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Biomedical subjects

Andrew W Dick

Publications and source records attributed to Andrew W Dick.

At least 19 recordsLinked to original sources
PubMed2007

Accuracy of Medicare claims data in identifying Parkinsonism cases: comparison with the Medicare current beneficiary survey.

STUDY PURPOSE: Administrative databases are commonly used to examine use of healthcare service, with researchers relying on diagnostic codes to identify medical conditions. This study evaluates the accuracy of administrative claims in identifying Parkinsonism cases compared to the self-reported Parkinson's disease (PD). METHODS: The reference cases were identified based on the self-reported PD status and the use of PD drugs collected by the 1992-2000 Medicare Current Beneficiary Survey that contained 72,922 observations from 30,469 individuals. Using ICD-9 CM, cases with PD were extracted from the corresponding Medicare claims. We compared prevalence of PD obtained using different types of claims. RESULTS: The sensitivities were the highest when all claims were used (66%). All the specificities were greater than 99%. When drug use information was included in the gold standard, the sensitivities became lower, while the specificities and positive predictive values (PPVs) increased. Using more diagnostic codes improved the sensitivity of the identification process but reduced PPVs. CONCLUSIONS: Administrative claims can provide fairly accurate and practical approach to "rule in" patients with PD. Depending on the purpose of evaluation, researchers may consider using more categories of claims to improve the sensitivity of the identification algorithm or use fewer diagnoses to minimize number of false positive cases.

Aged↗
PubMed2007

Racial differences in the use of epidural analgesia for labor.

BACKGROUND: There is strong evidence that pain is undertreated in black and Hispanic patients. The association between race and ethnicity and the use of epidural analgesia for labor is not well described. METHODS: Using the New York State Perinatal Database, the authors examined whether race and ethnicity were associated with the likelihood of receiving epidural analgesia for labor after adjusting for clinical characteristics, demographics, insurance coverage, and provider effect. This retrospective cohort study was based on 81,883 women admitted for childbirth between 1998 and 2003. RESULTS: Overall, 38.3% of the patients received epidural analgesia for labor. After adjusting for clinical risk factors, socioeconomic status, and provider fixed effects, Hispanic and black patients were less likely than non-Hispanic white patients to receive epidural analgesia: The adjusted odds ratio was 0.85 (95% CI, 0.78-0.93) for white/Hispanic and 0.78 (0.74-0.83) for blacks compared with non-Hispanic whites. Compared with patients with private insurance, patients without insurance were least likely to receive epidural analgesia (adjusted odds ratio, 0.76; 95% CI, 0.64-0.89). Black patients with private insurance had similar rates of epidural use to white/non-Hispanic patients without insurance coverage: The adjusted odds ratio was 0.66 (95% CI, 0.53-0.82) for white/non-Hispanic patients without insurance versus 0.69 (0.57-0.85) for black patients with private insurance. CONCLUSION: Black and Hispanic women in labor are less likely than non-Hispanic white women to receive epidural analgesia. These differences remain after accounting for differences in insurance coverage, provider practice, and clinical characteristics.

Adult↗
PubMed2006

The cost effectiveness of implantable cardioverter-defibrillators: results from the Multicenter Automatic Defibrillator Implantation Trial (MADIT)-II.

OBJECTIVES: We sought to evaluate the cost implications of the implantable cardioverter-defibrillator (ICD), using utilization, cost, and survival data from the Multicenter Automatic Defibrillator Implantation Trial (MADIT)-II. BACKGROUND: This trial showed that prophylactic implantation of a defibrillator reduces the rate of mortality in patients who experienced a previous myocardial infarction and low left ventricular ejection fraction. Given the size of the eligible population, the cost effectiveness of the ICD has substantial implications. METHODS: Our research comprises the cost-effectiveness component of the randomized controlled trial, MADIT-II, based on utilization, cost, and survival information from 1,095 U.S. patients who were assigned randomly to receive an ICD or conventional medical care. Utilization data were converted to costs using a variety of national and hospital-specific data. The incremental cost-effectiveness ratio (iCER) was calculated as the difference in discounted costs divided by the difference in discounted life expectancy within 3.5 years. Secondary analyses included projections of survival (using three alternative assumptions), corresponding cost assumptions, and the resulting cost-effectiveness ratios until 12 years after randomization. RESULTS: During the 3.5-year period of the study, the average survival gain for the defibrillator arm was 0.167 years (2 months), the additional costs were 39,200 dollars, and the iCER was 235,000 dollars per year-of-life saved. In three alternative projections to 12 years, this ratio ranged from 78,600 dollars to 114,000 dollars. CONCLUSIONS: The estimated cost per life-year saved by the ICD in the MADIT-II study is relatively high at 3.5 years but is projected to be substantially lower over the course of longer time horizons.

