A break-even analysis for dementia care collaboration: Partners in Dementia Care.

BACKGROUND: Dementia is a costly disease. People with dementia, their families, and their friends are affected on personal, emotional, and financial levels. Prior work has shown that the "Partners in Dementia Care" (PDC) intervention addresses unmet needs and improves psychosocial outcomes and satisfaction with care. OBJECTIVE: We examined whether PDC reduced direct Veterans Health Administration (VHA) health care costs compared with usual care. DESIGN: This study was a cost analysis of the PDC intervention in a 30-month trial involving five VHA medical centers. PARTICIPANTS: Study subjects were veterans (N = 434) 50 years of age and older with dementia and their caregivers at two intervention (N = 269) and three comparison sites (N = 165). INTERVENTIONS: PDC is a telephone-based care coordination and support service for veterans with dementia and their caregivers, delivered through partnerships between VHA medical centers and local Alzheimer's Association chapters. MAIN MEASURES: We tested for differences in total VHA health care costs, including hospital, emergency department, nursing home, outpatient, and pharmacy costs, as well as program costs for intervention participants. Covariates included caregiver reports of veterans' cognitive impairment, behavior problems, and personal care dependencies. We used linear mixed model regression to model change in log total cost post-baseline over a 1-year follow-up period. KEY RESULTS: Intervention participants showed higher VHA costs than usual-care participants both before and after the intervention but did not differ significantly regarding change in log costs from pre- to post-baseline periods. Pre-baseline log cost (p ≤ 0.001), baseline cognitive impairment (p ≤ 0.05), number of personal care dependencies (p ≤ 0.01), and VA service priority (p ≤ 0.01) all predicted change in log total cost. CONCLUSIONS: These analyses show that PDC meets veterans' needs without significantly increasing VHA health care costs. PDC addresses the priority area of care coordination in the National Plan to Address Alzheimer's Disease, offering a low-cost, structured, protocol-driven, evidence-based method for effectively delivering care coordination.

Surfactant protein D inhibits mite-induced alveolar macrophage and dendritic cell activations through TLR signalling and DC-SIGN expression.

BACKGROUND: Surfactant protein D (SP-D), a secreted pattern recognition molecule associated with pulmonary innate immunity, has been shown to mediate the clearance of pathogens in multiple ways. However, how SP-D interacts with alveolar macrophages (AMs) and dendritic cells (DCs) during allergen exposure remains unclear. OBJECTIVE: This study was performed to characterize the immunomodulatory effects of SP-D on mite allergen (Dermatophagoides pteronyssinus, Der p)-induced inflammatory signalling in AMs and DCs. METHODS: Murine AM, alveolar macrophage cell line derived from BALB/c mice (MH-S cells), and human monocyte-derived dendritic cells (MDDC) were used as model systems. The production of nitric oxide (NO) and TNF-alpha, expression of surface Toll-like receptors (TLRs), and expression of the C-type lectin receptor known as dendritic cell (DC)-specific ICAM-grabbing non-integrin (DC-SIGN) were measured as a function of pretreatment with SP-D and subsequent exposure to Der p. Der p-dependent cellular activations that were modified by SP-D in these model systems were then identified. RESULTS: Pretreatment of MH-S cells with SP-D reduced Der p-dependent production of NO, TNF-alpha, and the downstream activations of IL-1 receptor-associated kinase, mitogen activated protein kinase (MAPK) kinase, and nuclear factor-kappaB. SP-D interacted with CD14 such that CD14 binding to Der p was inhibited and Der p-induced signalling via TLRs was blocked. DC-SIGN expression was suppressed by Der p in MH-S and MDDC; this down-regulation of DC-SIGN expression was prevented by pretreatment with SP-D. CONCLUSIONS: These results indicated that the inhibition of Der p-induced activation of MH-S and MDDC by SP-D is mediated through suppression of the CD14/TLR signalling pathway and maintenance of DC-SIGN expression, which may protect allergen-induced airway inflammation.

