Biomedical subjects

Rajesh Balkrishnan

Publications and source records attributed to Rajesh Balkrishnan.

107 records · Page 6Linked to original sources

PubMed2002

Capitation payment, length of visit, and preventive services: evidence from a national sample of outpatient physicians.

OBJECTIVE: To test the hypothesis that capitation payment to physicians reduces the length of physician-patient encounters but increases use of preventive and health counseling services. STUDY DESIGN: Cross-sectional analysis of data from the National Ambulatory Medical Care Survey of outpatient physicians and their office staff (1997 and 1998). PATIENTS AND METHODS: A random national sample of 46,320 ambulatory care visits was used. Weight-adjusted multivariate regression techniques were utilized to examine the effects of capitation on duration of physician visit and number of preventive and health counseling services. RESULTS: Physicians spent 5.6% less time (P < .01) with patients in capitated plans than with those in noncapitated plans. The effect of payment method on length of visit was 3.5 times stronger among physicians receiving only capitated payment, compared with physicians receiving only noncapitated payment. Patients in capitated plans were 17% more likely to receive health counseling services (P < .01) than patients in noncapitated plans. Patients under capitation were 3% more likely to receive preventive services compared to patients in non-health maintenance organizations, noncapitated plans (P < .05). CONCLUSIONS: Capitation is associated with a modest decrease in the amount of time physicians spend with their patients and with increased receipt of preventive and health counseling services, on average. These trends are driven by physicians who receive capitated payment predominantly. Physicians with a mix of patients from capitated and noncapitated plans spend approximately equal time with each type of patient, which reflects an ethic of impartiality in medical judgment.

Aged↗

PubMed2002

Cost impact of botulinum toxin use in Medicaid-enrolled children with cerebral palsy.

The use of botulinum toxin type A (BTX) in the management of spasticity in childhood cerebral palsy (CP) is increasing. This study examined annual health care service utilization and costs associated with BTX therapy for spastic CP in Medicaid-enrolled children receiving complete health care coverage (1997 to 1999). We used pair matching as well as recent statistical technique improvements (bootstrap method) to work with limited samples. The introduction of BTX was associated with an increase of approximately $62 per month in prescription costs for the patient. However, these costs were made up by reductions in hospitalization. When each year was examined individually, reimbursements for BTX users were not different from those for pair-matched non-BTX users. These data suggest that BTX therapy does not significantly add to the costs of treating Medicaid-enrolled children with CP.

Adolescent↗

PubMedDate not supplied

The frequent use of oral retinoids in combination with other treatments for psoriasis: a retrospective analysis.

BACKGROUND: Combination treatment in psoriasis may be common, logical, and appropriate, even if not well tested or well documented by clinical trials. While oral retinoids such as acitretin can be used as monotherapy, efficacy can be further augmented by combination use with other agents. Similarly, because of its safety profile, acitretin can be added in low doses to help patients who have not achieved adequate control with other psoriasis treatments. OBJECTIVE: The purpose of this study was to assess how oral retinoids are used in combination with other drugs to treat psoriasis. METHODS: We assessed the use of acitretin and other oral retinoids for the treatment of psoriasis using two sources of information: nationally representative survey data from the National Ambulatory Medical Care Survey (NAMCS) and local data obtained by chart review of 518 patients seen in a university dermatology clinic. RESULTS: In the NAMCS, oral retinoids were prescribed with other psoriasis medications at 71% of visits. In the chart review, combination use was even more frequent (96% of subjects were on combination treatment) and included combinations of acitretin with topicals, phototherapy, and other systemic treatments. Adverse events were reported in 53% of patients treated with acitretin, although none were severe. CONCLUSION: Use of acitretin in combination with many other psoriasis treatments is a common practice. Mucocutaneous side effects of oral retinoids are common but with appropriate dosing are generally mild.

Acitretin↗

PubMedDate not supplied

The family impact of atopic dermatitis in children: the role of the parent caregiver.

