Specialty care and education associated with greater disease-specific knowledge but not satisfaction with care for chronic hepatitis C.

BACKGROUND: Little is known about differences among hepatitis C virus (HCV) patients managed by generalists vs. specialists with respect to patient-centred outcomes, such as disease-specific knowledge, health-related quality of life (HRQoL) and satisfaction with care. AIM: To examine selected patient-centred outcomes of HCV-related care provided in primary care, specialty care or both. METHODS: A total of 629 chronic HCV patients completed a survey including an HCV knowledge assessment and validated instruments for satisfaction and HRQoL. Multivariable linear regression was used to compare outcomes between groups. RESULTS: Adjusted total HCV knowledge score was lower among patients who did not attend specialty care (P < 0.01). Primary care and specialty patients did not differ in adjusted general HRQoL or satisfaction. Sixty percent of specialty patients underwent formal HCV education, which was associated with 5% higher knowledge score (P = 0.01). General HRQoL and patient satisfaction did not differ between primary care and specialty groups. Disease-specific knowledge and care satisfaction were independent of mental illness, substance abuse, socio-economic variables, history of antiviral treatment, formal HCV education and duration of time between last visit and survey completion. CONCLUSIONS: Primary care patients with chronic HCV have lower adjusted disease-specific knowledge than specialty patients, but no difference in general HRQoL or patient satisfaction.

Cost-effectiveness of growth factors during hepatitis C anti-viral therapy.

BACKGROUND: Although the current standard of care for controlling anaemia and neutropenia during anti-viral therapy for hepatitis C is to use dose reduction of ribavirin and pegylated interferon, respectively, erythropoietin and granulocyte colony-stimulating factor are now being advocated as alternatives to dose reduction. AIM: To determine the cost-effectiveness of erythropoietin and granulocyte colony-stimulating factor as an alternative to anti-viral dose reduction during antihepatitis C therapy. METHODS: Decision analysis was used to assess cost-effectiveness by estimating the cost of using a growth factor per quality-adjusted life-year gained. RESULTS: Under baseline assumptions, the cost per quality-adjusted life-year of using growth factors ranged from 16,247 US dollars for genotype 1 with neutropenia to 145,468 US dollars for genotype 2/3 patients with anaemia. These findings are sensitive to the relationship between dose reduction and sustained virological response. CONCLUSIONS: Based upon our findings and the varying strength of the evidence for a relationship between dose reduction and sustained virological response: granulocyte colony-stimulating factor may be cost-effective for genotype 1 patients; erythropoietin is probably not cost-effective for genotype 2/3 patients; no conclusion can be reached regarding the cost-effectiveness of erythropoietin for genotype 1 patients or granulocyte colony-stimulating factor for genotype 2/3 patients. Randomized trials are needed to firmly establish the relationship between dose reduction and sustained virological response.

Evaluation of a command-line parser-based order entry pathway for the Department of Veterans Affairs electronic patient record.

OBJECTIVE: To improve and simplify electronic order entry in an existing electronic patient record, the authors developed an alternative system for entering orders, which is based on a command- interface using robust and simple natural-language techniques. DESIGN: The authors conducted a randomized evaluation of the new entry pathway, measuring time to complete a standard set of orders, and users' satisfaction measured by questionnaire. A group of 16 physician volunteers from the staff of the Department of Veterans Affairs Puget Sound Health Care System-Seattle Division participated in the evaluation. RESULTS: Thirteen of the 16 physicians (81%) were able to enter medical orders more quickly using the natural-language-based entry system than the standard graphical user interface that uses menus and dialogs (mean time spared, 16.06 +/- 4.52 minutes; P=0.029). Compared with the graphical user interface, the command--based pathway was perceived as easier to learn (P<0.01), was considered easier to use and faster (P<0.01), and was rated better overall (P<0.05). CONCLUSION: Physicians found the command- interface easier to learn and faster to use than the usual menu-driven system. The major advantage of the system is that it combines an intuitive graphical user interface with the power and speed of a natural-language analyzer.

Improved outcomes associated with stenting in the healthcare cost and utilization project.

