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Biomedical subjects

Sally C Stearns

Publications and source records attributed to Sally C Stearns.

15 recordsLinked to original sources
PubMed2006

Medicare payment changes and nursing home quality: effects on long-stay residents.

The Balanced Budget Act of 1997 dramatically changed the way that Medicare pays skilled nursing facilities, providing a natural experiment in nursing home behavior. Medicare payment policy (directed at short-stay residents) may have affected outcomes for long-stay, chronic-care residents if services for these residents were subsidized through cost-shifting prior to implementation of Medicare prospective payment for nursing homes. We link changes in both the form and level of Medicare payment at the facility level with changes in resident-level quality, as represented by pressure sores and urinary tract infections in Minimum Data Set (MDS) assessments. Results show that long-stay residents experienced increased adverse outcomes with the elimination of Medicare cost reimbursement.

Aged↗
PubMed2006

Simulating cost-effectiveness of fluoride varnish during well-child visits for Medicaid-enrolled children.

OBJECTIVE: To examine the cost-effectiveness of fluoride varnish application by medical providers when implemented within a well-child periodicity schedule for Medicaid-enrolled children. DESIGN: Cost-effectiveness was analyzed using published probabilities and costs. Input parameters included the effectiveness of fluoride varnish (35.4%) applied according to the well-child periodicity schedule up to 3 years of age at $16.00 per application, annual caries increment (14%), age-specific dental care usage rates (0.2% at 9 months to 19% at 42 months), and age-related nonhospital treatment costs ($292.00-$503.00) and hospital treatment costs ($2191.00-$2940.00). Sensitivity analysis was conducted to assess the effects for varying input parameters. SETTING: Well-child visits during primary care. PARTICIPANTS: Children aged 9 to 42 months. INTERVENTION: Application of universal fluoride varnish (fluoride varnish-all) at 9, 18, 24, and 36 months vs no intervention (fluoride varnish-none) was compared. MAIN OUTCOME MEASURES: Cost per month without cavities and treatment averted during the first 42 months of life from a Medicaid payer's perspective. RESULTS: Fluoride varnish improved clinical outcomes by 1.52 cavity-free months but at a cost of $7.18 for each cavity-free month gained per child and $203 for each treatment averted. Considerable uncertainty existed for some parameters. Fluoride varnish was cost saving when dental services and nonhospital treatment costs were 1.5 to 2 times greater, respectively, than our base case estimate. CONCLUSIONS: Based on these assumptions, fluoride varnish use in the medical setting is effective in reducing early childhood caries in low-income populations but is not cost saving in the first 42 months of life. Potential total cost reductions with varying parameters suggest that evaluations using a longitudinal cohort are needed.

Cariostatic Agents↗
PubMed2006

Screening mammography after breast cancer treatment: patterns in community practice.

BACKGROUND: Guidelines for screening women post-breast cancer treatment are generally lacking. This study was conducted to review the literature on guidelines for this population and to evaluate whether there is a common practice in the community for following these women. METHODS: The literature was reviewed for presence of published or inferred guidelines. Data were then used from the Carolina Mammography Registry (CMR) to see if patterns exist in community practice. For the years 1995-1999, 3081 women with a new diagnosis of unilateral breast cancer and a post-treatment screening mammogram in CMR were included. Recommendations for initial mammographic examination and intervals of subsequent mammograms post-treatment were described and tested for patterns of follow-up time. RESULTS: The only evidence-based guidelines found for post-treatment mammographic examinations were from the American Society of Clinical Oncology. They recommend 6 month follow-up initially followed by 12 month follow-up if findings remain stable. Among the 3081 women included in the study, 17.4% were recommended to return at 6 months post-treatment following their initial mammogram. Of the women who had at least three post-cancer mammograms (1592/3081), 82.6% were recommended for 12 month intervals at all three visits; only 2.1% of women were recommended for 6 month intervals at all three visits. CONCLUSIONS: This study found that most community-based radiologists included in our study recommend following women at 12 month intervals post-treatment. Whether this 12 month screening interval is optimal for detecting recurrent cancers is not known and should be the focus of future research.

Adult↗
PubMed2006

Medicare prospective payment and quality of care for long-stay nursing facility residents.