Cost-Benefit Analysis↗
PubMed2006

Cost-effectiveness analysis of palivizumab in premature infants without chronic lung disease.

OBJECTIVES: To evaluate the cost-effectiveness of palivizumab as respiratory syncytial virus prophylaxis in premature infants without chronic lung disease and to evaluate the impact on cost-effectiveness of a potential reduction in risk of asthma following respiratory syncytial virus infection among infants receiving palivizumab. DESIGN: Two decision analytic models were designed, one with and the other without accounting for increased risk of asthma following respiratory syncytial virus infection. SETTING: A hypothetical community or university hospital. PARTICIPANTS: Hypothetical cohorts of infants without chronic lung disease born at 26 to 32 weeks' gestation. INTERVENTIONS: Palivizumab prophylaxis vs no prophylaxis. MAIN OUTCOME MEASURES: Expected costs and incremental cost-effectiveness ratio expressed as cost per quality-adjusted life-year. RESULTS: The expected costs were higher for palivizumab prophylaxis as compared with no prophylaxis. The incremental cost-effectiveness ratios were high for all gestations and are not considered cost-effective by today's standards (<$200 000 per quality-adjusted life-year). Both models were sensitive to variation in the cost of palivizumab. The model that included asthma was sensitive to variation in quality of life for children with asthma. In instances where asthma was considered severe with profound worsening in quality of life compared with life without asthma, some infants had an incremental cost per quality-adjusted life-year that was less than $200 000. CONCLUSIONS: Our model supports implementing more restrictive guidelines for palivizumab prophylaxis. Palivizumab was cost-effective for some infants in an analysis that accounted for increased risk of severe asthma following respiratory syncytial virus infection.

Antibodies, Monoclonal↗
PubMed2006

Economic burden associated with Parkinson's disease on elderly Medicare beneficiaries.

We evaluated medical utilization and economic burden of self-reported Parkinson's disease (PD) on patients and society. Using the 1992-2000 Medicare Current Beneficiary Survey, we compared health care utilization and expenditures (in 2002 U.S. dollars) of Medicare subscribers with and without PD, adjusting for sociodemographic characteristics and comorbidities. PD patients used significantly more health care services of all categories and paid significantly more out of pocket for their medical services than other elderly (mean+/- SE, 5,532 dollars+/- 329 dollars vs. 2,187 dollars+/- 38 dollars; P<0.001). After adjusting for other factors, PD patients had higher annual health care expenses than beneficiaries without PD (18,528 dollars vs. 10,818 dollars; P<0.001). PD patients were more likely to use medical care (OR=3.77; 95% CI=1.44-9.88), in particular for long-term care (OR=3.80; 95% CI=3.02-4.79) and home health care (OR=2.08; 95% CI=1.76-2.46). PD is associated with a significant economic burden to patients and society. Although more research is needed to understand the relationship between PD and medical expenditures and utilization, these findings have important implications for health care providers and payers that serve PD populations.

Activities of Daily Living↗
PubMed2006

Effect of a voucher benefit on the demand for paid personal assistance.

