Showing papers in "The American Journal of Managed Care in 1998"

Development and validation of a simple questionnaire to facilitate identification of women likely to have low bone density.

Abstract: The relationship between low bone mass and risk of fracture is well documented. Although bone densitometry is the method of choice for detecting low bone mass, its use may be limited by the availability of equipment, cost, and reimbursement issues. Improved patient selection for bone densitometry might increase the cost-effectiveness of screening for osteoporosis, a goal we sought to achieve by developing and validating a questionnaire based solely on patient-derived data. Responses to the questionnaire were used to assign postmenopausal women to one of two groups: (1) those unlikely to have low bone mineral density (defined as 2 standard deviations or more below the mean bone mass at the femoral neck in young, healthy white women) and therefore probably not currently candidates for bone densitometry; and (2) those likely to have low bone mineral density and therefore probably candidates for bone densitometry. We asked community-dwelling perimenopausal and postmenopausal women attending one of 106 participating multispecialty centers (both academic and community based) to complete a self-administered questionnaire and undergo bone density measurement using dual x-ray absorptiometry. We used regression modeling to identify factors most predictive of low bone density at the femoral neck in the postmenopausal group. A simple additive scoring system was developed based on the regression model. Results were validated in a separate cohort of postmenopausal women. Data were collected from 1279 postmenopausal women in the development cohort. Using only six questions (age, weight, race, fracture history, rheumatoid arthritis history, and estrogen use), we achieved a target of 89% sensitivity and 50% specificity. The likelihood ratio was 1.78. Validation in a separate group of 207 postmenopausal women yielded 91% sensitivity and 40% specificity. Assuming population characteristics similar to those of our development cohort, use of our questionnaire could decrease the use of bone densitometry by approximately 30%. Sensitivity and specificity can be varied by changing the level for referral for densitometry to provide the most cost-effective use within a particular healthcare setting. Thus use of our questionnaire, an inexpensive prescreening tool, in conjunction with physician assessment can optimize the use of bone densitometry and may lead to substantial savings in many healthcare settings where large numbers of women require evaluation for low bone mass.

Clinic visits and hospital admissions for care of acid-related upper gastrointestinal disorders in women using alendronate for osteoporosis.

Abstract: CONTEXT About 1 in 3 women taking alendronate for osteoporosis report gastrointestinal symptoms, a rate much higher than that found during clinical trials. OBJECTIVE To establish the frequency of outpatient visits and hospital admissions for acid-related upper gastrointestinal disorder (ARD) among women taking alendronate and to identify potential risk factors. METHODS A retrospective database analysis identified 812 women with osteoporosis who had filled one or more 10-mg alendronate prescriptions from October 1995 through October 1996. RESULTS One hundred (12.3%) of the 812 women received healthcare for ARD, a clinical encounter rate of 28.5 per 100 person-years. A reference group of 362,109 women from the same health plan had 17.6 ARD encounters per 100 person-years. Excluding women who had ARDs before receiving alendronate, alendronate users were 1.6 (95% CI = 1.2, 2.7) times more likely to have an ARD encounter than nonusers. Risk of having ARD increased with age [users aged 70 years and older had a relative risk of 1.5 (95% confidence interval (CI) 1.0-2.30) compared with younger women] and with concurrent use of nonsteroidal anti-inflammatory drugs (NSAIDS) (relative risk 1.7, 95% CI 1.1-2.6). CONCLUSIONS Elderly alendronate users or those concurrently taking NSAIDS should be carefully monitored because of their high risk of having ARD. Cost/benefit analyses of alendronate treatment for osteoporosis should include costs of treating ARD.

Factors affecting patient compliance with antihyperlipidemic medications in an HMO population.

Abstract: OBJECTIVE: To identify factors that influence compliance in patients taking antihyperlipidemic medications. STUDY DESIGN: This was a retrospective cohort study in which computerized pharmacy records were used to estimate medication compliance in patients in a Health Maintenance Organization from 1993 to 1995. PATIENTS AND METHODS: Data on 772 patients on antihyperlipidemic medications were obtained from pharmacy and healthcare utilization claims and from a cross-sectional survey. The medication compliance ratio for each patient was calculated from the prescription profile. Patient compliance was modeled as a function of four clusters of determinants: patient characteristics, complexity of drug regimen, health status, and patient-provider interaction. Correlation between specific characteristics and compliance was estimated by logistic regressions. RESULTS: Approximately 37% of patients complied with at least 90% or more of their antihyperlipidemic medications. The following variables had a significant influence on compliance: female gender (odds ratio [OR], 0.64), baseline compliance (high: OR, 3.42; medium: OR, 1.86), perceived health status (SF-36 bodily pain score: OR, 1.02; SF-36 vitality score: OR, 0.97), comorbidity (OR, 0.90), and number of daily doses of antihyperlipidemic medications (OR, 0.60). CONCLUSIONS: The findings suggest that women, patients with comorbidities, patients reporting high SF-36 vitality scores, and patients with multiple doses of antihyperlipidemic medications are less likely to be compliant. Patients who self-report good compliance with previous medications are more likely to comply. This information may be used to target interventions at patients who are likely to be noncompliant with their medication regimens.