Although some preliminary work exists examining the impact of atopic dermatitis (AD) in children on their families, there is no empirical work examining specific parent caregiver factors that could contribute to the family impact of this condition. We conducted a cross-sectional, exploratory analysis of how parent caregivers are affected by their child's AD, and how certain parent caregiver characteristics and perceptions affect the family impact of this condition. Parent caregivers of children with AD (n = 49) were administered a survey to collect detailed data on socioeconomic status, health perceptions, and caregiving issues. Family impact of the child's AD was measured using a modified AD Family Impact Scale. Multiple regression analyses revealed that three major factors associated with the parent caregiver were correlated with large increases in the family impact scores: 1) perception that the child's condition is severe (13%, p < 0.01), 2) high use of nonmedical services for child's condition (21%, p < 0.01), and 3) financial concern about the child's condition (18%, p < 0.01). These preliminary data indicate distinct characteristics of the parent caregiver that are associated with higher family impact of AD in children. These parent caregiver factors may be important in identifying suitable audiences and areas for education for optimal management of children's AD.

Adult↗

PubMedDate not supplied

Effects of an episode of specialist care on the impact of childhood atopic dermatitis on the child's family.

INTRODUCTION: Although some preliminary work has examined the impact of atopic dermatitis (AD) on families, no empirical work has examined changes in the impact on families dealing with AD over time. An exploratory analysis of change in impact on families dealing with AD before and after an episode of medical care in a physician office setting was conducted. METHOD: Baseline and follow-up surveys were completed by 35 parent caregivers before and 1 month after a dermatologist visit for the child at an academic medical center. RESULTS: In the postcare survey, there was a 43% reduction in the Dermatitis Family Impact Questionnaire (DFI) scores (P <.01) compared with baseline. Significant differences were also observed in other parent caregiver-reported characteristics. The significant change in parent caregiver characteristic associated with the decreased DFI score was the increased satisfaction with the medical care related to the child's treatment (P <.01). DISCUSSION: These data reveal that there is a strong decrease in impact on a family associated with an episode of specialist care for children with AD. The importance of pediatric health care professionals in decreasing the impact of AD on families needs further exploration.

Absenteeism↗

PubMedDate not supplied

Stress and adaptation in mothers of children with cerebral palsy.

OBJECTIVE: To assess the importance of disability severity and child functional status as predictors of maternal depressive symptoms and the moderating effects of maternal appraisal, social support, and family income on the relationship between disability factors (severity and functional status) and maternal depressive symptoms. METHOD: Mothers of 270 children with cerebral palsy completed surveys on their appraisal of the child's disability, social support, and family demographics. Physicians assessed the severity of the disability and the child's functional status. RESULTS: Thirty percent of the mothers had depressive symptoms above the cutoff on a depression screening instrument. Disability severity and child's functional status did not predict maternal depression. Perceived social support moderated the relationship between the child's functional status and maternal depressive symptoms. CONCLUSIONS: Mothers of children with cerebral palsy may be at risk for depression. Interventions that take into account the moderating effects of social support may increase maternal adaptation.

Adaptation, Psychological↗

PubMedDate not supplied

The burden of atopic dermatitis: impact on the patient, family, and society.

Atopic dermatitis is a common disease of increasing prevalence. Affected individuals must cope with a significant psychosocial burden, in addition to dealing with the medical aspects of the disease. Furthermore, because this is primarily a disease of childhood, family members, especially parents, are also affected by the condition. Individuals and family members are burdened with time-consuming treatment regimens for the disease, as well as dietary and household changes. The financial impact of atopic dermatitis on families can also be great. Moreover, the cost to society is significant, with estimates ranging from less than 100 dollars to more than 2000 dollars per patient per year. It is estimated that the direct cost of atopic dermatitis in the United States alone is almost 1 billion dollars per year. Reducing the onus of this disease must take into account the full breadth of its burden. Targeting parents and caregivers with education and psychosocial support can decrease family and personal burden, which in turn may decrease the cost of treating the condition because of better medical, psychosocial, and family outcomes.

Cost of Illness↗

PubMedDate not supplied

Healthcare utilization for acute and chronic diseases of young, school-age children in the rural and non-rural setting.