PURPOSE: We estimated the effect of a voucher benefit on the demand for personal assistance by Medicare beneficiaries aged 65 years or older who had functional disabilities. DESIGN AND METHODS: We performed a secondary data analysis on 645 Medicare beneficiaries from the Medicare Primary and Consumer-Directed Care Demonstration (a randomized controlled trial) between August 1998 and June 2000. We estimated a two-part model to determine the effect of the voucher on out-of-pocket personal assistance expenditures. The model controlled for individual health and functional status variables, sociodemographics, prior health care utilization, and state fixed effects. RESULTS: A modest experimental Medicare personal assistance voucher benefit (that reimbursed 80% of up to 250 dollars of eligible expenses per month) increased the likelihood of any out-of-pocket spending for assistance (by 12%, p < .05), but it did not increase the amount of personal assistance expenditures among users (p = .94). Overall, the voucher benefits increased average annual expenditures by 10% (5,304 dollars for the voucher group vs 4,836 dollars for the control group). However, this effect did not reach statistical significance (p = .66). IMPLICATIONS: The voucher benefit provided a small incentive to use personal assistance for older Medicare beneficiaries with functional disabilities. Thus, if Medicare were to implement such a benefit, Medicare expenditures may increase. Further research is needed to determine if the increased personal assistance use leads to better health outcomes and whether it is associated with offset cost savings for Medicare-covered services.

Aged↗
PubMed2006

Organizational climate and intensive care unit nurses' intention to leave.

OBJECTIVE: The purposes of this study were to a) estimate the incidence of intensive care units nurses' intention to leave due to working conditions; and b) identify factors predicting this phenomenon. DESIGN: Cross-sectional design. SETTING: Hospitals and critical care units. SUBJECTS: Registered nurses (RNs) employed in adult intensive care units. INTERVENTIONS: Organizational climate, nurse demographics, intention to leave, and reason for intending to leave were collected using a self-report survey. MEASUREMENTS AND MAIN RESULTS: Nurses were categorized into two groups: a) those intending to leave due to working conditions; and b) others (e.g., those not leaving or retirees). The measure of organizational climate had seven subscales: professional practice, staffing/resource adequacy, nurse management, nursing process, nurse/physician collaboration, nurse competence, and positive scheduling climate. Setting characteristics came from American Hospital Association data and a survey of chief nursing officers. RESULTS: A total of 2,323 RNs from 66 hospitals and 110 critical care units were surveyed across the nation. On average, the RN was 39.5 yrs old (SD = 9.40), had 15.6 yrs (SD = 9.20) experience in health care, and had worked in his or her current position for 8.0 yrs (SD = 7.50). Seventeen percent (n = 391) of the respondents indicated intending to leave their position in the coming year. Of those, 52% (n = 202) reported that the reason was due to working conditions. Organizational climate factors that had an independent effect on intensive care unit nurse intention to leave due to working conditions were professional practice, nurse competence, and tenure (p < .05). CONCLUSIONS: Improving professional practice in the work environment and clinical competence of the nurses as well as supporting new hires may reduce turnover and help ensure a stable and qualified workforce.

Adult↗
PubMed2006

Does date stamping ICD-9-CM codes increase the value of clinical information in administrative data?

CONTEXT: Comorbidity measures are designed to exclude complications when they map International Classification of Diseases (ICD-9-CM) codes to diagnostic categories. The use of data fields that indicates whether each secondary diagnosis was present at the time of hospital admission may lead to the more accurate identification of preexisting conditions. OBJECTIVE: To examine the rate of misclassification of ICD-9-CM codes into diagnostic categories by the Dartmouth-Manitoba adaptation of the Charlson index and by the Elixhauser comorbidity algorithm. DATA SOURCE: Analysis of 178,838 patients in the California State Inpatient Database (CA SID) admitted in 2000 for one of seven major medical and surgical conditions. The CA SID includes a condition present at admission (CPAA) modifier for each ICD-9-CM code. STUDY DESIGN: The Dartmouth/Charlson index and the Elixhauser comorbidity measure were used to map the ICD-9-CM codes into diagnostic categories for patients in each study population. We calculated the misclassification rate for each mapping algorithm, using information from the CPAA as the "gold standard." PRINCIPAL FINDINGS: The Dartmouth/Charlson index underestimated the prevalence of hemiplegia/paraplegia by 70 percent, cerebrovascular disease by 70 percent, myocardial infarction by 65 percent, congestive heart failure (CHF) by 45 percent, and peptic ulcer disease by 34 percent. The Elixhauser algorithm misclassified complications as preexisting conditions for 43 percent of the coagulopathies, 25 percent of the fluid and electrolyte disorders, 18 percent of the cardiac arrhythmias, 18 percent of the cardiac arrhythmias, and 9 percent of the cases of CHF. CONCLUSION: Adding the CPAA modifier to administrative data would significantly enhance the ability of the Dartmouth/Charlson index and of the Elixhauser algorithm to map ICD-9-CM codes to diagnostic categories accurately.

