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Biomedical subjects

Andrew W Dick

Publications and source records attributed to Andrew W Dick.

34 records · Page 2Linked to original sources
PubMed2004

Improved access and quality of care after enrollment in the New York State Children's Health Insurance Program (SCHIP).

BACKGROUND: Although many studies have noted that uninsured children have poorer access and quality of health care than do insured children, few studies have been able to demonstrate the direct benefits of providing health insurance to previously uninsured children. The State Children's Health Insurance Program (SCHIP), enacted as Title XXI of the Social Security Act, was intended to improve insurance coverage and access to health care for low-income, uninsured children. With limited state and federal resources for health care, continued funding of SCHIP requires demonstration of success of the program. As yet, little is known about the effectiveness of SCHIP on improving access and quality of care to enrollees. OBJECTIVES: To measure the impact of the New York State (NYS) SCHIP on access, utilization, and quality of health services for enrolled children. DESIGN SETTING: NYS, stratified into 4 regions. The NYS SCHIP is modeled on commercial insurance (32 managed care plans) and at the time of the study had 18% of SCHIP enrollees nationwide. STUDY DESIGN: For the study group, the design used pre/poststudy telephone interviews of parents of children enrolling in the NYS SCHIP, with baseline interviews soon after enrollment and follow-up interviews 1 year after enrollment. Baseline interviews reflected the child's experience during the 1-year period before enrollment in SCHIP. The follow-up interviews reflected the 1-year period after enrollment in SCHIP. For the comparison group, the design used baseline interviews of a comparison group enrolled 1 year after the study group to test for secular trends; these interviews reflected the 1-year period before enrollment in SCHIP. SUBJECTS: Children (n = 2644) 0 to 18 years of age who enrolled in the NYS SCHIP for the first time (November 2000 to March 2001), stratified by age (0-5, 6-11, and 12-18 years), race/ethnicity (white non-Hispanic, black non-Hispanic, and Hispanic; others excluded), and region of NYS. The comparison group consisted of 400 children. Telephone interviews were conducted in English or Spanish throughout the day and evening, 7 days per week, to obtain measures. MAIN OUTCOME MEASURES: Demographic and health measures (child and family characteristics, health status, presence of a special health care need, and prior health insurance), access (usual source of care [USC] and unmet needs for health care), utilization (visits for specific health services), and quality (continuity with USC and measures of primary care interactions). Analyses included bivariate tests, comparing the pre-SCHIP period to the 1-year period after enrollment in SCHIP. Multivariate models were computed to generate standardized populations comprised of key characteristics of the sample to test for differences in measures (after SCHIP versus before SCHIP), controlling for demographic characteristics. RESULTS: Of the 2644 study-group children who completed the initial interview, 2290 (87%) completed the follow-up interview. Key measures for the pre-SCHIP period and short-term "postenrollment" measures for the study group were not statistically different from measures for the comparison group, suggesting no major secular trends. Participants were non-Hispanic white (25%), non-Hispanic black (31%), and Hispanic (45%). Fifty-one percent of the parents were single, and 61% had a high school education or less; 81% of families had income <160% of the federal poverty level. Sixty-two percent of the children were uninsured > or = 12 months before the NYS SCHIP; of those insured, 43% previously had Medicaid. The proportion of children who had a USC increased after enrollment in the NYS SCHIP (86% to 97%). Two measures of accessibility (difficulty getting a medical person by telephone and difficulty getting an appointment) improved after enrollment in SCHIP. The proportion of children with any unmet health care needs decreased (31% to 19%). Specific types of unmet need also were reduced after enrollment; for example, among SCHIP enrollees who had a need for specific type of care, unmet needs wds were significantly lower postenrollment versus pre-SCHIP for specialty care (-15.5% in unmet need), acute care (-10.1%), preventive care (-9.6%), dental care (-13.0%%), and vision care (-13.2%). Emergency and total ambulatory visits did not change, but the proportion of children with a preventive care visit increased (74% to 82%). The proportion of children who used their USC for most or all visits increased (47% to 89%), demonstrating increased continuity of care. Several indicators of health care quality improved, including an overall rating of quality, the 4 indicators of physician-patient interaction used by the Consumer Assessment of Health Plans Survey, and a measure of parental worry about their child's health. Improvements were noted among major subgroups of children, with the greatest improvements for those with the lowest baseline levels. For example, at baseline, a lower percentage of children living at <160% of the federal poverty level had a presence of a USC or continuity with their USC than children living in families at >160% of the federal poverty level, and these poorer children experienced the greatest gains in having a USC or having continuity with their USC after enrollment in SCHIP. CONCLUSIONS: Enrollment in the NYS SCHIP was associated with 1) improved access, continuity, and quality of care and 2) a change in the pattern of health care, with a greater proportion of care taking place within the usual source of primary care.

