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PubMed2005

Epidemiology of pacemaker procedures among Medicare enrollees in 1990, 1995, and 2000.

Using Medicare hospital claims records and beneficiary enrollment data, the investigators describe the epidemiology of inpatient pacemaker procedures (International Classification of Diseases, Ninth Revision, Clinical Modification codes 37.80 to 37.89) in Medicare enrollees. From 1990 to 2000, the age-standardized inpatient pacemaker procedure prevalence (per 100,000 enrollees) increased from 325.4 to 504.4 in all Medicare beneficiaries. The prevalence increased significantly with age; was less for women than for men; and was less for blacks, Hispanics, and Asians than for whites.

Aged↗

PubMed2005

A multistate comparison of patient characteristics, outcomes, and treatment practices in acute myocardial infarction.

The primary purpose of this study was to examine variations in patient characteristics, outcomes, and treatment practices in acute myocardial infarction (AMI) across 11 states. Data from 11 states were extracted from the Healthcare Cost and Utilization Project State Inpatient Dataset. Patients who had a primary diagnosis of AMI (International Classification of Diseases, Ninth Revision, Clinical Modification, code 410.x1) from 11 states were extracted from the Healthcare Cost and Utilization Project 1999 dataset. Bivariate comparisons were conducted to examine the characteristics, treatment practices, and outcomes of patients who had AMI. Multivariate regression models were used to examine the association between geographic location (and other factors) and the likelihood of in-hospital mortality, undergoing coronary artery bypass grafting (CABG), or percutaneous coronary interventions (PCIs). Results revealed considerable variations across states in practice patterns and treatment outcomes. New York had the highest average length of stay (8.2 days, p <0.01), rate of patients who had AMI being transferred (20.7%, p <0.01), and in-hospital case fatality rate (10.7%, p <0.01) and the lowest rate of alive discharges being routine (65.6%, p <0.01). PCI was performed 2 times as often as CABG for patients who had AMI (23.9% vs 11.3%, p <0.01), with patients who underwent CABG being transferred more often. Multivariate analyses showed that state of residence, age, female gender, transfer status, and number of co-morbidities were predictors of in-hospital mortality and the likelihood of undergoing CABG or PCI. In conclusion, large differences in practice patterns and treatment outcomes exist across states.

Age Distribution↗

PubMed2006

Propoxyphene use and risk for hip fractures in older adults.

BACKGROUND: Published guidelines have identified propoxyphene as an inappropriate medication for use in aged patients. It is no more effective than acetaminophen, yet has been associated with the same adverse effects (AEs) associated with other opioid drugs. In particular, its central nervous system-related AEs, dizziness and sedation, may increase the risk for fracture resulting from falls in older adults. Nonetheless, US studies have reported widespread use of propoxyphene in the elderly US population. OBJECTIVE: The aim of this study was to examine the risk for fracture associated with propoxyphene use in older adults. METHODS: This prospective cohort study used a large administrative claims data set from adults aged > or =65 years. A time-varying (lagged) covariate defined each person as a propoxyphene user or nonuser based on propoxyphene exposure in the 14 days before each fracture event in the cohort. Another time-varying measure stratified propoxyphene users based on their mean daily dose of propoxyphene (high dose = >260 mg; low dose = < or =260 mg of propoxyphene hydrochloride or equivalent napsylate salt). Time-dependent Cox regression models were used to estimate the association between propoxyphene exposure and occurrence of hip fracture (using International Classification of Diseases, Ninth Revision, Clinical Modification code 820.xx). RESULTS: A total of 362,503 patients were included in the analysis. During a mean follow-up of 464 days, approximately 10% (37,569) of the sample had > or =1 propoxyphene prescription filled and approximately l% (5065) sustained a hip fracture. Propoxyphene users had a 2-fold higher risk for hip fracture (hazard ratio [HR] [95% CI], 2.05 [1.87-2.25]) compared with nonusers of analgesics. Multivariate analysis found a dose-response relationship between propoxyphene and hip fracture risk (low dose, HR [95% CI], 1.45 [1.26-1.67]; high dose, HR [95% CI], 2.05 [1.85-2.29]). Other opioid analgesics were associated with an increased risk for hip fractures. CONCLUSIONS: The results of this cohort database study suggest that propoxyphene use among adults aged > or =65 years is associated with increased risk for hip fracture and suggest a need for interventions to reduce propoxyphene use in older adults. Clinicians should be aware of the risk for hip fracture with other opioids as well and weigh them against potential benefits when prescribing for older adults.

