RESUMO
OBJECTIVES: Unintentional weight loss is a prevalent and costly clinical problem among nursing home (NH) residents. One of the most common nutrition interventions for residents at risk for weight loss is oral liquid nutrition supplementation. The purpose of this study was to determine the cost effectiveness of supplements relative to offering residents' snack foods and fluids between meals to increase caloric intake. DESIGN: Randomized, controlled trial. SETTING: Three long-term care facilities. PARTICIPANTS: Sixty-three long-stay residents who had an order for nutrition supplementation. INTERVENTION: Participants were randomized into one of three groups: (1) usual NH care control; (2) supplement, or (3) between-meal snacks. For groups two and three, trained research staff provided supplements or snacks twice daily between meals, five days per week, for six weeks with assistance and encouragement to promote consumption. MEASUREMENTS: Research staff observed residents during and between meals for two days at baseline, weekly, and post six weeks to estimate total daily caloric intake. For both intervention groups, research staff documented residents' caloric intake between meals from supplements or snack items, refusal rates and the amount of staff time required to provide each intervention. RESULTS: Both interventions increased between meal caloric intake significantly relative to the control group and required more staff time than usual NH care. The snack intervention was slightly less expensive and more effective than the supplement intervention. CONCLUSIONS: Offering residents a choice among a variety of foods and fluids twice per day may be a more effective nutrition intervention than oral liquid nutrition supplementation.
Assuntos
Ingestão de Energia/fisiologia , Métodos de Alimentação/economia , Instituição de Longa Permanência para Idosos , Casas de Saúde , Terapia Nutricional/economia , Terapia Nutricional/métodos , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Suplementos Nutricionais/economia , Feminino , Alimentos Formulados/economia , Humanos , Masculino , Projetos Piloto , Resultado do Tratamento , Redução de PesoRESUMO
Workers under 50 on average will spend 10-20% of their future hours working. So, assuming they value leisure time at the wage rate, the value of their lives is 5-10 times their future lifetime earnings. This value is close to values of life estimated by compensating wage differentials or willingness to pay.
Assuntos
Salários e Benefícios , Valor da Vida , Adulto , Idoso , Emprego/economia , Feminino , Humanos , Masculino , Métodos , Pessoa de Meia-Idade , Estados UnidosRESUMO
OBJECTIVES: To evaluate the costs of implementing a church-based, telephone-counseling program for increasing mammography use, and to identify the components of costs and the likely cost-effectiveness in hypothetical communities with varying characteristics. DATA SOURCES/STUDY SETTING: An ethnically and socioeconomically diverse sample of 1,443 women recruited from 45 churches participating in the Los Angeles Mammography Promotion (LAMP) program were followed from 1995 to 1997. STUDY DESIGN: Churches were stratified into blocks and randomized into three intervention arms-telephone counseling, mail counseling, and control. We surveyed participants before and after the intervention to collect data on mammography use and demographic characteristics. DATA COLLECTION/EXTRACTION METHODS: We used call records, activity reports, and interviews to collect data on the time and materials needed to organize and carry out the intervention. We constructed a standard model of costs and cost-effectiveness based on these data and the Year One results of the LAMP program. PRINCIPAL FINDINGS: The cost in materials and overhead to the church site was $10.89 per participant and $188 per additional screening. However, when the estimated cost for church volunteers' time was included, the cost of the intervention increased substantially. CONCLUSIONS: A church-based program to promote the use of mammography would be feasible for many churches with the use of volunteer labor and resources.
