The burden of disease of retinal vein occlusion: review of the literature.

Retinal vein occlusion (RVO) is the second most common cause of vision loss due to retinal vascular disease. A literature review was undertaken to understand the epidemiology, clinical consequence, current practice patterns, and cost of RVO. Pertinent articles were identified by computerized searches of the English language literature in MEDLINE supplemented with electronic and manual searches of society/association proceedings and bibliographies of electronically identified sources. Population-based studies report a prevalence rate of 0.5-2.0% for branch RVO and 0.1-0.2% for central RVO. The 15-year incidence rate is estimated to be 1.8% for branch RVO and 0.2% for central RVO. Patients with RVO report lower vision-related quality of life than those without ocular disease. Available treatment options are limited. Until recently there was no treatment for central RVO. Laser photocoagulation is only recommended for branch RVO in patients who have not experienced severe vision loss. Emerging evidence on the effectiveness of intravitreal anti-vascular endothelial growth factor therapy and dexamethasone intravitreal implant is promising. Information on the treatment patterns and cost of RVO is extremely limited with one retrospective analysis of secondary insurance payment data identified and limited to the United States population only. A better understanding of the economic and societal impact of RVO will help decision makers evaluate emerging medical interventions for this sight-threatening disease.

Measuring and averting underuse of necessary cardiac procedures: a summary of results and future directions.

BACKGROUND: Attempting to explain the marked variation in utilization of medical procedures has vexed health policy analysts for nearly three decades. Most health services research to date has been directed at identifying and reducing excessive utilization. Little attention has been given to underuse of care. THE LOS ANGELES CARDIAC UNDERUSE PROJECT OVERVIEW: A research group at the University of California, Los Angeles (UCLA), performed two separate, published studies seeking to measure underuse of coronary angiography and coronary artery revascu-larization (bypass surgery and angioplasty), two critical links in the chain of care leading from initial diagnosis of coronary artery disease to definitive treatment. In each study, the necessity criteria developed by the panel were used to identify patients needing an invasive procedure. RESULTS: Within this population of patients (sampled predominantly from public hospitals), substantial underuse of clinically necessary coronary angiography (41% without refusers) and revascularization (23% without refusers) was detected. In this select population of patients, receiving a necessary revascularization procedure appeared to both reduce the risk of death and improve quality of life. DISCUSSION: Despite limitations of the method, detection of underuse is feasible, valid, and affordable in the context of overall health care expenditures. Moreover, the case for implementing "underuse prevention" systems is increasingly compelling. Measuring and disseminating data on underuse of expensive but highly beneficial procedures would provide health care consumers (patients and employers) with useful information and enable health care providers to develop quality improvement strategies aimed at rational use of health care resources.

Underuse of coronary revascularization procedures: application of a clinical method.

OBJECTIVES: Our main objective was to apply a new method to determine whether coronary revascularization procedures are underused, especially among African-Americans and uninsured patients. BACKGROUND: Although overuse of revascularization procedures has been studied, underuse as defined clinically has not been examined before. METHODS: The study was conducted at four public and two academically affiliated private hospitals in Los Angeles; 671 patients who underwent coronary angiography between June 1, 1990 and September 30, 1991 and met explicit clinical criteria for coronary revascularization were included. The main outcome measure was the proportion of patients undergoing an indicated procedure within 12 months (ascertained by medical record review and confirmed with a telephone survey). Adjusted relative odds of undergoing an indicated procedure for African-Americans and patients in public hospitals compared with whites and patients in private hospitals were calculated. RESULTS: Overall, 75% of patients underwent a revascularization procedure. Of 424 patients requiring bypass surgery, 107 angioplasty and 140 either bypass surgery or angioplasty, 59%, 66% and 75% underwent the procedure, respectively. African-Americans were less likely than whites to undergo operation (adjusted odds ratio [OR] 0.49, p < 0.05) and angioplasty (adjusted OR 0.20, p < 0.05). Patients in public hospitals were less likely than those in private hospitals to undergo angioplasty (adjusted OR 0.10, p < 0.005). CONCLUSIONS: Underuse of coronary revascularization procedures is measurable and occurs to a significant degree even among insured patients attending private hospitals. Underuse is especially pronounced among African-Americans and patients attending public hospitals. Future cost-containment efforts must incorporate safeguards against underuse of necessary care.

Under use of coronary angiography: application of a clinical method.

OBJECTIVE: To estimate the extent of under use of coronary angiography and to determine whether women, ethnic minorities and poor and uninsured patients are less likely than their counterparts to receive necessary coronary angiography. DESIGN: Retrospective cohort study employing chart review and patient interviews. SETTING: Four teaching hospitals: three government owned (public) and one private university medical center in Los Angeles, California. PATIENTS: Three hundred and fifty two patients who had a positive exercise stress test between 1 January 1990 and 30 June 1991 and met explicitly defined criteria for the necessity of coronary angiography established by a multidisciplinary expert panel. MAIN OUTCOME MEASURES: Percentage of patients who received necessary coronary angiography within 3 and 12 months following exercise stress testing, adjusted for demographic and clinical characteristics using logistic regression. RESULTS: Overall 43% received necessary coronary angiography within 3 months and 56% within 12 months of the stress test. Women were less likely than men to receive necessary coronary angiography. Adjusted odds ratio (AOR) 0.54, 95% confidence interval (CI) 0.34-0.90 for angiography within 3 months of the stress test; AOR 0.47, 95% CI 0.29-0.77 for angiography within 12 months of the stress test. Public hospital patients underwent necessary coronary angiography less often than private hospital patients. AOR 0.40, 95% CI 0.23-0.79 for within 3 months; AOR 0.52, 95% CI 0.30-0.91 for within 12 months. CONCLUSIONS: Under use of coronary angiography can be measured and occurs to a significant degree. It is important to develop standards of quality to address and safeguard against under use of necessary medical care.