Adolescent↗
PubMed2003

Using hierarchical modeling to measure ICU quality.

OBJECTIVE: To determine whether hierarchical modeling agrees with conventional logistic regression modeling on the identity of ICU quality outliers within a large multi-institutional database. DESIGN: Retrospective database analysis. SETTING AND PATIENTS: Subset of the Project IMPACT database consisting of 40435 adult patients admitted to surgical, medical, and mixed surgical-medical ICUs ( n=55) between 1997 and 1999 who met inclusion criteria for SAPS II. MEASUREMENTS AND RESULTS: The SAPS II score was customized to this database using conventional logistic regression and using a hierarchical (random coefficients) model. Both models exhibited excellent discrimination ( Cstatistic) and calibration (Hosmer-Lemeshow statistic). The hierarchical and nonhierarchical models had C statistics of.870 and.865, and HL statistics of 3.71 ( p>.88, df=8) and 8.94 ( p>.35, df=8), respectively. Since the random effects component of the hierarchical model accounts for between-hospital variability, only the fixed-effects coefficients were used to calculate the expected mortality rate based on the hierarchical model. The ratio and 95% confidence intervals of the observed to expected mortality rate were calculated using both models for each ICU. ICUs whose observed/expected ratio was either less than 1 or greater than 1, and whose 95% confidence interval did not include 1 were labeled as either high-performance or low-performance outliers, respectively. Analysis using kappa statistic revealed almost perfect agreement between the two models (nonhierarchical vs. hierarchical) on the identity of ICU quality outliers. CONCLUSIONS: Models obtained by customizing SAPS II using a nonhierarchical and a hierarchical approach exhibit excellent agreement on the identity of ICU quality outliers.

APACHE↗
PubMed2003

Is the hospital volume-mortality relationship in coronary artery bypass surgery the same for low-risk versus high-risk patients?

BACKGROUND: There is evidence to support the existence of an inverse relation between mortality after coronary artery bypass graft (CABG) surgery and procedure volume. It is unclear whether all patients benefit equally from having CABG surgery performed at high-volume centers. The objective of this study was to determine whether the volume-outcome association for CABG surgery is modified by patient risk. METHODS: This retrospective cohort analysis was conducted using data from the Cardiac Surgery Reporting System database on all patients (20,078) undergoing CABG surgery in New York State who were discharged in 1996. The main outcome measure was in-hospital mortality as a function of procedure volume after adjusting for severity of disease. Logistic regression modeling was used to explore the interaction between patient risk and procedure volume. RESULTS: There is a significant interaction between procedure volume and patient risk (p = 0.01). The final model exhibits excellent discrimination (C statistic = 0.818) and goodness-of-fit (Hosmer-Lemeshow statistic = 6.02; p = 0.645). Very low (<0.5%) and low-risk (0.5%-2.0%) patients exhibit a greater reduction in CABG mortality than high (5.0%-10.0%) and very high risk (>10%) patients at high-volume centers relative to low-volume centers. Among the highest risk patients (>25% risk of mortality), higher risk patients have better outcomes at higher volume centers. CONCLUSIONS: For the vast majority of patients, low-risk patients benefit significantly more than high-risk patients from undergoing CABG surgery at high-volume centers instead of at low-volume centers. Low-risk patients benefit significantly more than high-risk patients from undergoing CABG surgery at high-volume centers instead of at low-volume centers. However, before generalizing these findings to other states, this study should be repeated using other regional population-based clinical databases.

Cohort Studies↗
PubMed2003

Racial disparity in the dose and dose intensity of breast cancer adjuvant chemotherapy.

