Estimates of hospital and physician costs of epilepsy in the United States for 1995 comparing the provider -based survey method and a patient -based medical charts and billing method

This investigation compares two different methodologies for calculating the national cost of epilepsy: provider-based survey method (PBSM) and the patient-based medical charts and billing method (PBMC&BM). The PBSM uses the National Hospital Discharge Survey (NHDS), the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Ambulatory Medical Care Survey (NAMCS) as the sources of utilization. The PBMC&BM uses patient data, charts and billings, to determine utilization rates for specific components of hospital, physician and drug prescriptions. ^ The 1995 hospital and physician cost of epilepsy is estimated to be $722 million using the PBSM and $1,058 million using the PBMC&BM. The difference of $336 million results from $136 million difference in utilization and $200 million difference in unit cost. ^ Utilization. The utilization difference of $136 million is composed of an inpatient variation of $129 million, $100 million hospital and $29 million physician, and an ambulatory variation of $7 million. The $100 million hospital variance is attributed to inclusion of febrile seizures in the PBSM, $−79 million, and the exclusion of admissions attributed to epilepsy, $179 million. The former suggests that the diagnostic codes used in the NHDS may not properly match the current definition of epilepsy as used in the PBMC&BM. The latter suggests NHDS errors in the attribution of an admission to the principal diagnosis. ^ The $29 million variance in inpatient physician utilization is the result of different per-day-of-care physician visit rates, 1.3 for the PBMC&BM versus 1.0 for the PBSM. The absence of visit frequency measures in the NHDS affects the internal validity of the PBSM estimate and requires the investigator to make conservative assumptions. ^ The remaining ambulatory resource utilization variance is $7 million. Of this amount, $22 million is the result of an underestimate of ancillaries in the NHAMCS and NAMCS extrapolations using the patient visit weight. ^ Unit cost. The resource cost variation is $200 million, inpatient is $22 million and ambulatory is $178 million. The inpatient variation of $22 million is composed of $19 million in hospital per day rates, due to a higher cost per day in the PBMC&BM, and $3 million in physician visit rates, due to a higher cost per visit in the PBMC&BM. ^ The ambulatory cost variance is $178 million, composed of higher per-physician-visit costs of $97 million and higher per-ancillary costs of $81 million. Both are attributed to the PBMC&BM's precise identification of resource utilization that permits accurate valuation. ^ Conclusion. Both methods have specific limitations. The PBSM strengths are its sample designs that lead to nationally representative estimates and permit statistical point and confidence interval estimation for the nation for certain variables under investigation. However, the findings of this investigation suggest the internal validity of the estimates derived is questionable and important additional information required to precisely estimate the cost of an illness is absent. ^ The PBMC&BM is a superior method in identifying resources utilized in the physician encounter with the patient permitting more accurate valuation. However, the PBMC&BM does not have the statistical reliability of the PBSM; it relies on synthesized national prevalence estimates to extrapolate a national cost estimate. While precision is important, the ability to generalize to the nation may be limited due to the small number of patients that are followed. ^

Étude du suivi conjoint par un médecin spécialiste chez les adultes avec maladies chroniques suivis en première ligne

