Persistence of full glacial conditions in the central Pacific until 15,000 years ago.

The magnitude of atmospheric cooling during the Last Glacial Maximum and the timing of the transition into the current interglacial period remain poorly constrained in tropical regions, partly because of a lack of suitable climate records. Glacial moraines provide a method of reconstructing past temperatures, but they are relatively rare in the tropics. Here we present a reconstruction of atmospheric temperatures in the central Pacific during the last deglaciation on the basis of cosmogenic 3He ages of moraines and numerical modelling of the ice cap on Mauna Kea volcano, Hawaii--the only highland in the central Pacific on which moraines that formed during the last glacial period are preserved. Our reconstruction indicates that the Last Glacial Maximum occurred between 19,000 and 16,000 years ago in this region and that temperatures at high elevations were about 7 degrees C lower than today during this interval. Glacial retreat began about 16,000 years ago, but temperatures were still about 6.5 degrees C lower than today until 15,000 years ago. When combined with estimates of sea surface temperatures in the central Pacific Ocean, our reconstruction indicates that the lapse rate during the Last Glacial Maximum was higher than at present, which is consistent with the proposal that the atmosphere was drier at that time. Furthermore, the persistence of full glacial conditions until 15,000 years ago is consistent with the relatively late and abrupt transition to warmer temperatures in Greenland, indicating that there may have been an atmospheric teleconnection between the central Pacific and North Atlantic regions during the last deglaciation.

Cost-effectiveness of treatments for major depression in primary care practice.

BACKGROUND: This study augments a randomized controlled trial to analyze the cost-effectiveness of 2 standardized treatments for major depression relative to each other and to the "usual care" provided by primary care physicians. METHODS: A randomized controlled trial was conducted in which primary care patients meeting DSM-III-R criteria for current major depression were assigned to pharmacotherapy (where nortriptyline hydrochloride was given) or interpersonal psychotherapy provided in a standardized framework or a primary physician's usual care. Two outcome measures, depression-free days and quality-adjusted days, were developed using information on depressive symptoms over time. The costs of care were calculated. Cost-effectiveness ratios comparing the incremental outcomes with the incremental costs for the different treatments were estimated. Sensitivity analyses were performed. RESULTS: In terms of both economic costs and quality-of-life outcomes, patients assigned to the pharmacotherapy group did slightly better than those assigned to interpersonal psychotherapy. Both standardized therapies provided better outcomes than primary physician's usual care, but each consumed more resources. No meaningful cost-offsets were found. The incremental direct cost per additional depression-free day for pharmacotherapy relative to usual care ranges from $12.66 to $16.87 which translates to direct cost per quality-adjusted year gained from $11270 to $19510. CONCLUSIONS: Standardized treatments for depression lead to better outcomes than usual care but also lead to higher costs. However, the estimates of the cost per quality-of-life year gained for standardized pharmacotherapy are comparable with those found for other treatments provided in routine practice.

Treating major depression in primary care practice. Eight-month clinical outcomes.

BACKGROUND: We studied whether standardized treatments of major depression whose efficacy was established with psychiatric patients are equally effective when provided to primary care patients, and whether standardized treatments are more effective than a primary care physician's usual care. METHODS: A randomized controlled trial was conducted, in which primary care patients meeting DSM-III-R criteria for a current major depression were assigned to nortriptyline (n = 91) or interpersonal psychotherapy (n = 93) provided within well-structured parameters, or a physician's usual care (n = 92). The main outcome measures were degree and rate of improvement in severity of depressive symptoms and proportion of patients recovered at 8 months. RESULTS: Severity of depressive symptoms was reduced more rapidly and more effectively among patients randomized to pharmacotherapy or psychotherapy than among patients assigned to a physician's usual care. Among treatment completers, approximately 70% of patients participating in the full pharmacotherapy or psychotherapy protocol but only 20% of usual care patients were judged as recovered at 8 months. CONCLUSIONS: Pharmacotherapy and psychotherapy effectively treat major depression among primary care patients when provided within specific parameters and for the full acute and continuation phases. Treatment principles recommended by the Depression Guideline Panel of the Agency for Health Care Policy and Research are supported.

Preferences for home vs hospital care among low-risk patients with community-acquired pneumonia.

