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PubMed2006

The influence of Israel Health Insurance Law on the Negev Bedouin population--a survey study.

The extension of universal health service insurance to national populations is a relatively new phenomenon. Since 1995, the Israeli National Health Insurance Law (NHIL) has provided universal health services to every resident, but the effect of this law on health and health services among minorities has not been examined sufficiently. The goals of this study were to track some of the first changes engendered by the NHIL among the Negev Bedouin Arabs to examine the effects of universal health care services. Methods included analysis of historical and health policy documents, three field appraisals of health care services (1994, 1995, 1999), a region-wide interview survey of Negev Bedouins (1997), and key informant interviews. For the interview survey, a sample of 515 households was chosen from different Bedouin localities representing major sedentarization stages. Results showed that prior to the NHIL, a substantial proportion of the Negev Bedouins were uninsured with limited, locally available health service. Since 1995, health services, particularly primary care clinics and health manpower, have dramatically expanded. The initial expansion appears to have been a marketing ploy, but real improvements have occurred. There was a high level of health service utilization among the Bedouins in the Negev, especially private medical services, hospitals, and night ambulatory medical services. The NHIL brought change to the structure of health services in Israel, namely the institution of a national health system based on proportional allocation of resources (based on size and age) and open competition in the provision of quality health care. The expansion of the pool of potential members engendered by the new universal coverage had profound effects on the Health Funds' attitudes towards Negev Bedouins. In addition, real consumer choice was introduced for the first time. Although all the health care needs of this rapidly growing population have yet to be met fully, the assurances under the Law and the new level of competition promise a higher level of service in the future.

Adolescent↗

PubMed2000

Physicians' responses to Medicare fee schedule reductions.

BACKGROUND: Relatively little empirical research has addressed physicians' responses to fee changes under the Medicare Fee Schedule. OBJECTIVES: We analyzed Medicare claims data for ophthalmologists and orthopedic surgeons for the years 1991 through 1994 to evaluate the relative importance of profit-maximizing and target-income theories in determining physicians' supply responses to specific Medicare fee reductions. RESEARCH DESIGN: This study was designed to estimate the impact of fee reductions for cataract extractions and major joint repair/replacement procedures through pooled cross-section time series data. RESULTS: The supply function for cataract extractions has both strong own-price and cross-price effects, as well as a highly significant negative income effect. Yet, the magnitude of the income effect is small; thus, the substitution effect dominates the income effect. Similarly, in the supply functions for joint procedures, the own price has the expected positive sign, implying that as the fee declines, orthopedic surgeons will perform fewer joint surgeries. However, the cross-price variable has the correct sign only if treated as exogenous, and the variables measuring the income effect have the wrong sign, although their magnitude is small. CONCLUSIONS: These results suggest that the Medicare Fee Schedule does have the potential to influence physicians' supply decisions, but these effects may vary by specialty and service.

Adult↗

PubMed2005

Increasing general dentists' provision of care to child patients through changes in the undergraduate pediatric dentistry program.

Reduced caries rates and an increased percentage of children with dental insurance have made it more difficult for dental schools to provide undergraduates with sufficient numbers of pediatric dental patients requiring restorative procedures. This may result in graduates who are not competent and are reluctant to treat children after graduation. To ensure the quality of the undergraduate clinical training program, the Division of Pediatric Dentistry at the University of Manitoba changed from a comprehensive-based clinic to a block system in 1998-99. Specific communities with limited access to dental care (neighboring core area schools and Hutterite colonies) were specifically targeted as potential sources for child patients. This format increased the exposure of students to patient management as well as to complex pediatric dentistry procedures. To assess the learning experiences before and after the changes to the clinical pediatric dentistry program, sixty general dentists who had graduated from the University of Manitoba were randomly selected using the Manitoba Dental Association Directory. Surveys were sent to twenty general dentists who graduated in each of the following years: 1993, 2000, and 2002. Forty-five dentists responded, fifteen from each of the three surveyed classes. Dentists who graduated after the changes to the program (2000, 2002) reported that they performed a greater number of complex pediatric dentistry procedures and treated more toddler and preschool children than the group that graduated before the changes (1993). Referrals to pediatric dentistry specialists were higher in the 1993 group than in the 2000 and 2002 groups. In conclusion, an adequate pool of pediatric patients is critical to provide dental students with sufficient learning experiences. The dentists who graduated from the program after the changes were implemented are providing more comprehensive treatment to younger children.

Child↗

PubMed2000

The association between pharmacy closures and prescription drug use: a retrospective analysis of Medicaid prescription claims in Iowa.

