Longitudinal DRG-based survey of all-cause and pneumococcal pneumonia and meningitis for inpatients in France (2005-2010).

OBJECTIVE: This population-based retrospective study quantified the burden of all-cause and pneumococcal pneumonia and meningitis in the Rhône-Alpes region of France from 2005 to 2010, when the 7-valent pneumococcal conjugate vaccine uptake increased from 50 to>90% in children. PATIENTS AND METHODS: Hospital admission data was obtained from the French Diagnosis Related Groups program database (French acronym PMSI). Patients were residents of the Rhône-Alpes region hospitalized for the diseases of interest during 2005-2010. Hospitalization and in-hospital mortality rates were calculated by age, sex, and year on the basis of the Rhône-Alpes region population. Hospitalization and in-hospital mortality rates were compared using Chi(2) tests with statistical significance adjusted for multiple comparisons. RESULTS: The highest hospitalization rates by age group were: all-cause pneumonia, oldest group (>65 years); all-cause and pneumococcal meningitis, youngest group (0-4 years), and pneumococcal pneumonia, youngest and oldest groups. Hospitalization rates significantly decreased for all-cause pneumonia (5-19 years: -12.71%) and all-cause meningitis (20-49 years: -29.22%). Pneumococcal disease rates did not significantly change in any age group. Mortality rates from all-cause pneumonia and meningitis were highest in the oldest age groups. CONCLUSIONS: The burden of all-cause and pneumococcal pneumonia and meningitis remains substantial. Significant changes (decreases) between 2005 and 2010 in hospitalization rates were limited and varied among age groups, most likely because this study began 2 years after PCV7 was first introduced in France for children at broadly-defined high risk. Further research is needed on the relationship between serotype epidemiology and clinical patterns of disease.

Factors associated with the initiation of alpha-interferon treatment in Medicaid patients diagnosed with hepatitis C.

We aimed to determine rates of treatment with alpha-interferon medication in patients diagnosed with hepatitis C virus (HCV), to ascertain the prevalence of selected conditions that could influence initiation of interferon treatment, and to examine the association between the presence of these conditions and interferon treatment. A nested case-control design was used in California Medicaid (Medi-Cal) claims data covering the period from 1 January 1996 to 30 June 2002. Interferon-treated cases and non-treated controls were selected in a 1 : 2 ratio that matched the length of the observation period and year of index HCV diagnosis. Predictor variables examined in bivariate and multivariate analyses included demographics, substance abuse and dependence, psychotropic drug use, selected chronic conditions and medical utilization. The proportion of eligible subjects diagnosed with HCV and treated with interferon ranged from 10.7 to 13.9%. There were 529 treated cases that met the eligibility criteria and 1058 non-treated HCV patients selected as controls. Multivariate factors that increased the likelihood of treatment were a liver biopsy, a diagnosis of mild liver disease, a diagnosis of psoriasis, antidepressant use and classification of race/ethnicity as 'other'. A decreased likelihood of treatment was linked to age > or =65 years, a diagnosis of kidney disease, one to four emergency visits and five or more emergency visits. The proportion of patients receiving interferon treatment in the Medi-Cal-insured population was low compared with published rates in HCV patients in other general medical settings. The diverse factors linked to initiation of HCV therapy raise compelling questions for further research.

The use of proxy respondents in studies of older adults: lessons, challenges, and opportunities.

