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2.
BMJ ; 368: l6831, 2020 01 15.
Artigo em Inglês | MEDLINE | ID: mdl-31941686

RESUMO

OBJECTIVES: To determine whether patients discharged after hospital admissions for conditions covered by national readmission programs who received care in emergency departments or observation units but were not readmitted within 30 days had an increased risk of death and to evaluate temporal trends in post-discharge acute care utilization in inpatient units, emergency departments, and observation units for these patients. DESIGN: Retrospective cohort study. SETTING: Medicare claims data for 2008-16 in the United States. PARTICIPANTS: Patients aged 65 or older admitted to hospital with heart failure, acute myocardial infarction, or pneumonia-conditions included in the US Hospital Readmissions Reduction Program. MAIN OUTCOME MEASURES: Post-discharge 30 day mortality according to patients' 30 day acute care utilization; acute care utilization in inpatient and observation units and the emergency department during the 30 day and 31-90 day post-discharge period. RESULTS: 3 772 924 hospital admissions for heart failure, 1 570 113 for acute myocardial infarction, and 3 131 162 for pneumonia occurred. The overall post-discharge 30 day mortality was 8.7% for heart failure, 7.3% for acute myocardial infarction, and 8.4% for pneumonia. Risk adjusted mortality increased annually by 0.05% (95% confidence interval 0.02% to 0.08%) for heart failure, decreased by 0.06% (-0.09% to -0.04%) for acute myocardial infarction, and did not significantly change for pneumonia. Specifically, mortality increased for patients with heart failure who did not utilize any post-discharge acute care, increasing at a rate of 0.08% (0.05% to 0.12%) per year, exceeding the overall absolute annual increase in post-discharge mortality in heart failure, without an increase in mortality in observation units or the emergency department. Concurrent with a reduction in 30 day readmission rates, stays for observation and visits to the emergency department increased across all three conditions during and beyond the 30 day post-discharge period. Overall 30 day post-acute care utilization did not change significantly. CONCLUSIONS: The only condition with increasing mortality through the study period was heart failure; the increase preceded the policy and was not present among patients who received emergency department or observation unit care without admission to hospital. During this period, the overall acute care utilization in the 30 days after discharge significantly decreased for heart failure and pneumonia, but not for acute myocardial infarction.


Assuntos
Unidades de Observação Clínica/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Insuficiência Cardíaca , Infarto do Miocárdio , Pneumonia , Cuidados Semi-Intensivos , Idoso , Idoso de 80 Anos ou mais , Feminino , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Humanos , Revisão da Utilização de Seguros , Masculino , Sobremedicalização/prevenção & controle , Medicare/estatística & dados numéricos , Mortalidade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Pneumonia/mortalidade , Pneumonia/terapia , Estudos Retrospectivos , Cuidados Semi-Intensivos/métodos , Cuidados Semi-Intensivos/organização & administração , Cuidados Semi-Intensivos/tendências , Estados Unidos/epidemiologia
3.
BMJ ; 368: l6968, 2020 01 29.
Artigo em Inglês | MEDLINE | ID: mdl-31996352

RESUMO

OBJECTIVE: To examine the distribution and patterns of opioid prescribing in the United States. DESIGN: Retrospective, observational study. SETTING: National private insurer covering all 50 US states and Washington DC. PARTICIPANTS: An annual average of 669 495 providers prescribing 8.9 million opioid prescriptions to 3.9 million patients from 2003 through 2017. MAIN OUTCOME MEASURES: Standardized doses of opioids in morphine milligram equivalents (MMEs) and number of opioid prescriptions. RESULTS: In 2017, the top 1% of providers accounted for 49% of all opioid doses and 27% of all opioid prescriptions. In absolute terms, the top 1% of providers prescribed an average of 748 000 MMEs-nearly 1000 times more than the middle 1%. At least half of all providers in the top 1% in one year were also in the top 1% in adjacent years. More than two fifths of all prescriptions written by the top 1% of providers were for more than 50 MMEs a day and over four fifths were for longer than seven days. In contrast, prescriptions written by the bottom 99% of providers were below these thresholds, with 86% of prescriptions for less than 50 MMEs a day and 71% for fewer than seven days. Providers prescribing high amounts of opioids and patients receiving high amounts of opioids persisted over time, with over half of both appearing in adjacent years. CONCLUSIONS: Most prescriptions written by the majority of providers are under the recommended thresholds, suggesting that most US providers are careful in their prescribing. Interventions focusing on this group of providers are unlikely to effect beneficial change and could induce unnecessary burden. A large proportion of providers have established relationships with their patients over multiple years. Interventions to reduce inappropriate opioid prescribing should be focused on improving patient care, management of patients with complex pain, and reducing comorbidities rather than seeking to enforce a threshold for prescribing.


