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Selected AbstractsBreast Cancer Knowledge and Preventive Behaviors An Urban Emergency Department-based SurveyACADEMIC EMERGENCY MEDICINE, Issue 12 2000Kevin M. Takakuwa MA Abstract. Objective: To assess general knowledge and preventive behaviors regarding breast cancer among women who present to an urban emergency department. Methods: During a six-month study period, a convenience sampling of women aged 21 years and older who were in treatment and waiting areas was surveyed. The anonymous written survey asked about demographic variables, knowledge, and preventive behaviors regarding breast cancer. Knowledge was assessed with questions about the recommended frequency of breast self-examination and the recommended age for first mammography. Performance was assessed by questions about breast self-exam and mammography. Subgroup analysis was done by age (above and below 40 years old), race, income (above and below the median), insurance type, history of breast lump, and family history (FH) of breast cancer. Results: Four hundred women completed surveys. Two hundred twelve (53%) correctly knew the answers to the two knowledge questions. Knowledge was greater in women with private insurance. Knowledge of the frequency of breast self-exam was significantly greater among whites and Native Americans than among African Americans, Asians, or Hispanics. Stated performance of preventive behaviors was 72% (288) for breast self-exam and for mammography. Preventive behaviors were significantly more likely to be performed by higher-income and privately-insured women. Breast self-exam was more likely to be done in older women, those with a history of a breast lump, and those with a FH of breast cancer. Conclusions: Women with lower income and without private insurance were less likely to be knowledgeable and practice preventive measures for detecting breast disease. [source] Immigrants and the use of preventive care in the United States,HEALTH ECONOMICS, Issue 7 2009Yuriy Pylypchuk Abstract Using data from the Medical Expenditure Panel Survey, we compare immigrants' use of preventive care with that of natives. We employ a multinomial switching regression framework that accounts for non-random selection into continuous private insurance, temporary private insurance, public insurance, and no insurance. Our results indicate that among the populations with continuous private coverage and without coverage (uninsured), immigrants, especially non-citizens, are less likely to use preventive care than natives. We find that the longer immigrants stay in the US the more their use of care approximates to that of natives. However, for most types of care, immigrants' use of care never fully converges to that of natives. Among the publicly insured population, immigrants' use of care is similar to natives, but non-citizen immigrants are significantly less likely to use preventive measures. We find that the ability to speak English does not have a significant effect on the use of preventive care among publicly insured persons. Published in 2008 by John Wiley & Sons, Ltd. [source] The Impact of Private Insurance Coverage on Veterans' Use of VA Care: Insurance and Selection EffectsHEALTH SERVICES RESEARCH, Issue 1p1 2008Yujing Shen Objective. To examine private insurance coverage and its impact on use of Veterans Health Administration (VA) care among VA enrollees without Medicare coverage. Data Sources. The 1999 National Health Survey of Veteran Enrollees merged with VA administrative data, with other information drawn from American Hospital Association data and the Area Resource File. Study Design. We modeled VA enrollees' decision of having private insurance coverage and its impact on use of VA care controlling for sociodemographic information, patients' health status, VA priority status and access to VA and non-VA alternatives. We estimated the true impact of insurance on the use of VA care by teasing out potential selection bias. Bias came from two sources: a security selection effect (sicker enrollees purchase private insurance for extra security and use more VA and non-VA care) and a preference selection effect (VA enrollees who prefer non-VA care may purchase private insurance and use less VA care). Principal Findings. VA enrollees with private insurance coverage were less likely to use VA care. Security selection dominated preference selection and naïve models that did not control for selection effects consistently underestimated the insurance effect. Conclusions. Our results indicate that prior research, which has not controlled for insurance selection effects, may have underestimated the potential impact of any private insurance policy change, which may in turn affect VA enrollees' private insurance coverage and consequently their use of VA care. From the decline in private insurance coverage from 1999 to 2002, we projected an increase of 29,400 patients and 158 million dollars for VA health care services. [source] Infant colic and maternal depressionINFANT MENTAL HEALTH JOURNAL, Issue 1 2005Aimee E. Maxted The combined impact of infant colic and maternal depression on infant, parent, and family difficulties was examined. The sample included 93 consecutive patients seen at an outpatient Colic Clinic. Most mothers had private insurance and completed high school. Infants were approximately 2 months of age. Questionnaires completed by the mother prior to treatment onset were used to measure depressive symptoms in the mothers, infant cry, sleep and temperament, characteristics, parenting