Biomedical subjects

Stephen Crystal

Publications and source records attributed to Stephen Crystal.

34 records · Page 2Linked to original sources

PubMed2004

Sensitivity of an AIDS case-finding algorithm: who are we missing?

OBJECTIVE: The objective of this study was to determine the sensitivity of an AIDS case-finding algorithm. METHOD: This study applied the AIDS case-finding algorithm to paid Medicaid claims linked to New Jersey AIDS surveillance data and assesses its sensitivity across subgroups of patients. FINDINGS: Of the 7183 cases with confirmed AIDS, based on the state's registry information, 95% (n = 6818) were correctly detected using all Medicaid claims, including pharmacy. For patients in a community-based waiver program, covered by Medicare, diagnosed with a severe mental illness, or continuously enrolled in Medicaid, with regular contact with the medical system, the algorithm identified almost all patients. To further evaluate algorithm performance, it was used with 2 groups of interest to researchers. For AIDS patients in the last 6 months of life, 88% were correctly detected without use of pharmacy claims and 95% when pharmacy claims were included. For pregnant women, data from the 6 months before the latest delivery date identify 27% of pregnant women without pharmacy claims and 41% when pharmacy claims were included. Using claims made after the latest delivery date, 81% of pregnant women were detected without pharmacy claims and 93% when pharmacy claims were included CONCLUSION: Results demonstrate that a multilevel screen can be used with Medicaid claims to effectively to detect most patients with AIDS. Detection is lower for some subgroups, and the absence of pharmacy claims can compromise detection.

Acquired Immunodeficiency Syndrome↗

PubMed2004

Mental illness and length of inpatient stay for medicaid recipients with AIDS.

OBJECTIVE: To examine the associations between comorbid mental illness and length of hospital stays (LOS) among Medicaid beneficiaries with AIDS. DATA SOURCE AND COLLECTION/STUDY SETTING: Merged 1992-1998 Medicaid claims and AIDS surveillance data obtained from the State of New Jersey for adults with >or=1 inpatient stay after an AIDS diagnosis from 1992 to 1996. STUDY DESIGN: Observational study of 6,247 AIDS patients with 24,975 inpatient visits. Severe mental illness (SMI) and other less severe mental illness (OMI) diagnoses at visits were ascertained from ICD-9 Codes. About 4 percent of visits had an SMI diagnosis; 5 percent had an OMI diagnosis; 43 percent did not have a mental illness diagnosis, but were patients who had been identified as having an SMI or OMI history; and 48 percent were from patients with no identified history of mental illness. PRINCIPAL FINDINGS: The overall mean hospital LOS was 12.7 days. After adjusting for measures of HIV disease severity and health care access in multivariate models, patients presenting with primary and secondary severe mental illness (SMI) diagnoses had approximately 32 percent and approximately 11 percent longer LOS, respectively, than did similar patients without a mental illness history (p<0.001 for each). But in these adjusted models of length of stay: (1) diagnosis of OMI was not related to LOS, and (2) in the absence of a mental illness diagnosed at the visit, an identified history of either SMI or OMI was also not related to LOS. In adjusted models of time to readmission for a new visit, current diagnosis of SMI or OMI and in the absences of a current diagnosis, history of SMI or OMI all tended to be associated with quicker readmission. CONCLUSIONS: This study finds greater (adjusted) LOS for AIDS patients diagnosed with severe mental illness (but not for those diagnosed with less severe mental comorbidity) at a visit. The effect of acute severe mental illness on hospitalization time may be comparable to that of an acute AIDS opportunistic illness. While previous research raises concerns that mental illness increases LOS by interfering with treatment of HIV conditions, the associations here may simply indicate that extra time is needed to treat severe mental illnesses or arrange for discharge of afflicted patients.

Acquired Immunodeficiency Syndrome↗

PubMed2004

Use of newer antiretroviral treatments among HIV-infected medicaid beneficiaries with serious mental illness.