Assuntos
Analgésicos Opioides/uso terapêutico , Prescrição Inadequada/prevenção & controle , Administração dos Cuidados ao Paciente/normas , Médicos , Padrões de Prática Médica , Adulto , Prescrições de Medicamentos/normas , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Revisão da Utilização de Seguros/estatística & dados numéricos , Masculino , Médicos/classificação , Médicos/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Padrões de Prática Médica/tendências , Medicamentos sob Prescrição/uso terapêutico , Melhoria de Qualidade , Estudos Retrospectivos , Estados Unidos/epidemiologia
4.
Medicine (Baltimore) ; 98(49): e17825, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31804305

RESUMO

This study tried to investigate the effects of number of medications and age on antihypertensive medication adherence in a real-world setting using a nationwide representative cohort.We obtained data from the National Health Insurance Service-National Sample Cohort (NHIS-NSC) of Korea, which is a sample of 2.2% (N = 1,048,061) of total population (N = 46,605,433). Patients aged 20 years or older (N = 150,550) who took antihypertensive medications for at least 1 year were selected. Medication possession ratio (MPR) was used for measuring adherence. The subjects were divided into 5 subgroups according to total number of medications: 1-2, 3-4, 5-6, 7-8, and 9 or more. The mean age and the mean number of medications were 60.3 ±â€Š12.6 years and 4.1 ±â€Š2.2, respectively. The mean MPR was 80.4 ±â€Š23.9%, and 66.9% (N = 100,645) of total subjects were adherent (MPR ≥ 80%). The overall tendency of antihypertensive medication adherence according to the total number of medications displayed an inverted U-shape with a peak at 3-4 drugs. Adherence consistently increased as the age increased until age 69 and started to decrease from age 70. The proportion of adherent patients (MPR ≥ 80%) according to the total number of medications also showed an inverted U-shape with a peak at 3-4 drugs. When the same number of drugs was taken, the proportion of adherent patients according to age featured an inverted U- shape with a peak at 60 to 69 years. Patients taking 9 or more total drugs had the overall odds ratio (95% CI) of non-adherence (MPR < 80%) with 1.17 (1.11-1.24) compared with those taking 1 to 8 total drugs and the odds ratios in the age subgroups of 40 to 49, 50 to 59, 60 to 69 years were 1.57 (1.31-1.87), 1.21 (1.08-1.36), and 1.14 (1.04-1.25), respectively (P < .05).Association between age, total number of medications, and antihypertensive adherence displayed an inverted U-shape with a peak at 3 to 4 total medications and at age 60 to 69 years. When the total number of drugs was 9 or more, adherence decreased prominently, regardless of age.


Assuntos
Anti-Hipertensivos/uso terapêutico , Adesão à Medicação/estatística & dados numéricos , Polimedicação , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Anti-Hipertensivos/administração & dosagem , Feminino , Humanos , Revisão da Utilização de Seguros , Masculino , Pessoa de Meia-Idade , República da Coreia , Estudos Retrospectivos , Fatores Sexuais , Fatores Socioeconômicos
5.
BMC Health Serv Res ; 19(1): 776, 2019 Oct 30.
Artigo em Inglês | MEDLINE | ID: mdl-31666066

RESUMO

BACKGROUND: In 2002, a voluntary diagnosis-related groups (DRGs) payment system was introduced in South Korea for seven disease groups, and participation in the DRGs was mandated for all hospitals beginning in 2013. The primary aim of this study was to compare results reflective of patient care between voluntary participation hospitals (VPHs) and mandatory participation hospitals (MPHs) governed by either the DRGs or fee-for-service (FFS) payment system. METHODS: We collected DRGs and FFS inpatient records (n=3,038,006) from the Health Insurance Review and Assessment for the period of July 2011 to July 2014 and compared length-of-stay, total medical costs, shifting services to an outpatient setting, and readmission rates according to payment system, time of DRGs implementation, and hospital type. We analyzed the effects of mandatory introduction in DRGs payment system on results for patient care and used generalized estimating equations with difference-in-difference methodology. RESULTS: Most notably, patients at MPHs had significantly shorter LOS and lower readmission rates than VPH patients after mandatory introduction of the DRGs. Shifting services to an outpatient setting was similar between the groups. CONCLUSIONS: Our findings suggest that the DRGs payment policy in Korea has decreased LOS and readmission rates. These findings support the continued implementation and enlargement of the DRGs payment system for other diseases in South Korea, given its potential for curbing unnecessary resource usage encouraged by FFS. If the Korean government deliberates on expansion of the DRGs to include other diseases with higher rates of complications, policymakers need to monitor deterioration of health care quality caused by fixed pricing.