BACKGROUND: The Balanced Budget Act of 1997 dramatically changed the way that Medicare pays skilled nursing facilities and also cut per-diem rates. Previous studies have found effects on facility-wide staffing but not on quality for short-stay residents. Because facilities may combine revenue streams to be used where needed, spillover effects on quality of care for long-stay residents are possible. OBJECTIVE: We sought to investigate effects of financial pressures from Medicare payment changes on quality of care for long-stay residents. METHODS: We investigated the effect of Medicare's Prospective Payment System for skilled nursing facilities on incidence of urinary tract infections and pressure sores among long-stay residents while controlling for resident severity. We conducted panel data analysis of nursing home residents in Ohio, Kansas, Maine, Mississippi, and South Dakota using Minimum Data Set data from 1995 to 2000. Each facility's Medicare dependence was used to separate effects of the policy from underlying industry trends. RESULTS: The probability of developing a urinary tract infection or pressure sore increased significantly among long-stay residents after Medicare's prospective payment system was implemented. Effects were roughly proportional to the percent of residents in a facility covered by Medicare. CONCLUSIONS: Although Medicare prospective payment and rate cuts were directly applicable only to Medicare (largely short-stay) residents in skilled nursing facilities, the resulting financial pressures lowered the quality of care experienced by long-stay residents, as measured by the likelihood of adverse outcomes. The observed quality decreases were likely due to decreases in nurse staffing prompted by the payment reductions.

Humans↗
PubMed2006

Using propensity stratification to compare patient outcomes in hospital-based versus freestanding skilled-nursing facilities.

Medicare skilled-nursing facility (SNF) patients exhibit differences in resource use and outcomes by whether the SNF is hospital-based or freestanding. Some of the differences may be attributable to patient selection rather than underlying institutional differences. This study adjusts for patient selection by stratifying Medicare SNF patients by their likelihood of hospital-based SNF referral. Three outcomes are analyzed to illustrate this approach: Medicare SNF length of stay, discharge to home within 30 days, and preventable hospital readmissions. The estimations use claims and patient-assessment data merged with facility and market characteristics. The results provide strong evidence that good candidates for faster recovery and discharge to the community are preferentially selected into hospital-based units. While the unstratified regression approach controls for much of the selection, stratified regressions provide further reductions in setting-specific differences. Remaining differences may be because of patterns of care or reflect residual bias from unobserved factors.

Aged↗
PubMed2005

Cost-effectiveness of a home-based environmental intervention for inner-city children with asthma.

BACKGROUND: Exposure to indoor allergens contributes to increased asthma morbidity. The Inner-City Asthma Study, a randomized trial involving home environmental allergen and irritant remediation among children aged 6 through 11 years with moderate-to-severe asthma, successfully reduced asthma symptoms. A cost-effectiveness analysis can help stakeholders to evaluate the potential costs and benefits of adopting such a program. OBJECTIVE: We sought to assess the cost-effectiveness of the environmental intervention of the Inner-City Asthma Study. METHODS: Incremental cost-effectiveness ratios for a 2-year study period were calculated. Health outcome was measured as symptom-free days. Resource use measures included ambulatory visits, hospitalizations, and pharmaceutical use. CIs were obtained by using bootstrapping. RESULTS: The intervention, which cost $1469 per family, led to statistically significant reductions in symptom days, unscheduled clinic visits, and use of beta-agonist inhalers. Over the year of the intervention and a year of follow-up, the intervention cost was $27.57 per additional symptom-free day (95% CI, $7.46-$67.42). Subgroup analysis showed that targeting the intervention to selected high-risk subgroups did not reduce the incremental cost-effectiveness ratio. CONCLUSIONS: A targeted home-based environmental intervention improved health and reduced service use in inner-city children with moderate-to-severe asthma. The intervention is cost-effective when the aim is to reduce asthma symptom days and the associated costs.

Air Pollution, Indoor↗
PubMed2005

Hemodialysis for end-stage renal disease: a cost-effectiveness analysis of treatment-options.

BACKGROUND: During 2001, over 32,000 patients in the United Kingdom received renal replacement therapy (RRT). Approximately half had a functioning transplant, with the remainder receiving dialysis therapy. The main form of dialysis is hemodialysis (HD), which is provided to 37.1 percent of the RRT population. HD is provided in three main settings: hospital (24.5 percent), satellite (10.9 percent), or home (1.7 percent). The objective of this study is to explore the cost-effectiveness of these different modalities. METHODS: By using clinical and cost data from a systematic review, a Markov model was developed to assess the costs and benefits of the three different modalities. The model included direct health service costs and quality-adjusted life years (QALYs). Sensitivity analyses were performed to assess the robustness of the results. RESULTS: Satellite HD has lower costs 46,000 pounds sterling and 62,050 pounds sterling at 5 and 10 years than home HD 47,660 pounds sterling and 63,540 pounds sterling. The total effectiveness of home HD was slightly greater than for satellite HD, so the incremental cost per QALY of home versus satellite HD was modest at 6,665 pounds sterling at 5 years and 3,943 pounds sterling at 10 years. Both modalities dominated hospital HD. CONCLUSIONS: Results from the study reveal that satellite HD was less costly than home HD, and home HD was less costly than hospital HD. The lack of robust data on the effectiveness and new dialysis equipment, which were not included in this review, throws some caution on these results. Nonetheless, the results are supportive of a shift from hospital HD to satellite and home HD.

