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Biomedical subjects

D A Freund

Publications and source records attributed to D A Freund.

At least 37 records · Page 2Linked to original sources
PubMed1993

Influence of organizational components on the delivery of asthma care.

The documented growing morbidity, mortality, and disability from asthma indicate a failure in effective delivery of appropriate care. This article reviews how different components of organizational technology in hospitals, free-standing emergency centers, physician practices, prepaid groups, and schools may be linked to asthma care and asthma outcomes. A framework to address how practice patterns, risk factors, and outcomes relate to organizational characteristics, such as time orientation, uncertainty, available technology, standardization of work, specialization of work, coordination, and control strategies, is presented.

Ambulatory Care Facilities↗
PubMed1992

Principles of pharmacoeconomic analysis of drug therapy.

Economic analyses have become increasingly important in healthcare in general and with respect to pharmaceuticals in particular. If economic analyses are to play an important and useful role in the allocation of scarce healthcare resources, then such analyses must be performed properly and with care. This article outlines some of the basic principles of pharmacoeconomic analysis. Every analysis should have an explicitly stated perspective, which, unless otherwise justified, should be a societal perspective. Cost minimisation, cost-effectiveness, cost-utility and cost-benefit analyses are a family of techniques used in economic analyses. Cost minimisation analysis is appropriate when alternative therapies have identical outcomes, but differ in costs. Cost-effectiveness analysis is appropriate when alternative therapies differ in clinical effectiveness but can be examined from the same dimension of health outcome. Cost-utility analysis can be used when alternative therapies may be examined using multiple dimensions of health outcome, such as morbidity and mortality. Cost-benefit analysis requires the benefits of therapy to be described in monetary units and is not usually the technique of choice. The technique used in an analysis should be described and explicitly defended according to the problem being examined. For each technique, the method of determining costs is the same; direct, indirect, and intangible costs can be considered. The specific costs to be used depend on the analytical perspective; a societal perspective implies the use of both direct and indirect economic costs. A modelling framework such as a decision tree, influence diagram, Markov chain, or network simulation must be used to structure the analysis explicitly. Regardless of the choice of framework, all modelling assumptions should be described. The mechanism of data collection for model inputs must be detailed and defended. Models must undergo careful verification and validation procedures. Following baseline analysis of the model, further analyses should examine the role of uncertainty in model assumptions and data.

Costs and Cost Analysis↗
PubMed1991

Rollover effects in gatekeeper programs: cushioning the impact of restricted choice.

Public and private medical care plans that restrict the beneficiary's choice of providers have experienced rapid growth in the past decade as a means to contain costs and coordinate care. Such plans have been criticized for engendering beneficiary dissatisfaction and potentially impeding access to necessary care. Some of the objections to primary care "gatekeeping" may be diminished by recruiting the physician who served previously as the beneficiary's "usual source of care" to assume the role of formal gatekeeper. This study examines how persons whose gatekeepers were their regular source of care before plan implementation differed in their use and satisfaction from persons required to change their regular source of care. Our findings indicate that satisfaction was significantly higher among individuals who experienced no change in usual source of care. These individuals also tended to be less likely to use the emergency department as a source of care. Although the data are from Medicaid managed care programs, the findings may also be applicable to private sector point-of-service plans that adopt the primary care gatekeeper model.

Ambulatory Care↗
PubMed1991

Gatekeeper effects on patterns of physician use.

The impact of primary care gatekeeping on selected patterns of physician use was examined among Medicaid beneficiaries in two demonstration programs. The evidence indicates that beneficiaries enrolled with gatekeepers were significantly less likely to see specialists when compared with unenrolled beneficiaries in comparison groups. Primary care visits increased to offset these reductions only when gatekeepers were paid on a fee-for-service basis. Increased overall reliance on primary care physicians as opposed to specialists was also observed in the gatekeeper programs. Findings also indicate that enrolled beneficiaries received care from fewer sources than they had prior to enrollment. Although these changes in patterns of use have the potential to assure access to a more stable and structured system of care, the clinical and long-term economic consequences of such changes remain unknown.

Adult↗
PubMed1990

The performance of urban and public hospitals and NHCs (neighborhood health centers) under Medicaid capitation programs.

This article reports the results of a study that examined what happened to the utilization of Medicaid beneficiaries, eligible under Aid to Families with Dependent Children, who were mandatorily enrolled in several capitated alternatives in the Kansas City area. Their experience is contrasted with that of a comparison group selected from the St. Louis area. The types of plans analyzed include those sponsored by hospitals, neighborhood health centers, HMOs, and private physicians (IPAs). With the exception of emergency room use, all plans controlled utilization equally well. Results are explained in light of their management and policy implications.

Adult↗
PubMed1989

Going into gatekeeping: an empirical assessment.