Assuntos
Cristianismo , Relações Comunidade-Instituição/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Promoção da Saúde/economia , Mamografia/economia , Programas de Rastreamento/economia , Serviços de Saúde da Mulher/economia , Idoso , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Estudos de Viabilidade , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Los Angeles , Mamografia/estatística & dados numéricos , Pessoa de Meia-Idade , Grupos Minoritários , Modelos Econométricos , Pobreza , Avaliação de Programas e Projetos de Saúde , Sensibilidade e Especificidade , Inquéritos e Questionários , Serviços de Saúde da Mulher/estatística & dados numéricosRESUMO
OBJECTIVE: To determine the effect of postpartum length of stay on newborn readmission. DATA SOURCES: Secondary data set consisting of newborns born in Washington state in 1989 and 1990. The data set contains information about the characteristics of the newborn and its parents, physician, hospital, and insurance status. STUDY DESIGN: Analysis of the effect of length of stay on the probability of newborn readmission using hour of birth and method of delivery as instrumental variables (IVs) to account for unobserved heterogeneity. Of approximately 150,000 newborns born in Washington in 1989 and 1990, 108,551 (72 percent) were included in our analysis. PRINCIPAL FINDINGS: Newborns with different lengths of stay differ in unmeasured characteristics, biasing estimates based on standard statistical methods. The results of our analyses show that a 12-hour increase in length of stay is associated with a reduction in the newborn readmission rate of 0.6 percentage points. This is twice as large as the estimate obtained using standard statistical (non-IV) methods. CONCLUSION: An increase in the length of postpartum hospital stays may result in a decline in newborn readmissions. The magnitude of this decline in readmissions may be larger than previously thought.
Assuntos
Interpretação Estatística de Dados , Pesquisa sobre Serviços de Saúde/métodos , Tempo de Internação/estatística & dados numéricos , Modelos Econométricos , Readmissão do Paciente/estatística & dados numéricos , Assistência Perinatal/estatística & dados numéricos , Viés , Parto Obstétrico/métodos , Parto Obstétrico/estatística & dados numéricos , Feminino , Humanos , Recém-Nascido , Seguro Saúde/estatística & dados numéricos , Análise dos Mínimos Quadrados , Masculino , Estado Civil/estatística & dados numéricos , Método de Monte Carlo , Paridade , Fatores de Tempo , WashingtonRESUMO
OBJECTIVE: To assess additional risk of newborn death owing to early discharge. METHODS: This was a historical cohort study using Washington State linked birth certificates, death certificates, and hospital discharge records that covered 47,879 live births in 1989 and 1990. Logistic regression was used to assess risk of death within the first year of life after early discharge (less than 30 hours after birth) compared with later discharge (30-78 hours after birth). RESULTS: Newborns discharged early were more likely to die within 28 days of birth (odds ratio [OR] 3.65; 95% confidence interval [CI] 1.56, 8.54), between 29 days and 1 year (OR 1.61; 95% CI 1.10, 2.36), and any time within the first year (OR 1.84; 95% CI, 1.31, 2.60) of life than newborns sent home later. Newborns discharged early also were more likely to die of heart-related problems (OR 3.72; CI 1.25, 11.04) and infections (OR 4.72; CI 1.13, 19.67) within 1 year of birth than newborns discharged later. CONCLUSION: Newborns discharged within 30 hours of birth are at increased risk of death within the first year of life.