Aged↗
PubMed2005

How good is assisted living? Findings and implications from an outcomes study.

OBJECTIVES: The objective of this work was to determine 1-year medical outcomes, nursing home transfer, and functional change of assisted living (AL) residents and their relationship to care. METHODS: On-site interviews and observations regarding the status and care of 2,078 residents in 193 facilities across four states were conducted; follow-up was by telephone interview with care providers. RESULTS: Annual mortality and transfer rates were 14.4 and 21.3 per 100 residents. The probability of hospitalization and new/worsening morbidities over a standardized quarter per 100 residents was 12.7 and 22.7. Standardized change in function was notable among those who were transferred or died and small among others. Facility characteristics did not generally relate to medical outcomes and transfer, and those that related to functional change were small and occurred across multiple functions. Facilities that are affiliated with another level of care were more likely to transfer; nurse staffing was favorable for hospitalization but not transfer; and aide turnover was protective for mortality. DISCUSSION: No single component defines "good" AL care. Predictors and outcomes are inconsistent, and effect sizes are small. Therefore, practice and policy should not focus narrowly on any one area or restrict the type of care-this being welcome news that supports diversity to accommodate individual preferences.

Aged↗
PubMed2004

Time to include time to death? The future of health care expenditure predictions.

Government projections of future health care expenditures--a great concern given the aging baby-boom generation--are based on econometric regressions that control explicitly for age but do not control for end-of-life expenditures. Because expenditures increase dramatically on average at the end of life, predictions of future cost distributions based on regressions that omit time to death as an explanatory variable will be biased upward (or, more explicitly, the coefficients on age will be biased upward) if technology or other social factors continue to prolong life. Although health care expenditure predictions for a current sample will not be biased, predictions for future cohorts with greater longevity will be biased upwards, and the magnitude of the bias will increase as the expected longevity increases. We explore the empirical implications of incorporating time to death in longitudinal models of health expenditures for the purpose of predicting future expenditures. Predictions from a simple model that excludes time to death and uses current life tables are 9% higher than from an expanded model controlling for time to death. The bias increases to 15% when using projected life tables for 2020. The predicted differences between the models are sufficient to justify reassessment of the value of inclusion of time to death in models for predicting health care expenditures.

Aged↗
PubMed2004

Cost effectiveness of tension-free vaginal tape for the surgical management of female stress incontinence.

OBJECTIVES: Stress urinary incontinence affects between 10 percent and 50 percent of women. Surgery is commonly recommended for troublesome incontinence that does not respond to nonsurgical management. Tension-free vaginal tape (TVT) is a newer, minimal access surgical sling procedure, which is being increasingly adopted worldwide. The cost-effectiveness of TVT in comparison with other surgical procedures, particularly open colposuspension, is assessed. METHODS: Effectiveness estimates came from a systematic review of TVT compared with other surgical procedures (open and laparoscopic colposuspension, traditional slings, and injectables). Deterministic and probabilistic analyses were used to assess the likelihood of TVT being cost-effective. Sensitivity analyses assessed the impact of changing assumptions about cure rates and costs for TVT, cure rates for retreatment open colposuspension, and proportions of women who choose retreatment. RESULTS: Reliable estimates of relative effectiveness were difficult to derive because the few randomized controlled comparisons had not been optimally analyzed or fully reported. Results of the economic model suggested that TVT dominates open colposuspension (lower cost and same quality of life years [QALYs]) within 5 years after surgery. Stochastic analysis indicated that the likelihood of TVT being cost-effective was 100 percent if decision-makers are unwilling to pay for additional QALYs. TVT's dominance depended on the assumption fact that retreatment open colposuspension has lower cure rates than a first colposuspension. CONCLUSIONS: Analysis based on current short-term data indicates dominance of TVT over open colposuspension from approximately 5 years. There is a need for longer-term follow-up data from methodologically rigorous randomized trials to provide a sounder basis for estimating the relative benefits and cost implications.

Cost-Benefit Analysis↗
PubMed2003

Longevity and health care expenditures: the real reasons older people spend more.

