PubMed Health⌕ Search

Biomedical subjects

D M Mirvis

Publications and source records attributed to D M Mirvis.

At least 19 recordsLinked to original sources
PubMed2001

The cumulative effects of historical and physical examination findings on the prognostic value of the electrocardiogram.

The electrocardiogram has been shown in epidemiologic studies to be an independent predictor of survival. These studies have adjusted for selected covariates simultaneously. This article assesses the value of the electrocardiogram as a predictor of survival when introduced at progressive stages of the common clinical encounter. Data collected from 4,518 patients ages of 60 to 96 years with isolated systolic hypertension who were followed-up for up to 6 years as part of the Systolic Hypertension in the Elderly Project were analyzed. Survival curves and 3- and 5-year survival rates (Cox regression methods) of groups with normal and abnormal resting electrocardiograms were compared. Blocks of covariates representing demographic information, risk factors for cardiovascular disease, clinical history, and physical examination findings were added to the survival models sequentially to mimic the sequence of the common clinical encounter, and the independent significance of the electrocardiogram as a predictor of survival was assessed at each step. An abnormal electrocardiogram was associated with reduced survival when no adjustment for covariates is made. Survival was also significantly (P <.05) different for groups with normal and abnormal electrocardiograms when demographic and risk factor variables were included in the statistical models, but not after findings from the clinical history and physical examination were added. The prognostic value of the electrocardiogram varies with the stage in the clinical encounter in which it is introduced.

Aged↗
PubMed1999

Academic managed care organizations and adverse selection under Medicaid managed care in Tennessee.

CONTEXT: Health plans competing in a managed care system may face serious financial consequences if they are disproportionately selected by enrollees with expensive health conditions. Academic medical centers (AMCs) have traditionally provided medical care for the sickest patients and may be at particularly high risk for adverse selection, but whether this occurs is not known. OBJECTIVE: To determine whether managed care organizations (MCOs) representing AMCs are adversely selected by Medicaid managed care (MMC) enrollees with expensive chronic health conditions. DESIGN AND SETTING: Observational study using state Medicaid claims data from all of 1994 and January to August 1995 for Tennessee's statewide MMC program (TennCare). PARTICIPANTS: All 12 capitated MCOs in Tennessee, which collectively provided services for 1.2 million Medicaid enrollees from January 1994 through August 1995 following the initiation of TennCare. MAIN OUTCOME MEASURES: Prevalence of 6 state-specified high-cost chronic conditions-acquired immunodeficiency syndrome (AIDS), coagulation defects, cystic fibrosis, pregnancy, prematurity, and organ transplantation-and 27 additional high-cost conditions compared by academic, statewide, and regional MCOs. RESULTS: The prevalence of state-specified high-cost chronic conditions was generally higher for academic MCOs compared with other MCOs. Specifically, prevalence of AIDS was 14.1 times higher in academic MCOs than in statewide MCOs; coagulation defects, 6.4 times higher; transplantations, 4.4; pregnancy, 3.3; cystic fibrosis, 2.4; and prevalence of prematurity was equivalent. Prevalence was higher for academic than for statewide MCOs for 22 of the additional 27 high-cost conditions considered and similar for the remaining 5 conditions. CONCLUSIONS: Our results suggest that academic MCOs in an MMC system are selected by a large percentage of the sickest patients. Adverse selection may present serious financial risks for AMCs participating in managed care.

Academic Medical Centers↗
PubMed1999

Variations in the use of cardiac procedures in the Veterans Health Administration.

BACKGROUND: Considerable variability exists in the use of cardiac procedures for patients with heart disease. One cause for this variability is the availability of local facilities to perform these procedures. This study was initiated to identify health system features that are related to rates of catheterization, percutaneous coronary angioplasty, and coronary artery bypass graft surgery in the Veterans Affairs health care system in which structured referral systems are intended to compensate for variation in local resource availability. METHODS: Medical records of 30,901 patients admitted to a Veterans Affairs medical center with coronary artery disease were analyzed. Odds ratios (OR) and 95% confidence intervals (CI) for undergoing each procedure, based on clinical variables (age, sex, race, coronary artery disease type, and a computed comorbidity score), and local Veterans Affairs facility features (geographic region, primary service area size, and hospital complexity) were estimated by logistic regression. RESULTS: Regression models demonstrated significant associations between the odds of undergoing each procedure and medical center geographic and complexity features, after adjustment for clinical variables. Associations included the presence of a cardiac catheterization laboratory for undergoing catheterization (OR 1.86, CI 1.76 to 1.95) and the presence of a cardiac surgical program for angioplasty (OR 1.46, CI 1.36 to 1.57) and bypass grafting (OR 1.43, CI 1.34 to 1.53). Including health system variables in addition to clinical variables in the regression models improved the discriminating ability of the models by 44.2% to 51.4%. CONCLUSIONS: Geographic location and the complexity of the local Veterans Affairs hospital are important determinants of the use of cardiac procedures in the Veterans Affairs health care system, even though referral networks are intended to correct for local differences in hospital complexity.