OBJECTIVE: To measure preferences for initial outpatient vs hospital care among low-risk patients who were being actively treated for community-acquired pneumonia (CAP). METHODS: Study patients included 159 patients with CAP, 57 (36%) initially hospitalized, who were identified as being at low risk for early mortality using a validated prediction model. Subjects were enrolled from university and community health care facilities located in Boston, Mass, Halifax, Nova Scotia, and Pittsburgh, Pa, participating in the Pneumonia Patient Outcome Research Team prospective cohort study of CAP. Three utility assessment techniques (category scaling, standard gamble, and willingness to pay) were used to measure the strength of patient preferences for the site of care for low-risk CAP. At the time of initial therapy or during the early recuperative period, patient preferences were assessed across a spectrum of potential clinical outcomes using 7 standardized pneumonia clinical vignettes. RESULTS: Responses to the 7 pneumonia scenarios indicated that most patients consistently preferred outpatient-based therapy. This pattern was observed regardless of whether patients had actually been treated initially at home or in a hospital. Patients (74%) who stated that they generally preferred home care for low-risk CAP were willing to pay a mean of 24% of 1 month's household income to be assured of this preference. Preference for home care, as measured by the category scaling and the willingness to pay, persisted after adjustment for sociodemographic and baseline health status covariates. Sixty nine percent of interviewed patients said that their physician alone determined whether they would be treated in the hospital or at home. Only 11% recalled being asked if they had a preference for either site of care. CONCLUSIONS: Most patients, even those treated initially in a hospital, who were at low risk for mortality from CAP prefer outpatient treatment. However, most physicians appear not to involve patients in the site-of-care decision. More explicit discussion of patient preferences for the location of care would likely yield more highly valued care by patients as well as less costly treatment for CAP.

Processes and outcomes of care for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team (PORT) cohort study.

BACKGROUND: Although understanding the processes of care and medical outcomes for patients with community-acquired pneumonia is instrumental to improving the quality and cost-effectiveness of care for this illness, limited information is available on how physicians manage patients with this illness or on medical outcomes other than short-term mortality. OBJECTIVES: To describe the processes of care and to assess a broad range of medical outcomes for ambulatory and hospitalized patients with community-acquired pneumonia. METHODS: This prospective, observational study was conducted at 4 hospitals and 1 health maintenance organization in Pittsburgh, Pa, Boston, Mass, and Halifax, Nova Scotia. Data were collected via patient interviews and reviews of medical records for 944 outpatients and 1343 inpatients with clinical and radiographic evidence of community-acquired pneumonia. Processes of care and medical outcomes were assessed 30 days after presentation. RESULTS: Only 29.7% of outpatients had 1 or more microbiologic tests performed, and only 5.7% had an assigned microbiologic cause. Although 95.7% of inpatients had 1 or more microbiologic tests performed, a cause was established in only 29.6%. Six outpatients (0.6%) died, and 3 of these deaths were pneumonia related. Of surviving outpatients, 8.0% had 1 or more medical complications. At 30 days, 88.9% (nonemployed) to 95.6% (employed) of the surviving outpatients had returned to usual activities, yet 76.0% of outpatients had 1 or more persisting pneumonia-related symptoms. Overall, 107 inpatients (8.0%) died, and 81 of these deaths were pneumonia related. Most surviving inpatients (69.0%) had 1 or more medical complications. At 30 days, 57.3% (non-employed) to 82.0% (employed) of surviving inpatients had returned to usual activities, and 86.1% had 1 or more persisting pneumonia-related symptoms. CONCLUSIONS: In this study, conducted primarily at hospital sites with affiliated medical education training programs, virtually all outpatients and most inpatients had pneumonia of unknown cause. Although outpatients had an excellent prognosis, pneumonia-related symptoms often persisted at 30 days. Inpatients had substantial mortality, morbidity, and pneumonia-related symptoms at 30 days.

Health insurance and the financial impact of IDDM in families with a child with IDDM.

