Biomedical subjects

David C Goodman

Publications and source records attributed to David C Goodman.

7 recordsLinked to original sources

PubMed2003

The relationship between pediatric residency program size and inpatient illness severity and diversity.

BACKGROUND: A critical component of pediatric residency training is exposure to diverse and challenging hospitalized patients, yet little is known about the differences in pediatric inpatient educational experiences across residencies. OBJECTIVE: To examine variations in inpatient illness severity and diagnostic diversity at the affiliated hospitals of small, medium, and large pediatric residencies. DESIGN: A retrospective analysis of hospital discharges among children aged 0 to 18 years (excluding newborns) in a sample of pediatric residency programs within the University HealthSystems Consortium. Main Outcomes of Interest The study compares the mean and median Diagnosis-Related Group (DRG) weights of hospital discharges (illness severity) as well as the percentage of discharges for the 5 most common diagnoses and the percentage of discharges for asthma (diagnostic diversity). RESULTS: There was no relationship between mean and median medical DRG weights and residency size (mean DRG weight: small, 0.89; medium, 0.86; and large, 0.85; small vs medium, P =.29; small vs large, P =.23). Larger programs had surgical patients with more severe illness (mean DRG weight, small, 2.11; medium, 2.08; and large, 2.47; small vs medium, P =.85; small vs large, P =.02) but less diagnostic diversity (small, 24.9%; medium, 25.9%; and large, 29.9%; small vs medium, P<.001; small vs large, P =.07). The proportion of medical discharges for asthma increased with residency size (small, 6.5%; medium, 7.4%; and large, 9.3%; small vs medium and large, P<.001). CONCLUSION: Large variations in inpatient illness severity and diagnostic diversity were seen across programs, but program size was found to be a poor indicator of inpatient learning opportunities.

Asthma↗

PubMed2003

Primary care service areas: a new tool for the evaluation of primary care services.

OBJECTIVE: To develop and characterize utilization-based service areas for the United States which reflect the travel of Medicare beneficiaries to primary care clinicians. DATA SOURCE/STUDY SETTING: The 1996-1997 Part B and 1996 Outpatient File primary care claims for fee-for-service Medicare beneficiaries aged 65 and older. The 1995 Medicaid claims from six states (1995) and commercial claims from Blue Cross Blue Shield of Michigan (1996). STUDY DESIGN: A patient origin study was conducted to assign 1999 U.S. zip codes to Primary Care Service Areas on the basis of the plurality of beneficiaries' preference for primary care clinicians. Adjustments were made to establish geographic contiguity and minimum population and service localization. Generality of areas to younger populations was tested with Medicaid and commercial claims. DATA COLLECTION/EXTRACTION METHODS: Part B primary care claims were selected on the basis of provider specialty, place of service, and CPT code. Selection of Outpatient File claims used provider number, type of facility/service, and revenue center codes. PRINCIPAL FINDINGS: The study delineated 6,102 Primary Care Service Areas with a median population of 17,276 (range 1,005-1,253,240). Overall, 63 percent of the Medicare beneficiaries sought the plurality of their primary care from within area clinicians. Service localization compared to Medicaid (six states) and commercial primary care utilization (Michigan) was comparable but not identical. CONCLUSIONS: Primary Care Service Areas are a new tool for the measurement of primary care resources, utilization, and associated outcomes. Policymakers at all jurisdictional levels as well as researchers will have a standardized system of geographical units through which to assess access to, supply, use, organization, and financing of primary care services.

Aged↗

PubMed2003

Outcomes of patients treated with fluticasone propionate or montelukast sodium.

The authors conducted a retrospective database study of patients with asthma (age range, 6-55 yr) who initiated fluticasone propionate or montelukast sodium treatment between an index period of July 1998 and June 1999. All patients were observed for 12 months before and after the index period. Changes in asthma-related hospitalizations, emergency department visits, oral corticosteroid use, and short-acting beta-agonist use were analyzed. The odds of postindex asthma-related events were estimated. In multivariate analysis, use of a short-acting beta agonist (SABA) was significantly associated with fluticasone treatment (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.21-2.26) and preindex use of SABAs (OR, 1.84; 95% CI, 1.34-2.53). In this managed care population, fluticasone and montelukast provided similar effectiveness.

Acetates↗

PubMed2002

The relation between the availability of neonatal intensive care and neonatal mortality.

BACKGROUND: There is marked regional variation in the availability of neonatal intensive care in the United States. We conducted a study to determine whether a greater supply of neonatologists or neonatal intensive care beds is associated with lower neonatal mortality. METHODS: We used the 1996 master files of the American Medical Association and the American Osteopathic Association and 1998 and 1999 surveys of neonatal intensive care units to calculate the supply of neonatologists and neonatal intensive care beds in 246 neonatal intensive care regions. We used linked birth and death records from the 1995 U.S. birth cohort to assess associations between the supply of both neonatologists and neonatal intensive care beds per capita (in quintiles) and the risk of death within the first 27 days of life. RESULTS: Among 3,892,208 newborns with a birth weight of 500 g or greater, the mortality rate was 3.4 per 1000 births. After adjustment for neonatal and maternal characteristics associated with an increased risk of neonatal death, the rate was lower in the regions with 4.3 neonatologists per 10,000 births than in those with 2.7 neonatologists per 10,000 births (odds ratio for death, 0.93; 95 percent confidence interval, 0.88 to 0.99). Further increases in the number of neonatologists were not associated with greater reductions in the risk of death. There was no consistent relation between the number of neonatal intensive care beds and neonatal mortality. CONCLUSIONS: A minority of regions in the United States may have inadequate neonatal intensive care resources, whereas many others may have more resources than are needed to prevent the death of high-risk newborns. The effect of the availability of neonatologists on other health outcomes is not known.