Aged↗

PubMed2006

National study of emergency department visits for sepsis, 1992 to 2001.

STUDY OBJECTIVE: Epidemiologic data on emergency department (ED) patients with sepsis are limited. Inpatient discharge records from 1979 to 2000 show that hospitalizations for sepsis are increasing. We examine the epidemiology of sepsis in US EDs and the hypothesis that sepsis visits are increasing. METHODS: The National Hospital Ambulatory Medical Care Survey data (1992 to 2001) provided nationally representative estimates of frequency and disposition in adult ED visits for sepsis. Sepsis visits were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes; severe sepsis was defined as sepsis in conjunction with organ failure. RESULTS: Of 712 million adult visits during the 10-year period, approximately 2.8 million (0.40%, 95% confidence interval [CI] 0.33% to 0.46%) were related to sepsis. We found no significant increase in overall ED visits for sepsis from 1992 to 2001 (P for trend=.09). ED patients with sepsis were more likely to be elderly, non-Hispanic, and publicly insured and to arrive by ambulance compared with nonsepsis patients (all P<.01). The overall admission rate was 87% (95% CI 82% to 92%), with only 12% (95% CI 8% to 16%) of patients admitted to the ICU. The most frequent codiagnoses were pneumonia (13%), urinary tract infection (13%), and dehydration (11%). Severe sepsis accounted for 8% (95% CI 5% to 11%) of sepsis visits, for an annual incidence of 0.01%; 98% of patients with severe sepsis were admitted. CONCLUSION: In contrast to data from hospital discharges, ED visits for sepsis demonstrated no increase. Most ED visits for sepsis resulted in admission to non-critical care units.

Adult↗

PubMed2005

Mental illness, traumatic brain injury, and medicaid expenditures.

OBJECTIVE: To estimate the rates of mental illness among Medicaid beneficiaries with traumatic brain injury (TBI) and associated Medicaid-paid expenditures. DESIGN: Retrospective claims-based calendar year data. SETTING: Claims data. PARTICIPANTS: Medicaid recipients with diagnosed TBI and mental illness who received Medicaid services in 4 states in 1995. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Annual expenditures for total, inpatient, and noninpatient services, as derived from Medicaid personal summary files. Mental illness and TBI were identified by using International Classification of Diseases, 9th Revision , Clinical Modification codes recorded in Medicaid claims. RESULTS: Of a total of 493,663 Medicaid recipients, 3641 (0.7%) were diagnosed with TBI in the 4 states. Significant demographic and racial differences were found in the rates of TBI; 18% of patients with TBI were diagnosed with serious mental illness. People with TBI in the age group 40 to 49 years were more likely to have a mental disorder. There were significant differences in estimated total, inpatient, and noninpatient expenditures between those with and without mental illness. In general, those with serious mental illness had higher Medicaid-paid expenditures than those without any mental illness. CONCLUSIONS: Psychiatric comorbidity in TBI increases the overall expenditures in this population. This increased cost is an important consideration in programming for those with TBI.

Adult↗

PubMed2006

Adherence to infectious diseases society of America guidelines for empiric therapy for patients with community-acquired pneumonia in a commercially insured cohort.

