Mortality in the uninsured compared with that in persons with public and private health insurance.

OBJECTIVE: To compare mortality in persons with employer-provided health insurance, Medicare, Medicaid, military health benefits, other private health insurance, and no health insurance, before and after adjustment for income and employment status. DESIGN: Cohort study using national survey data containing information on social, economic, and demographic factors and health insurance, with deaths identified through matching to the National Death Index resulting in a mortality follow-up period of 5 years. SETTING: Noninstitutionalized population of the United States. PARTICIPANTS: Approximately 150,000 respondents to national surveys conducted by the US Bureau of the Census (Current Population Surveys), aged 25 to 64 years. RESULTS: After adjustment for age and income, persons with Medicare and Medicaid had the highest mortality in comparison with those with employer-provided insurance, with relative risks generally greater than 2. With adjustment for age and income, persons without insurance had higher mortality than those with employer-provided insurance, with relative risks of 1.2 for white men and 1.5 for white women. These relationships held after adjustment for employment status, with the working uninsured showing mortality between 1.2 and 1.3 times higher than that of the working insured. Mortality was higher in those with lower incomes after adjustment for insurance status. Those with annual income of $10,000 or less per year had mortality about two times that of persons with incomes greater than $25,000 per year. CONCLUSION: Mortality was lowest in employed persons with employer-provided health insurance. The higher mortality in those with public insurance or with no insurance reflects an indeterminate mix of selection on existing health status and access to medical care.

Office-based physician services provided by dermatologists in the United States in 1990.

Published epidemiologic data regarding dermatologic practice may no longer be current. The National Ambulatory Medical Care Survey conducted in 1990 provides a comprehensive assessment of ambulatory medical practice including patient demographics, chief and secondary complaints, diagnoses, and drug treatments prescribed. Many specialties including dermatology were represented in the sampling technique. The database was reviewed for descriptive aspects of visits to dermatologists surveyed. Using standardized weighting techniques, we estimated the total number of physician visits. Dermatologists had an estimated 24.0 million patient encounters in 1990. Dermatologists treated a disproportionately large number of female and younger patients. After adjusting for their proportion of the population, Asians and Whites had greater numbers of dermatologic encounters than Blacks and Native Americans. Patients had two or more complaints 27.2% of the time, and received two or more diagnoses 28.9% of the time. The most common complaints accounting for 49.7% of visits included "pimples," "rash," "discoloration," "skin lesion," "wart," and "skin growth." The most common diagnoses, accounting for 52.7% of all encounters, were acne, keratosis, wart, dermatitis or eczema, benign neoplasm, and malignant neoplasm. This paper presents demographic information, chief and secondary complaints, and chief and secondary diagnoses of patients visiting dermatologists in the United States in 1990. Whites and Asian or Pacific Islanders have increased utilization of services compared with Blacks and Native Americans or Eskimos; this disparity correlates with median family income.

The Kidney Outcomes Prediction and Evaluation (KOPE) study: a prospective cohort investigation of patients undergoing hemodialysis. Study design and baseline characteristics.

PURPOSE: The purpose of the Kidney Outcomes Prediction and Evaluation (KOPE) study, was to more fully characterize the end-stage renal disease (ESRD) population with respect to social, psychological, and clinical characteristics, and to prospectively study the biomedical, social, and psychological factors that influence a range of ESRD outcomes in a large observational study of black and white patients on hemodialysis. This paper focuses on the KOPE study design as well as characteristics of patients at baseline. METHODS: KOPE was a prospective cohort investigation of patients treated at four dialysis centers in Forsyth County, North Carolina. Participants were interviewed at the dialysis centers, semi-annually over a 3 1/2 year period. Prevalent cases who were being treated with hemodialysis at the initiation of the study were enrolled into KOPE. Incident cases were subsequently enrolled as they presented to the participating units for hemodialysis. A total of 304 prevalent and 162 incident cases were enrolled into the study. The baseline health and sociodemographic characteristics of KOPE participants reported in this paper were obtained from medical records and Southeast Kidney Council data. Laboratory values taken within a 30-day interval around the baseline interview are also reported. RESULTS: KOPE participants differ from national statistics on race, age, and gender. Differences between KOPE participants and patients living in the region, but who did not participate in the study, can be explained by our recruitment criteria. CONCLUSIONS: KOPE will enable the characterization of the ESRD population, identification of factors related to poor outcomes, and identification of opportunities for interventions to prevent death and morbidity.