Contexte : Les médecins spécialistes peuvent participer aux soins ambulatoires des personnes atteintes de maladies chroniques (MCs) et comorbidité comme co-gestionnaire ou consultant selon qu’ils sont responsables ou non du suivi du patient. Il y a un manque d’évidences sur les déterminants et l’impact du type d’implication du médecin spécialiste, ainsi que sur la façon optimale de mesurer la comorbidité pour recueillir ces évidences. Objectifs : 1) déterminer chez les patients atteints de MCs les facteurs associés à la cogestion en spécialité, dont les caractéristiques des organisations de première ligne et la comorbidité; 2) évaluer si le type d’implication du spécialiste influence le recours à l’urgence; 3) identifier et critiquer les méthodes de sélection d’un indice de comorbidité pour la recherche sur l’implication des spécialistes dans le suivi des patients. Méthodologie : 709 adultes (65 +/- 11 ans) atteints de diabète, d’arthrite, de maladie pulmonaire obstructive chronique ou d’insuffisance cardiaque furent recrutés dans 33 cliniques de première ligne. Des enquêtes standardisées ont permis de mesurer les caractéristiques des patients (sociodémographiques, comorbidité et qualité de vie) et des cliniques (modèle, ressources). L’utilisation des services de spécialistes et de l’urgence fut mesurée avec une base de données médico-administratives. Des régressions logistiques multivariées furent utilisées pour modéliser les variables associées à la cogestion et comparer le recours à l’urgence selon le type d’implication du spécialiste. Une revue systématique des études sur l’utilisation des services de spécialistes, ainsi que des revues sur les indices de comorbidité fut réalisée pour identifier les méthodes de sélection d’un indice de comorbidité utilisées et recommandées. Résultats : Le tiers des sujets a utilisé les services de spécialistes, dont 62% pour de la cogestion. La cogestion était associée avec une augmentation de la gravité de la maladie, du niveau d’éducation et du revenu. La cogestion diminuait avec l’âge et la réception de soins dans les cliniques avec infirmière ayant un rôle innovateur. Le recours à l’urgence n’était pas influencé par l’implication du spécialiste, en tant que co-gestionnaire (OR ajusté = 1.06, 95%CI = 0.61-1.85) ou consultant (OR ajusté = 0.97, 95%CI = 0.63-1.50). Le nombre de comorbidités n’était pas associé avec la cogestion, ni l’impact du spécialiste sur le recours à l’urgence. Les revues systématiques ont révélé qu’il n’y avait pas standardisation des procédures recommandées pour sélectionner un indice de comorbidité, mais que 10 critères concernant principalement la justesse et l’applicabilité des instruments de mesure pouvaient être utilisés. Les études sur l’utilisation des services de spécialistes utilisent majoritairement l’indice de Charlson, mais n’en expliquent pas les raisons. Conclusion : L’implication du spécialiste dans le suivi des patients atteints de MCs et de comorbidité pourrait se faire essentiellement à titre de consultant plutôt que de co-gestionnaire. Les organisations avec infirmières ayant un rôle innovateur pourraient réduire le besoin pour la cogestion en spécialité. Une méthode structurée, basée sur des critères standardisés devrait être utilisée pour sélectionner l’indice de comorbidité le plus approprié en recherche sur les services de spécialistes. Les indices incluant la gravité des comorbidités seraient les plus pertinents à utiliser.

The determinants of physician and pharmacist utilization and equity of access under Korean universal health insurance

This study examines the social and behavioral determinants of two types of primary care, seeing a physician or a pharmacist, for Koreans and evaluates the equity of the Korean national health insurance system. The study applies the Aday and Andersen access framework to cross-sectional data from the 1992 Korean National Health Interview Survey (N = 21,841).^ The study found that in Korea, the elderly were most likely, and children least likely, to have used physician services. Women, household heads, those in small families, and the less educated were more likely than their counterparts to use physician and pharmacist services. Health status and need were important determinants of Koreans seeing a doctor or a pharmacist. Differences in need substantially accounted for the original differences observed between subgroups. Resources associated with having insurance coverage, a regular source of care, and place of residence (rural/urban) ameliorated to some extent the subgroup differences in the use of physicians' and pharmacists' services among Koreans. They were also major independent predictors of access. Having insurance remains a particularly important predictor of who uses physician services. Among the insured, trade-offs in the use of physician and pharmacist services were found in the current system, i.e., uninsured and poor Koreans were more likely to use pharmacist services, while insured and rural Koreans were more likely to use doctor services. Among the insured, cost sharing rates are lower for physician than for pharmacist services. Self-employed persons were less likely than government and industrial workers to use physician services. An underlying expectation under universal health insurance was that the Korean health care system would be equitable. The research results, however, did not fully support this expectation.^ The policy implications of these findings are that measures are required to extend insurance coverage to the uninsured, to equalize differences in benefit packages between health plans, and to expand the availability of physicians in rural areas. Further research is also needed to understand those who do not currently have a regular source of care and why and the access barriers that may exist for selected demographic subgroups (those in large families and unmarried or divorced/widowed persons). ^

