Enrolling community physicians and their patients in a study of prevention in the elderly.

Enrollment of senior citizens in a community Medicare demonstration project to explore the efficacy of preventive health screening and health education was accomplished by using a two-stage process. This process consisted of initial communication with community physicians through the University of California at Los Angeles Clinical Faculty Association to establish credibility for the program. Physicians who agreed to participate then selected potential participants to receive, by mail, a description of the study and an introductory letter from their own physician. Followup and actual enrollment of participants was then handled by the study team. A total of 57.6 percent of the elderly people approached agreed to participate in the study.

Appropriateness of acute medical care for the elderly: an analysis of the literature.

Over the past 30 years, an explosion in health care expenditures has occurred. Prior to 1960, health care accounted for 4.4% of the U.S. Gross National Product; today it is 11%. Before rational solutions to controlling this rise can be proposed, we must determine whether the care that we are currently paying for is appropriate to the needs of the elderly. This paper analyzes the literature regarding appropriateness of acute care provided to the elderly. We identified 17 articles that explicitly cited appropriate or inappropriate care (including under-, over- and misuse) provided in hospital and ambulatory settings and for procedures, and 19 articles that presented data on the appropriateness of medication use in the elderly. Virtually every study included in this review found at least double-digit levels of inappropriate care. Perhaps as much as one-fifth to one-quarter of acute hospital services or procedures were felt to be used for equivocal or inappropriate reasons, and two-fifths to one-half of the medications studied were overused in outpatients. The few studies that examined underuse or misuse of services also documented the existence of these phenomena. This was especially true for the ambulatory care of chronic physical and mental conditions and concerned the use of low-cost technologies (visits, preventive services, some medications). Thus, we conclude that there appears to be a substantial problem in the matching of acute services to the needs of elderly patients. This mismatch occurs both in terms of overuse and underuse, at least for areas where research has been conducted.

Developing a tool for analyzing medical care utilization of adult asthma patients in indemnity and managed care plans: can an episodes of care framework be used?

We evaluated the health care resource utilization between adult asthma patients in managed care organizations with those in indemnity plans using an episodes of care methodology. We also examined the importance of risk adjustment in explaining variation in resource utilization. Episodes were constructed using private insurance claims from 1992 to 1993. Bivariate and multivariate analyses were used to examine differences between managed care and indemnity plans on episode severity, resource utilization, and outcome measures (asthma-related hospitalizations and emergency room visits). Managed care plans showed higher resource utilization in terms of services and payments per episode compared with fee-for-service plans. Financial incentives to both providers and patients may have contributed to the higher utilization among managed care patients. An episodes of care methodology has potential to serve as a cost-effective "tool" in analyzing trends in medical care utilization within a health care plan. Validation of this methodology is necessary, however, before it can be used to compare trends in utilization across health plans.

Developing episodes of care for adult asthma patients: a cautionary tale.

An episodes of care methodology examines the contiguous cluster of services related to a particular health condition. We developed an episodes methodology for evaluating the quality of health care delivery to privately insured adult asthma patients. Computer algorithms were used for episode construction beginning with an index asthma diagnosis and ending with a final clinical event, yielding a sample of 30,553 episodes. Only service claims with an asthma diagnosis were assigned to an episode. We used a database of private insurance claims from 1992 to 1993. Disease staging served as the framework for evaluating episodes with similar severity and resource use. We found that episodes of care can be constructed from claims data and have the potential for use in physician profiling and as quality screens. Certain limitations in using this methodology suggest that caution needs to be exercised in applying this approach to evaluation of health care services.

Comparisons between dentist ratings and self-ratings of dental appearance in an elderly population.