Mite allergen induces nitric oxide production in alveolar macrophage cell lines via CD14/toll-like receptor 4, and is inhibited by surfactant protein D.

BACKGROUND: Previously, we have found that dust mite allergens can directly activate alveolar macrophages (AMs), induce inflammatory cytokines, and enhance T-helper type 2 cytokine production. A molecule of innate immunity in the lung, surfactant protein D (SP-D), is able to bind mite allergens and alleviates allergen-induced airway inflammation. OBJECTIVES: This study was aimed at investigating the activation pathway of mite allergen (Dermatophagoides pteronyassinus, Der p)-induced nitric oxide (NO) production by AMs, and the role of SP-D in the modulation of activated AMs by mite allergens. METHODS: Porcine SP-D was purified from bronchoalveolar lavage fluids of Lan-Yu mini-pigs, by affinity chromatography on maltose-sepharose. NO production, inducible expression of lipopolysaccharides (LPS)-related binding and responding surface receptors complex, CD14 and toll-like receptor 4 (TLR4), as well as inducible NO synthase (iNOs) and nuclear factor-kappaB activation were studied in two AMs cell lines, MH-S (BALB/c strain),and AMJ2-C11 (C57BL/6 strain), and one peritoneal macrophage cell line (RAW264.7), after stimulation with LPS, or Der p. RESULTS: LPS and Der p elicited different responses of NO production in the different cell lines, and the response might depend upon the expression of the cell surface CD14/TLR4 complex in different genetic backgrounds of macrophage cell lines. Pretreatment of macrophages with SP-D could inhibit NO production from Der p or LPS-stimulated alveolar macrophages. CONCLUSION: Mite allergen-induced alveolar macrophage activation is mediated by CD14/TLR4 receptors and can be inhibited by SP-D; it further supports the concept that SP-D may be an important modulator of allergen-induced pulmonary inflammation.

Nosocomial blood-stream infection in patients with end-stage renal disease: excess length of hospital stay, extra cost and attributable mortality.

Patients with end-stage renal disease undergoing haemodialysis are at high risk of nosocomial blood-stream infection (BSI), but data on the associated costs in this patient population are not available. Therefore, we conducted a retrospective matched (1:2) case-control study of such patients undergoing haemodialysis from January 1998 to December 1998 in a medical centre in southern Taiwan to determine the excess length of hospital stay, attributable mortality, and the extra cost caused by nosocomial BSI. The excess length of hospital stay was 30 days for cases vs. 16 days for controls (P<0.001), the mortality rate was 26.3% for cases vs. 0 for controls (P=0.003) (attributable mortality being 26.3%), and the median of overall costs was 131,584 dollars NT for cases vs. 65,282 dollars NT for controls (P<0.001). Based on these findings, we believe that an effective programme to minimize nosocomial BSI in this patient population would greatly reduce their medical and economic burdens.

Impact of global bundled payments on hospital costs of coronary artery bypass grafting.

The Health Care Financing Administration began the Medicare Participating Heart Bypass Center Demonstration in 1991, in which hospitals and physicians are paid a single negotiated global price for all inpatient care for heart bypass patients. This article analyzed the changes in total and departmental direct variable costs during the 1991-1993 period using micro-cost data. The results indicate that all participating hospitals had significant reductions in total direct variable costs, after controlling for preoperative risk factors and postoperative outcomes. However, the patterns in cost reductions across major departments were different across hospitals. The cost reductions primarily came from nursing intensive care unit, routine nursing, pharmacy, and catheter lab.

Preoperative correlates of the cost of coronary artery bypass graft surgery: comparison of results from three hospitals.