To determine the most frequently diagnosed conditions among rural and non-rural children age 5 to 9 and assess for environmental influences, data from the National Ambulatory Medical Care Survey (1996-2001) were used to examine frequencies of diagnoses in children age 5 to 9. Separately, we examined rural and non-rural outpatient physician visits in weighted multivariate logistic regression models. Overall, the most frequent diagnosis was routine health check, followed by several acute conditions. When analyzed separately, non-rural children were significantly more likely to visit a physician for routine health check (P = 0.002), asthma (P = 0.005), and acute upper respiratory infection (P = 0.037). Rural counterparts were significantly more likely to be seen for attention deficit disorder (P = 0.000), otitis media (P = 0.017), chronic rhinitis (P = 0.017) and influenza (P = 0.037). Children age 5 to 9 are healthy overall. When illness occurs, it is usually acute. Rural and non-rural, young, school-aged children exhibit many similarities in healthcare utilization, but differences occur. Most surprising is the difference in the diagnosis frequency of attention deficit disorder.

Acute Disease↗

PubMedDate not supplied

How disclosing HMO physician incentives affects trust.

Opinions are deeply divided over whether rewarding physicians for lowering costs decreases trust in physicians or insurers. To explore the effects of disclosing physician payment methods in HMOs, members of two similar HMO plans were randomized to intervention and control groups, and the experimental arm was told how the HMO paid their primary care physician. Separate disclosures were developed for each plan, one describing primarily capitation payment, and the other (mixed-incentive plan) describing fee-for-service payment with a bonus that rewards cost savings, satisfaction, and preventive services. The disclosures pointed out more of the positive than the negative features of these incentives. We found that the disclosures doubled the number of subjects with substantial knowledge of the physician incentives and halved the number with no knowledge. Nevertheless, the disclosures had no negative effects on trust of either physicians or insurers. The capitated plan disclosure had a small positive effect on trust of physicians. Disclosing the positive and negative features of incentives and increasing knowledge of these incentives does not, in the short term, reduce trust in physicians or insurers and may have a mild positive impact on physician trust, perhaps as a consequence of displaying candor and increasing understanding of positive features.

Adult↗

PubMedDate not supplied

Parent caregiver-related predictors of health care service utilization by children with cerebral palsy enrolled in Medicaid.

INTRODUCTION: This study examined the associations between characteristics of the parent caregiver and health care service utilization by children with cerebral palsy enrolled in Medicaid. METHODS: A questionnaire was administered to the parents of children with cerebral palsy being treated in a North Carolina hospital, and the responses were linked with health services claims data from Medicaid. Data were available for 93 patients who maintained 1 year of continuous enrollment. The impact of selected demographic variables (race, years the child had the condition, employment, transportation) and behavioral variables (belief the child was receiving appropriate care, willingness to use home nursing and respite services, self-assessment of the severity of the child's condition, and use of orthopedic aids) on the frequency and costs of health care services was explored with use of multiple regression analysis. RESULTS: Parents who were willing to use home nursing and respite services were more likely to utilize these services, as well as inpatient facilities and orthopedic care, for their children (P <.05). However, parents who perceived that their child was receiving adequate care were less likely to utilize orthopedic care and home nursing for their children (P <.05). DISCUSSION: The belief of the parents in the adequacy of care received by their child, as well as their willingness to utilize supplemental health care services, were major predictors of health care service utilization by children with cerebral palsy enrolled in Medicaid. Parents who believed that their children receive enough care may need to be targeted for care management and disease management programs to ensure the continuum of treatment and care for these children.

Adolescent↗

PubMedDate not supplied

Patient-centered outcomes of diabetes self-care. Associations with satisfaction and general health in a community clinic setting.

BACKGROUND: Despite the recognition of strategies for diabetes care management, information systems that screen patient diabetes self-care problems are not commonplace, especially among low-income patients. This study examined correlates of three patient-centered outcomes of diabetes self-care (awareness of self-care components, difficulties in diabetes self-care, and adherence to self-care) among low-income diabetic patients. METHODS: Clinical and patient survey data were obtained on 249 participants from 11 primary care community health clinics serving low-income populations in North Carolina in Project IDEAL (Improving Diabetes Education, Access to Care and Living). Measures of patient-centered outcomes of self-care were obtained from the Diabetes Quality Improvement Project (DQIP) Patient-Reported Measures set. RESULTS: A substantial proportion of patients reported difficulty achieving standard self-care treatment goals. The study identified distinct patient characteristics associated with poor self-care outcomes. Increased understanding of self-care components and adherence to them were associated with increased perception of quality of care and, in turn, better general health perceptions in these patients (p < 0.01). CONCLUSIONS: This study identified an unmet need for diabetes self-care knowledge and skills associated with patient outcomes in low-income patients. Routine monitoring of patient-centered self-care outcomes could help improve long-term outcomes of diabetes care in this population.