Aged↗
PubMed1999

Burnout among leaders of Department of Veterans Affairs medical centers: contributing factors as determined by a longitudinal study.

Significant increases in the intensity of psychological burnout among leaders of local Department of Veterans Affairs (VA) medical centers occurred from 1989 to 1997. This longitudinal study was designed to analyze which demographic and behavioral variables were associated with the intensity of burnout. Responses of 83 Medical Center Directors, Associate Directors, and Chiefs of Staff to questionnaires sent in 1989, 1992, and 1997 were analyzed using path analysis. Burnout was assessed by the Maslach Burnout Inventory and the phase model for analysis. Questions also assessed antecedents (e.g., role characteristics and job support) and consequences (e.g., job satisfaction) of burnout. The presence of high levels of burnout rose from 25.3% in 1989 to 38.1% in 1997. Burnout phase in 1997 was directly related to burnout phase in 1992 and inversely related to the respondent's age. Phase in 1992 was inversely related to both resource availability and role clarity in 1989 if only accepted antecedents of burnout were included in the model. If consequences and antecedents were included in the model, burnout phase in 1997 was inversely related to job satisfaction and resource availability and directly related to intent to stay in the VA in 1989. Findings demonstrated that specific demographic and job site characteristics are associated with high levels of burnout in the VA. These could form the basis for interventional efforts.

Burnout, Professional↗
PubMed1998

Impact of race and age on the effects of regionalization of cardiac procedures in the Department of Veterans Affairs Health Care System.

Previous studies have demonstrated that regionalization of resources for cardiac catheterization, percutaneous coronary artery angioplasty (PTCA), and coronary artery bypass graft surgery (CABG) reduces the rate of procedure use. It was hypothesized that the impact of regionalization would be greater for the elderly and for African-Americans than for other populations. Discharge medical records of 30,901 patients admitted to a Veterans Affairs (VA) medical center between October 1, 1993, and September 30, 1994, with a diagnosis of coronary artery disease were analyzed. The presence of a cardiac catheterization laboratory in the patients' local VA facility significantly increased the likelihood of undergoing catheterization, PTCA, and CABG, as determined by odds ratios and associated confidence limits estimated by logistic regression techniques. The presence of a cardiac surgical facility also significantly increased the likelihood of having the procedures. The odds ratios estimating the effects of resource availability were significantly greater for the subgroup of patients aged > or =70 years than for the younger subgroup for catheterization, PTCA, and CABG and for African-Americans than for white patients for PTCA and CABG. Thus, within the VA health care system, regionalization of cardiac procedures has a significant impact on utilization rates of tertiary cardiac procedures. These differences are significantly greater for the elderly and for African-Americans than for the general population.

Black or African American↗
PubMed1998

Tennessee's failed managed care program for mental health and substance abuse services.

In July 1996, Tennessee initiated a managed mental health and substance abuse program called TennCare Partners. This publicly funded "carve-out" experiment started chaotically and soon deteriorated into a crisis. Many patients did not receive care or lost continuity of care, and the traditional "safety net" mental health system nearly disintegrated. This qualitative case study sought to ascertain the impact of the TennCare Partners program. It points out that the program's difficulties stemmed directly from a flawed design that spread funds previously earmarked for severely mentally ill patients across the entire Medicaid population. States contemplating similar reforms should strive to protect vulnerable patients by risk-adjusting capitation payments and by focusing resources on care for severely mentally ill persons. States should also minimize program complexity and ensure the accountability of managed care networks for their patients' behavioral health care needs.

Adult↗