PubMed Health⌕ Search

Biomedical subjects

Rodney A Hayward

Publications and source records attributed to Rodney A Hayward.

At least 37 records · Page 2Linked to original sources
PubMed2004

Profiling quality of care: Is there a role for peer review?

BACKGROUND: We sought to develop a more reliable structured implicit chart review instrument for use in assessing the quality of care for chronic disease and to examine if ratings are more reliable for conditions in which the evidence base for practice is more developed. METHODS: We conducted a reliability study in a cohort with patient records including both outpatient and inpatient care as the objects of measurement. We developed a structured implicit review instrument to assess the quality of care over one year of treatment. 12 reviewers conducted a total of 496 reviews of 70 patient records selected from 26 VA clinical sites in two regions of the country. Each patient had between one and four conditions specified as having a highly developed evidence base (diabetes and hypertension) or a less developed evidence base (chronic obstructive pulmonary disease or a collection of acute conditions). Multilevel analysis that accounts for the nested and cross-classified structure of the data was used to estimate the signal and noise components of the measurement of quality and the reliability of implicit review. RESULTS: For COPD and a collection of acute conditions the reliability of a single physician review was quite low (intra-class correlation = 0.16-0.26) but comparable to most previously published estimates for the use of this method in inpatient settings. However, for diabetes and hypertension the reliability is significantly higher at 0.46. The higher reliability is a result of the reviewers collectively being able to distinguish more differences in the quality of care between patients (p < 0.007) and not due to less random noise or individual reviewer bias in the measurement. For these conditions the level of true quality (i.e. the rating of quality of care that would result from the full population of physician reviewers reviewing a record) varied from poor to good across patients. CONCLUSIONS: For conditions with a well-developed quality of care evidence base, such as hypertension and diabetes, a single structured implicit review to assess the quality of care over a period of time is moderately reliable. This method could be a reasonable complement or alternative to explicit indicator approaches for assessing and comparing quality of care. Structured implicit review, like explicit quality measures, must be used more cautiously for illnesses for which the evidence base is less well developed, such as COPD and acute, short-course illnesses.

Acute Disease↗
PubMed2004

Pharmacologic lipid-lowering therapy in type 2 diabetes mellitus: background paper for the American College of Physicians.

BACKGROUND: Cardiovascular disease is the primary complication and cause of death in patients with type 2 diabetes mellitus. Modification of cardiovascular risk factors may improve patient outcomes. PURPOSE: To evaluate the effectiveness of pharmacologic lipid-lowering therapy on outcomes in type 2 diabetes mellitus. DATA SOURCES: Review of the literature. STUDY SELECTION: Randomized trials evaluating clinical outcomes of lipid-lowering treatment in patients with diabetes. DATA EXTRACTION: Studies were identified by searching the Cochrane Library, MEDLINE, meta-analyses, review articles, and inquiries to experts. The Cochrane Library and MEDLINE searches were done in September 2002. Data were abstracted onto standardized forms by a single reviewer and were confirmed by a second reviewer. DATA SYNTHESIS: Meta-analysis of 6 primary prevention studies showed that lipid-lowering medications reduced risks for cardiovascular outcomes (relative risk, 0.78 [95% CI, 0.67 to 0.89]; absolute risk reduction, 0.03 [CI, 0.01 to 0.04] in 4.3 years of treatment); 1 major cardiovascular event was prevented by treating 34 to 35 patients. Meta-analysis of 8 studies of secondary prevention showed a similar relative risk (0.76 [CI, 0.59 to 0.93]) but more than twice the absolute risk reduction (0.07 [CI, 0.03 to 0.12] in 4.9 years of treatment) and a number needed to treat for benefit of 13 to 14. Most studies compared a lipid-lowering drug with placebo but did not evaluate the effect of reaching specific cholesterol levels. The benefit of lipid lowering with a fixed dose of a statin appeared to be similar regardless of starting cholesterol levels. LIMITATIONS: Target cholesterol levels and the effectiveness of dose titration (or the use of multiple agents) have not been rigorously examined. CONCLUSIONS: In patients with type 2 diabetes, treatment with lipid-lowering agents reduces cardiovascular risk. Most patients, including those whose baseline low-density lipoprotein cholesterol levels are below 2.97 mmol/L (<115 mg/dL), and possibly below 2.59 mmol/L (<100 mg/dL), benefit from statins. Moderate doses of these drugs suffice in most patients with diabetes.

