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PubMed2003

Enhancing communication for end-of-life care: an electronic advance directive process.

An advance directive, a description of one's future preferences for medical treatment, must be easily available to care providers to ensure that one's treatment preferences are honored. The transition of our health care system to an electronic medical record complicated the availability of a patient's written advance directive. This paper describes the development of an electronic advance directive to facilitate access to a patient's treatment wishes at any site in our health care system. The successes and challenges encountered in the development process are discussed.

Advance Directives↗
PubMed1989

Changes in functional status during pregnancy.

Changes in self-reported functional status during pregnancy were studied in 100 women. The baseline interview at 20 weeks was used for assessing subsequent change in maximal physical, mental, and emotional function as well as in global function and global sense of health. Although the transition instruments were only tested at three points during pregnancy (30, 35, and 40 weeks), they succeeded in detecting changes. In particular, both maximal physical function and global function tended to deteriorate as pregnancy progressed toward term, although few women considered themselves to be sick. The authors suggest that changes in functional status should be considered an important "outcome" of pregnancy. Patient-specific measures of change in self-reported maximal function might be used in future trials to help assess the impact of interventions on individual patient's maximal function. The timing of the baseline interview and frequency of the transition assessments should depend on the specific clinical problem under study.

Activities of Daily Living↗
PubMed2001

The effectiveness of CAHPS among women enrolling in Medicaid managed care.

The large-scale transition of public health insurance programs to managed care has shifted much of the responsibility for selecting appropriate coverage to beneficiaries--a role for which many have had little preparation. This study evaluates the impact of a CAHPS (Consumer Assessment of Health Plans Study) health care report card in assisting newly enrolled Medicaid case heads in selecting a managed care plan. The major finding is that the CAHPS report card helped consumers make more informed decisions. Those who received the report cards found judging quality between plans easier, felt that they had significantly more information on which to make decisions, and recognized the importance of their decision more often than those receiving only standard enrollment packets.

Adult↗
PubMed1994

Preparing for trust status--an investigation into the morale of nurses undergoing change.

The morale of nurses is a phenomenon often open to public comment without substantiated evidence. This study objectively explored the morale of nurses in a large district general hospital preparing for transition to National Health (NHS) Trust status. Information was sought using a 72-item questionnaire. The investigation was firmly centred around a structured theory which construes morale in terms of nine dimensions. The notion of morale being a construct synthesized of nine dimensions adds to the uniqueness of the study. Other studies fail to differentiate between the dynamic morale construct and the more complacent attitudes of job satisfaction.

Adaptation, Psychological↗
PubMed2005

A cost-benefit analysis of external hip protectors in the nursing home setting.

OBJECTIVES: To estimate potential cost savings generated by a program of hip protectors in the nursing home from a Medicare perspective. DESIGN: A state-transition Markov model considering short-term and long-term outcomes of hip protectors for a hypothetical nursing home population, stratified by age, sex, and functional status. Costs, transition probabilities between health states, and estimates of hip protectors' effectiveness were derived from published secondary data. SETTING: Nursing home facilities in the United States. PARTICIPANTS: Hypothetical cohort of permanent nursing home residents aged 65 and older without a previous hip fracture. INTERVENTION: Program of hip protectors reimbursed by Medicare. MEASUREMENTS: Number of fractures, life years, and dollars saved. RESULTS: Three pairs of hip protectors replaced annually would result in a weighted average lifetime absolute risk reduction for hip fracture of 8.5%, with net lifetime savings to Medicare of 223 dollars per resident. When the annual cost of hip protectors is less than 151 dollars per person, relative risk of fracture is less than or equal to 0.65 with hip protectors, or adherence is greater than 42%, hip protectors are cost saving to Medicare over a wide range of assumptions. Extrapolating these results to the estimated population of U.S. nursing home residents without a previous hip fracture, Medicare could save 136 million dollars in the first year of a hip-protector reimbursement program. CONCLUSION: From a Medicare perspective, hip protectors are a cost-saving intervention in the nursing home setting when hip protector effectiveness is less than or equal to 0.65 over the remaining lifetime of subjects.

Aged↗
PubMed2004

A longitudinal study of caries onset in initially caries-free children and baseline salivary mutans streptococci levels: a Kaplan-Meier survival analysis.

