Biomedical subjects

Matthew L Maciejewski

Publications and source records attributed to Matthew L Maciejewski.

18 recordsLinked to original sources

PubMed2007

Impact of a managed-Medicare physical activity benefit on health care utilization and costs in older adults with diabetes.

OBJECTIVE: The purpose of this article was to determine the effects of a managed-Medicare physical activity benefit on health care utilization and costs among older adults with diabetes. RESEARCH DESIGN AND METHODS: This retrospective cohort study used administrative and claims data for 527 patients from a diabetes registry of a staff model HMO. Participants (n = 163) were enrolled in the HMO for at least 1 year before joining the Enhanced Fitness Program (EFP), a community-based physical activity program for which the HMO pays for each EFP class attended. Control subjects were matched to participants according to the index date of EFP enrollment (n = 364). Multivariate regression models were used to determine 12-month postindex differences in health care use and costs between participants and control subjects while adjusting for age, sex, chronic disease burden, EFP attendance, prevention score, heart registry, and respective baseline use and costs. RESULTS: Participants and control subjects were similar at baseline with respect to age (75 +/- 5.5 years), A1C levels (7.4 +/- 1.4%), chronic disease burden, prevention score, and health care use and costs. After exposure to the program, there was a trend toward lower hospital admissions in EFP participants compared with control subjects (13.5 vs. 20.9%, P = 0.08), whereas total health care costs were not different (P = 0.39). EFP participants who attended > or = 1 exercise session/week on average had approximately 41% less total health care costs compared with those attending <1 session/week (P = 0.03) and with control subjects (P = 0.02). CONCLUSIONS: Although elective participation in a community-based physical activity benefit at any level was not associated with lower inpatient or total health care costs, greater participation in the program may lower health care costs. These findings warrant additional investigations to determine whether policies to offer and promote a community-based physical activity benefit in older adults with diabetes can reduce health care costs.

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PubMed2006

Correlates of health-related quality of life in overweight and obese adults with type 2 diabetes.

OBJECTIVE: This paper describes and examines conceptually relevant correlates of health-related quality of life (HRQL) in overweight or obese persons with type 2 diabetes. Research Design and Procedures: The investigation was a cross-sectional study of 5145 overweight or obese adults with type 2 diabetes between the ages of 45 and 74 years. Analyses examined the relationship that demographic characteristics, disease burden, and cardiovascular fitness had with HRQL: the Short Form 36 (SF-36) and the Beck Depression Inventory (BDI) II. RESULTS: Means for the SF-36 physical component summary (PCS) scores, the mental component summary scores, and the BDI-II were as follows: 47.0, 54.0, and 5.7. Less desirable PCS scores were related to several comorbidities, insulin use, physical complaints, a high BMI, low metabolic equivalent (MET) capacity, and lower education. Interactions between categories of obesity and MET capacity revealed that greater BMI was related to lower PCS scores when individuals had lower MET capacities yet was absent for those individuals who had higher MET capacities. In addition, although greater BMI was associated with more severe depressive symptomatology, this association was the most dramatic for those with class III obesity who had low MET capacity. DISCUSSION: Although participants in Look AHEAD had a favorable profile on the SF-36 and the BDI-II at baseline, lower PCS scores were related to disease severity and the presence of other comorbidities. More important, although the temporal ordering of associations cannot be determined in a cross-sectional design, the interactions between obesity class and MET capacity suggest that the adverse effect of BMI on PCS and BDI-II scores may be buffered by higher MET capacities.

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PubMed2006

Cost and utilization outcomes of patients receiving hospital-based palliative care consultation.

