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PubMed2000

Identifying persons with chronic conditions in a managed care setting. A comparison of methods.

PURPOSE: Together, the sophisticated computerized information systems and defined, stable populations within Health Maintenance Organizations (HMOs) can reduce imprecision associated with modeling disease incidence and prevalence. Such data are useful for resource allocation, intervention planning, epidemiological study and surveillance. Identifying all cases of illness within such a defined population is vital to these aims, yet detailed diagnostic information is lacking in many pre-paid plans. In this presentation, diagnostic and prescription data are compared for their ability to assess the treatment prevalence for 28 chronic medical conditions.METHODS: Group Health Cooperative is a mixed model HMO in Western WA state. Automated records for calendar year 1999 were examined for 182,174 commercially insured patients age 20-64. Prescription drug data and International Classification of Disease-9(th) Clinical Modification codes (ICD-9CM) were used to identify 28 chronic medical conditions among patients. Chi square tests were performed to compare results produced by the two methods.RESULTS: The diagnostic method worked best for conditions with no clear pharmacologic treatment. However, the pharmacy-based method better identified patients with chronic illnesses initially diagnosed prior to 1999, and with disorders for which standard diagnostic codes are inconsistently utilized, such as mental health conditions.CONCLUSIONS: While both diagnostic and pharmacy-based methods perform well in identifying a limited set of conditions, each performs poorly under certain circumstances. A hybrid method utilizing both diagnostic and pharmacy data may be more appropriate for an HMO setting. Additional research is needed to develop and refine such a method.

Journal Article↗
PubMed1995

Verbal exchange structure of brief psychodynamic-interpersonal and cognitive-behavioral psychotherapy.

A verbal exchange is a set of 2 people's co-occurring speech-act categories that accomplish some subtask within an interpersonal encounter. Factor analysis of verbal response mode (speech act) frequencies in 1,630 segments (each approximately 10 to 12 min) drawn from the brief psychodynamic-interpersonal or cognitive-behavioral treatment of 39 mainly depressed clients identified 6 exchanges in each treatment--4 that were the same in both treatments (Revealing, Storytelling, Explaining, and Inquiring) and 2 that distinguished each treatment (Exploring and Interpreting in psychodynamic-interpersonal treatment; Prescribing and Reframing in cognitive-behavioral treatment). The exchanges showed distinctive temporal patterns across segments of sessions and across sessions of each time-limited treatment. The verbal exchange is a midsize concept that links atomistic verbal codes with clinical or theoretical concepts.

Adult↗
PubMed2001

Increasing rates of hospitalization due to septicemia in the US elderly population, 1986-1997.

Rates of hospitalization due to septicemia (International Classification of Diseases, Ninth Revision, Clinical Modification, code 038) in the US elderly population for 1986-1997 were examined, using Medicare administrative data. Age group-, sex-, and race-adjusted rates more than doubled from 1986 through 1997, from 3.42 to 7.42 per 1000 beneficiaries. The 1997 rates of septicemia increased with age, from 4.47 per 1000 beneficiaries among persons 65-74 years old to 18.1 per 1000 beneficiaries among persons > or =85 years old. The rates of septicemia were slightly greater among men (7.46 per 1000 beneficiaries) than among women (7.39 per 1000 beneficiaries) and were higher among blacks (13.61 per 1000 beneficiaries) than among whites (6.89 per 1000 beneficiaries). The most likely sites of the origin of the septicemia were the urinary tract (40.1%) and lungs (15.3%). Escherichia coli and Staphylococcus species were the most frequently reported organisms. Diabetes was listed as a comorbidity in 24.5% of the hospitalizations. We estimate that the cost to Medicare for septicemia hospitalizations in 1997 was >$1.8 billion.

Aged↗
PubMed2000

Use of comorbidity scores for control of confounding in studies using administrative databases.

