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PubMed1986

Another look at sex differences in the use of medical care: illness orientation and the types of morbidities for which services are used.

The purpose of this investigation is to build on the findings of earlier studies and, focusing on specific disease categories, further explore the factors which may contribute to the sex differential in medical care utilization rates. In pursuing this objective, the study attempts to differentiate those types of disease categories for which illness orientation has a significant effect on utilization rates from those where the effects are minimal. The study population includes 1648 adults between the ages of 18 and 59. Medical record data covering 7 years of outpatient services are linked with survey data on the respondents. The findings show that the largest sex differences in utilization rates occur in those categories which represent more mild morbidities and those where there is more discretion in defining illness and/or the need for care. It is in these categories showing the largest sex differences in doctor office visits in which illness orientation factors appear to be most influential. Thus, the findings provide further evidence for the hypothesis that sex differences in morbidity reports and utilization rates are due to differences in the way symptoms are perceived, evaluated and acted upon. Interpretations and implications are discussed.

Adult↗

PubMed1997

Predictive validity of the Pra instrument among older recipients of managed care.

OBJECTIVE: To determine the validity of the Pra instrument in predicting the use of health-related services by older enrollees in a managed care plan. DESIGN: Cohort study. At baseline, a survey was administered by mail. Responses were entered into the Pra formula to estimate each person's probability of using health-related services heavily in the future. The subjects' use of services during the following year was monitored through claims submitted to their managed care organization. SETTING: Urban and suburban areas of Southern California. PARTICIPANTS: Persons aged 65 years and older enrolled in a Medicare risk health plan (n = 6802). MEASUREMENTS: Baseline data included demographic, health-related, social, functional, and previous-use-of-service characteristics. Follow-up data included the use of and claims for payment for inpatient hospital care, emergency room services, nursing home services, home care, ambulance services, outpatient surgery, and durable medical equipment. RESULTS: High-risk subjects (highest quartile of Pra values) incurred hospital admissions and claims that were 2.5 and 2.7 times greater than those of low-risk subjects (lower three quartiles). CONCLUSIONS: The Pra formula is recommended for screening older adults enrolled in managed care organizations (as well as for screening those in the fee-for-service environment). It identifies older people who may benefit from interventions designed to avert health crises and the need for expensive care.

Aged↗

PubMed1986

[Modalities for a coordinated approach to crisis situations in institutions, from the viewpoint of the patient care team].

The authors, while questioning the admission's services too specialized, commend a greater personalization of the treatments. They propose for this the use of a procedure: the care's process. Arguing in favour of an interdisciplinary approach, they remind us of some important principles of the work in teams, using for this both an individual and contextual approach. Finally, they express a postulate for the future, that the in-and outpatients' services should be enough coordinated to take better into account the necessary continuity in the treatments.

Adaptation, Psychological↗

PubMed1983

Gender roles, illness orientation and use of medical services.

The study investigates illness orientation as a factor which may account for sex differences in the utilization of medical care. First, sex differences in the way symptoms are perceived, evaluated and acted upon (illness orientation) are analyzed. Then gender role factors which may account for sex differences in illness orientation are examined. Finally, the degree to which gender role factors and illness orientation account for sex differences in medical care utilization are assessed. The study population includes 1648 adults between the ages of 18 and 59. Medical record data covering 7 years of outpatient services are linked with survey data on the respondents. The findings show that while females are more likely to perceive symptoms than males, there is no apparent sex difference in a tendency to adopt the sick role when ill. In addition, results indicate that gender role factors such as level and type of role responsibility and concern with health are related to female though not male symptom reports. Illness orientation variables are related to rates of medical utilization for both sexes. However, it is primarily the perception of symptoms and an interest and concern with health which contributes to sex differences in utilization rates. When examining respondents who report either a very low or very high number of symptoms, sex differences in utilization rates fall below statistical significance.

Adolescent↗

PubMed1978

[Epidemiology of mental disorders and psychiatric care. Part 2. Discussion of results].