Algorithms↗
PubMed2006

Accuracy of hospital report cards based on administrative data.

CONTEXT: Many of the publicly available health quality report cards are based on administrative data. ICD-9-CM codes in administrative data are not date stamped to distinguish between medical conditions present at the time of hospital admission and complications, which occur after hospital admission. Treating complications as preexisting conditions gives poor-performing hospitals "credit" for their complications and may cause some hospitals that are delivering low-quality care to be misclassified as average- or high-performing hospitals. OBJECTIVE: To determine whether hospital quality assessment based on administrative data is impacted by the inclusion of condition present at admission (CPAA) modifiers in administrative data as a date stamp indicator. DESIGN, SETTING, AND PATIENTS: Retrospective cohort study based on 648,866 inpatient admissions between 1998 and 2000 for coronary artery bypass graft (CABG) surgery, coronary angioplasty (PTCA), carotid endarterectomy (CEA), abdominal aortic aneurysm (AAA) repair, total hip replacement (THR), acute MI (AMI), and stroke using the California State Inpatient Database which includes CPAA modifiers. Hierarchical logistic regression was used to create separate condition-specific risk adjustment models. For each study population, one model was constructed using only secondary diagnoses present at admission based on the CPAA modifier: "date stamp" model. The second model was constructed using all secondary diagnoses, ignoring the information present in the CPAA modifier: the "no date stamp model." Hospital quality was assessed separately using the "date stamp" and the "no date stamp" risk-adjustment models. RESULTS: Forty percent of the CABG hospitals, 33 percent of the PTCA hospitals, 40 percent of the THR hospitals, and 33 percent of the AMI hospitals identified as low-performance hospitals by the "date stamp" models were not classified as low-performance hospitals by the "no date stamp" models. Fifty percent of the CABG hospitals, 33 percent of the PTCA hospitals, 50 percent of the CEA hospitals, and 36 percent of the AMI hospitals identified as low-performance hospitals by the "no date stamp" models were not identified as low-performance hospitals by the "date stamp" models. The inclusion of the CPAA modifier had a minor impact on hospital quality assessment for AAA repair, stroke, and CEA. CONCLUSION: This study supports the hypothesis that the use of routine administrative data without date stamp information to construct hospital quality report cards may result in the mis-identification of hospital quality outliers. However, the CPAA modifier will need to be further validated before date stamped administrative data can be used as the basis for health quality report cards.

Aged↗
PubMed2006

Improved asthma care after enrollment in the State Children's Health Insurance Program in New York.

BACKGROUND: Uninsured children with asthma are known to face barriers to asthma care, but little is known about the impact of health insurance on asthma care. OBJECTIVES: We sought to assess the impact of New York's State Children's Health Insurance Program (SCHIP) on health care for children with asthma. DESIGN: Parents of a stratified random sample of new enrollees in New York's SCHIP were interviewed by telephone shortly after enrollment (baseline, n = 2644 [74% of eligible children]) and 1 year later (follow-up, n = 2310 [87%]). Asthma was defined by parent report using questions based on National Heart, Lung, and Blood Institute criteria. A comparison group (n = 401) who enrolled in SCHIP 1 year later was interviewed as a test for secular trends. MAIN OUTCOME MEASURES: Access (having a usual source of care [USC], unmet health needs, problems receiving acute asthma care), asthma-related medical visits, quality (continuity of care at the USC, problems receiving chronic asthma care, use of antiinflammatory medications), and asthma outcomes (change in asthma care or severity) were the main outcome measures used. Bivariate and multivariate analyses compared measures at baseline (year before SCHIP) versus follow-up (year during SCHIP). RESULTS: Three-hundred eighty-three children (14%) had asthma at baseline, and 364 had asthma at follow-up (16%). No secular trends were detected between the baseline study group and the comparison group. After enrollment in SCHIP, improvements were noted in access: lacking a USC (decrease from 5% to 1%), unmet health needs (48% to 21%), and problems getting to the USC for asthma (13 to 4%). Children had fewer asthma-related attacks and medical visits after SCHIP (mean number of attacks: 9.5 to 3.8: mean number of asthma visits: 3.0 to 1.5; hospitalizations: 11% to 3%). Quality of asthma care improved for general measures (most/all visits to USC: 53% to 94%; mean rating of provider: 7.9 to 8.8 of 10) and asthma-specific measures (problems getting to the USC for asthma care when child was well: 13% to 1%). More than two thirds of the parents at follow-up reported that both quality of asthma care and asthma severity were "better or much better" than at baseline, generally because of insurance coverage or lower costs of medications and medical care. CONCLUSIONS: Enrollment in New York's SCHIP was associated with improvements in access to asthma care, quality of asthma care, and asthma-specific outcomes. These findings suggest that health insurance improves the health of children with asthma.

