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1.
Lupus Sci Med ; 7(1)2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-33051264

RESUMO

OBJECTIVE: Long-term extension (LTE) studies of belimumab in SLE do not include a comparator arm, preventing comparisons between belimumab plus standard therapy and standard therapy alone for organ damage accrual. Propensity score matching can be used to match belimumab-treated patients from LTE studies with standard therapy-treated patients from observational cohort studies. This analysis was designed to compare organ damage progression between treatment groups (belimumab plus standard therapy vs standard therapy alone) in patients with SLE with ≥5 years of follow-up, reproducing our previous study with more generalisable data. METHODS: This exploratory post hoc analysis used a heterogeneous population of US and non-US patients receiving monthly intravenous belimumab from pooled BLISS LTE trials (BEL112234/NCT00712933) and standard therapy-treated patients from the Toronto Lupus Cohort. Sixteen clinical variables were selected to calculate the propensity score. RESULTS: The 592 LTE and 381 Toronto Lupus Cohort patients were highly dissimilar across the 16 variables; an adequately balanced sample of 181 LTE and 181 matched Toronto Lupus Cohort patients (mean bias=3.7%) was created using propensity score matching. Belimumab treatment was associated with a smaller increase in Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) over 5 years than standard therapy alone (mean treatment difference=-0.453 (95% CI -0.646 to -0.260); p<0.001). Patients treated with belimumab were 60% less likely to progress to a higher SDI score over any given year of follow-up, compared with standard therapy alone (HR (95% CI) 0.397 (0.275 to 0.572); p<0.001). CONCLUSION: Using propensity score matching, this highly heterogeneous sample was sufficiently matched to the Toronto Lupus Cohort, suggesting that patients treated with intravenous belimumab may have reduced organ damage progression versus standard therapy alone. This analysis of a large and diverse pooled SLE population was consistent with our previously published US-focused study.

2.
Med Care ; 58(2): 137-145, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31651740

RESUMO

BACKGROUND: Research on frequent emergency department (ED) use shows that a subgroup of patients visits multiple EDs. This study characterizes these individuals. OBJECTIVE: The objective of this study was to determine how many frequent ED users seek care at multiple EDs and to identify sociodemographic, clinical, and contextual factors associated with such behavior. RESEARCH DESIGN: We used the 2011-2014 Healthcare Cost and Utilization Project State Emergency Department Databases data on all outpatient ED visits in New York, Massachusetts, and Florida. We studied all adult ED users with ≥5 visits in a year and defined multisite use as visits to ≥3 different sites. We estimated predictors of multisite use with multivariate logistic regressions. RESULTS: Across all 3 states, 1,033,626 frequent users accounted for 7,613,077 ED visits. Of frequent users, 25% were multisite users, accounting for 30% of the visits studied. Frequent users with at least 1 visit for mental health or substance use-related diagnosis were more likely to use multiple sites. Uninsured frequent users and those with public insurance were associated with less use of multiple EDs than those with private coverage while lacking consistent coverage by the same insurance within each year were associated with using multiple sites. CONCLUSIONS: Health policy interventions to reduce duplicative or unnecessary ED use should apply a population health perspective and engage multiple hospitals. Community-level preventive approaches and a stronger infrastructure for mental health and substance use are essential to mitigate multisite ED use.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Adolescente , Adulto , Distribuição por Idade , Idoso , Grupos de Populações Continentais/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Serviços de Saúde Mental/estatística & dados numéricos , Pessoa de Meia-Idade , Distribuição por Sexo , Transtornos Relacionados ao Uso de Substâncias/terapia , Estados Unidos , Adulto Jovem
3.
Popul Health Manag ; 23(1): 59-67, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31107162

RESUMO

Care coordination is an increasingly popular strategy to help patients with complex health conditions manage their diseases more effectively. The purpose of the current study was to assess associations between patient-reported receipt of care coordination and their experiences of health, health care quality, and cost-related outcomes. Regression analyses of data from 431 patients across 13 Texas providers indicate that patients who reported receiving care coordination had higher odds of perceiving having enough information about how to manage their conditions (OR 2.02, P < .01), having information about education and treatments available (OR 1.87, P < .01), and reporting better access to care (beta = .27, P < .01). Receipt of care coordination was not associated with patients' reports of how up-to-date their doctors were about care from other providers, patients' health-related functioning, or patients' intention to return to the emergency department. Patients' reasons for intending to return to the emergency department included the speed of care there relative to alternatives and satisfaction with the quality of care they had received previously in the emergency department. Results suggest that care coordination in usual practice may improve patient preventive care, but not some other health or cost-related outcomes.