OBJECTIVE: To examine the health insurance experience and out-of-pocket health care costs of families with a child with IDDM. RESEARCH DESIGN AND METHODS: A case-control study of 197 families with a child with IDDM and 142 control families with no diabetic children was conducted. IDDM-affected families were identified from the Allegheny County IDDM Registry. Brothers and sisters of the parents in the IDDM-affected families were asked to participate as control subjects. Health insurance coverage and the money that families spent on health care services and supplies not reimbursed by insurance (out-of-pocket costs) were assessed by questionnaire. RESULTS: No difference was found between the IDDM-affected and control families in the percentages with or without insurance. Families with low household incomes ($10,000-$19,999) were at the greatest risk for having no insurance. While coverage provided by private plans was similar between the IDDM-affected and control families, many families had no reimbursement for insulin (10%), syringes (10%), or blood testing strips (30%). Out-of-pocket expenses were 56% higher in the IDDM-affected families than in the control families. Seventeen percent of the IDDM-affected families had expenses over 10% of their household income. This particularly affected families with low household incomes. Pre-existing illness clauses and insurance denial affected only a small proportion of the case families. CONCLUSIONS: These data illustrate that most families with a child with IDDM have health insurance, yet still incur larger out-of-pocket health care costs than do families without the presence of diabetes. IDDM-affected families likely face a number of economic decisions regarding health insurance and the use of health care.

Psychiatry under prospective payment: experience in the first year.

The authors present data on changes in resource use by Medicare psychiatric patients in general hospitals after the introduction of the prospective payment system in 1984. Length of stay and charges per discharge during fiscal year 1984 fell 13.8% and 15.9%, respectively, after the new system began, even though 31.8% of the discharges for Medicare psychiatric cases were from exempt psychiatric units. The decrease in length of stay was considerably larger (23.2%) in hospitals with no psychiatric units, which were not exempt from prospective payment.

Impact of immunosuppression on health care use by men in the Multicenter AIDS Cohort Study (MACS).

The effects of human immunodeficiency virus type 1 (HIV-1) serostatus, AIDS, and level of immunosuppression on health service use were examined in the Multicenter AIDS Cohort Study. Data on self-reported hospitalizations, outpatient medical services (non-emergency room) and emergency room care during the preceding 6 months were collected for 3,447 homosexual/bisexual men returning for their 14th and/or 15th semiannual visits in Chicago, Baltimore, Los Angeles, and Pittsburgh. AIDS-free seropositive men with CD4+ cells < 200/microliters were more likely to be hospitalized [odds ratio (OR) = 2.3, 95% confidence limits (CL) = 1.4, 3.8] and use outpatient medical care (OR = 7.9, 95% CL = 4.9, 12.6), compared with seronegative men. Increased outpatient care was initiated at the earliest stages of HIV-1 infection, even when CD4+ cells were > 500/microliter. Dramatic increases in outpatient care for each level of immunosuppression were observed. HIV-1-related symptoms were associated with increased hospitalizations (OR = 4.8, 95% CL = 3.2, 7.3), use of outpatient medical services (OR = 3.3, 95% CL = 1.9, 5.6), and emergency room care (OR = 3.1, 95% CL = 2.1, 4.6). Persons with AIDS and < or = 50 CD4+ cells/microliter most likely to be hospitalized (OR = 8.1; 95% CL = 4.4, 14.9). No significant difference (p > 0.05) in emergency room use was observed according to HIV-1 serostatus, AIDS, or immunosuppression, after adjusting for insurance and clinical symptoms. To the extent that CD4+ cell counts are used as one of the criteria for an AIDS diagnosis and such a diagnosis broadens available benefits to persons with HIV disease, the pattern of health care services described here will be important for health care providers and planners.

Validation of a pneumonia prognostic index using the MedisGroups Comparative Hospital Database.

PURPOSE: Our purpose was to validate a previously developed pneumonia-specific prognostic index in a large, multicenter population. PATIENTS AND METHODS: We developed a pneumonia-specific prognostic index in a prospective, multicenter study of 346 patients with clinical and radiographic evidence of pneumonia admitted to 3 Pittsburgh hospitals (the derivation cohort), and validated the index in 14,199 patients with a principal ICD-9-CM diagnosis of pneumonia admitted to 78 hospitals in the 1989 MedisGroups Comparative Hospital Database (the validation cohort). The prognostic index classified patients into five ordered risk classes based on six predictors of mortality: age greater than 65 years, pleuritic chest pain, a vital sign abnormality, altered mental status, neoplastic disease, and high-risk pneumonia etiology. Each patient in the validation cohort was assigned to a risk class by obtaining values for the index's six predictors in the MedisGroups population. The performance of the prognostic index in the derivation and validation cohorts was assessed by comparing hospital mortality rates within each of the index's five prognostic risk classes. RESULTS: The hospital mortality rate was 13.0% in the derivation cohort, and 11.1% in the validation cohort (p = 0.26). The agreement in the risk class-specific mortality rates was striking with the exception of class V: in class I, mortality was 0% in the derivation cohort versus 1% in the validation cohort; in class II, 0% versus 1.1%; class III, 10.9% versus 8.6%; class IV, 21.8% versus 26.2%; and class V, 73.7% versus 37.7%. There were no statistically significant differences in mortality rates within the first four risk classes, which represented the vast majority of patients in the derivation (94%) as well as the validation (98%) cohorts. CONCLUSIONS: These data support the generalizability of a pneumonia-specific prognostic index. This index, which performs exceptionally well in classifying low-risk patients, may help physicians identify patients with community-acquired pneumonia who could safely be managed in the ambulatory setting, or if hospitalized, the patients that could be treated with abbreviated inpatient care.