Assuntos
Mortalidade Infantil , Tempo de Internação/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Estudos de Coortes , Intervalos de Confiança , Feminino , Humanos , Lactente , Recém-Nascido , Modelos Logísticos , Masculino , Prontuários Médicos , Razão de Chances , Período Pós-Parto , Fatores de Risco , Sensibilidade e Especificidade , Classe Social , Washington/epidemiologiaRESUMO
OBJECTIVE: To simulate whether allowing small businesses to offer employer-funded medical savings accounts (MSAs) would change the amount or type of insurance coverage. STUDY SETTING: Economic policy evaluation using a national probability sample of nonelderly non-institutionalized Americans from the 1993 Current Population Survey (CPS). STUDY DESIGN: We used a behavioral simulation model to predict the effect of MSAs on the insurance choices of employees of small businesses (and their families). The model predicts spending by each family in a FFS plan, an HMO plan, an MSA, and no insurance. These predictions allow us to compute community-rated premiums for each plan, but with firm-specific load fees. Within each firm, employees then evaluate each option, and the firm decides whether to offer insurance-and what type-based on these evaluations. If firms offer insurance, we consider two scenarios: (1) all workers elect coverage; and (2) workers can decline the coverage in return for a wage increase. PRINCIPAL FINDINGS: In the long run, under simulated conditions, tax-advantaged MSAs could attract 56 percent of all employees offered a plan by small businesses. However, the fraction of small-business employees offered insurance increases only from 41 percent to 43 percent when MSAs become an option. Many employees now signing up for a FFS plan would switch to MSAs if they were universally available. CONCLUSIONS: Our simulations suggest that MSAs will provide a limited impetus to businesses that do not currently cover insurance. However, MSAs could be desirable to workers in firms that already offer HMOs or standard FFS plans. As a result, expanding MSA availability could make it a major form of insurance for covered workers in small businesses. Overall welfare would increase slightly.
Assuntos
Comércio/economia , Poupança para Cobertura de Despesas Médicas/economia , Modelos Econômicos , Adolescente , Adulto , Comércio/estatística & dados numéricos , Saúde da Família , Gastos em Saúde/estatística & dados numéricos , Humanos , Seguro Saúde/economia , Seguro Saúde/estatística & dados numéricos , Poupança para Cobertura de Despesas Médicas/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricosRESUMO
OBJECTIVE: To evaluate whether adjusting the Health Plan Employer Data and Information Set (HEDIS) low birth weight (LBW) measure for maternal risk factors is feasible and improves its validity as a quality indicator. DATA SOURCE: The Washington State Birth Event Record Data for calendar years 1989 and 1990, including birth certificate data matched with mothers' and infants' hospital discharge records, with 5,837 records of singlet on infants identified as LBW (< 2,500 g) and a 25 percent sample ( n = 31,570) of the normal-weight births ( = 2,500 g). STUDY DESIGN: We reviewed literature on factors associated with birth weight and identified factors for risk adjustment that are associated with LBW and th at are not modifiable by the health plan . We used vit al records Data to develop and test possible risk adjustment strategies. Finally, because feasibility is important for a HEDIS measure, we assessed health plan readiness to produce a risk-adjusted measure. PRINCIPAL FINDINGS: An LBW indicator that is adjusted for maternal risks represents health plan performance better than the unadjusted rate. In the most parsimonious risk adjustment model LBW risk was higher for mothers with a history of prior preterm birth , LBW, or fet al death . Risk was also high er for primiparas or mothers with high parity, mothers less than 19 years of age, and primiparas over age 35. In a model adding race to these obstetric factors, black, Asian/Pacific Islander, or other non-white, non-Hispanic race were also significantly associated with higher LBW risk. While adjusting for maternal risk improved the LBW measure's validity, the rate adjustment magnitude was small (0.17 percentage points) for the most plausible model. Th is may not be mean in gf ul clinically or for measuring differences in quality. The costs and data collection requirements of risk adjustment could be substantial for health plans lacking access to State birth records data. CONCLUSIONS Selection of risk adjusters for quality measures depends on judgments of their effect, legitimacy, and feasibility. A comprehensive examination of validity and feasibility is needed to understand to what extent outcome measures represent quality and how their value compares to their cost of collection .
