Biomedical subjects

Willard G Manning

Publications and source records attributed to Willard G Manning.

13 recordsLinked to original sources

PubMed2007

Cost-effectiveness of systematic depression treatment among people with diabetes mellitus.

CONTEXT: Depression co-occurring with diabetes mellitus is associated with higher health services costs, suggesting that more effective depression treatment might reduce use of other medical services. OBJECTIVE: To evaluate the incremental cost and cost-effectiveness of a systematic depression treatment program among outpatients with diabetes. DESIGN: Randomized controlled trial comparing systematic depression treatment program with care as usual. SETTING: Primary care clinics of group-model prepaid health plan. PATIENTS: A 2-stage screening process identified 329 adults with diabetes and current depressive disorder. INTERVENTION: Specialized nurses delivered a 12-month, stepped-care depression treatment program beginning with either problem-solving treatment psychotherapy or a structured antidepressant pharmacotherapy program. Subsequent treatment (combining psychotherapy and medication, adjustments to medication, and specialty referral) was adjusted according to clinical response. MAIN OUTCOME MEASURES: Depressive symptoms were assessed by blinded telephone assessments at 3, 6, 12, and 24 months. Health service costs were assessed using health plan accounting records. RESULTS: Over 24 months, patients assigned to the intervention accumulated a mean of 61 additional days free of depression (95% confidence interval [CI], 11 to 82 days) and had outpatient health services costs that averaged $314 less (95% CI, $1007 less to $379 more) compared with patients continuing in usual care. When an additional day free of depression is valued at $10, the net economic benefit of the intervention is $952 per patient treated (95% CI, $244 to $1660). CONCLUSIONS: For adults with diabetes, systematic depression treatment significantly increases time free of depression and appears to have significant economic benefits from the health plan perspective. Depression screening and systematic depression treatment should become routine components of diabetes care.

Ambulatory Care↗

PubMed2006

Using the SF-12 health status measure to improve predictions of medical expenditures.

BACKGROUND: Relatively few studies have used self-reported health status in models to predict medical expenditures, and many of these have used the SF-36. OBJECTIVES: We sought to examine the ability of the briefer SF-12 measure of health status to predict medical expenditures in a nationally representative sample. METHODS: We used data from the 2000-2001 panel of the Medical Expenditure Panel Study. Respondents (n = 5542) completed the SF-12 in a questionnaire. Interviews obtained data on demographics and selected chronic conditions. Data on expenditures incurred subsequent to the interview were obtained in part from provider records. We examined different regression model specifications and compared different statistical estimation techniques. RESULTS: Adding the SF-12 to a regression model improved the prediction of subsequent medical expenditures. In a model with only age and gender, adding the SF-12 increased R from 0.06 to 0.13. The coefficients for the Physical Component Summary (PCS) and the Mental Component Summary (MCS) of the SF-12 for this model were -0.045 (P < 0.01) and -0.012 (P < 0.01), respectively. In a model including demographic characteristics, chronic conditions, and previous expenditures, adding the SF-12 increased the R from 0.26 to 0.29. The coefficients for the PCS and the MCS for this model were -0.025 (P < 0.001) and -0.005 (P = 0.15), respectively. A single general health status question performed almost as well as the full SF-12. Models estimated using ordinary least squares had undesirable properties. In terms of R, a generalized linear model (GLM) with a Poisson variance function was consistently superior to a GLM with a gamma variance function. CONCLUSIONS: Information on self-reported health status is useful in predicting medical expenditures. The extent to which the SF-12 adds predictive power over a comprehensive array of diagnostic data remains to be examined.

Adolescent↗

PubMed2005

Cardiovascular risk profile earlier in life and Medicare costs in the last year of life.