PURPOSE: The purpose of this study was to investigate the impact of race and obesity on dose and dose intensity of adjuvant chemotherapy. METHODS: We abstracted data on patient/tumor characteristics, treatment course, physicians' intention to give a first cycle dose reduction, and reasons for dose reductions/delays from oncology records of 489 women treated from 1985 to 1997 in 10 treatment sites in two geographical regions. Administered doses and dose intensity were compared to standard regimens. Multivariate regression models determined the impact of race and body mass index (BMI) on dose proportion (actual:expected doses) and relative dose intensity (RDI) controlling for patient characteristics, comorbidity, chemotherapy regimen, site, and year of treatment. Logistic regressions explored race and BMI versus use of first cycle dose reductions. RESULTS: African-Americans received lower chemotherapy dose proportion and RDI than whites (0.80 vs. 0.85, p = 0.03 and 0.76 vs. 0.80, p = 0.01). In multivariate analyses, dose proportion was 0.09 lower (p = 0.002), and RDI was 0.10 (p < 0.001) lower in non-overweight African-Americans than whites. Obesity was associated with lower dose proportion (p < 0.01) and RDI (p < 0.03). Race and BMI were independently associated with first cycle dose reductions. Non-overweight African-Americans (p < 0.05) and overweight and obese African-American and white women (p < 0.001) were more likely to have first cycle dose reductions than non-overweight whites. CONCLUSION: We identified systematic differences in the administration of chemotherapy given to African-Americans and to overweight and obese women. These differences may contribute to documented disparities in outcome.

Adult↗
PubMed2003

Guidelines for palivizumab prophylaxis: are they based on infant's risk of hospitalization for respiratory syncytial viral disease?

BACKGROUND: The American Academy of Pediatrics (AAP) guidelines for respiratory syncytial virus (RSV) prophylaxis aim to prioritize palivizumab administration to infants at highest risk for RSV disease. Multiple studies have been published that assess the risk of hospitalization for RSV disease by gestational age (GA) at birth and severity of lung disease. OBJECTIVE: To evaluate whether the AAP guidelines for RSV prophylaxis correlate with the available data in the literature on the degree of risk of hospitalization for RSV disease by GA at birth and severity of lung disease. METHODS: We considered a hypothetical population of infants with and without chronic lung disease. This population was then divided into hypothetical cohorts depending on GA at birth and month of neonatal intensive care unit discharge. We assumed that infants are discharged from neonatal intensive care unit at 36 to 37 weeks postconceptional age. By applying the AAP policy for RSV prophylaxis, the numbers of palivizumab injections were determined for the different cohorts. RESULTS: In some instances infants who are currently known to be at higher risk of hospitalization for RSV disease receive fewer palivizumab injections than infants known to be at lower risk. CONCLUSION: Some discrepancies exist between the RSV prophylaxis guidelines and the published data on the level of risk of hospitalization for RSV disease by GA and lung disease. AAP policy for RSV prophylaxis must be amended to better correlate the amount of palivizumab prophylaxis with the level of risk of hospitalization for RSV disease as determined by the above factors.

Antibodies, Monoclonal↗
PubMed2003

The effect of capitation on switching primary care physicians.

OBJECTIVE: To examine the relationship between patient case-mix, utilization, primary care physician (PCP) payment method, and the probability that patients switch their PCPs. DATA SOURCES/STUDY SETTING: Administrative enrollment and claims/encounter data for 1994-1995 from four physician organizations. STUDY DESIGN: We developed a conceptual model of patient switching behavior, which we used to guide the specification of multivariate logistic analyses focusing on interactions between patient case-mix, utilization, and PCP reimbursement methods. DATA COLLECTION/EXTRACTION METHODS: Claims data were aggregated to the encounter level; a switch was defined as a change in PCP since the previous encounter. The PCPs were reimbursed on either a capitated or fee-for-service (FFS) basis. PRINCIPAL FINDINGS: Patients with stable chronic conditions (Ambulatory Diagnostic Groups [ADG] 10) and capitated PCPs were 36 percent more likely to switch PCPs than similar patients with FFS PCPs, controlling for patient age and sex and physician fixed effects. When the number of previous encounters was included in the model this relationship was no longer significant. Instead high utilizers with capitated PCPs were significantly more likely to switch PCPs than were similar patients with FFS PCPs. CONCLUSIONS: A patient's demographics and utilization are associated with the probability that the patient will switch PCPs. Capitated PCP payment was associated with higher rates of switching among high utilizers of health care resources. These findings raise concerns about the continuity and quality of care experienced by vulnerable patients in an era of changing financial incentives.