Anticholesteremic Agents↗
PubMed2004

When there is too much to do: how practicing physicians prioritize among recommended interventions.

BACKGROUND: Recent evidence suggests that patients are receiving only 50% of recommended processes of care. It is important to understand physician priorities among recommended interventions and how these priorities are influenced both intentionally as well as unintentionally. METHODS: A survey was mailed to all primary care physicians (PCPs) from two VA hospital networks (N= 289), one of which had participated in a broad, evidence-based guideline development effort 8 to 12 months earlier, and all endocrinologists nationwide in the VA (N= 213); response rate, 63% (n= 315). Using the method of paired comparisons, we assessed physician priorities among 11 clinical triggers for interventions in the management of an uncomplicated patient with type 2 diabetes. RESULTS: Both PCPs and specialists consistently identified several high-impact clinical triggers for treatment as the highest priority interventions (hemoglobin A1c = 9.5%, diastolic blood pressure [DBP]= 95 mm Hg, low-density lipoprotein = 145 mg/dl). Several low-impact interventions that are commonly used as performance measures also received relatively high ratings. Treatments that have recently been found to be highly beneficial were often rated as being of low importance (e.g., treating when DBP = 88 mm Hg). Almost 80% of PCPs rated tight glycemic control as more important than tight DBP control, in direct contrast to clinical trial evidence. Specialists' ratings followed the same general pattern, but were more consistent with the epidemiological evidence. The PCPs at the sites that participated in the guideline intervention rated blood pressure control significantly higher. CONCLUSION: Although several high-priority aspects of diabetes care were clearly identified, there were also notable examples of ratings that were clearly inconsistent with the epidemiological literature. Recommendations based upon more recent evidence were substantially underrated and some guidelines used as performance measures were relatively overrated. These results support the arguments that a more proactive approach is needed to facilitate rapid dissemination of new high-priority findings, and that intervention priority, and not just ease of measurement, should be considered carefully when disseminating guidelines and when selecting performance measures.

Attitude of Health Personnel↗
PubMed2004

Tissue plasminogen activator was cost-effective compared to streptokinase in only selected patients with acute myocardial infarction.

OBJECTIVE: We sought to explore the patient-specific cost-effectiveness in a community-based sample for a therapy for which the average cost-effectiveness in a clinical trial has been well-described. STUDY DESIGN AND SETTING: Based on a validated multivariate model, we generated predictions of the effectiveness and cost-effectiveness of t-PA compared to streptokinase on 921 consecutive patients who received thrombolytic therapy for acute myocardial infarction. RESULTS: The average cost-effectiveness of t-PA was US dollar 40,140 per life-year saved. For the quartile of patients most likely to benefit, the incremental cost-effectiveness of t-PA was US dollar 15,396. However, only 44% of patients who received thrombolytic therapy had an estimated cost-effectiveness ratio below US dollar 50,000 per year of life saved; the ratio was greater than US dollar 100,000 in 37% of treated patients. Patients in the lowest quartile of expected benefit are, overall, more likely to be harmed than to benefit from t-PA. CONCLUSION: Compared to the pattern of thrombolytic agent choice observed, targeting t-PA to the half of patients most likely to benefit could save 247 lives and US dollar 174 million nationally per year.

Aged↗
PubMed2004

The impact of diabetes on workforce participation: results from a national household sample.