Adolescent↗
PubMed2006

Short-term persistence of high health care costs in a nationally representative sample of children.

OBJECTIVES: Little is known about the persistence of health care costs in children. Determining whether children with high health expenses continue to have high expenses over time can help in the development of targeted programs and policies to decrease costs, plan equitable health insurance strategies, and provide insights into the effects of costly conditions on families. The objectives of this study were to (1) identify the characteristics of children who are in the top 10th percentile for health costs, (2) investigate whether those in the top percentiles for costs in 1 year continue in the same percentiles the next year, and (3) identify factors that predict whether a child stays in the top percentiles. METHODS: Data from 2 consecutive years (2000-2001) of the Medical Expenditure Panel Survey were analyzed. Changes in a child's position in the expenditure distribution were examined. An estimated multivariate model conditional on insurance was developed to predict the true resource costs of providing services. Statistical analyses, including logistic-regression and multivariate linear-regression modeling, were done to account for the weighted sampling used in Medical Expenditure Panel Survey. RESULTS: A total of 2938 children were included in the survey for both years. In 2000, the top 10% of the children accounted for 54% of all costs. They had a mean total expenditure of 6422 dollars with out-of-pocket expenditures of 1236 dollars; 49% of the children in the top decile in 2000 persisted in the top decile in 2001, whereas 12% dropped into the bottom half. Children who had been in the top 10% in 2000 were 10 times more likely than other children to be in the top 10% for 2001. Other characteristics in 2000 that predicted membership in the top decile for 2001 included age (11-15 and 16-17 years), having any insurance (public and private), being positive on the standardized Children With Special Health care Need screener, and having a functional limitation. CONCLUSIONS: Almost half of the children in the top 10% for costs in 2000 persisted in the top 10% in 2001. Older children, children with special health care needs, and children with functional limitations were more likely to be in the top decile. These findings do not support the belief that black and Latino children who are on Medicaid account for a disproportionate share of costs or expenditures. Because the children who were among the top 10% used health care services in a variety of inpatient, emergency department, outpatient, and ancillary venues, providing care coordination throughout the entire health care system is important to address both the cost and the quality aspects of health care for the most costly children. Targeted programs to decrease expenditures for those with the greatest costs have the potential to save future health care dollars. Assessment of the factors that predict persistence of high expenditures can be used to help in the planning of equitable health insurance strategies such as catastrophic care, carve-outs, reinsurance, and risk adjustment. Clinicians should review regularly the extent of care coordination that they are providing for their high-need and high-cost patients, especially preteens and adolescents. Studies that examine the persistence of expenditures over longer periods and include assessment of quality of care are needed.

Adolescent↗
PubMed2005

Evaluating trauma center quality: does the choice of the severity-adjustment model make a difference?