OBJECTIVES: In this study, we investigated the relative contributions of both age and time to death to health care expenditures for elderly Medicare beneficiaries. We also analyzed differences in expenditure patterns by age and time to death for various service types and payers. METHODS: We conducted graphical analysis of person-month level data on 25,994 elderly persons from the 1992-1998 Medicare Current Beneficiary Survey Cost and Use files. RESULTS: Monthly health care expenditures for elderly people increase substantially with age primarily because mortality rates increase with age and health care expenditures increase with closeness to death. Time to death is the main reason for higher inpatient care expenditures, whereas aging is the main reason for higher long-term care expenditure. DISCUSSION: Both increases in the absolute number of elderly persons and in their longevity will increase future Medicare expenditures. Yet, the expected increase in per person health care expenditures caused by greater longevity of Medicare beneficiaries will be less than expected because of the concentration of expenditures at the end of life rather than during extra years of a relatively healthy life. The latter conclusion may be altered, however, because of other underlying considerations, such as technological change.

Age Factors↗
PubMed2003

Assisted living and nursing homes: apples and oranges?

PURPOSE: The goals of this study are to describe the current state of residential care/assisted living (RC/AL) care and residents in comparison with nursing home (NH) care and residents, identify different types of RC/AL care and residents, and consider how variation in RC/AL case-mix reflects differences in care provision and/or consumer preference. DESIGN AND METHODS: Data were derived from the Collaborative Studies of Long-Term Care, a four-state study of 193 RC/AL facilities and 40 NHs. Multivariate analyses examined differences in ten process of care measures between RC/AL facilities with less than 16 beds; traditional RC/AL with 16 or more beds; new-model RC/AL; and NHs. Generalized estimating equation models determined differences in resident case-mix across RC/AL facilities using data for 2,078 residents. RESULTS: NHs report provision of significantly more health services and have significantly more lenient admission policies than RC/AL facilities, but provide less privacy. They do not differ from larger RC/AL facilities in policy clarity or resident control. Differences within RC/AL types are evident, with smaller and for-profit facilities scoring lower than other facilities across multiple process measures, including those related to individual freedom and institutional order. Resident impairment is substantial in both NHs and RC/AL settings, but differs by RC/AL facility characteristics. IMPLICATIONS: Differences in process of care and resident characteristics by facility type highlight the importance of considering: (1) the adequacy of existing process measures for evaluating smaller facilities; (2) resident case-mix when comparing facility types and outcomes; and (3) the complexity of understanding the implication of the process of care, given the importance of person-environment fit. Work is continuing to clarify the role of RC/AL vis-à-vis NHs in our nation's system of residential long-term care.

Aged↗
PubMed2003

Understanding biased selection in Medicare HMOs.

OBJECTIVE: To investigate the extent of favorable health maintenance organization (HMO) selection for a longitudinal cohort of Medicare beneficiaries, examine whether the extent of favorable selection varies with the degree of Medicare HMO market penetration in a county, and explain conflicting findings in the literature on favorable HMO selection. DATA SOURCES: A panel of 1992-1996 data from the Medicare Current Beneficiary Survey (MCBS), supplemented with linked data from the Area Resource File and Medicare administrative datasets. STUDY DESIGN: Using random effects probit estimation, we model a beneficiary's HMO enrollment status as a function of self-reported health status and Medicare HMO market penetration. DATA EXTRACTION METHODS: The MCBS data for beneficiaries residing in states served by Medicare HMOs in 1992-1996 were linked by county to the supplementary datasets. PRINCIPAL FINDINGS: We find that favorable selection persists in the cohort over time on some, but not all, measures. We find no substantial association between favorable HMO selection and HMO market penetration. We find that conflicting findings in the literature on favorable HMO selection may be explained by several methodological choices, including the choice of health status measure and the structure of the sample. CONCLUSIONS: Our results support further risk adjustment of the adjusted average per capita cost (AAPCC) payment formula.

Aged↗
PubMed2002

Do Medicare HMOs still reduce health services use after controlling for selection bias?

This study models the relationship between Medicare beneficiary decisions to join Medicare HMOs and subsequent health services utilization. The relationship between health plan choice and utilization is thought to be endogenous because of favorable selection into HMOs. Previous studies found significantly lower inpatient utilization among Medicare HMO enrollees than among nonenrollees, but lacked strong controls for selection bias. Thus, a firm conclusion could not be drawn as to whether the observed differences were attributable to the HMO practice setting or to baseline differences in the illness profiles of the two groups studied. The present study uses simultaneous equations methods, including discrete factor estimation, to test the effect of Medicare HMOs on utilization when strong controls for selection bias are imposed. The model was run on a panel of 1993-1996 data from the Medicare Current Beneficiary Survey, supplemented with linked data on Medicare HMO characteristics and area supply characteristics. The study found that even when favorable selection is controlled for, Medicare HMOs significantly reduce both the probability of hospitalization and the number of inpatient days used by those who are hospitalized. Medicare HMOs do not, however, appear to reduce the use of physician services.

Aged↗