Financial performance among adult day centers: results of a national demonstration program.

OBJECTIVES: This paper describes the financial performance (defined as percent of total expenses covered by net operating revenue) of 16 adult day centers participating in a national demonstration program on day services for people with dementia, including examination of possible predictors of financial performance. METHODS: Participating sites submitted quarterly financial and utilization reports to the National Program Office. Descriptive statistics summarize the factors believed to influence financial performance. RESULTS: Sites averaged meeting 35% of expenses from self-pay and 29% from government (mainly Medicaid) revenue, totaling 64% of all (cash plus in-kind) expenses met by operating revenue. Examination of center characteristics suggests that factors related to meeting consumer needs, such as being open a full day (i.e., 7:30 am to 6:00 pm) rather than shorter hours, and providing transportation, may be related to improved utilization and, thus, improved financial performance. Higher fees were not related to lower enrollment, census, or revenue. CONCLUSIONS: Adult day centers are able to achieve financial viability through a combination of operating (i.e., fee-for-service) and non-operating revenue. Operating revenue is enhanced by placing emphasis on consumer responsiveness, such as being open a full day. Because higher fees were not related to lower utilization, centers should set fees to reflect actual costs. The figure of 64% of expenses met by operating revenue is conservative inasmuch as sites included in-kind revenue as expenses in their budgeting calculations, and percent of cash expenses met by operating revenue would be higher (approximately 75% for this group of centers).

Exercise rehabilitation improves functional outcomes and peripheral circulation in patients with intermittent claudication: a randomized controlled trial.

OBJECTIVE: To determine the effects of a 6-month exercise program on ambulatory function, free-living daily physical activity, peripheral circulation, and health-related quality of life (QOL) in disabled older patients with intermittent claudication. DESIGN: Prospective, randomized controlled trial. SETTING: University Medical (Center and Veterans Affairs Medical Center, Baltimore, Maryland. PARTICIPANTS: Thirty-one of 61 patients with Fontaine stage II peripheral arterial occlusive disease (PAOD) were randomized to exercise rehabilitation and 30 to usual-care control. Three patients from the exercise group and six patients from the control group dropped out, leaving 28 and 24 patients, respectively, completing the study in each group. INTERVENTION: Six months of exercise rehabilitation. MEASUREMENTS: Treadmill distance walked to onset of claudication and to maximal claudication, ambulatory function, peripheral circulation, perceived QOL, and daily physical activity. RESULTS: Compliance with the exercise program was 73% of the possible sessions. Exercise rehabilitation increased treadmill distance walked to onset of claudication by 134% (P < .001) and to maximal claudication by 77% (P < .001), walking economy by 12% (P = .003), 6-minute walk distance by 12% (P < .001), and maximal calf blood flow by 30% (P < .001). Changes in distance walked to maximal pain correlated with changes in walking economy (r = -.50, P = .013) and changes in maximal calf blood flow (r = .38, P = .047). Exercise rehabilitation increased accelerometer-derived daily physical activity by 38% (P < .001); this change correlated with the change in distance walked to maximal pain (r = .45, P = .020). These improvements were significantly better than the changes in the control group (P < .05). CONCLUSION: Improvements in claudication following exercise rehabilitation in older PAOD patients are dependent on improvements in peripheral circulation and walking economy. Improvement in treadmill claudication distances in these patients translated into increased accelerometer-derived physical activity in the community, which enabled the patients to become more functionally independent.

Use of GnRH agonist before hysterectomy: a cost simulation.

OBJECTIVE: To evaluate the potential savings in cost of care derived from performing vaginal hysterectomies instead of abdominal hysterectomies in selected women with fibroid uteri equivalent in size to a 14-18 week gestation. METHODS: Women 35-46 years of age undergoing hysterectomy for fibroid uteri were selected to allow application of conversion rates gained in a separate randomized study using leuprolide acetate depot 3.75 mg. Statewide public data for North Carolina's hospital discharges provided relative rates of hospital charges and leiomyomas for all hysterectomies, by age. Professional charges were omitted from the analysis. Estimated savings were projected to the national level. RESULTS: During 1992 in North Carolina, 18,110 inpatient hysterectomies were performed for women of all ages; 28.1% of these were for uterine leiomyomas. For women 35-46 years old (12.7% of all hysterectomies), there were 1904 abdominal and 390 vaginal hysterectomies; the mean total charge for abdominal hysterectomy was $5590, and $4732 for the vaginal alternative. These statewide data provide missing elements to allow a national estimate of the potential savings of using GnRH agonist preoperatively. The projected national savings, if 1987 utilization data are used, was $4.6 million, nearly 1.4% of the inpatient charges. The 1992 value of these savings is $6.7 million. CONCLUSION: The use of preoperative GnRH agonist therapy before hysterectomy for patients with a uterine size equivalent to a 14-18 week gestation represents a significant cost-saving alternative, increasing the use of vaginal hysterectomy and resulting in potential savings in direct inpatient medical care charges.