Assuntos
Grupos Diagnósticos Relacionados/economia , Hospitais , Programas Obrigatórios , Qualidade da Assistência à Saúde/estatística & dados numéricos , Adulto , Idoso , Planos de Pagamento por Serviço Prestado/economia , Feminino , Humanos , Revisão da Utilização de Seguros , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , República da Coreia , Adulto Jovem
6.
Anesthesiology ; 131(4): 818-829, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31584884

RESUMO

BACKGROUND: Difficult or failed intubation is a major contributor to morbidity for patients and liability for anesthesiologists. Updated difficult airway management guidelines and incorporation of new airway devices into practice may have affected patient outcomes. The authors therefore compared recent malpractice claims related to difficult tracheal intubation to older claims using the Anesthesia Closed Claims Project database. METHODS: Claims with difficult tracheal intubation as the primary damaging event occurring in the years 2000 to 2012 (n = 102) were compared to difficult tracheal intubation claims from 1993 to 1999 (n = 93). Difficult intubation claims from 2000 to 2012 were evaluated for preoperative predictors and appropriateness of airway management. RESULTS: Patients in 2000 to 2012 difficult intubation claims were sicker (78% American Society of Anesthesiologists [ASA] Physical Status III to V; n = 78 of 102) and had more emergency procedures (37%; n = 37 of 102) compared to patients in 1993 to 1999 claims (47% ASA Physical Status III to V; n = 36 of 93; P < 0.001 and 22% emergency; n = 19 of 93; P = 0.025). More difficult tracheal intubation events occurred in nonperioperative locations in 2000 to 2012 than 1993 to 1999 (23%; n = 23 of 102 vs. 10%; n = 10 of 93; P = 0.035). Outcomes differed between time periods (P < 0.001), with a higher proportion of death in 2000 to 2012 claims (73%; n = 74 of 102 vs. 42%; n = 39 of 93 in 1993 to 1999 claims; P < 0.001 adjusted for multiple testing). In 2000 to 2012 claims, preoperative predictors of difficult tracheal intubation were present in 76% (78 of 102). In the 97 claims with sufficient information for assessment, inappropriate airway management occurred in 73% (71 of 97; κ = 0.44 to 0.66). A "can't intubate, can't oxygenate" emergency occurred in 80 claims with delayed surgical airway in more than one third (39%; n = 31 of 80). CONCLUSIONS: Outcomes remained poor in recent malpractice claims related to difficult tracheal intubation. Inadequate airway planning and judgment errors were contributors to patient harm. Our results emphasize the need to improve both practitioner skills and systems response when difficult or failed tracheal intubation is encountered.


Assuntos
Anestesiologistas/estatística & dados numéricos , Revisão da Utilização de Seguros/estatística & dados numéricos , Intubação Intratraqueal/efeitos adversos , Intubação Intratraqueal/estatística & dados numéricos , Imperícia/estatística & dados numéricos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos
7.
Urology ; 134: 103-108, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31536742

RESUMO

OBJECTIVE: To measure the incidence of persistent opioid use following ureteroscopy (URS). Over 100 Americans die every day from opioid overdose. Recent studies suggest that many opioid addictions surface after surgery. METHODS: Using claims data, we identified adults who underwent outpatient URS for treatment of upper tract stones between January 2008 and December 2016 and filled an opioid prescription attributable to URS. We then measured the rate of new persistent opioid use-defined as continued use of opioids 91-180 days after URS among those who were previously opioid-naive. Finally, we fit multivariable models to assess whether new persistent opioid use was associated with the amount of opioid prescribed at the time of URS. RESULTS: In total, 27,740 patients underwent outpatient URS, 51.2% of whom were opioid-naïve. Nearly 1 in 16 (6.2%) opioid-naïve patients developed new persistent opioid use after URS. Six months following surgery, beneficiaries with new persistent opioid use continued to fill prescriptions with daily doses of 4.2 oral morphine equivalents. Adjusting for measured sociodemographic and clinical differences, patients in the highest tercile of opioids prescribed at the time of URS had 69% higher odds of new persistent opioid use compared to those in the lowest tercile (odds ratio, 1.69; 95% CI, 1.41-2.03). CONCLUSION: Nearly 1 in 16 opioid-naive patients develop new persistent opioid use after URS. New persistent opioid use is associated with the amount of opioid prescribed at the time of URS. Given these findings, urologists should re-evaluate their post-URS opioid prescribing patterns.