BACKGROUND: There is little published research addressing how the 2003 Infectious Diseases Society of America (IDSA) guidelines for empiric therapy of community-acquired pneumonia (CAP) are implemented in clinical practice. OBJECTIVE: This study was designed to describe antibiotic treatment patterns among patients with CAP treated in ambulatory settings in light of the IDSA guidelines. METHODS: Health insurance claims data from a large managed care organization with -30 million enrollees located in geographically diverse regions of the United States were analyzed. Patients > or =18 years of age with CAP who received a prescription for any antibiotic in an ambulatory setting during 2004 were identified via International Classification of Diseases, Ninth Revision, Clinical Modification codes for diagnosis (481-486). Recent antibiotic use was defined as receipt of any antibiotics <90 days before the date of diagnosis. Antibiotics were identified through National Drug Codes and from outpatient medical claims data with the use of J codes. Individuals were classified, per IDSA guidelines, as previously healthy without recent antibiotic use (group 1); previously healthy with recent antibiotic use (group 2); with comorbidities and without recent antibiotic use (group 3); and with comorbidities and recent antibiotic use (group 4). The guideline adherence was calculated using the number of patients receiving recommended treatment divided by the total number of patients in each group. RESULTS: Of 34,342 patients identified, 76.5% had no reported comorbidities. Among group-1 patients, 52.0% received the recommended empiric therapy (macrolide or doxycycline). In group-2 patients, 42.5% received the recommended therapy (respiratory quinolone alone or advanced-generation macrolide plus amoxicillin or amoxicillin-clavulanate). A high rate of compliance with recommended empiric therapy (advanced-generation macrolides or respiratory quinolones) was observed in group-3 patients (81.5%). In group-4 patients, 43.4% received the recommended therapy (respiratory quinolone or advanced-generation macrolide plus ss-lactam). Patients whose therapy was adherent with the guidelines had fewer respiratory-infection-related hospital admissions within 30 days after initiation of antibiotic treatment (overall, relative risk = 0.81 [95% CI, 0.71-0.94]). CONCLUSION: Although these data reflect a period shortly after the 2003 IDSA guidelines were published, they suggest that there is room for improvement with regard to choice of empiric antibiotic therapy among these patients with CAP treated in ambulatory settings.

Adult↗

PubMed2005

Patterns of asthma control: a 3-year analysis of patient claims.

BACKGROUND: The goal of asthma therapy is to maintain consistent control. OBJECTIVE: We sought to examine the patterns of asthma control recorded over 3 years using administrative claims and resource utilization definition. METHODS: We performed a retrospective observational study with a nationally representative patient-level database containing pharmacy and medical claims. Patients with asthma (International Classification of Diseases, Ninth Revision-Clinical Modification code 493.xx), patients undergoing treatment with at least 1 asthma medication, and patients with 36 months of continuous claims coverage during the calendar years 1996 through 2002 were identified. A total of 63,324 patients were included in the study. Patients were classified as having controlled asthma in year 1 if they had less than 4 claims for a short-acting beta 2 -agonist, no claims for an OCS, and no asthma-related emergency department visits or hospitalizations. Patients were then followed over the next 8 quarters (2 years) to observe whether control was maintained. Control during a quarter was defined with the same criteria, except the reliever threshold was adjusted to 2 or more claims per quarter. RESULTS: Thirty-nine thousand ninety-five (57%) patients were defined as having controlled asthma during year 1. During the 2-year follow-up period, a range of 10% to 14% of these patients with controlled asthma met the criteria of uncontrolled asthma during any given quarter. Overall, 46,227 (73%) patients identified met the criteria for uncontrolled asthma at least once during the 3-year period. CONCLUSIONS: This study demonstrates that almost 75% of asthmatic patients experience an uncontrolled asthma episode 1 or more times over a 3-year period. Furthermore, we found that significant fluctuations in asthma control exist, even in patients with prior controlled asthma.

Adolescent↗

PubMed2026

Psychiatric Diagnoses and Psychotropic Medications Among Military-Affiliated Adolescents and Young Adults With Polycystic Ovary Syndrome.