BACKGROUND: Health care costs are generally highest in the year before death, and much attention has been directed toward reducing costs for end-of-life care. However, it is unknown whether cardiovascular risk profile earlier in life influences health care costs in the last year of life. This study addresses this question. METHODS: Prospective cohort of adults from the Chicago Heart Association Detection Project in Industry included 6582 participants (40% women), aged 33 to 64 years at baseline examination (1967-1973), who died at ages 66 to 99 years. Medicare billing records (1984-2002) were used to obtain cardiovascular disease-related and total charges (adjusted to year 2002 dollars) for inpatient and outpatient services during the last year of life. Participants were classified as having favorable levels of all major cardiovascular risk factors (low risk), that is, serum cholesterol level lower than 200 mg/dL (<5.2 mmol/L), blood pressure 120/80 mm Hg or lower and no antihypertensive medication, body mass index (calculated as weight in kilograms divided by the square of height in meters) lower than 25, no current smoking, no diabetes, and no electrocardiographic abnormalities, or unfavorable levels of any 1 only, any 2 only, any 3 only, or 4 or more of these risk factors. RESULTS: In the last year of life, average Medicare charges were lowest for low-risk persons. For example, cardiovascular disease-related and total charges were lower by 10,367 dollars and 15,318 dollars compared with those with 4 or more unfavorable risk factors; the fewer the unfavorable risk factors, the lower the Medicare charges (P for trends <.001). Analyses by sex showed similar patterns. CONCLUSION: Favorable cardiovascular risk profile earlier in life is associated with lower Medicare charges at the end of life.

Adult↗

PubMed2005

Relationship of fruit and vegetable consumption in middle-aged men to medicare expenditures in older age: the Chicago Western Electric Study.

BACKGROUND: High fruit and vegetable intake is associated with lower risk of hypertension, cardiovascular disease, and cancer. Little is known about the relationship of fruit and vegetable intake to health care expenditures. OBJECTIVE: Examine whether fruit and vegetable intake among middle-aged adults is related to Medicare charges-total, cardiovascular disease, cancer-related-in older age. DESIGN: Participants were grouped into one of three strata according to fruit and vegetable intake, determined from detailed dietary history (1958-1959): less than 14 cups per month, 14 to 42 cups per month, or more than 42 cups per month. Combined intake was classified as low, medium, or high. Medicare claims data (1984-2000) were used to estimate mean annual spending for eligible surviving participants (65 years and older) from the Chicago Western Electric Study: 1,063 men age 40 to 55 and without coronary heart disease, diabetes, and cancer at baseline (1957-1958). Cumulative charges before death (n = 401) were also calculated. RESULTS: Higher fruit and fruit plus vegetable intakes were associated with lower mean annual and cumulative Medicare charges (P values for trend .019 to .862). For example, with adjustment for baseline age, education, total energy intake, and multiple baseline risk factors, annual cardiovascular disease-related charges were 3,128 dollars vs 4,223 dollars for men with high vs low intake of fruit plus vegetables. Corresponding figures were 1,352 dollars vs 1,640 dollars for cancer-related charges and 10,024 dollars vs 12,211 dollars for total charges. Results were generally similar for vegetable intake. CONCLUSION: These findings, albeit mostly not statistically significant, suggest that for men high intake of fruits and fruits plus vegetables earlier in life has potential not only for better health status but also for lower health care costs in older age.

Adult↗

PubMed2005

Generalized modeling approaches to risk adjustment of skewed outcomes data.

There are two broad classes of models used to address the econometric problems caused by skewness in data commonly encountered in health care applications: (1) transformation to deal with skewness (e.g., ordinary least square (OLS) on ln(y)); and (2) alternative weighting approaches based on exponential conditional models (ECM) and generalized linear model (GLM) approaches. In this paper, we encompass these two classes of models using the three parameter generalized Gamma (GGM) distribution, which includes several of the standard alternatives as special cases-OLS with a normal error, OLS for the log-normal, the standard Gamma and exponential with a log link, and the Weibull. Using simulation methods, we find the tests of identifying distributions to be robust. The GGM also provides a potentially more robust alternative estimator to the standard alternatives. An example using inpatient expenditures is also analyzed.

Models, Statistical↗

PubMed2005

One-hour postload plasma glucose in middle age and Medicare expenditures in older age among nondiabetic men and women: the Chicago Heart Association Detection Project in Industry.

OBJECTIVE: To examine associations in nondiabetic individuals of 1-h postload plasma glucose measured in young adulthood and middle age with subsequent Medicare expenditures for cardiovascular disease (CVD), diabetes, cancer, and all health care at age 65 years or older using data from the Chicago Heart Association Detection Project in Industry (CHA). RESEARCH DESIGN AND METHODS: Medicare data (1984-2000) were linked with CHA baseline records (1967-1973) for 8,580 men and 6,723 women ages 33-64 years who were free of coronary heart disease, diabetes, and major electrocardiogram (ECG) abnormalities and who were Medicare eligible (65+ years) for at least 2 years. Participants were classified based on 1-h postload plasma glucose levels <120, 120-199, or > or =200 mg/dl. RESULTS: With adjustment for baseline age, cigarette smoking, serum cholesterol, systolic blood pressure, BMI, ethnicity, education, and minor ECG abnormalities, the average annual and cumulative Medicare, total, and diabetes- and CVD-related charges were significantly higher with higher baseline plasma glucose in women, while only diabetes-related charges were significantly higher in men. For example, in women, multivariate-adjusted CVD-related cumulative charges were, respectively, USD 14,260, 18,909, and 21,183 for the three postload plasma glucose categories (P value for trend = 0.035). CONCLUSIONS: These findings suggest that maintaining low glucose levels early in life has the potential to reduce health care costs in older age.