Assuntos
Analgésicos Opioides , Transtornos Relacionados ao Uso de Opioides , Dor Pós-Operatória , Padrões de Prática Médica , Ureteroscopia , Cálculos Urinários/cirurgia , Adulto , Procedimentos Cirúrgicos Ambulatórios/estatística & dados numéricos , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Demografia , Feminino , Humanos , Revisão da Utilização de Seguros , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/epidemiologia , Dor Pós-Operatória/etiologia , Fatores de Risco , Fatores Socioeconômicos , Estados Unidos/epidemiologia , Ureteroscopia/efeitos adversos , Ureteroscopia/métodos , Urologistas/estatística & dados numéricos
8.
BMC Public Health ; 19(1): 1090, 2019 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-31409319

RESUMO

BACKGROUND: Seasonal influenza contributes substantially to the burden of communicable diseases in Europe, especially among paediatric populations and the elderly. The aim of the present study was to estimate the incidence of seasonal influenza in Germany, the probabilities of related complications and the economic burden of influenza per case and on a population level for different age groups. METHODS: Claims data from 2012 to 2014 from > 8 million insured of a large German sick-ness fund were analysed. A matched case control study was used on a sub-sample of 100,000 influenza cases to calculate complication rates for ear infections/acute otitis media (AOM) and community-acquired pneumonia (CAP) as well as resource use and costs for seven age groups. RESULTS: Incidence of seasonal influenza varies between the years and is highest among infants and children 2 to 5 years of age. AOM is more likely in the younger age groups with up to 14% more patients in the influenza group than in the control group. CAP is more frequently observed in the younger age groups and in influenza patients 60 years and older. The manifestation of one influenza complication (AOM or CAP) significantly in-creases the occurrence of a second complication (AOM or CAP). The economic burden per case is highest in infants (€251.91) and persons over 60 years of age (€131.59). CONCLUSION: The burden of influenza is highest among infants and young children, which is also reflected in the economic burden. Influenza related costs per case are nearly double for infants compared to persons over 60 years of age.


Assuntos
Efeitos Psicossociais da Doença , Influenza Humana/economia , Influenza Humana/epidemiologia , Adolescente , Adulto , Estudos de Casos e Controles , Criança , Pré-Escolar , Feminino , Alemanha/epidemiologia , Humanos , Incidência , Lactente , Recém-Nascido , Revisão da Utilização de Seguros , Masculino , Pessoa de Meia-Idade , Estações do Ano , Adulto Jovem
9.
BMC Public Health ; 19(1): 1091, 2019 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-31409349

RESUMO

BACKGROUND: The United States appears to be in the midst of an opioid epidemic. National data indicate a rise in emergency department visits for opioid-related causes over the past decade. This data, while important in helping to explain the magnitude of the epidemic nationally offers only a glimpse of what can be expected to occur locally. The objective of this secondary data analysis was to describe the impact that opioid abuse, adverse events, poisoning, and dependence have on emergency department utilization for individuals who purchased health insurance under the Affordable Care Act in Central Texas from a community-based health maintenance organization. METHODS: Individuals who purchased health insurance from Sendero Health Plans in calendar years 2016, 2017, and 2018 were eligible for participation if they had both an emergency department encounter and an opioid-related ICD-10-CM diagnosis. Eligible individuals were assessed to determine if they were dispensed an opioid agonist or opioid antagonist prescription during the year of their emergency department encounter. Sendero medical claims data for calendar years 2016, 2017, and 2018 were used to calculate both the incidence and ratio of emergency department visits per 100,000-person Sendero member population. Sendero data were compared to available national data estimates. RESULTS: A total of 55 individuals had an emergency department encounter with a primary or secondary opioid-related diagnosis from January 1, 2016 through December 31, 2018. These 55 individuals had 69 unique emergency department encounters during this time period. The incidence of new claims per 100,000-member Sendero population was 67.1, 64.5, and 62.6 in 2016, 2017, and 2018 respectively. The ratio of unique emergency department encounters per 100,000-member Sendero population was 95.9, 82.6, and 66.5 in 2016, 2017, and 2018 respectively. CONCLUSION: Health insurance claims data from a community-based health plan can be used as a source of local information by policy makers and officials as they seek to address the impact of opioid abuse, adverse events, poisoning, and dependence in Central Texas as national data may not represent the local impact of this epidemic.