4.
Clin Drug Investig ; 39(10): 979-990, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31302899

RESUMO

BACKGROUND: Migraine is a common, chronic neurovascular brain disorder with non-negligible multifaceted economic costs. Existing preventive treatments involve the selective use of onabotulinumtoxinA, which aims at migraine morbidity reduction for patients who have failed initial preventive treatment with oral agents. Erenumab is a new preventive treatment for migraines. OBJECTIVE: To evaluate the differences in costs and outcomes of the preventive treatment with erenumab versus onabotulinumtoxinA in patients with chronic migraines (CM) in Greece to assess the economic value of this treatment. METHODS: We conducted a cost-effectiveness analysis from both the payer and the societal perspective using a decision-tree analytic model. Outcomes were expressed in migraines avoided and in quality-adjusted life-years (QALYs). We obtained model inputs from the existing literature. The decision path adjusted for variation in the probability of adherence and the resulting differential effectiveness between the two treatments. Direct costs included the cost of the two drugs and administration costs, the costs of acute drugs used under usual care, and the costs of hospitalization, physician, and emergency department visits. Indirect costs for the societal perspective analyses included wages lost on workdays. The time-horizon of the analysis was 1 year and all costs were calculated in 2019 euros (€). Sensitivity analyses were conducted to control for parameter uncertainty and to evaluate the robustness of the findings. RESULTS: Our results indicate that treatment of CM with erenumab compared to onabotulinumtoxinA resulted in incremental cost-effectiveness ratios (ICERs) of €218,870 and €231,554 per QALY gained and €620 and €656 per migraine avoided, from the societal and the payer's perspective, respectively. Using a common cost-effectiveness threshold equal to three times the local gross domestic product (GDP) per capita (€49,000), for the erenumab ICERs to fall below this threshold, the erenumab price would have to be no more than €192 (societal perspective) or €173 (payer perspective). CONCLUSION: The prophylactic treatment of CM with erenumab in Greece might be cost effective compared to the existing alternative of onabotulinumtoxinA from both the payer and the societal perspective, but only at a highly discounted price. Nevertheless, erenumab could be considered a therapeutic option for patients who fail treatment with onabotulinumtoxinA.


Assuntos
Anticorpos Monoclonais Humanizados/economia , Toxinas Botulínicas Tipo A/economia , Antagonistas do Receptor do Peptídeo Relacionado ao Gene de Calcitonina/economia , Análise Custo-Benefício/métodos , Transtornos de Enxaqueca/tratamento farmacológico , Transtornos de Enxaqueca/economia , Adulto , Anticorpos Monoclonais Humanizados/administração & dosagem , Toxinas Botulínicas Tipo A/administração & dosagem , Antagonistas do Receptor do Peptídeo Relacionado ao Gene de Calcitonina/administração & dosagem , Doença Crônica , Árvores de Decisões , Método Duplo-Cego , Feminino , Grécia/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos de Enxaqueca/epidemiologia , Anos de Vida Ajustados por Qualidade de Vida
5.
J Eval Clin Pract ; 25(3): 420-433, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31044484

RESUMO

STUDY OBJECTIVE: We conducted a systematic literature review to identify and to update patient characteristics and contextual factors for adult frequent emergency department users (FEDUs) compared with non-FEDU in an era where the US health care system underwent substantial changes. METHODS: We searched MEDLINE, CINAHL, and EMBASE to identify all relevant articles after 2010 through July 2018 that describe FEDU. We included US studies on adult FEDU only and excluded studies on specific subgroups of FEDU. We included demographic, clinical, and health care utilization information, and two reviewers independently evaluated the studies using the Joanna Briggs Institute Critical Appraisal tool. RESULTS: The 11 studies included in the review indicated that FEDU were 4% to 16% of total ED users but accounted for 14% to 47% of ED visits, with six to nine visits per year on average. The majority of FEDU were young or middle-aged adults, females, of low socioeconomic status and high school or less education, with public insurance, multiple primary care provider visits, and chronic conditions. Fair or poor self-perceived health status, unemployment, unmet needs from primary care providers (PCPs), mental health, and substance abuse were predictors of FEDU. CONCLUSION: FEDUs are disproportionally sicker and are also heavy users of non-ED health care service providers. The limited data for non-ED health services use in facility-specific studies of FEDU may contribute to findings in such studies that complex and unmet needs from PCPs contributed to ED visits. This suggests the need for more comprehensive data analysis beyond a few sites that can inform systemic management approaches.