CONTEXT: The Major Trauma Outcome Study (MTOS) database was created by the American College of Surgeons over 20 years ago to establish national norms for trauma care. The primary trauma outcome prediction models used for evaluating the quality of trauma care, TRISS and ASCOT (A Severity Characterization of Trauma), were developed using the MTOS database. OBJECTIVE: First, to determine whether TRISS and ASCOT agree on hospital quality. Second, to determine whether TRISS and ASCOT accurately reflect contemporary outcomes in trauma care. DESIGN, SETTING AND PATIENTS: A retrospective cohort study based on 91,112 patients admitted to 69 hospitals between 2000 and 2001 in the National Trauma Databank. Using TRISS and ASCOT, the ratio of the observed to expected mortality rate (O/E ratio) was calculated for each hospital. Hospitals whose O/E ratio was statistically different from 1 were identified as quality outliers. Kappa analysis was used to assess the degree to which TRISS and ASCOT agreed on the identity of hospital quality outliers. RESULTS: TRISS and ASCOT disagreed on the outlier status of 35 of the 69 hospitals. Kappa analysis revealed only fair agreement (kappa = 0.23; p = 0.0015) between TRISS and ASCOT in identifying quality outliers. Thirty-eight hospitals were identified by the TRISS method as high-performance hospitals. CONCLUSION: First, TRISS and ASCOT exhibit substantial disagreement on the identity of quality outliers within the NTDB. Second, an unrealistically high number of hospitals were identified as high-performance outliers using either TRISS or ASCOT. These findings have important implications for the use of TRISS and ASCOT for benchmarking performance and quality improvement.

Calibration↗
PubMed2005

Cost-effectiveness of implanted defibrillators in young people with inherited cardiac arrhythmias.

BACKGROUND: The implanted cardioverter-defibrillator (ICD) has been shown to improve survival in adult patients with high risk acquired cardiac disease, with a cost-effectiveness ratio in the range of $30,000 to $185,000 per quality-adjusted-life-year saved. However, data on the benefit and cost-effectiveness of device therapy in high-risk patients with inherited cardiac disorders are limited. METHODS: We developed two separate computer-based analytical models to compare non-ICD with ICD therapy in patients (age range: 10-75 years) with long QT syndrome (LQTS) and hypertrophic cardiomyopathy (HCM). In each disease entity patients were stratified into low-risk (no known risk factors); high-risk (known risk factors [primary prevention]); and very high-risk (prior near-fatal events [secondary prevention]). Net costs were defined as the difference between costs resulting from treatment of the disease and savings due to gained productivity attributable to prevention of sudden cardiac death. Outcome was defined as costs per quality-adjusted life-years saved. RESULTS: In LQTS, defibrillator therapy was shown to be cost effective in high-risk male patients (incremental cost-effectiveness ratio [ICER]=$3328 per quality-adjusted-life-year saved), and cost saving in high-risk females (ICER=$7102 gained per quality-adjusted-life-year saved) and very high-risk males and females (ICER=$15,483 and 19,393 gained per quality-adjusted-life-year saved, respectively). In HCM, defibrillator therapy was cost saving in both male and female high-risk (ICER=$17,892 and $17,526 gained per quality-adjusted-life-year saved, respectively) and very high-risk (ICER $22,944 and $22,329 gained per quality-adjusted-life-year saved, respectively) patients. Defibrillator therapy was not shown to be cost effective in low-risk patients with either LQTS or HCM (ICER in the range of $400,000 to $600,000 lost per quality-adjusted-life-year saved). Sensitivity analyses were consistent with the results in each risk group. CONCLUSIONS: In appropriately selected patients with inherited cardiac disorders, early intervention with ICD therapy is cost-effective to cost saving due to added years of gained productivity when the lifespan of an individual at risk is considered.

Arrhythmias, Cardiac↗
PubMed2005

The relation between surgeon volume and outcome following off-pump vs on-pump coronary artery bypass graft surgery.