Assuntos
Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/envenenamento , Serviço Hospitalar de Emergência/estatística & dados numéricos , Epidemias , Transtornos Relacionados ao Uso de Opioides/terapia , Adolescente , Adulto , Planejamento em Saúde Comunitária , Feminino , Humanos , Revisão da Utilização de Seguros , Classificação Internacional de Doenças , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Patient Protection and Affordable Care Act , Texas/epidemiologia , Estados Unidos/epidemiologia , Adulto Jovem
10.
Health Serv Res ; 54(6): 1255-1262, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31429471

RESUMO

OBJECTIVE: To compare predictive analytic approaches to characterize medication nonadherence and determine under which circumstances each method may be best applied. DATA SOURCES/STUDY SETTING: Medicare Parts A, B, and D claims from 2007 to 2013. STUDY DESIGN: We evaluated three statistical techniques to predict statin adherence (proportion of days covered [PDC ≥ 80 percent]) in the year following discharge: standard logistic regression with backward selection of covariates, least absolute shrinkage and selection operator (LASSO), and random forest. We used the C-index to assess model discrimination and decile plots comparing predicted values to observed event rates to evaluate model performance. DATA EXTRACTION: We identified 11 969 beneficiaries with an acute myocardial infarction (MI)-related admission from 2007 to 2012, who filled a statin prescription at, or shortly after, discharge. PRINCIPAL FINDINGS: In all models, prior statin use was the most important predictor of future adherence (OR = 3.65, 95% CI: 3.34-3.98; OR = 3.55). Although the LASSO regression model selected nearly 90 percent of all candidate predictors, all three analytic approaches had moderate discrimination (C-index ranging from 0.664 to 0.673). CONCLUSIONS: Although none of the models emerged as clearly superior, predictive analytics could proactively determine which patients are at risk of nonadherence, thus allowing for timely engagement in adherence-improving interventions.


Assuntos
Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Revisão da Utilização de Seguros/estatística & dados numéricos , Medicare/estatística & dados numéricos , Adesão à Medicação/estatística & dados numéricos , Infarto do Miocárdio/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Feminino , Previsões , Humanos , Modelos Logísticos , Masculino , Estudos Retrospectivos , Estados Unidos
11.
Clin Drug Investig ; 39(11): 1077-1092, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31399894

RESUMO

BACKGROUND AND OBJECTIVES: In Japan, polypharmacy reduction policy, which reduces the reimbursement of medical cost, was introduced to address unnecessary psychotropic polypharmacy. The rule was applied to the prescriptions of three or more anxiolytics or three or more hypnotics in the policy introduced in 2012. The prescriptions of four or more antidepressants or four or more antipsychotics were added to the rule in the policy revised in 2014. Furthermore, the prescriptions of three or more drugs of anxiolytics, hypnotics, antidepressants, or antipsychotics were subject to the reduction criteria of the policy revision in 2016. Benzodiazepine receptor agonists (BZs) are classified both into anxiolytics and hypnotics, and the reduction rule was not applied to the category of BZs before April 2018. This study aimed to examine the effect of the policy on the prescriptions of four drug categories as well as BZs from the point of view of the number of drugs and doses. METHODS: This was a retrospective observational study using a large-scale Japanese health insurance claims database. Patients who were prescribed at least one psychotropic drug (anxiolytic, hypnotic, antidepressant, or antipsychotic) during the study period (from April 2011 to March 2017) were selected. Segmented regression analysis was used to analyze the proportions of patients with three or more or four or more drugs as well as patients above clinically recommended doses, and the means of the average daily doses by drug category. RESULTS: A total of 312,167 patients were identified as a study population. The proportions of patients with three or more drugs in anxiolytics, hypnotics, antidepressants, and antipsychotics significantly decreased after the introduction or revisions of the policy, but not BZs. The proportions of patients with three or more drugs in March 2017 were 0.9%, 2.0%, 1.2%, 2.4%, and 8.9% in anxiolytics, hypnotics, antidepressants, antipsychotics, and BZs, respectively. The effect of the policy in reducing the proportions of patients above clinically recommended doses was identified in antipsychotics after the revision in 2016, but not identified in the sum of anxiolytics and hypnotics as well as BZs after the revision in 2014, and antidepressants after the revision in 2016. The proportions of monotherapy were increased from April 2011 to March 2017 only for antidepressants (76.9% → 80.8%) and antipsychotics (79.8% → 82.1%), and not changed or decreased for anxiolytics (85.2% → 85.7%), hypnotics (78.6% → 77.6%), sum of anxiolytics and hypnotics (68.1% → 65.7%), BZs (68.0% → 67.3%), and sum of psychotropic drugs (52.1% → 49.9%). CONCLUSIONS: The polypharmacy reduction policy reduced the proportions of patients with three or more drugs in four drug categories, but not BZs. Only limited effects were seen for reducing the proportions of patients above clinically recommended doses. The policy was revised in April 2018 again. Further investigation is needed to examine the effect of the revision in 2018.