Recent results from Medicare indicated that both hospital mortality and the use of same admission coronary artery bypass graft (CABG) surgery were lower in patients receiving stents, and that stenting did not alter the finding of improved outcomes at high volume centers. The purpose of this report is to compare outcomes in a national sample of patients of all ages receiving stents with those undergoing conventional balloon angioplasty. A second purpose is to evaluate the volume outcome hypothesis. This study included 100,318 angioplasties from 191 hospitals in 19 states; 43,966 (44%) involved stent placement. The major outcomes of interest were same admission hospital death and same admission CABG surgery. In comparison to patients with conventional angioplasty, patients receiving stents were younger, less often female and nonwhite, and had less diabetes and hypertension. In the group without infarction, hospital mortality was lower in the stent group (0.7% vs 0.9%, P = 0.01), as was the use of same admission bypass surgery (1.4% vs 2.7%, P < 0.0001). The same pattern was true for myocardial infarction; hospital mortality (2.7% vs 4.2%, P < 0.0001) and bypass surgery rates (1.6% vs 5.3%, P < 0.0001) were lower in the stent group. These results persisted after adjustment for important predictors of outcome. In general, outcomes were better in high volume centers, although in the stent group, there was no clear relationship between volume and outcome. These results support earlier findings that hospital mortality and particularly same admission surgery rates are lower with stenting. Although the volume outcome association for stenting was less clear in this study than in Medicare, these results do not mean that the fundamental volume outcome relationship has been changed by stenting.

Outcomes of coronary angioplasty procedures performed in rural hospitals.

PURPOSE: To determine how many rural hospitals in the United States performed coronary angioplasty; to compare patient outcomes in rural and urban hospitals; and to assess whether outcomes were better in rural hospitals in which more procedures were performed. SUBJECTS AND METHODS: In 1996, among patients 65 years of age and older, 201,869 coronary angioplasties were performed in 996 hospitals that were included in the Medicare Provider Analysis and Review files. Geographic location was defined as rural or urban, according to U.S. Census Bureau criteria. Outcome variables were in-hospital death and coronary artery bypass surgery performed during the same admission. Hospital volumes were categorized as low (< or = 100 cases or fewer per year), medium (101 to 200 cases per year), or high (> 200 cases per year). RESULTS: Fifty-one rural hospitals accounted for 4% of all angioplasties performed. After angioplasty, in-hospital mortality was greater in rural hospitals (8.1% versus 6.4%, P = 0.001) among patients with acute myocardial infarction, but was not different for patients without infarction (1.4% versus 1.3%, P = 0.41). Coronary artery bypass surgery rates during the same admission were similar in rural and urban hospitals. In general, in-hospital mortality and same-admission surgery rates were lower in high-volume centers in both rural and urban areas. CONCLUSION: Although in-hospital mortality after angioplasty for acute myocardial infarction was worse in low- and medium-volume rural centers, overall outcomes in rural and urban hospitals were similar.

A randomized controlled trial of a clinic-based support staff intervention to increase the rate of fecal occult blood test ordering.

BACKGROUND: Colorectal cancer is the second most common fatal malignancy in the United States. Early detection using fecal occult blood tests has been shown to reduce mortality, but these tests are underutilized among those eligible for this screening. Attempts to increase use of fecal occult blood tests in eligible populations have focused on the provider, patient, or system. But none have examined whether a support-staff intervention is effective in achieving this aim. We therefore conducted a randomized controlled trial to test the impact of authorizing support staff to order fecal occult blood tests in a general internal medicine clinic organized into four teams. METHODS: A total of 1,109 patients were included in the study, 545 of whom were in the two teams randomized to treatment. Univariate and multivariate regression analyses were used to evaluate the impact of the intervention. RESULTS: The intervention resulted in significantly more fecal occult blood test ordering in the treatment group than in the control group for all patients (52% vs 15%, P < 0.001). Treatment fecal occult blood test cards were returned as frequently as the control cards for all patients (44% vs 48%, P = 0.571). CONCLUSION: Delegation of selected screening tasks to support staff can enhance patient access to preventive care.

Institutional volumes and coronary angioplasty outcomes before and after the introduction of stenting.