Assuntos
Serviço Hospitalar de Emergência , Mau Uso de Serviços de Saúde , Aceitação pelo Paciente de Cuidados de Saúde , Adolescente , Adulto , Demografia , Feminino , Humanos , Masculino , Adulto Jovem
6.
Clin Gastroenterol Hepatol ; 17(5): 976-987.e4, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30616961

RESUMO

BACKGROUND & AIMS: Hepatocellular carcinoma (HCC) screening of patients with cirrhosis is recommended by professional societies to increase detection of early stage tumors and survival, but is underused in clinical practice. METHODS: We conducted a retrospective cohort study of 13,714 patients diagnosed with HCC from 2003 through 2013 included in the Surveillance, Epidemiology, and End Results Program-Medicare database. We characterized receipt of HCC screening in the 3 years before HCC diagnosis using mutually exclusive categories (consistent vs inconsistent vs no screening) and the proportion of time covered with screening. Correlates for screening receipt were assessed using a multivariable 2-part regression model. We examined the association between screening receipt and early detection of tumors using multivariable logistic regression. We evaluated associations between screening receipt and overall survival using a Cox proportional hazards model, after adjustments for effects of lead-time bias and length-time bias on survival rate estimators. RESULTS: Most patients with cirrhosis (51.1%) did not receive any screening in the 3 years before a diagnosis of HCC, and only 6.8% of patients underwent consistent annual screening. The proportion with consistent screening increased from 5.4% in 2003 to 2006 to 8.8% in 2011 to 2013 (P < .001). The mean proportion of time covered was 13.4% overall, which increased from 11.7% in 2003 to 2006 to 15.2% in 2011 to 2013. Receipt of consistent screening was associated with detection of early stage tumors (odds ratio, 1.98; 95% CI, 1.68-2.33) and a reduced risk of death after correction for lead-time bias (hazard ratio, 0.76; 95% CI, 0.70-0.83). Inconsistent screening was associated with a slightly smaller increase in early detection of HCC (odds ratio, 1.31; 95% CI, 1.20-1.43) and a reduced risk of death (hazard ratio, 0.86; 95% CI, 0.83-0.90). After correction for lead- and length-time biases, higher proportions of patients with consistent (23%; 95% CI, 21%-25%) and inconsistent screening (19%; 95% CI, 19%-20%) survived for 3 years compared with patients without screening (13%; 95% CI, 12%-14%). CONCLUSIONS: In an analysis of the Surveillance, Epidemiology, and End Results Program-Medicare database, we found HCC screening to be underused for patients with cirrhosis. This contributes to detection of liver tumors at later stages and shorter times of survival. However, the proportion of patients screened for HCC has increased over time.


Assuntos
Carcinoma Hepatocelular/diagnóstico , Carcinoma Hepatocelular/mortalidade , Utilização de Instalações e Serviços/estatística & dados numéricos , Cirrose Hepática/complicações , Programas de Rastreamento/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Estudos Retrospectivos , Análise de Sobrevida
7.
Ann Rheum Dis ; 78(3): 372-379, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30610066

RESUMO

OBJECTIVES: The study (206347) compared organ damage progression in patients with systemic lupus erythematosus (SLE) who received belimumab in the BLISS long-term extension (LTE) study with propensity score (PS)-matched patients treated with standard of care (SoC) from the Toronto Lupus Cohort (TLC). METHODS: A systematic literature review identified 17 known predictors of organ damage to calculate a PS for each patient. Patients from the BLISS LTE and the TLC were PS matched posthoc 1:1 based on their PS (±calliper). The primary endpoint was difference in change in Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) score from baseline to 5 years. RESULTS: For the 5- year analysis, of 567 (BLISS LTE n=195; TLC n=372) patients, 99 from each cohort were 1:1 PS matched. Change in SDI score at Year 5 was significantly lower for patients treated with belimumab compared with SoC (-0.434; 95% CI -0.667 to -0.201; p<0.001). For the time to organ damage progression analysis (≥1 year follow-up), the sample included 965 (BLISS LTE n=259; TLC n=706) patients, of whom 179 from each cohort were PS-matched. Patients receiving belimumab were 61% less likely to progress to a higher SDI score over any given year compared with patients treated with SoC (HR 0.391; 95% CI 0.253 to 0.605; p<0.001). Among the SDI score increases, the proportion of increases ≥2 was greater in the SoC group compared with the belimumab group. CONCLUSIONS: PS-matched patients receiving belimumab had significantly less organ damage progression compared with patients receiving SoC.