OBJECTIVES: To apply survival analysis to a longitudinal study of the relationship between salivary mutans streptococci (MS) levels at baseline in initially caries-free children and caries onset in deciduous, mixed, and permanent dentition. METHODS: The Kaplan-Meier survival analysis method was used to compare survival times to caries onset for initially caries-free children with low levels of MS at baseline with survival times to caries onset for initially caries-free children with high levels of MS at baseline. RESULTS: Data from a 6-year longitudinal study of caries risk in initially caries-free children in Rochester and the Finger Lakes Region of western New York were utilized for this study. Of 464 children analyzed, 327 had a low level of MS and 137 had a high level of MS at baseline. Survival analyses showed that children with a low level of MS at baseline remained caries-free for a longer period than children with a high level of MS at baseline. Statistically significant relationships [hazard ratios (HR)] with onset of caries in deciduous, mixed and permanent teeth were found with high and low levels of salivary MS. CONCLUSIONS: Based on our analysis, we concluded that children who were caries-free at baseline and who had high salivary MS levels at baseline would be at greater risk, i.e. more susceptible to caries onset, at any given time than caries-free children who had low salivary MS levels at baseline. Survival functions for deciduous, mixed and permanent dentitions with their 95% confidence limits have been calculated. Survival analysis for the exploration of longitudinal caries studies has an advantage over traditional statistical methods, as it takes into account censored observations and incorporates the concept of risk over time. Hence, survival analysis is well suited for studying transitions from one health state to another, in this case, from a caries-free state to a caries-active state.

Child↗
PubMed2002

Morphometry of the corpus callosum in patients with questionable and mild dementia.

Previous studies have shown a reduction in corpus callosum area in advanced Alzheimer's disease, but it is unclear whether callosal atrophy is present in the transitional phase between health and the onset of dementia. The aim of this study was to investigate whether callosal atrophy is present in subjects with questionable and mild dementia and to assess the diagnostic value of callosal measures. In 83 subjects aged 72 to 85 years (33 normal controls, 27 patients with questionable dementia, 23 with mild Alzheimer's disease), magnetic resonance images were recorded and the mid-sagittal callosal area measured. Significant differences were found between normal controls and mild dementia. In subjects with questionable dementia callosal size was intermediate between normal controls and mild Alzheimer's disease. However, callosal measures were unsuitable for diagnostic differentiation between healthy subjects, subjects with questionable dementia, and subjects with mild Alzheimer's disease. The severity of white matter changes did not differ between the groups.

Aged↗
PubMed1997

Cost-effectiveness of interferon alfa in chronic myelogenous leukemia.

PURPOSE: To evaluate the cost-effectiveness of interferon alfa (IFN alpha) treatment of patients with chronic myelogenous leukemia relative to conventional chemotherapy. MATERIALS AND METHODS: A decision-analysis model that involved a multistate Markov process was designed to estimate the expected cost and quality-adjusted life expectancies for two cohorts of patients to be administered conventional chemotherapy or IFN alpha. Two IFN alpha strategies were modeled: prolonged treatment for patients who achieved a hematologic response (scenario A) or only for patients who achieved a cytogenetic remission in a 2-year period (scenario B). Data on response and transition probabilities between health states were obtained from the literature by a MEDLINE search and pooled with a meta-analytic method. Costs were based on local charges. Expected survival was adjusted for quality of life on the basis of an expert panel judgment. RESULTS: Baseline analysis showed IFN alpha treatment to increase the quality-adjusted life expectancy by 15.5 and 12.5 months relative to conventional chemotherapy, in scenarios A and B, respectively. Marginal cost-effectiveness was $89,500 and $63,500 per quality-adjusted life-year (QALY) gained. Sensitivity analysis confirmed IFN alpha as the most effective approach. Cost-effectiveness results were sensitive to the cost of IFN alpha therapy and to the assumptions about the rate of cytogenetic remission. Reducing the drug dose, as suggested by a recent report, would decrease the marginal cost-effectiveness to less than $20,000. CONCLUSION: IFN alpha is substantially superior to conventional chemotherapy in terms of quality-adjusted survival, but, at the current doses, marginal cost-effectiveness ranges from $50,000 to $100,000 per QALY gained under most of our assumptions.

Adult↗
PubMed2007

[Preliminary analysis of the Information System in the Brazilian Schistosomiasis Control Program, 1999-2003].

This study provides a preliminary analysis of the Information System in the Schistosomiasis Control Program (SISPCE) in the States of Bahia, Sergipe, Alagoas, and Pernambuco, Brazil, from 1999 to 2003. The data analysis suggests a sharp decline in data entry in the system during the transition period involving health services decentralization, followed by a gradual increase. Major under-recording was observed in Pernambuco. SISPCE-DATASUS and IBGE (National Census Bureau) data are insufficient to construct a surveillance index for serious forms of the endemic disease and other aspects that could relate sanitary conditions to schistosomiasis. Reformulation of the SISPCE is key for schistosomiasis control measures, given the new reality in the Brazilian health system. The data system should be redesigned in order to integrate the health policies with the Unified National Health System's guidelines, using a systematic data collection methodology in keeping with local specificities and allowing prospective comparisons and evaluations, in addition to constructing new indicators with an emphasis on morbidity and determinants of the endemic and the adoption of analytical of the that express the real situation of the schistosomiasis in the States.