OBJECTIVES: The study compares rates of protease inhibitor (PI) use during the 3 years following the introduction of these newer treatments among human immunodeficiency virus (HIV)-infected individuals with and without serious mental illness and examines persistence of use of these therapies across these subgroups. METHOD: We used merged autoimmune deficiency syndrome (AIDS)/HIV surveillance and Medicaid claims data to examine use of PIs and non-nucleoside reverse transcriptase inhibitors (NNRTIs) among New Jersey Medicaid beneficiaries with AIDS between 1996 and 1998. Based on the ICD-9-CM diagnoses assigned by a high-credibility source in 1 inpatient or 2 outpatient claims, we identified patients with schizophrenia (ICD-9-CM code 295) and those with severe affective disorder (combining patients with recurrent major depressive disorder [ICD-9-CM code 296.3] or bipolar disorder [296.4, 296.5, 296.6, 296.7, or 296.8]). These groups were compared with those patients with no serious mental illness. RESULTS: In this sample, patients with schizophrenia (68.3%) and those with severe affective disorder (75.6%) were more likely to have initiated new antiretroviral therapy than were those without serious mental illness (64.3%). Patients with severe affective disorder, but not those with schizophrenia, were significantly less persistent (p <.01) in their use of PI/NNRTI therapy than those without serious mental illness. CONCLUSIONS: No evidence was found that the presence of a serious mental illness discourages physicians from initiating new antiretroviral therapy, perhaps reflecting a comparatively high level of integration of these patients into the health care system. Patients with schizophrenia are as persistent in their use of PI/NNRTI therapy as those without a serious mental illness. Lower rates of medication compliance by those with severe affective disorder justify increased efforts to support optimal adherence.

Acquired Immunodeficiency Syndrome↗

PubMed2004

Dual-system utilization affects regional variation in prevention quality indicators: the case of amputations among veterans with diabetes.

OBJECTIVE: To determine the impact of dual-system utilization by veterans on regional variation in lower-extremity amputation rates. STUDY DESIGN: Retrospective longitudinal cohort analysis. PATIENTS AND METHODS: Subjects were veterans with diabetes who used Veterans Health Administration (VHA) care and were dually enrolled in Medicare fee for service in fiscal years (FY) 1997--1999. We evaluated the impact of Centers for Medicare and Medicaid Services (CMS) data on prevalence of baseline foot risk factors, medical comorbidities, and amputations in FY 1997--1998, and ranking of 22 regions using risk-adjusted major and minor amputation rates in FY 1999. RESULTS: The addition of CMS data significantly increased the prevalence of amputations and risk factors for the 218,528 dually eligible veterans (all Pvalues <.001). In FY 1999, we identified 3.1 minor and 4.5 major amputations per 1000 patients (VHA data) versus 5.5 minor and 8.6 major amputations per 1000 patients (VHA/CMS data); the prevalence of any peripheral vascular condition in FY 1997--1998 was 5.7% (VHA) versus 13.0% (VHA/CMS). The impact of including CMS data varied across regions for amputation outcomes, ranging from an additional 34.3% to 150.7%. Using observed-to-expected amputation ratios and 99% confidence intervals, the addition of CMS data changed the outlier status for 8 of 22 regions for both major and minor amputations. CONCLUSION: Risk covariates and amputation outcomes were substantially underestimated using VHA data only. Our findings demonstrate the importance of evaluating dual-system utilization when conducting program evaluations for healthcare systems with a substantial number of dual enrollees.

Aged↗

PubMed2003

HIV/AIDS interventions for midlife and older adults: current status and challenges.

Drawing on both domestic and global international perspectives, this special issue is devoted to articles that confront the challenges of understanding, preventing, and intervening, with HIV/AIDS as an epidemic that carries increasingly serious consequences for a growing number of adults who are 50 years of age or older. This issue builds on papers first presented at an HIV/AIDS and aging conference sponsored in the fall of 2000 by the National Institute on Aging of the National Institutes of Health. The editors have selected articles that focus dually on what is currently known and what needs to be known to successfully address the needs of persons 50 years of age or older who are vulnerable to the virus's effects. This special issue is organized around a series of subsections representing key issues and research findings related to HIV/AIDS and aging issues, including the epidemiology of HIV/AIDS and aging, HIV/AIDS risk and risk behavior, settings and situations as social contexts of risk, clinical challenges with older populations, living with and managing HIV/AIDS, interventions and research methods, new frontiers and challenges, and strategies for action. Some articles are data driven, whereas others are reflective pieces that recount personal experiences in living with the virus or point to new directions for research and practice. In this introduction, the editors highlight findings and approaches from each article and further add to our knowledge by setting these articles within the context of major themes relevant to the study of HIV/AIDS in an aging population.