Identifying diabetes mellitus or heart disease among health maintenance organization members: sensitivity, specificity, predictive value, and cost of survey and database methods.

Abstract: We conducted a study of the sensitivity, specificity, positive predictive value, and cost of two methods of identifying diagnosed diabetes mellitus or heart disease among members of a health maintenance organization (HMO). Among 3186 adult HMO members who were attending one primary care clinic, 2326 were reached for a telephone survey (efficiency = 0.73). Among these members, 1991 answered standardized questions to ascertain whether they had diabetes or heart disease (corrected response rate = 0.85). Linkage was then made to computerized diagnostic databases. By means of both a database method and a survey method, the 1976 members with complete data for analysis were classified as having or not having diabetes or heart disease. When results with the two methods disagreed, charts were reviewed to confirm the presence or absence of diabetes or heart disease. Diabetes was identified among 4.7% of adult members, and heart disease was identified among 3.7%. Identification of diabetes differed between the database method and the survey method (sensitivity 0.91 vs 0.98, specificity 0.99 vs 0.99, positive predictive value 0.94 vs 0.83). Identification of heart attach history was similar for the database method and the survey method (sensitivity 0.89 vs 0.95, specificity 0.99 vs 0.99, positive predictive value 0.79 vs 0.81). The cost of obtaining data was $13.50 per member for the survey method and $0.30 per member for the database method. Database methods or survey methods of identifying selected chronic diseases among HMO members may be acceptable for various purposes, but database identification methods appear to be less expensive and provide information on a higher proportion of HMO members than do survey methods. Accurate identification of chronic diseases among patients supports clinic-level measures for clinical improvement, research, and accountability.

Consequences of intermittent treatment for hypertension: the case for medication compliance and persistence.

Abstract: OBJECTIVE To review patient compliance with once-daily antihypertensive medications and the impact of partial compliance on healthcare outcomes. DATA SOURCES A MEDLINE search of the literature using the terms "patient compliance," "antihypertensive medications," and "hypertension" for the period 1976-1996 was conducted. In addition, papers cited in reference lists of source articles were reviewed. STUDY SELECTION Articles were selected if they described patterns of compliance, including rates for differing dosing regimens. Articles discussing once-daily dosing were selected only if they included information on the methodology for compliance assessment. Thirteen reports met these criteria. DATA SYNTHESIS Patterns of compliance vary, with only a partial relationship to dosing regimens. Overall compliance was 76% for once-daily antihypertensive medications, with a wide range found (53% to 85%). These data were comparable to the mean 75% compliance found for other medical disorders. CONCLUSIONS Persistence with treatment is necessary for reduction of long-term consequences of hypertension. Enhancing compliance with antihypertensive medications could thus have a profound impact on health outcomes. Once-daily dosing should be coupled with selection of a drug with long duration of action to overcome problems of missed doses. Widespread adoption of simple compliance enhancement methods could lead to decreased morbidity and mortality from cardiovascular disease and stroke.

A cost-effectiveness clinical decision analysis model for schizophrenia.

Abstract: A model was developed to estimate the medical costs and effectiveness outcomes of three antipsychotic treatments (olanzapine, haloperidol, and risperidone) for patients with schizophrenia. A decision analytic Markov model was used to determine the cost-effectiveness of treatments and outcomes that patients treated for schizophrenia may experience over a 5-year period. Model parameter estimates were based on clinical trial data, published medical literature, and, when needed, clinician judgment. Direct medical costs were incorporated into the model, and outcomes were expressed by using three effectiveness indicators: the Brief Psychiatric Rating Scale, quality-adjusted life years, and lack of relapse. Over a 5-year period, patients on olanzapine had an additional 6.8 months in a disability-free health state based on Brief Psychiatric Rating Scale scores and more than 2 additional months in a disability-free health state based on quality-adjusted life years, and they experienced 13% fewer relapses compared with patients on haloperidol. The estimated 5-year medical cost associated with olanzapine therapy was $1,539 less than that for haloperidol therapy. Compared with risperidone therapy, olanzapine therapy cost $1,875 less over a 5-year period. Patients on olanzapine had approximately 1.6 weeks more time in a disability-free health state (based on Brief Psychiatric Rating Scale scores) and 2% fewer relapses compared with patients on risperidone. Sensitivity analyses indicated the model was sensitive to changes in drug costs and shortened hospital stay. Compared with both haloperidol and risperidone therapy, olanzapine therapy was less expensive and provided superior effectiveness outcomes even with conservative values for key parameters such as relapse and discontinuation rates.

Prevalence of insomnia: a survey of the enrollees at five managed care organizations.

