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Biomedical subjects

A Milstein

Publications and source records attributed to A Milstein.

17 recordsLinked to original sources
PubMed2000

Selective referral to high-volume hospitals: estimating potentially avoidable deaths.

CONTEXT: Evidence exists that high-volume hospitals (HVHs) have lower mortality rates than low-volume hospitals (LVHs) for certain conditions. However, few employers, health plans, or government programs have attempted to increase the number of patients referred to HVHs. OBJECTIVES: To determine the difference in hospital mortality between HVHs and LVHs for conditions for which good quality data exist and to estimate how many deaths potentially would be avoided in California by referral to HVHs. DESIGN, SETTING, AND PATIENTS: Literature in MEDLINE, Current Contents, and First-Search Social Abstracts databases from January 1, 1983, to December 31, 1998, was searched using the key words hospital, outcome, mortality, volume, risk, and quality. The highest-quality study assessing the mortality-volume relationship for each given condition was identified and used to calculate odds ratios (ORs) for in-hospital mortality for LVHs vs HVHs. These ORs were then applied to the 1997 California database of hospital discharges maintained by the California Office of Statewide Health Planning and Development to estimate potentially avoidable deaths. MAIN OUTCOME MEASURES: Deaths that potentially could be avoided if patients with conditions for which a mortality-volume relationship had been treated at an HVH vs LVH. RESULTS: The articles identified in the literature search were grouped by condition, and predetermined criteria were applied to choose the best article for each condition. Mortality was significantly lower at HVHs for elective abdominal aortic aneurysm repair, carotid endarterectomy, lower extremity arterial bypass surgery, coronary artery bypass surgery, coronary angioplasty, heart transplantation, pediatric cardiac surgery, pancreatic cancer surgery, esophageal cancer surgery, cerebral aneurysm surgery, and treatment of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). A total of 58,306 of 121,609 patients with these conditions were admitted to LVHs in California in 1997. After applying the calculated ORs to these patient populations, we estimated that 602 deaths (95% confidence interval, 304-830) at LVHs could be attributed to their low volume. Additional analyses were performed to take into account emergent admissions and distance traveled, but the impact of loss of continuity of care for some patients and reduction in the availability of specialists for patients remaining at LVHs could not be assessed. CONCLUSIONS: Initiatives to facilitate referral of patients to HVHs have the potential to reduce overall hospital mortality in California for the conditions identified. Additional study is needed to determine the extent to which selective referral is feasible and to examine the potential consequences of such initiatives.

California↗
PubMed1999

An employer's perspective on hospitalists as a source of improved health care value.

The probable perspective of large employers toward the phenomenon of hospitalists can be derived by examining the four essential elements of health care value to employers. Current hospital care in the United States is thought to offer substantial opportunities for improvement, and the impact of hospitalist programs on an employer's sense of health care value is predicted to be favorable. This prediction, however, should be validated through outcomes research before it is widely propagated. If innovations as promising as hospitalist programs are to occur in ambulatory care, employers and other health care purchasers must be proactive in identifying and rewarding them.

Cost-Benefit Analysis↗
PubMed1999

Using employer purchasing power to improve the quality of perinatal care.

Large employers have become increasingly involved in helping to set the agenda for quality measurement and improvement. Moreover, they are beginning to hold health care organizations accountable for their performance through marketplace incentives, including the public reporting of comparative quality data and the linkage of reimbursement to performance on quality measures. The Pacific Business Group on Health (PBGH) is an employer coalition that has been prominent in establishing models for collaborative quality measurement and improvement in the California marketplace. PBGH's involvement in quality stems from an environment in which purchasers were faced with high health care costs, yet virtually no information with which to assess the value their employees received from that care. Research indicating widespread variation in performance across health care organizations and seemingly limited oversight for quality of care within the industry has further motivated purchasers' efforts to better understand the quality of care being delivered to their em-ployees. Using the purchasing power of employers representing 2.5-million covered lives, PBGH endeavors to encourage the transition of the health care marketplace from one that competes solely on price to one that competes on price and quality. This entails collaborating with the health care industry to develop and publicly report valid performance data for use by both large employers and consumers of health care services. It also includes communicating to the marketplace purchasers' commitment to making purchasing decisions based on quality as well as cost. PBGH efforts to measure, report, and improve quality have been demonstrated by several undertakings in the perinatal care arena, including research to assess cesarean section rates and newborn readmission rates across California hospitals.employer coalition, purchaser, quality measurement, quality improvement, report cards, perinatal quality of care.