Little is known about dental appearance in terms of the elderly population. The purpose of this paper is to compare self-reported dental appearance with dentist-rated appearance for individuals over 65. The subjects (N = 550) were participants in the Los Angeles based Medicare Screening and Health Promotion Trial. Most were female (57.3%), white (89.0%), and married (62.0%), with a mean age of 74.5 years. About one-third had incomes greater than $25,000. Results are based on a 45 minute telephone interview and onsite dental screening. Findings show that 40% of the self-ratings on a five point scale were higher than the dentist ratings, and 22% were lower. Bivariate analyses showed that both sets of ratings were related to dental status variables, self-reported health, and education. High self-ratings were also associated with being white and having a positive mental health status, while high dentist ratings were associated with patients who were younger, married, and who had higher income and social network scores. Comparison of results from two multiple regressions showed unique predictors for the self-ratings (marital status and GOHAI scores) and for the dentist ratings (sex and income). These discrepancies can raise barriers to effective treatment planning in the elderly, which could affect utilization and satisfaction.

Episodes of care: theoretical frameworks versus current operational realities.

BACKGROUND: Fundamental changes in the structure of the health care industry have stimulated the need for improved definitions of output and for better methods of organizing utilization data into appropriate units. Although the "episode of care" concept has existed since the 1960s, its recognition as integral to the management of health care cost and utilization is relatively recent. Conceptually, episodes of care represent a meaningful unit of analysis for assessing the full range of primary and specialty services provided in treating a particular health problem. Proprietary episode software grouper products are currently being used by health care organizations for the purposes of provider profiling, clinical benchmarking, disease management, and quality measurement. DESCRIPTION OF EPISODE GROUPER SOFTWARE PRODUCTS: Four episode grouper products are described that use a computerized approach for developing episodes of care from administrative data. They are compared on several characteristics, including purpose, case-mix adjustment, comprehensiveness, and clinical flexibility. Their differences in episode construction, such as how the start points and endpoints of an episode are defined, are also delineated. CONCLUSIONS: Episode groupers are critical to the analysis of health care delivery, since they focus on the entire process of care. Although all the groupers reviewed have many strengths, much developmental work still needs to occur in order to standardize the measurement and operationalization of episodes of care as units of analysis. Furthermore, until the data sources used are more valid and reliable, they will at best remain gross screening measures of quality.

Screening for depression among a well elderly population.

This article describes a geriatric wellness program in which social work practitioners played a major role. The focus of this article is twofold: to examine the use of a telephone screening test for depression among a well elderly population and to compare the results of that screening with the clinical judgment of social workers. Overall findings indicated that a telephone screening instrument incorporating the Rand Mental Health Inventory and the Center for Epidemiological Studies Depression Scale was an efficient tool for assessing a population with a higher rate of major depression. Furthermore, the social workers identified many previously undetected cases of major depression, and a majority of people referred for treatment completed those referrals.

Predicting future functional status for seriously ill hospitalized adults. The SUPPORT prognostic model.

OBJECTIVE: To develop a model estimating the probability of an adult patient having severe functional limitations 2 months after being hospitalized with one of nine serious illnesses. DESIGN: Prospective cohort study. SETTING: Five teaching hospitals in the United States. PARTICIPANTS: 1746 patients (model development) who survived 2 months and completed an interview, selected from 4301 patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT); independent validation sample of 2478 patients. MEASUREMENTS AND MAIN OUTCOMES: Patient function 2 months after admission categorized as absence or presence of severe functional limitations (defined as Sickness Impact Profile scores > or = 30 or as activities of daily living scores > or = 4 [levels that require near-constant personal assistance]). A logistic regression model was constructed to predict severe functional limitation. RESULTS: One third (n = 590) of patients who were interviewed at 2 months had severe functional limitations. Changes in functional status were common: Of those with no baseline dependencies (not dependent on personal assistance), 21% were severely limited at 2 months; of those with 4 or more baseline limitations, 30% had improved. The patient's ability to do activities of daily living was the most important predictor of functional status. Physiologic abnormalities, diagnosis, days in hospital, age, quality of life, and previous exercise capacity also contributed substantially. Model performance, assessed using receiver-operating characteristic curves, was 0.79 for the development sample and 0.75 for the validation sample. The model was well calibrated for the entire risk range. CONCLUSIONS: Functional outcome varied substantially after hospitalization for a serious illness. A small amount of readily available clinical information can estimate the probability of severe functional limitations.