A prior analysis of treated patients is required in order to develop effectively a system of psychiatric health services. Data are presented respectively for a rural small town area of Upper Bavaria with 424,000 residents. Incidence and prevalence rates of treated mental illness are considered according to various criteria, especially diagnosis. Morbidity rates for localities of varying size are cited as an example of ecological approach. When planning, one must conclude the necessity for differentiated psychiatric treatment within the community, with emphasis on outpatient services.

Adult↗

PubMed2001

Health care utilization and cost among health maintenance organization members with temporomandibular disorders.

AIMS: Little has been reported on the use of health care services and consequent costs among persons with temporomandibular disorders (TMD). This project compared the use and cost of medical and dental care services for TMD patients and matched comparison subjects. METHODS: Patients were continuously enrolled members of Kaiser Permanente Northwest Division who had at least 1 TMD Clinic visit or TMD-related procedure between January 1990 and December 1995 (n = 8,801). An equal number of comparison subjects were identified electronically and matched on 14 variables, including age and gender. Utilization and cost estimates were determined and compared for selected medical and dental services. RESULTS: For both groups, the mean age was about 40.5 years, and approximately 80% were female. The TMD subjects used significantly more services than did comparison subjects and had mean costs that were 1.6 times higher for all services. Outpatient visits accounted for about 40% of the difference in mean costs. About 10% of TMD subjects and comparison subjects accounted for about 40% and 47% of the costs in each group, respectively. Female TMD subjects and comparison subjects had higher costs than their male counterparts, and male TMD subjects had higher costs than female comparison subjects. CONCLUSION: Patients with TMD used more of all types of services and had higher costs. A small proportion of the subjects accounted for a large proportion of the costs. Gender was an important factor in utilization and cost. Utilization and cost differences were consistent over a wide range of service categories and could not be explained by TMD alone.

Adult↗

PubMed1978

An ambulatory training model for an obstetrics and gynecology residency program.

An important educational objective of an obstetric-gynecologic residency program is to provide an ambulatory experience from which residents can develop attitudes and skills that will enable them to provide high-quality comprehensive care to their patients. Often traditional outpatient clinics hold second-class positions in a training program, with surgical or obstetrical procedures being more highly valued experiences. From the patients' point of view many of these clinics are uncomfortable, noisy, and unattractive; and the patients in many instances receive depersonalized, discontinuous care. There is, therefore, a pressing need to implement efficient strategies to meet the increasing community demands for outpatient services while at the same time providing an innovative and effective ambulatory experience for residents. This paper describes how in a cooperative effort between a hospital's Department of Ambulatory Services and Department of Obstetrics and Gynecology these educational objectives were successfully integrated with those of continuous and comprehensive patient care.

Ambulatory Care↗

PubMed1990

Strategies for boosting outpatient care profitability.

With outpatient charges approaching one-fourth of hospital revenues nationwide, healthcare providers are pressed to handle this care more efficiently and profitably. Five steps toward healthier profit margins for outpatient services involve finding ways to expand volume and market share; setting and meeting strict quality standards; studying operational efficiency; working with physicians to improve productivity; and monitoring price-cost relationships.

Costs and Cost Analysis↗

PubMed1995

Effect of a prior-authorization requirement on the use of nonsteroidal antiinflammatory drugs by Medicaid patients.