STUDY OBJECTIVE: Off-pump coronary artery bypass graft (CABG) surgery has been recently reintroduced into clinical practice. In light of the relatively low level of experience of most cardiac surgeons with off-pump CABG surgery, and the exceptional technical challenge of working on a "beating heart," off-pump CABG surgery presents a unique opportunity to explore the effect of surgeon case volume on surgical outcome after controlling for the effects of patient case mix and hospital volume. DESIGN: A retrospective cohort study analyzing the association between surgeon volume and in-hospital mortality rate for off-pump and on-pump CABG surgery using random-effects logistic regression modeling. SETTING AND PATIENTS: The analyses were based on the New York State clinical CABG surgery registry. The study sample consisted of 36,930 patients undergoing isolated CABG surgery between 1998 and 1999 that was performed by 181 surgeons at 33 hospitals. INTERVENTIONS: None. RESULTS: There is no association between the number of CABG procedures performed off-pump by an individual surgeon and in-hospital mortality rates (p = 0.93) after controlling for hospital CABG surgery volume and patient-level risk factors. There is also no association between the off-pump CABG surgery mortality rate and the total number of both off-pump and on-pump CABG surgery cases (p = 0.78). In the on-pump CABG surgery cohort, surgeons performing a high volume of CABG procedures had significantly lower risk-adjusted mortality rates among their patients compared to those performing a very low volume, a low-volume, and a medium volume of CABG procedures (p < 0.006). CONCLUSION: For off-pump CABG surgery, surgeons performing a high volume of procedures do not have better mortality outcomes than those performing a low volume of procedures. However, higher surgeon case volumes are associated with lower mortality rates for on-pump CABG surgery. The absence of a volume-outcome association for off-pump CABG surgery is especially surprising in light of the more technically demanding nature of off-pump CABG surgery compared to on-pump CABG surgery.

Cohort Studies↗
PubMed2005

Reduction in racial and ethnic disparities after enrollment in the State Children's Health Insurance Program.

BACKGROUND: Racial/ethnic disparities are associated with lack of health insurance. Although the State Children's Health Insurance Program (SCHIP) provides health insurance to low-income children, many of whom are members of racial/ethnic minority groups, little is known about whether SCHIP affects racial/ethnic disparities among children who enroll. OBJECTIVES: The objectives of this study were to (1) describe demographic characteristics and previous health insurance experiences of SCHIP enrollees by race, (2) compare racial/ethnic disparities in medical care access, continuity, and quality before and during SCHIP, and (3) determine whether disparities before or during SCHIP are explained by sociodemographic and health system factors. METHODS: Pre/post-parent telephone survey was conducted just after SCHIP enrollment and 1 year after enrollment of 2290 children who had an enrollment start date in New York State's SCHIP between November 2000 and March 2001, stratified by race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic). The main outcome measures were usual source of care (USC), preventive care use, unmet needs, patterns of USC use, and parent-rated quality of care before versus during SCHIP. RESULTS: Children were white (25%), black (31%), or Hispanic (44%); 62% were uninsured > or =12 months before SCHIP. Before SCHIP, a greater proportion of white children had a USC compared with black or Hispanic children (95%, 86%, and 81%, respectively). Nearly all children had a USC during SCHIP (98%, 95%, and 98%, respectively). Before SCHIP, black children had significantly greater levels of unmet need relative to white children (38% vs 27%), whereas white and Hispanic children did not differ significantly (27% vs 29%). During SCHIP, racial/ethnic disparities in unmet need were eliminated, with unmet need at 19% for all 3 racial/ethnic groups. Before SCHIP, more white children made all/most visits to their USC relative to black or Hispanic children (61%, 54%, and 34%, respectively); all improved during SCHIP with no remaining disparities (87%, 86%, and 92%, respectively). Parent-rated visit quality improved for all groups, but preexisting racial/ethnic disparities remained during SCHIP, with improved yet relatively lower levels of satisfaction among parents of Hispanic children. Sociodemographic and health system factors did not explain disparities in either period. CONCLUSIONS: Enrollment in SCHIP was associated with (1) improvement in access, continuity, and quality of care for all racial/ethnic groups and (2) reduction in preexisting racial/ethnic disparities in access, unmet need, and continuity of care. Racial/ethnic disparities in quality of care remained, despite improvements for all racial groups. Sociodemographic and health system factors did not add to the understanding of racial/ethnic disparities. SCHIP improves care for vulnerable children and reduces preexisting racial/ethnic disparities in health care.

Adolescent↗
PubMed2005

Pramipexole and levodopa in early Parkinson's disease: dynamic changes in cost effectiveness.