Abstract: The purpose of the study was to assess the prevalence of and factors associated with insomnia among enrollees of managed care organizations (MCOs) A survey was distributed either by mail or during a clinic visit to 7,500 enrollees of five MCOs in the United States The survey included a sleep questionnaire, demographic questions, and questions about medical encounters and prescription drug use Three levels of insomnia (none; level I--difficulty initiating or maintaining sleep; level II--insomnia with daytime dysfunction) were defined from the responses Comorbidities were determined by proxy from prescription drug use reported by respondents A total of 3,447 survey responses were received, yielding a response rate of 46% Level I and level II insomnia was reported by 135% and 325% of the respondents, respectively Level II insomnia increased with decreasing education, income, and age and was more prevalent in women and non-Caucasians Insomnia was significantly correlated with all daytime sleepiness and most nighttime disturbances factors Fifty-two percent of all respondents reported at least one comorbid condition Respondents with multiple comorbidities reported level II insomnia more frequently than those with no comorbidities Only 09% of clinic visitors were seeing a physician specifically for sleep problems Of those with level I and level II insomnia, only 55% and 116%, respectively, were taking prescription medications specifically for sleep problems; 112% and 214%, respectively, were taking over-the-counter medications for sleep Insomnia occurs in MCO enrollees at rates comparable to those found in the general population However, few patients with insomnia are actually being treated for their condition Proper evaluation, diagnosis, and treatment of insomnia are warranted

Treatment of allergic rhinitis: an evidence-based evaluation of nasal corticosteroids versus nonsedating antihistamines.

Abstract: Allergic rhinitis is a high-cost, high-prevalence disease. In the 12 months ending March 31, 1997 $3.1 billion was spent in the United States for medications to manage this illness. Allergic rhinitis affects quality of life and interferes with work productivity. Nonsedating antihistamines are the most common and most expensive therapy for this condition. This study reviewed 13 randomized studies in which blinded investigators compared management of allergic rhinitis by means of intranasal steroids to management by means of nonsedating antihistamine. Evidence tables demonstrated that in all studies in which total nasal symptoms and nasal obstruction were recorded, the nasal steroid was statistically superior to the nonsedating antihistamine. For nasal blockage the nonsedating antihistamines did not perform better than placebo. For all other nasal symptoms the intranasal steroid was statistically superior in most reports and equal or numerically better in the remaining papers. When these data are linked to those from cost analysis and quality-of-life studies, the evidence strongly suggests that nasal steroids should be first-line therapy for allergic rhinitis. In four reports on the combination of a nonsedating antihistamine compared to a nasal steroid alone, there was no significant difference between these two treatments. Like asthma, allergic rhinitis is an inflammatory disease and should be managed with anti-inflammatory medication. Making such a change in the management of allergic rhinitis should increase efficacy and decrease costs.

The cost of inpatient endometriosis treatment: an analysis based on the Healthcare Cost and Utilization Project Nationwide Inpatient Sample

Abstract: Objective To determine the prevalence and cost of endometriosis-related hospitalizations based on the Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP-3). Study design Retrospective analysis based on nationwide clinical practice data. Patients and methods Data were obtained for 1991 and 1992 from the HCUP-NIS database, which was a 20% sample of all US hospital discharges. ICD-9 codes (236.0, 617.0 to 617.9) were used to identify females, aged 15 to 54, with endometriosis as a diagnosis. The distribution of endometriosis admissions by admission type, length of stay (LOS), mean total charge, specific types of endometriosis, principal procedures, and other diagnosed diseases was described. Results In 1991 and 1992, 37,273 (22.6/1000) and 38,834 (23.7/1000) hospital admissions, respectively, were for endometriosis (as any diagnosis). The average LOS and total hospital charges for endometriosis as the primary diagnosis were 3.8 days and $6,597 for 1991, and 3.5 days and $7,450 for 1992. Most endometriosis admissions occurred in females aged 35 to 49. About 87% of the endometriosis hospitalizations were routine admissions. The most common diagnosis was endometriosis of the uterus (51%); the most common procedure was a total abdominal hysterectomy (55%-60%). Older and African-American patients had the longest LOS and the highest total charges. The estimated total hospitalization costs, as represented by hospital charges, for women with endometriosis as the primary diagnosis in the United States were $504 million for 1991 and $579 million for 1992. Conclusion Endometriosis-related hospitalization is a major burden on healthcare systems.

Formulary limitations and the elderly: results from the Managed Care Outcomes Project.

