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Biomedical subjects

M J Long

Publications and source records attributed to M J Long.

At least 19 recordsLinked to original sources
PubMed2000

The relationship of impending death and age category to treatment intensity in the elderly.

The purpose of this study was to isolate and quantify the age-related treatment intensity differential in elderly clients (n = 278) with functional disability in one managed care setting. For those who died during the study, treatment intensity changes for the last year and month of life were examined. The subjects were categorized into four age groups: 75-79 years; 80-84 years; 85-89 years and 90 + years, and a treatment intensity index was calculated for each group using a ratio of actual to expected costs. Indices of overall costs and cost per day for all clients, and also indices for the year and month prior to death for the deceased clients were calculated. The results clearly show that for all clients, the oldest age group was treated less intensively than the youngest age group. For the deceased clients, the older age group was treated less intensively than the youngest age group in the last year and month of life but, for all age groups, the intensity of treatment increased during the last month of life.

Age Distribution↗
PubMed2000

What price an additional day of life? A cost-effectiveness study of case management.

OBJECTIVE: To examine the costs and benefits of a case-management program for an elderly, functionally impaired population in a managed care setting. STUDY DESIGN: A post hoc, cost-effectiveness study of case management. SUBJECTS AND METHODS: As part of a larger study, 317 elderly, functionally impaired clients were randomly assigned to a case-managed or regular-care group. During the 2-year study period, 34 clients in the case-managed and 43 clients in the regular-care group died. A post hoc analysis of the difference in average total cost per person, death rates, and average number of days of exposure per person were assessed to determine the cost per life saved and cost per additional day of life. RESULTS: Although the average costs for the case-managed group were greater than the costs for the regular-care group, clients in the case-managed group lived an average of 106 days longer. The cost per additional day of life was $40. The difference in death rates was so small that, by extrapolation, the cost per life saved was over $42 million. CONCLUSION: Although the case-management program was more costly when viewed from a purely fiscal perspective, it may very well be considered a success when its benefits are evaluated. The case-management program improved quality and was associated with prolonged life at a cost of $40 per day of additional life. Additional research involving other patient populations, study settings, and case-management models is warranted.

Aged↗
PubMed1999

Case management and the cost of care in the last month of life: evidence from one managed care setting.

Elderly, functionally disabled enrollees in a managed care organization were randomly assigned to case management or regular care. The service use and cost of care for the last month life for the case managed deceased is compared with that of the regular care group. The results suggest that contrary to general expectation, the managed care clients experienced greater use and costs of care in the last month of life.

Activities of Daily Living↗
PubMed1999

Defining the utility of clinically acceptable variations in evidence-based practice guidelines for evaluation of quality improvement activities.

This study examines the utility of systematically accounting for acceptable physician variations in guideline application. The results argue against assuming that even seemingly noncontentious guideline protocol offer a threshold of variation similar to conventional Continuous Quality Improvement (CQI) assessment standards. Findings also suggest that health service organizations can derive greater benefits from expending the resources necessary to standardize guidelines if compliance with both the medical review criteria, and the guidelines as originally constructed, is monitored as part of the evaluation activity.

Acute Disease↗
PubMed1999

Using collectively-derived standards to evaluate individual performance: a cautionary note on clinical practice guidelines.

The purpose of this work is to demonstrate the problem of evaluating an individual physician's performance relative to practice guidelines which have typically been derived from group consensus or some measure of central tendency. It is argued that when evaluated against a set of criteria derived at the macro-level, an individual physician's performance may justifiably vary due to the patient characteristics or the evolving process of care. It is also argued that it is not necessarily true that costs are reduced when practice variation is reduced. The results indicate that there are cost reduction in areas not targeted by the guidelines, suggesting a possible 'spillover effect' due to the increased vigilance in monitoring provider performance. The results also provide some evidence of increased costs following a reduction in variation. Caution should be exercised when evaluating individual physician performance relative to guidelines established at the aggregate level. Acceptable individual physician performance should be judged within the upper and lower boundaries of the implicit distribution of physicians' performances from which the established guidelines generated.

Coronary Care Units↗
PubMed1999

The relationship between self-assessed health status, mortality, service use, and cost in a managed care setting.

This article explores the extent to which Self-Assessed Health Status (SAH) can contribute to the development of capitation and premium rates by predicting mortality, service use, and service cost in an elderly population in a managed care setting. Those who rated their health as poor were three times as likely to die, and service use and cost were positively associated with those who rated their health as poor. Performance indices based on the ratio of actual-to-expected cost within each SAH category suggest a more aggressive treatment of those who rated their health as poor.

Activities of Daily Living↗
PubMed1997

Utilization of hospital services by the elderly: geriatric crisis in one Canadian single payer system.

