Biomedical subjects

Dana Mukamel

Publications and source records attributed to Dana Mukamel.

8 recordsLinked to original sources

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↗

PubMed2005

Effect of a consumer-directed voucher and a disease-management-health-promotion nurse intervention on home care use.

PURPOSE: We describe the impact of two interventions, a consumer-directed voucher for in-home supportive services and a chronic disease self-management-health-promotion nurse intervention, on the probability of use of two types of home care-skilled home health care and personal assistance services-received by functionally impaired Medicare beneficiaries. DESIGN AND METHODS: The Medicare Primary and Consumer-Directed Care Demonstration was a randomized controlled trial in 19 counties in New York, West Virginia, and Ohio with four groups: disease-management-health-promotion nurse, consumer-directed voucher, combination (nurse plus voucher), and control. We estimated a bivariate probit model for the 1,394 individuals aged 65 or older who had no private long-term-care insurance. RESULTS: Whereas the nurse intervention alone had no effect on the probability of using either type of home care, the voucher alone increased the probability of personal assistance services use by 13% (p =.002) but not that of skilled home health care use. The combination of the two interventions increased the probability of personal assistance services use by 18% (p <.001). IMPLICATIONS: The implementation of disease-management-health-promotion nurse interventions should not lead to a greater probability of skilled home health care or personal assistance services use, whereas the provision of consumer-directed vouchers should result in an increased probability of personal assistance services use, as intended.

Aged↗

PubMed2004

Explaining disparities in access to high-quality cardiac surgeons.

BACKGROUND: Racial disparities in access to coronary artery bypass graft (CABG) surgery are well documented. Recent evidence shows that even when patients receive CABG surgery, racial minorities are more likely to be treated by lower quality providers. METHODS: New York State (NYS) hospital discharge data for 1996 and 1997 for patients undergoing CABG surgery were combined with risk-adjusted mortality rates for cardiac surgeons calculated by the NYS Department of Health. Statistical analysis was performed to determine the relationship between patients' race and the quality of the surgeon performing the CABG, as measured by the surgeon's risk-adjusted mortality rate, after controlling for patient characteristics such as comorbidities and socioeconomic status; the hospital where the surgery was performed; and the number of surgeries the surgeon performed over a 3-year period. RESULTS: African Americans and Asian/Pacific Islanders are treated by surgeons with higher risk-adjusted mortality rates compared with whites. This association does not appear to be a result of inadequate risk adjustment. It is explained to some degree by the hospital to which these patients are admitted, and to a lesser degree by (1) the education and income level in the patient's zipcode of residence and (2) being treated by a low-volume surgeon. After controlling for these factors, race continues to be associated with treatment by a surgeon with a higher risk-adjusted mortality rate. CONCLUSIONS: Efforts to achieve the "Healthy People 2010" goals of eliminating health disparities should address not only access to care, but also access to high-quality care.

Black or African American↗

PubMed2004

Measuring interdisciplinary team performance in a long-term care setting.

OBJECTIVES: The objectives of this study were to test the reliability and the validity of a survey instrument for assessing interdisciplinary team performance in long-term care settings and to measure team performance in the Program of All-Inclusive Care for the Elderly (PACE). RESEARCH DESIGN AND METHODS: The analysis is based on 1220 surveys completed by team members of 26 PACE programs. Cronbach's alphas, analysis of variance, and regression models were used to assess the reliability and the validity of the instrument. Multivariate regression analysis was used to examine factors associated with team performance in PACE. RESULTS: Cronbach's alphas ranging from 0.76 to 0.89 demonstrate good-to-high reliability for all domains of the team process and performance (effectiveness). Construct validity is demonstrated through the results of the regression analysis showing that leadership, communication, coordination, and conflict management are positive and significant (P <0.001) predictors of team cohesion and team effectiveness. The data also support the appropriateness of aggregating individual-level responses to the unit level. Perceived team effectiveness significantly (P <0.05) increases with: age of the respondents; longer length of the team's professional work experience; shorter duration of the team's PACE experience; more ethnically diverse composition of the team; greater ethnic concordance between team members and the participants; and greater perceived resource availability. CONCLUSIONS: Several of the factors influencing team effectiveness in PACE are potentially modifiable and, therefore, could offer insights for improving team practice.

Aged↗

PubMed2004

Judging trauma center quality: does it depend on the choice of outcomes?

BACKGROUND: Trauma centers routinely benchmark their survival outcomes against a national norm using the TRISS methodology. However, the use of survival as a measure of the effectiveness of trauma care may be too limited in scope because it fails to capture information regarding functional outcomes. METHODS: The objective of this study was to develop a prediction model that allows hospitals to benchmark their functional outcomes in blunt trauma patients, and to determine whether the assessment of hospital "quality" depends on the choice of outcome measure: survival or survival combined with functional outcome. This retrospective cohort study was based on patients, aged 18 years or older, in the National Trauma Database who sustained blunt trauma in 1999 without associated head or spinal cord injury. We developed a sequential logistic model to predict the probability of a good functional outcome. The TRISS methodology was customized to this data set to obtain a survival model. Using each of these prediction models, we then obtained two standardized measures of hospital performance: one based on the number of survivors and the other based on the number of survivors with good functional outcomes. These standardized outcome measures were then used to identify low-performance and high-performance hospitals. The ranking based on these two different measures were compared. RESULTS: Fifteen of the 27 hospitals in the study cohort were categorized differently when their performance was benchmarked using survival versus functional outcome. Kappa analysis revealed minimal agreement between these two quality measures on the identity of hospital quality outliers (kappa = 0.04; p = 0.35). CONCLUSION: The evaluation of hospital quality depends on whether hospital performance is judged by looking at survival or at survival combined with functional outcome. Because functional status is an important outcome of major concern to survivors, it is important to include it in hospital performance assessment. Consideration should be given to including functional outcome in the evaluation of trauma center performance.

Benchmarking↗

PubMed2004

The relation between trauma center outcome and volume in the National Trauma Databank.

BACKGROUND: Regionalization of trauma care services aims to improve outcomes by limiting trauma care delivery to a select group of dedicated trauma centers. However, the evidence linking trauma center volume and outcome is not conclusive. The objective of this study was to examine the volume-mortality relation for patients with severe trauma in the National Trauma Databank. METHODS: This study was based on data for adult patients 18 years of age or older in the National Trauma Databank with an Injury Severity Score (ISS) of 15 or more who sustained either blunt or penetrating trauma. The main outcome measure was in-hospital survival as a function of trauma center volume. Logistic regression modeling was used to analyze the relation between survival and hospital volume for patients sustaining either severe blunt or severe penetrating trauma. RESULTS: For the blunt trauma cohort, model diagnostics showed that the single highest-volume center was an outlier. After exclusion of the patients from this center, no association could be demonstrated between trauma volume and outcome (p = 0.465) for blunt trauma. A separate multivariate analysis of patients with penetrating trauma also could not demonstrate a significant volume-mortality association (p = 0.919). Both regression models exhibited excellent discrimination and acceptable calibration. CONCLUSION: The findings of this study do not support the position that higher trauma center volumes are associated with improved survival. The implication of this study is that the hospital volume criteria established by the American College of Surgeons may need to be reexamined.

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

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↗