BACKGROUND: Prior authorization--mandatory advance approval for the use of expensive medications--is now the primary method by which Medicaid programs control expenditures for drugs. However, whether this policy reduces expenditures for specific drugs without causing the unwanted substitution of other drugs or medical services has been largely unstudied. We evaluated the effects of a prior-authorization policy involving nongeneric nonsteroidal antiinflammatory drugs (NSAIDs) in the Medicaid program in Tennessee. METHODS: We compared monthly Medicaid expenditures that were potentially affected by the policy change during the year before and the two years after its implementation. We studied prescriptions for NSAIDs, other analgesic or antiinflammatory drugs, and psychotropic drugs, as well as outpatient services and inpatient admissions for the management of pain or inflammation. RESULTS: At the midpoint of the base-line year, 495,821 people were enrolled in Medicaid. During that year, mean annualized Medicaid expenditures for NSAID prescriptions amounted to $22.41. Expenditures decreased by 53 percent (95 percent confidence interval, 48 to 57 percent) during the next two years, for an estimated savings of $12.8 million. The reduction in expenditures resulted from the increased use of generic NSAIDs, as well as from a 19 percent decrease in overall NSAID use (95 percent confidence interval, 13 to 25 percent). There was no concomitant increase in Medicaid expenditures for other medical care. Regular users of nongeneric NSAIDs, those most affected by the policy change, had similar reductions in NSAID expenditures and use, with no increase in expenditures for other medical care. CONCLUSIONS: Prior-authorization requirements may be highly cost effective with regard to expenditures for NSAIDs, drugs that have very similar efficacy and safety but substantial variation in cost.

Adolescent↗

PubMed1986

Medicare outpatient clinical laboratory services payments: relative value scale approach.

The Health Care Financing Administration is in the process of designing a competitive bidding model for the purchase of outpatient clinical laboratory services. One segment of this process involves the development of a relative value scale (RVS). The RVS could be used as part of the bidding process and as the basis of payment. The RVS could also be used as the basis of a national fee schedule, as stipulated in the Deficit Reduction Act of 1984. Potential problems with the development of an RVS from local (carrier) fee schedules for outpatient clinical laboratory services were investigated.

Centers for Medicare and Medicaid Services, U.S.↗

PubMed1984

Staffing patterns in rural health services for children and adolescents.

This paper reviews several current human resources issues in delivering mental health services to children and adolescents, focusing primarily on the lack of systematic data regarding staff involved in these programs. Data from twenty counties in rural western Pennsylvania are then presented demonstrating the personal, educational, employment, and caseload characteristics of this group of staff, as well as their primary job functions and areas of job satisfaction. Professional staff were likely to have terminal master's degrees and to work primarily in outpatient services, whereas bachelor's-level staff were more likely to perform "generalist" functions, often without adequate supervision and clinical training. Paraprofessional staff were most numerous in community residential settings and performed a variety of functions. The implications of these findings for services development and staff training are discussed.

Adolescent↗

PubMed1995

Geographic variation in primary care visits in Iowa.

OBJECTIVE: This study investigates the determinants of primary care office visit rates. DATA SOURCES: Blue Cross and Blue Shield of Iowa subscriber information was sorted by residence into geographic health service areas. Cost-sharing information was also obtained from Blue Cross. Physician supply data were obtained from The University of Iowa, Office of Community-Based Programs. Hospital data were reported by the Iowa Hospital Association. STUDY DESIGN: Cases were classified into ambulatory care groups (ACGs). Use rates were computed for each group in each service area. Ordinary least squares regression models were developed to model geographic variation in each ACG-specific primary care visit rate. PRINCIPAL FINDINGS: Regression models were not significant for five out of eleven ACGs studied. Out-of-pocket expense significantly affected utilization in three out of six. The number of primary care practices per capita had a significant effect on utilization in two ACGs. The supply of hospital outpatient services was significant in one ACG. CONCLUSIONS: Study findings reveal that some ACGs are price-sensitive and some are not. Policies aimed at changing levels of primary care use should taken into account whether varying cost-sharing will influence consumer behavior in the desired direction.

Adult↗

PubMed2000

Olanzapine versus risperidone. A prospective comparison of clinical and economic outcomes in schizophrenia.