OBJECTIVES: The objectives of this study were 2-fold: (1) to examine the association of pharmacy closures with prescription drug use by Medicaid recipients in Iowa; and (2) to evaluate how drug utilization patterns differ between patients whose pharmacies closed and patients whose pharmacies remained open. DESIGN: A 2-group pretest-posttest study of Medicaid enrollees who may have been affected by pharmacy closures. Prescription medication use during the periods preceding and after pharmacy closures was compared. A comparison group was used to account for extraneous factors. PATIENTS AND METHODS: Sixteen community pharmacies were selected from a pool of pharmacies that closed during 1994; 1092 patients were identified as the main users of these pharmacies, and a comparison group of 3491 patients whose main pharmacies had not closed also was identified. The average number of each patient's prescription claims for the 6 months preceding closing and the 6 months after closing was computed. Multiple regression analysis was conducted to determine whether any association existed between pharmacy closures and the use of prescription drugs. RESULTS: Patients whose pharmacies closed during 1994 had fewer prescription claims after the closings than before the closings. In contrast, patients whose pharmacies remained open had more prescription claims. This difference remains statistically significant after controlling for other factors, such as patient demographics and health status. CONCLUSIONS: A decrease in prescription drug use was associated with pharmacy closures. Attention should be directed to patient access to prescription medications in rural areas, as relatively more pharmacies close in rural areas.

Drug Prescriptions↗

PubMed1998

Stability study of LSD under various storage conditions.

A controlled study was undertaken to determine the stability of LSD in pooled urine samples. The concentrations of LSD in urine samples were followed over time at various temperatures, in different types of storage containers, at various exposures to different wavelengths of light, and at varying pH values. LSD concentrations were measured quantitatively by the Abuscreen RIA and by HPLC using a fluorescence detection method. Good correlation was observed between the immunoassay and the fluorescent integrity of the LSD molecule. Thermostability studies were conducted in the dark with various containers. These studies demonstrated no significant loss in LSD concentration at 25 degrees C for up to 4 weeks. After 4 weeks of incubation, a 30% loss in LSD concentration at 37 degrees C and up to a 40% at 45 degrees C were observed. Urine fortified with LSD and stored in amber glass or nontransparent polyethylene containers showed no change in concentration under any light conditions. Stability of LSD in transparent containers under light was dependent on the distance between the light source and the samples, the wavelength of light, exposure time, and the intensity of light. After prolonged exposure to heat in alkaline pH conditions, 10 to 15% of the parent LSD epimerized to iso-LSD. Under acidic conditions, less than 5% of the LSD was converted to iso-LSD. We also demonstrated that trace amounts of metal ions in buffer or urine could catalyze the decomposition of LSD and that this process can be avoided by the addition of EDTA. This study demonstrates the importance of proper storage conditions of LSD in urine in order to insure proper analytical testing results over time.

Chlorides↗

PubMed1989

Point-of-service computer system and drug-use evaluation: implications for pharmacy practice in ambulatory care.

The point-of-service (POS) computer system and its possible effects on ambulatory-care pharmacy practice are described. The POS system, a key component of the Medicare Catastrophic Coverage Act, is an electronic claims-transmittal device to be installed in community pharmacies. The system transmits information about the patient and the prescribed drug to a claims processor, which verifies the eligibility of the patient for Medicare drug benefits, determines the amount of payment allowed, and sends information back to the POS terminal in less than 30 seconds. Because prescription information can be consolidated into a central data pool, drug-use patterns can be reviewed. The system will also permit automated screening of drug-drug interactions. Problems posed by the POS system relate to (1) the lack of a claims-transmittal device that can communicate with all claims processors, (2) the lack of a direct interface between the POS system and all pharmacy computer systems, (3) the expense of training personnel to operate the POS system, (4) the cost incurred by pharmacies in installing the POS system, and (5) the conflict between protecting the privacy of a patient's drug profile and permitting the monitoring of drug interactions. The catastrophic coverage act proposes that POS data be used to assess the appropriateness of drug use with a focus on outcome and quality-of-care issues; for the full intent of the act to be achieved, the components of an effective drug-use-evaluation program must be employed. Drug-use evaluation should eventually decrease health-care costs and improve quality of care.(ABSTRACT TRUNCATED AT 250 WORDS)

Ambulatory Care Information Systems↗

PubMed2006

Are shorter courses of filgrastim prophylaxis associated with increased risk of hospitalization?