Relation between length of hospital stay and costs of care for patients with community-acquired pneumonia.

PURPOSE: Patients with pneumonia often remain hospitalized after becoming clinically stable, without demonstrated benefits on outcome. The purposes of this study were to assess the relation between length of hospital stay and daily medical care costs and to estimate the potential cost savings associated with a reduced length of stay for patients with pneumonia. SUBJECTS AND METHODS: As part of a prospective study of adults hospitalized with community-acquired pneumonia at a community hospital and two university teaching hospitals, daily medical care costs were estimated by multiplying individual charges by department-specific cost-to-charge ratios obtained from each hospital's Medicare cost reports. RESULTS: The median total cost of hospitalization for all 982 inpatients was $5, 942, with a median daily cost of $836, including $491 (59%) for room and $345 (41%) for non-room costs. Average daily non-room costs were 282% greater on the first hospital day, 59% greater on the second day, and 19% greater on the third day than the average daily cost throughout the hospitalization (all P <0.05), and were 14% to 72% lower on the last 3 days of hospitalization. Average daily room costs remained relatively constant throughout the hospital stay, with the exception of the day of discharge. A projected mean savings of $680 was associated with a 1-day reduction in length of stay. CONCLUSIONS: Despite institutional differences in total costs, patterns of daily resource use throughout hospitalization were similar at all institutions. A 1-day reduction in length of stay might yield substantial cost-savings.

Variation in length of hospital stay in patients with community-acquired pneumonia: are shorter stays associated with worse medical outcomes?

PURPOSE: To assess the variation in length of stay for patients hospitalized with community-acquired pneumonia and to determine whether patients who are treated in hospitals with shorter mean stays have worse medical outcomes. SUBJECTS AND METHODS: We prospectively studied a cohort of 1,188 adult patients with community-acquired pneumonia who had been admitted to one community and three university teaching hospitals. We compared patients' mean length of stay, mortality, hospital readmission, return to usual activities, return to work, and pneumonia-related symptoms among the four study hospitals. All outcomes were adjusted for baseline differences in severity of illness and comorbidity. RESULTS: Adjusted interhospital differences in mean length of stay ranged from 0.9 to 2.3 days (P <0.001). When the risk of each medical outcome was compared between patients admitted to the hospital with the shortest length of stay and those admitted to longer stay hospitals, there were no differences in mortality [relative risk (RR) = 0.7; 95% CI, 0.3 to 1.7], hospital readmission (RR = 0.8; 95% CI, 0.5 to 1.2), return to usual activities (RR = 1.1; 95% CI, 0.9 to 1.3), or return to work (RR = 1.2; 95% CI, 0.8 to 2.0) during the first 14 days after discharge, or in the mean number of pneumonia-related symptoms 30 days after admission (P = 0.54). CONCLUSIONS: We observed substantial interhospital variation in the lengths of stay for patients hospitalized with community-acquired pneumonia. The finding that medical outcomes were similar in patients admitted to the hospital with the shortest length of stay and those admitted to hospitals with longer mean lengths of stay suggests that hospitals with longer stays may be able to reduce the mean duration of hospitalization for this disease without adversely affecting patient outcomes.

Variations in antimicrobial use and cost in more than 2,000 patients with community-acquired pneumonia.