As the number and proportion of elderly persons in the Canadian population increase, utilization of health services by the elderly becomes a growing concern for health service insurers, financial managers and policy makers, as well as for care providers. The purpose of this paper is to present the results of a study to analyse the use of hospital services by the elderly in Alberta since the introduction of a universal single payer health care insurance system in 1970. The study period coincides with the implementation of publicly-financed comprehensive medical and hospital insurance programmes for all Alberta residents, making it possible to perform historical and population-based utilization analyses. Thus the data used for the study included all hospital discharge abstracts generated by all Alberta hospitals from 1971 to 1991. Trends in hospital service utilization by the elderly in terms of total number of separations, patient-days, and per case measures such as average length of stay as well as per capita utilization rates were reviewed to identify utilization patterns over the study period. Further, relative per capita utilization measures, in comparison with the base year (1971), age group 15-44, male, metropolitan residents, were derived and historical trends identified. A series of regression analyses were carried out to estimate the effects of age, sex and origin on utilization rates. In addition, for the period of 1984-1991, Diagnosis Related Groups (DRG) case weights were used to measure per capita and per case rates and to analyse historical relative utilization rates over the 8-year period. In general, there has been a significant decline in hospital utilization by Albertans under the publicly-financed single payer system, but utilization rates for elderly have remained high, resulting in high relative utilization rates in comparison with other age groups. It was also noted that per capita utilization rates for rural residents were substantially higher than urban residents. It appears that these higher utilization rates by the elderly and rural residents in combination with tight bed and financial control by the government have been causing significant bed shortage problems for non-elderly elective patients in urban areas.

Adolescent↗
PubMed1996

Quality of life improvement in patents with osteoarthritis: the potential for office-based assessment.

OBJECTIVE: This study presents the initial findings from our evaluation of the Nottingham Health Profile, a short and simple quality of life instrument, to determine its ease and robustness as a routine office tool for evaluating changes in the quality of life for arthritis patients undergoing joint replacement. METHODS: Thirty-five patients awaiting total joint replacement surgery were asked to complete the Nottingham Health Profile at their pre-operative clinic. A post-joint replacement evaluation profile, with a self-addressed stamped envelope, was mailed to each participant 3-4 months post-surgery. The profile was self-administered on both occasions. RESULT: The follow-up response rate was 69%. The t-test for the paired difference of related populations was used to determine pre-test and post-test changes. Significant improvement was found in the profile's 6 subscales, with energy, pain, and physical mobility significant at the 0.001 level, emotion and social isolation significant at the 0.005 level, and sleep significant at the 0.05 level. The before and after comparison of the profile's global self-assessment of health was not significant. CONCLUSION: Preliminary findings suggest that the Nottingham Health Profile is a useful office tool for the routine assessment of intervention-related changes in quality of life. The instrument was easy to self-administer and was associated with a mail return response rate consistent with other investigations using the profile. Even with a small sample size, the profile rendered data consistent with large-scale research evaluations of changes in quality of life for joint replacement patients. The finding that patients' global health status measures did not change despite improvements in quality of life subscales indicates that the instrument reliably netted out the quality of life benefits of the arthritis-related intervention from the patients' total burden of illness.

Activities of Daily Living↗
PubMed1996

The relationship between resource constraints and physician problem solving. Implications for improving the process of care.

OBJECTIVES: Research suggests that physicians will engage in more vigilant problem-solving under conditions of resource constraints than under conditions of resource slack. Increased vigilance related to physicians' clinical strategies enhances care by disposing physicians toward more optimal care choices. The authors examine whether pressures for clinical resource constraints encourage increased and sustained vigilance in problem-solving among cardiologists treating acute myocardial infarction. METHODS: The physician problem-solving process is reconstructed from the medical records of all eligible cases of acute myocardial infarction treated by the physician sample set over a 6-year period. The sample period encompasses phases of both resource slack and resource constraints. The Herfindahl index is used to measure the relative amount of vigilant problem-solving activity exhibited in each of five major tactical areas of the physician care strategies in each year of the study. RESULTS: The results support the hypothesis that resource constraints initially promote a shift to increased vigilance in physician problem-solving. Only one of the five major tactical areas, however, is characterized by sustained vigilance over time. The other areas are, instead, associated with a substantial reduction in vigilant activity after the initial peak period. CONCLUSIONS: The results suggest that resource constraints do set the stage for improved clinical decision-making. Sustained vigilance, however, appears to apply only to those portions of the care strategy for which the physician can draw a clear link between optimizing clinical activity and reducing resource consumption. For those portions of the care strategy for which the physician cannot establish a clear link, ongoing pressures to conserve resources results in reduced vigilance and a potential reduction in quality of clinical decision-making.

Cardiology↗
PubMed1996

An atypical T-cell lymphosarcoma in a calf with bovine immunodeficiency-like virus infection.