BACKGROUND: Comorbidity scores are increasingly used to reduce potential confounding in epidemiological research. Our objective was to compare metrical and practical properties of published comorbidity scores for use in epidemiological research with administrative databases. METHODS: The literature was searched for studies of the validity of comorbidity scores as predictors of mortality and health service use, as measured by change in the area under the receiver operating characteristic (ROC) curve for dichotomous outcomes, and change in R(2) for continuous outcomes. RESULTS: Six scores were identified, including four versions of the Charlson Index (CI) which use either the three-digit International Classification of Diseases, Ninth Revision (ICD-9) or the full ICD-9-CM (clinical modification) code, and two versions of the Chronic Disease Score (CDS) which used outpatient pharmacy records. Depending on the population and exposure under study, predictive validities varied between c = 0.64 and c = 0.77 for in-hospital or 30-day mortality. This is only a slight improvement over age adjustment. In one study the simple measure 'number of diagnoses' outperformed the CI (c = 0.73 versus c = 0.65). Proprietary scores like Ambulatory Diagnosis Groups and Patient Management Categories do not necessarily perform better in predicting mortality. Comorbidity indices are susceptible to a variety of coding errors. CONCLUSIONS: Comorbidity scores, particularly the CDS or D'Hoore's CI based on three-digit ICD-9 codes, may be useful in exploratory data analysis. However, residual confounding by comorbidity is inevitable, given how these scores are derived. How much residual confounding usually remains is something that future studies of comorbidity scores should examine. In any given study, better control for confounding can be achieved by deriving study-specific weights, to aggregate comorbidities into groups with similar relative risks of the outcomes of interest.

Comorbidity↗
PubMed1999

Epidemiology of Crohn's disease and ulcerative colitis in a central Canadian province: a population-based study.

The aim of this study was to assess the accuracy and utility of administrative health data in identifying persons with inflammatory bowel disease on a population basis and to determine the incidence and prevalence of this disease in the Canadian province of Manitoba. The data from Manitoba Health (the province's single insurer) were used to identify residents with physician and/or hospital contacts for Crohn's disease or ulcerative colitis based on International Classification of Diseases, Ninth Revision, Clinical Modification, codes between 1984 and 1995. Of 5,182 eligible individuals, 4,514 were mailed questionnaires and 2,725 responded. Cases were defined as individuals with five or more separate medical contacts with one of these diagnoses or three or more such contacts if they were resident for less than 2 years. The accuracy of the study case definitions was high when compared with either self-report or chart review. The 1989-1994 age- and sex-adjusted annual incidence was 14.6/100,000 for Crohn's disease and 14.3/100,000 for ulcerative colitis. The prevalence of Crohn's disease in 1994 was 198.5/100,000, and that of ulcerative colitis was 169.7/100,000. In conclusion, the authors have successfully established and validated a population-based database of inflammatory bowel disease based on administrative data. The high incidence rates and dynamic epidemiology of inflammatory bowel disease in Manitoba indicate the presence of important environmental risk factors, which warrants further investigation.

Adolescent↗
PubMed1999

Placenta previa: preponderance of male sex at birth.

To determine the relation between placenta previa and male sex at birth, the authors conducted two types of analysis: 1) a historical cohort analysis of singleton live births in New Jersey hospitals during 1989-1992 (N = 447,963); and 2) a meta-analysis of previously published studies on the subject. For the cohort analysis, subject mother-infant dyads were identified from linked birth certificate and maternal and infant hospital claims data. The infant's sex for mothers with an International Classification of Diseases, Ninth Revision, Clinical Modification, code of 641.0-641.1 for placenta previa (n = 2,685) was compared with infant's sex for mothers without placenta previa (n = 445,270). For the meta-analysis, seven published articles were located and summary effects were calculated using both fixed-effect and random-effects models. In the present cohort study, the male:female ratio at birth was significantly higher in women with placenta previa (1.19) than in those without placenta previa (1.05) (p<0.001). The association of placenta previa with male sex persisted when the analysis was either stratified or adjusted for the effects of maternal age, maternal parity, maternal smoking during the index pregnancy, race/ethnicity, the infant's gestational age, and the infant's birth weight. The meta-analytic results from the fixed-effect and random-effects models showed a 14% excess of placenta previa when women were carrying a viable male fetus as compared with a viable female fetus during pregnancy. The results were the same regardless of whether the present cohort study was included in the meta-analysis. In conclusion, the evidence obtained from these analyses strongly argues for an association between placenta previa and male sex at birth. The mechanism for this association remains to be determined.

Cohort Studies↗
PubMed1999

A computerized method of identifying potentially preventable heart failure admissions.

Heart failure (HF) is both highly prevalent and costly to society. Successful self-care is essential to effective HF management. This study sought to develop a method to identify, via medical records (International Classification of Diseases, 9th Revision, Clinical Modification) coding, HF admissions attributable to ineffective self-care. Expert panels completed an iterative series of mailed surveys to generate and validate a list of coded diagnoses that represent HF sequelae modifiable through self-care. Sixteen diagnoses resulted. Chart review at one hospital revealed that these modifiable sequelae were frequently present but not coded. A computerized method of identifying self-care deficits would allow nurses to identify patients in need of patient education.