Abstract: OBJECTIVE: To examine whether restrictive formularies are associated with differences in healthcare resource utilization, including number of office visits, prescriptions, and hospitalizations, and whether this association varies by age. STUDY DESIGN: Cross-sectional, longitudinal study. PATIENTS AND METHODS: Patients enrolled in one of six health maintenance organizations in six different states, three in the eastern and three in the western United States, were eligible for the study. Data from between 1309 and 3938 patients were available for analysis for each of the five diseases studied, for a total of 12,997 patients across all study diseases. Healthcare utilization by patients in the study included more than 99,000 office visits, 1000 hospitalizations, and 240,000 prescriptions. We used severity-adjusted prescription counts, prescription costs, office visit counts, and measures of inpatient hospital utilization to assess the effects of formulary limitations. RESULTS: We found positive, significant associations between the independent variable formulary limitations in drug class and the dependent variables measuring resource utilization. These associations were sometimes significantly greater for elderly patients after controlling for severity of illness and other variables. CONCLUSIONS: Common strategies for decreasing drug expenditures may be associated with higher severity-adjusted resource utilization. In specific areas, this association is more pronounced in the elderly.

Safety and clinical efficacy of zileuton in patients with chronic asthma.

Abstract: Zileuton, a leukotriene pathway inhibitor used to treat asthma, improves lung function, relieves symptoms, and is well tolerated. The purpose of this 12-month, parallel-group, open-label study was to assess the efficacy of zileuton and evaluate liver function in patients treated with this drug (approximately 2% of patients treated with zileuton in controlled trials had reversible liver enzyme elevations). A total of 2,947 patients at 233 centers in the United States were randomly assigned in a 5:1 ratio to treatment with zileuton plus usual asthma care or usual asthma care alone. Efficacy variables included asthma exacerbations; need for alternative treatment, steroid rescue, emergency care, and hospitalizations; forced expiratory volume in 1 second (FEV1); and asthma symptom scores. The safety evaluation included measurement of alanine aminotransferase levels. Patients treated with zileuton had significantly fewer corticosteroid rescues (P < 0.001), required less emergency care (P < 0.05), had fewer hospitalizations, and had greater increases in FEV1 (P = 0.048). They also had significantly greater improvements in asthma symptoms. Increases in alanine aminotransferase levels to three times or more the upper limit of normal occurred in 4.6% of patients treated with zileuton and 1.1% of those receiving usual care (P < 0.001); most increases occurred during the first 2 to 3 months. Alanine aminotransferase levels decreased to less than two times the upper limit of normal or to baseline levels during zileuton treatment or after drug cessation. Jaundice or chronic liver disease did not develop in any patient. Adding zileuton to the therapeutic regimens of patients with asthma is likely to improve asthma control and lower utilization of healthcare resources.

The limited state of technology assessment for medical devices: facing the issues.

Abstract: Medical devices are an integral part of clinical practice and account for a substantial proportion of the national health budget. Clinical testing and regulation of medical devices, however, is vastly different from and inferior to the testing and regulation of drugs. As managed care organizations begin to exert controls on device use, providers are being caught between the policies of their organizations and the demands of device manufacturers and patients, who want wider access to devices. We outline several reasons for the poor state of medical device evaluations and the dangers of using devices without adequate information, and include the recently developed device assessment and reporting guidelines created by the Task Force on Technology Assessment of Medical Devices.

Compliance with antihypertensive therapy: raising the bar of expectations.

Abstract: Recent advances in the effectiveness of antihypertensive therapies and the measurement of medication-taking behavior have raised the bar of expectations, both for patients and prescribing clinicians. This article reviews the principal findings and makes recommendations to improve pill taking among patients with hypertension. It summarizes several studies related to hypertension epidemiology, component behaviors contributing to suboptimal compliance with prescribed antihypertensive medications, the direct and indirect costs of nonadherent behaviors, and measures of pill-taking behavior. Based on this analysis, current levels of hypertension detection, treatment, and control remain suboptimal. Heuristics for adjusting antihypertensive regimens may be misleading and too simplistic. More than half of those patients failing to achieve goal blood pressure display suboptimal compliance rather than an inadequate regimen. In conclusion, there is a need for enhanced sophistication about medication-taking behavior, especially for hypertension, so that more patients with this condition can fully benefit from effective treatments.

Effects of an asthma management program on the asthmatic member: patient-centered results of a 2-year study in a managed care organization.

Abstract: OBJECTIVE To report the results of a 2-year pilot program of asthma education based on National Heart, Lung, and Blood Institute treatment guidelines. PATIENTS AND METHODS Asthmatic members (n = 6698) of a managed care organization received education about their condition directly or through their primary care physician. Medical and pharmacy administrative claims data were reviewed to measure acute asthma events and prescribed therapies in the first (the baseline) and second years of the study. The claims data were augmented by member surveys from a stratified random sample of 2734 asthmatic patients who were members (6 years of age or older) in the baseline year. RESULTS Compared with the first year, asthmatic members received fewer inpatient services and the proportion of asthmatic members prescribed oral inhaled corticosteroids increased 30% in the second year. Health-related quality of life, measured with validated general and disease-specific instruments; satisfaction with the quality of care; exposure to patient education; knowledge of the disease; and member's confidence in their ability to manage their disease showed statistically significant improvements during the follow-up year of the program for both adult and child asthmatic members. CONCLUSION For asthmatic members of this health plan, a comprehensive asthma health management program improved processes of care and outcomes.