OBJECTIVE: Proxies play a critical role as sources of health information for older persons with cognitive impairment and other chronic debilitating conditions. This paper reviews the validity of proxy responses for people older than age 60 in the following areas: functioning, physical and mental health, cognition, medical care utilization, and preferences for types of care and health states. DESIGN: A Medline review identified 24 clinical studies from 1990 to 1999 that use proxy data as a source of information about older adults. RESULTS: In general, studies report fairly good agreement between subjects and proxies in assessments of functioning, physical health, and cognitive status, and fair-to-poor agreement in assessments of psychological well-being. Proxies tend to describe more impairment in functioning and emotional well-being, relative to subjects, a pattern that is particularly marked among persons with cognitive impairment. In addition, proxies who report more caregiver responsibilities and subjective stress from caregiver duties provide more negative assessments of subjects' health and well-being. CONCLUSIONS: Findings tend to support the use of proxy ratings among older adults in many areas but not all when self-reports are not feasible. There is a need for more evaluation of proxy data in relation to other measures, such as performance assessments, medical records, and claims data, which may be less subject to respondent biases.

Impact of donepezil on caregiving burden for patients with Alzheimer's disease.

Comprehensive Alzheimer's disease (AD) treatment should address caregiver well-being. We predicted that caregiver burden would be lower among caregivers of AD patients who received donepezil relative to caregivers of patients not treated with donepezil. A self-administered, nationwide survey of AD caregivers was used to match caregivers of patients treated with donepezil (n = 274) to caregivers of patients not treated with donepezil (n = 274). The Caregiver Burden Scale measured time demands and distress linked to commonly performed caregiving tasks. Respondents were three-quarters female, with an average age of 60 years. Results demonstrated that donepezil caregivers reported significantly lower scores on difficulty of caregiving. This difference remained when statistical controls for multiple patient and caregiver variables were imposed. However, selection factors must be recognized as a possible explanation for differences. The groups reported no difference on the time-demand subscale. In conclusion, better management of AD symptoms through donepezil treatment may reduce the burden of caregiving, providing physicians with a pharmacologic approach to improving quality of life for AD patients and their families.

Patterns of care in the early stages of Alzheimer's disease: impediments to timely diagnosis.

OBJECTIVE: Description of factors associated with delay in diagnosis of Alzheimer's disease (AD). DESIGN: A self-administered mail questionnaire. SETTING: Households including someone with AD identified through a nationwide marketing database. PARTICIPANTS: A total of 1480 caregivers of patients diagnosed with AD. MEASUREMENTS: There were two measures of delay examined through caregiver reports: (1) duration in years from first AD signs until determination of a definite problem, and (2) duration from problem recognition to first physician consultation. Also, caregivers were categorized by time since patient's diagnosis and relationship to patient. Within-group analyses examined the impact of these characteristics on delay measures. RESULTS: Mean lag in years from observation of first symptoms to problem recognition for those diagnosed in the past 12 months, the past 13 to 48 months, and the past 49 months or more was, respectively, 1.20, 1.56, and 2.25 (P < .001). The timing of diagnosis also influenced lag from problem recognition to first physician consultation so that subgroups with recent, less recent, and distant diagnosis reported delays in years of .82, .84, and 1.31 (P < .001). Caregiver relationship was not significantly related to these lags. Correct diagnosis of AD was reported by caregivers in only 38% of cases at initial physician consultation. CONCLUSIONS: These results suggest that both caregivers and physicians lack ready understanding of the difference between memory processes in aging and AD. Ongoing public and professional education is needed to convey the basics of the diagnosis of AD. In addition, routine screening for dementia should be considered to surmount attitudinal and logistical barriers.

Cost of Alzheimer's disease and related dementia in managed-medicare.