Acquired Immunodeficiency Syndrome↗

PubMed2003

The diverse older HIV-positive population: a national profile of economic circumstances, social support, and quality of life.

The objectives of this study were to provide a national profile of socioeconomic circumstances of the middle-aged and older population living with HIV and to evaluate variations in social support and quality of life (QOL) across age and socioeconomic subgroups, controlling for indicators of disease progression. The design used was a cross-sectional analysis of nationally representative interview data on HIV-infected individuals collected in the HIV Cost and Services Utilization Study. Multiple measures of social support and QOL were used. Bivariate comparisons of outcomes across categories of age and exposure category were performed; multivariate analyses to isolate the effect of older age on outcomes within exposure categories were performed, controlling for socioeconomic and clinical co-variates. Study results indicate that older gay men with HIV/AIDS are a predominantly white population and more likely to have health insurance than their younger counterparts; 38% were employed and 48% reported incomes of more than $25,000. Older injection drug users (IDUs) with HIV/AIDS are a predominantly black population with a particularly high concentration of disadvantages; only 11% were employed and 74% reported incomes of less than $10,000. Older IDUs reported especially low levels of physical functioning and emotional support in comparison with their younger counterparts, whereas older gay men did not significantly differ from younger gay men in these respects. The authors conclude that characteristics and care needs of the older HIV-positive population are very diverse and vary sharply by exposure route. Interventions need to be tailored to the needs of these distinct subpopulations, with an emphasis on development of supportive care interventions for older IDUs.

Acquired Immunodeficiency Syndrome↗

PubMed2003

Patterns of coping among persons with HIV infection: configurations, correlates, and change.

This study examines coping in response to HIV infection, using longitudinal data from a nationally representative sample (n = 2,864) of HIV-infected persons. We investigated configurations of coping responses, the correlates of configuration membership, the stability of coping configurations, and the relationship of coping to emotional well-being. Four coping configurations emerged from cluster analyses: relatively frequent use of blame-withdrawal coping, frequent use of distancing, frequent active-approach coping, and infrequent use of all three coping strategies ("passive" copers). Passive copers had few symptoms, high levels of physical functioning, and high emotional well-being; blame-withdrawal copers had the opposite pattern. Of those completing a second interview 1 year after baseline, 46% had the same coping configuration. Increases in the number of HIV-related symptoms raised the probability of blame-withdrawal coping at follow-up, whereas decreases raised the probability of passive coping. Infrequent use of coping responses at baseline was related to greater emotional well-being 1 year later. This result, in conjunction with the high levels of emotional well-being in the passive cluster, suggests that high levels of distress can induce blame-withdrawal coping whereas coping efforts are minimal when social support and emotional well-being are high. Results highlight issues in ascertaining the causal direction between coping and psychological outcomes, as well as in specifying the nature of stressful situations with which people are coping.

Adaptation, Psychological↗

PubMed2003

Diagnosis and treatment of depression in the elderly medicare population: predictors, disparities, and trends.

OBJECTIVES: To develop nationally representative estimates of rates of diagnosis of depression; to determine rates and type of treatment received by those diagnosed with depression; and to ascertain socioeconomic differences and trends in treatment rates of depression, including the effect of supplemental insurance coverage, for elderly Medicare fee-for-service beneficiaries. DESIGN: Analysis of merged interview and Medicare claims data for multiple years from merged Medicare claims and interview data from the Medicare Current Beneficiary Survey (MCBS), a nationally representative survey of Medicare participants. SETTING: Community dwellers. PARTICIPANTS: Twenty thousand nine hundred sixty-six community-dwelling respondents aged 65 and older in the MCBS cost and use files for 1992 through 1998. MEASUREMENTS: Diagnoses recorded in Medicare claims were used to identify individuals who received a diagnosis of depression from a healthcare provider; pharmacy and claims data were used to identify receipt of antidepressants and psychotherapy by those diagnosed. RESULTS: The rate of depression diagnosis more than doubled, reaching 5.8% in 1998. Overall, about two-thirds of those diagnosed received treatment in each year; but those aged 75 and older, those of "Hispanic or other" ethnicity, and those without additional coverage to supplement Medicare were significantly less likely to receive treatment, controlling for other characteristics. If treated, members of these disadvantaged subgroups were less likely to receive psychotherapy. CONCLUSION: Although depression has been thought until recent years to be underrecognized in the elderly, rates of diagnosis increased dramatically in the 1990s, with concomitant increases in treatment. Nevertheless, significant disparities by age, ethnicity, and supplemental insurance coverage persist in treatment of those diagnosed. Because depression is a major source of potentially treatable morbidity in older people, increased efforts are needed to ensure access to appropriate treatment across all subgroups of older people and to remove economic barriers to treatment.