Assuntos
Bases de Dados Factuais/tendências , Prescrições de Medicamentos , Revisão da Utilização de Seguros/tendências , Polimedicação , Psicotrópicos/administração & dosagem , Adolescente , Adulto , Idoso , Antidepressivos/administração & dosagem , Antipsicóticos/administração & dosagem , Bases de Dados Factuais/normas , Prescrições de Medicamentos/normas , Feminino , Humanos , Hipnóticos e Sedativos/administração & dosagem , Revisão da Utilização de Seguros/normas , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
12.
BMC Cancer ; 19(1): 856, 2019 Aug 29.
Artigo em Inglês | MEDLINE | ID: mdl-31464597

RESUMO

BACKGROUND: To investigate the association between pre-diagnostic colonoscopy and colorectal cancer mortality in South Australia. METHODS: Colonoscopy histories were obtained for colorectal cancer patients diagnosed in 2003-2013 using linked Medical Benefits Schedule (MBS) claims, hospital-inpatient and cancer-registry data. Colonoscopy histories included the year of colonoscopy, numbers of examinations, and the time from first colonoscopy to diagnosis. Histories of multiple exposures to colonoscopies, and exposures of greater than a year from initial colonoscopy to diagnosis, were regarded as indicators of screening or surveillance activity. Colonoscopies occurring within one year of diagnosis were regarded as more likely to be a response to cancer symptoms than those occurring > 1 year before diagnosis. Associations between colonoscopy history and post-diagnostic survival were analysed using sub-hazard ratios (SHRs) from competing risk regression adjusted for socio-demographic and cancer characteristics. RESULTS: Having pre-diagnostic colonoscopy was associated with an unadjusted reduction in risk of colorectal cancer death of 17% (SHR: 0.83, 95% CI 0.78-0.89). After adjusting for time period and sociodemographic characteristics, the risk of colorectal cancer death reduced by 17% for one pre-diagnostic colonoscopy examination; 27% for two pre-diagnostic colonoscopy examinations; and 45% for three or more pre-diagnostic colonoscopy examinations. Those with a time of over one year from first colonoscopy in the study window to diagnosis, when compared with less than one year, had a 17% lower risk of colorectal cancer death in this adjusted analysis. These reductions were substantially reduced or eliminated when also adjusting for less advanced stage. CONCLUSIONS: Pre-diagnostic colonoscopy, and more so, multiple colonoscopies and first colonoscopy occurring over one year from initial colonoscopy to diagnosis, were associated with longer survival post diagnosis. This was largely explained by less advanced cancer stage at the time of diagnosis.


Assuntos
Colonoscopia/estatística & dados numéricos , Neoplasias Colorretais/mortalidade , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Pacientes Internados , Revisão da Utilização de Seguros , Masculino , Pessoa de Meia-Idade , Mortalidade , Sistema de Registros , Austrália do Sul/epidemiologia , Análise de Sobrevida
13.
Drug Discov Ther ; 13(3): 137-144, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31327789

RESUMO

Existing evidence suggests that protease inhibitors (PIs) used to prevent or treat pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) are ineffective, and their use is not recommended by clinical practice guidelines. However, in Japan, PIs are administered with the aim to prevent or treat post-ERCP pancreatitis. This study aimed to clarify the gap between guideline recommendations and contents of practice. We used the health insurance claims database of Japan Medical Data Center. Among patients who had undergone ERCP, those with acute pancreatitis or post-ERCP pancreatitis recorded in claims as disease names were defined as post-ERCP pancreatitis patients. The study period was divided into three terms according to the date of publication of clinical practice guidelines for acute pancreatitis. Among 2,945 patients who had undergone ERCP, 2,847 were eligible for analysis. Of these, 1,375 (48.3%) patients had claims with pancreatitis recorded as the disease name; PIs were prescribed to 1,238 (90.0%). Rates of prescription of PIs were 72.3% in 2005-07, 70.9% in 2008-09, and 83.6% in 2010-15, showing a significant increase (p < 0.001). In conclusion, PIs are administered in clinical practice in Japan for the purpose of preventing or treating pancreatitis, with an increasing trend in prescription in recent years.


Assuntos
Pancreatite/prevenção & controle , Pancreatite/terapia , Lacunas da Prática Profissional/métodos , Inibidores de Proteases/administração & dosagem , Colangiopancreatografia Retrógrada Endoscópica , Medicina Baseada em Evidências , Feminino , Humanos , Revisão da Utilização de Seguros , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Prescrições/estatística & dados numéricos , Inibidores de Proteases/uso terapêutico
16.
N Engl J Med ; 381(6): 543-551, 2019 08 08.
Artigo em Inglês | MEDLINE | ID: mdl-31291511