The impact of a simulated immunization registry on perceived childhood immunization status.

Abstract: We developed a simulated immunization registry to assess the impact on the perceived immunization status in a population-based sample of 2-year-olds living in Olmsted County, MN, in 1995. We compiled records of all immunizations by abstracting immunization data from all medical care facilities in the county. The data collected from each facility were analyzed separately to provide the immunization rate as perceived by each facility. This perceived rate was compared to the rate obtained by combining all recorded immunizations from all facilities (simulated registry). Information on children not receiving any carefrom facilities in Olmsted County was compiled from birth certificate data and community school lists. Data from the simulated registry indicated that 69.1% of all children in Olmsted County with medical records were up-to-date on their immunizations by 20 months of age. By 24 months, this increased to 74.2%. The immunization rate of 24-month-old children recorded at individual healthcare facilities in Olmsted County ranged from 24.3% to 79.5%. The addition of data from the simulated registry increased the immunization rate at each site: a 27.7% relative increase in the site with the lowest recorded immunization rate, a 14.0% increase in the site with the intermediate immunization rate, and a 6.9% increase in the site with the highest internally perceived immunization rate. The registry also identified excess immunizations in 5% of the county's 2-year-olds. Each healthcare facility in this community gained an immediate benefit from the development of a simulated immunization registry. This immediate improvement in one quality-of-care measure (up-to-date immunization rate) should be factored into the cost/benefit assessment of immunization registries.

A new method of developing expert consensus practice guidelines.

Abstract: To improve the quality of medical care while reducing costs, it is necessary to standardize best practice habits at the most crucial clinical decision points. Because many pertinent questions encountered in everyday practice are not well answered by the available research, expert consensus is a valuable bridge between clinical research and clinical practice. Previous methods of developing expert consensus have been limited by their relative lack of quantification, specificity, representativeness, and implementation. This article describes a new method of developing, documenting, and disseminating expert consensus guidelines that meets these concerns. This method has already been applied to four disorders in psychiatry and could be equally useful for other medical conditions. Leading clinical researchers studying a given disorder complete a survey soliciting their opinions on its most important disease management questions that are not covered well by definitive research. The survey response rates among the experts for the four different psychiatric disorders have each exceeded 85%. The views of the clinical researchers are validated by surveying separately a large group of practicing clinicians to ensure that the guideline recommendations are widely generalizable. All of the suggestions made in the guideline are derived from, and referenced to, the experts' survey responses using criteria that were established a priori for defining first-, second-, and third-line choices. Analysis of survey results suggests that this method of quantifying expert responses achieves a high level of reliability and reproducibility. This survey method is probably the best available means for standardizing practice for decisions points not well covered by research.

Impact of pharmacist consultations provided to patients with diabetes on healthcare costs in a health maintenance organization.

Abstract: We conducted a study to assess the impact on healthcare utilization and costs of pharmacist consultations provided to patients with diabetes. Data for this study were derived from a larger study conducted by Kaiser Permanente and the University of Southern California that evaluated three alternative models of pharmacist consultations (control, state, and Kaiser). Computerized data were available for patient demographic characteristics and healthcare utilization. We used medication data to classify patient cohorts as insulin only or oral antidiabetics +/- insulin. We estimated hospitalization costs based on diagnostic related group and medication costs based on average wholesale price; office visits were estimated at $70 each. In the insulin only cohort, total costs for patients who had their prescriptions filled at a state model pharmacy were 7.8% less than those for patients filling prescriptions at a control model pharmacy (P = 0.008). In the oral +/- insulin cohort, total costs for patients filling new prescriptions at a Kaiser model pharmacy were 21.9% less than those for patients using a control model pharmacy (P = 0.0001). The state model also was negatively correlated (beta coefficient, -0.0997) with total costs (P = 0.0001). These data suggest that pharmacist consultations provided to patients with diabetes can decrease total healthcare costs in a health maintenance organization.

Treatment of schizophrenia: let's talk dollars and sense.

Abstract: Schizophrenia is a major neurologic illness with an impact on public health that has been unappreciated. Newer and arguably more effective medication treatments are now available and hold considerable promise. The higher up-front cost of these drugs is, on current evidence, offset by other economic advantages and, from a humanitarian perspective, by the expectation of improved patient outcome with less drug toxicity. The extent to which these drugs replace older drug treatments will be determined by the relative influences of clinical, pharmacoeconomic, mental health administrative, and advocacy factors over the coming years.

Healthcare technology assessment: methods, framework, and role in policy making.

Abstract: UNLABELLED This activity is designed for healthcare organization managers and clinicians, particularly those involved in technology-related decisions, including coverage decisions, technology acquisition, practice guideline development, and evidence-based medicine. GOAL To provide a basic understanding of the principles, methods, and systematic framework of healthcare technology assessment. OBJECTIVES 1. Understand the role of healthcare technology assessment in policy making and the technical properties and impact assessed. 2. Become familiar with the categories and basic attributes of methods used in healthcare technology assessment. 3. Comprehend the ten-step framework for conducting a healthcare technology assessment.