Adult↗
PubMed2003

Who's enrolled in the State Children's Health Insurance Program (SCHIP)? An overview of findings from the Child Health Insurance Research Initiative (CHIRI).

BACKGROUND: The State Children's Health Insurance Program (SCHIP) was enacted in 1997 to provide health insurance coverage to uninsured low-income children from families who earned too much to be eligible for Medicaid. OBJECTIVES: To develop a "baseline" portrait of SCHIP enrollees in 5 states (Alabama, Florida, Kansas, Indiana, and New York) by examining: 1) SCHIP enrollees' demographic characteristics and health care experiences before enrolling in SCHIP, particularly children with special health care needs (CSHCN), racial and ethnic minority children, and adolescents; 2) the quality of the care adolescents received before enrollment; and 3) the changes in enrollee characteristics as programs evolve and mature. METHODS: Each of 5 projects from the Child Health Insurance Research Initiative (CHIRI) surveyed new SCHIP enrollees as identified by state enrollment data. CHIRI investigators developed the CHIRI common core (a set of survey items from validated instruments), which were largely incorporated into each survey. Bivariate and multivariate analyses were conducted to ascertain whether there were racial and ethnic disparities in access to health care and differences between CSHCN and those without. Current Population Survey data for New York State were used to identify secular trends in enrollee characteristics. RESULTS: Most SCHIP enrollees (65% in Florida to 79% in New York) resided in families with incomes < or =150% of the federal poverty level. Almost half of SCHIP enrollees lived in single-parent households. A majority of SCHIP parents had not had education beyond high school, and in 2 states (Alabama and New York) approximately 25% had not completed high school. The vast majority of children lived in households with a working adult, and in a substantial proportion of households both parents worked. Children tended to be either insured for the entire 12 months or uninsured the entire 12 months before enrolling in SCHIP. Private insurance was the predominant form of insurance before enrollment in SCHIP in most states, but 23.3% to 51.2% of insured children had Medicaid as their most recent insurance. HEALTH CARE USE AND UNMET NEEDS BEFORE SCHIP: The vast majority of all SCHIP enrollees had a usual source of care (USC) during the year before SCHIP. The proportion of children who changed their USC after enrolling in SCHIP ranged from 29% to 41.3%. A large proportion of SCHIP enrollees used health services during the year before SCHIP, with some variability across states in the use of health care. Nevertheless, 32% to almost 50% of children reported unmet needs. CSHCN: The prevalence of CSHCN in SCHIP (between 17% and 25%) in the study states was higher than the prevalence of CSHCN reported in the general population in those states. In many respects, CSHCN were similar to children without special health care needs, but CSHCN had poorer health status, were more likely to have had unmet needs, and were more likely to use the emergency department, mental health care, specialty care, and acute care in the year before enrolling in SCHIP than children without special health care needs. RACE AND ETHNICITY: A substantial proportion of SCHIP enrollees were black non-Hispanic or Hispanic children (Alabama: 34% and <1%; Florida: 6% and 26%; Kansas: 12% and 15%; and New York: 31% and 45%, respectively). Minority children were poorer, in poorer health, and less likely to have had a USC or private insurance before enrolling in SCHIP. The prevalence and magnitude of the disparities varied among the states. QUALITY OF CARE FOR ADOLESCENTS: Seventy-three percent of adolescent SCHIP enrollees engaged in one or more risk behaviors (ie, feeling sad or blue; alcohol, tobacco, and drug use; having sexual intercourse; and not wearing seat belts). Although almost 70% of adolescents reported having had a preventive care visit the previous year, a majority of them did not receive counseling in each of 4 counseling areas. Controlling for other factors, having a private, confidential visit with the physician was associated with an increased liked likelihood (2-3 times more likely) that the adolescent received counseling for 3 of 4 counseling areas. TRENDS OVER TIME: New York SCHIP enrollees in 2001, compared with 1994 enrollees in New York's SCHIP-precursor child health insurance program, were more likely to be black or Hispanic, older, from New York City, and from families with lower education, income, and employment levels. A greater proportion of 2001 enrollees was uninsured for some time in the year before enrollment, was insured by Medicaid, and lacked a USC. Secular trends in the low-income population in the state did not seem to be responsible for these differences. Program modifications during this time period that may be related to the shift in enrollee characteristics include changes to benefits, outreach and marketing efforts, changes in the premium structure, and the advent of a single application form for multiple public programs. CONCLUSIONS: SCHIP enrollees are a diverse group, and there was considerable variation among the 5 study states. Overall, SCHIP enrollees had substantial and wide-ranging health care needs despite high levels of prior contact with the health care system. A sizable minority of SCHIP enrollees has special health care needs. There is racial and ethnic diversity in the composition of enrollees as well, with racial and ethnic disparities present. The quality of care adolescents received before enrollment in SCHIP was suboptimal, with many reporting unmet health care needs and not receiving recommended counseling. The characteristics of SCHIP enrollees can be expected to change as SCHIP programs evolve and mature. POLICY IMPLICATIONS: 1) Benefits should be structured to meet the needs of SCHIP enrollees, which are comparable to Medicaid enrollees' needs in many respects. 2) Provider networks will have to be broad if continuity of care is to be achieved. 3) Multiple outreach strategies should be used, including using providers to distribute information about SCHIP. 4) The quality of care delivered to vulnerable populations (eg, minority children, CSHCN, and adolescents) should be monitored. 5) States and health plans should actively promote quality health care with the goal of improving the care received by SCHIP enrollees before enrollment. 6) States will have to craft policies that fit their local context. 7) Collecting baseline information on SCHIP enrollees on a continuous basis is important, because enrollee characteristics and needs can change, and many vulnerable children are enrolling in SCHIP.