PURPOSE: To study rates of psychiatric diagnoses and psychotropic medication prescription among U.S. military-affiliated adolescents and young adults (AYA) with polycystic ovary syndrome (PCOS). METHODS: This retrospective matched cohort study included U.S. military-affiliated AYA (aged 15-21 years) enrolled in TRICARE Prime for at least 6 months during the surveillance period (January 2016 to October 2023). Military-affiliated AYA were grouped into three categories: individuals diagnosed with PCOS (N = 6,911), age-matched individuals with no diagnosed PCOS symptoms (N = 35,814), and individuals with diagnosed symptoms suggestive of PCOS (N = 2,136). The presence of a psychiatric diagnoses and prescriptions for psychotropic medications were obtained via the International Classification of Diseases, 10th Revision, Clinical Modification codes and National Drug codes, respectively. RESULTS: AYA with diagnosed PCOS had higher odds of having a psychiatric diagnosis and being prescribed a psychotropic medication compared to an age-matched comparison group (psychiatric diagnosis odds ratio [OR] = 2.48 [2.35-2.62], medication OR = 2.14 [2.03-2.25]) and individuals with symptoms suggestive of PCOS (psychiatric diagnosis OR = 1.11 [1.003-1.23], medication OR = 1.16 [1.05-1.28]). DISCUSSION: The odds of psychiatric comorbidities and psychotropic medication prescription were more than twice as high as among U.S. military-affiliated AYA with PCOS. More research is needed to determine whether health-care utilization and military-related factors impact mental health outcomes among AYA with PCOS. Additionally, tailored, multidisciplinary mental health services for AYA with PCOS are needed.

Humans↗

PubMed2006

Effect of postoperative epidural analgesia on morbidity and mortality after lung resection in Medicare patients.

STUDY OBJECTIVE: To perform an analysis of the Medicare claims database in patients undergoing lung resection to determine whether there is an association between postoperative epidural analgesia and mortality. DESIGN: Retrospective cohort (database) design. SETTING: University hospital. MEASUREMENTS: We examined a cohort of 3501 patients obtained from a 5% nationally random sample of 1997 to 2001 Medicare beneficiaries who underwent nonemergency segmental excision of the lung (International Classification of Diseases, 9th Revision, Clinical Modification codes 32.3 and 32.4). Patient data were divided into two groups depending on the presence or absence of billing for postoperative epidural analgesia (Current Procedural Terminology code 01996). The primary outcomes assessed were death at 7 and 30 days after the procedure. The rates of major morbidity (acute myocardial infarction, angina, cardiac dysrhythmias, heart failure, pneumonia, pulmonary edema, respiratory failure, deep venous thrombosis, pulmonary embolism, sepsis, acute renal failure, somnolence, acute cerebrovascular event, transient organic syndrome, and paralytic ileus) were also compared. Multivariate regression analysis incorporating race, gender, age, comorbidities, hospital size, hospital teaching status, and hospital technology status was performed to determine whether the presence of postoperative epidural analgesia had an independent effect on mortality or major morbidity. MAIN RESULTS: Multivariate regression analysis showed that the presence of epidural analgesia was associated with a significantly lower odds of death at 7 days (odds ratio, 0.39; 95% confidence interval, 0.19-0.80; P = 0.001) and 30 days (odds ratio, 0.53; 95% confidence interval, 0.35-0.78; P = 0.002) after surgery. There was no difference between the groups with regard to overall major morbidity. CONCLUSIONS: Postoperative epidural analgesia may contribute to lower odds of death after segmental excision of the lung, although the mechanism of such a benefit is not clear from our analysis.

Aged↗

PubMed2006

Influenza vaccine effectiveness in healthy 6- to 21-month-old children during the 2003-2004 season.

OBJECTIVE: To assess the clinical effectiveness of influenza vaccine in preventing influenza-like illness (ILI) office visits. STUDY DESIGN: We analyzed billing and immunization registry data for healthy 6- to 21-month-olds from 5 Denver, Colorado pediatric practices (n = 5193). ILI and pneumonia/influenza (a subset of ILI) were defined from International Classification of Diseases, Ninth Revision, Clinical Modification codes for office visits occurring during peak influenza season. Partially vaccinated (PV) and fully vaccinated (FV) patients were defined as having 1 shot and 2 shots, respectively, more than 14 days before the first ILI visit. The likelihood of an ILI visit was determined using a Cox proportional hazards model accounting for patient characteristics, practice site, and immunization status. RESULTS: A total of 28% of the patients had an ILI office visit, and 5% had a pneumonia/influenza visit. Hazard ratios (HRs) for FV versus UV were 0.31 (95% confidence interval [CI] = 0.3 to 0.4) for ILI and 0.13 (95% CI = 0.1 to 0.2) for pneumonia/influenza, corresponding to a vaccine effectiveness (1 - HR x 100) of 69% for ILI and 87% for pneumonia/influenza. The corresponding HRs for PV versus UV were 1.0 (95% CI = 0.9 to 1.2) and 1.1 (95% CI = 0.8 to 1.5). CONCLUSIONS: Although 2 doses of vaccine were 69% effective against ILI office visits and 87% effective against pneumonia/influenza office visits, 1 dose did not prevent office visits during the 2003-2004 influenza season.