OBJECTIVE: To compare per diem total direct, ancillary (laboratory and radiology) and pharmacy costs of palliative care (PC) compared to usual care (UC) patients during a terminal hospitalization; to examine the association between PC and ICU admission. DESIGN: Retrospective, observational cost analysis using a VA (payer) perspective. SETTING: Two urban VA medical centers. MEASUREMENTS: Demographic and health characteristics of 314 veterans admitted during two years were obtained from VA administrative data. Hospital costs came from the VA cost accounting system. ANALYSIS: Generalized linear models (GLM) were estimated for total direct, ancillary and pharmacy costs. Predictors included patient age, principal diagnosis, comorbidity, whether patient stay was medical or surgical, site and whether the patient was seen by the palliative care consultation team. A probit regression was used to analyze probability of ICU admission. Propensity score matching was used to improve balance in observed covariates. RESULTS: PC patients were 42 percentage points (95% CI, -56% [corrected] to -31%) less likely to be admitted to ICU. Total direct costs per day were $239 (95% CI, -387 to -122) lower and ancillary costs were $98 (95% CI, -133 to -57) lower than costs for UC patients. There was no difference in pharmacy costs. The results were similar using propensity score matching. CONCLUSION: PC was associated with significantly lower likelihood of ICU use and lower inpatient costs compared to UC. Our findings coupled with those indicating better patient and family outcomes with PC suggest both a cost and quality incentive for hospitals to develop PC programs.

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PubMed2006

Distance as a barrier to using a fitness-program benefit for managed Medicare enrollees.

This study evaluated the effect of distance on the likelihood of initiating and maintaining regular use of a fitness-program benefit in a population of managed Medicare seniors. We studied 8,162 participants and nonparticipants in a managed-care fitness-program benefit: a structured group exercise program or an unstructured health-club membership. Participants in both programs lived significantly closer to facilities than nonparticipants did (structured, p < .001; unstructured, p = .017). Participants living closer to unstructured-program sites attended more frequently than those farther away (p = .008). Distance was not correlated with frequency of use in the structured program (p = .49). Collectively, these analyses demonstrate that distance is related to uptake and, in some cases, continued use of a fitness-program benefit. Health systems providing fitness-program benefits as a way to increase physical activity levels of their plan members should consider location of program facilities in relation to members' home addresses to maximize use of the benefit.

Age Factors↗

PubMed2005

A structured review of randomized controlled trials of weight loss showed little improvement in health-related quality of life.

OBJECTIVE: To estimate the effect of weight-loss interventions on health-related quality of life (HrQoL) in randomized controlled trials (RCTs); to conduct a meta-analysis of weight-loss treatment on depressive symptoms; and, to examine methodological and presentation issues that compromise study validity. STUDY DESIGN AND SETTING: We conducted a structured review of 34 RCTs with weight-loss interventions that reported the relationship between HrQoL and treatment at two or more time points. We also evaluated study quality. RESULTS: Trials lasted 6 weeks to 208 weeks and evaluated behavioral, surgical, or pharmacologic interventions. Nine of 34 trials showed HrQoL improvements in generic measures. Obesity-specific measures were more likely to show improvement in response to treatment than non-obesity-specific measures. Meta-analysis showed no treatment effect on depressive symptoms. Most trials tracked loss to follow-up and conducted intent-to-treat analysis, but only four trials concealed recruitment staff to randomization and 14 blinded the investigation team to randomization. CONCLUSION: HrQoL outcomes, including depression, were not consistently improved in RCTs of weight loss. The overall quality of these clinical trials was poor. Better-designed RCTs using standardized HrQoL measures are needed to determine the extent to which weight loss improves HrQoL.

Adult↗

PubMed2005

Changes in characteristics of veterans using the VHA health care system between 1996 and 1999.

BACKGROUND: The Department of Veterans Affairs' Veterans Health Administration (VHA) provides a health care safety net to veterans. This study examined changes in characteristics of veterans using the VHA health care system between 1996 and 1999 when VHA implemented major organizational changes to improve access of ambulatory care and to provide care to more veterans. METHODS: The study used two cross-sectional samples of the Medical Expenditures Panel Survey (MEPS), a national representative survey, in 1996 and 1999. The 1996 MEPS survey included 1,944 veterans and the 1999 MEPS survey included 1,974 veterans. There were 534 veterans and 740 veterans who used VHA services in 1996 and 1999, respectively. RESULTS: The proportion of veterans using the VHA system increased from 12.4% in 1996 to 14.6% in 1999. In both years, veterans were more likely to use VHA care if they were older, male, less educated, uninsured, unemployed, and in fair or poor health status. Only two variables, marital status and income, were different between the two years. Married veterans were more likely to use VHA care in 1999, but not in 1996. Veterans with higher incomes had greater odds of using VHA care in 1996, but there was no significant association between income and VHA use in 1999. CONCLUSION: Characteristics of VHA users did not fundamentally change despite the reorganization of VHA health care delivery system and changes in eligibility and enrollment policy. The VHA system maintains its safety net mission while attracting more veterans.