Barriers to Influenza Immunization: The Role of Physician Training on Influenza Vaccine Utilization in Six to Twenty-Three Month Old Infants

Digital Preservation

The physician capacity utilization surveys : a report on the telephone resurvey /

Prepared under contract no. HRA-231-75-0023 from Health Resources Administration

Dietary supplements utilization: an explanatory survey among Swiss consumers

Dietary supplement (DS) use increased rapidly over the last years. However evidence of benefits of many DS for healthy users are scarce and may not equate known risks of overdose, drug interaction and recently discovered negative long-term effects. Therefore this study aimed to investigate perceptions and motivations of DS users in Lausanne, Switzerland. Method A convenience sample was recruited at the entrance of local sales points. Data were collected in on-site semi-structured interviews to assess dietary supplementation habits. Results The 119 participants provided information on 147 users. Among 273 declared products, the majority were mixed products, containing minerals and vitamins (78), mineral products (69), and herbal products (28). 55% of DS users took more than one product simultaneously. Seventy five percent of participants indicated that DS use presents no risk or nearly no risk and about half (49%) of participants did not inform their physician about their consumption. Male participants reported to share this information with their physicians significantly less frequently than female participants (p = 0.008). About half of participants looked for information on potential risks of DS, men significantly more often than women (p=0.001). Discussion According to other studies in the US, our study shows that, in Lausanne (Switzerland), DS are commonly used as mixed products. Risk perception seems generally low among DS users. Implications Physicians should be trained to evaluate patientsʼ health behaviour and needs in order to provide good evidence based information or propose alternatives to DS use.

Psychiatric services utilization in completed suicides of a youth centres population

Affiliation: Johanne Renaud & Claude Marquette : CHU Ste-Justine, Université de Montréal

Longitudinal patterns in survival, comorbidity, healthcare utilization and quality of care among older women following breast cancer diagnosis

OBJECTIVES To compare longitudinal patterns of health care utilization and quality of care for other health conditions between breast cancer-surviving older women and a matched cohort without breast cancer. DESIGN Prospective five-year longitudinal comparison of cases and matched controls. SUBJECTS Newly identified breast cancer patients recruited during 1997–1999 from four geographic regions (Los Angeles, CA; Minnesota; North Carolina; and Rhode Island; N = 422) were matched by age, race, baseline comorbidity and zip code location with up to four non-breast-cancer controls (N = 1,656). OUTCOMES Survival; numbers of hospitalized days and physician visits; total inpatient and outpatient Medicare payments; guideline monitoring for patients with cardiovascular disease and diabetes, and bone density testing and colorectal cancer screening. RESULTS Five-year survival was similar for cases and controls (80% and 82%, respectively; p = 0.18). In the first follow-up year, comorbidity burden and health care utilization were higher for cases (p < 0.01), with most differences diminishing over time. However, the number of physician visits was higher for cases (p < 0.01) in every year, driven partly by more cancer and surgical specialist visits. Cases and controls adhered similarly to recommended bone density testing, and monitoring of cardiovascular disease and diabetes; adherence to recommended colorectal cancer screening was better among cases. CONCLUSION Breast cancer survivors’ health care utilization and disease burden return to pre-diagnosis levels after one year, yet their greater use of outpatient care persists at least five years. Quality of care for other chronic health problems is similar for cases and controls.