RESUMO

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) developed the Accountable Care Organization (ACO) Investment Model (AIM) to encourage the growth of Medicare Shared Savings Program (MSSP) ACOs in rural and underserved areas. AIM provides financial support to eligible MSSP ACOs by means of prepayment of shared savings. Estimation of the performance of AIM ACOs on measures of spending and utilization in their first performance year would be useful for understanding the viability of ACOs located in these areas. METHODS: We analyzed Medicare claims and enrollment data for a group of fee-for-service beneficiaries who had been attributed to 41 AIM ACOs and for a comparable group of beneficiaries who resided in the ACO markets but were served primarily by non-ACO providers. We used a difference-in-differences study design to compare changes in outcomes from the baseline period (2013 through 2015) to the performance period (2016) among beneficiaries attributed to AIM ACOs with concurrent changes among beneficiaries in the comparison group. The primary outcome of interest was total Medicare Part A and B spending. RESULTS: Provider participation in AIM was associated with a differential reduction in total Medicare spending of $28.21 per beneficiary per month relative to the comparison group, which amounted to an aggregate decrease of $131.0 million. Over the same period, CMS made $76.2 million in prepayments and paid an additional $6.2 million in shared savings to ACOs in which shared savings exceeded the prepayments. After we accounted for this $82.4 million in CMS spending, the aggregate net reduction was $48.6 million, which corresponded to a net reduction of $10.46 per beneficiary per month. Decreases in the number of hospitalizations and use of institutional post-acute care contributed to the observed reduction in overall spending. CONCLUSIONS: With up-front investments, participation in ACO shared savings contracts by providers serving rural and underserved areas was associated with lower Medicare spending than that among non-ACO providers. (Funded by the Centers for Medicare and Medicaid Services.).


Assuntos
Organizações de Assistência Responsáveis/economia , Gastos em Saúde , Área Carente de Assistência Médica , Medicare/economia , Serviços de Saúde Rural/economia , Idoso , Idoso de 80 Anos ou mais , Redução de Custos , Feminino , Custos de Cuidados de Saúde , Humanos , Revisão da Utilização de Seguros , Masculino , Poupança para Cobertura de Despesas Médicas , Pessoa de Meia-Idade , Estados Unidos
17.
JAMA ; 322(1): 57-68, 2019 07 02.
Artigo em Inglês | MEDLINE | ID: mdl-31265101

RESUMO

Importance: Hawaii Medical Service Association (HMSA), the Blue Cross Blue Shield of Hawaii, introduced Population-based Payments for Primary Care (3PC), a new capitation-based primary care payment system, in 2016. The effect of this system on quality measures has not been evaluated. Objective: To evaluate whether the 3PC system was associated with changes in quality, utilization, or spending in its first year. Design, Setting, and Participants: Observational study using HMSA claims and clinical registry data from January 1, 2012, to December 31, 2016, and a propensity-weighted difference-in-differences method to compare 77 225 HMSA members in Hawaii attributed to 107 primary care physicians (PCPs) and 4 physician organizations participating in the first wave of the 3PC and 222 233 members attributed to 312 PCPs and 14 physician organizations that continued in a fee-for-service model in 2016 but had 3PC start dates thereafter. Exposures: Participation in the 3PC system. Main Outcomes and Measures: The primary outcome was the change in a composite measure score reflecting the probability that a member achieved an eligible measure out of 13 pooled Healthcare Effectiveness Data and Information Set quality measures. Primary care visits and total cost of care were among 15 secondary outcomes. Results: In total, the study included 299 458 HMSA members (mean age, 42.1 years; 51.5% women) and 419 primary care physicians (mean age, 54.9 years; 34.8% women). The risk-standardized composite measure scores for 2012 to 2016 changed from 75.1% to 86.6% (+11.5 percentage points) in the 3PC group and 74.3% to 83.5% (+9.2 percentage points) in the non-3PC group (differential change, 2.3 percentage points [95% CI, 2.1 to 2.6 percentage points]; P < .001). Of 15 prespecified secondary end points for utilization and spending, 11 showed no significant difference. Compared with the non-3PC group, the 3PC system was associated with a significant reduction in the mean number of primary care visits (3.3 to 3.0 visits vs 3.3 to 3.1 visits; adjusted differential change, -3.9 percentage points [95% CI, -4.6 to -3.2 percentage points]; P < .001), but there was no significant difference in mean total cost of care ($3344 to $4087 vs $2977 to $3564; adjusted differential change, 1.0% [95% CI, -1.3% to 3.4%]; P = .39). Conclusions and Relevance: In its first year, the 3PC population-based primary care payment system in Hawaii was associated with small improvements in quality and a reduction in PCP visits but no significant difference in the total cost of care. Additional research is needed to assess longer-term outcomes as the program is more fully implemented and to determine whether results are generalizable to other health care markets.