Adult↗

PubMed2005

Welfare reform, insurance coverage pre-pregnancy, and timely enrollment: an eight-state study.

Implementation of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) broke the automatic linkage between Medicaid eligibility/enrollment and welfare cash assistance for women eligible at welfare income levels. This study used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) for the period 1996-1999 to examine insurance coverage of these and other pregnant women pre- and post-PRWORA. Controlling for individual characteristics and economic growth, the relative odds of having private insurance did not change while the odds of being Medicaid enrolled versus uninsured pre-pregnancy declined for welfare-eligible women post-PRWORA. The absolute effect was a decline of 7.9 percentage points in the probability of welfare-eligible women being insured. While these results apply to the early years of welfare reform, it is still likely that states can improve Medicaid outreach and enrollment of women eligible prior to pregnancy.

Adolescent↗

PubMed2004

Comparing alternative models: log vs Cox proportional hazard?

Health economists often use log models (based on OLS or generalized linear models) to deal with skewed outcomes such as those found in health expenditures and inpatient length of stay. Some recent studies have employed Cox proportional hazard regression as a less parametric alternative to OLS and GLM models, even when there was no need to correct for censoring. This study examines how well the alternative estimators behave econometrically in terms of bias when the data are skewed to the right. Specifically we provide evidence on the performance of the Cox model under a variety of data generating mechanisms and compare it to the estimators studied recently in Manning and Mullahy (2001). No single alternative is best under all of the conditions examined here. However, the gamma regression model with a log link seems to be more robust to alternative data generating mechanisms than either OLS on ln(y) or Cox proportional hazards regression. We find that the proportional hazard assumption is an essential requirement to obtain consistent estimate of the E(y|x) using the Cox model.

Health Services Research↗

PubMed2003

Alcohol dependence and the price of alcoholic beverages.

This study estimates the impact of the price of alcoholic beverages on latent dimensions of current alcohol dependence and abuse. A three-part econometric model is used to estimate the impact of price on three latent dimensions (factors). For heavier drinking, the estimated price elasticity is -1.325 (P = 0.027); for physical and other consequences of drinking, -1.895 (P = 0.003); for increased salience of drinking, -0.411 (P = 0.339). For a single latent factor characterized simply as dependence/abuse, estimated price elasticity is -1.487 (P = 0.012). These results suggest that higher prices for alcohol reduce important dimensions of current alcohol dependence and abuse.

Alcoholic Beverages↗

PubMed2003

Improving risk adjustment for Medicare capitated reimbursement using nonlinear models.

OBJECTIVES: This article compares a linear risk-adjusted model of medical expenditures for Medicare patients with a model that explicitly account for skewness in distribution of expenditures. METHODS: A model of expenditures and a model of the square root of expenditures, each expressed as linear combinations of risk adjusters, are estimated using data from the 1992 through 1994 Medicare Current Beneficiary Surveys. Five sets of risk adjusters are considered. Each combination of model and set of risk adjusters is tested for linearity, heteroscedasticity, in-sample fit (R2), forecast performance (forecast bias and forecast mean squared error), and overfitting the data. We analyze forecast performance (1)based on forecasts in same year used for estimation, and (2)based on forecasts in the year following that used for estimation. RESULTS: In the first analysis, the model using a square root transformation of expenditures as the dependent variable and the more parsimonious specification of risk adjusters performs best in terms of forecast squared error and overfitting. The untransformed model performs best in terms of forecast bias in each group based on severity of disability, with the exception of the severely disabled for whom the square root model is best. In the second analysis, the square root model performs better than the untransformed model in terms of forecast squared error, but neither model is statistically distinguishable from zero in terms of bias. CONCLUSIONS: Accounting for skewness in expenditures tends to improve precision but not necessarily bias, except among the severely disabled. Adjusting for health status improves risk adjustment.

Activities of Daily Living↗

PubMed2003

Association between interruptions in medicaid coverage and use of inpatient psychiatric services.

