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PubMed2002

Health care utilization and costs among privately insured patients with bipolar I disorder.

OBJECTIVE: This study examined health care resource utilization and direct health care costs among patients diagnosed with bipolar I disorder in a privately insured population. METHODS: Health care claims data for 2883 patients with a primary diagnosis of bipolar disorder were compared over a 1-year period (1997) with claims data for 2883 randomly selected, age- and sex-matched, non-bipolar patients, all covered under the same large private insurer in USA. Resource use (i.e. original and refill pharmaceutical dispensing, medical and procedural services received, inpatient hospitalization, outpatient services, physician visits and emergency room treatment) and their costs are described overall, as well as by bipolar disorder diagnosis (based on ICD-9 codes) and type of care (i.e. mental health versus non-mental health). RESULTS: Bipolar patients utilized nearly three to four times the health care resources and incurred over four times greater costs per patient compared with the non-bipolar group during the 1-year period ($7663 versus $1962). Inpatient care (hospitalizations) accounted for the greatest disparity between groups, as it was the single-most costly resource in the bipolar group ($2779 versus $398). Patients with bipolar depression (among the single bipolar diagnostic categories of mixed, manic or depressed) incurred the highest health care costs. While mental health care cost was a significant component of total cost in the bipolar group, it accounted for only 22% of the total per-patient cost; in comparison, it accounted for only 6% of the total per-patient cost in the non-bipolar group. CONCLUSION: Treatment of bipolar disorder, particularly inpatient care, is costly to patients and health insurers. Further study is needed to find ways to reduce the overall cost of managing these patients without jeopardizing patient care.

Adolescent↗
PubMed1996

Results of limited versus comprehensive toxicology screening in a university medical center.

Both comprehensive toxicology screening (COM) and limited toxicology screening (LIM) were performed on the same urine in 1,734 consecutive cases over a 6-month period at a university medical center. About half of the screens originated from inpatient services and half from outpatient services (mostly emergency department). In 71 % of the cases, there was agreement between the results of LIM and COM, with 47% of cases being negative. For 500 screens (accounting for 655 individual discrepant findings), at least one discrepancy was noted between LIM and COM. Of these, 399 cases demonstrated at least one finding with COM, but not with LIM ("false-negative" LIM). Topical anesthetics (including cocaine and cocaethylene), antiepileptics, and sympathomimetic amines accounted for 65% of findings. In contrast, 147 cases showed a finding with LIM, but not with COM ("false-positive" LIM), mostly amphetamines. In certain specified clinical circumstances, LIM may be a more cost effective and efficient approach than COM.

Academic Medical Centers↗
PubMed1999

The Outpatient Developmental Services Project: integration of pediatric psychology with primary medical care for children infected with HIV.

OBJECTIVE: To present a model in which pediatric psychology services are programmatically integrated into the primary care of children seen in a special immunology program. The program centers around serial neurodevelopmental/neuropsychological evaluation of children infected with HIV. METHOD: We describe the population served and the particular services provided, with specific focus on how the program was developed. We include a discussion of the barriers to service provision that have been encountered and the strategies employed to overcome these challenges. CONCLUSIONS: This approach, while not ideal, serves as a good example of how pediatric psychology can merge with primary medical care to maximize the benefits of both specialties for a patient population that is underserved in many respects.

Acquired Immunodeficiency Syndrome↗
PubMed1992

An economic evaluation of home-care assistance for AIDS patients: a pilot study in a town in northern Italy.

OBJECTIVE: To evaluate the costs and cost-effectiveness of home-care assistance (HCA) as an alternative to hospital-based care only for patients with AIDS (PWA). DESIGN: A 6-month prospective study. Use of resources by a control group of PWA receiving ordinary hospital-based care (OC group) was compared with that by a random group of PWA who, in addition to hospital care, were also receiving home care (HC group). SETTING: Home- and hospital-based care for PWA in Vicenza, Italy. PATIENTS: HC group selection was based on eligibility criteria for severity of illness, home location and economic and family support. Ten of the PWA satisfying all eligibility criteria were randomly allocated to the HC group. The control group consisted of 32 PWA lacking one or more of the eligibility criteria. INTERVENTION: HCA involved the provision of palliative care for PWA by a multidisciplinary team of caregivers. Hospital-based services covered inpatient and outpatient services. MAIN OUTCOME MEASURE: The health benefits for HC and OC groups using a quantitative quality of life measure (the Quality of Well-Being Scale). RESULTS: Overall health-care cost savings of 6-7%, relative to the OC group, were predicted for the HC group. Costs per well week were estimated at US$482 for the HC group and US$791 for the OC group. CONCLUSION: Home-care assistance appears to be a cost-effective strategy for the treatment and care of PWA if strict eligibility criteria are adhered to.

Acquired Immunodeficiency Syndrome↗
PubMed1978

Urgent care in the HMO: evolution of a system in Washington, D.C.