Cost-effectiveness of aerobic and resistance exercise in seniors with knee osteoarthritis.

PURPOSE: The purpose of this study was to determine, in a randomized clinical trial of 439 individuals with knee osteoarthritis, the incremental cost-effectiveness of aerobic versus weight resistance training, compared with an education control intervention. METHODS: Cost estimates of the intervention were based upon the cost of purchasing from the community similar services to provide exercise or health education. Effect at 18 months was measured using several variables, including: self-reported disability score, 6-min walking distance, stair climb, lifting and carrying task, car task, and measures of pain frequency and pain intensity on ambulation and transfer. RESULTS: The total cost of the educational intervention was $343.98 per participant. The aerobic exercise intervention cost $323.55 per participant, and the resistance training intervention cost $325.20 per participant. On all but two of the outcome variables, the incremental savings per incremental effect for the resistance exercise group was greater than for the aerobic exercise group. CONCLUSION: The data obtained from this study suggest that, compared with an education control, resistance training for seniors with knee osteoarthritis is more economically efficient than aerobic exercise in improving physical function. However, the magnitude of the difference in efficiency between the two approaches is small.

A feedback system for reducing excessive laboratory tests.

At the James A. Haley Veterans Hospital in Tampa, Fla, a program has been implemented to reduce the amount of potentially excessive laboratory testing. The major program components are a set of test frequency guidelines and a system of feedback to resident physicians that compares their test ordering patterns against the predetermined guidelines. The guidelines are analyte specific and differentiate between normal and abnormal test values reported during 1-day and 7-day time periods. The feedback process includes both systematic reporting of objective data and individual and group education and counseling sessions related to the appropriate use of laboratory tests. A reduction in the percentage of tests that fell outside the guidelines (outliers) was achieved following implementation of the program.

Self-care and illness response behaviors in a frontier area.

Self-care and illness response to a recent medical event were examined based on a mailed questionnaire to a random sample of 416 adults in a frontier area in north-central Idaho. A total of 494 questionnaires were returned (45% response rate), and 78 were eliminated. Self-care behaviors were classified as: (1) waiting to see what would happen, (2) purchasing or taking a nonprescription medication, (3) taking a prescription medication that was on hand, (4) taking both a prescription and a nonprescription medication, (5) contacting a physician, and (6) going to a hospital. These six variables were classified into three intervention constructs of no intervention (waiting), informal intervention (self-medicating), and formal intervention (contacting a health care professional). Fifty-six percent of the respondents reported self-medicating behaviors. Correlation analysis indicated that initial self-care and illness response behaviors in this frontier area were generally appropriate. Three multiple discriminant models were tested to differentiate those people who waited, self-medicated, and contacted formal providers from those who did not. A significant model could not discriminate between those who waited and those who did not. Models for self-medicating and contacting formal providers correctly classified cases 60 to 70 percent of the time. The analyses indicate that self-medicating was more likely to be reported by younger individuals, by those who lived further from the hospital, who perceived their health status to be better, who reported less satisfaction with community health care services, and that the self-medicating was appropriate.(ABSTRACT TRUNCATED AT 250 WORDS)

The ability of aggregate data to predict self-sufficiency levels in subsidized rural primary care practices.