BACKGROUND: In clinical trials in patients receiving myelosuppressive chemotherapy, 10-11 days of prophylaxis with filgrastim has been found to reduce the incidence of febrile neutropenia. In clinical practice, however, many patients receive shorter courses of therapy, even though the effectiveness of this regimen is unknown. OBJECTIVE: To examine the relationship between duration of filgrastim prophylaxis and risk of hospitalization in patients receiving chemotherapy for non-Hodgkin's lymphoma (NHL), breast cancer, or lung cancer. METHODS: Using a large, automated, US healthcare claims database, we identified all adults who received chemotherapy for NHL, breast cancer, or lung cancer between 1998 and 2002. For these patients, we identified their first course of chemotherapy and each unique cycle within that course. We then focused attention on all patient cycles in which filgrastim was administered on or before cycle day 5 (filgrastim prophylaxis). Pooling all such cycles, we examined the relationship between duration of filgrastim prophylaxis and risk of hospitalization for neutropenia or infection and risk of hospitalization for any reason, using generalized estimating equations. RESULTS: Mean +/- SD duration of filgrastim prophylaxis was 6.5 +/- 3.1 days across 332 cycles for 133 NHL patients, 6.1 +/- 2.9 days across 482 cycles for 205 breast cancer patients, and 4.3 +/- 3.1 days across 522 cycles for 260 lung cancer patients. In multivariate analyses, risk of hospitalization for neutropenia or infection was found to decline with each additional day of filgrastim prophylaxis for patients with NHL (OR 0.81; p = 0.003), breast cancer (OR 0.77; p = 0.001), and lung cancer (OR 0.91; p = 0.084). Risk reductions with each additional day of prophylaxis ranged from 15% to 19% for patients with NHL, 17% to 23% for those with breast cancer, and 8% to 9% for those with lung cancer. Similar reductions in risk were noted for all-cause hospitalization. CONCLUSIONS: Among patients with NHL, breast cancer, or lung cancer, shorter courses of filgrastim prophylaxis may increase the risk of hospitalization.

Aged↗

PubMed1995

Which physicians limit their Medicaid participation, and why.

OBJECTIVE: This study identifies factors differentiating Medicaid participating physicians who accept all Medicaid patients from those limiting their Medicaid participation. DATA SOURCES: Data come from periodic telephone surveys of random samples of physicians conducted by the American Medical Association (AMA). STUDY DESIGN: Surveys conducted in 1990-1993 were pooled to form a sample of 4,188 Medicaid-participating office-based physicians. Respondents were classified as accepting all Medicaid patients or as limiting their Medicaid participation. Descriptive statistics are used to examine differences between these groups with respect to selected personal, practice, community, and reimbursement variables. Logistic regression analysis is used to identify factors associated with physicians accepting all Medicaid patients or limiting their Medicaid participation in some way. DATA COLLECTION METHODS: Survey data were supplemented with 1990 census data, 1990 AMA Physician Masterfile data, and 1989 data on physician payment levels. PRINCIPAL FINDINGS: Less than half of Medicaid-participating physicians and only about one-third of participating primary care physicians accept all Medicaid patients. Higher Medicaid fees are associated with physicians participating fully, but the marginal effects of changes in fees on the probability of physicians participating fully is small. CONCLUSIONS: Increases in Medicaid reimbursement aimed at primary care physicians or those in underserved areas may convert limited participants into full participants and, in so doing, improve the access of Medicaid eligibles to care. The increases in payment level needed to increase the proportion of physicians participating fully would be substantial, however, and may not be politically feasible.

Data Collection↗

PubMed1983

Group practice--trend for the future.

Group practices in various forms and combinations appear to set the trend for small animal practice management. By pooling their financial resources, energies, and talents, veterinarians can share the burden of increasing overhead costs and enjoy the benefits of specialization, new technologies, continuing education, consultations and referrals, peer review, applied research and publication, and fringe benefits such as paid vacation and sick leave, profit sharing, and pension. Group practices preserve ownership continuity at fair market value and afford opportunities for the utilization of expert business consultants. There are prerequisites to establishing a successful group practice: An adequate personal income base, a sufficient pet population, and business associates with compatible practice philosophy. Special considerations must be given to the social, economic, and psychological forces at work in a group practice environment. Professional and personal interactions can make or break a group practice. The group concept, MIP treatment of clients and their pets, and personalized appointments are important features which must be emphasized. The law of supply and demand and the law of diminishing returns must be kept in focus at all times. In tandem, they dictate the fortunes of all business enterprises and group practices can be particularly vulnerable to them. Long-term business commitment is a condition of group practice ownership and may pose a conflict with other interests. A predetermined buy-sell agreement and deferred compensation plan may provide the answer in case of dissolution, termination, or early retirement. A system of animal and material transport and transfer of business transactions and medical records must be set up between satellite clinics and the base hospital. A hospital-owned-and-operated shuttle service appears to offer the greatest flexibility and convenience. Cost-effectiveness of a shuttle service depends on the volume of referral cases generated for the base hospital. Computers may provide the answer to rapid and reliable transfer of data between satellite clinics and central or base hospitals in the near future. New approaches to small animal medicine and practice management must be explored and adopted. Prepaid pet medical insurance seems to be the answer to rapidly growing sophistication and escalating cost of small animal patient care. Human and companion animal interactions have been given a fresh impetus by veterinary educators, clinical psychologists, psychiatrists, humane societies, organizations for the mentally and physically handicapped, gerontologic centers, and others.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗

PubMed2001

Disenrollment from Medicare HMOs.