Brazil↗
PubMed2005

The cost effectiveness of infliximab for severe treatment-resistant rheumatoid arthritis in the UK.

OBJECTIVE: To estimate the cost effectiveness (from the UK NHS and personal social service perspectives) of infliximab plus methotrexate (MTX) compared with MTX alone, in the treatment of patients with severe rheumatoid arthritis (RA) who were not adequately controlled on disease-modifying antirheumatic drugs and who were resistant to MTX. METHOD: Clinical data for the first year of therapy were taken from the ATTRACT (Anti-Tumour Necrosis Factor Trial in Rheumatoid Arthritis with Concomitant Therapy) and a Markov model developed to assess costs and consequences in the longer term. Transition probabilities and health state valuations for the model were estimated based on the ARAMIS (Arthritis, Rheumatism, and Aging Medical Information System) cohort, and resource use and costs ( 2,000 pounds values) obtained from various sources in the UK. Univariate sensitivity analyses were conducted to test the robustness of the results. RESULTS: The primary analysis suggested that infliximab plus MTX had an ICER of 33,618 pounds per QALY gained. Alternative modelling assumptions and various other sensitivity analyses were applied, but the ICER always remained within the range for interventions typically funded by the NHS. CONCLUSION: This model suggests, with its underlying assumptions and data, that the combination of infliximab and MTX may be a cost-effective treatment (from the UK NHS and personal social service perspectives) for patients experiencing RA that cannot be maintained on MTX alone.

Antibodies, Monoclonal↗
PubMed1997

Medicaid AIDS waivers: seeking cost effective financing of AIDS care.

The epidemic of Acquired Immunodeficiency Syndrome (AIDS) emerged at a time of transition in American health care and health care policy. The waiver of traditional Medicaid limitations on home and community-based health care services for persons with AIDS has been utilized by several states attempting to demonstrate models of care where quality of life as well as financial concerns are addressed. The Medicaid AIDS Waiver programs in New Jersey and Florida note promising results in the cost-effectiveness of such programs when compared with traditional Medicaid. Variations in patient participation by geographic area and demographic characteristics indicate areas for future improvement in program accessibility.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

Social planning in Canada for families with HIV infection.

Parents living with HIV and their children face complex medical and social problems. Whether the children are infected or not, they are all affected by the presence of HIV in a parent. The purpose of this article is to describe the problems of families with HIV and to propose social planning measures to respond to their psychosocial needs. It is based on a multicentre study that included in-depth interviews with 110 parents representing 91 Canadian families living with HIV. The study's findings and recommendations were reviewed by parents with HIV, social workers specializing in helping affected families, and a multidisciplinary consensus conference. This process identified six areas needing attention: stigma and disclosure; promoting and supporting family health; planning and transitions for the care of children; economic issues; cultural and immigrant issues; and education, advocacy, policy development, and research. Recommendations for action were made in each area.

Canada↗
PubMed2001

Single-participant research design. Bringing science to managed care.

The ongoing transition to managed health care continues to have repercussions for health care providers, perhaps the most important of which is an emphasis on accountability for demonstrating the usefulness of clinical interventions. This requirement places a premium on intervention research and highlights the historically strained relationship between psychological research and professional practice. In the midst of this challenge, researchers have increasingly criticized the logic and practice of traditional null hypothesis significance testing. This article describes the history, epistemology, and advantages of single-participant research designs for behavioral scientists and professionals in clinical settings. Although its lack of correspondence with the Fisherian tradition has precluded widespread adoption, the single-participant alternative features a design power and flexibility well suited to both basic science and applied research.

Behaviorism↗
PubMedDate not supplied

Managing knowledge workers in clinical systems.

In Future Work, Coates and colleagues cite seven forces that are reshaping work and the workforce. One is the advent of "knowledge workers," who gather, distribute, and add value to information. In health care, the transition to integrated delivery systems, replete with care plans, critical paths, and assessment of clinical outcomes supported by information technology, is driving the need to reeducate for a knowledge-based workforce. Managers of clinical systems need to be familiar with the characteristics of knowledge workers affecting the delivery environment, organizational structure, and culture of an organization. These same managers will be expected to develop strategies to manage the transition to a knowledge-based workforce.

Clinical Laboratory Information Systems↗
PubMedDate not supplied

[Longitudinal studies: concepts and particularities].