Female↗

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↗

PubMed2007

Influence of post-cystectomy complications on cost and subsequent outcome.

PURPOSE: Of commonly performed urological cancer procedures radical cystectomy is associated with the highest morbidity and mortality. The impact of each individual type of complication or a combination of them on various outcome measures, such as mortality, charges and length of stay, is unclear. We quantified the impact of specific post-cystectomy complications and combinations thereof in terms of mortality, charges and length of stay. MATERIALS AND METHODS: All 6,577 patients undergoing radical cystectomy for bladder cancer were identified from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project (1998 to 2002). The prevalence of different International Classification of Diseases, 9th Revision, Clinical Modification coded complications following cystectomy were determined. Outcome variables of interest were in-hospital mortality, total charges and length of stay. The association between types of complications and measured outcomes were examined using univariate and multivariate regression models. The cumulative impact of multiple complications and various combinations of complications on outcomes was also examined. RESULTS: The overall complication rate was 28.4% in 1,869 cases and the mortality rate was 2.6%. Median total charges was 41,905 dollars and median length of stay was 9 days. Overall 20.7% of patients had 1, 6.1% had 2, 1.2% had 3 and 0.42% had greater than 3 complications. At least 1 complication almost doubled the odds of mortality and increased median total charges and length of stay by 15,000 dollars and 4 days, respectively. We defined expected levels of increase in the various outcome measures with increasing numbers of complications. The combination of postoperative infection and respiratory complication had the greatest impact on mortality, while the combination of wound and urinary tract infection had the greatest impact on length of stay and total charges. CONCLUSIONS: Although most patients undergoing cystectomy are older and have multiple comorbidities, the postoperative complications with the most significant impact were those directly related to surgery (primary complications). Secondary complications (cardiac, respiratory, vascular, etc) appear to have less of an impact on most common outcome measures. Hence, the greatest gains can be achieved by limiting primary complications. These data could be used to develop benchmarks of expected levels of primary and secondary complications after cystectomy.

Costs and Cost Analysis↗

PubMedDate not supplied

Effect of postoperative epidural analgesia on morbidity and mortality following surgery in medicare patients.

BACKGROUND: Because of the uncertainty and limitations in available randomized controlled trials, we performed an analysis of the Medicare claims database to determine whether an association exists between postoperative epidural analgesia and mortality. METHODS: A 5% nationally random sample of Medicare beneficiaries from 1997 to 2001 was analyzed to identify patients undergoing segmental excision of the lung (International Statistical Classification of Diseases, Ninth Revision, Clinical Modification codes 32.3 and 32.4), complete pneumonectomy (code 32.5), partial excision of large intestine (codes 45.73 and 45.76), anastomosis of the esophagus (codes 42.5 and 42.6), total knee replacement/revision (codes 81.54 and 81.55), total/radical abdominal hysterectomy (codes 68.4 and 68.6), partial/radical pancreaticoduodenectomy (codes 52.5 and 52.7), partial/complete nephrectomy (codes 55.4 and 55.5), partial/complete cystectomy (codes 57.6 and 57.7), hepatotomy/lobectomy of the liver (codes 50.0 and 50.3), partial/total gastrectomy (codes 43.5 to 43.9), and radical retropubic prostatectomy (codes 60.4 and 60.5). Patients were divided into 2 groups, depending on the presence or absence of postoperative epidural analgesia. The rate of major morbidity and death at 7 and 30 days after surgery were compared. Multivariate regression analyses incorporating race, gender, age, comorbidities, hospital size, hospital teaching status, and hospital technology status were performed. RESULTS: The presence of epidural analgesia was associated with a significantly lower odds of death at 7 days (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.38 to 0.73; P = .0001) and 30 days (OR, 0.74; 95% CI, 0.63 to 0.89; P = .0005) after surgery; however, no difference was seen between the groups with regard to overall major morbidity, with the exception of an increase in pneumonia at 30 days for the epidural group (OR, 1.91;[95% CI, 1.09 to 3.34; P = .02). CONCLUSIONS: Postoperative epidural analgesia may contribute to lower odds of death after surgery.