Behavioral Economics and Physician Behavior

This study seeks to answer whether the availability heuristic leads physicians to utilize more medical care than is economically efficient. Do rare, salient events alter physicians' perceptions about the probability of patient harm? Do these events lead physicians to overutilize certain medical procedures? This study uses Pennsylvania inpatient hospital admissions data from 2009 aggregated at the physician level to investigate these questions. The data come from the 2009 Pennsylvania Health Care Cost Containment Council (PHC4). The study is divided into two parts. In Part I, we examine whether bad outcomes during childbirth (defined as maternal mortality, an obstetric fistula or a uterine rupture) lead physicians to utilize more cesarean sections on future patients. In Part II, we examine whether bad outcomes associated with appendicitis (defined as patient death, a perforated or ruptured appendix or sepsis) lead physicians to perform more negative appendectomies (appendectomies performed when the patient did not have appendicitis) on future patients. Overall the study does not find evidence to support the claim that the availability heuristic leads physicians to overutilize medical care on future patients. However, the study does find evidence that variations in health care utilization are strongly correlated with individual physician practice patterns. The results of the study also imply that physicians' financial incentives may be a source of variation in health care utilization.

Home care service utilization in British Columbia: Substitute or complement to acute care?

The desire to promote efficient allocation of health resources and effective patient care has focused attention on home care as an alternative to acute hospital service. in particular, clinical home care is suggested as a substitute for the final days of hospital stay. This dissertation evaluates the relationship between hospital and home care services for residents of British Columbia, Canada beginning in 1993/94 using data from the British Columbia Linked Health database. ^ Lengths of stay for patients referred to home care following hospital discharge are compared to those for patients not referred to home care. Ordinary least squares regression analysis adjusts for age, gender, admission severity, comorbidity, complications, income, and other patient, physician, and hospital characteristics. Home care clients tend to have longer stays in hospital than patients not referred to home care (β = 2.54, p = 0.0001). Longer hospital stays are evident for all home care client groups as well as both older and younger patients. Sensitivity analysis for referral time to direct care and extreme lengths of stay are consistent with these findings. Two stage regression analysis indicates that selection bias is not significant.^ Patients referred to clinical home care also have different health service utilization following discharge compared to patients not referred to home care. Home care nursing clients use more medical services to complement home care. Rehabilitation clients initially substitute home care for physiotherapy services but later are more likely to be admitted to residential care. All home care clients are more likely to be readmitted to hospital during the one year follow-up period. There is also a strong complementary association between direct care referral and homemaker support. Rehabilitation clients have a greater risk of dying during the year following discharge. ^ These results suggest that home care is currently used as a complement rather than a substitute for some acute health services. Organizational and resource issues may contribute to the longer stays by home care clients. Program planning and policies are required if home care is to provide an effective substitute for acute hospital days. ^

Determining the association between nativity status and mammography utilization among women in the United States using 2000 and 2005 NHIS data

Objective. To determine the association between nativity status and mammography utilization among women in the U.S. and assess whether demographic variables, socioeconomic factors healthcare access, breast cancer risk factors and acculturation variables were predictors in the relationship between nativity status and mammography in the past two years. ^ Methods. The NHIS collects demographic and health information using face-to-face interviews among a representative sample of the U.S. population and a cancer control module assessing screening behaviors is included every five years. Descriptive statistics were used to report demographic characteristics of women aged 40 and older who have received a mammogram in the last 2 years from 2000 and 2005. We used chi square analyses to determine statistically significant differences by mammography screening for each covariate. Logistic regression was used to determine whether demographic characteristics, socioeconomic characteristics, healthcare access, breast cancer risk factors and acculturation variables among foreign-born Hispanics affected the relationship between nativity status and mammography use in the past 2 years. ^ Results. In 2000, the crude model between nativity and mammography was significant but results were not significant after adjusting for health insurance, access and reported health status. Significant results were also reported for years in U.S. and mammography among foreign-born born women. In 2005, the crude model was also significant but results were not significant after adjusting for demographic factors. Furthermore, there was a significant finding between citizenship and mammography in the past 2 years. ^ Conclusions. Our study contributes to the literature as one of the first national-based studies assessing mammography in the past two years based on nativity status. Based on our findings, health insurance and access to care is an important predictor in mammography utilization among foreign-born women. For those with health care access, physician recommendation should further be assessed to determine whether women are made aware of mammography as a means to detect breast cancer at an early stage and further reduce the risk of mortality from the breast cancer.^