Abstracting and Indexing↗
PubMed1995

Triage in an established trauma system.

OBJECTIVE: The goal of this study was to determine patient and injury characteristics that predict undertriage and overtriage. DESIGN: This study was a retrospective analysis of admissions for acute injury. MATERIALS AND METHODS: All admissions for acute injuries in a 2 1/2-year period were included (N = 26,025). ICD-9 clinical modification codes were converted to Injury Severity Scores. MAIN RESULTS: Seventy-nine percent of severely injured patients were admitted to level I trauma centers. Severely injured patients admitted to other hospitals (undertriage) were more likely elderly (odds ratio = 5.44) and less likely had multisystem injuries (odds ratio = 0.55). One-fourth of patients with minor injuries were admitted to level I trauma centers (overtriage). Overtriaged patients were more likely intoxicated, obese, or had an injury to the head or face. CONCLUSIONS: In a developed trauma system, severely injured elderly trauma patients (especially females) are at risk for undertriage. The characteristics of patients at risk for overtriage reflect the difficulties of prospective out-of-hospital triage.

Adult↗
PubMed1997

Influence of a statewide trauma system on pediatric hospitalization and outcome.

BACKGROUND: During the years 1987-1991, a statewide trauma system was implemented in Oregon (Ore) but not in Washington (Wash). Incidence of hospitalization, frequency of death and risk-adjusted odds of death for injured children (< 19 years) in the two adjacent states were compared for two time periods (1985-1987 and 1991-1993). METHODS: State populations of injured children (International Classification of Diseases, 9th Revision-Clinical Modification, code 800-959) were identified through a Hospital Discharge Index. Hospitals in counties with a population density < 50 persons/square mile were designated rural. Incidence rates are events/10,000 pediatric population per year. RESULTS: The pediatric population increased in both states (Ore: 687,000-758,000; Wash: 1,159,000-1,336,000). Incidence of hospitalization for all injured children in entire states declined (Ore: 66.5-38.5; Wash: 54-33); also in rural hospitals (Ore: 67.5-32; Wash: 48 to 31). Seriously injured children (score on the Injury Severity Scale > 15) had a lower incidence in 1991-1993 of admission to rural hospitals (Ore: 2.98; Wash: 2.82) compared with incidence for entire states (Ore: 4.61; Wash: 4.62); in 1985-1987 the incidence was not different. Furthermore risk adjusted odds of death for seriously injured children was significantly lower in Oregon than in Washington in the later time period. CONCLUSION: Both states show a similar temporal trend toward a declining frequency of death for children hospitalized with injuries. Injury prevention strategies appear to have reduced the number of serious injuries in both states. However, seriously injured children demonstrated a reduced risk of death in Oregon, consistent with benefit from a statewide trauma system.

Adolescent↗
PubMed1992

Risk factors for disease in a homeless population.

Risk factors of smoking, drug and alcohol abuse, obesity, and sedentary lifestyle were related to health problems of clients at a walk-in clinic for the homeless. The sample of 1252 clients was predominately male (91.4%) and multiethnic, with a majority (65%) age 18 to 40 years. Data on diagnoses of health-related conditions were collected from clinic charts, coded into ICD categories, analyzed for relationships of risk factors to health problems, and compared with categories of diagnoses in a matched national sample of ambulatory care visits. Findings indicate that a larger proportion of homeless suffered from health problems in 24 of 27 diagnostic categories than the nonhomeless. Most prevalent were respiratory, dermal conditions, injuries, and digestive problems, in that order. Risk factors of alcohol abuse, smoking, sedentary lifestyle, drug abuse, and obesity were predictive of health problems in 18 of the categories analyzed. The findings suggest that immediate interventions such as education and rehabilitation to reduce risk factors, and provision of facilities for personal hygiene and cleaning of clothing could reduce some of the health-related conditions in this population while longer-term solutions of housing and employment are sought. The analysis model developed here appears to be a useful way of comparing relative effects of risk factors as a basis for establishing priorities for interventions.

Adolescent↗
PubMed2001

The prevalence of extraintestinal diseases in inflammatory bowel disease: a population-based study.