Adolescent↗
PubMed2003

The role of race and ethnicity in the State Children's Health Insurance Program (SCHIP) in four states: are there baseline disparities, and what do they mean for SCHIP?

BACKGROUND: Elimination of racial and ethnic disparities in health has become a major national goal. The State Children's Health Insurance Program (SCHIP) has the potential to reduce disparities among the children who enroll if they exhibit the same disparities that have been documented in previous studies of low-income children. To determine the potential impact of SCHIP on racial and ethnic disparities, it is critical to assess baseline levels of health disparities among children enrolling in SCHIP. OBJECTIVE: To use data from the Child Health Insurance Research Initiative (CHIRI) to 1) describe the sociodemographic profile of new enrollees in SCHIP in Alabama, Florida, Kansas, and New York; 2) determine if there were differences in health insurance and health care experiences among white, black, and Hispanic SCHIP enrollees before enrollment in SCHIP; and 3) explore whether race or ethnicity, controlled for other factors, affected pre-SCHIP access to health coverage and health care. SETTING: SCHIP programs in Alabama, Florida, Kansas, and New York, which together include 26% of SCHIP enrollees nationwide. DESIGN: Telephone interview (mailed survey in Alabama) about the child's health, health insurance, and health care experiences conducted shortly after SCHIP enrollment to assess experience during the time period before SCHIP. SAMPLE: New SCHIP enrollees (0-17.9 years old in Alabama, Kansas, and New York and 11.5-17.9 years old in Florida). Stratified sampling was performed in Kansas and New York, with results weighted to reflect statewide populations of new SCHIP enrollees. MEASURES: Sociodemographic characteristics including income, education, employment, and other characteristics of the child and the family, race and ethnicity (white non-Hispanic, black non-Hispanic, and Hispanic [any race]), prior health insurance, health care access and utilization, and health status. ANALYSES: Bivariate analyses were used to compare baseline measures upon enrollment for white, black, and Hispanic SCHIP enrollees. Multivariate analyses were performed to assess health status and health care access measures (prior insurance, presence of a usual source of care (USC), and use of preventive care), controlling for demographic factors described above. Weighted analyses (where appropriate) were performed by using SPSS, STATA, or SUDAAN. RESULTS: Racial and ethnic composition varied across the SCHIP cohorts studied, with black and Hispanic children comprising the following proportion of enrollees, respectively: Alabama, 33% and <1%; Florida, 16% and 26%; Kansas, 12% and 15%; and New York, 24% and 36%. Black and Hispanic children were more likely to reside in single-parent and lower-income families. With some variation by state, children from minority groups were more likely to report poorer health status than were white children. Relative to white children, children from minority groups in Florida and New York were more likely to have been uninsured for the entire year before SCHIP enrollment. In all states, children from minority groups who had prior coverage were more likely to have previously been enrolled in Medicaid than in private health insurance and were less likely to have had employer-sponsored coverage compared with white children. Except in Alabama, there was a difference in having a USC, with children from minority groups less likely to have had a USC before SCHIP enrollment compared with white children. No consistent pattern of health care utilization before SCHIP was noted across states with respect to race or ethnicity. Findings from multivariate analyses, controlling for sociodemographic factors, generally confirmed that black and Hispanic children were more likely to have lacked insurance or a USC before enrollment in SCHIP and to have poorer health status compared with white children. CONCLUSIONS: SCHIP is enrolling substantial numbers of racial and ethnic minority children. There are baseline racial and ethnic disparities among new enrollees in SCHIP, with black and Hispanic children faring worse than white children on many sociodemographic and health system measures, and there are differences among states in the prevalence and magnitude of these disparities. After controlling for sociodemographic factors, these disparities persisted. IMPLICATIONS FOR MONITORING AND IMPROVING SCHIP: SCHIP has the potential to play a critical role in efforts to eliminate racial and ethnic disparities in health among the children it serves. However, study findings indicate that programmatic efforts are necessary to ensure that disparities are not perpetuated. Program effectiveness and outcomes should be monitored by race and ethnicity to ensure equity in access, use, and outcomes across all racial and ethnic groups. Assessing the health characteristics and needs of new SCHIP enrollees can provide a benchmark for evaluating the program's impact on eliminating racial and ethnic disparities in health and inform service delivery enhancements.