Purchasers of medical care in the United States have focused attention on the gatekeeping role performed by primary care physicians as a means to control expenditures while assuring access to care. This research reports on the experience of a group of Medicaid beneficiaries in Missouri whose primary care providers agreed to become formal gatekeepers to virtually all medical services for their patients enrolled in the program. The results suggest that this relationship contributed to changes in health care utilization, including reductions in use of emergency rooms, specialists, and nonphysician providers and some increase in the likelihood of obtaining care from a primary care physician. There was, however, no evidence of significant cost reductions.

Cost Control↗
PubMed1989

The treatment of patients with asthma by specialists and generalists.

The authors investigated possible differences between specialists and generalists in the intensity with which they treat patients with asthma by studying the care of 283 patients between the ages of six and 40 provided by 13 allergists and 40 randomly selected physicians in two primary care specialties: pediatrics and family practice. After excluding patients with more than one physician, allergists' patients were nearly identical to primary care physicians' patients in the frequency and duration of symptoms, and they had a similar number of asthma-related emergency room visits in the previous year and asthma-related hospitalizations in the preceding 3 years. The allergists treated their patients significantly more intensively than did the primary care physicians. Sixty-two percent of allergists' patients had received oral corticosteroids in the preceding year compared with 30% of primary care patients (P less than 0.001). More of the allergists' patients had received oral corticosteroids throughout the year (9% vs. 0%, respectively, P less than 0.01). They were also more likely to have used corticosteroid inhalers (46% vs. 19%) and a greater number of asthma medications (mean = 2.8 vs. 1.3). In a separate survey of the same physicians, using clinical vignettes, the allergists were more likely to prescribe corticosteroid tablets and inhalers. These findings suggest that specialists and generalists differ in the intensity with which they treat patients with asthma and cannot be explained by patient selection or severity differences.

Administration, Inhalation↗
PubMed1989

Emergency room use and primary care case management: evidence from four Medicaid demonstration programs.

Claims-based utilization data collected in four Medicaid demonstration programs are used to examine the impact of primary care case management on patterns of reliance on the emergency room as a source of services. The experience of stratified random samples of AFDC (Aid to Families with Dependent Children) adults and children in the demonstration programs is compared with that of equivalent samples from comparison groups in traditional Medicaid programs. Data were analyzed in multivariate models controlling for person characteristics in a pre/post, demonstration/comparison design. Results indicated large reductions in the proportion of persons with at least one emergency room visit ranging from 27 to 37 per cent for children and 30 to 45 per cent for adults. Use levels for persons with at least one ER visit are less substantially affected. The findings suggest that gatekeeping designs can alter patterns of enrollee use with respect to the emergency room and some discussion of these implications is presented.

Adult↗
PubMed1989

Evaluation of the Medicaid competition demonstrations.

In 1983, the Health Care Financing Administration funded a multiyear evaluation of Medicaid demonstrations in six States. The alternative delivery systems represented by the demonstrations contained a number of innovative features, most notably capitation, case management, limitations on provider choice, and provider competition. Implementation and operation issues as well as demonstration effects on utilization and cost of care, administrative costs, rate setting, biased selection, quality of care, and access and satisfaction were evaluated. Both primary and secondary data sources were used in the evaluation. This article contains an overview and summary of evaluation findings on the effects of the demonstrations.

California↗
PubMed1989

The impact of the prospective payment system on the treatment of hip fractures in the elderly.

A review of 386 Medicare patients with hip fractures admitted to a private, suburban, teaching hospital from 1981 through 1987 revealed that since the implementation of the prospective payment system in 1984, average hospital stays declined from 17.0 days to 12.9 days (24.1%). Although the mean number of physical therapy sessions declined from 11.1 to 9.8 (11.7%), the average number of treatments per day during the physical therapy phase actually increased from 1.2 before to 1.4 after the prospective payment system. The proportion of patients discharged to nursing homes remained the same (52.9% vs 53.6%); the proportion of patients remaining in a nursing home 6 months after hospital discharge did not differ significantly (22.6% vs 19.9%). Furthermore, there were no differences in the 6-month ambulation status. Total adjusted average hospital charges for the pre- and post-prospective payment system groups did not increase significantly ($7295 vs $7565). These findings do not support the contention that the quality of care provided Medicare patients with hip fractures has deteriorated in this hospital environment.

Aged↗
PubMed1988

A typology of Medicaid managed care.

This article presents a typology for use in classifying and interpreting the findings of the growing empirical literature on managed care initiatives in the Medicaid program. Six key program attributes are identified for use in examining similarities and differences among these programs. Several alternative arrangements for each attribute are described from among the more than 60 different programs attempted. The typology is illustrated with five specific program designs, and selected empirical results from them are used to demonstrate how the typology can be employed.

Delivery of Health Care↗