Assuntos
Anticorpos Monoclonais Humanizados/uso terapêutico , Imunossupressores/uso terapêutico , Lúpus Eritematoso Sistêmico/tratamento farmacológico , Lúpus Eritematoso Sistêmico/patologia , Adulto , Progressão da Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Índice de Gravidade de Doença , Padrão de Cuidado , Resultado do Tratamento
8.
J Immigr Minor Health ; 21(1): 98-104, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29564642

RESUMO

Heart failure (HF) is one of the leading causes of hospitalization and readmissions. Our study aimed to examine racial disparities in heart failure patients including onset, mortality, length of stay (LOS), direct costs, and readmission rates. This is a secondary data analysis. We analyzed the risk-adjusted inpatient data of all patients admitted with HF to one health academic center. We compared five health outcomes among three racial groups (white, black, and Hispanic). There were 1006 adult patients making 1605 visits from 10/01/2011 to 09/30/2015. Most black patients were admitted in younger age than other racial groups which indicates the needs for more public health preventions. With risk adjustments, the racial differences in LOS and readmission rates remain. We stratified health outcomes by race/ethnic and type of HF. The findings suggest that further studies to uncover underlying causes of these disparities are necessary. Using risk-adjusted hospitalization data allows for comparisons of quality of care across three racial groups. The study suggests that more prevention and protection services are needed for African American patients with heart failure.


Assuntos
Grupos de Populações Continentais/estatística & dados numéricos , Disparidades nos Níveis de Saúde , Insuficiência Cardíaca/etnologia , Hospitalização/estatística & dados numéricos , Adulto , Afro-Americanos/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Gastos em Saúde/estatística & dados numéricos , Insuficiência Cardíaca/economia , Insuficiência Cardíaca/mortalidade , Hispano-Americanos/estatística & dados numéricos , Hospitalização/economia , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Qualidade da Assistência à Saúde , Fatores Sexuais , Fatores Socioeconômicos , Estados Unidos , Adulto Jovem
9.
Health Serv Res Manag Epidemiol ; 4: 2333392817721109, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28894766

RESUMO

BACKGROUND: An estimated 4% of hospital admissions acquired healthcare-associated infections (HAIs) and accounted for $9.8 (USD) billion in direct cost during 2011. In 2010, nearly 140 000 of the 3.5 million potentially preventable hospitalizations (PPHs) may have acquired an HAI. There is a knowledge gap regarding the co-occurrence of these events. AIMS: To estimate the period occurrences and likelihood of acquiring an HAI for the PPH population. METHODS: Retrospective, cross-sectional study using logistic regression analysis of 2011 Texas Inpatient Discharge Public Use Data File including 2.6 million admissions from 576 acute care hospitals. Agency for Healthcare Research and Quality Prevention Quality Indicator software identified PPH, and existing administrative data identification methodologies were refined for Clostridium difficile infection, central line-associated bloodstream infection, catheter-associated urinary tract infection, and ventilator-associated pneumonia. Odds of acquiring HAIs when admitted with PPH were adjusted for demographic, health status, hospital, and community characteristics. FINDINGS: We identified 272 923 PPH, 14 219 HAI, and 986 admissions with PPH and HAI. Odds of acquiring an HAI for diabetic patients admitted for lower extremity amputation demonstrated significantly increased odds ratio of 2.9 (95% confidence interval: 2.16-3.91) for Clostridium difficile infection. Other PPH patients had lower odds of acquiring HAI compared to non-PPH patients, and results were frequently significant. CONCLUSIONS: Clinical implications include increased risk of HAI among diabetic patients admitted for lower extremity amputation. Methodological implications include identification of rare events for inpatient subpopulations and the need for improved codification of HAIs to improve cost and policy analyses regarding allocation of resources toward clinical improvements.

10.
Health Serv Insights ; 10: 1178632917701025, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28469457

RESUMO

BACKGROUND: The proportion of outpatient surgeries performed in physician offices has been increasing over time, raising concern about the impact on outcomes. OBJECTIVE: To use a private insurance claims database to compare 7-day and 30-day hospitalization rates following relatively complex outpatient surgical procedures across physician offices, freestanding ambulatory surgery centers (ASCs), and hospital outpatient departments (HOPDs). METHODS: A multivariable logistic regression model was used to compare the risk-adjusted probability of hospitalization among patients after any of the 88 study outpatient procedures at physician offices, ASCs, and HOPDs over 2008-2012 in Florida. RESULTS: Risk-adjusted hospitalization rates were higher following procedures performed in physician offices compared with ASCs for all procedures grouped together, for most procedures grouped by type, and for many individual procedures. CONCLUSIONS: Hospitalizations following surgery were more likely for procedures performed in physician offices compared with ASCs, which highlights the need for ongoing research on the safety and efficacy of office-based surgery.