Community Health Services↗

PubMedDate not supplied

Effect of language immersion on communication with Latino patients.

BACKGROUND: In the US, the fastest growing segment of the general pediatric population is Latino children. Language barriers may impede optimal care for these patients. Programs are needed to enhance communication effectiveness with Latino patients. We examined the effect of language immersion training for pediatric faculty on their communication with Latino patients. METHODS: Five general pediatric faculty physicians were sent to Guatemala for a two-week language immersion course and then had monthly one-hour Spanish language meetings for one year. Before and after immersion, six, and twelve months later, their Spanish skills were assessed. Before and after faculty training, Latino parents of pediatric patients were surveyed to assess their trust in and communication with the attending pediatricians. Spanish survey instruments were pilot tested and revised (trust scale alpha = 0.79; communication scale alpha = 0.80). RESULTS: Language proficiency increased for all the faculty participants, from a baseline score of 28% to a post-intervention score of 55%, p < 0.001. This increase in proficiency was sustained six and twelve months after the intervention. General linear modeling with repeated measures was used to examine associations between physician, parent, and clinic variables and the doctor-patient communication and patient trust scores. Even though baseline communication and trust scores were high, both improved after the intervention, p < 0.01. CONCLUSION: A two-week faculty language-training program can improve physician' language skills, communication, and trust between non-Latino doctor and Latino patient. Other measures of cultural competence should be measured and cost-benefit analyses conducted to assess the impact of immersion versus classroom experience.

Adult↗

PubMedDate not supplied

Medication and health care service utilization related to depressive symptoms in older adults with psoriasis.

OBJECTIVE: This study examined the relationship between depressive symptoms and related medication adherence and health care costs in older adults (age > or = 65 years) with psoriasis. DESIGN: Prospective longitudinal cohort study over a 2-year post enrollment period in a population of older adults with psoriasis enrolled in managed care. SETTING: A Medicare Health Maintenance Organization (HMO) in southeastern United States with prescription benefits. PARTICIPANTS: Sixty-three older adults with psoriasis using topical corticosteroids therapy and enrolled in a Medicare HMO for a 2-year continuous period. MEASUREMENT: Upon enrollment, each enrollee was mailed a comprehensive health status assessment battery, which included the Center for Epidemiologic Studies Depression (CES-D) scale. Information on medication adherence (using medication possession ratio) and total health care utilization/costs following enrollment were retrieved from the Medicare HMO database. RESULTS: Nearly one-fifth of the patient population had depressive symptoms. Patients with psoriasis who had depressive symptoms at the time of enrollment were less likely to be adherent to topical corticosteroid medication (r= -0.29, p<0.01) and less likely to utilize health care resources as evidenced by lower health care costs (r= -0.27, p<0.05), after confounder adjustment. CONCLUSIONS: The prevalence of depressive symptoms in older adults with psoriasis is commonplace, with strong, yet unexplained correlations between presence of depressive symptoms and lower rates of medication and health care service use among these patients.

Aged↗

PubMedDate not supplied

Prescribing patterns for topical retinoids within NAMCS data.