American rural health policy has as its long-term goal the reallocation of health facilities and manpower to permit equitable access to primary care for all citizens. Rural health centers subsidized by governmental and philanthropic programs frequently have been placed in places of high need for their services. Yet both government and philanthropic policymakers expect these primary care practices to become economically self-sufficient within a few years of practice. The problem is how to assign rural practices to communities with a planning process that will enhance the likelihood that these conflicting goals of serving need and financial self-sufficiency will be achieved. This study uses actual 1980 self-sufficiency data from 167 randomly selected rural primary care clinics as the dependent variable. Independent variables for the corresponding communities five or more years earlier were taken from a database often used by policymakers to make site evaluations. These data tend to be selected from aggregate county level measures. Regression analysis were used to determine how well these data could predict actual self-sufficiency in later years. The result of the analysis is that these aggregate level data have little capacity to predict the ability of rural primary care practices to achieve self-sufficiency. Much better predictions can be made on the basis of local, practice-specific variables. Therefore, planning for economically viable rural practices calls for a much different forecasting approach.

Rural and urban differences in mortality among Americans 55 years and older: analysis of the National Longitudinal Mortality Study.

Previous research on rural and urban differences in risk of mortality has been inconclusive. This article used data from the National Longitudinal Mortality Study to establish whether all-cause mortality risk among persons 55 years and older varies by degree of urbanization, controlling for the potential sociodemographic confounders of age, gender, race/ethnicity, education, income, and marital status. Using the Cox Proportional Hazards Regression Procedure, the authors found that persons living in the most rural locales and those living in rural communities in standard metropolitan statistical areas (SMSAs) have the lowest risk of mortality, while those living in SMSA central cities had the highest risk of dying during the study period. The protective effect of rural residence declines in older age cohorts.

Economic value of caregiver effort in maintaining long-term ventilator-assisted individuals at home.

OBJECTIVE: To estimate the economic value of caregivers' efforts in maintaining ventilator-assisted individuals at home. DESIGN: Nonexperimental, cross-sectional survey. SETTING: Households of home-based ventilator-assisted individuals residing in 37 states. PARTICIPANTS: Caregivers of 1404 ventilator-assisted individuals; 277 (19.7%) responses were received. OUTCOME MEASURES: The Home Ventilator Care Cost and Utilization Survey and the Modified Katz Index. METHODS: The economic value of caregiver effort was estimated deterministically by opportunity cost, aggregated market value, and aggregated replacement cost and estimated stochastically by ordinary least squares regression. Cost of formal home care services was estimated with the Medicare Schedule of Limits for Home Health Agency Costs. Estimates of total cost of home care for each method of valuing caregiver effort were calculated by summing the cost of formal home care services with the value of caregiver effort. RESULTS: The average monthly cost of formal home care services was estimated to be $6411 (SD, $8490; median, $2006; range, $0 to $38,607). After adding various values of caregiver effort to the cost of formal home care services, the average cost of home care increases by $960 to $12,483, depending on the method used to calculate the value of the caregiver's time; the median total cost of home care increased by $1403 to $17,793. Data also showed that, depending on the figure used to estimate the cost of long-term care and which method was used to calculate caregiver value, home care was more expensive for at least 4.6% of ventilator-assisted individuals and for as many as 36.7%. CONCLUSIONS: The incorporation of the caregiver's time value into cost estimates did not substantially reduce the proportion of patients for whom home care was the least expensive alternative, except when caregiver effort was valued at a registered nurse's wage rate. However, the methods used to place an economic value on caregiver effort did not take into consideration the long-term economic impact on caregivers who reduce their work hours or forego employment or educational opportunities, nor did they take into account the lost wages of the ventilator-assisted individual or the extent to which the caregiver was financially dependent on the ventilator-assisted individual.

Caregivers' unmet needs for support in caring for functionally impaired elderly persons: a community sample.

Few estimates have been made of the extent to which the needs of caregivers are met. In addition to the inadequate capacity of services, many caregivers lack adequate financial resources, social resources, or other means to access them. Caregivers who provide services to minority or poor elderly may be particularly needy since their care receivers tend to be less healthy and are less likely to use institutional facilities. To address this issue, the authors studied a community sample of 124 caregivers who identified correlates of their perceived unmet caregiver needs and their use of supportive services available for their caregiving. Results indicated that 51.8 percent of women and 67.4 percent of men reported needs for one or more community services that were not met. It was concluded that caregivers who are poor or who required financial assistance are at the highest risk for needing assistance while providing caregiving services. Community services may more effectively target potential needs of caregivers through routine screenings.

Obesity-related hospitalization costs to the U.S. Navy, 1993 to 1998.