In 1961, Group Health Association, a large, non-hospital based, prepaid group practice in Washington, D.C. established an after-hours walk-in clinic on its premises for the care of medical problems requiring prompt attention. Within a year, this clinic's operation was extended to daytime hours for the use of the consumer-member at his own discretion. After 10 years, in the plan's main health center, the volume of adult visits to the acute care/walk-in center exceeded the number seen in the Department of Internal Medicine; most were of a routine rather than urgent nature. More visits to the acute care service were made during the day, when the full range of ambulatory services were available by appointment, than were made after hours. The choic of immediate first-come, first-served care over the conventional care-by-appointment by so many members was felt to have resulted in discontinuous suboptimal care, segregation of the membership along socioeconomic lines, as well as unnecessary and very costly duplications of service. The background of organizational behavior and community medical practices contribuing to this pattern of utilization are explored. Compared to traditional fee-for-service medicine, demands for outpatient services in the HMO tend to be greater. Acceptable alternatives to off-line channeling of patients with unexpected or acute conditions can be designed. In the general community today, utilization of medical services is strongly influenced by imbalances in available resources and by financial factors which are under no central control. In the HMO, all costs are prepaid and services are planned for a membership of known size. Even so, consumers' use of services in prepaid plans tends to follow the patterns seen in the community. More appropriate distribution of demands requires an active and ongoing system of patient education. A commitment by the HMO's providers and managers toward this goal is indispensable.

Ambulatory Care↗
PubMed1999

Characteristics of asthma care provided by hospitals in a large metropolitan area: results from the Chicago Asthma Surveillance Initiative.

INTRODUCTION: Little is known of the approaches of United States hospitals to the management of persons with asthma. The purpose of this study is to characterize the extent to which hospitals within a large community have implemented various types of asthma-specific health-care delivery processes. METHODS: A cross-sectional, self-administered survey was mailed to a "key informant" in asthma care at each of the hospitals in the Chicago area. The survey instrument covered the following content areas: asthma-related inpatient services, asthma-related outpatient services, selected asthma-related quality improvement activities, and asthma-related community outreach. The survey was administered between August 1996 and January 1997. RESULTS: Data were collected from respondents at 59 of the 89 eligible hospitals, yielding a response rate of 66.3%. Of the responding hospitals, 42.4% indicated they had clinical practice guidelines for inpatient asthma management, and 37.3% reported using critical pathways. Four selected aspects of bedside care were also explored. All of the responding hospitals reported routine provision of nebulization therapy at the bedside, and nearly all routinely obtained peak flow measurements (96.6%). In the area of patient instruction, 93.2% provided bedside evaluation of proper inhaler technique, and 86.4% routinely provided instruction on the use of peak flowmeters. Only 54.0% of the hospitals reported routinely administering some type of asthma education program prior to discharge. The hospitals with clinical practice guidelines in place were also more likely to have critical pathways (p < 0.01); to have asthma-specific ICU policies/guidelines/critical pathways (p < 0.01); to provide bedside instruction on the use of peak flowmeters (p < 0.01); to provide an asthma education (p < 0.01) prior to discharge; and to conduct utilization review. Very few hospitals indicated that they had community outreach programs for asthma care. CONCLUSION: The results of this survey suggest that among Chicago-area hospitals appropriate bedside care for persons with asthma is provided, but there are large variations in other types of asthma services and programs. The hospitals that have adopted asthma clinical practice guidelines are more likely to have other asthma-specific quality improvement activities than hospitals without guidelines. This relationship between use of guidelines and quality of services needs further exploration, as it may prove to be an important marker for hospitals with staff that are interested in improving asthma care.

Adolescent↗
PubMed2003

Outpatient health service utilization and associated factors: a population-based study.

OBJECTIVE: To identify factors that lead people to visit a doctor in Brazil and assess differences between socioeconomic groups. METHODS: A cross-sectional study comprising 1,260 subjects aged 15 or more was carried out in southern Brazil. Demographic, socioeconomic, health needs and regular source of care data were analyzed concerning visits to a doctor within two months from the interview. Adjusted prevalence ratios and 95% confidence intervals were calculated using Poisson regression. RESULTS: Adjusted PR showed that women having stressful life events, health insurance, and a regular doctor increased the outcome. A dose-related response was found with self-reported health, and the probability of visiting a doctor increased with health needs. Analysis in the chronic disease group revealed that uneducated lower income subjects had a 62% reduction in the chance of visiting a doctor compared to uneducated higher income ones. However, as it was seen a significant interaction between income and education, years of schooling increased utilization in this group. CONCLUSIONS: Results suggest the existence of health inequity in the poorest group that could be overcome with education. Specific measures reinforcing the importance of having a regular doctor may also improve access in the underserved group.

Adolescent↗
PubMed1993

Consumer satisfaction and perceived quality of outpatient health services.

The authors examined factors related to consumer satisfaction and willingness to recommend the provider among 1,366 patients receiving examinations at a free-standing medical imaging facility. The nontechnical (nonmedical) characteristics of the service encounter were drawn from three conceptual domains--staff behavior, atmospherics, and information--and two subjective judgments regarding the medical service itself: examination comfort and perceived worth. The authors hypothesized that all of these factors are related to increased consumer satisfaction and willingness to recommend the provider. Data collection was based on a service script, and factor analysis was used to organize elements from each domain into a map of consumer perceptions. Multivariate logistic regression indicated that items from each domain were significantly related to patient satisfaction and willingness to recommend the provider.

Ambulatory Care Facilities↗