Journal Article↗

PubMed2005

An analysis of disenrollment from Medicare managed care plans by Medicare beneficiaries with diabetes.

RESEARCH OBJECTIVE: The purpose of this work is to determine whether high-cost high-risk Medicare patients with diabetes in managed care plans disenroll more quickly than lower-cost lower-risk Medicare patients with diabetes. If high-cost high-risk patients with diabetes do disenroll more quickly, Medicare managed care plans benefit financially from favorable disenrollment. STUDY DESIGN: Time in a health maintenance organization (HMO) was modeled using a duration model with the number of months in the HMO as the dependent variable, controlling for censoring. Data were drawn from a representative sample of Medicare patients with diabetes in the FFS sector in 1994. The panel was followed for 4 years, 1995-1998. The sample included all 6839 individuals who enrolled in a Medicare HMO for at least 1 month during the 48-month observation window. PRINCIPAL FINDINGS: We found a statistically significant negative association between the time in an HMO and pre-enrollment Part B expenditures (beta = -0.00001, t = -4.39) and any Part A expenditures (beta = -0.465, t = -1.98), and 2 of 4 diabetic complications (heart complications: beta = -0.0773, t = -4.61; vision complications beta = -0.2474, t = -1.94). Of the plan characteristics, only the drug benefit variable (beta = 0.151, t = 5.64) had a statistically significant coefficient. CONCLUSIONS: Overall, our results support the hypothesis that high-cost, high-risk individuals disenroll from Medicare HMOs sooner than lower-cost lower-risk individuals. However, this effect is mitigated by plans offering better prescription drug benefits. We did find some evidence that patients with diabetes with very high pre-enrollment Part A costs may remain longer in HMOs relative to patients with diabetes with lower Part A prior year expenditures.

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PubMed2005

The performance of administrative and self-reported measures for risk adjustment of Veterans Affairs expenditures.

OBJECTIVE: To evaluate the performance of different prospective risk adjustment models of outpatient, inpatient, and total expenditures of veterans who regularly use Veterans Affairs (VA) primary care. DATA SOURCES: We utilized administrative, survey and expenditure data on 14,449 VA patients enrolled in a randomized trial that gave providers regular patient health assessments. STUDY DESIGN: This cohort study compared five administrative data-based, two self-report risk adjusters, and base year expenditures in prospective models. DATA EXTRACTION METHODS: VA outpatient care and nonacute inpatient care expenditures were based on unit expenditures and utilization, while VA expenditures for acute inpatient care were calculated from a Medicare-based inpatient cost function. Risk adjusters for this sample were constructed from diagnosis, medication and self-report data collected during a clinical trial. Model performance was compared using adjusted R2 and predictive ratios. PRINCIPAL FINDINGS: In all expenditure models, administrative-based measures performed better than self-reported measures, which performed better than age and gender. The Diagnosis Cost Groups (DCG) model explained total expenditure variation (R2=7.2 percent) better than other models. Prior outpatient expenditures predicted outpatient expenditures best by far (R2=42 percent). Models with multiple measures improved overall prediction, reduced over-prediction of low expenditure quintiles, and reduced under-prediction in the highest quintile of expenditures. CONCLUSIONS: Prediction of VA total expenditures was poor because expenditure variation reflected utilization variation, but not patient severity. Base year expenditures were the best predictor of outpatient expenditures and nearly the best for total expenditures. Models that combined two or more risk adjusters predicted expenditures better than single-measure models, but are more difficult and expensive to apply.

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PubMed2005

Does improving geographic access to VA primary care services impact patients' patterns of utilization and costs?