Activities of Daily Living↗

PubMed2003

Total and out-of-pocket expenditures for prescription drugs among older persons.

PURPOSE: The burden of prescription drug costs on Medicare beneficiaries has become a critical policy issue in improving the Medicare program, yet few studies have provided detailed and current information on that burden. The present study estimates total and out-of-pocket expenditures for prescription drugs and the burden of these costs in relation to income among the elderly population. We also compare spending and burden across major subgroups of the elderly population, as defined by socioeconomic and health characteristics, and we distinguish the impact of these factors by using multivariate models. DESIGN AND METHODS: The study uses nationally representative data on Medicare beneficiaries from the 1997 Medicare Current Beneficiary Survey Cost and Use files. The study estimates out-of-pocket prescription drug spending and burden through ordinary least square, median, and logistic regression models with corrections for the complex survey design. RESULTS: Our results show that in 1997, nearly 8% of the older population, more than 2.3 million people, spent greater than 10% of their income on prescription drugs. Despite pharmacy coverage, out-of-pocket cost burden fell most heavily on women and those with chronic health conditions. Burden was also higher among those with self-purchased supplemental coverage. IMPLICATIONS: The impact of Medicare reform proposals on these subgroups has to be carefully evaluated.

Age Distribution↗

PubMed2003

Consumer satisfaction in long-term care: state initiatives in nursing homes and assisted living facilities.

PURPOSE: We report the results of a survey of state initiatives that measure resident satisfaction in nursing homes and assisted living facilities, and we describe several model programs for legislators and public administrators contemplating the initiation of their own state programs. DESIGN AND METHODS: Data on state initiatives and programs were collected during March and April 2000 through a mailed questionnaire and follow-up telephone interviews and were current as of September 2002. RESULTS: Of the 50 states surveyed, 50 responses were received (response rate = 100%); 12 states (24%) reported the use of consumer satisfaction measures, and 7 (Florida, Iowa, Ohio, Oregon, Texas, Vermont, and Wisconsin) reported using resident satisfaction data within their consumer information systems for nursing homes or assisted living facilities. Additionally, 2 states (Iowa and Wisconsin) use resident satisfaction data for facility licensing and recertification. The design of the instruments and collection methods vary in these states, as do the reported response rates, per-resident cost, and the purpose for satisfaction data collection. IMPLICATIONS: State satisfaction efforts are in an early stage of development. Well-produced, easily understandable reports on nursing home and assisted living quality could provide information and guidance for patients and families contemplating the utilization of long-term care services. Dissemination of quality information may also facilitate sustained quality and efficiency improvements in long-term care facilities and thus enhance the quality of care for and quality of life of long-term care residents.

Assisted Living Facilities↗

PubMed2003

Diffusion of new generation antidepressant treatment among elderly diagnosed with depression.