BACKGROUND: Managed care organizations (MCOs) will have increased responsibility for the care of large numbers of persons with dementia. There are, however, few studies that inform about decisions of healthcare utilization and expenditures for individuals with dementia in managed care. OBJECTIVES: To examine in a large MCO whether people diagnosed with dementia have higher healthcare utilization and costs than enrollees without dementia. DESIGN: A retrospective study of medical and prescription claims. SETTING: An MCO covering more than 80,000 Medicare enrollees in four geographical locales between January 1, 1996, and March 31, 1998. SUBJECTS: There were 677 paired cases with and without dementia. Controls were selected randomly and matched to cases on age, gender, and region. MEASUREMENTS: Summed total costs and number of claims accrued during the study period, as well as a breakdown of costs and claims with respect to place of service, were annualized and adjusted for age, gender, and comorbid conditions. Costs and claims were broken down by place of service. RESULTS: Dementia prevalence was 0.83%. Mean total costs were 1.5 times higher for patients with dementia relative to controls ($13,487 vs $9,276, P < .001) when annualized and adjusted for level of comorbidity. Almost 75% of the higher costs among cases were linked to inpatient expenses. CONCLUSIONS: Higher costs for individuals with dementia and disproportionate inpatient costs in this MCO parallel patterns among Medicare enrollees in fee-for-service. The high prevalence of dementia among the oldest old coupled with the high costs of dementia care create very significant clinical and financial incentives for managed care plans to improve the care of members suffering from dementia.

Donepezil use in managed Medicare: effect on health care costs and utilization.

Donepezil is one of the first effective and well-tolerated medications approved for the treatment of Alzheimer's disease (AD). This study examined the impact of donepezil on the costs of AD in a multisite managed care organization between January 1, 1996, and March 31, 1998. A pretreatment/posttreatment study was conducted using retrospective medical and prescription claims data for 70 individuals with AD and related dementias who were prescribed donepezil. The outcomes of interest were costs during the pretreatment and posttreatment phases, which were categorized as medical, prescription, and combined costs. Per diem costs were adjusted for differences in the duration of follow-up. We found that median per diem medical costs were $1.22 lower in the posttreatment phase than in the pretreatment phase (P = 0.02). Moreover, posttreatment costs were reduced in 6 of 7 service settings, with median per diem savings of $0.77 in outpatient care (P = 0.002) and $0.65 in office visits (P < 0.001). In the posttreatment phase, the median per diem costs for prescriptions and all claims combined were higher by $2.59 (P < 0.001) and $2.11 (P = 0.04), respectively. Donepezil treatment was associated with a decrease in medical costs, particularly in the outpatient components of health care. However, overall costs were increased due to the higher costs of medication. Further pharmacoeconomic studies are needed to determine the exact impact of acetylcholinesterase-inhibitor therapy on the overall costs of care for individuals with dementia.

Is diagnosis relevant in the hospitalization of potentially dangerous children and adolescents?

OBJECTIVE: This study tests the assumption that psychiatric diagnosis facilitates clinical evaluations of need in emergency care before and after controlling for danger. METHOD: The data are from structured crisis assessments completed by emergency clinicians in four ethnically diverse locales (N = 653). Clinician-assigned diagnosis was categorized as adjustment, disruptive, mood, psychotic, and other, and a Danger scale score reflected danger to self or others. RESULTS: Mood and psychotic disorders significantly increased hospital rates in multivariate analyses which controlled for demographic characteristics, site, and danger when relevant. The model with the best fit included both diagnosis and danger. CONCLUSIONS: Decisions should be linked to verifiable ratings of need and attention to danger, and its measurement should complement the current focus on diagnosis.

Death rates among patients hospitalized with community-acquired pneumonia: a reexamination with data from three states.

OBJECTIVES: Death rates for community-acquired pneumonia based on relatively small-scale, published studies tend to exceed 15% to 20%. This study reexamined these estimates by using very large, population-based databases. METHODS: Death rates from 1993 associated with community-acquired pneumonia were reexamined with hospital discharge data from all of Washington, Illinois, and Florida. RESULTS: These death rates were substantially lower (7.0%, 8.1%, and 9.7%, respectively) than what appears in the literature. Significant risk factors for dying were being 65 years of age or older (odds ratio [OR] = 2.9), being positive for human immunodeficiency virus (OR = 2.9), and having a high severity of illness (OR = 7.1). CONCLUSION: Sampling bias associated with selection for hospital admissions explain the discrepancy between previous and this study's results.

Determinants for hospitalization from an emergency mental health service.