CONTEXT: An increasing number of patients undergoing percutaneous transluminal coronary angioplasty (PTCA) are receiving coronary stents. OBJECTIVES: To assess whether the introduction of coronary stenting has changed hospital mortality or same-admission coronary artery bypass grafting (CABG) and whether the hospital's procedure volume affects these outcomes. DESIGN: Observational study using hospital claims. SETTING: Nonfederal hospitals that performed PTCA in California in 1993 and 1996. PATIENTS: 35,350 patients who underwent PTCA in 1993 (before the introduction of stenting) and 43,040 patients who had PTCA in 1996 (43% of whom received stents). MEASUREMENTS: Hospital stenting volumes for 1996 were divided into terciles; total PTCA procedures per year were categorized as low (< or = 200), medium (201 to 400), or high (> 400). Outcome variables included hospital death and coronary artery bypass grafting (CABG) performed during the same admission. Patients with a principal diagnosis of acute myocardial infarction (AMI) were analyzed separately from those without such a diagnosis. RESULTS: From 1993 to 1996, the characteristics of patients undergoing PTCA did not change substantially. The use of same-admission CABG decreased by 13% (from 6.0% to 5.2%; P = 0.008) in the AMI group and by 30% (from 3.7% to 2.6%; P < 0.001) in the no-AMI group. Hospital mortality did not change significantly in either group. Procedure volume was not related to hospital mortality. However, rates of same-admission CABG were significantly lower at hospitals with high annual stenting volumes than at low-volume centers (1.3% vs. 2.3% among patients in the no-AMI group; P < 0.001). CONCLUSIONS: Hospital mortality rates after PTCA have not changed considerably since the introduction and diffusion of coronary stenting. However, rates of same-admission CABG have decreased in recent years and are lowest at hospitals with high procedure volumes.

Coronary artery stent outcomes in a Medicare population: less emergency bypass surgery and lower mortality rates in patients with stents.

BACKGROUND: Randomized trials of coronary stents versus conventional balloon angioplasty have demonstrated improved short- and long-term outcomes for selected patients receiving stents. The purpose of this study was to compare outcomes in patients receiving stents with those undergoing conventional balloon angioplasty in everyday clinical practice. METHODS AND RESULTS: This study uses information from the Medicare Provider Analysis and Review files for fiscal years 1994 and 1996, the first year the coronary stent code was used. For patients 65 years of age and older, 165,657 cases in 1994 and 201,869 in 1996, including 74,836 cases with stent placement, were identified. Outcomes included hospital deaths, use of same- admission coronary artery bypass surgery, and either or both. Analyses were performed separately for those with and those without a principal diagnosis of acute myocardial infarction. Hospital mortality rates were similar in both years, but the use of same-admission coronary artery bypass surgery was lower in 1996. In that year, for both patients with and those without acute myocardial infarction, hospital death and the use of same-admission coronary artery bypass surgery were lower in the stent group. Additionally, results in the stent group were generally better at high-volume (>200 cases per year) institutions, as was the case for the prestent, 1994 results. CONCLUSIONS: This study documents improved short-term outcomes in older patients who undergo coronary stent placement. Stenting did not eliminate the finding of improved outcomes at high-volume centers.

Predictors of rape in the Central African Republic.

This is a study of women in the Central African Republic (CAR) whose first sexual encounter was the result of rape. The analyses presented here are based on a national HIV/AIDS survey conducted in 1989. Respondents were selected through multistage cluster sampling, where census districts and households within districts were randomly selected. A total of 1307 females responded to the question regarding the circumstances of their first intercourse. Nearly 22% of female respondents reported that their first experience with intercourse was rape. Bivariate analyses found that rape during first intercourse was significantly related to the following respondent characteristics at the time of the survey: age, marital status, having a child, education, occupation, urban versus rural living, ethnic group, age at first date, and consumption of alcohol. Rape was not significantly related to ability to read, religion, and years in current village or town. Rape during first intercourse was found in a stepwise logistic regression to be related to age, marital status, occupation, and ethnic group. These data indicate that the incidence of rape is higher than previously reported in Africa, there are specific risk factors, and there are serious negative consequences.

When should this patient be seen again?