Adolescent↗
PubMed2003

The evolution of the State Children's Health Insurance Program (SCHIP) in New York: changing program features and enrollee characteristics.

BACKGROUND: The State Children's Health Insurance Program (SCHIP) has been operating for >5 years. Policy makers are interested in the characteristics of children who have enrolled and changes in the health care needs of enrolled children as programs mature. New York State's SCHIP evolved from a similar statewide health insurance program that was developed in 1991 (Child Health Plus [CHPlus]). Understanding how current SCHIP enrollees differ from early CHPlus enrollees together with how program features changed during the period may shed light on how best to serve the evolving SCHIP population. OBJECTIVE: To 1) describe changes in the characteristics of children enrolled in 1994 CHPlus and 2001 SCHIP; 2) determine if changes in the near-poor, age-eligible population during the time period could account for the evolution of enrollment; and 3) describe changes in the program during the period that could be responsible for the enrollment changes. SETTING: New York State, stratified into 4 regions: New York City, New York City environs, upstate urban counties, and upstate rural counties. DESIGN: Retrospective telephone interviews of parents of 2 cohorts of CHPlus enrollees: 1) children who enrolled in CHPlus in 1993 to 1994 and 2) children who enrolled in New York's SCHIP in 2000 to 2001. The Current Population Survey (CPS) 1992 to 1994 and 1999 to 2001 were used to identify secular trends that could explain differences in the CHPlus and SCHIP enrollees. PROGRAM CHARACTERISTICS: 1994 CHPlus and 2001 SCHIP were similar in design, both limiting eligibility by age, family income, and insurance status. SCHIP 2001 included 1) expansion of eligibility to adolescents 13 to 19 years old; 2) expansion of benefits to include hospitalizations, mental health, and dental benefits; 3) changes in premium contributions; 4) more participating insurance plans, limited to managed care; 5) expansions in marketing and outreach; and 6) a combined enrollment application for SCHIP and several low-income programs including Medicaid. SAMPLE: Cohort 1 included 2126 new CHPlus enrollees 0 to 13 years old who were enrolled for at least 9 months, stratified by geographic region. Cohort 2 included 1100 new SCHIP enrollees 0 to 13 years old who were enrolled for at least 9 months, stratified by geographic region, age, race, and ethnicity. Results were weighted to be representative of statewide CHPlus or SCHIP new enrollees who met the sampling criteria. Samples of age- and income-eligible children from New York State were drawn from the CPS and pooled and reweighted (1992-1994 and 1999-2001) to generate a comparison group of children targeted by CHPlus and SCHIP. MEASURES: Sociodemographic characteristics, race and ethnicity (white non-Hispanic, black non-Hispanic, and Hispanic), prior health insurance, health care access, and first source of information about the program. ANALYSES: Weighted bivariate analyses (comparisons of means and rates) adjusted for the complex sampling design to compare measures between the 2 program cohorts and between the 2 CPS samples. We tested for equivalence by using chi2 statistics. RESULTS: As the program evolved from CHPlus to SCHIP, relatively more black and Hispanic children enrolled (9% to 30% black from 1994 to 2001, and 16% to 48% Hispanic), more New York City residents (46% to 69% from 1994 to 2001), more children with parents who had less than a high school education (10% to 25%), more children from lower income families (59% to 75% below 150% of the federal poverty level), and more children from families with parents not working (7% to 20%) enrolled. These socioeconomic and demographic changes were not reflected in the underlying age- and income-eligible population. A greater proportion of 2001 enrollees were uninsured for some time immediately before enrollment (57% to 76% had an uninsured gap), were insured by Medicaid during the year before enrollment (23% to 48%), and lacked a USC (5% to 14%). Although "word of mouth" was the most common means by which families heard about both programs, a greater proportion of 2001 enrollees learned about SCHIP from marketing or outreach sources. CONCLUSION: As New York programs for the uninsured evolved, more children from minority groups, with lower family incomes and education, and having less baseline access to health care were enrolled. Although changes in the underlying population were relatively small, progressively increased marketing and outreach, particularly in New York City, the introduction of a single application form for SCHIP and Medicaid, and expansions in the benefit package may have accounted, in part, for the large change in the characteristics of enrollees.