BACKGROUND: Since the program's inception, there has been great interest in determining whether beneficiaries who enter and subsequently leave Medicare health maintenance organizations (HMOs) are more or less costly than those remaining in fee-for-service (FFS) Medicare. OBJECTIVES: To examine whether relatively high-cost beneficiaries disenroll from Medicare HMOs (disenrollment bias) and whether disenrollment bias varies by Medicare HMO market characteristics. In addition, we compare rates of surgical procedures and hospitalizations for ambulatory care-sensitive conditions for disenrollees and continuing FFS beneficiaries. DESIGN: Cross-sectional analysis of 1994 Medicare data. PARTICIPANTS AND METHODS: Medicare beneficiaries were first sampled from the 124 counties with at least 1000 Medicare HMO enrollees. From this pool, HMO disenrollees and a sample of continuing FFS beneficiaries were drawn. The FFS beneficiaries were assigned dates of "pseudodisenrollment." Expenditures and inpatient service use were compared for 6 months after disenrollment or pseudodisenrollment. RESULTS: The HMO disenrollees were no more likely than the continuing FFS beneficiaries to have positive total expenditures (Part A plus Part B) or Part B expenditures in the first 6 months after disenrollment. However, disenrollees were more likely to have Part A expenditures. Among beneficiaries with spending, disenrollees had higher total and Part B expenditures than continuing FFS beneficiaries. Moreover, the disparity in total and Part B spending between disenrollees and continuing FFS beneficiaries increased with HMO market penetration. Although Part A spending was higher for disenrollees with spending, it was not sensitive to changes in market share. The HMO disenrollees received more surgical procedures and were hospitalized for more of the ambulatory care-sensitive conditions than the FFS beneficiaries. CONCLUSIONS: On several measures, Medicare HMOs experienced favorable disenrollment relative to continuing FFS beneficiaries as recently as 1994, which increased as HMO market share increased.

Aged↗

PubMed2005

Orlistat in responding obese type 2 diabetic patients: meta-analysis findings and cost-effectiveness as rationales for reimbursement in Sweden and Switzerland.

OBJECTIVE: The aim of this study is to review the clinical and economic rationale for the reimbursement of orlistat in responding obese patients with type 2 diabetes. METHODS: Data from seven randomized controlled clinical trials of orlistat in overweight and obese patients with type 2 diabetes were pooled. A subgroup analysis involving patients who achieved a response (defined as a weight loss of >/=5% after 12 weeks of treatment) was conducted. The outcomes of the pooled analysis were then used to construct a Markov health economic model covering an 11-y period. The incidences of diabetes-related micro- and macrovascular complications were derived from the United Kingdom Prospective Diabetes Study. The effects of changes in body mass index, and the impact of micro- and macrovascular complications on utilities were derived from published sources. Publicly available cost data were used and are presented here in 2001 Euros. Discounting of 3% was applied. A probabilistic sensitivity analysis was conducted to examine the robustness of results. RESULTS: A total of 1249 patients treated with orlistat and 1230 given placebo were eligible for the intent-to-treat analysis. At the end of the study period, 23% of orlistat patients achieved a weight reduction of >/=5%. These patients showed a mean decrease in HbA1C of 1.16%, a weight reduction of 8.6 kg, a reduction in total cholesterol of 5.3% and a reduction in systolic blood pressure of 5.2 mmHg. The base-case economic analysis revealed costs per quality-adjusted life year gained of euro14 000 in Sweden and euro13 600 in Switzerland. CONCLUSION: The data presented here support the utilization and reimbursement of orlistat in overweight and obese diabetic patients who respond to the treatment.

Anti-Obesity Agents↗

PubMedDate not supplied

Cost benefit analysis of neurostimulation for chronic pain.

OBJECTIVES: To assess the healthcare utilization of patients with intractable chronic neuropathic pain treated with spinal cord stimulation and peripheral nerve stimulation and to provide a cost-benefit analysis. METHODS: The case records of 222 consecutive patients who received spinal cord stimulation or peripheral nerve stimulation implants at the Cleveland Clinic Foundation between 1990 and 1998 were reviewed retrospectively. Patients were asked to complete a Neurostimulation Outcome Questionnaire designed to gather data on utilization of healthcare resources starting 1 year before surgical implantation. These data were pooled and net differences in events per patient per year, before and after device implantation were calculated and modeled to 2000 cost data obtained from the Medicare Fee Schedule and Healthcare Financing Administration. RESULTS: Neurostimulation Outcome Questionnaires were returned by 128 patients. The mean patient age was 46 +/- 12.5 years (range 21-71 years) and the mean implant duration was 3.1 +/- 2.3 years (range 0.5-8.9 years). The mean per patient total reimbursement of spinal cord stimulation/peripheral nerve stimulation absent pharmacotherapy was $38,187. Patients treated with spinal cord stimulation/peripheral nerve stimulation for pain management achieved reductions in physician office visits, nerve blocks, radiologic imaging, emergency department visits, hospitalizations, and surgical procedures, which translated into a net annual savings of approximately $30,221 and a savings of $93,685 over the 3.1-year implant duration. The large reduction in healthcare utilization following spinal cord stimulation/peripheral nerve stimulation implantation resulted in a net per patient per year cost savings of approximately $17,903. DISCUSSION: The reduced demand for healthcare resources by patients receiving neurostimulation suggests that peripheral nerve stimulation and spinal cord stimulation treatment, although associated with relatively high initial costs, demonstrates substantial long-term economic benefits. Thus, neurostimulation should be considered as a viable option for the early treatment of patients with intractable chronic neuropathic pain.