Empiric investigation on direct costs-of-illness and healthcare utilization of Medicaid patients with diabetes mellitus

Abstract: Objective To determine total direct costs-of-illness and to study the influence of different factors affecting these costs In addition, we examined each type of service (eg, hospitalization, outpatient care, prescription drugs, physician encounters, and laboratory tests) for diabetic Medicaid patients to provide evidence about the relationship between diabetic patients' healthcare utilization and their related predictors Patients and methods A total of 7931 patients with diabetes who were 65 years or younger in the Alabama Medicaid program from 1992 to 1995 were studied Using a relational database created from Medicaid claims, multiple regression and canonical correlation methods were used to analyze the patients' direct costs-of-illness, including the costs associated with each healthcare service used by each patient Results The costs of hospitalization, outpatient care, prescription drugs, and physician encounters were the four largest components of the direct costs-of-illness for diabetic Medicaid patients, comprising 299%, 213%, 282%, and 143%, respectively After controlling for other factors in an empiric model, the direct costs-of-illness for a patient with insulin-dependent diabetes mellitus was $5160 higher than for a patient with noninsulin-dependent diabetes mellitus during the 3-year study The cost for a patient with renal dysfunction was $59,920 higher than for other diabetic patients Each increase in the number of different prescribing physicians per patient was associated with a cost increase of $450 Each additional comorbidity increased the cost by $735 per patient The cost for a male patient was $2140 higher than that for a female patient, and the cost for a white patient was $1330 higher than that for a non-white patient For a patient who relied on diet to control diabetes, there were $2750 less in costs compared with other patients during the study period More than 20% of the variability in patients' healthcare utilization costs was explained by the set of predictive factors Conclusions The direct costs-of-illness and healthcare utilization for Medicaid diabetic patients were significantly accounted for by the number of comorbidities, the number of different physicians visited, insulin-dependent diabetes mellitus, and complications (especially renal dysfunction) Patients who relied on dietary therapy and exercise to control their diabetes had lower healthcare costs and utilization than other patients A significant amount of healthcare costs and utilization might be controlled or reduced if diabetes disease management can successfully be aimed at preventing diabetic complications, controlling comorbidities, and minimizing the number of different physicians visited

In vitro and skin testing for allergy: comparable clinical utility and costs

Abstract: Controversy exists concerning the appropriate use of skin testing and in vitro testing for the diagnosis of allergy, particularly inhalant allergy. Earlier comparisons of skin testing and in vitro testing concluded that skin testing had superior accuracy at lower expense. In light of new developments with in vitro allergy testing, however, this issue should be reconsidered. A review of the recent scientific literature indicates that in vitro and skin testing are highly correlated. However, without the existence of an independent gold standard for inhalant allergy, it is not possible to determine which test is more accurate. The accuracy of either test can be compromised if conducted using different protocols or having insufficient quality control. Given their respective trajectories for technological advancement, quantification, and quality control, in vitro testing may offer the more standardized approach. Although the cost per test of in vitro testing remains greater than that of skin testing, the per-patient costs of the two modalities appear to be comparable, given the greater number of allergens typically used in skin testing. In summary, both skin testing and in vitro testing are acceptable as frontline diagnostic tools.

Prevalence and cost of hospitalization for gastrointestinal complications related to peptic ulcers with bleeding or perforation: comparison of two national databases.

Abstract: The purpose of this study was to determine the prevalence and cost of hospitalization for upper gastrointestinal complications, including peptic ulcers with hemorrhage or perforation. Upper gastrointestinal complications and corresponding economic data were obtained from two sources. The first was a 20% sample of all community hospital discharges (about 6 million per year) from 11 states for 1991 and 1992 Hospital Cost Utilization Project; HCUP-3). The second source of data was a claims database for employees of large US corporations and their dependents for 1992, 1993, and 1994 (about 3.5 million covered lives per year; MarketScan). A group of ICD-9 codes for the diagnosis of peptic and gastroduodenal ulcers with bleeding or perforation were used to identify hospital admissions because of upper gastrointestinal complications. Similar patterns were observed across the MarketScan and HCUP-3 databases regarding hospitalization with diagnoses related to gastrointestinal complications identified according to the ICD-9 codes. The average age of patients with upper gastrointestinal complications was 66 years in the HCUP-3 database and 52 years in the MarketScan database. The average annual rates of upper gastrointestinal complications as a primary or secondary diagnosis were 6.4 and 6.7 per 1000 discharges for 1991 and 1992, respectively (HCUP-3), and 4.3, 4.2, and 4.9 per 1000 admissions for 1992, 1993, and 1994, respectively (MarketScan). The average length of stay for upper gastrointestinal complications as a primary diagnosis was 7.8 days in 1991 and 7.5 days in 1992 (HCUP-3) and 6.1, 5.1, and 5.1 days in 1992, 1993, and 1994, respectively (MarketScan). The national average total charge for hospitalization for gastrointestinal problems as a primary diagnosis was $12,970 in 1991 and $14,294 in 1992 (HCUP-3). The average total reimbursement for hospitalizations related to upper gastrointestinal problems was $15,309 in 1992, $12,987 in 1993, and $13,150 in 1994 (MarketScan). Hospital admissions for upper gastrointestinal complications are expensive. The rate and cost per admission are higher for the older population. The results on the elements covered by both databases are consistent. Therefore the databases complement each other on the type of information abstracted.

