Sedentary behavior and blood pressure control among osteoarthritis initiative participants.

OBJECTIVE: To examine the association between sedentary behavior and blood pressure (BP) among Osteoarthritis Initiative (OAI) participants. DESIGN: We conducted a cross-sectional analysis of the OAI 48-month visit participants whose physical activity was measured using accelerometers. Participants were classified into four quartiles according to the percentage of wear time that was sedentary (<100 activity counts per min). Users of antihypertensive medications or non-steroidal anti-inflammatory drugs (NSAIDs) were excluded. Our main outcomes were systolic and diastolic blood pressures (SBP and DBP) and "elevated BP" defined as BP ≥ 130/85 mm Hg. RESULTS: For this study cohort (N = 707), mean BP was 121.4 ± 15.6/74.7 ± 9.5 mm Hg and 33% had elevated BP. SBP had a graded association with increased sedentary time (P for trend = 0.02). The most sedentary quartile had 4.26 mm Hg higher SBP (95% confidence interval (CI), 0.69-7.82; P = 0.02) than the least sedentary quartile, adjusting for age, moderate-to-vigorous (MV) physical activity, and other demographic and health factors. The probability of having elevated BP significantly increased in higher sedentary quartiles (P for trend = 0.046). There were no significant findings for DBP. CONCLUSION: A strong graded association was demonstrated between sedentary behavior and increased SBP and elevated BP, independent of time spent in MV physical activity. Reducing daily sedentary time may lead to improvement in BP and reduction in cardiovascular risk.

Cost-effectiveness of Veterans Administration hospital-based home care. A randomized clinical trial.

A randomized design was used to examine the cost-effectiveness of a Veterans Administration hospital-based home care program that case managed inpatient and outpatient care. Patients (N = 419) with two or more functional impairments or a terminal illness were randomized to hospital-based home care (n = 211) or customary care (n = 208). Functional status, satisfaction with care, and morale were measured at baseline and at 1 and 6 months after discharge from the hospital; health care utilization was tracked for 6 months. Findings included significantly higher (0.1 on a three-point scale) patient and caregiver satisfaction with care at 1 month and lower Veterans Administration and private sector hospital costs ($3000 vs $4245) for the experimental group. Net per person health care costs were also 13% lower in the experimental group. We conclude that this model of hospital-based home care is cost-effective and that its expansion to cover these two patient groups throughout the Veterans Administration system can improve patient care at no additional cost.

Prepayment with office-based physicians in publicly funded programs: results from the Children's Medicaid Program.

This paper is a report of the results of a demonstration designed to provide empirical evidence regarding the effects of alternative approaches to paying physicians for serving children in the Medicaid program: (1) visit fees set at twice regular Medicaid fees in return for physician agreement to manage utilization and (2) capitation and financial risk-sharing along with the same physician agreement to manage utilization. Participating physicians were assigned randomly to either of the two payment groups. Comparisons of utilization and expenditures were made between these two plans and the regular Medicaid program (fee-for-service, low fees). Results showed no adverse effect of capitation payments on primary care visits to office-based physicians. Capitation physician referrals to specialists decreased relative to all other groups studied, consistent with the theory that the financial incentives in capitation will lead primary care physicians to reduce referrals to specialists.

Organizational characteristics, client characteristics, and the delivery of home care services.

This research examines the extent to which organizational professional orientation, client perceived needs, and client characteristics jointly determine long-term care service delivery to a frail elderly population. The study uses primary data collected from 16 community networks that were part of a national demonstration of the Living at Home Program, conducted from 1986 to 1989. Data include baseline assessments of individuals enrolled at each site, subsequent utilization data, and data on community network characteristics. Site professional orientation has a significant role in determining services provided to clients, with social service agencies more likely to provide nonmedical services and less likely to provide skilled-care services. Despite systematic site variation in the services provided to individuals, sites appear to reasonably allocate resources among individuals with differing levels of functional disability.

Use of nursing homes by a high-risk long-term care population.

