficacy and effectiveness studies to focus on rigorous evaluations of these and other strategies to enhance guideline implementation and dissemination.

Databases, Factual↗
PubMed2004

Cancer prevention services and physician consensus in primary care group practices.

BACKGROUND: We conducted a randomized clinical trial of interventions to achieve physician consensus, practice changes, and patient activation designed to help primary care group practices enhance the delivery of cancer prevention and screening services. METHODS: In each of 42 primary care practices in 1991 to 1994, we studied approximately 60 patients per physician who were between the ages 53 and 64. Data sources included patient and physician questionnaires, medical record audits of consenting patients for evidence of 11 cancer prevention services during the previous 3 years, and telephone interviews with key practice personnel. RESULTS: None of the interventions was associated with significant changes in frequency of services or procedures received or provided. Increased frequencies of services overall and of specific activities were associated with HMO membership or insurance coverage for six screening procedures. Patient reports of clinic staff recommendations to have each of six screening procedures were specifically associated with higher frequencies of services (P = 0.001). CONCLUSIONS: Demonstration of intervention impact may have been limited because the rates of prevention services were significantly higher in this study than have been reported elsewhere. These results might be explained by selection biases inherent in studying patients with a regular provider, overall practice trends for changes in provision of the studied services, and the study methods.

Attitude of Health Personnel↗
PubMed2005

Factors associated with the utilization and content of prenatal care in a western urban district of Turkey.

OBJECTIVE: To define the prenatal care utilization pattern in Bornova and determine the factors affecting the amount and content of prenatal care. DESIGN: Follow-up study. SETTING: Bornova is an urban district in western Turkey. STUDY PARTICIPANTS: Two hundred and forty-five pregnant women registered with primary care settings in Bornova during the year 2000. Response rate was 83.7%. Main outcome measure. We determined the amount of prenatal care using Adequacy of Prenatal Care Utilization Index. Criteria used to assess the content of services include number of checks for maternal weight gain, blood pressure and foetal heart-beat measurements, advice about healthy lifestyles, laboratory examinations, and tetanus immunization. RESULTS: Rates of the women who visited public primary health care settings, private care sources, and public hospitals at least once were 76.0, 57.1, and 54.6%, respectively. As to prenatal care, 64.9% of the participants received an adequate amount and 25.9% an adequate content. Parity (P = 0.00), insurance coverage (P = 0.00), abortion history (P = 0.03), husband's occupation (P = 0.00), maternal age (P = 0.04), and level of educational attainment (P = 0.03) were related to the amount of care. Employment status (P = 0.03), continuous use of private sources (P = 0.00) and public hospitals (P =0.01) were associated with the content. CONCLUSION: This study has highlighted considerable associations between the amount of prenatal care and individual features in addition to those among the content of care, individual features and type of care sources. Causes of variations in prenatal care delivered in urban and relatively wealthy populations of developing countries must be explored using the appropriate criteria.

Adolescent↗
PubMed2001

[Analysis of inquiries about prescriptions at the pharmacy of Gifu Pharmaceutical University].

The Ministry of Health, Labour and Welfare explains the objectives of promotion of separation of the pharmacy and clinics as the elimination of duplicated prescription of similar drugs and drug interactions caused by treatment at several departments or hospitals, and sufficient guidance in the use of drugs by pharmacists. The Pharmacy of Gifu Pharmaceutical University has dispensed prescriptions by outside medical organizations as its routine activity. In this study, the contents of question inquiries handled in routine activities were compiled and analyzed, and their meaning was evaluated. The contents of question inquiries were accumulated using data cards. The data obtained during 2 and a half years (562 cases) were analyzed. The percentage of the number of inquiries relative to the number of prescriptions was highest at 1.86% during the first 3 months and was 1.05-1.71% per 3 months thereafter. The inquiries were most frequently about "the dosage/regimen" (153 cases), followed by "discrepancy between the contents of prescription and understanding of the patient" (88 cases) and "problems about insurance coverage" (80 cases). There were also 16 inquiries about "the possibility of contraindications and adverse reactions" and 15 inquiries about "duplicated prescription", which may have exerted serious effects on the patients. Eighty nine % of the inquiries have led to changes in the prescriptions, and about half of these cases were discovered by consultation with the patients or a review of the drug history. Proper and positive execution of these operations in routine pharmacy work is considered to lead to appropriate inquiries about problems with prescriptions and, thus, contribute to the proper use of drugs and prevention of malpractice.

Drug Administration Schedule↗
PubMed2005

Increase in obstacles to abortion: the American perspective in 2004.

This paper summarizes the barriers to abortion in the United States, including the determination of viability, cost and insurance coverage, waiting periods and parental consent laws, restrictions on medical abortion, provider unavailability, harassment, targeted regulation of abortion providers laws, refusal clauses, anti choice laws, and the fetal legal rights movement. Federally subsidized abstinence-only sex education, which has not been shown to decrease the rate of unintended pregnancy (and may increase it), has expanded and access to a full range of contraceptive options has been limited. The policies of the current and past administrations have strengthened barriers to abortion both at home and abroad. Preserving women's right to choose will require improved public and professional education, legislative and legal efforts, and advocacy by physicians and other health care professionals.

Abortion, Legal↗
PubMed2006

Patient-reported underuse of prescription medications: a comparison of nine surveys.

Nine national surveys documenting patient underuse of prescription medications were examined to describe the variation and trends in that underuse and identify possible reasons for the substantially different rates that were reported. Underuse includes unfilled prescriptions, delayed therapy, reduced frequency, and lowered dosage. Rates of cost-related patient underuse in the studies ranged from 1.6 to 22 percent. Insurance coverage, level of wealth, age, and health status were the sociodemographic variables most strongly related to underuse. Seven additional factors in the design and administration of the surveys were identified as providing plausible explanations for the variance across surveys. The most conspicuous variation was between three government-sponsored periodic surveys and six generally one-time assessments, with the latter yielding higher rates and greater variance in underuse. Understanding the factors contributing to the variation in reported rates of underuse of medications is an important prerequisite for the design of effective prescription-drug benefit programs.

Adolescent↗