OBJECTIVE: Diabetes is a highly prevalent condition that results in substantial morbidity and premature mortality. We investigated how diabetes-associated mortality, disability, early retirement, and work absenteeism impacts workforce participation. DATA SOURCE: We used the Health and Retirement Study (HRS), a national household sample of adults aged 51-61 in 1992, as a data source. STUDY DESIGN: We conducted cross-sectional analyses on the baseline HRS data, and longitudinal analyses using data from eight years of follow-up. We used two-part regression models to estimate the adjusted impact of diabetes on workforce participation, and then estimated the economic impact of diabetes-related losses in productivity. PRINCIPAL FINDINGS: Diabetes is a significant predictor of lost productivity. The incremental lost income due to diabetes by 1992 was 60.0 billion US dollars over an average diabetes duration of 9.7 years. From 1992 to 2000, diabetes was responsible for 4.4 billion US dollars in lost income due to early retirement, 0.5 billion US dollars due to increased sick days, 31.7 billion US dollars due to disability, and 22.0 US dollars billion in lost income due to premature mortality, for a total of 58.6 billion dollars in lost productivity, or 7.3 billion US dollars per year. CONCLUSIONS: In the U.S. population of adults born between 1931 and 1941, diabetes is associated with a profound negative impact on economic productivity. By 1992, an estimated 60 billion US dollars in lost productivity was associated with diabetes; additional annual losses averaged 7.3 billion US dollars over the next eight years, totaling about 120 billion US dollars by the year 2000. Given the rising prevalence of diabetes, these costs are likely to increase substantially unless countered by better public health or medical interventions.

Chronic Disease↗
PubMed2004

Physical activity and mortality across cardiovascular disease risk groups.

PURPOSE: Several cohort studies suggest that sedentary individuals have an increased risk of death compared with individuals who are physically active. Most of these studies have been conducted in highly selected patient populations who tend to be healthier and are from higher socioeconomic status (SES) groups. We examined the impact of a sedentary lifestyle on mortality by cardiovascular disease (CVD) risk group in a national sample of U.S. adults who represent a wide range of activity levels, health conditions, and SES groups. METHODS: Using data from the HRS, a nationally representative, observational study of 9824 U.S. adults aged 51-61 yr in 1992, we estimated the relative risk of death comparing sedentary individuals with those who are physically active by CVD risk group in a multivariate logistic regression model. RESULTS: Even after adjusting for confounders, regular moderate to vigorous physical activity was associated with substantially lower overall mortality (odds ratio (OR) = 0.62 (95% CI 0.44-0.86)) compared with sedentary individuals. High CVD risk individuals (21% of the population) accounted for 64% of deaths attributable to a sedentary lifestyle. Those with high CVD risk had the most significant benefit from being active (regular moderate to vigorous exercisers OR = 0.55 (95% CI 0.31-0.97) and occasional or light exercisers OR 0.55 (95% CI 0.41-0.74)) compared with high CVD risk individuals who were sedentary. CONCLUSION: A sedentary lifestyle is associated with a higher risk of death in preretirement-aged U.S. adults. Individuals with high CVD risk appear to get the largest benefit from being physically active. Physical activity interventions targeting high CVD risk individuals should be a medical and public health priority.

Cardiovascular Diseases↗
PubMed2004

Quality improvement initiatives: issues in moving from diabetes guidelines to policy.

OBJECTIVE: To outline the principles that direct the Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) dedicated to diabetes quality improvement (QUERI-DM). RESEARCH DESIGN AND METHODS: We discuss the VA initiatives aimed at improving diabetes care for veterans as well as general issues that should be considered in quality improvement initiatives. We specifically describe some of the epidemiological, statistical, and organizational issues that have guided our quality improvement (QI) programs. RESULTS: The five principles that have guided the QUERI-DM process are: 1) treating clinical guidelines and goals distinct from quality standards and quality improvement priorities; 2) targeting high-risk patients and high-impact quality issues; 3) profiling processes over outcomes; 4) targeting processes that will improve patient outcomes; and 5) paying attention to the loci of practice variation. CONCLUSIONS: The authors recommend that all five principles be considered when moving from practice guidelines to performance measures and QI initiatives. Targeting high-priority problems and high-risk groups can greatly improve the effectiveness and efficiency of QI interventions.

Diabetes Mellitus↗
PubMed2003

Accepting critically ill transfer patients: adverse effect on a referral center's outcome and benchmark measures.