In this review the definition of "longitudinal study" is analysed. Most current textbooks on epidemiology do not define a longitudinal study, whereas statistical textbooks do. It is more common to talk about longitudinal data than about longitudinal studies. A longitudinal study implies the existence of repeated measurements (more than two) across follow-up. According to these ideas, a longitudinal study can be considered a subtype of cohort study that, in contrast with life-table cohort studies, allows inference to the subject level, to analyze changes in variables (exposures and outcomes) and transitions among different health states. The characteristics of this design force to paid special attention to quality control during data collection, losses during follow-up, and missing data in some measurements. The statistical analysis should take repeated measures into account, and it is what finally gives the longitudinal character to a study with repeated measurements.

Biomedical Research↗
PubMed2003

Pharmacoeconomic analysis of osteoporosis treatment with risedronate.

Hip fracture is an important and costly problem. Therapy with the bisphosphonate risedronate effectively prevents hip and other fractures among women with established osteoporosis. Risedronate is a first-choice therapy option in the German Guidelines of the Dachverband Osteologie for Osteoporosis according to evidence-based medicine criteria for the treatment of postmenopausal osteoporosis, osteoporosis of the elderly (women aged > 75 years) and glucocorticoid-induced osteoporosis. There are few published economic evaluations of bisphosphonates in Germany. Therefore, an assessment of the cost-effectiveness of risedronate utilizing a state transition Markov model of established postmenopausal osteoporosis based on randomized clinical trial data was developed. Uncertainty underlying model parameters and outcomes was dealt with using traditional sensitivity analysis and stochastic sensitivity analysis to produce quasi-95% Cls. We focused on patients aged 70 years, since this population most closely matches the randomized controlled trial and is typical of osteoporosis patients in Germany. The baseline model was a cohort of 1,000 70-year-old women, who received risedronate for 3 years and were followed up for an overall observation period of 10 years, modelling transitions through estimated health states and evaluating outcomes. Over the 3-year treatment period and 10-year observation period, risedronate dominated the current average basic treatment in Germany. In the risedronate group 33 hip fractures were averted and 32 quality-adjusted life years (QALYs) were gained (discounted values). Risedronate treatment saves costs for German social insurance: the present net value of the associated costs from the perspective of German social insurance is [symbol: see text]10.66 million if risedronate treatment is used versus [symbol: see text]11 million if basic treatment is used. Thus, net savings of [symbol: see text]340,000 for the treatment group per 1,000 treated women were calculated. Furthermore, risedronate treatment is cost effective from the perspective of the statutory health insurance with costs per averted hip fracture in the analyzed population of [symbol: see text]33,856 and cost per QALY gained of [symbol: see text]35,690. Both results demonstrate cost-effectiveness and are far below the accepted threshold level of [symbol: see text]50,000. Based on this analysis, risedronate is a cost-effective treatment for postmenopausal osteoporosis within the German health care system, offering benefits for osteoporotic patients and for budget decision-makers.

Aged↗
PubMed2006

Saving time, improving satisfaction: the impact of a digital radiology system on physician workflow and system efficiency.

The objective of the study was to assess UC Davis Health System's transition to digital radiology. The study involved pre- and post-PACS analyses of workflow and costs, physician satisfaction surveys, and self-recorded radiology interactions by on-call residents. The study revealed significant results. Before the PACS implementation, physicians spent one to three hours searching for films daily and were dissatisfied with radiology services. After implementation, images were readily available, physicians were more likely to view and interpret images themselves, and they reported increased satisfaction. From real-time reporting, residents viewed studies with radiologists 90.2 percent less often. Average image search time decreased, from 16 to 2 minutes, saving 21.5 physician years, worth dollar 1,034,150 annually. Reductions in film printing (73.4 percent) and file clerk full-time equivalents (50.3 percent) saved dollar 1,001,452 annually, and freed up 1,218 hospital and 8,108 warehouse square feet, worth dollar 2,018,320. As a result, UCDHS's digital radiology system improved clinician satisfaction and workflow, increased clinician image viewing, and decreased clinician engagement with radiologists. System implementation saved 21 physician years and dollar 2 million annually.

California↗
PubMed2006

The transition study: a look at youth and adults with cerebral palsy, spina bifida and acquired brain injury.

A group of 100 adults and 190 youth who have cerebral palsy (CP), spina bifida (SB), and acquired brain injuries from childhood (ABIc) participated in a multi-method study focused on the transition to adult health care. The results show that 95% of youth and 61% of adults were living with their parents; 23% of the youth and 55% of adults were employed; and 60% of youth and 42% of adults reported "excellent" or "very good" health. The lowest health scores were reported by adults with SB. These findings provide a starting point for examining health issues specific to youth and young adults with CP, SB, and ABIc.

Adolescent↗