11.
Front Public Health ; 5: 345, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29326920

RESUMO

Introduction: Diabetes is a major chronic disease that can lead to serious health problems and high healthcare costs without appropriate disease management and treatment. In the United States, the number of people diagnosed with diabetes and the cost for diabetes treatment has dramatically increased over time. To improve patients' self-management skills and clinical outcomes, diabetes management education (DME) programs have been developed and operated in various regions. Objective: This community case study explores and calculates the economic and clinical impacts of expanding a model DME program into 26 counties located in South Texas. Methods: The study sample includes 355 patients with type 2 diabetes and a follow-up hemoglobin A1c level measurement among 1,275 individuals who participated in the DME program between September 2012 and August 2013. We used the Gilmer's cost differentials model and the United Kingdom Prospective Diabetes Study (UKPDS) Risk Engine methodology to predict 3-year healthcare cost savings and 10-year clinical benefits of implementing a DME program in the selected 26 Texas counties. Results: Changes in estimated 3-year cost and the estimated treatment effect were based on baseline hemoglobin A1c level. An average 3-year reduction in medical treatment costs per program participant was $2,033 (in 2016 dollars). The total healthcare cost savings for the 26 targeted counties increases as the program participation rate increases. The total projected cost saving ranges from $12 million with 5% participation rate to $185 million with 75% participation rate. A 10-year outlook on additional clinical benefits associated with the implementation and expansion of the DME program at 60% participation is estimated to result in approximately 4,838 avoided coronary heart disease cases and another 392 cases of avoided strokes. Conclusion: The implementation of this model DME program in the selected 26 counties would contribute to substantial healthcare cost savings and clinical benefits. Organizations that provide DME services may benefit from reduction in medical treatment costs and improvement in clinical outcomes for populations with diabetes.

12.
J Rural Health ; 33(3): 275-283, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-27424940

RESUMO

PURPOSE: To examine the difference between rural and urban hospitals as to their overall level of readiness for stage 2 meaningful use of electronic health records (EHRs) and to identify other key factors that affect their readiness for stage 2 meaningful use. METHODS: A conceptual framework based on the theory of organizational readiness for change was used in a cross-sectional multivariate analysis using 2,083 samples drawn from the HIMSS Analytics survey conducted with US hospitals in 2013. FINDINGS: Rural hospitals were less likely to be ready for stage 2 meaningful use compared to urban hospitals in the United States (OR = 0.49) in our final model. Hospitals' past experience with an information exchange initiative, staff size in the information system department, and the Chief Information Officer (CIO)'s responsibility for health information management were identified as the most critical organizational contextual factors that were associated with hospitals' readiness for stage 2. Rural hospitals lag behind urban hospitals in EHR adoption, which will hinder the interoperability of EHRs among providers across the nation. The identification of critical factors that relate to the adoption of EHR systems provides insights into possible organizational change efforts that can help hospitals to succeed in attaining meaningful use requirements. CONCLUSION: Rural hospitals have increasingly limited resources, which have resulted in a struggle for these facilities to attain meaningful use. Given increasing closures among rural hospitals, it is all the more important that EHR development focus on advancing rural hospital quality of care and linkages with patients and other organizations supporting the care of their patients.


Assuntos
Eficiência Organizacional/normas , Registros Eletrônicos de Saúde/estatística & dados numéricos , Sistemas de Informação Hospitalar/tendências , Hospitais Rurais/tendências , Uso Significativo/normas , Estudos Transversais , Humanos , Inquéritos e Questionários , Estados Unidos
13.
J Clin Anesth ; 35: 157-162, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27871514

RESUMO

STUDY OBJECTIVE: To provide estimates of the costs and health outcomes implications of the excess risk of unexpected disposition for nurse anesthetist (NA) procedures. DESIGN: A projection model was used to apply estimates of costs and health outcomes associated with the excess risk of unexpected disposition for NAs reported in a recent study. SETTING: Ambulatory and inpatient surgery. PATIENTS: Base-case model parameters were based on estimates taken from peer-reviewed publications when available, or from other sources including data for all hospital stays in the United States in 2013 from the Healthcare Cost and Utilization Project Web site. The impact of parameter uncertainty was assessed using 1-way and 2-way sensitivity analyses. INTERVENTIONS: Not applicable. MEASUREMENTS: Major complication rates, relative risks of complications, anesthesia costs, costs of complications, and cost-effectiveness ratios. MAIN RESULTS: In the base-case model, there were on average 2.3 fewer unexpected dispositions for physician anesthesiologists compared with NAs. Overall, anesthesia-related costs (including the cost of managing unexpected dispositions) were estimated to be about $31 higher per procedure for physician anesthesiologists compared with NAs. Alternative model scenarios in the sensitivity analysis produced estimates of smaller additional costs associated with physician anesthesia administration, to the point of cost savings in some scenarios. CONCLUSIONS: Provision of anesthesia for ambulatory knee and shoulder procedures by physician anesthesiologists results in better health outcomes, at a reasonable additional cost, compared with procedures with NA-administered anesthesia, at least when using updated cost-effectiveness willingness-to-pay benchmarks.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/economia , Anestesia/economia , Análise Custo-Benefício , Procedimentos Ortopédicos/economia , Avaliação de Resultados em Cuidados de Saúde/economia , Complicações Pós-Operatórias/economia , Adulto , Idoso , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Anestesia/efeitos adversos , Anestesia/métodos , Anestesiologistas/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Enfermeiras Anestesistas/economia , Procedimentos Ortopédicos/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Resultado do Tratamento , Estados Unidos , Adulto Jovem
14.
JAAPA ; 29(9): 44-8, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-27575904