Assuntos
Peso ao Nascer , Planos de Assistência de Saúde para Empregados/normas , Recém-Nascido de Baixo Peso , Bem-Estar Materno/classificação , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Cuidado Pré-Natal/normas , Indicadores de Qualidade em Assistência à Saúde , Risco Ajustado/estatística & dados numéricos , Adulto , Causalidade , Estudos de Viabilidade , Feminino , Hospitais/normas , Humanos , Recém-Nascido , Modelos Logísticos , Masculino , Bem-Estar Materno/etnologia , Análise Multivariada , Avaliação de Resultados em Cuidados de Saúde/métodos , Probabilidade , Fatores de Risco , Washington/epidemiologiaRESUMO
The authors discuss a system that describes the resources needed to treat different subgroups of the population under age 65, based on burden of disease. It is based on 173 conditions, each with up to 3 severity levels, and contains models that combine prospective diagnoses with retrospectively determined elements. We used data from four different payers and standardized the cost of most services. Analyses showed that the models are replicable, are reasonably accurate, explain costs across payers, and reduce rewards for biased selection. A prospective model with additional payments for birth episodes and for serious problems in newborns would be an effective risk adjuster for Medicaid programs.
Assuntos
Efeitos Psicossociais da Doença , Doença/classificação , Cuidado Periódico , Recursos em Saúde/economia , Modelos Econométricos , Risco Ajustado/economia , Índice de Gravidade de Doença , Adolescente , Adulto , Criança , Pré-Escolar , Doença/economia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Medicaid , Michigan , Pessoa de Meia-Idade , Estados UnidosRESUMO
BACKGROUND: Comprehensive geriatric assessment (CGA) can be effective in inpatient units, but such inpatient settings are prohibitively expensive. If similar benefits could be obtained in outpatient settings, CGA might be a more attractive option. OBJECTIVES: To assess the cost-effectiveness (CE) of an outpatient geriatric assessment with an intervention to increase adherence. SUBJECTS: Three hundred fifty-one community-dwelling, elderly subjects with at least one of four geriatric conditions. MEASURES: In addition to the measures of functioning, we collected data on the costs of the intervention itself and on the use of medical services in the 64 weeks after the intervention. RESULTS: The intervention, which prevented functional decline, cost $273 per participant. The intervention group averaged three more visits than the control group in the first 32 weeks after the intervention, but only 1.2 extra visits in the next 32 weeks. We estimate that the costs of these additional medical services would be $473 for the 5 years after the intervention, leading to a total cost per Quality Adjusted Life Year (QALY) of $10,600. CONCLUSIONS: The CE of this program compares favorably with many common medical interventions. Whether investments should be made in health care resources on treatments that lead to modest improvements in the functioning of community-dwelling elderly people remains a societal decision.
Assuntos
Assistência Ambulatorial/economia , Assistência Ambulatorial/psicologia , Avaliação Geriátrica , Serviços de Saúde para Idosos/economia , Cooperação do Paciente/psicologia , Atividades Cotidianas , Idoso , Assistência Ambulatorial/estatística & dados numéricos , Assistência Integral à Saúde/organização & administração , Análise Custo-Benefício , Pesquisa sobre Serviços de Saúde , Serviços de Saúde para Idosos/estatística & dados numéricos , Humanos , Equipe de Assistência ao Paciente/organização & administração , Cooperação do Paciente/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Anos de Vida Ajustados por Qualidade de Vida , Estados UnidosRESUMO
Dramatic changes in hospitals' operating environments are leading to major restructuring of hospital organizations. Hospital mergers and acquisitions are increasing each year, and conversions by hospitals to different forms of ownership also are continuing apace. Such changes require policymakers and regulators to develop and implement policies to ensure that consumers' interests are protected. An important consideration in this process is the impact on the price of hospital care following such transactions. This paper reviews empirical evidence that mergers that reduce competition will lead to price increases at both merging hospitals and their competitors, regardless of ownership status. We show that nonprofit and government hospitals have steadily become more willing to raise prices to exploit market power and discuss the implications for antitrust regulators and agencies that must approve nonprofit conversions.