CONTEXT: The decision about when to ask a patient to return to the clinic for his or her next visit is common to all outpatient encounters in longitudinal care. It directly affects provider workloads and has a potentially great impact on health care costs and outcomes. GENERAL QUESTION: What are the effects of lengthening or shortening revisit intervals (the recommended period between one visit and the next) on health status and health care costs? SPECIFIC RESEARCH CHALLENGE: How can we change the average revisit interval while preserving provider input for individual patients? PROPOSED APPROACH: Patients could be randomly assigned to either short or long revisit intervals. So that provider input would be preserved, providers would select from among three discrete categories of revisit intervals: near-term (1 to 2 months); intermediate-term (2 to 4 months); and long-term (4 to 8 months). On the basis of randomization, patients would receive appointments at either the lower or the upper bound of the category selected. POTENTIAL DIFFICULTIES: Because blinding would be almost impossible, providers might "game" randomization at subsequent visits. ALTERNATE APPROACHES: A comparison of shorter and longer revisit intervals might be achieved with less direct approaches. In one such approach, patients would be randomly assigned to 1) having an appointment made immediately after the initial visit or 2) calling back for an appointment according to the interval recommended by the provider. In another approach, patient panel size would be held constant and providers would be randomly assigned to either an increased or a reduced number of clinic sessions.

Cost as a study outcome: sensitivity of study conclusions to the method of estimating cost.

OBJECTIVES: The analyses presented here are intended to provide empirical guidance to two questions faced by researchers performing clinical trials which include a cost component: Which health care services should we track? Should we use facility specific costs or national average costs for individual services in estimating total costs? METHODS: We reanalyzed cost data from the Department of Veterans Affairs (VA) multisite clinical trial which compared Adult Day Health Care (ADHC) to Customary Care for patients at high risk for nursing home care. The data presented here compares the original analysis (a combination of local and national costs) to an analysis based on purely facility-specific costs and to an analysis based upon purely VA national costs. Costs for hospital, clinic, nursing home, ADHC, hospital based home care, rehabilitation, pharmacy, and laboratory were included. RESULTS: Hospital, nursing home, clinic, and ADHC in combination account for 98% of the variation in total cost per patient. Including only hospital, clinic, nursing home, ADHC, and hospital-based home care in total cost per patient closely replicated the findings for total cost when all services were included. The originally reported analysis and the 2 new analyses, using respectively facility specific costs and national average costs, did differ substantially in the magnitude of the difference between the total cost per patient of ADHC and Customary Care. They did differ with regard to statistical significance as the P values were either slightly above or below 0.05. CONCLUSIONS: Ideally all health care costs should be included in the analysis. When this is not feasible, one should determine utilization and cost for the intervention itself, costly services (usually hospital, nursing home, and clinic care), and lower cost services that are likely to be affected by the intervention. Sensitivity analysis should be performed to determine if different methods of costing (eg, facility specific versus national costs) materially affect the conclusions of the study.

The role of patients and providers in the timing of follow-up visits. Telephone Care Study Group.

OBJECTIVE: Although the decision about how frequently to see outpatients has a direct impact on a provider's workload and may impact health care costs, revisit intervals have rarely been a topic of investigation. To begin to understand what factors are correlated with this decision, we examined baseline data from a Department of Veterans Affairs (VA) Cooperative Study designed to evaluate telephone care. DESIGN: Observational study based on extensive patient data collected during enrollment into the randomized trial. Providers were required to recommend a revisit interval (e.g., "return visit in 3 months") for each patient before randomization, under the assumption that the patient would be receiving clinic visits as usual. POPULATION/SETTING: Five hundred seventy-one patients over age 55 cared for by one of the 30 providers working in three VA general medical clinics. Patients for whom immediate follow-up (

Association between percutaneous transluminal coronary angioplasty volumes and outcomes in the Healthcare Cost and Utilization Project 1993-1994.