An 11-month-old Holstein calf experimentally infected with bovine immunodeficiency-like virus (BIV) developed T-cell lymphosarcoma 5 months postinoculation, concurrent with progressive monocytosis. Tumors were found in the thymus, multiple lymph nodes, and brain. Tumor cells were CD2+, CD4-, CD8-T cells. Infectious BIV could be recovered from splenic tissue and blood mononuclear cells. Bovine leukemia virus was not present. Because this calf was part of an ongoing experiment on the pathogenesis of BIV infection, immune function data were also available both before and after lymphosarcoma developed. Neutrophil and monocyte function were normal, but lymphocyte blastogenesis was enhanced before the development of lymphosarcoma. Follicular hyperplasia in lymphoid tissues was also seen. This case raises the possibility that BIV infection may cause or be associated with some cases of atypical T-cell lymphosarcoma, without evidence of immune suppression at the time of tumor onset.

Animals↗
PubMed1993

Case mix management: a cautionary note.

Using data from a study that involved 500 U.S. acute care hospitals, the author examines the relationship between the profitability of Diagnostic Related Groups (DRGs) and their DRG weight, and the similarity/difference of the most/least profitable DRGs across hospital types. Hospital administrators are cautioned that to engage in case mix management, they must use a management information system that provides the data necessary for determining the cost of treating each patient type within their own institution, not information derived from other facilities or other systems.

Data Collection↗
PubMed1993

The impact of diagnosis related group profitability on the skimming and dumping of psychiatric diagnosis related groups.

Psychiatric DRGs are identified in terms of their relative profitability within each hospital of a 386 hospital cohort. It is then determined whether hospitals admitted more of the more profitable and fewer of the less profitable patients over the period 1983-1987 (skimming). Also determined is whether hospitals discharged more of the less profitable to other short term hospitals over the same period of time (dumping). The findings generally indicate that this did not happen.

Cost-Benefit Analysis↗
PubMed1993

Profitable and unprofitable DRGs: the implications for access.

Given a choice, hospitals would prefer to admit a patient with the potential to contribute to an accounting profit and prefer not to admit a patient with the potential to contribute to an accounting loss. It is suggested that if all hospitals found the same DRGs to be unprofitable, access to inpatient care would be denied those patient types. A set of 509 hospitals was stratified according to bedsize, Medicare load, type of control, teaching status and geographic location. The 10 most and 10 least profitable DRGs were identified for each hospital category and a Spearman's rank order correlation was used to determine the similarity or dissimilarity across hospital category. The results indicate that the more alike hospitals are in terms of bedsize, Medicare load and teaching status, the more alike are the DRGs that are determined to be unprofitable (or profitable). Conversely, the less alike they were on these characteristics, the less alike were the unprofitable (or profitable) DRGs. There were no differences evident when the hospitals were classified according to type of control or geographic location. These results are generally encouraging in terms of potential access but disturbing in terms of possible further financial threat to rural hospitals.

Diagnosis-Related Groups↗
PubMed1991

Identification of a hypervariable region in the long terminal repeat of equine infectious anemia virus.

An avirulent, field-derived isolate of equine infectious anemia virus (EIAV), designated MA-1, was molecularly cloned, and the complete nucleotide sequence was determined for the 3' half of the viral genome. Comparisons between MA-1 and the prototype Wyoming strain of EIAV identified a 66-nucleotide stretch between CAAT (-91) and TATAA (-25) in the U3 region of the long terminal repeat, where sequence divergence was as high as 39.3%. The polymerase chain reaction was used to amplify and clone long terminal repeat sequences from Th-1, the in vivo parental stock of MA-1. Results indicated that the nucleotide sequences of MA-1 and Th-1 clones were less variable than was observed between MA-1 and Wyoming. However, MA-1 and Th-1 markedly differed in the types of enhancer sequences located in the hypervariable region. These results suggest that variation in lentivirus regulatory sequences may be important in EIAV host cell tropism and pathogenesis.

Amino Acid Sequence↗
PubMed1990

A reassessment of hospital product and productivity changes over time.

Were the changes found in the first year of the prospective payment system (PPS) one-time changes that attenuated as hospitals gained familiarity with the system? The results of this research show that, over time, discharges to home (self-care) continued to decrease, discharges to home health agencies continued to increase, but transfers and discharges to skilled nursing facilities or intermediate care facilities accounted for an increasing share of total discharges. After a dramatic decrease in the first year, the use of laboratory tests, diagnostic tests, and X-rays returned, over time, almost to pre-PPS levels.

Efficiency↗
PubMed1989

Were hospitals selective in their product and productivity changes? The top 50 DRGs after PPS.

Five separate hospital products are identified based on the concept of the amount of disease remission achieved by the hospital. The parameters of this concept are illness level on admission and discharge location. In a cohort of 646 nonfederal, short-term hospitals over the period 1980-1984, changes in the hospital product are examined separately in the 50 diagnosis-related groups (DRGs) with the greatest volume of Medicare discharges. Productivity changes, as defined by the number of certain inputs, are also examined. In both sets of analyses, patient severity level is controlled for by indexing to the base year (1980) case mix. The purpose of this study was to examine whether the dramatic product and productivity changes following implementation of the prospective payment system, as found in our earlier work, were across-the-board changes or the result of selective changes, specific to certain DRGs or products. The results suggest that the changes were an across-the-board phenomenon. Policy implications are discussed.

Adolescent↗