PubMed Health⌕ Search

Biomedical subjects

M E Stuart

Publications and source records attributed to M E Stuart.

At least 19 recordsLinked to original sources
PubMed2001

Benchmarking applications: linking state strategic planning, quality improvement, and consumer reporting.

This article demonstrates the value of using benchmark patient satisfaction data for Medicaid program quality improvement. The authors compare surveys of Maryland Medicaid and federal employees in Maryland, utilizing the latter as an external benchmark. Unadjusted and adjusted analyses found a significantly lower percentage of Medicaid than federal respondents rated telephone access excellent, very good, or good, whereas more Medicaid respondents rated advice on prevention and choice of primary care doctor highly. Patient satisfaction external benchmark data provide managed care organizations (MCOs) and state policy makers with goals to improve quality and standards to measure care objectively in vulnerable populations.

Benchmarking↗
PubMed1998

Beyond managing Medicaid costs: restructuring care.

The apparent success of managed care plans in controlling medical costs has made the prospect of managed care for Medicaid recipients attractive for state health policy makers. However, because the principles upon which managed care was created do not apply to the most costly segments of the Medicaid population, efforts to address their needs through traditional managed care strategies are likely to be self-defeating. The Maryland Medicaid database was used to review and analyze the successes and failures of managed care Medicaid initiatives to date. This review led to the suggestion that the integration of specialized systems for specific subgroups of the Medicaid population into managed care, in conjunction with broader public policies, could lead to improved quality and lower costs.

Adolescent↗
PubMed1998

A comparison of ambulatory Medicaid claims to medical records: a reliability assessment.

This study compares the documentation of ambulatory care visits and diagnoses in Medicaid paid claims and in medical records. Data were obtained from Maryland Medicaid's 1988 paid claims files for 2407 individuals who were continuously enrolled for the fiscal year, had at least one billed visit for one of six indicator conditions, and had received the majority of their care from one provider. The patients sampled were also stratified on the basis of the case-mix adjusted cost of their usual source of care. The medical records for these individuals as maintained by their usual source of care were abstracted by trained nurse reviewers to compare claims and record information. Linked claim and medical record data for sampled patients were used to calculate: (i) the percent of billed visits documented in the record, (ii) the percent of medical record visits where both the date and the diagnosis agreed with the claims data, and (iii) the ratio of medical record visits to visits from billed claims. Included in the analysis were independent variables specifying place of residence, type and costliness of usual care source, level of patient utilization, and indicator condition on which patient was sampled. Ninety percent of the visits chronicled in the paid claims were documented in the medical record with 82% agreeing on both date and diagnosis. Compared to the medical records kept by private physicians and community health centers, a significantly lower percent of hospital medical records agreed with the claims data. Total volume of visits was 2.6% higher in the medical records than in the claims. Claims data substantially understated visits in the medical record by 25% for low cost providers and by 41% for patients with low use rates (based on claims information). Conversely, medical records substantially understated billed visits by 19% for rural patients and by 10% for persons with high visit rates. Although Medicaid claims are relatively accurate and useful for examining average ambulatory use patterns, they are subject to significant biases when comparing subgroups of providers classified by case-mix adjusted cost and patients classified by utilization rates. Medicaid programs are using claims data for profiling and performance assessment need to understand the limitations of administrative data.

Adult↗
PubMed1997

Successful implementation of an evidence-based clinical practice guideline: acute dysuria/urgency in adult women.

This paper describes the development and successful implementation of an evidence-based clinical practice guideline dealing with uncomplicated urinary tract infection in adult women (acute dysuria guideline). This guideline was based on an evaluation and synthesis of the medical literature using the best available evidence. Following guideline implementation, clinical practice changes recommended by the guideline were observed, including a significant decrease in laboratory testing and clinic visits for acute dysuria. Successful implementation of this guideline is attributed to the use of an explicit, evidence-based guideline development process, a combination of implementation strategies including decision support for providers, and a change in the roles of registered nurses.

Acute Disease↗
PubMed1996

Evidence for selective health maintenance organization enrollment among children and adolescents covered by Medicaid.

OBJECTIVE: To determine whether children and adolescents are selectively enrolled in health maintenance organizations (HMOs) based on age, gender, diagnosis, or prior utilization. DESIGN: Case-control study. New HMO enrollees were compared with a control population of non-HMO enrollees. SETTING: Medicaid claims data and HMO participation records for the Medicaid and Aid to Families of Dependent Children sector in Baltimore, Md. RESULTS: Controlling for age, significant differences in prior health care utilization as measured by Medicaid expenditures and hospital days were noted. Children enrolling in HMOs had significantly lower prior utilization than children from the control population as measured by dollar expenditures and hospital days. Young children enrolling in HMOs were only half as likely to have prior claims for asthma. Conversely, adolescents enrolling in HMOs had significantly higher prior utilization than adolescents from the control population. The difference among adolescents was due to a higher birth rate among new HMO enrollees in that age bracket. CONCLUSIONS: Voluntary HMO enrollment of children covered by Medicaid and Aid to Families of Dependent Children sector was subject to selection biases that may be economically favorable to the HMOs and may undermine the cost-containment goals of prepaid health care for Medicaid participants. Voluntary capitated systems where fee-for-service remains a significant alternative must monitor for these selection biases that are not allowed for in the adjustments to capitation rates.