Influence of an interventional program on resource use and cost in pediatric asthma.

Abstract: OBJECTIVE Asthma is the most common chronic condition of childhood, for which morbidity, mortality, and cost are increasing This study was performed to determine whether patient education and assignment to a primary care provider improve outcomes and cost in the management of pediatric asthma STUDY DESIGN A prospective pilot study of 61 patients was conducted with a retrospective review Data were obtained from health and pharmacy records PATIENTS AND METHODS Sixty-one unassigned pediatric asthma patients who were noted to be frequent users of emergency department services and who had no primary care provider were identified This cohort received asthma education and was assigned a provider trained in the national asthma guidelines Hospital admissions, Emergency Department and clinic visits, use of beta 2 agonists and anti-inflammatory drugs, number of chest radiographs, and continuity of care were recorded for a mean of 581 months before and 112 months after the intervention A cost analysis was done RESULTS All measured parameters showed favorable changes after intervention, with the decrease in the number of prescriptions of monthly inhaled anti-inflammatory drugs and chest radiographs ordered being statistically significant (P = 0007 and P = 0040, respectively) Monthly admissions, Emergency Department visits, and clinic visits declined after intervention when evaluated after 228 months of follow up Annual resource savings after intervention was estimated to be $484529 per patient for this military hospital CONCLUSIONS A combined intervention consisting of provider and patient education and assignment to a primary care provider was associated with improved care and economic outcomes in this group

Identification and assessment of high-risk seniors

Abstract: CONTEXT Many older adults with chronic illnesses and multidimensional needs are at high risk of adverse health outcomes, poor quality of life, and heavy use of health-related services. Modern proactive care of older populations includes identification of such high-risk individuals, assessment of their health-related needs, and interventions designed both to meet those needs and to prevent undesirable outcomes. OBJECTIVE This paper outlines an approach to the tasks of identifying and assessing high-risk seniors. Intervention identification of high-risk seniors (also called case finding) is accomplished through a combination of periodic screening, recognition of high-risk seniors by clinicians, and analysis of administrative databases. Once identified, potentially high-risk individuals undergo on initial assessment in eight domains: cognition, medical conditions, medications, access to care, functional status, social situation, nutrition, and emotional status. The initial assessment is accomplished in a 30- to 45-minute interview conducted by a skilled professional--usually one with a background in nursing. The data are used to link some high-risk persons with appropriate services and to identify others who require more detailed assessments. Detailed assessment is often performed by interdisciplinary teams of various compositions and methods of operation, depending on local circumstances. CONCLUSION The rapid growth in Medicare managed care is presenting many opportunities for developing more effective strategies for the proactive care for older populations. Identification and assessment of high-risk individuals are important initial steps in this process, paving the way for testing of interventions designed to reduce adverse health consequences and to improve the quality of life.

Experience with a managed care approach to HIV infection: effectiveness of an interdisciplinary team

Abstract: To evaluate the function and effectiveness of a multidisciplinary team for managing human immunodeficiency virus (HIV) infection, we conducted a follow-up cohort study of HIV-positive patients managed according to a clinical care path at a staff-based health maintenance organization (HMO). The study group consisted of 230 HIV-positive health plan members who received care at the Kaiser Permanente Santa Rosa medical center (KPMC-SRO). In 1994, the comparison group consisted of 4747 HIV-positive health plan members who received care at Kaiser Permanente's 18 other medical centers in northern California. The percentages of acquired immunodeficiency syndrome (AIDS) and HIV-positive patients as determined by CD4+ T-cell counts were similar (P = 0.97). Compared with patients at the other Kaiser Permanente medical centers, KPMC-SRO patients had more visits with nurse practitioners (rate ratio [RR] = 1.72) and nutritionists (RR = 12.3) and fewer visits with primary care physicians (RR = 0.82). More HIV-positive members at KPMC-SRO received social workers' services (27% at KPMC-SRO vs 6% for patients at the other Kaiser Permanente medical centers) and fewer used emergency services (RR = 0.92) and psychiatric services (RR = .89). At KPMC-SRO, the mean number of days that AIDS patients spent in the hospital decreased from 7.8 (1991) to 2.01 (1994). Hospital admissions were fewer (AIDS patients, RR = 0.67; HIV-positive patients without AIDS, RR = 0.45), and length of stay was briefer, compared with patients at the other Kaiser Permanente Medical Centers. The mean cost of HIV-related drugs for patients seen at KPMC-SRO ($2343 per infected member) was lower than that for patients seen elsewhere in the region ($3289 per infected member). These results suggest that in an HMO setting, managed care provided by a dedicated interdisciplinary team according to a clinical care path can substantially and favorably affect resource use.