Aged↗

PubMedDate not supplied

Obstetric complications during labor and delivery: assessing ethnic differences in California.

PURPOSE: We sought to compare obstetric complications during labor and delivery among white non-Latina (white), black, Asian, and Latina women who delivered in California hospitals. Many intrapartum complications are preventable. METHODS: We used linked 1996-1998 state hospital discharge and birth certificate data to examine obstetric complications International Classification of Diseases, 9th Revision, Clinical Modification codes considered relevant for population surveillance. We compared the observed and adjusted odds of experiencing a complication among women of color, using white women as the reference group. FINDINGS: One out of 5 deliveries had >or=1 complication. White (21.3%) and Asian women (21.1%) had similar prevalence rates, whereas black women (24.2%) had higher and Latina women (19.6%) had lower rates. After adjusting for covariates, the odds of experiencing >or=1 complication was lower for Asians (odds ratio [OR] = 0.95; 95% confidence interval [CI] = 0.93, 0.96) and Latinas (OR = 0.97; 95% CI = 0.96, 0.98) than whites; the odds for black women remained elevated (OR = 1.25; 95% CI = 1.23, 1.27). Asian women stood a higher risk of deliveries with major lacerations, postpartum hemorrhage, and major puerperal infections. Rates for the latter complication were higher among all women of color. CONCLUSIONS: The burden of morbidity is high for all women, regardless of ethnicity. Yet, compared to white women, blacks suffer more aggregate morbidities, and Asians stand a high risk of all 3 intrapartum care-sensitive conditions. Furthermore, all women of color experience disproportionate rates of puerperal infections. Collective action is needed to reduce these disparities and improve maternal health.

Adult↗

PubMed2001

Time trends in cost of caring for people with gastroesophageal reflux disease.

OBJECTIVE: Increasing acceptance of the many permutations of gastroesophageal reflux disease (GERD) has led to diverse study of the disease and its effects. The goal of this study was to estimate medical care costs attributable to a defined GERD population over time. METHODS: A retrospective cohort control design was used. All participants were identified from the database of a managed care organization serving 300,000 people in the northeastern United States. The index population (n = 600) was defined as anyone who obtained medical services during 1997 or 1998, for any International Classification of Diseases (ninth revision, Clinical Modification) codes suggestive of GERD, and/or anyone who received at least one prescription and one refill for antisecretory or GERD medications during at least two 3-month periods in 1997 or 1998. A matched cohort (n = 600) without any diagnosis of GERD was randomly selected as a control group. Both populations were observed restrospectively from January 1, 1990 through December 31, 1998. RESULTS: The cost of treating GERD averaged around $510 per year, about 15% of all medical costs for those with GERD. Treating people with GERD was about 2-fold more costly than treating those without GERD, a marginal cost of $1500 to $2000 per annum. CONCLUSION: Although GERD is a low-cost disease to treat, the cost of treating people with GERD is subtantially greater than that for a comparable population without GERD. Two explanations may account for the large difference of costs between the study populations. First, the GERD group may be sicker than the control group. Disease severity variables and diagnoses associated with GERD were more commonly diagnosed in the GERD group. Second, an additional disease that is not treated appropriately increases the cost of treatment geometrically for all diseases.

Adult↗

PubMed2006

Use of nephrectomy at select medical centers--a case of follow the crowd?