RESUMO

OBJECTIVE: This study compared the cost of physician versus physician assistant (PA) education for women practicing in family medicine. METHODS: Using 2013 salary survey data from both the Medical Group Management Association and the American Academy of PAs as well as other publicly available data sources, the authors compared the current net present value (NPV) of physician and PA training for women practicing in family medicine. RESULTS: Considering a base case scenario involving a 24-year-old woman, the NPV to become a family medicine physician was $2,015,000 compared with an NPV of $1,751,000 to become a family medicine PA. Alternative projections produced an NPV for PA training that slightly exceeded the NPV for family medicine physician training. CONCLUSIONS: For a woman practicing in family medicine, becoming a physician or a PA offers similar financial rewards.


Assuntos
Escolha da Profissão , Medicina de Família e Comunidade , Assistentes Médicos/economia , Adulto , Custos e Análise de Custo , Feminino , Humanos , Salários e Benefícios , Adulto Jovem
15.
Health Econ Rev ; 5(1): 31, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26481141

RESUMO

BACKGROUND: Concerns have been raised about physician ownership of onsite advanced imaging equipment as allowed under Stark laws by the in-office ancillary service exception (IOASE). METHODS: A web-based survey of orthopedic practices in the United States was used to assign a first date of onsite MRI capacity acquisition (if any) to specific orthopedic practices. Medicare claims data for 2006-2010 was obtained for providers in orthopedic practices acquiring onsite MRI capacity and in matched orthopedic practices without an onsite MRI over the same period of time. Multivariate regression was used to estimate the change in provider Medicare MRI volume one year before and one year after the onsite MRI acquisition year for providers in MRI practices compared to providers in propensity-score matched non-MRI practices. RESULTS: In all of the MRI volume change models estimated, the association between onsite MRI acquisition and the change in provider Medicare MRI volume (one-year post-onsite-MRI-acquisition less one year pre-acquisition) was consistently small and not statistically significant. This lack of association was robust to changes in model specification in terms of types of MRI exams considered, specific covariates included in the multivariate model, or the process used to confirm individual provider affiliation with study practices in study years. CONCLUSIONS: Our analysis of Medicare claims data provides no empirical support for the proposition that acquisition of onsite MRI capacity within an orthopedic surgery practice induces an increase in the rate of MRI use for Medicare patients among practice providers, relative to physicians in practices without MRI capacity over the same time period.

16.
Rural Remote Health ; 15(3): 3335, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26280454

RESUMO

INTRODUCTION: Conditions such as postpartum complications and mental disorders of new mothers contribute to a relatively large number of maternal rehospitalizations and even some deaths. Few studies have examined rural-urban differences in hospital readmissions, and none of them have addressed maternal readmissions. This research directly compares readmissions for patients who delivered in rural versus urban hospitals. METHODS: The data for this cross-sectional study were drawn from the 2011 California Healthcare Cost and Utilization Project. Readmission rates were reported to demonstrate rural-urban differences. Generalized estimating equation models were also used to estimate the likelihood of a new mother being readmitted over time. RESULTS: The 323 051 women who delivered with minor assistance and 158 851 women who delivered by cesarean section (C-section) were included in this study. Of those, seven maternal mortalities occurred after vaginal deliveries and 14 occurred after C-section procedures. Fewer than 1% (0.98% or 3171) women with normal deliveries were rehospitalized. The corresponding number for women delivering via C-section was 1.41% (2243). For both types of deliveries, women giving birth in a rural hospital were more likely to be readmitted. CONCLUSIONS: This is the first study examining rural-urban differences in maternal readmissions. The results indicate the importance of monitoring and potentially improving the quality of maternal care, especially when the delivery involves a C-section. More studies investigating rural health disparities in women's health are clearly necessary.