BACKGROUND: Common methods of benchmarking clinical performance rarely, if ever, account for admission source and, in particular, the effect of a patient being transferred from one medical center to another. Small biases in comparisons of observed versus expected deaths can substantially affect how high-quality institutions compare with peer hospitals. With the most sophisticated and validated set of case-mix measures available for patients, the intensive care unit is an ideal setting in which to study the effect of a patient's being transferred from another hospital. OBJECTIVE: To determine the extent of bias in benchmarking outcomes when performance measures do not account for transfer patients' greater severity of illness. DESIGN: Prospectively developed cohort study. SETTING: Medical intensive care unit (MICU) at a tertiary care university hospital. PATIENTS: 4579 consecutive admissions for 4208 patients from 1 January 1994 to 1 April 1998. MEASUREMENTS: MICU and hospital lengths of stay, MICU readmission, and hospital mortality rates. RESULTS: Compared with directly admitted patients, MICU patients transferred from another hospital had significantly higher Acute Physiology Scores at the time of admission and discharge (P = 0.001). Even after full adjustment for case mix and severity of illness, transfer patients had a 38% longer MICU stay (95% CI, 32% to 45%), a 41% longer hospital stay (CI, 34% to 50%), and a 2.2 times greater odds of hospital mortality (CI, 1.7 to 2.8) than directly admitted patients. With identical efficiency and quality, a referral hospital with a 25% MICU transfer rate compared with another with a 0% transfer rate would be penalized by 14 excess deaths per 1000 admissions when a benchmarking program adjusts only for case mix and severity of illness and not for the source of admission. CONCLUSIONS: In a setting with the most thorough diagnostic-based, case-mix adjustment and the most physiologically precise severity-of-illness information, accepting transfer patients can adversely affect efficiency and quality benchmarks. Benchmarking and profiling efforts beyond intensive care units must also recognize and account for this phenomenon; otherwise, referral centers may have an incentive to refuse care for patients who could benefit from being transferred to their facility.

APACHE↗
PubMed2003

Treatment of hypertension in type 2 diabetes mellitus: blood pressure goals, choice of agents, and setting priorities in diabetes care.

BACKGROUND: Hypertension in patients with type 2 diabetes mellitus is a prevalent condition that leads to substantial morbidity and mortality. PURPOSE: To evaluate the goals and optimal agents for treatment of hypertension in type 2 diabetes. DATA SOURCES: Review of the medical literature STUDY SELECTION: Randomized trials that evaluated the pharmacologic treatment of hypertension in patients with diabetes and reported microvascular and macrovascular outcomes. DATA EXTRACTION: Studies were identified by using the Cochrane Library, MEDLINE, meta-analyses, review articles, and expert recommendation. The searches of the Cochrane Library and MEDLINE were performed in May 2000 and updated in April 2002. Data were abstracted to standardized forms by a single reviewer and were confirmed by a second reviewer. DATA SYNTHESIS: Treatment of hypertension in type 2 diabetes provides dramatic benefit. Target diastolic blood pressures of less than 80 mm Hg appear optimal; systolic targets have not been as rigorously evaluated, but targets of 135 mm Hg or less are reasonable. Studies that compare drug classes do not suggest obviously superior agents. However, it is reasonable to conclude that thiazide diuretics, angiotensin-II receptor blockers, and perhaps angiotensin-converting enzyme (ACE) inhibitors may be the preferred first-line agents for treatment of hypertension in diabetes. beta-Blockers and calcium-channel blockers are more effective than placebo, but they may not be as effective as diuretics, angiotensin-II receptor blockers, or ACE inhibitors; however, study results are inconsistent in this regard. CONCLUSIONS: Treatment of hypertension in type 2 diabetes, with blood pressure goals of 135/80 mm Hg, provides dramatic benefits. Thiazide diuretics, angiotensin II receptor blockers, and ACE inhibitors may be the best first-line treatments, although other agents are usually necessary and goals may not be achieved even with three or four agents. Aggressive blood pressure control may be the most important factor in preventing adverse outcomes in patients with type 2 diabetes.

Adrenergic beta-Antagonists↗
PubMed2003

What effect does increasing inpatient time have on outpatient-oriented internist satisfaction?