The objective of this work was to estimate the cost to the U.S. Navy for obesity-related hospital admissions by examining (1) inpatient utilization associated with obesity; (2) the rank order, probability, and total facility costs of obesity-related diagnosis-related groups (DRGs); and (3) expected inpatient expenses. The frequency and probability of inpatient events in the Navy's active duty population were derived from the Department of Defense's Retrospective Case Mix Analysis System. Medicare-based facility costs per DRG were estimated. These measures were combined in a decision-analytic model. Expected facility costs per obesity-related admission for active duty Navy personnel increased by age group from $3,328 for 18 to 24 year olds to $5,746 for 45 to 64 year olds. The annual avoidable inpatient cost for the Navy was estimated to be $5,842,627 for the top 10 obesity-related DRGs. Improvements to the Navy Physical Readiness Program and other interventions that may reduce obesity, obesity-related health care use, and the public economic burden should be pursued.

An evaluation of the education of hospital pharmacy directors.

The education received by hospital pharmacy directors was evaluated by the 1981 survey responses of the directors of pharmacy practicing in hospitals with over 300 beds. A total of 657 out of 1,531 (42.9 percent) usable questionnaires were returned. Directors ranked the following academic areas in decreasing order of importance to them; personnel and financial management, computers, hospital organization, clinical pharmacy practice, traditional pharmacy practice, and statistics. Directors with MBA degrees perceived themselves to be stronger in these same academic areas than did directors with MS, PharmD, and BS degrees. Only directors with MBA and MS degrees believed they had been adequately prepared through their academic programs for their administrative role as director. Recommendations for changes in the education received by future hospital pharmacy directors are included in this paper.

Linking innovative nursing practice to health services research.

For many nurses, the first step toward becoming a nurse researcher is to obtain help to develop and conduct research that documents outcomes of their novel innovation. These opportunities to engage in health services research often require collaborating with trained researchers who may not have clinical backgrounds. Collaboration generates learning and sharing processes that can be rewarding on many levels. To understand the realities of the collaboration process, this article provides a case study as the authors recount their experiences.

Chronic disease self-management: improving health outcomes.

Chronic disease has become pandemic in the United States, and estimates are that it will affect 148 million people by the year 2030. Patients with chronic illnesses cost the health care system over three times more than individuals without chronic conditions. The US Department of Veterans' Affairs (VA) Sunshine HealthCare Network, composed of VA health care facilities in Florida and Puerto Rico, recognized that the needs of its increasing number of veterans with chronic diseases were unmet by traditional medical interventions. The Network implemented a chronic disease self-management pilot program to evaluate its value for the veteran population. Results of the pilot indicate that this program will make a positive, lasting change in the health status and quality of life for veterans with chronic disease.

Use of subdermal contraceptive implants in a community-based family planning program. Experience after two years.

PIP: In North Carolina, the Rutherford County Family Planning Council obtained funds from a special grant for levonorgestrel implants for women not eligible for medical assistance benefits. The Council approved the following approaches to promoting responsible sexual behavior and preventing unwanted pregnancy: creation of an interagency council to monitor the program, education in the schools on responsible sexual behavior, establishment of an information-sharing network for social service agencies, and expanded, low-cost or free family planning services. During 1992-1993, clinicians at the county health department and in private practices inserted implants in 287 women aged 13-37 living mainly in Rutherford County but also in McDowell and Polk counties. A survey was also conducted in the public high school to obtain self-assessment and information about family planning from female adolescents. Age distribution of the acceptors of the contraceptive implants was 40% for 13-19 year olds (the initiative's target group), 34% for 21-25 year olds, and 32% for 18-20 year olds (32%). The two-year insertion rate for women aged 10-19 was 17.3/1000 compared to 20.8/1000 for women aged 20-29. The implantation rate was greatest among 18-25 year olds and lowest among women aged 26 and older. The method of payment for implantation was medical assistance in 69% of cases and a philanthropic foundation for women not eligible for medical assistance in 29% of cases. 8% had the implants removed during the study period. The leading reason for removal was psychological distress (25%), followed by headaches (20.8%), desire to conceive (16.7%), bleeding (12.5%), and medical contraindication (12.5%). The interval between implantation and removal ranged from less than 3 months to more than 12 months. 2.3% of the female high school students used implants. Among the 596 students who were sexually active, 4.2% used implants, 1.85% used a diaphragm, 27.5% used condoms, and 15% used oral contraceptives. The implant acceptors attended 65% of scheduled 3-month follow-up visits.^ieng