OBJECTIVES: Persons with schizophrenia are heavy and persistent users of Medicaid services. Interruptions in their Medicaid coverage may have serious consequences for the mental health of these individuals and their subsequent use of mental health services. This study sought to determine the impact of interruptions in Medicaid coverage on the use of Medicaid-reimbursed inpatient psychiatric services over a four-year period. METHODS: Inpatient Medicaid claims and eligibility files for 1,830 Medicaid beneficiaries with schizophrenia in Utah from December 1990 to December 1994 were used to identify differences in hospital admissions and total number of days in a hospital associated with interrupted Medicaid coverage. Of the 1,830 Medicaid beneficiaries identified, 1,463 experienced continuous Medicaid eligibility, and 367 had interruptions in their eligibility. RESULTS: Interruptions in Medicaid coverage were associated with an average of.63 more psychiatric hospitalizations per beneficiary over the four-year period, representing an 86 percent higher hospital admission rate. This increase appeared to be largely due to a subset of persons who have much higher hospitalization rates after an interruption in Medicaid coverage. Interruptions in Medicaid coverage were associated with a mean of 8.3 more days of psychiatric hospitalization over the four-year period, representing 61 percent more hospital days. CONCLUSIONS: Medicaid beneficiaries who experience interruptions in coverage have, on average, a significantly greater use of inpatient psychiatric services while participating in Medicaid than beneficiaries with continuous Medicaid coverage. These findings suggest potential benefits of maintaining continuous Medicaid eligibility for beneficiaries with a severe mental illness.

Eligibility Determination↗

PubMed2002

Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists.

BACKGROUND: Hospitalists may decrease costs and improve outcomes in hospitalized patients, but existing evidence is limited and has not identified mechanisms for such effects. OBJECTIVE: To study the costs and outcomes for patients on an academic general medicine service assigned to teams led by hospitalists and nonhospitalists. DESIGN: Cohort study. SETTING: Academic general medicine service. PATIENTS: 6511 patients admitted to the hospital from July 1997 through June 1999. INTERVENTION: All patients admitted every fourth day were assigned to 1 of 2 hospitalists caring for inpatients 6 months each year or 1 of 58 nonhospitalists caring for inpatients 1 to 2 months each year. MEASUREMENTS: Length of stay; inpatient costs; and 30-, 60-, and 365-day mortality. RESULTS: Patients assigned to hospitalists (24.8%) and nonhospitalists (75.2%) did not differ in age, race, sex, diagnosis mix, or Charlson index score. In year 1, average adjusted length of stay was 0.29 day shorter for patients cared for by hospitalists than by nonhospitalists (95% CI, -0.66 to 0.06 day; P = 0.06); in year 2, average adjusted length of stay was 0.49 day shorter for patients cared for by hospitalists (CI, -0.79 to -0.15 day; P = 0.01). Average adjusted costs were not significantly reduced for hospitalists compared with nonhospitalists in year 1 but were reduced by $782 in year 2 (CI, -$1313 to -$187; P = 0.01). When years 1 and 2 were combined or when year 1 was analyzed alone, 30-day mortality was not significantly different for hospitalists and nonhospitalists; however, 30-day mortality was 4.2% for hospitalists compared with 6.0% for nonhospitalists in year 2 (CI for difference, 1.8 percentage points [-3.6 to -0.1 percentage points]; P = 0.04) and the adjusted relative risk was 0.65 (CI, 0.44 to 0.96; P = 0.03). In multivariate analyses, resource use decreased with the physician's cumulative experience in caring for a patient's primary diagnosis. Mortality showed a similar pattern. CONCLUSIONS: Hospitalist care was associated with lower costs and short-term mortality in the second but not the first year of hospitalists' experience. Disease-specific physician experience may reduce resource use and improve patient outcomes; in addition, it may be an important determinant of the effectiveness of hospitalists.

Chicago↗

PubMedDate not supplied

Covering the uninsured: what is it worth?

One out of six Americans under age sixty-five lacks health insurance, a situation that imposes sizable hidden costs upon society. The poorer health and shorter lives of those without coverage account for most of these costs. Other impacts are manifested by Medicare and disability support payments, demands on the public health infrastructure, and losses of local health service capacity. We conclude that the estimated value of health forgone each year because of uninsurance (dollars 65-dollars 130 billion) constitutes a lower-bound estimate of economic losses resulting from the present level of uninsurance nationally.

Costs and Cost Analysis↗