Effect of physician specialty on use of necessary coronary angiography.

OBJECTIVES: This study sought to determine whether having a cardiologist as a regular source of care influences likelihood of undergoing necessary coronary angiography. BACKGROUND: An important element of the current health policy debate is the respective roles of primary care and specialist physicians. However, there are few data on interspecialty differences in quality of care for patients with ischemic heart disease. METHODS: We contacted 243 patients by telephone (response rate 72%) who had positive (or very positive) exercise stress test results and met additional clinical criteria for necessary coronary angiography. Study patients were randomly sampled from those undergoing exercise stress testing at one university and three public hospitals in Los Angeles between January 1, 1990 and June 30, 1991. Patients were asked whether they had a regular source of care during the time after their exercise stress test and, if so, whether that provider was a cardiologist or cardiology clinic. RESULTS: Among survey responders, 47% underwent necessary coronary angiography within 3 months of exercise testing and 61% within 12 months. After adjustment for sociodemographics and clinical presentation, patients with a cardiologist as a regular source of care were more likely than all other patients to have undergone necessary angiography within 3 months (52% vs. 38%, p = 0.05) and within 12 months (74% vs. 44%, p = 0.0001) of the exercise test. At 3 months, there was a trend toward a more pronounced effect of ongoing cardiologic care within the public hospitals compared with the private hospital (p = 0.09 for interaction between hospital types). CONCLUSIONS: Patients with a cardiologist as a regular source of care were more likely than all other patients to undergo clinically necessary coronary angiography within both 3 and 12 months of exercise stress testing.

Validity of criteria used for detecting underuse of coronary revascularization.

OBJECTIVE: To assess criteria used for detecting underuse of coronary artery revascularization procedures in terms of patient outcomes. DESIGN: Retrospective cohort study using medical records supplemented by a telephone survey and review of county death records. SETTING: Four public hospitals and two academically affiliated private hospitals in Los Angeles County, California. PARTICIPANTS: A total of 671 patients who had coronary angiography between June 1, 1990 and September 30, 1991, and who met explicit clinical criteria for the necessity of coronary artery bypass graft (CABG) surgery or percutaneous transluminal coronary angioplasty (PTCA). MAIN OUTCOME MEASURES: For all patients (n = 671), we estimated the association between receipt of necessary revascularization and mortality (median follow-up after angiography, 797 days) after adjusting for potential confounders. For the patients completing the telephone interview (n = 374), we examined the relationship between receipt of necessary revascularization and frequency of chest pain. RESULTS: Patients who received necessary revascularization within 1 year of angiography had lower mortality than those who did not (8.7% vs 15.8%, P = .01), and this association persisted after adjustment for extent of coronary artery disease, clinical symptom complex, ejection fraction, and cardiac surgical risk index (adjusted odds ratio = 0.49; 95% confidence interval, 0.28 to 0.86). The same general results were obtained whether revascularization was received within 1 year or within 30 days of the catheterization, whether panelists' ratings or individual clinical variables were entered as covariates, and whether the statistical procedure used was logistic regression or Cox proportional hazards analysis. In addition, among patients responding to the telephone survey, those receiving necessary revascularization had less chest pain at follow-up (P = .03). CONCLUSIONS: Among patients meeting criteria for the necessity of revascularization, those receiving a revascularization procedure within 1 year had lower mortality than those treated medically. These results support the validity of the RAND/UCLA criteria for detecting underuse of these procedures, but more research is needed to confirm the findings and to determine the validity of guidelines for other procedures.

Utilization of preventive health services by an employed population.

To determine the utilization rates of selected preventive services in an employed population, we analyzed the responses of 18,053 health profile participants. Overall utilization rates for preventive services were high: 86.0% of respondents had their blood pressure checked, 94.0% of all women had a Pap smear and 81.3% had clinical breast examinations, 42.4% of respondents aged 40 and older had a rectal examination and 31.8% of those aged 50 and older had a test for occult blood in the stool, and 33.7% had a routine sigmoidoscopy. With the exception of blood pressure screening, the percentage of our respondents utilizing preventive services was considerably higher than the corresponding percentages in the US population as reported in the National Health Interview Survey. Nevertheless, the results suggest substantial opportunity for employers to encourage the appropriate use of preventive health services among employees.

Prevalence and characteristics of employees reporting heavy or problem drinking.

INTRODUCTION: This study examined the prevalence and demographic characteristics of chronic heavy drinkers, binge drinkers, those who report a problem with alcohol, and those at high risk for alcohol-related problems. METHODS: The sample comprised a worksite population of 18,053 employees. The study was based on responses to questions contained in a confidential health profile administered to employees at seven companies by an outside vendor (Johnson & Johnson Health Management, Inc.). RESULTS: Almost 1 in 4 participants (23.0%) was found to be at risk for alcohol-related problems. About 1 in 5 respondents (20.1%) reported binging, 1 in 10 reported chronic heavy drinking (9.8%), and 2.6% reported a drinking problem within the past month. Younger respondents were more likely to report binging but older respondents were more likely to report chronic heavy drinking. Men were more than twice as likely to report binging and almost four times as likely to report chronic heavy drinking, but only one and one-half times as likely to report a drinking problem within the past month. Other differential demographic associations with alternative measures of heavy drinking are described. CONCLUSION: The results suggest that a health profile administered at the worksite can be an effective screening tool for identifying employees at high risk for alcohol-related problems.