Limited information exists concerning lifetime use of nursing home services by the aged. This article examines the longitudinal experience, over four years, of elderly individuals at high risk of institutionalization, and develops a simple model of nursing home use based on these observations. This model allows us to predict future lifetime use under alternative assumptions. The main observations drawn from this sample are that high-risk elderly tend to move from the community to nursing homes, but not back to the community except for short, transitional stays. Further, despite high overall mortality rates, the expected nursing home use by these high-risk elderly is very high, due to long average stays by a minority of the sample that enters a nursing home and remains there longer than six months.

The effect of investor-owned chain acquisitions on hospital expenses and staffing.

Much concern has been raised about the effect of "corporatization" of health through the expansion of investor-owned hospital chains. One method of expansion is through hospital acquisition. At issue is the question of the effect of acquisitions on expenses and on such patient care inputs as staffing levels. In this article, we examine the effect of acquisition by one investor-owned chain on hospital costs and staffing. Subsequent to acquisition, hospital costs increase and staffing decreases, relative to competitor hospitals. However, since investor-owned hospitals not recently acquired do not have higher cost levels than their competitors, the increase in costs appears to be due to factors associated with the acquisition itself rather than factors associated with being an investor-owned hospital. Under the retrospective payment system in effect at the time, revenues also were higher for acquired hospitals. Under prospective payment, increasing revenues has been more difficult, decreasing acquisition incentives.

Impact of long-term home care on hospital and nursing home use and cost.

This article reports the long-range impact of a long-term home care program in Chicago on hospital and nursing home use and on overall health care costs over four client-years of observation. The evaluation utilized a quasi-experimental design with a comparison group composed of clients who received home-delivered meals. The health services utilization experience of consecutively accepted treatment (N = 157) and comparison group (N = 156) subjects was monitored for 48 client-months following acceptance to care. Imputed costs were then assigned to each type of care measured. Findings include a significantly lower risk of permanent admission to sheltered and intermediate-level nursing home care in the treatment group but no difference in risk of permanent admission to skilled-level nursing home care. Despite savings in low-intensity nursing home days, preliminary findings indicate that total costs of care were 25 percent higher in the treatment group. However, these costs are accompanied by significant quality-of-life benefits in the treatment group (reported elsewhere).

Impact of long-term home care on mortality, functional status, and unmet needs.

This article reports the outcomes of a four-year follow-up evaluation of the Five Hospital Program, a long-term home care program in Chicago. Outcomes assessed include the mortality, comprehensive functional status, and perceived unmet needs of its frail elderly clientele (mean age 81 years at entry). The evaluation utilized a pretest, multiple posttest design with a comparison group consisting of similarly elderly and impaired individuals receiving OAA Title III-C home-delivered meals. Consecutively accepted treatment (N = 157) and comparison group clients (N = 156) were interviewed using the OARS Multidimensional Functional Assessment Questionnaire at baseline, 9 months, and 48 months after acceptance to care. A multivariate analysis of mortality rates revealed no between-group differences attributable to treatment on this outcome. Major findings included significantly better cognitive functioning and reduced unmet needs in the treatment group at nine months. A longer-range, continued beneficial effect of treatment on cognitive status was also observed at 48 months. We conclude that long-term home care provided important benefits to clients at both 9 and 48 months, with no effect on mortality. However, we suggest that the four-year findings be interpreted with caution, since only a small percentage of clients (18 percent) were still alive and receiving active care in the community at that time.

Regional variation in Medicare hospital mortality.

This study examines variation in severity-adjusted Medicare hospital mortality rates across nine U.S. census regions. The extent to which regional variation is reduced by controlling for differences in hospital resources and structure, county-level population characteristics, and the level of federal SuperPRO-identified hospital quality problems is estimated. Hospital resources, population characteristics, and SuperPro process quality scores are significant predictors of hospital mortality rates, but they do not explain the important, highly significant regional differences observed after controlling for hospital case-mix severity.

Evaluation of a prospective payment system for VA contract nursing homes.