Adult↗

PubMed2003

Cost-effectiveness of transfusion of platelet components prepared with pathogen inactivation treatment in the United States.

BACKGROUND: The Intercept Blood System (IBS) for platelets has been developed to reduce pathogen transmission risks during transfusions. OBJECTIVE: This study was a comprehensive economic analysis of the cost-effectiveness of using the IBS for single-donor apheresis platelets (AP) and random-donor pooled platelet concentrates (PC) versus AP and PC without the IBS in the United States in patient populations in which platelets are commonly transfused. METHODS: All data used in this analysis were summarized from existing published sources (primarily indexed in MEDLINE) and data on file at Baxter Healthcare Corporation (Chicago, Illinois) and Cerus Corporation (Concord, California). A literature-based decision-analytic model was developed to assess the economic costs and clinical outcomes associated with the use of AP and PC treated with the IBS for several conditions and procedures that account for a considerable proportion of the platelet usage in the United States: acute lymphocytic leukemia, non-Hodgkin's lymphoma, coronary artery bypass graft, and hip arthroplasty Risks of infection with HIV, hepatitis C virus (HCV), hepatitis B virus, human T-cell lymphotropic virus type 1, or bacterial agents were incorporated into the model. Possible benefits of reduction of the risk of emerging HCV like pathogens and elimination of the need for gamma irradiation were explored in sensitivity analyses. RESULTS: The incremental cost per quality-adjusted life-year gained by using AP + IBS versus untreated AP ranged from 1,308,833 dollars to 4,451,650 dollars (without bacterial testing) and 4,759,401 dollars to 22,968,066 dollars (with bacterial testing). Corresponding figures for PC + IBS versus untreated PC ranged from 457,586 dollars to 1,816,060 dollars. Inclusion of emerging HCV like virus and the elimination of the need for gamma irradiation improved the cost-effectiveness to a range of 177,695 dollars to 1,058,127 dollars for AP without bacterial testing, 176,572 dollars to 1,330,703 dollars for AP with bacterial testing, and 22,888 dollars to 153,564 dollars for PC. The model was most likely to be affected by mortality from bacterial contamination, IBS effect on platelet utilization, and the inclusion of potential benefits (ie, gamma irradiation and/or emergent HCV-like virus). The model was relatively insensitive to changes in the IBS price and viral transmission risks. CONCLUSIONS: The cost-effectiveness of pathogen inactivation via the IBS for platelets is comparable to that of other accepted blood safety interventions (eg, nucleic acid amplification technology). The IBS for platelets may be considered a desirable strategy to increase the safety of platelet transfusions and a potential insurance against the threat of emerging pathogens.

Bacterial Infections↗

PubMed2002

Health care use and charges for adolescents enrolled in a title XXI program.

PURPOSE: To examine the use patterns and charges for adolescents with special health care needs (ASHCN) and adolescents engaging in risky behaviors (ARB) and both (BOTH), compared with adolescents with no identified special health care or risky behavior diagnosis (ANIC) in a pool of adolescent enrollees eligible for Title XXI services. METHODS: Claims and encounter data were used to classify 11,459 who had been enrolled in Florida's Healthy Kids Program for 2 consecutive years into 4 groups: ASHCN (n = 1363); ARB (n = 1801); BOTH (n = 773); and ANIC (n = 7522). Monthly per capita inpatient, outpatient, emergency room, and total use and charges were calculated and compared across groups using the Wilcoxon rank sum test, descriptive statistics, and odds ratios. RESULTS: The data indicated that ASHCN, ARB, and BOTH consume significantly more health care services than ANIC and that their higher use and charges are attributable not only to condition-related costs but also to their higher use of non-condition-related services as well. The data also revealed that adolescents with a special health care diagnosis (ASHCN and BOTH) had a higher percentage of costs owing to inpatient stays, whereas adolescents with a risky behavior diagnosis (ARB and BOTH) had a higher percentage of costs owing to emergency room usage. Finally, relevant to the total resources necessary to provide health care for adolescents, the data showed that 65% of the total annual costs of this program emanate from the 35% of adolescents who have special health care needs, engage in risky behaviors, or both. CONCLUSIONS: This study underscores two important points that can be used to ensure that adequate financing, provider network, and service delivery systems are developed to best meet the needs of the adolescent population: (a) the importance of considering the unique needs of adolescents in reimbursement rate setting strategies and (b) the importance of considering category of service utilization in weighting premiums for various groups.