Adolescent↗
PubMed1996

Ambulatory care practice variation within a Medicaid program.

STUDY QUESTIONS: What is the extent of variation in patterns of ambulatory care practice across one state's Medicaid program once case mix is controlled for? How much of this variation in resource consumption is explained by factors linked to the provider, patient, and geographic subarea? DATA SOURCES/STUDY SETTING: Practices of all providers delivering care to persons who were continuously enrolled in the Maryland Medicaid program during FY 1988 were studied. A computerized summary of all services received during this year for 134,725 persons was developed using claims data. We also obtained data from the state's beneficiary and provider files and the American Medical Association's masterfile. Each patient was assigned a "usual source of care" (primary provider) based on the actual patterns of service. The Ambulatory Care Group (ACG) measure was used to help control for case mix. STUDY DESIGN: This was a cross-sectional study based on the universe of continuously enrolled Medicaid enrollees in one state. PRINCIPAL FINDINGS: After controlling for case mix, the variation in patient resource use by type of primary provider was 19 percent for ambulatory visits, 46 percent for ancillary testing, 61 percent for prescriptions, and 81 percent for hospitalizations. Across Maryland counties, comparing the low- to high-use jurisdiction, there was 41 percent variation in case mix-adjusted visit rates, 72 percent variation in pharmacy use, and 325 percent variation in hospital days. At the individual practice level, physician characteristics explain up to 17 percent of ambulatory resource use and geographic area explains only a few percent, while patient characteristics explain up to 60 percent of variation. CONCLUSIONS: Since a large proportion of variation was explained by patient case mix, it is evident that risk adjustment is essential for these types of analyses. However, even after adjustment, resource use varies considerably across types of ambulatory care provider and region, with consequent implications for efficiency of health services delivery.

Ambulatory Care↗
PubMed1995

Public health issues in the development of centralized health care databases.

The establishment of centralized databases, in conjunction with health care reform, offers us an opportunity to enhance the collection of data supportive of public health functions. However, this opportunity may be lost without the informed, persuasive, and persistent participation of the public health community in the database development process. Maryland's effort to construct a statewide database illustrates the political forces and technical complexity involved in the task. It also demonstrates how public health officials, by making their views known, can influence database design and health care reform.

Cost Control↗
PubMed1995

Improving Medicaid pediatric care.

This article uses Medicaid claims data to examine the adequacy of well-child care provided by different ambulatory care providers for selected children enrolled in Maryland Medicaid. Considerable provider variation was observed. The majority of the nearly one-quarter of the children with no well-child visits during the year appeared to have had no regular primary care source. Results contributed to the development of a managed care program designed to increase care accessibility and continuity and improve provider practices. Advantages and disadvantages of using claims data to investigate this public health issue care discussed.

Child Health Services↗
PubMed1994

The use of prostate specific antigen for prostate cancer screening: a managed care perspective.

A large nonprofit staff model Health Maintenance Organization experienced increased use of prostate specific antigen (PSA) as a screening test for prostate cancer beginning in May 1991. A critical evaluation of the evidence in support of PSA screening was done and concluded that the use of PSA to screen for prostate cancer did not meet the criteria for an effective screening program. A guideline stating that PSA was not recommended as a screening test was implemented focusing on a model of shared decision making. PSA test ordering decreased significantly when patients were fully informed about the evidence for PSA screening. If PSA screening had continued at the peak rate, the cascade of intervention initiated by screening would have resulted in significant complications and approximately $4,800,000 in increased costs.

Health Maintenance Organizations↗
PubMed1994

An evidence-based approach to evaluating and improving clinical practice: guideline development.

Group Health Cooperative of Puget Sound has developed a model for evaluating and improving clinical practice based on an explicit, evidence-based approach. It is designed to identify gaps between current and optimal practices, and to bring about changes in physician behavior so that health care outcomes (health status, patient satisfaction, provider satisfaction, cost/utilization) are maximized. This model stresses the importance of a rigorous process in looking objectively at evidence in working to improve outcomes. Discrete tools have been developed which help teams move successfully from problem identification to the ongoing evaluation and improvement of a new clinical practice.

Clinical Medicine↗
PubMed1994

An evidence-based approach to evaluating and improving clinical practice: implementing practice guidelines.