OBJECTIVE: The aim of this study was to determine the prevalence of the major extraintestinal manifestations of inflammatory bowel disease (IBD) and their relation to disease diagnosis and gender. METHODS: We used the population-based University of Manitoba IBD Database, which includes longitudinal files on all subjects of all health system contacts identified by International Classification of Diseases, 9th Revision, Clinical Modification codes for visit diagnosis. We extracted a cohort from our database, which included subjects with a known diagnosis of IBD for at least 10 yr. We then determined how many contacts each subject had for each of the following extraintestinal IBD-associated immune diseases: primary sclerosing cholangitis, ankylosing spondylitis, iritis/uveitis, pyoderma gangrenosum, and erythema nodosum. We calculated the prevalence of the extraintestinal diseases using an administrative definition of having at least five health system contacts for the diagnosis in question. This administrative definition has previously been validated in Crohn's disease and ulcerative colitis (UC). RESULTS: A total of 6.2% of patients with IBD had one of six major extraintestinal diseases studied in this report. Only 0.3% of patients had multiple extraintestinal diseases. Iritis/uveitis was the most common extraintestinal disease of all assessed (2.2% of women and 1.1% of men). Iritis/uveitis was more common among women, particularly those with UC (3.8%). Primary sclerosing cholangitis was most common among men with UC (3%). Ankylosing spondylitis was more common among men, and the highest rate was seen among men with Crohn's disease (2.7%). Pyoderma gangrenosum was more common in Crohn's (1.2%) with no gender predilection. Erythema nodosum was similarly present in Crohn's and UC but was more common among women (1.9%). CONCLUSIONS: The associations of immune mediated diseases in extraintestinal sites may help us to further our understanding of IBD pathogenesis, and it may help us in developing a paradigm of disease subsets.

Adult↗
PubMed1983

Ethical aspects of clinical chemistry.

The work performed by the clinical chemist may deeply affect the decisions of the doctor and the well-being of the patient. Yet in contrast to the doctor and to the nurse the clinical chemist usually has no personal relationship with the patient. Being encumbered by much technology and anonymity is itself a reason for scrutinising his involvement in issues of health care ethics. This is an attempt at clarifying some major aspects: the relationship of his professional ethics to medical ethics as a whole, his ethical obligations to the patient and to society, and other aspects.

Chemistry, Clinical↗
PubMed2000

Socioeconomic status is an important determinant of the use of invasive procedures after acute myocardial infarction in New York State.

BACKGROUND: Patient and hospital characteristics influence the use of invasive cardiac procedures. Whether socioeconomic status (SES) has an influence that is independent of these other determinants is unclear. The purpose of the present study was to examine the influence of household income as a measure of SES on the use of invasive cardiac procedures among a large group of patients with acute myocardial infarction. METHODS AND RESULTS: We analyzed administrative discharge data from 231 nonfederal acute care hospitals in New York State that involved 28 698 black or white inpatients with International Classification of Diseases, Ninth Revision, Clinical Modification code 410.XX in the principal diagnosis position between January 1 and December 31, 1995. Household income was derived from postal ZIP codes and census data. The use of cardiac catheterization, PTCA, CABG, and any revascularization procedure was examined across groups stratified by income. Patients who resided in lower-income neighborhoods were more often female or black, had a higher prevalence of coexistent illness, had a higher use of Medicaid insurance, and were less often admitted to urban hospitals or hospitals that provide on-site CABG and PTCA. Crude and adjusted odds ratios for catheterization, PTCA, CABG, and any revascularization procedure were related to income in a graded fashion. After adjustment, patients in the highest quintile of income were 22% more likely to undergo catheterization, 74% more likely to undergo PTCA, 48% more likely to undergo CABG, and 76% more likely to undergo any revascularization procedure than were patients in the lowest quintile. The difference in cardiac catheterization did not fully account for income-based differences in revascularization, because income remained a significant determinant of revascularization after accounting for whether a catheterization was performed. Even among patients treated in hospitals that provide on-site CABG and PTCA, income was a significant determinant of procedures. CONCLUSIONS: Lower-income patients hospitalized for acute myocardial infarction are more often female or black, have more coexisting illnesses, and are less often admitted to urban hospitals or hospitals that provide CABG and PTCA. Even after adjustment for these and other factors, lower income is a negative predictor of procedure use.

Black or African American↗
PubMed1994

Use of Medicare claims data to estimate national trends in stroke incidence, 1985-1991.