Assuntos
Competição Econômica/organização & administração , Instituições Associadas de Saúde/economia , Preços Hospitalares/tendências , Hospitais Filantrópicos/economia , Setor de Assistência à Saúde , Instituições Associadas de Saúde/estatística & dados numéricos , Política de Saúde , Preços Hospitalares/estatística & dados numéricos , Hospitais Públicos/economia , Hospitais Públicos/organização & administração , Hospitais Filantrópicos/organização & administração , Humanos , Modelos Econométricos , Propriedade/economia , Análise de Regressão , Estados UnidosRESUMO
Has the nature of hospital competition changed from a medical arms race in which hospitals compete for patients by offering their doctors high quality services to a price war for the patients of payors? This paper uses time-series cross-sectional methods on California hospital discharge data from 1986-1994 to show the association of hospital prices with measures of market concentration changed steadily over this period, with prices now higher in less competitive areas, even for non-profit hospitals. Regression results are used to simulate the price impact of hypothetical hospital mergers.
Assuntos
Competição Econômica/tendências , Setor de Assistência à Saúde/tendências , Instituições Associadas de Saúde/economia , Preços Hospitalares/tendências , Hospitais com Fins Lucrativos/economia , Hospitais Filantrópicos/economia , California , Área Programática de Saúde/economia , Área Programática de Saúde/estatística & dados numéricos , Grupos Diagnósticos Relacionados , Setor de Assistência à Saúde/estatística & dados numéricos , Pesquisa sobre Serviços de Saúde/métodos , Preços Hospitalares/estatística & dados numéricos , Hospitalização/economia , Hospitais Públicos/economia , Medicaid , Medicare , Propriedade/economia , Análise de Regressão , Estados UnidosRESUMO
Flat capitation (uniform prospective payments) makes enrolling healthy enrollees profitable to health plans. Plans with relatively generous benefits may attract the sick and fail through a premium spiral. We simulate a model of idealized managed competition to explore the effect on market performance of alternatives to flat capitation such as severity-adjusted capitation and reduced supply-side cost-sharing. In our model flat capitation causes severe market problems. Severity adjustment and to a lesser extent reduced supply-side cost-sharing improve market performance, but outcomes are efficient only in cases in which people bear the marginal costs of their choices.
Assuntos
Capitação/estatística & dados numéricos , Comportamento do Consumidor/estatística & dados numéricos , Competição em Planos de Saúde/economia , Modelos Econométricos , Sistema de Pagamento Prospectivo/estatística & dados numéricos , Comportamento do Consumidor/economia , Setor de Assistência à Saúde , Necessidades e Demandas de Serviços de Saúde/economia , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Humanos , Seleção Tendenciosa de Seguro , Competição em Planos de Saúde/estatística & dados numéricos , Reembolso de Incentivo , Gestão de Riscos/economia , Gestão de Riscos/estatística & dados numéricosRESUMO
OBJECTIVES: (1) To describe the issues in developing a clinical predictor of cesarean delivery that could be used to adjust reported cesarean rates for case mix, and (2) to compare its performance to other, simpler predictors using clinical and statistical criteria. DATA SOURCES: Singleton births greater than 2,500 grams in Washington State in 1989 and 1990 for whom mothers and infant hospital discharge records could be matched to birth certificate data. DESIGN: Statistical analysis of retrospective merged hospital and birth certificate data, which were used to develop variables and models to predict the probability that any particular delivery would be a cesarean. PRINCIPAL FINDINGS: Merged data led to better predictor variables than those based on one source. A simple four-category hierarchical classification into births with prior cesarean, breech but no prior cesarean, first birth, and other explains 30 percent of the variance in individual cesarean rates. The full clinical model fit the data well and explained 37 percent of the variance. Multiparas without serious complications comprised 35 percent of the mothers and averaged less than 2 percent cesareans. A hospital's predicted cesarean rate depends strongly on the proportion of its births that are first births. CONCLUSION: Government and private agencies have reported cesarean rates as measures of hospital performance. Depending on data and resources available, both simple and complex measures of case mix can be used to adjust reported rates. These adjustments should not include all variables related to the rates. Proper adjustments may not alter hospital rankings greatly, but they will improve the validity and acceptability of the reports.