An evaluation of a pilot program for community nursing home care reimbursement by Department of Veterans Affairs Medical Centers (VAMCs) was undertaken. Eight VAMCs began using the Enhanced Prospective Payment System (EPPS) in 1992. These sites were compared to eight customary payment sites in a pretest/posttest quasi-experimental design. Outcomes included access to care, administrative workload, quality of care, and cost. As expected, per diem costs were significantly higher for EPPS than customary reimbursement patients ($106 vs. $87). However, EPPS sites placed veterans more quickly (81 days vs. 113 days; p < .01) than comparison sites and reduced administrative workload associated with placement. EPPS sites also increased the number of Medicare-certified homes under contract (76% vs. 54%) and placed significantly more veterans who received therapy (20% vs. < 1%). Savings in hospital days more than offset the increased cost of nursing home placement. Because the findings were attributed largely to a few veterans with long lengths of hospital stay, the early success of EPPS may diminish as the backlog of these long-stay patients decreases.

Health services research clinical trials: issues in the evaluation of economic costs and benefits.

The costs and benefits of treatment interventions are difficult both to conceptualize and to measure. This paper discusses methodologic issues that arise in measuring costs, distinguishing between social costs and transfer payments, measuring the value of life and limb, and assessing the meaning of cost differences. Long-run vs. short-run costs and average vs. marginal costs are considered. Sensitivity analysis to assess the robustness of results to alternative assumptions is stressed. Cost-benefit and cost-effectiveness analyses are seen as important in assessing the policy implications of clinical trials; a proper cost-benefit analysis allows the reader to understand how results relate to the assumptions made in the analyses.

Hospital cost incentives in a fragmented health care system.

During the mid-1980s, hospital prospective payment regulation was associated with major changes in medical practice, resulting in initially significant reductions in the rate of growth of inpatient costs. More recently, the rate of growth of hospital costs has returned to historic levels, yet most hospitals have been reluctant to intensify their economic monitoring of physicians. Using data from a large teaching hospital in the Midwest, this article presents a model of marginal profitability by payor and by relative physician costliness. The results illustrate the mixed incentives for hospitals to reduce costly medical practice variations.

Pediatric rheumatology: a survey of physician practices and fellowship programs.

We report the results of a 1982 pilot survey of pediatric rheumatology physicians and fellowship training programs in the United States. All physicians indicating in the ARA directory that they could care for rheumatic diseases of children were surveyed, with a response rate of 57.6%. There were 35 directors of United States pediatric rheumatology programs among the respondents. The survey provided basic information concerning training and practice characteristics of respondent physicians and the sources of funding, size, and emphasis of the fellowship programs. Specific attention is given to indicators of demand for pediatric rheumatology services.

Predicting agency participation in interorganizational networks providing community care.

In response to health care reform, health care providers have begun to develop interorganizational networks. At present, however, relatively little is known about factors facilitating participation in networks. To this end, organizational characteristics and views were obtained from key informants from both "Lead" and "Affiliate" Agencies participating in the networks for the Living-at-Home Program (LAHP) Demonstration (N = 131) using an Organizational Change Survey. Logistic regression analysis was used to examine factors related to network member agencies' participation. Significant relationships were found between decreased participation and lack of agreement between network agencies regarding expectations (P = 0.02), membership in a network with a Medical Lead Agency (P < 0.01), and Lead Agency inexperience (P < 0.01). Agencies with lower ratings of the impact that LAHP had on their community were more likely to decrease their participation (P = 0.01). The number of unoccupied nursing home beds in the community was positively and significantly related to decreased participation (P < 0.001). These results suggest that leadership skills of the Lead Agency, and in particular, experience, may be among the chief requirements for the creation and development of successful networks, and confirm that inexperienced Lead Agencies may face an uphill battle in terms of recruiting and maintaining network members.

Disability in activities of daily living: patterns of change and a hierarchy of disability.