BACKGROUND AND PURPOSE: Although stroke mortality has been declining in the United States for decades, recent trends in stroke incidence based on national data have not been described. We used Medicare hospitalization data to estimate national trends in the incidence of stroke among Americans aged 70 years or older, and we provide evidence of the validity of the estimate. METHODS: We defined stroke as a principal diagnosis with International Classification of Diseases, 9th Revision, Clinical Modification codes 430 to 434 or 436 to 437. We excluded many recurrent cases from the analysis by eliminating persons hospitalized for stroke during the 5 years preceding the index stroke. We calculated annual adjusted incidence rates and examined trends graphically. We investigated the effect of different exclusion periods, trends in in-hospital mortality of stroke patients, and trends in out-of-hospital stroke mortality. We examined trends in relation to sex, race, and age. RESULTS: The estimated age- and sex-adjusted stroke incidence declined 9.5% from 1985 to 1989, then increased 3.3% to 1991. The pattern did not vary with the length of the exclusion period or when all listed diagnosis rather than principal diagnoses were used to identify stroke cases. Incidence trends resembled the overall trend for both men and women, for 5-year age groups, and for whites; the trend did not change for blacks. CONCLUSIONS: Stroke incidence declined steadily from 1985 to 1989 and then increased slightly to 1991. Several postulated potential sources of bias were investigated and found to be unlikely to account for the incidence decline, although some may have contributed to the subsequent incidence increase.

Age Factors↗
PubMed1993

The MMPI and MMPI-2 in an outpatient sample: comparisons of code types, validity scales, and clinical scales.

Two hundred (N = 200) outpatients completed MMPI (W.G. Dahlstrom, Walsh, & L.G. Dahlstrom, 1989) and MMPI-2 (Butcher, W.G. Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) items at one time, permitting comparison of alternate forms. The concordance rate for elevated codetypes was 58%; for 2-point codetypes independent of elevation, it was also 58%. Only 50% of the men compared to 66% of the women showed concordance between forms. Of the 200 cases, 72 (36%) had codetypes that were both elevated and "well defined." The concordance rate among these 71 cases was 72%. Comparison of mean raw scores for the validity and clinical scales showed a small difference for MMPI versus MMPI-2 (Form) on Scales 2 and 5, small differences for Gender on Scales 1, 2, and 3, and no Gender by Form interactions. There were significant MMPI versus MMPI-2 differences for T-scores on all scales, and there were significant Gender by Form interactions for T-scores on all scales except Scale L, Scale K, and Scale 6 (excluding Scale 5). Comparison of mean T-scores (excluding Scale 5) showed no significant differences for Gender on the 12 scales. In spite of significant mean differences, correlational analyses show correlations above .96 for the raw scores and T-scores for each gender, indicating that rank ordering of cases is maintained between forms. These results are discussed in terms of the issues for use of the MMPI-2 compared to the MMPI.

Adult↗
PubMed2000

Factors influencing infant visits to emergency departments.

OBJECTIVES: To follow the 1995 birth cohort of infants, born in the State of Missouri, through their first birthday to: 1) examine their rates of visits to emergency departments (EDs), 2) identify predictors of any ED visit, 3) examine rates of nonurgent ED visits, and 4) identify predictors of nonurgent visits. METHODS: This was a retrospective population cohort study. Using deterministic linkage procedures, 2 databases at the Missouri Department of Health (DOH; (the patient abstract database and the birth registry database) were linked by DOH personnel. International Classification of Diseases, Ninth Revision-Clinical Modification codes for ED visits were classified as emergent, urgent, or nonurgent by 2 researchers. Eight newborn characteristics were chosen for analysis. Negative binomial regression was used to examine the rates and predictors of both total and nonurgent ED visits. RESULTS: There were 935 total ED visits and 153 nonurgent ED visits per 1000 infant years. The average number of visits was.94, with 59% of infants having no visits, 21% having 1 ED visit, and 20% having 2 or more visits. Factors associated with increases in both total and nonurgent ED visits were Medicaid, self-pay, black race, rural region, presence of birth defects, and a nursery stay of >2 days. Significant interactions were found between Medicaid and race and Medicaid and rural regions on rates of ED use and nonurgent use. The highest rate of ED use, 1.8 per person year, was seen in white, rural infants on Medicaid, and the lowest rate (.4 per person year) was seen in urban white infants not on Medicaid. The highest rates of nonurgent use,.3 per person year, were among urban and rural Medicaid infants of both races and among black infants on commercial insurance. The lowest nonurgent rate,.04 per person year, was seen in white urban infants on commercial insurance. CONCLUSION: Infants in the State of Missouri have high rates of ED visits. Nonurgent visits are only a small portion of ED visits and cannot explain large variations in ED usage. Increased ED use by Medicaid patients may reflect continuing difficulties in accessing primary care.

Age Factors↗