Assuntos
Cesárea/estatística & dados numéricos , Grupos Diagnósticos Relacionados/classificação , Declaração de Nascimento , Feminino , Humanos , Recém-Nascido , Alta do Paciente/estatística & dados numéricos , Gravidez , Probabilidade , Análise de Regressão , Estudos Retrospectivos , Medição de Risco , WashingtonRESUMO
To identify easily ascertainable sociodemographic and health characteristics that are associated with hypoalbuminemia in community-dwelling older persons, we used data from the first National Health and Nutrition Examination Survey. This population-based stratified probability sample survey included 4728 persons aged 55-74 y. We defined hypoalbuminemia in two ways: < 35 g/L (1.2% of the sample) or < or = 38 g/L (7.9% of the sample) and used multivariate logistic models to identify independent predictors of hypoalbuminemia. Older age; receiving welfare; a condition interfering with eating; vomiting > or = 3 d/mo; previous surgery for gastrointestinal tumor; self-reported heart failure; recurring cough attacks; feeling tired or wornout; edentulous, fair, or poor condition of teeth; little or no exercise; a low-salt diet; trouble chewing meat; self-reported protein albumin, blood, or sugar in urine; and current cigarette smoking were independently associated with albuminemia (< or = 38 g/L) or progressively lower albumin concentrations < 40 g/L. Persons with 3-5 of these factors (51.5% of the sample) had an odds ratio of 2.73 (95% CI: 1.64, 4.54) and those with > or = 6 factors (9.4% of the sample) had an odds ratio of 6.44 (95% CI: 3.49, 11.86) of albuminemia < or = 38 g/L compared with those with 0-2 risk factors (39.1% of the sample). These findings suggest that several easily assessed sociodemographic, lifestyle, and disease-related factors are associated with hypoalbuminemia and might be valuable items to include on general health surveys to identify older persons who have this marker of poor health status.
Assuntos
Avaliação Geriátrica , Albumina Sérica , Idoso , Feminino , Nível de Saúde , Humanos , Estilo de Vida , Masculino , Pessoa de Meia-Idade , Inquéritos Nutricionais , Fatores Socioeconômicos , Inquéritos e QuestionáriosAssuntos
Planos de Seguro Blue Cross Blue Shield/economia , Cesárea/estatística & dados numéricos , Tabela de Remuneração de Serviços/normas , Obstetrícia/economia , Organizações de Prestadores Preferenciais/economia , Planos de Seguro Blue Cross Blue Shield/normas , California , Cesárea/economia , Parto Obstétrico/economia , Parto Obstétrico/métodos , Feminino , Reforma dos Serviços de Saúde , Pesquisa sobre Serviços de Saúde , Humanos , Organizações de Prestadores Preferenciais/normas , Gravidez , Métodos de Controle de PagamentosRESUMO
The Quality of Well-Being Scale (QWB) quantifies health-related quality of life with a single number that represents community-based preferences for combinations of symptom/problem complexes, mobility, physical activity, and social activity. The aim of this study was to compare preferences of a long-term care population with those of the general population, determine whether preferences vary by the age of the hypothetical (target) person depicted in the health-state case description, and derive weights for new symptom/problem complexes of particular relevance to frail, older individuals. A sample of 38 female and 12 male long-term care residents with an average age of 86 years was asked to rate health-state scenarios that combined the four health domains of the QWB. This sample rates quality of life 0.10 units lower on average (on a 0-1 scale) than did the general population sample from which the QWB preferences were originally developed. Ratings of the same health state for younger versus older target persons did not differ significantly (all p values > 0.05 for t statistics). Weights derived for 11 new symptom/problem complexes were: disturbed sleep (-0.252), sit-to-stand requires maximal effort (-0.259), lonely (-0.265), walking a short distance causes extreme fatigue (-0.273), agitated (-0.284), hallucinating (-0.355), incontinent (0-359), unable to control one's behavior (-0.36), urinary catheter (-0.374), restrained in bed or chair (-0.374), and feeding tube through the nose or stomach (-0.402). These new weights increase the relevance of the QWB for cost-utility evaluations of health interventions for long-term care residents.