There has been limited systematic study of determinants of acute psychiatric hospitalization of children and adolescents. This study reviewed the records of children and adolescents who received emergency mental health services in one New Jersey county during 6 months of 1990 (N = 226). Using a structured form to abstract data, information was obtained on demographics, precipitating problems, past mental health services, substance use, family problems, and disposition. While suicidal behavior was not a predictor of acute hospitalization, the interaction of assaultive and suicidal behavior was predictive. Other contributory factors identified in the multivariate analysis included: child's substance use, family member's substance use, and initial emergency screening site. Recognition of present utilization patterns will facilitate the development of intensive community-based options for those with acute mental health problems.

Acute health effects among firefighters exposed to a polyvinyl chloride (PVC) fire.

Firefighters are frequently being called on to fight fires that are chemical in nature. In the aftermath of a chemical fire in Plainfield, New Jersey on March 20-21, 1985, the authors conducted a retrospective cohort study which surveyed 80 firefighters exposed to burning polyvinyl chloride (PVC) as well as 15 nonexposed firefighter subjects. By means of an 81-item symptom checklist, exposed firefighters reported more frequent and severe symptoms at 5-6 weeks post incident. This was true for a total symptomatology score as well as 19 individual items. Some of the items with an elevated risk were consistent with exposure to hydrogen chloride, the main pyrolysis product of polyvinyl chloride. Other items with an elevated risk appeared to be related to smoke inhalation while others seemed psychosocial in nature. Analyses conducted within the exposed firefighter group showed that fighting the fire the first day, being a truckman, and residence within 1 mile (1.6 km) of the firehouse were significant risk factors for high total symptom scores. These risk factors may have been associated with level or duration of exposure to the toxic substances produced during the fire.

Psychological response of firefighters to a chemical fire.

Samples of firefighter subjects (n = 80) and a comparison group (n = 15) were contrasted on a number of postincident psychological distress measures in the aftermath of a polyvinyl chloride (PVC) fire. Using a structured, self-administered questionnaire, firefighter subjects were found to be more psychologically distressed on demoralization, specific emotional distress, and perceived threat to physical health. After controlling for baseline characteristics on which subjects and the comparison group differed, these between-group effects remained significant. The three outcome scales, while correlated, measure different components of psychological distress.

Self-reported physical and psychological effects following a malathion pesticide incident.

To assess effects attributed to malathion which escaped from an overheated tank at a chemical plant in Linden, New Jersey, researchers surveyed seamen subjects (n = 22) on board a nearby tanker and seamen control subjects (n = 21). Self-report measurement strategies included a medical review of body systems, the "demoralization" scale reflecting psychological symptoms of distress, demographics, and factors that may buffer stress, specifically, social support and knowledge regarding toxic chemicals. Self-reported postincident physical health differences between the two groups of seamen were noted. There were no differences between subjects and control subjects on demoralization levels. Further analysis indicated higher levels of demoralization among less knowledgeable seamen subjects.

Vulnerability to stress among women with in utero diethylstilbestrol (DES) exposed daughters.

In utero exposure to diethylstilbestrol (DES) was initially linked to vaginal-cervical cancer and subsequently to reproductive difficulties. These unanticipated and ongoing health risks to female offspring may constitute a chronic source of stress for DES mothers. We interviewed 60 mothers of exposed daughters and 30 acquaintance controls. Two hypotheses were tested in regard to DES mothers: DES discovery and its aftermath have a direct, long-term, negative effect on psychological health and the DES experience intensifies the negative psychological effects of other adverse life circumstances. To operationalize psychological health, we measured symptoms of "demoralization" and positive health practices--the latter as a behavioral indicator of mastery and personal control. We also measured adversities that may mediate the threat posed by DES, including stressful events, medical problems, and chronic burdens. We found DES history to be associated with poorer psychological health only when mothers encountered other losses and threats to themselves and their families. We concluded that DES mothers may manifest increased vulnerability to subsequent stresses in their lives.