OBJECTIVE: Because career satisfaction among general internists is relatively low, we sought to understand the impact on satisfaction of general internists managing patients both in and outside of the hospital. Using data from a national survey, we asked, "Among outpatient-oriented general internists (i.e., internists who spend less than 50% of their clinical time caring for inpatients), what effect does time spent in the hospital have on physician satisfaction, stress, and burnout?" DESIGN/PARTICIPANTS: The Physician Worklife Study, in which 5,704 physicians in primary and specialty nonsurgical care selected from the American Medical Association's Masterfile were surveyed (adjusted response rate = 52%), was used. Our analyses focused on clinically active outpatient-oriented general internists (N = 339). MEASUREMENTS AND MAIN RESULTS: We constructed multivariate linear models to test for statistically significant associations between the amount of time spent seeing inpatients and physician satisfaction as measured by several satisfaction scales. Even after controlling for total hours worked and other possible confounding variables, we found that increased time working in the hospital was significantly associated with decreases in satisfaction with administration, specialty, autonomy, and personal time, and significantly associated with an increase in life stress. There was also a significant association between increased time spent in the hospital and burnout. CONCLUSIONS: Our findings imply that there may be a tension between the practice of inpatient and outpatient medicine by general internists, and suggest that fewer hospital duties may increase career satisfaction for outpatient-oriented internists. Although additional studies are warranted in order to better understand why these relationships exist, our data suggest that the hospitalist model of inpatient care might be one approach to alleviate stress and improve satisfaction for many general internists.

Adult↗
PubMed2003

Building a better quality measure: are some patients with 'poor quality' actually getting good care?

BACKGROUND: National performance measures monitor the proportion of diabetic patients with low-density lipoprotein (LDL) levels >/=130 mg/dL, but such simple intermediate outcomes measure poor control, not necessarily poor care. "Tightly linked" quality measures define good quality either by a good intermediate outcome (LDL <130 mg/dL) or by evidence of appropriate responses to poor control (eg, starting or optimizing medications for high LDL or not doing so in the face of contraindications). OBJECTIVES: We examined hyperlipidemia therapy for patients with diabetes to determine the relative accuracy of quality assessment using simple intermediate outcome versus tightly linked quality measures. RESEARCH DESIGN: Retrospective longitudinal cohort. SUBJECTS: A total of 1154 diabetic patients with an LDL test done between October 1, 1998, and March 31, 1999, in 2 large VA facilities. MEASURES: LDL levels, medication treatment, and explanations for poor quality. RESULTS: Although 27% (307 of 1154) of patients had an LDL >/=130 mg/dL using the simple intermediate outcome measure, only 13% (148 of 1154) were classified as having substandard quality using the tightly linked measure. Among the 159 reclassified to adequate quality, 117 had lipid-lowering medication started or increased within 6 months of an LDL >/=130 mg/dL, 8 were already on high-dose medication, 12 had a repeat LDL <130 mg/dL, and 22 had contraindications to treatment. CONCLUSION: Simple intermediate outcome measures can be an inaccurate reflection of true quality of care, and many patients classified as having substandard quality by "poor control" might actually be receiving good quality of care.

Aged↗
PubMed2003

Racial disparities in diabetes care processes, outcomes, and treatment intensity.

