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PubMed2006

Discharge practice patterns following cystectomy for bladder cancer: evidence for the shifting of the burden of care.

PURPOSE: Between 1985 and 2000 the incidence of bladder cancer in this country increased by 33%. Radical cystectomy is the primary treatment modality in patients with invasive disease. We characterized trends in cystectomy use and discharge practice patterns following cystectomy during a recent 13-year period. MATERIALS AND METHODS: The Nationwide Inpatient Sample comprises a 20% probability sample of hospital discharges in the United States each year. Patients who underwent cystectomy for bladder cancer from 1988 to 2000 were identified using International Classification of Disease, 9th Revision, Clinical Modification codes. Outcome variables included in-hospital mortality, length of stay and hospital discharge status. RESULTS: From 1988 to 2000 an estimated 119,491 patients underwent cystectomy for bladder cancer. Cystectomy rates decreased by 17% from 3.91/100,000 (1988 to 1990) to 3.25/100,000 (1997 to 2000), largely due to a decreasing number of partial cystectomies. In-hospital mortality decreased from 3.3% (1988 to 1990) to 2.5% (1997 to 2000) (p = 0.027). Similarly median length of stay decreased from 13 days (1988 to 1990) to 9 (1997 to 2000) (p <0.001). During the same period the percent of patients being discharged to subacute care facilities increased from 5.3% to 13.2% (p <0.001), as did the percent of patients requiring home health care services (24.1% to 38.7%, p <0.001). CONCLUSIONS: From 1988 to 2000 there was a decrease in the rate of cystectomies being performed for bladder cancer with a substantial decrease in partial cystectomy use. During this period short-term outcomes following cystectomy improved, while the use of subacute care facilities and home health services increased dramatically, underscoring a shift in the burden of care in this patient population.

Aftercare↗

PubMedDate not supplied

[Mental and behavior disorders in children placed in long term care institutions in Hunedoara, Cluj and Timis, Romania].

This article originated from a descriptive study done in 1992-1993 in Romania. The study was initiated and coordinated by the French NGO "Médecins du Monde", was directed by three health organizations (the "Observatoire régional de la santé de Languedoc-Roussillon", the "Unité 265 INSERM", the Romanian League for Mental Health) and was granted by the Romanian government and the European Community Commission. There are many publications about children's mental and behavioural disorders. But there are few epidemiological studies concerning the prevalence of these disorders among children suffering from social difficulties. This article explores the prevalence of mental and behavioral disorders among Romanian children institutionalized and examines specifically the prevalence among children in homes for children ("Casa de Copii") to compare it with similar data published in other countries. First, this article explores the prevalence of mental and behavioral disorders among a population of 4.692 children institutionalized in three Romanian districts in 1992. Second, this article examines the prevalence of these disorders among a population of 1.610 children institutionalized in homes for children ("Casa de Copii"), i.e. 1,610 children ages ranging from 4 to 18 years and suffering from social difficulties. Homes for children are out of home care institutions which are specialised neither in physical deficiencies nor in mental disorders. From this population, a randomized sample of 508 children has been screened by physicians and psychologists based on an evaluation protocol. Then each disorder has been coded as a diagnosis, according to the Tenth International Disease Classification (WHO). Fifty-four percent (54%) of the children institutionalized in homes for children in three Romanian districts in 1992 had a main diagnosis of mental or behavioural disorder. Third, this article compares our results to the prevalence found in other studies. Only three studies could be selected for comparison because they were the only ones with the three following criteria: 1) a focus on a population of children or a randomized sample of children ages ranging from 4 to 18 years, 2) a focus on children suffering from social difficulties and living in out of home care, 3) disorders evaluated by health professionals or a validated methodology. Our results lies within the range of prevalence found in the literature (41-70%). A discussion follows regarding methodological matters and critiques that may be launched from such a comparative designs. Finally, the high frequency of institutionalization in Romania in 1992 illustrates how few solutions there were to social difficulties and how exaggerated institutionalization was. This was a very different situation compared to Western Europe and Northern America. This should not hide, however, the actual modifications that took place in Romania. This article concludes with a brief description of the modifications which have been generated by the evaluation protocol used here.

Adolescent↗

PubMed2005

Identification of individuals with CKD from Medicare claims data: a validation study.

BACKGROUND: Medicare claims data might provide an efficient source for outcomes research in patients with chronic kidney disease (CKD). However, in the absence of laboratory data, one would need to identify patients with CKD from diagnosis codes associated with health care claims. The validity of this approach to identify patients with CKD has not been sufficiently studied. METHODS: From chart abstraction, we obtained the first serum creatinine measurement of 1,852 elderly Medicare beneficiaries upon hospitalization for myocardial infarction and estimated each patient's glomerular filtration rate. We then searched all Medicare claims of the preceding year for the presence of a diagnosis code for diabetic nephropathy, hypertensive nephropathy, chronic renal insufficiency, acute renal failure, and miscellaneous other renal diseases. Using the gold standard of an estimated glomerular filtration rate less than 60 mL/min/1.73 m2 (<1.00 mL/s/1.73 m2) for definition of CKD, we calculated the sensitivity, specificity, and positive and negative predictive values for each of these diagnoses and combinations of these diagnoses. RESULTS: The sensitivity of individual diagnosis algorithms ranged from 2.7% for diabetic nephropathy to 17.5% for miscellaneous. However, miscellaneous had a lower specificity (95.5%) than all other individual diagnosis algorithms (all > or =99%). Using combinations of these algorithms improved sensitivity up to 26.6%, but at the cost of lower specificity. Positive predictive values generally were high (85.7% to 97.5%), but negative predictive values were low (32.4% to 37.4%). CONCLUSION: High positive predictive values indicate that Medicare claims data can be used to accurately identify patients with CKD for study. However, the utility of such databases for comparison of patients with CKD versus lesser degrees of CKD is limited.

Aged↗

PubMed2004

Cost of illness of chronic angina.

BACKGROUND: Angina pectoris is one of the principal manifestations of coronary artery disease (CAD). Chronic angina is a debilitating condition that affects millions of people in the United States. OBJECTIVE: The objective of the study is to estimate, from a societal perspective, the direct costs of chronic angina in the year 2000. METHODS: Data on medical utilization related to chronic angina were extracted from National Center for Health Statistics public-use databases and from IMS databases on medications (nitrates, beta-blockers, and calcium channel blockers). National average Medicare reimbursement rates were used to estimate costs. We identified medical utilization related to chronic angina based on International Classification of Diseases, Ninth Revision (ICD-9) codes. When ICD-9 codes that do not explicitly identify angina are used in medical databases, people with chronic angina may be coded as having CAD only. To address this, we developed upper- and lower-boundary estimates of the costs of chronic angina. The lower-boundary estimate is based on diagnoses that narrowly define the presence of chronic angina, and is termed "narrowly defined chronic angina." The upper-boundary estimate is based on diagnoses of CAD. RESULTS: The lower boundary on the cost of chronic angina is the estimated direct medical cost of narrowly defined chronic angina ($1.9 billion when it is the first-listed diagnosis and $8.9 billion when it is listed in any position). The upper boundary on the cost of chronic angina is the estimated total direct medical cost of CAD, which is $33 billion when it is the first-listed diagnosis and $75 billion when it is listed in any position. CONCLUSION: These analyses capture the range of direct costs that might be attributed to the care of chronic angina in the United States for the year 2000. Some components of care were not available, and estimated costs will be significantly higher if private payer reimbursement rates are used.

Angina Pectoris↗