Adolescent↗
PubMed2002

Clinical trial end points: on the road to nowhere?

Over the past decade, there have been an increasing number of therapeutic clinical trials of PD. Despite many of these trials showing a positive treatment effect, few have resulted in clear and unambiguous recommendations regarding clinical practice, unlike trials of cerebrovascular disease. The authors hypothesize that lingering therapeutic uncertainty exists because many of the clinical trial end points have been surrogate outcome measures rather than end points with clear and convincing value to patients. The theoretical advantage of using validated surrogate outcomes in definitive trials includes smaller, faster, and less expensive studies. Consequences of using surrogate outcomes that have not been validated include ambiguous evidence and wasted resources as well as patient harm and missed opportunities. To optimize the chance that future trial results will provide clear treatment verdicts and to take full advantage of exciting developments in biomarker technology such as SPECT and PET, it is becoming progressively more urgent to understand the proper role, use, and challenges of using surrogate outcome measures in PD therapeutics.

Biomarkers↗
PubMed2002

Identifying quality outliers in a large, multiple-institution database by using customized versions of the Simplified Acute Physiology Score II and the Mortality Probability Model II0.

OBJECTIVE: To assess whether customized versions of the Simplified Acute Physiology Score (SAPS) II and the Mortality Probability Model (MPM) II0 agree on the identity of intensive care unit quality outliers within a multiple-center database. DESIGN: Retrospective database analysis. SETTING AND PATIENTS: Patient subset of the Project IMPACT database consisting of 39,617 adult patients admitted to surgical, medical, and mixed surgical-medical intensive care units at 54 hospitals between 1995 and 1999 who met inclusion criteria for SAPS II and MPM II0. INTERVENTIONS: Customized versions of SAPS II and MPM II0 were obtained by fitting new logistic regressions to the data by using the risk score as the independent variable and outcome at hospital discharge as the dependent variable. The data set was divided randomly into a training set and a validation set. Each model was customized by using the training set; model performance was then assessed in the validation set by using the area under the receiver operating characteristic curve and the Hosmer-Lemeshow statistic. The final models were based on the entire data set. The level of agreement between the customized models on the identity of quality outliers was evaluated by using kappa analysis. MEASUREMENTS AND MAIN RESULTS: Both customized models exhibited good discrimination and good calibration in this database. The area under the receiver operating characteristic curve was 0.83 for MPM II0 and 0.872 for SAPS II following model customization. The Hosmer-Lemeshow statistic was 12.3 ( >.14) for MPM II0, and 8.17 (p >.42) for SAPS II, after customization. Kappa analysis showed only fair agreement between the two customized models with regard to the identity of the quality outliers: kappa = 0.44 (95% confidence interval, 0.24, 0.65). CONCLUSIONS: Customization of SAPS II and MPM II0 to the Project IMPACT database resulted in well-calibrated models. Despite this, the models exhibited only a moderate level of agreement in which hospitals were designated as quality outliers. Seventeen of the 54 hospitals were categorized differently depending on which of the two scoring systems was used. Therefore, the rating of quality of care appears, in part, to be a function of the prediction model used.