The Department of Veterans Affairs (VA) has been establishing community-based outpatient clinics (CBOCs) across the country to improve veterans' access to and use of primary care services, thereby decreasing the need for costly specialty outpatient and inpatient care. Using a quasi-experimental, pre-post study design, we examined whether the establishment of CBOCs has affected access, use, and costs for VA patients residing in their catchment areas. Most patients residing in CBOC catchment areas did not receive care at CBOCs, resulting in only small increases in primary care utilization. While CBOCs improved veterans' access, they had little impact on overall patterns of utilization and cost.

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PubMed2005

Predicting costs of Veterans Affairs health care in Gulf War veterans with medically unexplained physical symptoms.

Measures of post-traumatic stress disorder (PTSD) and depression were used to predict Veterans Affairs outpatient treatment costs among Persian Gulf War veterans with medically unexplained physical symptoms. Patients (N = 206) enrolled in a Veterans Affairs primary care clinic for Persian Gulf War veterans completed study assessments at the initial appointment or at a proximal follow-up visit. Costs of care for mental health, medical, and pharmacy services for these veterans were computed for the subsequent 6-month period. Depression and PTSD symptoms explained a significant share of variance in costs of mental health care and pharmacy services, after adjustment for covariates. None of the mental status measures was significantly related to costs of medical care. Models using global measures of mental health status were as robust as models using disorder-specific measures of PTSD and depression in predicting mental health care and pharmacy costs. The implications of these findings for anticipating costs of care for Persian Gulf War veterans are discussed.

Adult↗

PubMed2004

Multiple prior years of health expenditures and Medicare health plan choice.

This study examines the effect of multiple prior years of health expenditures on the probability of enrollment in a Medicare HMO. Beneficiaries may require more than one year of prior expenditure data to form a reliable estimate of future expenditures if health expenditures have a significant transitory component. We used a logit model to estimate the influence of 1991-1993 Part A expenditures and demographic data on the choice of health plans in 1994. The results indicate that beneficiaries use multiple years of expenditures in their choice of health plan and the effect of prior spending declined with time.

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PubMed2004

Effectiveness of diabetic therapeutic footwear in preventing reulceration.

OBJECTIVE: To review the evidence for the effectiveness of therapeutic footwear in preventing foot reulceration in individuals with diabetes and foot risk factors. RESEARCH DESIGN AND METHODS: We conducted a structured literature review based on a Medline search for studies of therapeutic footwear that examined prevention of reulceration. Nine published articles were identified. Characteristics of the study population, components of the intervention, and level of adherence were evaluated. U.S. Preventive Services Task Force criteria for evaluating research were applied to rate each study on study design and internal validity. RESULTS: Risk ratios in all studies assessing the association between therapeutic footwear and reulceration were below 1.0, suggesting some protective footwear benefit. However, in the most rigorous experimental study, no statistically significant benefit was observed between control patients wearing their own footwear and intervention patients wearing study footwear. Annual reulceration in these studies' control groups ranged from 8.4 to 59.3%. In patients with severe foot deformity or prior toe or ray amputation, observational studies suggested a significant protective benefit from therapeutic footwear. CONCLUSIONS: Therapeutic footwear has been used for decades as one of many strategies to prevent reulceration in patients with diabetes and foot risk factors. The findings of several studies reporting statistically significant protective effects from therapeutic footwear may have been influenced by several design issues. When considering the appropriateness of therapeutic footwear recommendations for moderate-risk patients, clinicians and patients should jointly explore individual strategies to decrease events that lead to foot ulcers.

Diabetic Foot↗

PubMed2004

Diabetes-related utilization and costs for inpatient and outpatient services in the Veterans Administration.

OBJECTIVE: -The purpose of this study was to calculate the total number of inpatient hospitalizations, outpatient clinic visits, and total direct health care costs associated with veterans with diabetes receiving care in Veterans Administration (VA) facilities. RESEARCH DESIGN AND METHODS-The number of inpatient hospitalizations is tracked for years 1994-1998, and outpatient clinic visits are tracked for years 1997 and 1998. Trends in utilization across different age and racial groups, as well as total direct inpatient and outpatient costs for 1998, are presented. RESULTS: -Between 1994 and 1998, hospitalization rates decreased from 1.68 to 1.61. The average number of outpatient visits was 4.5 in 1997 and 4.6 in 1998. VA incurred $214.8 million in outpatient expenditures and $1.45 billion in inpatient expenditures for veterans with diabetes receiving VA care. CONCLUSIONS: -Health care delivery systems and payors track the cost and utilization of services by specific patient groups to support disease management, quality improvement, external reporting, and cost containment. Tracking the utilization and cost of diabetes care is necessary to understand the financial impact of diabetes on health care systems and the overall burden of diabetes on individuals.