This article furthers our understanding of the cost of coronary artery bypass graft (CABG) surgery by analyzing the extent to which preoperative correlates of cost differ among hospitals. A total of 2828 patient who underwent bypass surgery at 3 hospitals (2 teaching and 1 nonteaching) were analyzed. The preoperative correlates of direct variable cost (marginal cost) were determined by ordinary least squares regression. Age, urgent/emergent surgical priority, previous CABG, and chronic obstructive pulmonary disease (COPD) were significant contributors (P < .05) to cost in all hospitals, but overall, there were many differences. The major contributor to cost was non-white race (31.3%) at teaching hospital A, previous CABG (30.5%) at teaching hospital B, and preop insertion of intra-aortic balloon pump (IABP) (35.9%) at the nonteaching hospital. The number of significant risk factors also differed. Preoperative characteristics that contribute to cost can be quite different among hospitals and therefore results from one hospital cannot be broadly generalized to others.

Interpreting results in mental health research.

It is often difficult to interpret the clinical or policy significance of findings from mental health research when results are presented only in terms of statistical significance. Results expressed in terms of p values or as a metric corresponding to a mental health status scale are seldom intuitively meaningful. To help interpret the significance of research results, we demonstrate a social validity approach that relates scores on mental health status scales to four subsequent major life events. A logistic regression model is used to estimate the relation between mental health status scores and the probability of subsequent major life events, using data obtained on Medicaid beneficiaries with schizophrenia from an evaluation of the Utah Prepaid Mental Health Plan. Using this relatively simple approach will demonstrate to policy makers, clinicians, and researchers the social impact of an outcome, thereby aiding in the interpretation of the significance of results.

Principal inpatient diagnostic cost group model for Medicare risk adjustment.

The Balanced Budget Act (BBA) of 1997 required HCFA to implement health-status-based risk adjustment for Medicare capitation payments for managed care plans by January 1, 2000. In support of this mandate, HCFA has been collecting inpatient encounter data from health plans since 1997. These data include diagnoses and other information that can be used to identify chronic medical problems that contribute to higher costs, so that health plans can be paid more when they care for sicker patients. In this article, the authors describe the risk-adjustment model HCFA is implementing in the year 2000, known as the Principal Inpatient Diagnostic Cost Group (PIPDCG) model.

Outcomes for Medicaid beneficiaries with schizophrenia under a prepaid mental health carve-out.

This study examines the impact of a mental health carve-out program in Utah on mental health status of Medicaid beneficiaries with schizophrenia. Three community mental health centers contracted to provide mental health care for all Medicaid beneficiaries in their service areas under managed care arrangements, while beneficiaries in the remainder of the state remained under traditional Medicaid. A pre-post evaluation was utilized, with a contemporaneous control group of Utah Medicaid beneficiaries with schizophrenia under traditional Medicaid. From 1991 to 1994, the average beneficiary's mental health status improved, but the improvement was less under the carve-out program than under traditional fee-for-service Medicaid. The difference was the greatest for beneficiaries with the worst mental health status at baseline, with effects growing over time. Medicaid beneficiaries with schizophrenia experienced less improvement in mental health status under a carve-out arrangement for mental health care compared to what would have happened under traditional Medicaid.

Patterns of outpatient use of mental health services for Medicaid beneficiaries under a prepaid mental health carve-out.

This study examines the impact of a mental health carve-out, the Utah Prepaid Mental Health Plan (UPMHP), on use of outpatient mental health services by Medicaid beneficiaries with schizophrenia. Data were collected through interviews with the same group of Medicaid schizophrenic beneficiaries. A pre/post comparison with a contemporaneous control group examined the impact of the program on type of outpatient services used by beneficiaries. The results indicate a greater reliance on medically-oriented outpatient mental health services in treatment of beneficiaries under the UPMHP. Medicaid beneficiaries with schizophrenia in the UPMHP group received relatively fewer day treatment visits, but relatively more medication visits and individual therapy visits over the first 3 1/2 years of the program.

The demand for health insurance by employees in a voluntary small group insurance program.

