Biomedical subjects

Gerald Kominski

Publications and source records attributed to Gerald Kominski.

11 recordsLinked to original sources

PubMed2006

Cost-effectiveness analysis of core decompression.

Core decompression is widely used to treat the early stages of osteonecrosis of the hip. The purpose of this analysis is to assist orthopedic surgeons in judging whether currently available data support the use of core decompression as cost-effective. A decision model was created for the treatment of osteonecrosis of the femoral head. Literature review was used to identify possible outcomes and their probability after initial treatment with either observation or core decompression. This model demonstrates core decompression must delay the need for total hip arthroplasty for a minimum of 5 years to maintain an incremental cost-effectiveness ratio lower than 50,000 dollars per quality-adjusted life year gained. Treatment options with ratios higher than 50,000 dollars per quality-adjusted life year are generally considered to have limited cost-effectiveness. This study demonstrates that core decompression has the potential to be a highly cost-effective alternative if it is leads to a delay in the need for total hip arthroplasty of 5 years or longer.

Arthroplasty, Replacement, Hip↗

PubMed2006

Impact of changes in Medicare Home Health care reimbursement on month-to-month Home Health utilization between 1996 and 2001 for a national sample of patients undergoing orthopedic procedures.

BACKGROUND: Beginning October 1, 1997, Medicare implemented a series of major changes to the Home Health (HH) reimbursement system. Reimbursements were first significantly reduced under the Interim Payment System (IPS) and then relaxed slightly until implementation of the HH Prospective Payment System (PPS) on October 1, 2000. OBJECTIVE: The objective of this study was to examine the impact of reimbursement policy on HH care utilization. RESEARCH DESIGN: We postulated that in response to the initial changes, there would be reductions in both the probability of any HH use and the number of HH visits per HH user. Under PPS, we postulated there would be further reduction in number of HH visits. We tested whether the policy response differed by HH agency structure and whether subgroups of patients were differentially affected. An interrupted time-series analysis was conducted to examine month-to-month probability of HH selection and the number of HH visits among users. SUBJECTS: A 100% sample of all Medicare recipients undergoing either elective joint replacement (1.6 million hospital discharges) or surgical management of hip fracture (1.2 million hospital discharges) between January 1996 and December 2001 was selected. RESULTS: Under the IPS, the probability of any HH use and number of visits per episode of HH care fell until the IPS was refined in October 1998. With implementation of the PPS, HH visits fell commensurately. Differentially larger reductions in care were noted at for-profit HH agencies, for the elderly, women, patients receiving state assistance, and patients first discharged to skilled nursing facility or rehabilitation hospitals. CONCLUSIONS: Changes in month-to-month utilization of HH services were sharp and well correlated with policy implementation dates, strengthening the evidence for a causal association between policy and patient care in the midst of a sea of concurrent policy changes. Greater reductions in HH visits were noted for vulnerable groups.

Aged↗

PubMed2006

Cost-effectiveness analysis of unicompartmental knee arthroplasty as an alternative to total knee arthroplasty for unicompartmental osteoarthritis.

BACKGROUND: The purpose of this study was to compare the cost-effectiveness of unicompartmental knee arthroplasty as an alternative to total knee arthroplasty in patients with degenerative arthritis limited to either the medial or lateral compartment. METHODS: A decision model was created for the treatment of end-stage unicompartmental knee arthritis. A literature review was used to identify possible outcomes and their probabilities following treatment with either unicompartmental or total knee arthroplasty. Each outcome was weighted for quality of life with use of a utility factor, and effectiveness was expressed in units of quality-adjusted life years. Gross costs were estimated from Medicare reimbursement data for the relevant Current Procedural Terminology and Diagnosis-Related Group codes. RESULTS: Sensitivity analysis demonstrated that the cost-effectiveness of unicompartmental knee arthroplasty is dependent on the assumption that its durability and functional outcomes approach those of total knee arthroplasty. Specifically, it is necessary for the survival of unicompartmental implants to be within three to four years of the assumed survival of total knee implants for unicompartmental arthroplasty to remain a cost-effective alternative. Under these assumptions, the use of unicompartmental arthroplasty is a cost-effective choice as it results in incremental gains in effectiveness at a cost of less than US dollars 50,000 (in 1998 United States dollars) per quality-adjusted life year gained. CONCLUSIONS: This study supports unicompartmental knee arthroplasty as a cost-effective alternative for the treatment of unicompartmental arthritis when the durability and function of a unicompartmental replacement are assumed to be similar to those of a primary total knee replacement. This suggests that, with appropriate patient selection, the currently available literature supports unicompartmental arthroplasty as a cost-effective alternative to total knee arthroplasty. LEVEL OF EVIDENCE: Economic and decision analysis, Level II.