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PubMed2002

Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial.

CONTEXT: Many people with diabetes experience lower-limb ulcers. Footwear has been implicated as a primary cause of foot ulcers, yet research is limited on the efficacy of shoe and insert combinations to prevent reulceration. OBJECTIVE: To determine whether extra-depth and -width therapeutic shoes used with 2 types of inserts reduce reulceration in diabetic individuals with a history of foot ulcer. DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial of 400 diabetes patients with history of foot ulcer in 2 Washington State health care organizations who did not require custom shoes for foot deformity and were enrolled between August 1997 and December 1998 and followed up for 2 years. Data collected at regular intervals documented physical, foot, and diabetes characteristics; footwear use; foot lesions; and ulcers. INTERVENTIONS: Participants were randomly assigned to receive 3 pairs of therapeutic shoes and 3 pairs of customized medium-density cork inserts with a neoprene closed-cell cover (n = 121); to receive 3 pairs of therapeutic shoes and 3 pairs of prefabricated, tapered polyurethane inserts with a brushed nylon cover (n = 119); or to wear their usual footwear (controls; n = 160). MAIN OUTCOME MEASURE: Foot reulceration, compared among the 3 groups. RESULTS: Two-year cumulative reulceration incidence across the 3 groups was low: 15% in the cork-insert group, 14% in the prefabricated-insert group, and 17% in controls. In the intent-to-treat analysis, patients assigned to therapeutic shoes did not have a significantly lower risk of reulceration compared with controls (risk ratio [RR] for the cork-insert group, 0.88; 95% confidence interval [CI], 0.51-1.52 and RR the for prefabricated-insert group, 0.85; 95% CI, 0.48-1.48). All ulcer episodes in patients assigned to therapeutic shoes and 88% wearing nonstudy shoes occurred in patients with foot insensitivity. CONCLUSIONS: This study of persons without severe foot deformity does not provide evidence to support widespread dispensing of therapeutic shoes and inserts to diabetic patients with a history of foot ulcer. Study shoes and custom cork or preformed polyurethane inserts conferred no significant ulcer reduction compared with control footwear. This study suggests that careful attention to foot care by health care professionals may be more important than therapeutic footwear but does not negate the possibility that special footwear is beneficial in persons with diabetes who do not receive such close attention to foot care by their health care providers or in individuals with severe foot deformities.

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PubMed2002

Common methodological terms in health services research and their synonyms [correction of symptoms].

OBJECTIVE: Health services researchers use methods and terminology from a variety of disciplines to understand individual and organizational behavior related to health, health care, and health insurance. Although this diversity benefits the process of research, the resulting differences in terminology can occasionally lead to confusion among even the most experienced researchers. The purpose of this paper is to clarify different methodological terms used to represent common study designs and statistical concepts in health services research. METHOD: Faculty from the departments of Health Services, Biostatistics and Epidemiology at the University of Washington were asked to provide a list of terms commonly used in health services research that had one or more methodological terms with the same or similar meaning. Consistent with the Delphi method, the initial list was then circulated to internal and external methodologists and additional terms were added for completeness. Terms related to study designs, equation specification, and estimation problems with synonymous terminology were included. RESULTS: A "methodological thesaurus" is developed and described in this paper. Many terms were found which described essentially identical concepts. In other cases, terms had slight but important differences in meaning across disciplines, leading to potential confusion in their use. CONCLUSION: In light of these differences in terminology, it is not surprising that health services researchers with a particular disciplinary orientation currently find literature within their own discipline entirely readable and literature from another discipline considerably less accessible. The "methodological thesaurus" presented in this paper should be of value to health services researchers who are interested in exploring the full array of methods developed to address a particular problem. Teachers and students of health services research should also find this article of use in relating similar concepts across disciplines in quantitative health services research publications.