OBJECTIVES: This study examined the decisions of small group employees to enroll in prepaid plans offered through Healthcare Group of Arizona (HCGA), a state-sponsored and state-administered voluntary insurance program. METHODS: The study population included 653 potential employee enrollees who were offered the option of two health plans between January 1993 and June 1993, with 447 enrolling in one of the two plans. Data sources included two telephone surveys, HCGA administrative files, and enrollment application forms. RESULTS: The estimates of adjusted price elasticity were in the range of -0.12 to -0.24 for employees with prior insurance and were in the range of -0.42 to -0.51 for employees without prior insurance. The likelihood of enrolling in HCGA increased with log(income) and decreased with log(income) squared. The average income elasticity across income groups was 0.12. CONCLUSIONS: The results indicate that small group employees without prior insurance were more sensitive to the price of health insurance than those with prior insurance. Healthcare Group of Arizona health plans may have been viewed as inferior goods by high income employees possible because of their association with the Medicaid program.

The early experience of a voluntary small group insurance program utilizing managed care plans.

HealthCare Group of Arizona (HCGA), a state-sponsored, voluntary health insurance purchasing program offering prepaid health plans to small businesses, became operational in 1988. This article summarizes the results from a wide-ranging evaluation of that program and discusses their implications. In general, enrollees were satisfied with their experience in their plans. HCGA did not appear to attract an adverse mix of health risks, and service utilization rates were consistent with HMO industry averages. However, these findings varied across health plans and the marketing approaches they adopted. Enrollment growth in HCGA has been steady, but premium subsidies may be necessary if HCGA is to substantially increase its enrollment of low-wage, uninsured workers.

Income, health status, and insurance coverage of small group employees in a voluntary purchasing arrangement.

The ongoing health care reform discussion has highlighted the problems of insuring small group employees. Several state and private initiatives have attempted to address some of these problems through the formation of voluntary small group purchasing arrangements. This article uses data from one such initiative, Health Care Group of Arizona (HCGA), to describe the income, health status, and prior insurance of small group employees who enrolled in prepaid health plans through HCGA. It also compares employee enrollees to nonenrollees along these dimensions. The findings suggest that HCGA enrollees had relatively low incomes and that about three-quarters were without health insurance prior to enrollment. Higher income employee enrollees were more likely to report health conditions at enrollment even after controlling for other factors including age. Enrollees were less likely than nonenrollees to have prior health insurance but were more likely to be drawn from lower income groups and to report recent health conditions.

Prospecting for customers in the small employer market: the experience of Arizona Health Care Group.

The findings of this study provide an interesting profile of the small employer "prospects" for prepaid health plans, where a prospect is defined as an employer that responds to a mass mailing effort with a request for information and further contact. About 60% of these prospects already have insurance, with 40% having group insurance. Therefore, a substantial portion of prospects are seeking to replace their existing health benefit package with a different one. Of those who do not offer existing insurance, the most common reason is that it is "too expensive" or the employer is "not profitable." A very small proportion do not offer insurance because they do not qualify for it due to medical underwriting considerations. Prospects tend to be larger than non-prospects in terms of sales, but employ lower wage employees, on average. About half of prospects are in service industries, a proportion typical of small employers in general. Somewhat surprisingly, most prospects have been in operation for over five years. They are not new firms attempting to establish their benefit packages. This is consistent with the findings on gross sales, suggesting that some maturity is necessary before an employer considers offering group health insurance as a benefit. The prepaid plans in this study also appeared to target established employers for their marketing efforts. In responding to questions about their attitudes towards health insurance, over one-quarter of prospects indicated that they would be unwilling to offer insurance at rates so low that they would not normally apply to the coverages offered by prepaid plans. Thus, although they were "prospects" by the study's definition, they were unlikely to eventually contract with prepaid plans. Those prospects that had offered insurance previously, but had discontinued it, tended to cite premium increases as the reason. This suggests that prospects among small employers are likely to be very price sensitive, and that further prescreening of prospects by phone, during which premium levels are discussed, might be cost-effective in following up leads from mass mailings. The study data also suggest the importance of quick follow-up for mass mailing leads, as the drop-off in recall and interest appears to be substantial. About half of the prospects interviewed stated that they were unaware of AHCG, although they or someone in their business had returned a mailer requesting more information. In addition to their implications for marketing to small employers, the results of the study appear to have broader policy implications as well.(ABSTRACT TRUNCATED AT 400 WORDS)