PURPOSE: To assess the patterns of antimicrobial use, costs of antimicrobial therapy, and medical outcomes by institution in patients with community-acquired pneumonia. PATIENTS AND METHODS: The route, dose, and frequency of administration of all antimicrobial agents prescribed within 30 days of presentation were recorded for 927 outpatients and 1328 inpatients enrolled in the Pneumonia Patient Outcomes Research Team (PORT) multicenter, prospective cohort study. Total antimicrobial costs were estimated by summing drug costs, using average wholesale price for oral agents and institutional acquisition prices for parenteral agents, plus the costs associated with preparation and administration of parenteral therapy. Thirty-day outcome measures were mortality, subsequent hospitalization for outpatients, and hospital readmission for inpatients. RESULTS: Significant variation (P <0.05) in prescribing practices occurred for 17 of the 23 antimicrobial agents used in outpatients across 5 treatment sites, and for 18 of the 20 parenteral agents used in inpatients across 4 treatment sites. The median duration of antimicrobial therapy for treatment site ranged from 11 to 13 days for outpatients (P=0.01), and from 13 to 15 days for inpatients (P=0.49). The overall median cost of antimicrobial therapy was $12.90 for outpatients, and ranged from $10.80 to $58.90 among treatment sites (P <0.0001). The overall median cost of antimicrobial therapy was $228.70 for inpatients, and ranged from $183.70 to $315.60 among sites (P <0.0001). Mortality and hospital readmission for inpatients were not significantly different across sites after adjusting for baseline differences in patient demographic characteristics, comorbidity, and illness severity. Although subsequent hospitalization for outpatients differed by site, the rate was lowest for the site with the lowest antimicrobial costs. CONCLUSION: Variations in antimicrobial prescribing practices by treatment site exist for outpatients and inpatients with community-acquired pneumonia. Although variation in antimicrobial prescribing practices across institutions results in significant differences in antimicrobial costs, patients treated at institutions with the lowest antimicrobial costs do not demonstrate worse medical outcomes.

The impact of a Children's health insurance program by age.

OBJECTIVES: 1) To examine age variation in unmet need/delayed care, access, utilization, and restricted activities attributable to lack of health insurance in children before they receive health insurance; and 2) to examine the effect of health insurance on these indicators within each age group of children (in years). METHODS: We use cohort data on children before and after receiving health insurance. The study population consists of 750 children, 0 through 19 years of age, newly enrolling in two children's health programs. The families of the newly enrolled children were interviewed at the time of their enrollment (baseline), and again at 6 months and 1 year after enrollment. The dependent variables measured included access to regular provider, utilization, unmet need or delayed health care, and restrictions on activities attributable to health insurance status. All these indicator variables were examined by age groups (0-5, 6-10, 11-14, and 15-19 years of age). chi(2) tests were performed to determine whether these dependent variables varied by age at baseline. Using logistic regression, odds ratios were calculated for baseline indicators by age group of child, adjusting for variables commonly found to be associated with health insurance status and utilization. Changes in indicator variables from before to after receiving health insurance within each age group were documented and tested using the McNemar test. A comparison group of families of children enrolling newly 12 months later were interviewed to identify any potential effects of trend. RESULTS: All ages of children saw statistically significant improvements in access, reduced unmet/delayed care, dental utilization, and childhood activities. Before obtaining health insurance, older children, compared with younger children, were more likely to have had unmet/delayed care, to have not received health care, to have low access, and to have had activities limited by their parents. This pattern held for all types of care except dental care. Age effects were strong and independent of covariates. After being covered by health insurance, the majority of the delayed care, low utilization, low access, and limited activities in the older age groups (11-14 and 15-19 years) was eliminated. Thus, as levels of unmet need, delayed care, and limitations in activities approached zero in all age groups by 1 year after receipt of health insurance, age variation in these variables was eliminated. By contrast, age variation in utilization remained detectable yet greatly reduced. CONCLUSION: Health insurance will reduce unmet need, delayed care, and restricted childhood activities in all age groups. Health care professionals and policy makers also should be aware of the especially high health care delay, unmet need, and restricted activities experienced by uninsured older children. The new state children's health insurance programs offer the potential to eliminate these problems. Realization of this potential requires that enrollment criteria, outreach strategies, and delivery systems be effectively fashioned so that all ages of children are enrolled in health insurance.

Home oxygen therapy. A comparison of 2- vs 6-month patient reevaluation.