OBJECTIVES: This paper examines longitudinal data over 6 years to evaluate incidence rates of disability and the pattern of dependency in activities of daily living. METHODS: The Longitudinal Study of Aging (n = 5151) was used to evaluate incidence of disability in activities of daily living; biennial interview data from 1984 through 1990 were used. The median age to disability onset for individual activities was estimated from survival analysis. A prevalent ordering of incident disability was identified from patterns of disability onset within individuals. RESULTS: The progression of incident disability among the elderly supported by longitudinal data, based on both the ordering of median ages to disability onset and patterns of incident disability, was as follows: walking, bathing, transferring, dressing, toileting, feeding. Gender differences were found in disability incidence rates. CONCLUSIONS: This study provides a mathematical picture of physical functioning as people age. These findings, based on longitudinal data, indicate a different hierarchical structure of disability than found in previous reports using cross-sectional data. Furthermore, the study documents gender differences in incident impairment, which indicate that although women outlive men, they spend more time in a disabled state.

HCA's acquisition process: the physician's role and perspective.

Physicians play an active role in the acquisition process. A study of acquisition impact showed that postacquisition, medical staffs grew and became more specialized and board certified. Greatest physician satisfaction was with the overall facility, medical equipment, and administrative responsiveness.

Carotid endarterectomy: characterization of recent increases in procedure rates.

INTRODUCTION: Recent increases in the rate of carotid endarterectomies (CEAs) have been attributed to results of clinical trials demonstrating efficacy when CEA is performed in centers of excellence. Subsequent population-based data suggest that trial results may not be matched in the community. This study was undertaken to characterize trends in CEA procedure rates after the dissemination of trial data and to describe any change in patient outcomes with population-based data from a single state. METHODS: Hospital administrative data on CEAs from 1992 to 1996 (n = 45,744) were obtained for the state of Florida. Annualized CEA rates per 100, 000 Florida residents were analyzed to determine trends in patient age, sex, admission type, size of hospital beds, ownership type and teaching status, and annual hospital and surgeon CEA volume. Outcomes were examined to track trends in complication rates. RESULTS: The annual number of CEA procedures increased 74% from 63.7 per 100,000 residents per year to 110.8 per 100,000 residents per year between 1992 and 1996. A single large increase occurred during the second half of 1994 when CEAs increased 73.5% from 16.6 per 100, 000 residents per quarter to 28.8 per 100,000 residents per quarter after a clinical alert on benefits to CEAs in asymptomatic patients. Over 5 years, there were significant trends toward more nonemergent admissions, and more procedures were performed in high-volume hospitals and by high-volume surgeons. Procedure rates in both women and very elderly patients increased more than 70%, which was in step with younger patients and men. The incidence of inpatient stroke and death declined over the 5-year period, whereas the rate of perioperative myocardial infarction remained constant. CONCLUSIONS: Experience from Florida indicates that CEA rates increased as results of the Asymptomatic Carotid Artery Study disseminated. Trial results have been broadly interpreted to include women and very elderly patients. More patients are being referred to busier hospitals and to high-volume surgeons, which should continue to result in better patient outcomes.

Federal antitrust merger enforcement standards: a good fit for the hospital industry?

We examine the implications of the 1992 Horizontal Merger Guidelines for the hospital industry and subsequent policy statements that were developed for health care providers. Application of antitrust policy to hospitals has raised several concerns, mainly because many communities have few hospitals and economic forces in the industry are accelerating interest in intramarket mergers and provider network development. We address several issues, including the standing of hospitals relative to the market concentration thresholds of the merger guidelines, market concentration compared among challenged and unchallenged mergers of the 1980s, findings of previous research about the relationship between market concentration and competition in hospital markets, and differences in characteristics other than market concentration that are relevant to the merger guidelines among challenged and unchallenged mergers. We found that (1) the specific standards articulated in the merger guidelines do not provide good predictability of when a hospital merger challenge would occur, and (2) comparisons of challenged and unchallenged mergers in similarly structured markets suggest that enforcement actions may deviate in practice from the enforcement principles of the merger guidelines. We consider several options for refining antitrust enforcement policy. Refinement of enforcement policies is important given the industry restructuring that is likely through health care reform.