RESEARCH OBJECTIVE: This study analyzes the prevalence of new generation antidepressant treatment including selective serotonin reuptake inhibitor (SSRI) use from 1992 to 1997 among the elderly diagnosed with depression, using a large, nationally representative survey of Medicare beneficiaries. Relationships between use of new generation antidepressant treatment and socioeconomic characteristics, physical comorbidity, insurance coverage, and care sector (mental health specialty vs. general health services) are explored. RESEARCH DESIGN: Merged survey data, Medicare claims, and detailed self-reports from the Medicare Current Beneficiary Survey were used to explore use of new generation antidepressant treatment.SUBJECTS Medicare beneficiaries aged 65 and older living in the community, enrolled in fee-for-service Medicare throughout the year and diagnosed with depression. RESULTS: In 1997, among an estimated 1.1 million community dwelling older adults with diagnosis of depression in health care claims, nearly two thirds received antidepressant treatments. Among those diagnosed with depression and treated with antidepressants, the use of new generation antidepressants increased from 35% in 1992 to 77% in 1997. The rates of use increased among all subgroups examined. In the early years after the introduction of these new antidepressant medications (1992-1994), there were socioeconomic disparities in use of these medications, with less use by less educated and poor patients. However, these differences abated over time. CONCLUSIONS: An increasing proportion of elderly treated for depression with antidepressants received the new generation antidepressants. The diffusion of these new medications lagged for those with low socioeconomic status defined by education and income. This diffusion process conforms to a general model of diffusion in which during the initial years following introduction of a new treatment, especially one which is costly, early adopters of the treatment are likely to disproportionately represent those of higher socioeconomic status.

Age Factors↗

PubMed2003

Ante- and postpartum substance abuse treatment and antiretroviral therapy among HIV-infected women on Medicaid.

OBJECTIVE: To examine temporal associations between obstetrics/gynecology (ob/gyn) care, substance abuse treatment (SAT), and antiretroviral therapy (ART) during and after pregnancy among HIV-infected women on Medicaid. METHOD: We identified 345 women, representing 378 deliveries, from merged New Jersey AIDS/HIV surveillance data and paid Medicaid claims data between 1992 and 1998. T-tests were used to analyze person-level differences in service use before and after delivery. Data were converted to person-months to predict SAT and receipt of ART in multivariate regressions that corrected for correlations among repeated observations. RESULTS: Compared to antepartum months there were significant reductions in ART and ob/gyn care in postpartum months and a significant increase in substance abuse. Multivariate analyses showed that compared to other months, women were more likely to obtain SAT during the postpartum period (odds ratio [OR] 1.51, 95% confidence interval [CI], 1.31-1.74); conversely, women were more likely to receive ART in the antepartum period (OR 1.77, 95% CI, 1.43-2.17). Ob/gyn care predicted ART and SAT, regardless of the timing of care relative to delivery. African American women were least likely to receive SAT and ART. CONCLUSION: Our findings underscore that ob/gyn providers have a central position in pathways to care for a vulnerable population of women with multiple health care needs and that patterns of ART use and SAT shift markedly during the months before and after delivery. However, receipt of ob/gyn care during these months is not associated with the changes, suggesting that ob/gyn providers may have untapped opportunities during the ante- and postpartum months to educate women with HIV/AIDS about the importance of consistent use of ART and to provide SAT referrals as needed. These results may have implications for policy makers interested in promoting adherence to ART and decreasing substance abuse among women with HIV/AIDS.

Adult↗

PubMed2002

Zidovudine use during pregnancy among HIV-infected women on Medicaid.

OBJECTIVES: This study estimates the rate of zidovudine (ZDV) use during pregnancy among HIV-infected women receiving Medicaid. The rates of ZDV use during pregnancy are compared before (preperiod) and after (postperiod) the 1994 publication of US Public Service Task Force guidelines, recommending use of ZDV during pregnancy. The authors also compare and contrast the correlates of ZDV use during pregnancy in each of the preguideline and postguideline periods. METHODS: New Jersey AIDS/HIV surveillance data and paid Medicaid claims data between 1992 and 1996 were merged to examine ZDV use during pregnancy. Among ZDV users, the authors also examined persistence of ZDV use during the 3 months preceding delivery. In these analyses, the authors examined care received during pregnancy and differentiated routine medical care from pregnancy-specific care. Correlates of intrapregnancy ZDV use were examined using chi2 analysis and robust regression techniques that correct for correlation among repeated observations. RESULTS: Use of ZDV during pregnancy steadily increased from 13% in 1992 to 70% in 1996, with the upward trend beginning before the release of the guidelines. Averaged over the full preperiod (1992-1994), the rate was 29%, increasing to 57% during the full postperiod (1995-1996). Women with no health care during pregnancy did not receive any ZDV prophylaxis. Women who had some health care contacts, but did not receive pregnancy-specific care, had low rates of ZDV use that did not increase after the promulgation of the guidelines (21% in preperiod and 27% in postperiod). Women who received pregnancy-specific care, whether from obstetrician-gynecologists (OB-GYNs) or other providers, substantially increased their use of ZDV in the postguideline period (from 37% to 63% for those who saw OB-GYNS, and from 20% to 59% for those who received pregnancy-specific care from other providers). However, among users of ZDV, only a minority (24%) used ZDV persistently during the 3 months preceding delivery. African American women were less likely to be persistent ZDV users, even after controlling for other factors. CONCLUSIONS: The study highlights the underutilization of ZDV by women who did not receive pregnancy-related care, even after the publication of guidelines. Lack of pregnancy-specific medical care during pregnancy is an important barrier to ZDV prophylaxis. This study confirms that the receipt of prenatal care during pregnancy is a key intervening variable in the real world application of the PHS guidelines and underscores the importance of proactive efforts to provide prenatal care to pregnant women with HIV.