Clinical practice guidelines can improve health care outcomes, but they are only as effective as their implementation. We present a framework for implementing practice guidelines that begins by identifying the forces driving and restraining the adoption of the guideline. Strategies for changing physician behavior that strengthen the driving forces and weaken the restraining forces can then be incorporated into a comprehensive implementation program. Nine strategies for changing physician behavior are presented, based on a review of the literature and organizational experience at Group Health Cooperative of Puget Sound. In designing an implementation strategy, it is essential that the resources allocated to implementation are commensurate with the improvement in outcomes expected from the successful implementation of the guideline. All implementation programs should include plans for measuring outcomes to allow for continuing improvement. Guideline implementation, evaluation and improvement efforts are most likely to be successful when they are part of an explicit, evidence-based process for evaluating and improving clinical practice.

Decision Making↗
PubMed1994

Redefining boundaries in the financing and care of diabetes: the Maryland experience.

The story of the development of the Maryland Medicaid Diabetes Care Program is narrated in this policy case study. Maryland Medicaid, a funding authority willing to assume a proactive role, decided to promote health care system changes expected to improve the health status of its recipients with diabetes. A state Medicaid budget crisis presented opportunities for financing new and expanded preventive services for those with this chronic disease. Specifically recounted is how Maryland Medicaid redefined its financing boundaries in an effort to overcome finance-induced fragmentation in diabetes health care delivery. The difficulties encountered by a single payer in moving unilaterally to alter health care practices are discussed. Two commentaries follow.

Diabetes Mellitus↗
PubMed1993

Patient-mix differences among ambulatory providers and their effects on utilization and payments for Maryland Medicaid users.

Characteristics of the usual source of care (e.g. specialty, organizational type) are known to be related to utilization and cost levels. This study assesses the degree to which variations in utilization and cost are attributable to differences in patient mix (i.e. demographic and diagnostic characteristics). Comparisons are made with Medicaid payments with and without patient-mix adjustment among users of hospital outpatient departments, emergency rooms, Federally Qualified Health Centers and office-based physicians. The study builds upon previous work by including a well-developed set of ambulatory case-mix controls, a variety of provider types, a large number of providers, and a relatively comprehensive resource utilization component. Findings confirm significant differences in patient demographic and diagnostic characteristics among users of different types of providers. Controlling for these patient-mix characteristics explains 44% of the variation in ambulatory use, 21% in hospital admissions, and 13% in total Medicaid payments. The considerable remaining variation suggests differences in provider efficiency. For example, even after patient mix adjustment, 18% of those who rely on outpatient departments are hospitalized annually compared to 10% for users of office-based physicians. Overall findings indicate that patient-mix characteristics, as well as differences in provider efficiency, should be considered when developing and evaluating managed care and preferred provider initiatives for ambulatory care.

Adolescent↗
PubMed1993

Nursing: the endangered profession?

The history of nursing illustrates patterns that continue to threaten the recruitment and retention of nurses today. Three contemporary examples illustrate key dilemmas the nursing profession is facing. They also provide us with clues to patterns and themes that have recurred throughout our history.

Career Choice↗
PubMed1992

Clinical practice and new technology: prostate-specific antigen (PSA).

In response to a marked increase in the use of an available test, Group Health Cooperative of Puget Sound (GHC) evaluated the use of prostatic specific antigen (PSA) as a screening test for prostate cancer. A project team reviewed the literature and determined that PSA did not meet GHC's criteria for screening. An implementation team then developed a comprehensive program to educate staff, facilitate practice change, measure outcomes and provide continuing feedback to physicians. These efforts are described and preliminary reports reported.

Decision Support Techniques↗
PubMed1990

Immediate pigment darkening: visual and reflectance spectrophotometric analysis of action spectrum.

Immediate pigment darkening (IPD) occurs in human skin upon exposure to ultraviolet-A and visible radiation. The spectral changes that occur during IPD were measured with a rapid scanning reflectance spectrophotometer (RS) which employs optical fiber bundles for delivery and detection of light between 400 and 750 nm. The radiation dose dependence and wavelength dependence (334-549 nm irradiation) of IPD were studied by both the classical visual grading method and by spectrophotometric scoring using the RS system. The spectral changes that occur at long wavelengths with IPD mimic the natural absorption spectrum of melanin. Therefore, the IPD was scored in terms of the apparent change in melanin optical density, using the method Kollias and Baqer [Photochem. Photobiol. 43, 49-54 (1986)], based on reflectance in the 620-720 nm range. The nonlinearity of the visual grading method is demonstrated. The degree of IPD is first-order with respect to delivered dose and saturates after high doses. The maximum amount of IPD attained at saturation is greater for shorter wavelengths. Extrapolation of the reflectance data suggests the longest wavelength capable of eliciting IPD is about 470 nm.

Adult↗