OBJECTIVE: Fears of potentially costly use of topical retinoids for cosmetic treatment of photodamaged skin have resulted in many managed care organizations placing prior authorization requirements on this class of medications. The purpose of this investigation was to examine whether prescribing patterns of a nationally representative sample of US physicians shed light on the incidence of use of topical retinoids for indications other than acne. METHODS: A retrospective, cross-sectional study of data from the National Ambulatory Medical Care Survey (1996--2000) was used to examine the impact of physician specialty as well as patient diagnosis of acne on the probability of retinoid prescription in weighted multivariate logistic regression models. RESULTS: Topical retinoids were prescribed in 0.4% (14.7 million out of 3.67 billion) physician visits for any diagnosis in the 5-year period from 1996 to 2000, and in nearly 31% (12.0 million out of 38.7 million) of physician visits for a diagnosis of acne. Topical retinoids were prescribed for acne in 77.1% of the cases. This finding held when individual retinoids (tretinoin and adapalene) were examined separately. Clear age-related prescription trends are observed, with a significant decrease in prescriptions beyond the teen years. In older patients, tretinoin prescribing did not decrease as much as adapalene prescribing. CONCLUSIONS: These data suggest that managed care organizations may want to examine their own data to determine the optimum criteria for operation of prior authorization (PA) programs for retinoids. PA requirements for these medications appear unnecessary in young patients, given the very small probability of non-acne related use. PA in older patients might be targeted to those patients on topical retinoids (such as tretinoin) for which there is evidence of efficacy in treatment of cosmetic photoaging.

Acne Vulgaris↗

PubMedDate not supplied

Inpatient management of severe psoriasis.

Historically, severe psoriasis frequently required inpatient hospitalization for several weeks to reduce symptoms and prevent morbidity and mortality, Despite declining hospitalization rates there remain patients who undergo severe, acute psoriasis exacerbations requiring inpatient care. The majority of the literature describes the treatment of psoriasis in the outpatient setting. We review the inherent differences between the inpatient and outpatient management of psoriasis along several dimensions and discuss an approach to the inpatient treatment of severe psoriasis based upon therapeutic rate of onset, efficacy, and safety. The inpatient setting benefits from and lends itself to use of rapid acting, highly effective agents. Given the acute nature of psoriasis inpatient episodes, the risks associated with long-term use of a treatment are far less important in inpatient setting treatment planning than they are in the outpatient setting.

Biological Therapy↗

PubMedDate not supplied

Factors affecting prescription of ultra-high potency topical corticosteroids in skin disease: an analysis of US national practice data.

Of the topical preparations available, the ultra-high potency corticosteroids have an important role in treating psoriasis. However, the use of these agents in many other conditions and patient populations may not be appropriate. This study examines the prescribing patterns of Class I topical corticosteroids in patients with skin disease by analyzing data from the National Ambulatory Medical Care Survey (1990-2000). Of the nearly 718 million visits for skin disease, Class I topical corticosteroids were prescribed in nearly 3% of all skin disease-related visits, with prescription rates being highest in psoriasis (22%). The study found greater prescription rates of Class I topical steroids by dermatologists compared to non-dermatologists [Odds Ratio (OR) = 4.39 (95% CI: 2.15, 8.99)]. However, there were also a large number of questionable prescriptions for other conditions, which could be construed as misuse of these medications. Despite limitations and the potential dubious use seen here, Class I topical corticosteroid use is relatively commonplace. Education efforts and novel preparations of Class I agents will help to ensure the best possible care for patients suffering from significant skin diseases like psoriasis.

Administration, Cutaneous↗

PubMedDate not supplied

Cumulative irritation potential of metronidazole gel compared to azelaic acid gel after repeated applications to healthy skin.

BACKGROUND: Metronidazole 0.75% gel and azelaic acid 15% gel are commonly used to treat rosacea. Irritation is a common side effect. OBJECTIVE: To assess the cumulative irritation potential of metronidazole 0.75% gel and azelaic acid 15% gel. METHODS: Metronidazole 0.75% gel, azelaic acid 15% gel, and a white petrolatum negative control were applied under occlusive conditions to the upper back of a total of 33 healthy subjects. There were twelve 24-hour applications (4 times a week) and three 72-hour applications on weekends during a 3-week period. Skin reactions (erythema score +/- other local reaction) were assessed within 15 to 30 minutes of removal of the products. RESULTS: The mean cumulative irritancy index of metronidazole 0.75% gel was significantly lower than that of azelaic acid 15% gel and not significantly higher than the negative control product. There was increasing cumulative irritancy with azelaic acid; no cumulative irritancy was seen for either metronidazole or white petrolatum. CONCLUSION: Metronidazole 0.75% gel is less irritating in sustained use than azelaic acid 15% gel.

Administration, Cutaneous↗