STUDY OBJECTIVE: To contrast the effectiveness of 2- vs 6-month reevaluation intervals on both clinical outcome and cost in patients requiring continuous home oxygen therapy (HOT). DESIGN: Prospective, randomized clinical trial. SETTING: The outpatient program of a university-affiliated Veterans Affairs Medical Center (VAMC) Pulmonary Service. PATIENTS: Fifty patients were chosen from among a cohort of 200 patients currently enrolled in our HOT program. All met specific arterial blood gas criteria, were able to give informed consent, had at least 6 months of prior HOT usage, and did not have any illness expected to independently shorten life expectancy. INTERVENTIONS: Baseline resting oxygen flow rates were prescribed based on the results of arterial blood gas measurements so as to attain a PaO2 > 60 mm Hg. Flow rates were adjusted as needed during a 12-min walk to maintain pulse oximetry readings > 90%. No adjustments in baseline flow rates were made during sleep. Identical evaluations were repeated at either 2- or 6-month intervals. MEASUREMENTS AND RESULTS: At 1-year follow-up, there were no significant differences between the 2- and 6-month groups in any of the clinical outcome parameters measured, ie, number of emergency department visits, number of hospitalizations, number of days hospitalized, or mortality. Total costs were not significantly different between the two groups. Evaluation costs were less in the 6-month follow-up group. CONCLUSIONS: After attaining stability following at least 6 months of continuous HOT usage, patients receiving continuous HOT need not be routinely reevaluated more frequently than every 6 months.

Measuring resource use in the ICU with computerized therapeutic intervention scoring system-based data.

BACKGROUND AND OBJECTIVE: In this era of health-care reform, there is increasing need to monitor and control health-care resource consumption. This requires the development of measurement tools that are practical, uniform, reproducible, and of sufficient detail to allow comparison among institutions, among select groups of patients, and among individual patients. We explored the feasibility of generating an index of resource use based on the Therapeutic Intervention Scoring System (TISS) from hospital electronic billing data. Such an index is potentially comparable across institutions, allows assessment of care at many levels, is well understood by clinicians, and captures many of the resources relevant to the ICU. DESIGN: We developed an automated mapping of the hospital billing database into the different items of TISS and generated computerized active TISS scores on 1,372 ICU days. The computerized score was then validated by comparison to prospectively gathered active TISS scores by trained data collectors. SETTING: Eight ICUs within a university teaching institution. PATIENTS: We studied 1,229 general medical and surgical ICU patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Active TISS scores ranged from 0 to 31 points. The two scores were well correlated (R2=0.53) and highly calibrated (as assessed by regression of active TISS on mean computerized active TISS [R2=0.85]). The scores were identical on 756 days (55.6%) and differed by < or = 3 TISS points on an additional 387 (28.2%) days. Interreliability assessment suggested substantial agreement (kappa statistic=0.71). The discriminatory power of the computerized score to identify different levels of ICU resource use was excellent as assessed by area under the receiver operating characteristics curves at four threshold points (0.91, 0.87, 0.89, and 0.88). Performance of the computerized score was similar across medical, coronary, and surgical ICU patient groups. CONCLUSION: An automated algorithm can reproduce valid TISS scores from standard hospital billing data, allowing comparison of patients and groups of patients in order to better understand ICU resource use.

Evaluation of outpatient geriatric assessment: a randomized multi-site trial.

OBJECTIVE: To evaluate the process and outcome of outpatient consultative geriatric assessment compared with traditional community care. DESIGN: Randomized, controlled clinical trial, with 12-month follow-up. SETTING: Four hospital-based ambulatory geriatric assessment clinics and community physicians' offices. PARTICIPANTS: 442 recruited older adults with a health problem or recent change in health status. INTERVENTION: Outpatient consultative geriatric assessment or usual physician assessment. MAIN OUTCOME MEASURES: Identification of health problems, mortality, nursing home admissions, health status, health services utilization, satisfaction with care, and caregiver well-being. RESULTS: Geriatric assessment, in comparison with usual community care, resulted in the identification of a significantly greater number of patients with cognitive impairment (P < .0001), depression (P = .0004) and incontinence (P < .0001). The group receiving a geriatric assessment had greater improvement in anxiety levels at 1 year (P = .036). Caregivers of participants in the geriatric assessment group had less caregiver stress at 1 year (P = .002). No outcome differences in mortality, nursing home admissions, cognitive health, functional health, or health services utilization were observed. Some evidence of greater patient satisfaction with respect to qualities of the physician was found for the geriatric assessment group. CONCLUSIONS: Consultative outpatient geriatric assessment led to significantly improved diagnosis of the common health problems of cognitive impairment, depression, and incontinence, to psychological and emotional benefits for patients, and to reduced levels of caregiver stress. Even with limited follow-up care and control of treatment, outpatient geriatric assessment has potential for significant positive effects.