Assuntos
Comportamento de Escolha , Idoso Fragilizado/psicologia , Nível de Saúde , Assistência de Longa Duração/psicologia , Anos de Vida Ajustados por Qualidade de Vida , Atividades Cotidianas , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , California , Feminino , Necessidades e Demandas de Serviços de Saúde , Instituição de Longa Permanência para Idosos , Humanos , Masculino , Casas de Saúde , Inquéritos e QuestionáriosRESUMO
PURPOSE: This study examined the validity of medical-record-based nursing assessment and monitoring of signs and symptoms (nursing surveillance) in predicting patients who were admitted to ICUs and those admitted to non-ICUs. The association of this assessment and monitoring with differences in an intermediate patient outcome, instability at discharge, was also explored. Patients admitted to either setting with a diagnosis of acute myocardial infarction, cerebrovascular accident, congestive heart failure, or pneumonia, were included in the study. METHOD: A secondary analysis was carried out using a subset of data originally collected for a quality-of-care study. Data from the medical records of 11,246 patients (52% female, 48% male) with a mean age of 76.4 years were used in the present study. RESULTS: ICU patients (n = 3969) were found to have a longer length of stay and to be sicker on admission than non-ICU patients (n = 7277). Overall, patients in the ICU received significantly higher nursing assessment and monitoring of signs and symptoms scores than non-ICU patients. Nursing assessment and monitoring of signs and symptoms scores were lower for patients discharged with greater instability for three of the four diseases (cerebrovascular accidents, congestive heart failure, and pneumonia).
Assuntos
Unidades de Terapia Intensiva , Avaliação em Enfermagem , Admissão do Paciente , Idoso , Transtornos Cerebrovasculares/enfermagem , Feminino , Insuficiência Cardíaca/enfermagem , Fraturas do Quadril/enfermagem , Humanos , Tempo de Internação , Masculino , Prontuários Médicos , Infarto do Miocárdio/enfermagem , Pesquisa em Avaliação de Enfermagem , Pneumonia/enfermagem , Qualidade da Assistência à Saúde , Estudos de AmostragemRESUMO
OBJECTIVE: To understand how medical savings account (MSA) legislation for the nonelderly would affect health care costs. DESIGN: Economic policy evaluation based on the RAND Health Expenditures Simulation Model. SETTING: National probability sample of nonelderly noninstitutionalized households. PARTICIPANTS: Persons in 23 157 sampled households from the 1993 Current Population Survey. INTERVENTIONS: Medical savings account legislation would allow all Americans who are covered only by a catastrophic health care plan to set up a tax-exempt account that they can use to pay medical bills not covered by their health insurance. The interventions we evaluate differ in the deductibles of the catastrophic plan and in whether the employee or employer funds the MSA. MAIN OUTCOME MEASURES: Changes in national health expenditures and net societal benefits of health care. RESULTS: If all insured nonelderly Americans switched to MSAs, their health care expenditures would decline by between 0% and 13%, depending on how the MSAs are designed. However, not all nonelderly Americans would choose MSAs; taking into account selection patterns, health spending would change by + 1% to -2%. CONCLUSIONS: Medical savings account legislation would have little impact on health care costs of Americans with employer-provided insurance. However, depending on the size of the catastrophic limit, waste from the excessive use of generously insured care could be reduced, and MSAs would be attractive to both sick and healthy people.