BACKGROUND: Black Americans with diabetes have a higher burden of illness and mortality than do white Americans. However, the extent to which differences in medical care processes and treatment intensity contribute to poorer diabetes outcomes is unknown. OBJECTIVE: To assess racial disparities in the quality of diabetes care processes, intermediate outcomes, and treatment intensity. METHODS: We conducted an observational study of 801 white and 115 black patients who completed the Diabetes Quality Improvement Project survey (response rate=72%) in 21 Veterans Affairs (VA) facilities using survey data; medical record information on receipt of diabetes services (A1c, low-density lipoprotein [LDL], nephropathy screen, and foot and dilated eye examinations), and intermediate outcomes (glucose control measured by A1c; cholesterol control measured by LDL; and achieved level of blood pressure); and pharmacy data on filled prescriptions. RESULTS: There were no racial differences in receipt of an A1c test or foot examination. Blacks were less likely than whites to have LDL checked in the past 2 years (72% vs. 80%, P<0.05) and to have a dilated eye examination (50% vs. 63%, P<0.01). Even after adjusting for patients' age, education, income, insulin use, diabetes self-management, duration, severity, comorbidities, and health services utilization, racial disparities in receipt of an LDL test and eye examination persisted. After taking into account the nested structure of the data using a random intercepts model, blacks remained significantly less likely to have LDL testing than whites who received care within the same facility (68% vs. 83%, P<0.01). In contrast, there were no longer differences in receipt of eye examinations, suggesting that black patients were more likely to be receiving care at facilities with overall lower rates of eye examinations. After adjusting for patient characteristics and facility effects, black patients were substantially more likely than whites to have poor cholesterol control (LDL > or =130) and blood pressure control (BP > or =140/90 mm Hg) (P<0.01). Among those with poor blood pressure and lipid control, blacks received as intensive treatment as whites for these conditions. CONCLUSIONS: We found racial disparities in some diabetes care process and intermediate outcome quality measures, but not in intensity of treatment for those patients with poor control. Disparities in receipt of eye examinations were the result of black patients being more likely to receive care at lower-performing facilities, whereas for other quality measures, racial disparities within facilities were substantial.

Black or African American↗
PubMed2003

The association between three different measures of health status and satisfaction among patients with diabetes.

Studies suggest that health status influences patient satisfaction, but little work has examined the influence of different measures of health status on satisfaction. The authors examined whether the association between health status and satisfaction varied for different measures of health status among 2000 diabetic patients receiving care across 25 Veterans Affairs facilities. Health status was measured using (1) the diabetes-related components of the Total Illness Burden Index (DM TIBI), a measure of diabetes severity and comorbidities; (2) the Short Form 36 (SF-36) Physical Function Index (PFI10); and (3) the SF-36 general health perceptions question (SF-1). Satisfaction was measured both by a 5-item scale on satisfaction with patient-provider communication and by a single item on overall diabetes care satisfaction. In adjusted models, worse health on all three health status measures correlated with lower satisfaction, but the DM TIBI explained more of the variation in satisfaction than either the PFI10 or SF-1. Moreover, when the DM TIBI was added to the model containing PFI10, PFI10 was no longer significantly associated with satisfaction. In this diabetes population, health status appears to have a substantial impact on patient satisfaction, and this effect is considerably greater for diabetes severity than for physical functioning.

Aged↗
PubMed2003

How well do patients' assessments of their diabetes self-management correlate with actual glycemic control and receipt of recommended diabetes services?

OBJECTIVE: Although patient diabetes self-management is a key determinant of health outcomes, there is little evidence on whether patients' own assessments of their self-management correlates with glycemic control and key aspects of high-quality diabetes care. We explored these associations in a nationwide sample of Veterans' Affairs (VA) patients with diabetes. RESEARCH DESIGN AND METHODS: We abstracted information on achieved level of glycemic control (HbA(1c)) and diabetes processes of care (receipt of HbA(1c) test, eye examination, and nephropathy screen) from medical records of 1032 diabetic patients who received care from 21 VA facilities and had answered the Diabetes Quality Improvement Program survey in 2000. The survey included sociodemographic measures and a five-item scale assessing the patients' diabetes self-management (medication use, blood glucose monitoring, diet, exercise, and foot care [alpha = 0.68]). Using multivariable regression, we examined the associations of patients' reported self-management with HbA(1c) level and receipt of each diabetes process of care. We adjusted for diabetes severity and comorbidities, insulin use, age, ethnicity, income, education, use of VA services, and clustering at the facility level. RESULTS: Higher patient evaluations of their diabetes self-management were significantly associated with lower HbA(1c) levels (P < 0.01) and receipt of diabetes services. Those in the 95th percentile for self-management had a mean HbA(1c) level of 7.3 (95% CI 6.4-8.3), whereas those in the 5th percentile had mean levels of 8.3 (7.4-9.2). For every 10-point increase in patients' ratings of their diabetes self-management, even after adjusting for number of outpatient visits, the odds of receiving an HbA(1c) test in the past year increased by 15% (4-27%), of receiving an eye examination increased by 16% (7-27%), and of receiving a nephropathy screen increased by 13% (2-26%). CONCLUSIONS: In this sample, patients' assessments of their diabetes self-care using a simple five-question instrument were significantly associated both with actual HbA(1c) control and with receiving recommended diabetes services. These findings reinforce the usefulness of patient evaluations of their own self-management for understanding and improving glycemic control. The mechanisms by which those patients who are more actively engaged in their diabetes self-care are also more likely to receive necessary services warrant further study.