Social support, health status and health services utilization among the noninstitutionalized elderly: An analysis of the Supplement on Aging to the 1984 national health interview survey

The association between Social Support, Health Status, and Health Services Utilization of the elderly, was explored based on the analysis of data from the Supplement on Aging to the National Health Interview Survey, 1984 (N = 11,497) using a modified framework of Aday and Andersen's Expanded Behavioral Model. The results suggested that Social Support as operationalized in this study was an independent determinant of the use of health services. The quantity of social activities and the use of community services were the two most consistent determinants across different types of health services use.^ The effects of social support on the use of health services were broken down into three components to facilitate explanations of the mechanisms through which social support operated. The Predisposing and Enabling component of Social Support had independent, although not uniform, effects on the use of health services. Only slight substitute effects of social support were detected. These included the substitution of the use of senior centers for longer stay in the hospital and the substitution of help with IADL problems for the use of formal home care services.^ The effect of financial support on the use of health services was found to be different for middle and low income populations. This differential effect was also found for the presence of intimate networks, the frequencies of interaction with children and the perceived availability of support among urban/rural, male/female and white/non-white subgroups.^ The study also suggested that the selection of appropriate Health Status measures should be based on the type of Health Services Utilization in which a researcher is interested. The level of physical function limitation and role activity limitation were the two most consistent predictors of the volume of physician visits, number of hospital days, and average length of stay in the hospital during the past year.^ Some alternative hypotheses were also raised and evaluated, when possible. The impacts of the complex sample design, the reliability and validity of the measures and other limitations of this analysis were also discussed. Finally, a revised framework was proposed and discussed based on the analysis. Some policy implications and suggestions for future study were also presented. ^

MEDICAL CARE UTILIZATION IN TIME AMONG ELDERLY MEDICARE ENROLLEES IN AN HMO

Investigation into the medical care utilization of elderly Medicare enrollees in an HMO (Kaiser - Portland, Oregon): The specific research topics are: (1) The utilization of medical care by selected determinants such as: place of service, type of service, type of appointment, physician status, physician specialty and number of associated morbidities. (2) The attended prevalence of 3 chronic diseases: hypertension, diabetes and arthritis in addition to pneumonias as an example of acute diseases. The selection of these examples was based on their importance in morbidity/or mortality results among the elderly. The share of these diseases in outpatient and inpatient contacts was examined as an example of the relation between morbidity and medical care utilization. (3) The tendency of individual utilization patterns to persist in subsequent time periods. The concept of contagion or proneness was studied in a period of 2 years. Fitting the negative binomial and the Poisson distributions was applied to the utilization in the 2nd year conditional on that in the 1st year as regards outpatient and inpatient contacts.^ The present research is based on a longitudinal study of 20% random sample of elderly Medicare enrollees. The sample size is 1683 individuals during the period from August 1980-December 1982.^ The results of the research were: (1) The distribution of contacts by selected determinants did not reveal a consistent pattern between sexes and age groups. (2) The attended prevalence of hypertension and arthritis showed excess prevalence among females. For diabetes and pneumonias no female excess was noticed. Consistent increased prevalence with increasing age was not detected.^ There were important findings pertaining to the relatively big share of the combined 3 chronic diseases in utilization. They accounted for 20% of male outpatient contacts vs. 25% of female outpatients. For inpatient contacts, they consumed 20% in case of males vs. 24% in case of females. (3) Finding that the negative binomial distribution fit the utilization experience supported the research hypothesis concerning the concept of contagion in utilization. This important finding can be helpful in estimating liability functions needed for forecasting future utilization according to previous experience. Such information has its relevance to organization, administration and planning for medical care in general. (Abstract shortened with permission of author.) ^