Adult↗

PubMed2002

Medical expenditures during the last year of life: findings from the 1992-1996 Medicare current beneficiary survey.

OBJECTIVE: To compare medical expenditures for the elderly (65 years old) over the last year of life with those for nonterminal years. DATA SOURCE: From the 1992-1996 Medicare Current Beneficiary Survey (MCBS) data from about ten thousand elderly persons each year. STUDY DESIGN: Medical expenditures for the last year of life and nonterminal years by source of payment and type of care were estimated using robust covariance linear model approaches applied to MCBS data. DATA COLLECTION: The MCBS is a panel survey of a complex weighted multilevel random sample of Medicare beneficiaries. A structured questionnaire is administered at four-month intervals to collect all medical costs by payer and service. Medicare costs are validated by claims records. PRINCIPAL FINDINGS: From 1992 to 1996, mean annual medical expenditures (1996 dollars) for persons aged 65 and older were $37,581 during the last year of life versus $7,365 for nonterminal years. Mean total last-year-of-life expenditures did not differ greatly by age at death. However, non-Medicare last-year-of-life expenditures were higher and Medicare last-year-of-life expenditures were lower for those dying at older ages. Last-year-of-life expenses constituted 22 percent of all medical, 26 percent of Medicare, 18 percent of all non-Medicare expenditures, and 25 percent of Medicaid expenditures. CONCLUSIONS: While health services delivered near the end of life will continue to consume large portions of medical dollars, the portion paid by non-Medicare sources will likely rise as the population ages. Policies promoting improved allocation of resources for end-of-life care may not affect non-Medicare expenditures, which disproportionately support chronic and custodial care.

Aged↗

PubMed2002

Response to symptoms among a U.S. national probability sample of adults infected with human immunodeficiency virus.

Previous studies concerning disparities in Human Immunodeficiency Virus (HIV) services use among vulnerable groups did not control for specific clinical need for care such as symptom events. Using the Andersen Behavioral Model of Health Services Use, the authors determined whether minorities, women, and the less educated (vulnerable groups) were less likely to receive care for HIV symptoms. Persons enrolled in the HIV Cost and Services Utilization Study were asked whether they received care for their most bothersome symptom. Surprisingly, minorities and women were no more likely to go without care than other groups. Those with Medicaid, Medicare, private health maintenance organization (HMO) insurance, or no insurance were less likely to receive care for symptoms than those with private-non-HMO insurance. Vulnerable groups were no less likely to use services for HIV-related symptoms when need for care was considered. However, disparities may exist for symptom-specific care among HIV infected persons covered by public or HMO insurance.

Adolescent↗

PubMedDate not supplied

Trends in elderly patients' office visits for the treatment of depression according to physician specialty: 1985-1999.

Changes from 1985 to 1999 in diagnosis of depression and prescription of antidepressant medications during visits by elderly patients to primary care physicians, psychiatrists, and other specialists were examined. Using nationally representative surveys of office-based practices, estimates of the proportion of office visits by elderly patients during which a physician diagnosed depression or prescribed an antidepressant medication were obtained. Between 1985 and 1993-1994, a significant increase in the rate of depression diagnosis was seen, but no change was observed between 1993-1994 and 1998-1999. Rates of prescribing of antidepressants more than doubled between 1985 and 1998-1999. The majority of depression visits and visits where an antidepressant was prescribed were to primary care physicians in all time periods examined. Primary care depression treatment initiatives should place greater emphasis on elderly patients.

Aged↗