The cost-effectiveness of treatment with lamivudine and zidovudine compared with zidovudine alone: a comparison of Markov model and trial data estimates.

Abstract: In this paper, we present a Markov model for estimating the cost-effectiveness of combination therapy with lamivudine (LMV) and zidovudine (ZDV) compared with ZDV alone. We also compare the predictions of the Markov model for the impact of combination therapy on trial period costs with the actual impact of combination therapy on selected trial period costs estimated from data collected during the clinical trials. In the Markov model, disease stages were defined by CD4 cell count. Based on clinical trial data for patients with CD4 counts higher than 100 cells/mm3, the model assumed that the CD4 cell count level could be maintained above the level at the initiation of therapy for 6.5 months with monotherapy and for 18 months with combination therapy. After this period, transition rates for natural disease progression were used. Incremental lifetime costs and quality-adjusted life years gained with LMV/ZDV compared with ZDV alone were estimated for cohorts of patients initiating antiretroviral therapy at four different CD4 cell count stages. Cost per life year gained varied from $10,000 to $18,000, and cost per quality-adjusted life year gained varied from $14,000 to $27,000. In both cases, the combination therapy was more cost-effective when started earlier in disease progression. These estimates were not sensitive to changes in key parameter values. In addition, the model was used to estimate the impact of combination therapy on healthcare costs during the trial period; these estimated costs were compared with data on the cost of resource use collected during the clinical trial for hospital stays, unscheduled visits, medications, and outpatient procedures. Both the Markov model estimates and the trial data estimates for the trial period showed cost savings in other medical costs, though these were not large enough to completely offset the increased cost for antiretroviral therapy. The model estimates were more conservative than the estimates based on the trial data.

Patient waiting times in a physician's office.

Abstract: This observational study measured waiting times, appointment durations, and scheduling variables of a single family practice physician. Waiting time and appointment duration in four sequential groups of sessions were compared using analysis of variance; each group used different scheduling templates. Groups 1 and 2 used a 15-minute base interval; group 3 used a 20-minute base interval. Observations for group 4 were collected at a different health center using a 15-minute base interval. Scheduling variables were correlated with waiting time using correlation coefficients, and data were collected on 1783 appointments. The best waiting time (mean +/- SD) was 17.33 +/- 19.19 minutes. The mean appointment duration for this group was 17.99 +/- 7.97 minutes. The F statistic comparing the four groups of sessions for waiting times was 34.14 and for appointment duration was 37.37, both of which are significant (P < 0.001). The Spearman correlation coefficient for waiting time with queue was 0.2474 (P < 0.001). The Spearman correlation coefficients for mean waiting time and lateness of starting a session (0.4530), patients per hour (0.3461), and patients per session (0.3674) were all significant (P < 0.001). Both scheduling and patient flow affect patient waiting times. The best schedule would consist of shorter sessions that started on time and were extended to accommodate extra patients rather than adding in patients and crowding the schedule. In addition to reducing the actual waiting times, the perception of waiting can be managed to minimize patient dissatisfaction.

Discontinuity of care: urgent care utilization within a health maintenance organization.

Abstract: OBJECTIVE To determine the demographic characteristics, attitudes, and perceived barriers to primary care reported by patients seen in the urgent care department of a health maintenance organization (HMO) health center. STUDY DESIGN Cross-sectional survey. PATIENTS AND METHODS Patients aged 18 years or older who sought care at the urgent care department of a large, urban health center of a staff-model HMO were eligible for the study. Patients were handed a survey as they registered in the urgent care department. Demographic and visit diagnoses data were obtained through review of the computerized medical record. RESULTS Patients seeking treatment at the urgent care department were significantly younger than those seen at a primary care physician's office (mean age, 40 years versus 46 years; P < or = 0.0001) but otherwise had similar demographic characteristics. Nearly 90% of 421 patients seen in the urgent care department reported having a primary care physician. When asked to list the reasons why they came to the urgent care department instead of the primary care offices, 64% said they needed to be seen immediately, 47% came because the primary care offices were closed, 27% cited the constraints of work or childcare, and 25% said they were unable to get an appointment with their primary care physician. Almost half of patients (47%) said they would have preferred to see their primary care physician within a day or two rather than seeking care at the urgent care department. CONCLUSIONS Patients treated in the urgent care department reported various barriers to seeing their primary care physician. Improving same-day access to primary care providers will help alleviate this problem and may increase patient satisfaction.