OBJECTIVE: To compare the clinical and economic outcomes associated with olanzapine and risperidone treatment for schizophrenia. DESIGN AND SETTING: An international, multicentre, double-blind, prospective study. To facilitate economic comparisons, our sample was restricted to patients enrolled in US sites. 150 patients with a Diagnostic and Statistical Manual of mental disorders, 4th edition (DSM-IV) diagnosis of schizophrenia, schizoaffective disorder or schizophreniform disorder were randomised to therapy with either olanzapine 10 to 20 mg/day (n = 75) or risperidone 4 to 12 mg/day (n = 75) for a maximum of 28 weeks. In addition to tolerability and efficacy assessments, use of health services was assessed at baseline and prospectively, at 8-week intervals and at study completion. Clinically important response, defined as a 40% improvement in the Positive and Negative Syndrome Scale total score, maintenance of response and rates of treatment-emergent extrapyramidal symptoms were compared between groups. Direct medical costs were estimated by assigning standardised prices to resource units. Median total, inpatient/outpatient service and medication acquisition costs were compared between treatment groups. MAIN OUTCOME MEASURES AND RESULTS: The mean modal dosages for the olanzapine and risperidone treatment groups were 17.7 +/- 3.4 mg/day and 7.9 +/- 3.2 mg/day, respectively. Olanzapine-treated patients were more likely to maintain response compared with risperidone-treated patients (p = 0.048). In addition, a smaller proportion of olanzapine-treated patients required anticholinergic therapy compared with risperidone-treated patients (25.3 vs 45.3%; p = 0.016). Total per patient medical costs over the study interval were $US2843 (1997 values) [36%] lower in the olanzapine treatment group than in the risperidone treatment group (p = 0.342). Medication costs were significantly higher for olanzapine-treated patients ($US2513 vs $US1581; p < 0.001), but this difference was offset by a reduction of $US3774 (52%) in inpatient/outpatient service costs for olanzapine-treated patients in comparison with risperidone-treated patients ($US3516 vs $US7291, p = 0.083). Median cost findings were consistent with results observed using other robust measures of central tendency and provide conservative estimates of potential savings that may be obtained from olanzapine therapy. CONCLUSIONS: In this study, olanzapine-treated patients experienced clinical improvements that translated into savings in costs of care for both inpatient and outpatient services. These savings offset the difference in medication acquisition cost between olanzapine and risperidone.

Adult↗

PubMed2001

[Gastroenterologists in ambulatory care. The experience in Turin in the year 2000].

BACKGROUND: Digestive diseases (GI) have a major impact on public health in Italy. Hospital stay for digestive pathologies parallels that due to cardiovascular causes. Total mortality for GI causes is also very high. The management of GI pathologies is therefore a major task for the National Health System. To the experienced gastroenterologist it is clear that a large number of hospitalisation is linked to a lack of careful outpatient follow-up of diseases such as cirrhosis, ulcerative colitis and peptic ulcer. METHODS: One year of activity of our Gastro-entero-Hepatology outpatient service is examined. The management of the majority of GI diseases is organized in working teams of physicians and surgeons following cohorts of patients suffering of a specific disease. RESULTS: During the year 2000 not only a statistically significant higher number of patients has been examined (p<0.05), in comparison with 1994, but also the hospitalisation rate was lowered resulting in a very significative cost-containment. CONCLUSIONS: The specialization of outpatient activities into working teams offers advantages in terms of more appropriate medical care and cost reduction, partly due to a less frequent hospitalisation. The obvious counterpart was an increase of request of such form of follow-up from patients, resulting in longer delay to the access.

Ambulatory Care↗

PubMed1978

Resource allocation. Some problems in applying the national formula to area and district revenue allocations.

The inadequacy of the current national formula in dealing with flows of patients across administrative boundaries is illustrated. In particular, the problems of dealing with varying admission rates for inpatients and in allocating revenues for outpatient services are discussed. We draw attention to an oversight in the recommendations concerning psychiatric services and criticise the general approach to the allocation of revenue under this heading. It is concluded that the national formula should not be applied for revenue allocation at district level in an unmodified form.

Catchment Area, Health↗

PubMed1998

Economic consequences of diabetes mellitus in the U.S. in 1997. American Diabetes Association.