Adolescent↗

PubMedDate not supplied

[Factors associated with suicidal risk among consulting young people in a preventive health center].

UNLABELLED: The association between suicidal risk and various psychological or biographical factors in teenagers or young adults is already well documented. Yet, the role of stressful life events or contexts during childhood or of the recent past, as well as the respective weight of such determinants, has to be specified. METHODS: One thousand one hundred and thirty-nine individuals, aged 16 to 25, who consecutively consulted in a preventive health center supported by the National Health Insurance System, located in Seine-Saint-Denis (a French department characterized by an unfavourable socio-economic context) on the occasion of a free work up were invited to fill out several self-administered questionnaires, aimed at assessing especially the level of psychosocial distress (Golberg's GHQ-28) and the level of hopelessness (Beck's hopelessness scale). They were also invited to meet a psychologist for a semi-structured interview, when the day of their consultation coincided with one of the three days a week the psychologist was present in the center; the interview was aimed at collecting information upon the biographical context and ancient or recent life events and to determine the level of suicidal risk, on the basis of a scale of suicidal ideation [Ducher's Suicidal Risk Scale (ERSD)]. The concurrent validity of the later has already been previously tested and positive correlation coefficients were found with Beck Depression Inventory, Hamilton's Depression Rating Scale and Beck's Hopelessness Scale. RESULTS: One thousand and four records could be analysed, as regards self-administered questionnaires, and among those, 576 as regards the interview with the psychologist and data related to suicidal risk. The studied population included 61.3% of females and 59.3% of individuals aged 20 to 25: mean age was comparable in males and females. GHQ-28 global score and sub-scores (somatisation, anxiety, social dysfunction and depressive mood) were all higher in women (all the p<0.001). A high suicidal risk (ERSD score 4) was found in 24.1% of the studied population. Subjects presenting with a high suicidal risk were characterized by higher levels of GHQ-28 psychosocial distress and GHQ-28 sub-scores as well as hopelessness (all the p<0.001). Several biographical antecedents during childhood were significantly associated with suicidal risk: unknown father (p<0.001), death of parents (p<0.001), separation from parents (p<0.001), severe quarrel between parents (p<0.001), money problems within the family (p<0.007), disorders related with alcohol consumption in parents (p<0.016), drug addiction within the family (p<0.001). Other predictors were several recent stressful events or contexts: violence within the family (p<0.001), social isolation (p<0.001), lack of self-esteem of (p<0.002), school difficulties (p<0.001), educational failure (p<0.001); as well as the notion of a consumption of drugs (p=0,001) or medications: neuroleptics (p<0.015), antidepressants (p=0.001) and tranquilizers (p<0.001). A series of univariate regression analyses allowed to compute the Odds Ratios (OR) and the 95% Confidence Intervals (95% CI) of the sub-group characterized by a high suicidal risk for each socio-demographic, psychological and biographical independent variable, linked to suicidal risk at a threshold of p<0.10. A multiple regression analysis was then performed in 2 steps: in a first step, independent variables were pooled by blocks, according to their nature (psychological characteristics, relational deficiencies among biographical antecedents, other stressful conditions among antecedents, stressful conditions among recent biographical context, recent consumption of drugs or medications); in a second step, all the independent variables which still remained associated with suicidal risk within each block were included in a final multiple regression analysis. Five variables continued to independently predict a high suicidal risk: hopelessness at Beck's scale (OR=4.09), depressive mood at GHQ-28 (OR=3.75), the notion of an unknown father (OR=2.95), the notion of a recent destabilizing event other than a school problem or an aggression (OR=1.90) and the notion of an educational failure (OR=1.78). CONCLUSION: These results confirm previous scientific data on this topic and underline that childhood context, educational course, psychological vulnerability and the occurrence of recent stressful life events combine their effects, enhancing the risk of a suicidal attempt. They can be useful for better sensitising educational as well as social and health care circles, for settling more efficient screening and preventive programs.

Adolescent↗

PubMed2005

The effect of a change in epoetin alfa reimbursement policy on anemia outcomes in hemodialysis patients.