Studies from a variety of settings have indicated that outcomes for coronary angioplasty are improved when performed in institutions with high caseloads (> 400/year). The purpose of this investigation was to examine the volume outcome hypothesis for coronary angioplasty in a 20% stratified sample of acute care, non-federal hospitals in 17 states. Data were derived from the Nationwide Inpatient Sample from the Health Care Cost and Utilization Project releases 2 and 3. From these records, 163,527 angioplasties from 214 hospitals were selected. Outcomes included hospital mortality, same-admission coronary artery bypass surgery, and a combined end point of either death or same-admission surgery, or both. Hospital volumes were defined as low (< or = 200 cases/year), medium (201 to 400), and high (> 400). Analyses were conducted separately for patients with and without a principal discharge diagnosis of acute myocardial infarction (AMI). For both AMI and no-AMI groups, the rates of adverse outcomes were generally lower in high-volume institutions, and this finding was true in both univariate and multivariate analyses. Although 27% of hospitals were in the low-volume category, only 5% of all procedures were performed in these institutions. Projecting to all United States hospitals for the 2 years, if all procedures performed in low-volume centers had been done in high-volume institutions, 137 deaths could have been averted (90 AMIs, 47 no-AMIs) as well as 404 (46 AMIs, 358 no-AMIs) same-admission surgeries. The results of this study support the hypothesis that better results are obtained in higher volume institutions, but also show that in 1993 and 1994, relatively few patients had their procedures performed in low-volume institutions.

Physician participation in research surveys. A randomized study of inducements to return mailed research questionnaires.

The authors randomly selected 400 physicians from a population of 1,545 practicing physicians providing follow-up care to patients who received bone marrow or blood stem cell transplants at the Fred Hutchinson Cancer Research Center to determine interest in receiving Internet-based transplant information. In a two-factor completely randomized factorial design, the 400 physicians were assigned to receive mailed surveys with either no compensation or a $5 check and either no follow-up call or a follow-up call 3 weeks after mailing. Overall, 51.5% of the physicians returned the mailed surveys. Comparison of logit models showed that inclusion of a $5 check in the mailer significantly (p = .016) increased the probability of returning the surveys (57.5% vs. 45.5%). In contrast, the telephone follow-up had no overall effect. The authors concluded a modest financial reward can significantly improve physician response rates to research surveys but a telephone follow-up may be inefficient and even ineffective.

Prevalence and predictors of sexual dysfunction in long-term survivors of marrow transplantation.

PURPOSE: To describe the prevalence of sexual difficulties in men and women after marrow transplantation (MT), and to define medical, demographic, sexual, and psychologic predictors of sexual dysfunction 3 years after MT. PATIENTS AND METHODS: Four hundred seven adult MT patients were assessed pretransplantation. Survivors repeated measures of psychologic and sexual functioning at 1 and 3 years posttransplantation. RESULTS: Data were analyzed from 102 event-free 3-year survivors who defined themselves as sexually active. Men and women did not differ in sexual satisfaction pretransplantation. At 1 and 3 years posttransplantation, women reported significantly more sexual dysfunction than men. Eighty percent of women and 29% of men reported at least one sexual problem by 3 years after MT. No pretransplantation variables were significant predictors of 3-year sexual satisfaction for women. For men, pretransplantation variables of older age, poorer psychologic function, not being married, and lower sexual satisfaction predicted sexual dissatisfaction at 3 years (R2=.28; P < .001). Women who were more dissatisfied 3 years after MT did not receive hormone replacement therapy (HRT) at 1 -year posttransplantation and were less satisfied at 1 year, but not pretransplantation (R2=.35; P < .001). CONCLUSION: Sexual problems are significant in the lives of MT survivors, particularly for women. Although HRT before 1 year posttransplantation improves sexual function, it does not ensure sexual quality of life. Intervention for women is needed to apply hormonal, mechanical, and behavioral methods to prevent sexual difficulties as early after transplantation as possible.

A comparison of percutaneous transluminal coronary angioplasty in the Department of Veterans Affairs and in the private sector in the State of Washington.

Coronary angioplasty is performed > 1,000 times daily in a variety of health care settings in the public and private sectors in the USA. How outcomes for this procedure differ in the Department of Veterans Affairs and the private sector is unknown. The purpose of this study was to compare outcomes of coronary angioplasty performed in hospitals in the Department of Veterans Affairs and the State of Washington. This study used administrative data from the Department of Veterans Affairs patient treatment file (n = 8,326) and the State of Washington episode of illness file (n = 6,666) and included men who underwent coronary angioplasty in 1993 and 1994. Outcomes included (1) in-hospital mortality and mortality at 10 and 30 days after hospital admission, and (2) the use of coronary artery bypass surgery at similar intervals. Patients with a principal diagnosis of acute myocardial infarction were analyzed separately. Men in the Department of Veterans Affairs had more comorbid conditions than their counterparts in Washington State, and the length of hospital stay was longer in the former group. After using logistic regression to adjust for patient differences, mortality rates for the 2 groups of patients with acute myocardial infarction were similar, although bypass surgery was used more frequently in patients in Washington State. For patients without myocardial infarction, hospital and 10-day mortality did not differ with respect to health care system, and the use of bypass surgery subsequent to angioplasty was similar. In the Department of Veterans Affairs, most hospitals had low institutional caseloads (< 150 procedures per year), whereas > 40% of Washington State hospitals performed > or = 300 procedures per year. Although there were greatly differing institutional caseloads, mortality and the need for early bypass surgery were similar in the 2 systems.