Assuntos
Readmissão do Paciente/estatística & dados numéricos , População Rural/estatística & dados numéricos , População Urbana/estatística & dados numéricos , Adulto , California/epidemiologia , Estudos Transversais , Parto Obstétrico/mortalidade , Parto Obstétrico/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde , Pesquisa sobre Serviços de Saúde , Humanos , Complicações do Trabalho de Parto/epidemiologia , Gravidez , Características de Residência , Saúde da Mulher
17.
Clin Chem Lab Med ; 53(4): 583-92, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25581762

RESUMO

BACKGROUND: Whether or not antibiotic stewardship protocols based on procalcitonin levels results in cost savings remains unclear. Herein, our objective was to assess the economic impact of adopting procalcitonin testing among patients with suspected acute respiratory tract infection (ARI) from the perspective of a typical US integrated delivery network (IDN) with a 1,000,000 member catchment area or enrollment. METHODS: To conduct an economic evaluation of procalcitonin testing versus usual care we built a cost-impact model based on patient-level meta-analysis data of randomized trials. The meta-analytic data was adapted to the US setting by applying the meta-analytic results to US lengths of stay, costs, and practice patterns. We estimated the annual ARI visit rate for the one million member cohort, by setting (inpatient, ICU, outpatient) and ARI diagnosis. RESULTS: In the inpatient setting, the costs of procalcitonin-guided compared to usual care for the one million member cohort was $2,083,545, compared to $2,780,322, resulting in net savings of nearly $700,000 to the IDN for 2014. In the ICU and outpatient settings, savings were $73,326 and $5,329,824, respectively, summing up to overall net savings of $6,099,927 for the cohort. RESULTS were robust for all ARI diagnoses. For the whole US insured population, procalcitonin-guided care would result in $1.6 billion in savings annually. CONCLUSIONS: Our results show substantial savings associated with procalcitonin protocols of ARI across common US treatment settings mainly by direct reduction in unnecessary antibiotic utilization. These results are robust to changes in key parameters, and the savings can be achieved without any negative impact on treatment outcomes.


Assuntos
Antibacterianos/uso terapêutico , Análise Química do Sangue/economia , Calcitonina/sangue , Assistência à Saúde/economia , Precursores de Proteínas/sangue , Infecções Respiratórias/sangue , Infecções Respiratórias/tratamento farmacológico , Doença Aguda , Peptídeo Relacionado com Gene de Calcitonina , Análise Custo-Benefício , Humanos , Pacientes Internados , Tempo de Internação/economia , Metanálise como Assunto , Infecções Respiratórias/economia , Estados Unidos
18.
Popul Health Manag ; 18(3): 172-8, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25290852

RESUMO

Diabetes knows no age and affects millions of individuals. Preventing diabetes in children is increasingly becoming a major health policy concern and focus. The objective of this study is to project the number of children, aged 0-17 years, with diagnosed diabetes in the United States through 2030, accounting for changing demography, and diabetes and obesity prevalence rates. The study team combined historic diabetes and obesity prevalence data with US child population estimates and projections. A times-series regression model was used to forecast future diabetes prevalence and to account for the relationship between the forecasted diabetes prevalence and the lagged prevalence of childhood obesity. Overall, the prevalence of diagnosed diabetes is projected to increase 67% from 0.22% in 2010 to 0.36% in 2030. Lagged obesity prevalence in Hispanic boys and non-Hispanic black girls was significantly associated with increasing future diabetes prevalence. The study results showed that a 1% increase in obesity prevalence among Hispanic boys from the previous year was significantly associated with a 0.005% increase in future prevalence of diagnosed diabetes in children (P ≤ 0.01). Likewise, a unit increase in obesity prevalence among non-Hispanic black girls was associated with a 0.003% increase in future diabetes prevalence (P < 0.05). Obesity rates for other race/ethnicity combinations were not associated with increasing future diabetes prevalence. To mitigate the continued threat posed by diabetes, serious discussions need to focus on the pediatric population, particularly non-Hispanic black girls and Hispanic boys whose obesity trends show the strongest associations with future diabetes prevalence in children.