In 1997, the Health Care Financing Administration Hematocrit Measurement Audit (HMA) program initiated use of a 3-month rolling average hematocrit (Hct) level for reimbursement of epoetin claims in hemodialysis patients, with denial of payment when this value exceeded 36.5%. This study evaluated the impact of the HMA program on anemia-related outcomes in hemodialysis patients. An observational, retrospective study of 987 hemodialysis patients from 11 dialysis centers in the United States was performed, collecting data between October 1996 and December 1997. Centers were selected from a pool of nearly all facilities in the United States, which during May 1997 satisfied one of two criteria: greater than 75% of patients at the facility had mean Hct level of > or =33% (Group A) or fewer than 50% of patients at the facility had mean Hct level of > or =33% (Group B). Each facility maintained its own anemia management practices without specific anemia management interventions as part of this study. Hct level, hemoglobin (Hb) level, and epoetin dose were analyzed to compare the pre-HMA period (October 1996 to May 1997) to the HMA period (June to December 1997) and/or for each of the five quarters of the study period. The primary study endpoint was the percentage of patients with Hct levels of > or =33% during each study quarter. The mean Hct level at baseline was 34% in Group A and 33.4% in Group B (p = 0.01). Hct levels, which were increasing before implementation of the HMA program, decreased during the HMA period (p < 0.001 and p = 0.013 in Groups A and B, respectively). The percentage of patients in Groups A and B with mean quarterly Hct levels of > or =33% decreased during the last quarter of the HMA implementation period compared to the quarter immediately preceding the start of the HMA program (p < 0.001 for both comparisons). Changes in Hb levels were similar to those seen in Hct levels. The mean epoetin dose administered decreased from 13,090 U/week at the start of the study to 11,884 U/week immediately before the HMA program took effect (p < 0.05). The HMA program adversely affected anemia treatment outcomes, regardless of whether dialysis units before HMA implementation had <50% of patients with a Hct level of > or =33% or had >75% of patients with a Hct level of > or =33%. The decline in mean weekly dose of epoetin was likely a result of withholding doses out of concern among providers about risk of reimbursement denial.

Adult↗

PubMed2004

Implementing and using quality measures for children's health care: perspectives on the state of the practice.

OBJECTIVE: The objective of this study was to identify issues, obstacles, and priorities related to implementing and using child health care quality measures from the perspectives of 4 groups: 1) funders of quality-measurement development and implementation; 2) developers of quality measures; 3) users of quality measures (including Medicaid and the State Children's Health Insurance Program, employer coalitions, and consumer groups); and 4) health plans and providers (in their role as both subjects and users of quality measures). METHODS: A series of semistructured interviews was conducted with approximately 40 opinion leaders drawn from these 4 groups. The interviews were conducted by telephone between September and December of 2001. Major topic areas covered in the interviews were similar across the groups. Topic areas included 1) strategic vision and/or objectives for funding, developing, or using quality measures for children's health care; 2) a brief summary of the specific quality measures funded, developed, or used; 3) issues and challenges facing funders and developers of measures; 4) major successes achieved; 5) obstacles to implementation and use of measures; and 6) priority needs for future funding. RESULTS: Leaders from all 4 groups acknowledge the importance of developing a robust set of quality measures that can serve multiple objectives and multiple audiences. Standardization of measures is viewed as a critical feature related to all objectives. An assessment of specific quality measures funded, developed, or used by strategic objective shows a high correlation between the uses intended by funders and developers and the actual applications of the various users. The most commonly cited measures across all groups are the Consumer Assessment of Health Plans Survey and Health Plan Employer Data and Information Set, followed by the Child and Adolescent Health Measurement Initiative and special topic studies to support quality-improvement applications (eg, asthma, diabetes, etc). The major issues and challenges cited in common among funders and developers are 1) the lack of trained capacity in the field to conduct needed research and development, and 2) the difficulty in generating sustained interest and support among funders because of the complexity of quality-measurement issues, competing funding priorities in the face of limited funds available to allocate, and the lack of clear and compelling evidence that quality measurement and improvement actually result in better outcomes for children. The 3 most common successes cited across all 4 groups are 1) the growing consensus and collaboration among diverse stakeholder groups involved in measurement development and implementation; 2) the increasing collection and use of specific measures; and 3) early documentation of tangible results in terms of improved quality of care. Specific measurement tools cited as successes by funders and developers include the Medicaid Health Plan Employer Data and Information Set, Consumer Assessment of Health Plans Survey, the Child and Adolescent Health Measurement Initiative, and Rand QA Tools. The most important obstacle reported across all groups is the lack of a strong and compelling "business case" that clearly demonstrates the benefits of quality measurement relative to the costs of implementation. Strongly related to this barrier is the cost of implementing and using measures without a sustainable source of financing as well as the absence of strong public awareness and political support for children's health care quality measurement. Another major barrier cited is the lack of coordination among funders, which prevents the field from developing a unified approach to addressing the numerous technical, political, and administrative issues also cited at length by the leaders interviewed. The 5 top needs for future funding identified across all 4 groups follow directly from the major obstacles that they reported: 1) develop the business case for children's health care quality measurement and improvement based on rigorous cost-bigorous cost-benefit analysis and documentation of quantifiable successes; 2) develop new measures to fill the gaps in critical areas (including adolescent health care, behavioral health, and chronic conditions) that can be applied at the hospital and ambulatory care provider levels; 3) invest in building needed research capacity, a trained pool of users of quality measures, and the capacity among providers to understand and use quality-improvement methods and tools; 4) invest in developing an information infrastructure that will support the efficient collection and use of measures for multiple purposes, including clinical practice, quality measurement, and quality improvement; and 5) develop increased public awareness and support for quality measurement based on improved strategies for communicating with consumers, purchasers, providers, and policy makers. CONCLUSIONS: Several implications are suggested by these perspectives for the future direction of quality measurement in children's health care. First, to meet the funding needs identified, many funders must improve coordination to reduce the noise and fragmentation generated by numerous competing or redundant activities. Improved coordination among funders will help assure maximum impact and the efficient use of scarce resources. Second, the importance attached to standardization of measures by both users and developers may conflict at times with the need for innovation and flexibility. Child health quality leaders will need to manage this tension between standardization and innovation to maintain an appropriate balance between the benefits of both. Finally, many of the obstacles identified are not unique to children's health care. Child health quality leaders will need to determine to what extent their efforts to overcome these obstacles can be successfully undertaken independently as opposed to in concert with groups concerned about other populations and sectors in the health care system.