Arthroplasty, Replacement, Knee↗

PubMed2005

Methodologies for realizing the potential of health impact assessment.

Health impact assessment (HIA), a systematic assessment of potential health impacts of proposed public polices, programs, and projects, offers a means to advance population health by bringing public health research to bear on questions of public policy. The United States has been slow to adopt HIA, but considerable strides have been made in many other countries, and under the auspices of the World Health Organization and World Bank. Varied applications in these diverse milieu have given rise to diverse approaches to HIA-quantitative/analytic, participatory, and procedural-each with distinct disciplinary foundations, goals, and methodologies. Suitability of these approaches for different applications and their challenges are highlighted, along with areas in which methodologic work is most needed and most likely to advance the field from theory and infrequent application to more routine practice in the United States.

Community Health Planning↗

PubMed2005

Projected health impact of the Los Angeles City living wage ordinance.

STUDY OBJECTIVE: To estimate the relative health effects of the income and health insurance provisions of the Los Angeles City living wage ordinance. SETTING AND PARTICIPANTS: About 10 000 employees of city contractors are subject to the Los Angeles City living wage ordinance, which establishes an annually adjusted minimum wage (7.99 US dollars per hour in July 2002) and requires employers to contribute 1.25 US dollars per hour worked towards employees' health insurance, or, if health insurance is not provided, to add this amount to wages. DESIGN: As part of a comprehensive health impact assessment (HIA), we used estimates of the effects of health insurance and income on mortality from the published literature to construct a model to estimate and compare potential reductions in mortality attributable to the increases in wage and changes in health insurance status among workers covered by the Los Angeles City living wage ordinance. RESULTS: The model predicts that the ordinance currently reduces mortality by 1.4 deaths per year per 10,000 workers at a cost of 27.5 million US dollars per death prevented. If the ordinance were modified so that all uninsured workers received health insurance, mortality would be reduced by eight deaths per year per 10,000 workers at a cost of 3.4 million US dollars per death prevented. CONCLUSIONS: The health insurance provisions of the ordinance have the potential to benefit the health of covered workers far more cost effectively than the wage provisions of the ordinance. This analytical model can be adapted and used in other health impact assessments of related policy actions that might affect either income or access to health insurance in the affected population.

Cost-Benefit Analysis↗

PubMed2004

The effects of payment method on clinical decision-making: physician responses to clinical scenarios.

BACKGROUND: The influence of payment mechanisms on physician decisions is not well understood. OBJECTIVES: The objective of this study was to test 2 null hypotheses: 1) physicians' clinical decisions would not be influenced by payment incentives; and 2) physicians would have equal concern about medical decisions made under capitation or fee-for-service (FFS) arrangements. RESEARCH DESIGN: We conducted a physician survey in which patient insurance status (capitated or FFS) was randomly incorporated into 4 clinical scenarios using a Latin square design. SUBJECTS: We used a nationally representative random sample of family physicians in direct patient care. MEASURES: We used treatment decisions and physician "bother" scores (a measure of discomfort about decisions) in response to the clinical scenarios and adjusted for physician gender, age, board certification, income, practice location, practice mix, practice setting, geographic region, local area managed care penetration, and capitation or risk pool contracts in practice. RESULTS: Seventy-two percent of sampled physicians responded. Comparing decisions made under capitation to FFS, physicians were less likely to indicate they would perform discretionary care (relative risks [RR] range, .64-.82; P<0.001), but payment had no effect on selection of life-saving care (RR, 1.02, not significant). Physicians felt significantly more "bothered" when they made clinical decisions under capitated payment (P<0.001 in all scenarios), regardless of whether a treatment was discretionary or life-saving, and whether the decision was made for or against the treatment (P<0.001). CONCLUSIONS: Payment mechanism has significant effects on clinical decision-making. Reduction of resources spent for discretionary care might be achieved under capitated arrangements; however, physicians respond with greater levels of discomfort under capitation than FFS.