Aged↗
PubMed2003

Medicaid managed care: are academic medical centers penalized by attracting patients with high-cost conditions?

OBJECTIVE: To determine whether case-mix and health utilization disparities exist between Medicaid enrollees within a Michigan managed care organization (MCO) who selected primary care providers (PCPs) affiliated with a major academic medical center (AMC) and enrollees who selected community providers. STUDY DESIGN: A retrospective cohort study using cost estimates obtained from claims data and based on a standardized Medicaid fee schedule. METHODS: We established the prevalence of 25 high-cost chronic medical conditions from the claims data for capitated Medicaid enrollees from January 1, 1997, through October 31, 1999. We assessed differences in healthcare cost estimates per member for Medicaid enrollees at AMC primary care sites versus other community sites using t tests and linear regressions, including analyses stratified for Temporary Assistance for Needy Families (TANF) and Aid to Blind and Disabled (ABAD) programs. RESULTS: Enrollees with AMC providers had a much higher cumulative prevalence of the 25 high-cost chronic medical conditions (95.6 per 1000 enrollees versus 65.6 per 1000; P < .001), and virtually all of this difference was confined to ABAD enrollees. Estimated total costs were also higher for ABAD Medicaid enrollees at the AMC sites than for those at community sites. The average total services and pharmacy cost estimates per ABAD member were $1219 higher per member per year at the AMC sites (P < .001), primarily from costs of inpatient hospitalizations. Regression analyses demonstrated that differences in the prevalence of the 25 high-cost chronic medical conditions accounted for about 50% of the cost differences observed between sites. These analyses suggest that at least half of the observed cost disparity was due to adverse selection. CONCLUSIONS: This study found both significant case-mix and cost disparities for ABAD patients, suggesting that AMC primary care sites experienced substantial adverse selection. Unless approaches to account for adverse selection are put in place, this phenomenon could jeopardize ABAD Medicaid recipients' ongoing access to needed medical care.

Academic Medical Centers↗
PubMed2002

The rheumatoid hand: a predictable disease with unpredictable surgical practice patterns.

OBJECTIVES: To evaluate variation in fusion, arthroplasty, and tenosynovectomy rates among rheumatoid arthritis (RA) patients across states; to evaluate associations between surgery rates and the density of hand surgeons; and to evaluate differences in treatment by sex of the patient. METHODS: Data were obtained from the 1996 and 1997 Healthcare Cost and Utilization Project database. The procedure codes for fusion, arthroplasty, and tenosynovectomy were matched to patients with the diagnostic code of RA, which provided the total number of procedures performed in each state. The smoothed estimates of the RA population for each state were derived from age/sex strata in the 1995 US census using age/sex-adjusted RA prevalence data from the Third National Health and Nutrition Examination Survey. The number of hand surgeons was from the 1996 American Society for Surgery of the Hand. RESULTS: Procedure rates across states varied from 9-fold to 12-fold for all 3 procedures. The rates of the reconstructive procedures-fusion and arthroplasty-were highly correlated in each state, but these 2 procedures were only moderately correlated with tenosynovectomy. Surgeon density and procedure rates were minimally correlated. Procedure rates differed by patient sex, with significantly more arthroplasty and fusion procedures performed in women. More tenosynovectomy procedures were performed in men, and they were also performed at a younger age in men. CONCLUSIONS: Significant large area variations are present in the surgical management of the rheumatoid hand, but the correlations between reconstructive and early intervention procedures are modest. These rate differences are not explained by the number of hand surgeons, disease prevalence, or demographic composition of the states. However, men are more likely to receive more aggressive early surgical interventions, and women are more likely to receive end-stage reconstructive surgery.

Adolescent↗