Assuntos
Diabetes Mellitus Tipo 1/epidemiologia , Diabetes Mellitus Tipo 2/epidemiologia , Obesidade Pediátrica/epidemiologia , Adolescente , Afro-Americanos/estatística & dados numéricos , Criança , Pré-Escolar , Diabetes Mellitus Tipo 1/etnologia , Diabetes Mellitus Tipo 2/etnologia , Feminino , Hispano-Americanos/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Masculino , Inquéritos Nutricionais , Obesidade Pediátrica/etnologia , Prevalência , Análise de Regressão
19.
J Med Internet Res ; 16(4): e106, 2014 Apr 18.
Artigo em Inglês | MEDLINE | ID: mdl-24760950

RESUMO

BACKGROUND: Health risk assessments are becoming more popular as a tool to conveniently and effectively reach community-dwelling adults who may be at risk for serious chronic conditions such as coronary heart disease (CHD). The use of such instruments to improve adults' risk factor awareness and concordance with clinically measured risk factor values could be an opportunity to advance public health knowledge and build effective interventions. OBJECTIVE: The objective of this study was to determine if an Internet-based health risk assessment can highlight important aspects of agreement between respondents' self-reported and clinically measured CHD risk factors for community-dwelling adults who may be at risk for CHD. METHODS: Data from an Internet-based cardiovascular health risk assessment (Heart Aware) administered to community-dwelling adults at 127 clinical sites were analyzed. Respondents were recruited through individual hospital marketing campaigns, such as media advertising and print media, found throughout inpatient and outpatient facilities. CHD risk factors from the Framingham Heart Study were examined. Weighted kappa statistics were calculated to measure interrater agreement between respondents' self-reported and clinically measured CHD risk factors. Weighted kappa statistics were then calculated for each sample by strata of overall 10-year CHD risk. Three samples were drawn based on strategies for treating missing data: a listwise deleted sample, a pairwise deleted sample, and a multiple imputation (MI) sample. RESULTS: The MI sample (n=16,879) was most appropriate for addressing missing data. No CHD risk factor had better than marginal interrater agreement (κ>.60). High-density lipoprotein cholesterol (HDL-C) exhibited suboptimal interrater agreement that deteriorated (eg, κ<.30) as overall CHD risk increased. Conversely, low-density lipoprotein cholesterol (LDL-C) interrater agreement improved (eg, up to κ=.25) as overall CHD risk increased. Overall CHD risk of the sample was lower than comparative population-based CHD risk (ie, no more than 15% risk of CHD for the sample vs up to a 30% chance of CHD for the population). CONCLUSIONS: Interventions are needed to improve knowledge of CHD risk factors. Specific interventions should address perceptions of HDL-C and LCL-C. Internet-based health risk assessments such as Heart Aware may contribute to public health surveillance, but they must address selection bias of Internet-based recruitment methods.


Assuntos
Doença das Coronárias , Conhecimentos, Atitudes e Prática em Saúde , Internet , Autorrelato , Adulto , Pressão Sanguínea , Colesterol/sangue , Estudos Transversais , Autoavaliação Diagnóstica , Feminino , Humanos , Masculino , Medição de Risco/métodos , Fatores de Risco
20.
Patient Educ Couns ; 95(1): 111-7, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24468198

RESUMO

OBJECTIVE: This study compared time-to-hospitalization among subjects enrolled in different diabetes self-management programs (DSMP). We sought to determine whether the interventions delayed the occurrence of any acute event necessitating hospitalization. METHODS: Electronic medical records (EMR) were obtained for 376 adults enrolled in a randomized controlled trial (RCT) of Type 2 diabetes (T2DM) self-management programs. All study participants had uncontrolled diabetes and were randomized into either: personal digital assistant (PDA), Chronic Disease Self-Management Program (CDSMP), combined PDA and CDSMP (COM), or usual care (UC) groups. Subjects were followed for a maximum of two years. Time-to-hospitalization was measured as the interval between study enrollment and the occurrence of a diabetes-related hospitalization. RESULTS: Subjects enrolled in the CDSMP-only arm had significantly prolonged time-to-hospitalization (Hazard ratio: 0.10; p=0.002) when compared to subjects in the control arm. Subjects in the PDA-only and combined PDA and CDSMP arms showed no improvements in comparison to the control arm. CONCLUSION: CDSMP can be effective in delaying time-to-hospitalization among patients with T2DM. PRACTICE IMPLICATIONS: Reducing unnecessary healthcare utilization, particularly inpatient hospitalization is a key strategy to improving the quality of health care and lowering associated health care costs. The CDSMP offers the potential to reduce time-to-hospitalization among T2DM patients.


Assuntos
Diabetes Mellitus Tipo 2/terapia , Hospitalização/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde , Autocuidado , Adulto , Computadores de Mão , Feminino , Seguimentos , Comportamentos Relacionados com a Saúde , Serviços de Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Análise de Sobrevida , Texas , Fatores de Tempo
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