California↗
PubMed1996

Health education and patient satisfaction.

BACKGROUND: The objective of this research was to determine whether patients who reported that their physician or other health care professional had discussed health education topics with them were more satisfied with their physician than were patients who reported they had not. METHODS: Data were from the 1994 Health Plan Value Check conducted by the Pacific Business Group on Health (52% response rate). The study sample included 5066 employees ranging in age from 19 to 64 years and representing four large corporations and 21 health plans. This population was randomly sampled by company and health plan. Bivariate and multivariate analyses were used to assess the relationship between level of patient satisfaction with physician and reported discussion of health education topics with a physician or other health professional in the last 3 years. RESULTS: Patients who reported that their physician or other health care professional discussed at least one health education topic with them in the last 3 years were more likely to be satisfied with their physician (unadjusted odds ratio [OR] = 1.96; 95% confidence interval [CI] 1.79 to 2.25) compared with patients who did not. In the multivariate model, the relationship remained positive and statistically significant (adjusted OR = 1.49; 95% CI, 1.32 to 1.68). This relationship was observed for patients enrolled in all types of HMOs and managed care plans, as well as those with indemnity or fee-for-service insurance. CONCLUSIONS: Patients who reported that their physician or other health care professional had discussed one or more health education topics with them in the last 3 years were more likely to be very satisfied with their physician than were patients who reported they had not.

Adult↗
PubMed1994

Circumferential argon laser photocoagulation for prevention of retinal detachment.

Circumferential argon laser photocoagulation was administered as preventive treatment for retinal detachment in 53 eyes with extensive areas of lattice degeneration and/or retinal breaks and at least one additional high-risk factor for retinal detachment. Laser burns were applied in several continuous rows 360 degrees around the peripheral retina at the junction between the posterior border of the lesions and the unaffected retina. The retina posterior to the treated areas remained attached in 51 eyes (96.2%) during a mean follow-up period of 85.8 months (range 6 months to 18 years). The treatment did not affect visual acuity. The only complication was the appearance in 2 eyes (3.8%) of a delicate epiretinal membrane which, however, did not require surgical intervention.

Adolescent↗
PubMed1993

An unusual presentation of adenoid cystic carcinoma of the lacrimal gland.

Adenoid cystic carcinoma of the lacrimal gland is a highly malignant tumor usually characterized by symptoms of less than 1 year's duration. Computed tomographic (CT) findings of adjacent bony erosion or focal tumor sclerosis are also suggestive. We present a 57-year-old female patient who manifested symptoms of an enlarging mass in the right lacrimal fossa for almost 3 years prior to the establishment of the diagnosis of adenoid cystic carcinoma. CT findings during those years were not supportive for malignancy. The treatment included en bloc resection of the mass and adjacent bone and radiotherapy.

Carcinoma, Adenoid Cystic↗
PubMed1992

Increased costs and rates of use in the California workers' compensation system as a result of self-referral by physicians.