Coronary angioplasty outcomes in the Healthcare Cost and Utilization Project, 1993-1994.

It is estimated that >400,000 percutaneous transluminal coronary angioplasty (PTCA) procedures are performed in the Unites States annually. This study reports patient characteristics and outcomes for 163,527 PTCAs performed in 214 hospitals in 17 states from 1993 to 1994. These hospitals were a 20% random sample of hospitals in the Healthcare Cost and Utilization Project, which was designed to reflect hospitalization in the United States, generally. Cases with International Classification of Diseases, 9th Revision, Clinical Modification procedure codes 36.01, 36.02, and 36.05 were defined as PTCA and were categorized as to whether acute myocardial infarction (AMI) was the principal discharge diagnosis. The average age of 44,270 AMI discharges (27%) was 62 +/- 12 years and that of 119,257 no-AMI cases (73%) was 64 +/- 11 years; 1/3 of both groups were women, 88% were white, and almost 90% had Medicare or private insurance as the primary payer. The states contributing the most cases were Florida (26%), California (12%), and Wisconsin (10%). Hospital mortality was 1.7% overall and was 3.8% for AMI and 0.8% for no-AMI cases. Bypass surgery performed during the same admission was 3.4% overall and was 4.5% and 3.0% for AMI and no-AMI cases, respectively. Multivariate analysis showed that advanced age, diabetes, female gender, and Medicaid payer status were associated with increased risk of mortality. National estimates from this 20% sample indicate that >850,000 PTCAs were performed in the 2 years, with 452,319 cases estimated for 1994. In 1994 there were an estimated 2,789 deaths and 9,903 bypass surgeries in the no-AMI subset of 327,856 procedures. For the AMI group of 124,463 procedures, there were 4,486 deaths and 5,799 bypass surgeries in 1994. This study of PTCA outcomes contains the largest number of cases as well as the most representative sample reported to date.

CARE-PARTNER: a computerized knowledge-support system for stem-cell post-transplant long-term follow-up on the World-Wide-Web.

Evidence-based practice in medicine promotes the performance of medicine based upon proven and validated practice. The CARE-PARTNER system presented here is a computerized knowledge-support system for stem-cell post-transplant long-term follow-up (LTFU) care on the WWW, which means that it monitors the quality of the knowledge both of its own knowledge-base and of its users. Its aim is to support the evidence-based practice of the LTFU clinicians and of the home-town physicians who actually care for the transplanted patients. Currently, three fundamental characteristics of CARE-PARTNER are accountable for its knowledge-support function: the quality of its knowledge-base, its availability on the WWW, and its learning from experience capability. As a matter of fact, the integration of a case-based reasoner in the reasoning framework enables the system to introspectively study its results, and to learn from its successes and failures, thus confronting the quality of the guidelines and pathways it reuses to the reality and complexity of the clinical cases.

Evaluation of an AIDS training program for traditional healers in the Central African Republic.

Training designed to improve AIDS knowledge, attitude, and practice was delivered to 96 traditional healers in the Central African Republic. The training (17 to 36 hours) was conducted by traditional healers with the assistance of staff from the Ministry of Health. Training included the following topics: prevention of HIV transmission during traditional practice; diagnosis, treatment, and prevention of sexually transmitted diseases; condom promotion; AIDS education at the community level; psychosocial support for people with AIDS; and promotion of a positive image for traditional healers. The evaluation of the training consisted of a prospective assessment of knowledge and attitude immediately prior to and after training. These assessments were conducted using structured interviews. Improvement in knowledge and/or attitudes was observed in all areas assessed except for prevention of HIV transmission during traditional practice. We concluded that AIDS training can be successfully delivered to traditional healers.