Assuntos
Planos de Seguro Blue Cross Blue Shield/economia , Atenção Primária à Saúde/economia , Melhoria de Qualidade , Mecanismo de Reembolso , Adulto , Capitação , Redução de Custos , Feminino , Hawaii , Pesquisas sobre Serviços de Saúde , Humanos , Revisão da Utilização de Seguros , Masculino , Pessoa de Meia-Idade , Médicos de Atenção Primária , Indicadores de Qualidade em Assistência à Saúde
19.
Medicine (Baltimore) ; 98(24): e15869, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31192918

RESUMO

Higher trait optimism and/or lower cynical hostility are associated with healthier behaviors and lower risk of morbidity and mortality, yet their association with health care utilization has been understudied. Whether these psychological attitudes are associated with breast cancer screening behavior is unknown. To assess the association of optimism and cynical hostility with screening mammography in older women and whether sociodemographic factors acted as mediators of these relationships, we used Women's Health Initiative (WHI) observational cohort survey data linked to Medicare claims. The sample includes WHI participants without history of breast cancer who were enrolled in Medicare Parts A and B for ≥2 years from 2005-2010, and who completed WHI baseline attitudinal questionnaires (n = 48,291). We used survival modeling to examine whether screening frequency varied by psychological attitudes (measured at study baseline) after adjusting for sociodemographic characteristics, health conditions, and healthcare-related variables. Psychological attitudes included trait optimism (Life Orientation Test-Revised) and cynical hostility (Cook Medley subscale), which were self-reported at study baseline. Sociodemographic, health conditions, and healthcare variables were self-reported at baseline and updated through 2005 as available. Contrary to our hypotheses, repeated events survival models showed that women with the lowest optimism scores (i.e., more pessimistic tendencies) received 5% more frequent screenings after complete covariate adjustment (p < .01) compared to the most optimistic group, and showed no association between cynical hostility and frequency of screening mammograms. Sociodemographic factors did not appear to mediate the relationship between optimism and screenings. However, higher levels of education and higher levels of income were associated with more frequent screenings (both p < .01). We also found that results for optimism were primarily driven by women who were aged 75 or older after January 2009, when changes to clinical guidelines lead to uncertainty about risks and benefits of screening in this age group. The study demonstrated that lower optimism, higher education, and higher income were all associated with more frequent screening mammograms in this sample after repeated events survival modeling and covariate adjustment.


Assuntos
Mamografia/estatística & dados numéricos , Otimismo/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Idoso , Feminino , Comportamentos Relacionados com a Saúde , Humanos , Revisão da Utilização de Seguros , Estudos Longitudinais , Medicare , Fatores Socioeconômicos , Estados Unidos , Saúde da Mulher
20.
BMC Health Serv Res ; 19(1): 354, 2019 Jun 04.
Artigo em Inglês | MEDLINE | ID: mdl-31164130

RESUMO

BACKGROUND: We examined the utilization of rehabilitation resources among children with autism spectrum condition (ASC), a neurodevelopmental condition, in Taiwan. METHODS: We derived from the National Health Insurance Research Database of Taiwan data pertaining to 3- to 12-year-old children for the period 2008-2010. Based on diagnoses executed in accordance with the International Classification of Diseases, Ninth Revision, Clinical Modification, we classified these data into the ASC and non-ASC groups and analyzed them through multiple linear regression model, negative binomial model, independent sample t testing, and χ2 testing. RESULTS: Compared with the non-ASC group, the ASC group exhibited higher utilization of rehabilitation resources. Because hospitals are constrained by overall expenditure limits, expenditure on rehabilitation resources has plateaued, preventing any increase in the utilization of rehabilitation resources. In our ASC group, preschool-aged children significantly outnumbered (p < 0.001) school-aged children. When stratified by the hospital level, district hospitals reported the highest utilization (p < 0.001). When stratified by region, the highest utilization was in Taipei, whereas the lowest was in the East region (p < 0.001). The total annual cost, average frequency of visits, utilization of rehabilitation resources, and average cost were all affected by such elements as patient demographics, hospital type and location (p < 0.001). CONCLUSIONS: For improving treatment outcomes among children with ASC and decreasing treatment expenditure, policies that promote the timely ASC detection and treatment should be implemented.


Assuntos
Assistência Ambulatorial/economia , Transtorno Autístico , Gastos em Saúde/estatística & dados numéricos , Programas Nacionais de Saúde/economia , Pacientes Ambulatoriais , Transtorno Autístico/economia , Transtorno Autístico/reabilitação , Criança , Pré-Escolar , Bases de Dados Factuais , Feminino , Humanos , Revisão da Utilização de Seguros , Masculino , Taiwan
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