Attitude of Health Personnel↗

PubMed2004

Prospects for health impact assessment in the United States: new and improved environmental impact assessment or something different?

Health impact assessment (HIA) has been advanced as a means of bringing potential health impacts to the attention of policy makers, particularly in sectors where health impacts may not otherwise be considered. This article examines lessons for HIA in the United States from the related and relatively well-developed field of environmental impact assessment (EIA). We reviewed the EIA literature and conducted twenty phone interviews with EIA professionals. Successes of EIA cited by respondents included integration of environmental goals into decision making, improved planning, and greater transparency and public involvement. Reported shortcomings included the length and complexity of EIA documents, limited and adversarial public participation, and an emphasis on procedure over substance. Presently, EIAs consider few, if any, health outcomes. Respondents differed on the prospects for HIA. Most agreed that HIA could contribute to EIA in several areas, including assessment of cumulative impacts and impacts to environmental justice. Reasons given for not incorporating HIA into EIA were uncertainties about interpreting estimated health impacts, that EIA documents would become even longer and more complicated, and that HIA would gain little from the procedural and legal emphasis in EIA. We conclude that for HIA to advance, whether as part of or separate from EIA, well-formulated methodologies need to be developed and tested in real-world situations. When possible, HIA should build on the methods that have been utilized successfully in EIA. The most fruitful avenue is demonstration projects that test, refine, and demonstrate different methods and models to maximize their utility and acceptance.

California↗

PubMed2004

Cost-effectiveness analysis of total ankle arthroplasty.

BACKGROUND: There is renewed interest in total ankle arthroplasty as an alternative to ankle fusion in the treatment of end-stage ankle arthritis. Despite a lack of long-term data on the clinical outcomes associated with these implants, the use of ankle arthroplasty is expanding. The purpose of this cost-effectiveness analysis was to evaluate whether the currently available literature justifies the emerging use of total ankle arthroplasty. This study also identifies thresholds for the durability and function of ankle prostheses that, if met, would support more widespread dissemination of this new technology. METHODS: A decision model was created for the treatment of ankle arthritis. The literature was reviewed to identify possible outcomes and their probabilities following ankle fusion and ankle arthroplasty. Each outcome was weighted for quality of life with use of a utility factor, and effectiveness was expressed in units of quality-adjusted life years. Gross costs were estimated from Medicare charge and reimbursement data for the relevant codes. The effect of the uncertainty of estimates of costs and effectiveness was assessed with sensitivity analysis. RESULTS: The reference case of our model assumed a ten-year duration of survival of the prosthesis, resulting in an incremental cost-effectiveness ratio for ankle arthroplasty of $18,419 per quality-adjusted life year gained. This reflects a gain of 0.52 quality-adjusted life years at a cost of $9578 when ankle arthroplasty is chosen over fusion. This ratio compares favorably with the cost-effectiveness of other medical and surgical interventions. Sensitivity analysis determined that the cost per quality-adjusted life year gained with ankle arthroplasty rises above $50,000 if the prosthesis is assumed to fail before seven years. Treatment options with ratios above $50,000 per quality-adjusted life year are commonly considered to have limited cost-effectiveness. This threshold is also crossed when the theoretical functional advantages of ankle arthroplasty are eliminated in sensitivity analysis. CONCLUSIONS: The currently available literature has not yet shown that total ankle arthroplasty predictably results in levels of durability and function that make it cost-effective at this time. However, the reference case of this analysis does demonstrate that total ankle arthroplasty has the potential to be a cost-effective alternative to ankle fusion. This reference case assumes that the theoretical functional advantages of ankle arthroplasty over ankle fusion will be borne out in future clinical studies. Performance of total ankle replacement will be better justified if these thresholds are met in published long-term clinical trials.

Ankle Joint↗

PubMed2003

Assessment of tuberculosis treatment completion in an ethnically diverse population using two data sources. Implications for treatment interventions.