BACKGROUND: There is widespread concern that ownership by physicians of testing or treatment facilities to which they refer patients leads to overuse of such facilities. We determined the patterns of use of three services--physical therapy, psychiatric evaluation, and magnetic resonance imaging (MRI)--among physicians treating patients whose care was covered under workers' compensation. We then compared the rates of use among physicians who referred patients to facilities of which they were owners (self-referral group) with the rates among physicians who referred patients to independent facilities (independent-referral group). METHODS: We used a large data base to analyze claims under workers' compensation in California from October 1, 1990, through June 30, 1991, to determine the frequency and cost of these three selected services and determined whether the referring physicians were practicing self-referral or independent referral. We evaluated the cost per case for all three services, measured the frequency with which physical therapy was initiated, and evaluated the medical appropriateness of MRI. RESULTS: We found that physical therapy was initiated 2.3 times more often by the physicians in the self-referral group (68 percent) than by those in the independent-referral group (30 percent; P < 0.01). The mean cost per case for physical therapy was significantly lower in the self-referral group ($404 +/- 102) than in the independent-referral group ($440 +/- 167; P < 0.01). The mean cost of psychiatric evaluation services was significantly higher in the self-referral group than in the independent-referral group (psychometric testing, $1,165 +/- 728 vs. $870 +/- 482; P < 0.01, psychiatric evaluation reports, $2,056 +/- 1,063 vs. $1,680 +/- 578; P < 0.01). The total cost per case of psychiatric evaluation services was 26.3 percent higher in the self-referral group ($3,222 +/- 1,451) than in the independent-referral group ($2,550 +/- 742; P < 0.01). Of all the MRI scans requested by the self-referring physicians, 38 percent were found to be medically inappropriate, as compared with 28 percent of those requested by physicians in the independent-referral group (P < 0.05). There was no significant difference in the cost per case between the two groups. CONCLUSIONS: This study demonstrates that self-referral increases the cost of medical care covered by workers' compensation for each of the three types of service studied.

Ambulatory Care Facilities↗
PubMed1989

Methane production in patients with colorectal carcinoma.

In searching for a screening test to identify a population at high risk for large bowel cancer, methane production was measured in 45 patients with colorectal carcinoma compared with 67 individuals who served as a control group. There was no significant difference in methane production between the colorectal cancer patients and the control group (37.8 and 25.4% respectively). Within the colorectal cancer group 54% of the males were methane producers compared with 19% of the females (P = 0.03). There were no differences according to disease stage. In view of these results, we see little value in using expired air methane concentration as a screening test for large bowel cancer.

Breath Tests↗
PubMed1983

Evaluating the impact of physician peer review: factors associated with successful PSROs.

A five-component measurement method was developed and applied to the 1981 impact statements of 30 Professional Standards Review Organizations (PSROs) by four blind raters familiar with the PSRO program. High inter-rater reliability (.95) was achieved. Rater's scores for each PSRO were then averaged and regressed against five variables predicted to affect PSRO impact: geographical density of PSROs; PSRO affiliation with a medical society; surgical necessity review; use of data profiles; and pre-existing Medicare hospitalization rates. As a set, the variables accounted for 44 per cent of the variance in PSRO performance (p less than .05). When entered in stepwise regression, geographical density and use of surgical necessity review accounted for the largest share of the variance. The findings are believed to reflect the recency of PSRO motivation to demonstrate significant impact, and the value of surgical necessity review as an indicator of PSRO courage to risk unpleasant backlash from their medical communities.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1976

Anticipating the impact of Public Law 93-641 on mental health services.

Implementation of the new federal law setting up Health Systems Agencies (HSAs) on a regional basis offers many opportunities for participation by psychiatry. On the basis of interviews with mental health service providers, planners, and citizen representatives, the author formulated an inventory of the law's potential impacts, grouped around six general themes. He discusses the positive aspects of each, along with possible problems and hazards.

Delivery of Health Care↗
PubMedDate not supplied

Raising the bar: the use of performance guarantees by the Pacific Business Group on Health.

In 1996 the Pacific Business Group on Health (PBGH) negotiated more than two dozen performance guarantees with thirteen of California's largest health maintenance organizations (HMOs) on behalf the seventeen large employers in its Negotiating Alliance. The negotiations put more than $8 million at risk for meeting performance targets with the goal of improving the performance of all health plans. Nearly $2 million, or 23 percent of the premium at risk, was refunded to the PBGH by the HMOs for missed targets. The majority of plans met their targets for satisfaction with the health plan and physicians, as well as cesarean section, mammography, Pap smear, and prenatal care rates. However, eight of the thirteen plans missed their targets for childhood immunizations, refunding 86 percent of the premium at risk.

Adult↗
PubMedDate not supplied

Enhancing utilization review program results.

Utilization review programs are increasing in number and type, but their true contributions to payers' health care and cost management efforts vary tremendously, according to evaluations of over 100 private UR firms by National Medical Audit. Three senior executives of that firm discuss state-of-the-art criteria and methods for gauging the effectiveness of a UR program.

Evaluation Studies as Topic↗