PURPOSE: Regionalization of high risk surgical procedures to larger, teaching hospitals has been suggested as a means to improve the quality of care. We determined the extent to which the regionalization of nephrectomy has occurred and describe the potential causes and implications of any observed regionalization. MATERIALS AND METHODS: The Nationwide Inpatient Sample comprises a 20% sampling of hospital discharges in the United States yearly. Patients undergoing nephrectomy for kidney cancer between 1988 and 2002 were identified using International Classification of Disease, Ninth Revision, Clinical Modification codes. Regionalization was assessed using 6 structural hospital measures, including teaching status, urban location, discharge volume, nephrectomy volume, bed capacity and for-profit status. Adjusted models were developed to identify the significance of temporal trends in each regionalization measure. RESULTS: We identified 66,621 patients undergoing nephrectomy during the study period. Compared to procedures performed between 1988 and 1990 the likelihood of undergoing nephrectomy at teaching, high nephrectomy volume and high throughput (all diagnoses) hospitals increased by 2.0 (CI 1.9 to 2.2), 7.4 (CI 7.1 to 7.7) and 2.2 times (CI 2.1 to 2.2), respectively, in 2000 to 2002. Conversely nephrectomy was less likely to be performed at for-profit hospitals (OR 0.5, CI 0.5 to 0.6). Patients were more likely to undergo partial nephrectomy at teaching, high volume, high throughput, urban hospitals. CONCLUSIONS: Regionalization of nephrectomy to teaching and high volume (nephrectomy and all diagnoses) hospitals is currently under way. Although the implications are not entirely clear, this study provides further evidence for the crowding of complex surgical procedures into these institutions.

Aged↗

PubMed2002

Episiotomy use in the United States, 1979-1997.

OBJECTIVE: To describe episiotomy usage at vaginal delivery in the United States from 1979-1997. METHODS: We used the National Hospital Discharge Survey, a federal database of a national sample of inpatient hospitals. Data from 1979 to 1997 were analyzed using International Classification of Diseases, Ninth Revision, Clinical Modification codes for diagnoses and procedures. Rates per 1000 women were calculated using the 1990 census population for women aged 15-44 years. We calculated the number of episiotomies per 100 vaginal deliveries. Rates and percentages were compared using the score test for linear trend. RESULTS: The number of episiotomies ranged from a high of 2,015,000 in 1981 to a low of 1,128,000 in 1997. The age-adjusted annual rate for episiotomy with vaginal deliveries varied from 32.7 in 1979 to 18.7 in 1997 per 1000 women aged 15-44 years. The percentage of episiotomy with vaginal deliveries ranged from 65.3% in 1979 to 38.6% in 1997 (P <.001). Episiotomy with operative deliveries decreased over time (87.0% to 70.8%, P <.001), as did episiotomy with spontaneous deliveries (60.1% to 32.8%, P <.001). Women undergoing episiotomy were slightly younger (mean +/- standard deviation, 25.7 +/- 5.5 years) than women without episiotomy (26.2 +/- 5.7 years, P <.001). Black women (39%) were less likely to receive episiotomy than white women (60%, P <.001). More women with private insurance (62%) had episiotomy performed than women with government insurance (43%, P <.001). CONCLUSION: Although episiotomy use has decreased over time, the most recent rate of 39 per 100 vaginal deliveries remains higher than evidence-based recommendations for optimal patient care.

Adolescent↗

PubMed2003

Pregnancy-related mortality in the United States, 1991-1997.

OBJECTIVE: To describe trends in pregnancy-related mortality and risk factors for pregnancy-related deaths in the United States for the years 1991 through 1997. METHODS: In collaboration with the American College of Obstetricians and Gynecologists and state health departments, the Pregnancy Mortality Surveillance System, part of the Division of Reproductive Health at the Centers for Disease Control and Prevention, has collected information on all reported pregnancy-related deaths occurring since 1979. Data include those present on death certificates and, when available, matching birth or fetal death certificates. Data are reviewed and coded by clinically experienced epidemiologists. The pregnancy-related mortality ratio was defined as pregnancy-related deaths per 100,000 live births. RESULTS: The reported pregnancy-related mortality ratio increased from 10.3 in 1991 to 12.9 in 1997. An increased risk of pregnancy-related death was found for black women, older women, and women with no prenatal care. The leading causes of death were embolism, hemorrhage, and other medical conditions, although the percent of all pregnancy-related deaths caused by hemorrhage declined from 28% in the early 1980s to 18% in the current study period. CONCLUSION: The reported pregnancy-related mortality ratio has increased, probably because of improved identification of pregnancy-related deaths. Black women continue to have an almost four-fold increased risk of pregnancy-related death, the greatest disparity among the maternal and child health indicators. Although review of pregnancy-related deaths by states remains an important public health function, such work must be expanded to identify factors that influence the survival of women with serious pregnancy complications.

Adolescent↗