Many adolescents who are prescribed therapy for tuberculosis (TB) infection fail to complete it. This article presents the results of a demographic and epidemiological assessment of TB treatment completion in adolescent populations using (a) surveillance data from the Los Angeles Health County Department and (b) a prospective/retrospective medical chart review from targeted clinics. Patients who did not complete the 6-month recommended medical treatment for latent tuberculosis therapy (LTBI) averaged 13 weeks in care. Younger age (OR = 1.15; 95% CI 1.03-1.29), birth in the United States (OR = 1.92; 95% CI 1.14-3.22, compared to Mexico), and Asian ethnicity were associated with completion of care. In multiple logistic regression analysis, age (OR = .88; 95% CI .78-.98) and Latino ethnicity (OR = .53; 95% CI .29-.95) remained significant predictors of completion of treatment. These findings indicate the need for age-specific educational reinforcement and cultural differentials in completing care for LTBI.

Adolescent↗

PubMed2002

Are high-volume surgeons and hospitals the most important predictors of in-hospital outcome for colon cancer resection?

BACKGROUND: Although recent studies have reported that high-volume surgeons and hospitals have better outcomes for colon cancer resections, it remains unclear whether there are other factors that are more important than volume. This study aims to evaluate the importance of the volume variables relative to other factors in an attempt to target specific areas for improving outcomes. METHODS: Using nationwide data from the Healthcare Cost and Utilization Program, full-model logistic regression was performed on all patients undergoing colon cancer resection. In hospital mortality was regressed against more than 30 different independent variables, including demographic factors (eg, age, gender, race, ethnicity, and socioeconomic status), burden of morbid and comorbid disease (prevalence and severity), and provider variables (eg, hospital size, location, teaching status, hospital and surgeon volume). A separate baseline probability analysis was then performed to compare the relative importance for all predictor variables. RESULTS: The sample size for this analysis was 22,408; 622 in-hospital deaths occurred (2.8%). Average age was 70 years old, 51% of particIpants were male, and 60% had at least 1 comorbid disease. An operation was elective (64%), urgent (19%), or emergency (15%). The significant predictors for mortality (at P <.05) included age, gender, comorbid disease (ie, cardiovascular, pulmonary, liver), operation severity (ie, emergency, urgent), and volume (both hospital and surgeon). The baseline probability analysis shows that the mortality for a baseline case is 12/1000. If this baseline case goes to a high-volume hospital or surgeon, the mortality will decrease to 11/1000 and 10/1000, respectively. If a patient with a baseline case of colon cancer also has coexistent liver disease or requires an emergency operation, mortality increases to 44/1000 and 45/1000, respectively. Overall, the volume variables, although statistically significant, have a relatively smaller effect on outcome compared with other factors. CONCLUSIONS: Whereas other factors have a stronger association with outcome than volume, volume is the only acutely mutable variable. Although the regionalization controversy (ie, using only high-volume surgeons or hospitals) is not solved with our findings, this study elucidates and compares the relative importance of several different factors on outcome, which is essential when considering the conclusions and implications of this type of policy-relevant outcomes research.

Aged↗

PubMed2002

Who switches from Medigap to Medicare HMOs?

OBJECTIVE: To determine the factors affecting whether Medigap owners switch to Medicare managed care plans. DATA SOURCES: The primary data were the 1993-1996 Medicare Current Beneficiary Survey (MCBS) Cost and Use Files. These were supplemented by data available from the Centers for Medicare & Medicaid Services (CMS) website. STUDY DESIGN: Individuals on the MCBS files with Medigap coverage in the period 1993-1996 were included in the study. The person-year was the unit of analysis. We used multivariate logistic regression analysis to determine whether or not a Medigap owner switched to a Medicare-managed care plan during a particular year. Independent variables included measures of affordability, need for services, health insurance benefits, sociodemographics, and supply of managed care plans. PRINCIPAL FINDINGS: We did not detect strong evidence that beneficiaries in poorer health were more likely than others to switch from Medigap coverage to Medicare-managed care. In addition, higher Medigap premiums did not appear to induce beneficiaries to switch into managed care. CONCLUSIONS: We examined selection bias in joining managed care plans among the subset of Medicare beneficiaries who have Medigap policies. No strong evidence of selection bias was found in this population. We conclude that there was no evidence that the Medigap market is becoming prohibitively expensive as a result of unfavorable selection.

Aged↗