APACHE↗
PubMed2002

Consequences of states' policies for SCHIP disenrollment.

Policymakers are concerned about disenrollment from the State Children's Health Insurance Program (SCHIP). We describe disenrollment in Florida, Kansas, New York, and Oregon and assess the links between disenrollment and States' SCHIP policies. We found that SCHIP is used on a long-term basis (at least 2 years) for a significant group of new enrollees and as temporary coverage (fewer than 12 months) for many others. Recertification generates large disenrollments (about one-half of children still enrolled at the time), but as many as 25 percent return within 2 months. The increased disenrollment rate at recertification is completely eliminated by a policy of passive re-enrollment.

Adolescent↗
PubMedDate not supplied

Pramipexole versus levodopa in patients with early Parkinson's disease: effect on generic and disease-specific quality of life.

OBJECTIVE: Although health-related quality of life (HRQOL) has been included in multiple Parkinson's disease (PD) clinical trials, little is known about how HRQOL responds to treatments over time. Here we assess the effect of therapy on HRQOL and explore factors that influence the HRQOL profiles and subdomains. METHOD: A total of 301 subjects with early PD were randomized to either initial pramipexole or initial levodopa and followed every 3 months over a 4-year period. To estimate health outcomes, we used EQ-5D and PDQUALIF. We calculated the incremental effectiveness as the accumulated difference in the total HRQOL over time between treatments. The subgroup analyses (by sex, race, age, baseline patient characteristics, and occurrence of adverse events) were conducted using the same approach. Sensitivity analysis was performed to test the effect of missing data imputation on the results. RESULTS: All three HRQOL measures resulted in similar profiles over time characterized by initial improvement over the first 3 to 6 months and followed by a gradual decline in years 2, 3, and 4. The difference in HRQOL between the treatment arms widened in favor of pramipexole in years 3 and 4 for all HRQOL measures used (EQ-5D: Y3 0.048, P = 0.03; Y4 0.071, P = 0.04). Our analyses suggested that the effect of pramipexole on HRQOL was mediated through nonmotor functions, whereas levodopa improved primarily motor domains of HRQOL. CONCLUSION: Our results suggest that pramipexole and levodopa affect patient HRQOL via improvement on different domains of well-being: nonmotor effect for pramipexole and mobility improvement for levodopa.

Antiparkinson Agents↗
PubMedDate not supplied

Pramipexole v. levodopa as initial treatment for Parkinson's disease: a randomized clinical-economic trial.

PURPOSE: To determine the 2-year incremental cost effectiveness of initial pramipexole treatment compared with initial levodopa treatment in patients with early Parkinson's disease (PD). METHODS: 301 subjects with early PD were randomized to either pramipexole or levodopa and followed every 3 months over a 2-year period. Costs were assigned to patient collected health utilization data using a variety of methods. Health state preferences were estimated using the EuroQol. RESULTS: Pramipexole strategy was an estimated 2,138 dollars (SE = 1,182 dollars) more expensive than levodopa strategy. The incremental cost-effectiveness of pramipexole compared with levodopa was 106,900 dollars/QALY (EQ-5D), compared with pramipexole being dominated by levodopa using the EQVAS. CONCLUSIONS: Although considerable uncertainty exists in the 2-year cost-effectiveness of initial pramipexole compared with initial levodopa in the treatment of early PD, our estimates suggest that pramipexole may not be welfare enhancing during the first 2 years of treatment. If initial pramipexole results in long-term improvements in quality of life, its cost-effectiveness will become more favorable.

Adult↗
PubMedDate not supplied

SCHIP's impact in three states: how do the most vulnerable children fare?

This study provides consistent evidence, from three very diverse states with heterogeneous populations and distinct programs (Florida, Kansas, and New York), that the State Children's Health Insurance Program (SCHIP) increased access to and satisfaction with health care among enrolled low-income children and that vulnerable children-minorities, children and adolescents with special health care needs, and children who were uninsured for long periods of time-shared in these improvements. We highlight some areas to target for future improvement, such as reducing the high levels of unmet needs among special-needs children and increasing preventive care, especially for Hispanic children.

Adolescent↗