Assuntos
Custo Compartilhado de Seguro/legislação & jurisprudência , Financiamento Pessoal/legislação & jurisprudência , Custo Compartilhado de Seguro/estatística & dados numéricos , Dedutíveis e Cosseguros/legislação & jurisprudência , Cuidado Periódico , Estudos de Avaliação como Assunto , Financiamento Pessoal/estatística & dados numéricos , Custos de Cuidados de Saúde , Gastos em Saúde/estatística & dados numéricos , Sistemas Pré-Pagos de Saúde/economia , Pesquisa sobre Serviços de Saúde/métodos , Imposto de Renda/legislação & jurisprudência , Pessoas sem Cobertura de Seguro de Saúde , Modelos Econométricos , Estados UnidosRESUMO
BACKGROUND: The diffusion of comprehensive geriatric assessment services has been rather limited in North America partly because of reimbursement and organizational constraints. OBJECTIVE: To evaluate the impact of a comprehensive geriatric assessment intervention for frail older patients that is started before hospital discharge and is continued at home. METHODS: Patients older than 65 years were selected who had either unstable medical problems, recent functional limitations, or potentially reversible geriatric clinical problems. Patients (n = 354) were randomly assigned to either the intervention group or a control group. Information on survival, readmissions, nursing home placement, medication use, and health status was collected at 30 and 60 days after hospital discharge. RESULTS: No differences were observed between the two treatment groups in survival, hospital readmission, or nursing home placement by 60 days. After adjustment for baseline characteristics, no significant differences were observed between the two groups on measures of physical functioning, social functioning, role limitations, health perceptions, pain, mental health, energy and/or fatigue, health change, or overall well-being. CONCLUSIONS: Although efficacy has been demonstrated for some forms of comprehensive geriatric assessment, the types of services that are easier to establish (inpatient consultation services and ambulatory assessment) have not been shown to improve outcomes. Our results indicate that outcomes are unaffected by a limited form of comprehensive geriatric assessment begun in the hospital and completed at home. Further efforts are needed to develop and to evaluate realistic approaches to comprehensive geriatric assessment.
Assuntos
Idoso Fragilizado , Avaliação Geriátrica , Idoso , Humanos , Alta do PacienteRESUMO
OBJECTIVE: More than half of nursing home residents suffer from urinary incontinence. These residents typically have long stays and, because of comorbid cognitive and physical impairments, have little hope of living again in a noninstitutional environment The value of interventions to change functional status of this chronically institutionalized population is often questioned. This paper explores this value issue in the context of two incontinence management interventions that have been shown to improve functional status: (1) Functional Incidental Training (FIT), and (2) Prompted Voiding (PV). The relative value of the different interventions for the nursing home population was estimated using paired preferences. DESIGN: The cost of two interventions (FIT and PV) that target incontinent nursing home residents was related to the value of these interventions as perceived by consumers of nursing home services. Both interventions decrease incontinence frequency, and one intervention also improves mobility endurance. PARTICIPANTS: Ninety incontinent nursing home residents received the intervention; 37 older nondemented board and care residents and 31 family members of the nursing home residents provided estimates of the intervention's value. MEASUREMENT: The staff-time allocations involved in implementing both interventions were documented in more than 85 resident care episodes. These time data were converted to labor cost based on the cost of nursing aides who would actually implement the intervention. The value of each intervention was assessed by asking consumers to make choices between the intervention and its associated outcomes (such as increased dryness) and other nursing home services of known cost (e.g., moving to a private room). RESULTS: Both interventions had labor costs that were greater than "usual care" costs. The additional cost was estimated to be $4.31 per resident per day for PV and $6.42 per resident per day for FIT if these programs were implemented from 7 AM to 7 AM. Consumer preference data indicated that consumers preferred the FIT and PV outcomes to more expensive alternative services, calculated to cost $10.00 per day, often marketed to consumers, CONCLUSION: Consumers may prefer the FIT and PV interventions relative to the typical services often marketed to the nursing home consumer. The analysis completed in this paper suggests that both interventions have value for frail residents likely to live out their lives in a nursing home.