OBJECTIVE: Diabetes is a significant public health problem resulting in substantial morbidity and mortality. The objectives of this study were 1) to determine the direct medical and indirect costs attributable to diabetes and 2) to calculate total and per capita expenditures of people with and without diabetes. RESEARCH DESIGN AND METHODS: Direct medical and indirect expenditures attributable to diabetes in 1997 were estimated at $98 billion. Medical expenditures for the treatment of diabetes were estimated for all individuals in the U.S. in 1997 by age-group, sex, race, type of condition, and site of service. Productivity costs due to disability and premature mortality were also estimated for selected patient cohorts. Etiological fractions based on national health care survey data and published literature were used to estimate the proportion of health service utilization and mortality associated with diabetes-related chronic complications and general medical conditions. RESULTS: Direct medical expenditures attributable to diabetes in 1997 totaled $44.1 billion and comprised $7.7 billion for diabetes and acute glycemic care, $11.8 billion due to the excess prevalence of related chronic complications, and $24.6 billion due to the excess prevalence of general medical conditions. The majority of attributable expenditures were for inpatient care (62%), followed by outpatient services (25%) and nursing home care (13%). Two-thirds of all medical costs for diabetes were borne by elderly people. Attributable indirect costs totaled $54.1 billion and comprised $17.0 billion resulting from premature mortality and $37.1 billion from disability. Total medical expenditures incurred by people with diabetes totaled $77.7 billion or $10,071 per capita, compared with $2,669 for people without diabetes. CONCLUSIONS: The economic burden of diabetes mellitus in the U.S. is enormous. Medical innovations that can delay the onset and slow the progression of diabetes have tremendous potential to mitigate the associated clinical and cost repercussions.

Adolescent↗

PubMed1985

[Analysis of the activities of the Biella Mental Health Service during the 3-year period 1980-1982].

An account is presented of the work of the Biella local health unit in the province of Vercelli, Piedmont. Attention is drawn to the difficulties met with in applying the latest enactments concerning psychiatry. Delay in application of the health reforms is having an adverse effect on the operation of the new psychiatric care structures. Psychiatry is finding it difficult to become an integral part of the other health services. This is clear from the requests for consultation made to department psychiatrists at Biella Hospital. There has been an increase in applications for admission and compulsory treatment in the three-year period under review. In particular, there is the difficulty of taking on a small number of patients from the previous structures. By contrast, there has been a change for the better in the relationship between the community and the outpatient service. This relationship is becoming stable and is beginning to acquire a psychotherapeutic structure.

Community Mental Health Centers↗

PubMed2003

Managing perinatal outcomes: the clinical benefit and cost-effectiveness of pharmacologic treatment of recurrent preterm labor.

PURPOSE: To compare the clinical benefit and cost-effectiveness of utilizing continuous subcutaneous terbutaline versus oral tocolytics following recurrent preterm labor. DESIGN: Retrospective, 1:1 matched cohort. METHODOLOGY: From prospectively collected data in a nationwide, perinatal database of women receiving outpatient services, we identified singleton gestations having recurrent preterm labor, stabilized during hospitalization, and subsequently treated with oral tocolytics (PO group) or continuous subcutaneous terbutaline infusion (SQ group). Those without medically indicated delivery were eligible for inclusion. Each woman in the PO group was matched 1:1 by gestational age at recurrent preterm labor to a woman in the SQ group. A standardized cost model was applied to compare total antepartum hospital, nursery, and outpatient charges. Wilcoxon Signed Rank, paired t, and McNemar's C2 test statistics were used for comparisons. PRINCIPAL FINDINGS: 558 women were studied (279 per group). The PO group had less gestational gain following recurrent preterm labor than the SQ group (28.4 +/- 19.8 days vs. 33.9 +/- 19.0 days, respectively, P < .001). The SQ group had less per patient charges ($) for antepartum hospitalization (3,986 +/- 6,895 vs. 5,495 +/- 7,131, P = .009), and nursery (7,143 +/- 20,048 vs. 15,050 +/- 32,648, P < .001). Outpatient charges were less for the PO group (1,390 +/- 1,152 vs. 5,520 +/- 3,292, P < .001). Overall costs for those in the SQ group were $5,286 less per pregnancy compared to the PO group. CONCLUSION: In this population, continuous subcutaneous terbutaline infusion was both a clinically beneficial and cost-effective treatment following recurrent preterm labor.

Administration, Oral↗