BACKGROUND AND OBJECTIVE: In chronic disease, treatment effects and costs accumulate over time; hence, the choice of time horizon in cost-effectiveness analysis can be particularly important. In this article we analyse the dynamic changes in cumulative costs, effects and incremental cost effectiveness of two competing drug strategies in patients with early Parkinson's disease (PD). METHODS: Three hundred and one subjects with PD were randomised to initial pramipexole or levodopa and followed every 3 months over a 4-year period. Healthcare resource use was recorded in patient diaries and valued using a variety of sources at year 2002 US dollar values. Health-related quality of life (HRQoL) was measured using the EuroQoL EQ-5D. The study was conducted from a US societal perspective. Missing data were imputed using a multivariate fixed-effects model. Additional quality adjusted life years (QALY) gained by using pramipexole compared with levodopa were estimated as the area between the normalised treatment HRQoL profiles. The QALYs and costs for each treatment arm were calculated for various study horizons.The incremental cost-effectiveness ratio (ICER) and the net monetary benefit (NB) [using 50,000 US dollars, 100,000 US dollars and 150,000 US dollars as the value of a QALY] were estimated, and were bootstrapped to calculate the standard errors. Cost-effectiveness acceptability curves (CEAC) were built to estimate the probability that pramipexole was cost effective given different societal values of QALY, for various study horizons.We conducted sensitivity analyses on the ICER and the NB to test their robustness to various assumptions about missing data, for various subpopulations and under changes in the drug prices. RESULTS: Under the base-case assumptions, the ICER for pramipexole was 42,989 US dollars per QALY. Using the CEAC approach, the probability that pramipexole was cost effective relative to levodopa over the first 4 years was 0.57, 0.77 and 0.82 when a QALY was valued at 50,000 US dollars, 100,000 US dollars, and 150,000 US dollars, respectively. Over time, the ICER for pramipexole improved and uncertainty around the ICER decreased. If, after treatment withdrawal, HRQoL improved in pramipexole subjects and declined in levodopa subjects (best-case scenario for pramipexole), the probability of pramipexole being cost effective increased to 0.88, 0.96 and 0.98, respectively. Factors that improved the ICER of pramipexole were a decrease in the relative price of pramipexole and having low HRQoL or depression at baseline. CONCLUSIONS: The cost effectiveness of pramipexole compared with levodopa in the treatment of early PD increased as the time horizon of the clinical trial extended from 2 to 4 years. Our results suggest that pramipexole is more cost effective for patients with depression and low baseline HRQoL than in other patient subgroups.

Administration, Oral↗
PubMed2004

Variations in treatment for ductal carcinoma in situ in elderly women.

OBJECTIVE: The objective of this study is to quantify variation and variability in treatment of ductal carcinoma in situ (DCIS) over time and across registries of the Surveillance, Epidemiology, and End Results (SEER) program; to assess diffusion of treatments (breast-conserving surgery [BCS], BCS with radiotherapy, and mastectomy); and to identify correlates of treatment choice. DATA: The linked SEER-Medicare database from 1991 to 1996 includes 2701 women aged 65 and older diagnosed with unilateral DCIS. 1990 census data provide socioeconomic variables at the zip-code level, and the 1999 Dartmouth Atlas of Health Care provides number of radiation oncologists. STUDY DESIGN: Bivariate and multivariate analyses of retrospective cohort data assess factors that explain treatment choice. The multivariate model includes controls for comorbidity, marital status, age, race, education, poverty, rural, and radiation oncologists per 100,000 population. Chi-squared tests assess differences in treatment rates by registry and by year. Diffusion of treatments is analyzed by predicting yearly mean treatment rates and yearly variation in treatment rates across geographic areas and over time. RESULTS: There are significant geographic and temporal differences in treatment rates for DCIS with increasing use of BCS alone. Treatment choice is explained by SEER registry, diagnosis year, marital status, race, age, urban/rural status, educational attainment, and number of radiation oncologists. Variability in treatment of DCIS is increasing during the study period. CONCLUSIONS: Findings indicate that diagnosis year and socioeconomic factors explain treatment choice for DCIS, but unexplained variation at the geographic-region level remains. Increasing variability in treatment implies continued uncertainty about optimal treatment of DCIS.

Age Factors↗