Birth Weight↗

PubMed2002

Is more neonatal intensive care always better? Insights from a cross-national comparison of reproductive care.

BACKGROUND: Despite high per capita health care expenditure, the United States has crude infant survival rates that are lower than similarly developed nations. Although differences in vital recording and socioeconomic risk have been studied, a systematic, cross-national comparison of perinatal health care systems is lacking. OBJECTIVE: To characterize systems of reproductive care for the United States, Australia, Canada, and the United Kingdom, including a detailed analysis of neonatal intensive care and mortality. DESIGN/METHODS: Comparison of selected indicators of reproductive care and mortality from 1993-2000 through a systematic review of journal and government publications and structured interviews of leaders in perinatal and neonatal care. RESULTS: Compared with the other 3 countries, the United States has more neonatal intensive care resources yet provides proportionately less support for preconception and prenatal care. Unlike the United States, the other countries provided free family planning services and prenatal and perinatal physician care, and the United Kingdom and Australia paid for all contraception. The United States has high neonatal intensive care capacity, with 6.1 neonatologists per 10 000 live births; Australia, 3.7; Canada, 3.3; and the United Kingdom, 2.7. For intensive care beds, the United States has 3.3 per 10 000 live births; Australia and Canada, 2.6; and the United Kingdom, 0.67. Greater neonatal intensive care resources were not consistently associated with lower birth weight-specific mortality. The relative risk (United States as reference) of neonatal mortality for infants <1000 g was 0.84 for Australia, 1.12 for Canada, and 0.99 for the United Kingdom; for 1000 to 2499 g infants, the relative risk was 0.97 for Australia, 1.26 for Canada, and 0.95 for the United Kingdom. As reported elsewhere, low birth weight rates were notably higher in the United States, partially explaining the high crude mortality rates. CONCLUSIONS: The United States has significantly greater neonatal intensive care resources per capita, compared with 3 other developed countries, without having consistently better birth weight-specific mortality. Despite low birth weight rates that exceed other countries, the United States has proportionately more providers per low birth weight infant, but offers less extensive preconception and prenatal services. This study questions the effectiveness of the current distribution of US reproductive care resources and its emphasis on neonatal intensive care.

Australia↗

PubMedDate not supplied

Benchmarking the future generalist workforce.

CONTEXT: Previous workforce analyses by the Council on Graduate Medical Education (COGME) have concluded that the United States has too few, or just enough, generalists. However, recent trends suggest that more physicians are entering primary care, raising the possibility of a future surplus. OBJECTIVE: To project the future supply of generalists relative to future requirements. DESIGN: We developed a model that projects the supply of generalists into the future on the basis of the annual number of physicians entering and leaving the workforce. We calculated the number of clinically active generalists from the physician master-files of the American Medical Association and American Osteopathic Association. The number of graduating trainees entering the generalist workforce was calculated from the 1999 to 2000 AMA Annual Survey of GME. The number leaving was calculated by using age- and sex-specific rates or physician death and retirement provided by the Bureau of Health Professions. MEASUREMENTS: Projected per capita number of clinically active generalists to the year 2025, relative to physician requirements suggested by COGME and several regional benchmarks of physician supply. RESULTS: The supply of generalists is projected to grow from its current level of 69 per 100,000 to nearly 88 per 100,000 by the year 2025. Adjusting for the changing age-sex structure of the physician workforce decreases the "effective" supply to 85 generalists per 100,000. By the year 2025, the effective supply of generalists will exceed COGME's upper estimate of generalist requirements (80 per 100,000), resulting in an excess of about 18,000 full-time equivalent generalists. The future supply of generalists will also exceed most current regional benchmarks of generalist supply. CONCLUSION: At current levels of training, the supply of generalists will grow substantially and soon exceed several benchmarks for generalist requirements.

Benchmarking↗

PubMedDate not supplied

Treatment effectiveness of inhaled corticosteroids and leukotriene modifiers for patients with asthma: an analysis from managed care data.

We compared measures of treatment effectiveness when inhaled corticosteroids (ICSs) or leukotriene modifiers (LMs) were used as controller monotherapy for asthma. Asthma patients aged 6-55 years initiating ICS or LM monotherapy between July 1998 and June 1999 (index prescription) were identified using a managed care claims database. Asthma-related hospitalizations, emergency department (ED) visits, and use of short-acting beta-agonists and oral corticosteroids (OCSs) were assessed as proxies for treatment effectiveness. Propensity score was used to adjust for baseline differences between treatment cohorts. The change in the annual rate of claims from the preindex to postindex period for each measure was compared across treatment groups. Logistic regression models of the postindex composite events (hospitalization and/or ED) and OCS use were estimated. Nine hundred sixty patients were initiated on LMs (n = 153) and ICSs (n = 807). The mean annual rate of claims for OCSs increased in the ICS group (0.2) but was unchanged in the LM group (adjusted mean difference in change, 0.2; 95% CI, 0.05-0.4; p = 0.01). The mean annual rate of claims for short-acting beta-agonists increased in both the ICS and LM groups by 1.1 and 0.5, respectively (adjusted mean difference in change, 0.6; 95% CI, -0.06. 1.1; p = 0.08). Similar changes in annualized rates of claims for hospitalizations and ED visits were observed between treatment groups. In logistic regression models, greater odds of postindex OCS use was observed among the ICS group (odds ratio for ICS versus LM = 1.7; 95% CI, 1.04-2.8; p = 0.04). No association between treatment groups and postindex hospitalization and/or ED events was observed. In this managed care population, patients treated with ICSs or LMs had similar measures of treatment effectiveness, as measured by asthma-related health care resource use.

Administration, Inhalation↗