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PubMed2005

Retrospective study of the costs of care during the first year of therapy with etanercept or infliximab among patients aged > or =65 years with rheumatoid arthritis.

OBJECTIVE: The aim of this work was to retrospectively examine the costs of therapy with etanercept and infliximab, among patients aged > or = 65 years with rheumatoid arthritis (RA), from a health-care system perspective. METHODS: Data from 2 large, automated US health-care claims databases (Constella COMPASS and Ingenix LabRx) were pooled for the analyses. Each database is comprised of paid facility, professional service, and retail (ie, outpatient) pharmacy claims from participating health plans. Using the 2 databases, all RA patients aged > =65 years were identified who began therapy with etanercept or infliximab between July 1, 1999 (Constella COMPASS), or January 1, 2001 (Ingenix LabRx), and December 31, 2002. Costs of RA-related care (including study drugs, selected medications, and outpatient encounters for RA) and non-RA-related care (all other medications and services) for patients in the 2 treatment groups were assessed, in US dollars, over a 1-year period after therapy initiation. RESULTS: A total of 280 RA patients aged > or = 65 years initiated therapy with etanercept (n = 99) or infliximab (n = 181) and met all other selection criteria. Etanercept patients were younger than infliximab patients (mean [SD] age, 70.5 [4.6] vs 71.8 [4.6] years; P = 0.04), were less likely to be enrolled in a managed care organization (76.7% vs 87.8%; P < 0.01), and had fewer pretreatment rheumatologist visits (mean [SD], 1.3 [2.3] vs 2.2 [3.8]; P = 0.04). Other characteristics, including pretreatment levels of other types of health-care utilization, were generally similar. Mean (95% CI) total cost of RA-related care was lower for etanercept patients in both databases (US 12,159 dollars [US 10,795 dollars-US 13,380 dollars] for etanercept vs US 22,347 dollars [US 20,808 dollars-US 23,912 dollars] for infliximab in one, and US 14,297 [US 12,238 dollars-US 16,326 dollars] for etanercept vs US 22,154 dollars [US 19,688 dollars-US 24,703 dollars] for infliximab in the other), primarily due to lower costs of anti-tumor necrosis factor therapy (US 10,015 dollars [US 8754 dollars-US 11,224 dollars] for etanercept vs US 18,611 dollars [US 17,169 dollars-US 20,023 dollars] for infliximab in one database; US 11,917 dollars [US 10,128 dollars-US 13,480 dollars] for etanercept vs US 16,759 dollars [US 14,551 dollars-US 19,062 dollars] for infliximab in the other). Mean (95% CI) costs of non-RA-related care were similar among etanercept and infliximab patients in both databases (US 13,100 dollars [US 8956 dollars-US 18,377 dollars] for etanercept vs US 11,789 dollars [US 8326 dollars-US 16,001 dollars] for infliximab in one, and US 16,665 dollars [US 10,329 dollars-US 25,690 dollars] for etanercept vs US 13,959 dollars [US 10,216 dollars-US 18,168 dollars] for infliximab in the other). CONCLUSION: These results suggest that costs of RA-related care during the first year of therapy may be lower among RA patients aged > or =65 years receiving etanercept versus infliximab, a difference attributable primarily to lower costs of drug acquisition.

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