FACTORS INFLUENCING THE PATTERNS OF PHYSICIAN VISITS TO NURSING HOME RESIDENTS

This study was designed to identify some of the factors related to patterns of physician visits to nursing home residents. The relationship of ten resident and organizational characteristics to patterns of physician visits was investigated through secondary analysis of data abstracted from the 1973-74 National Nursing Home Survey of the National Center for Health Statistics. The study sample was composed of 11,135 of the 19,013 nursing home residents who participated in the survey.^ The analytic results revealed that all ten variables had a statistically significant relationship to patterns of physician visits, mainly due to the large sample size. The degrees of association between the variables, measured by the Cramer's V statistic, ranged from moderate to very weak.^ Certification status of the nursing home under Medicare and/or Medicaid was shown to be most strongly related to patterns of physician visits, followed by primary source of payment for nursing home care, and residence prior to nursing home admission. Several variables thought to be related to patterns of physician visits were found to have a very weak relationship: age of the resident, marital status, length of stay, primary diagnosis, number of chronic conditions, activities of daily living status, and levels of care.^ In order to get a more precise picture of the relative influence of certification status and primary source of payment when the other variables were statistically controlled, these two variables were combined into a single variable. The results revealed that the combined effects of certification status and primary source of payment were sustained, regardless of differences in the residents' personal, utilization, and health status characteristics, and the levels of care that they received. The results also indicated that the five groups created by combining the two variables differed in patterns of physician visits. For example, private pay residents in intermediate care facilities (ICF's) and non-certified facilities were more likely to receive unscheduled visits than private pay residents in skilled nursing homes (SNH's), residents in SNH's supported by Medicare or Medicaid, and residents in ICF's supported by Medicaid. ^

Attitudes and other barriers to the utilization of clinical research findings by American physicians: A systematic review

Background: The Institute of Medicine estimates that only a maximum of 25% of clinical research findings are incorporated into practice by physicians. To improve clinical practice, efforts have been made to promote evidence-based medicine and the use of clinical guidelines. Despite these efforts, the gap between research and clinical practice remains wide.^ Objective: To systematically review the literature describing the factors which influence the use of clinical research recommendations by American physicians.^ Hypothesis: Barriers exist in the application of clinical research into clinical practice, and are multifactorial. The establishment of the Clinical and Translational Awards (CTSA; special federal grants awarded to selected institutions to support clinical and translational research) has reduced the effect of these barriers and improved the process of clinical research translation into practice among American physicians.^ Aims: Identify barriers and facilitators of the use of research findings in clinical practice by American physicians. Contrast studies published six years before and after the creation of the CTSA.^ Methods: The sources of data include published literature from Medline, PubMed and PsycINFO. Selected studies must be qualitative, a survey of American clinicians, based on evidence-based medicine practice, clinical guidelines or treatment pathways. Systematic reviews and reports were excluded, as well as studies with less than 100 respondents.^ Results: In total, 1036 abstracts were reviewed; 115 full text potential articles were identified and reviewed, and a total of 31 studies met all criteria for inclusion in the final review.^ Conclusions: The barriers against the application of clinical research findings, in the forms of clinical guidelines, evidence-based medicine guides and clinical pathways, can be divided broadly into physician barriers, practice/system barriers and patient barriers. Physician barriers are the most common barriers, especially the lack of familiarity with guidelines and the lack of time. Of the factors which improve the use of research based guidelines, physician factors such as younger age, lower duration of clinical practice, specialty training, and practice in large group Health Maintenance Organization (HMO) settings with fewer patients seen were the most commonly cited.^