Participation in health promotion programs by the rural elderly.

The Health Care Financing Administration (HCFA) funded a series of demonstration programs to learn about the implications of extending coverage for disease prevention/health promotion services to Medicare beneficiaries. This article examines the use of such services by a rural population under this demonstration program. Individuals enrolled in the demonstration were eligible for specific risk reduction interventions. They were enrolled in one of two groups: (1) a hospital-based group in which hospitals were paid a capitated fee for providing all services and (2) a physician-based group in which physicians were paid fee-for-service for providing each service. Chi-square tests of association as well as logistic regression models were used to assess whether eligibility for services, and use of services by those eligible, varied by group and by sociodemographic characteristics. Forty-one percent were eligible for a nutrition program, 11% for smoking cessation, 2% for alcohol counseling, and 7% for dementia/depression evaluations. Participation in the programs varied across the programs and within programs by gender, education, and group assignment. Older rural Americans will use some disease prevention/health promotion services if they are covered by Medicare. Use will be higher among those with more education. Rural beneficiaries are more likely to use preventive services if encouraged to do so by their doctors rather than by hospital-based programs.

The decision to seek an exemption from PPS.

This paper examines the receipt of exemptions from Medicare's Prospective Payment System (PPS) for distinct part psychiatric units of general hospitals. A logit model of the exemption status of 1,045 psychiatric units is estimated using 1984 data. The results suggest that units that were expected to profit from a change in payment method (cost based on PPS) were least likely to obtain an exemption from PPS.

Effect of the structure of hospital payment on length of stay.

In response to rapidly rising costs, payers for health care services have made a number of changes in the way they reimburse hospitals for care. In this article we study the effect of different payment methods on the length of stay of Medicaid patients. We examine supply response by type of patient (medical, surgical, and psychiatric) and hospital ownership. We find that per case payment systems and negotiated contracts lead to significant decreases in the length of stay for all groups. Prospective per diem with limits in most cases leads to decreases in the length of stay. In general, we find that the supply response is stronger for psychiatric patients than for medical and surgical patients, and that publicly owned hospitals are more responsive to payment system incentives than are nonpublic hospitals.

Evaluation of a health promotion demonstration program for the rural elderly.

OBJECTIVE: This article evaluates a demonstration program that extended coverage for disease prevention/health promotion services to Medicare beneficiaries. STUDY SETTING/DATA SOURCES: Community-dwelling Medicare beneficiaries who lived in five rural counties in northwest Pennsylvania were recruited between May and December 1989. The demonstration lasted 18 months and beneficiaries were followed for an additional 18 months. Data for the evaluation came from an initial health risk assessment, Medicare administrative records, follow-up surveys, and redeemed vouchers for the waivered services. The waivered services included health screenings, influenza immunization, nutritional counseling, smoking and alcohol cessation, and depression/dementia evaluations. STUDY DESIGN: Medicare beneficiaries were randomized to one of two experimental groups and a control group. One experimental group received the newly waived services from hospitals that received a capitated fee; the other received services from providers who were paid fee-for-service. Eligibility for most waivered services was based on risk. Chi-square tests of association were used to determine if use of health promotion services and use of medical care services varied across groups. Logistic regressions were used to assess the factors associated with participation. Product-limit survival analysis was used to assess whether mortality rates varied across groups. PRINCIPAL FINDINGS: Participation rates in the new programs varied by program and by experimental group, and ranged from 16.8 percent for smoking cessation programs to 58 percent for influenza immunization. The demonstration led to an increase in influenza immunization rates relative to the control group. There were no differences in the use of medical care services or health outcomes between the experimental and control groups. CONCLUSIONS: Older rural Americans will modestly increase their use of disease prevention/ health promotion services if they are covered by Medicare. Use will be higher among those with more education. Further research is needed to assess long-term benefits of such programs.