Bias↗

PubMed2002

Evaluation of the Department of Veterans Affairs community-based outpatient clinics.

OBJECTIVE: This paper describes the history of the Department of Veterans Affairs (VA) Community-Based Outpatient Clinics (CBOCs), CBOC Performance Evaluation Project, and characteristics of CBOCs within the VA, and summarizes the findings and implications of the CBOC Performance Evaluation Project. SUBJECTS: There were 139 CBOCs in operation at the end of fiscal year 1998. Ninety-eight percent of CBOCs offered primary health care, and 28% offered primary health care and primary mental health care. The average CBOC was 70.7 miles from its parent VAMC. Sixty-one percent of the CBOCs were located in urban areas and 39% were in rural areas. Sixty-four percent of the CBOCs were VA-staff and 36% were contract. RESULTS: The details of the project's findings are reported in four companion papers that describe, respectively, health care access and utilization, cost of care, patient perceptions of care, and quality of care in VA CBOCs. For most measures, CBOC performance was equivalent to their parent VAMCs. However, there were a few areas of potential concern: CBOCs had fewer patients that reported having one provider or team in charge of care; CBOC patients had fewer specialty visits; and CBOCs served a smaller percent of women and black persons. CONCLUSION: CBOCs appear to be performing comparably to their parent medical centers but will benefit from ongoing monitoring.

Community Health Centers↗

PubMed2002

VA community-based outpatient clinics: access and utilization performance measures.

OBJECTIVES: The purpose of this study was to compare access and utilization performance measures between Community-Based Outpatient Clinics (CBOC) and primary care clinics at parent VA Medical Centers (VAMC) and between VA-staff CBOCs and contract CBOCs. METHODS: The study design was cross-sectional and retrospective. Performance measures were based on data routinely collected for administrative and research purposes by the VA. The sample included all primary care patients (n = 37,084) treated at the 38 CBOCs opened before 4/1/98 (30 VA-staff and 8 contract) and all primary care patients (n = 318,369) treated at the 32 parent VAMCs. Six months of service use data were used to derive the access and utilization performance measures. Multivariate regression analyses were used to control for observable casemix differences. RESULTS: CBOCs are attracting new high priority patients to the VA health care system. CBOC patients had more primary care encounters and fewer specialty encounters than patients in the primary care clinics of the parent VAMCs. VA-staffed CBOC patients had more primary care encounters and fewer specialty encounters than contract CBOC patients. CONCLUSIONS: CBOCs are helping the VA achieve its goals of attracting new patients and shifting the focus of care from the specialty to the primary care setting.

Community Health Centers↗

PubMed2002

VA community-based outpatient clinics: cost performance measures.

OBJECTIVE: To examine the direct costs of treating veterans in Community-Based Outpatient Clinics (CBOC) and primary care clinics operated by VA medical centers (VAMCs) between April 1998 and September 1998. RESEARCH DESIGN: In a retrospective observational study of patients in eighteen CBOCs and fourteen VAMCs, direct costs were compared. In addition, the costs of treating patients in new and established CBOCs were also examined. MEASURES: The three types of costs examined include direct cost per primary care visit, direct primary care cost per patient, and total direct cost per patient in ordinary least squares regressions with facility-specific random effects. Indirect costs for overhead and administration were excluded. All cost comparisons controlled for patient characteristics and case-mix differences via the Diagnostic Cost Group methodology. RESULTS: Results indicate that CBOC patients and VAMC patients had similar direct primary care costs on a per visit and per patient basis. Total direct costs for CBOC patients were lower compared with VAMC patients, because of lower specialty and ancillary care costs. Patients in new CBOCs had similar primary, specialty, ancillary and inpatient care costs when compared with patients in established CBOCs. CONCLUSION: Lower total costs for CBOC patients may be a consequence of substituting primary care at CBOCs for expensive specialty and ancillary care at VAMCs. CBOCs may be an alternative approach to providing care to veterans at a lower cost than traditional delivery models based in VA Medical Centers.

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