stress, maternal self-esteem, social support, and family function. Moderate to severe depressive symptoms were reported by 45.2% of the mothers. More severe depressive symptoms in the mothers were related to fussy/difficult infant temperament, more parenting stress, lower parental self-esteem, and more family-functioning problems. Pediatric health care providers need to be aware that the combined effects of colic and maternal depression can be problematic for the family. ©2005 Michigan Association for Infant Mental Health. [source] Inflammatory bowel disease patients who leave hospital against medical advice: Predictors and temporal trendsINFLAMMATORY BOWEL DISEASES, Issue 6 2009Gilaad G. Kaplan MD Abstract Background: Leaving hospital against medical advice (AMA) may have consequences with respect to health-related outcomes; however, inflammatory bowel disease (IBD) patients have been inadequately studied. Thus, we determined the prevalence of self-discharge, assessed predictors of AMA status, and evaluated time trends. Methods: We analyzed the 1995,2005 Nationwide Inpatient Sample (NIS) to identify 93,678 discharges with a primary diagnosis of IBD admitted to the hospital emergently and did not undergo surgery. We described the proportion of IBD patients who left AMA. Predictors of AMA status were evaluated using a multivariate logistic regression model and temporal trend analyses were performed with Poisson regression models. Results: Between 1995 and 2005, 1.31% of IBD patients left hospitals AMA. Crohn's disease (CD) patients were more likely to leave AMA (adjusted odds ratio [aOR], 1.53; 95% confidence intervals [CI]: 1.30,1.79). Characteristics associated with leaving AMA included: ages 18,34 (aOR, 7.77, 95% CI: 4.34,13.89); male (aOR, 1.75; 95% CI: 1.55,1.99); Medicaid (aOR, 4.55; 95% CI: 3.81,5.43) compared to private insurance; African Americans (aOR, 1.34; 95% CI: 1.09,1.64) compared to white; substance abuse (aOR, 2.75; 95% CI: 2.14,3.54); and psychosis (aOR, 1.55; 95% CI: 1.13,2.14). The incidence rates of self-discharge for CD patients were stable (P > 0.05) between 1995 and 1999, while they significantly (P < 0.0001) increased after 1999. In contrast, AMA rates for UC patients remained stable during the study period. Conclusions: Approximately 1 in 76 IBD patients admitted emergently for medical management leave the hospital AMA. These were primarily disenfranchised patients who may lack adequate outpatient follow-up. (Inflamm Bowel Dis 2009) [source] Voting on Unemployment InsuranceINTERNATIONAL ECONOMIC REVIEW, Issue 4 2001Stéphane Pallage In this article, we ask heterogeneous agents in a dynamic general equilibrium economy to vote on the generosity of their unemployment insurance program. We observe the influence on their vote of (1) moral hazard, (2) private alternatives, and (3) changes in employment status. Agents differ in skills, employment probabilities, income prospects, and assets. For a calibration to the United States, we show that: (1) in contrast to the literature, plausible levels of moral hazard need not induce large cuts in optimal benefits. (2) Switching to private insurance is rejected for most status quo, though it would be as generous. (3) Skill groups vote as a block. For reasonable discount factors, solidarity is never broken simultaneously for more than one group. [source] Use of Medicare and Department of Veterans Affairs Health Care by Veterans with Dementia: A Longitudinal AnalysisJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 10 2009Carolyn W. Zhu PhD The objectives of this study were to examine longitudinal patterns of Department of Veterans Affairs (VA),only use, dual VA and Medicare use, and Medicare-only use by veterans with dementia. Data on VA and Medicare use were obtained from VA administrative datasets and Medicare claims (1998,2001) for 2,137 male veterans who, in 1997, used some VA services, had a formal diagnosis of Alzheimer's disease or vascular dementia in the VA, and were aged 65 and older. Generalized ordered logit models were used to estimate the effects of patient characteristics on use group over time. In 1998, 41.7% of the sample were VA-only users, 55.4% were dual users, and 2.9% were Medicare-only users. By 2001, 30.4% were VA-only users, 51.5% were dual users, and 18.1% were Medicare-only users. Multivariate results show that greater likelihood of Medicare use was associated with older age, being white, being married, having higher education, having private insurance or Medicaid, having low VA priority level, and living in a nursing home or dying during the year. Higher comorbidities were associated with greater likelihood of dual use as opposed to any single system use. Alternatively, number of functional limitations was associated with greater likelihood of Medicare-only use and less likelihood of VA-only use. These results imply that different aspects of veterans' needs have differential effects on where they seek care. Efforts to coordinate care between VA and Medicare providers are necessary to ensure that patients receive high-quality care, especially patients with multiple comorbidities. [source] Risk Factors for Surgical Site Infections in Older PeopleJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 3 2006Keith S. Kaye MD OBJECTIVES: To identify risk factors for surgical site infection (SSI) in older people and to test a priori hypotheses regarding particular variables and SSI risk. DESIGN: Case-control study. SETTING: Duke University Medical Center and seven community hospitals in North Carolina and Virginia. PARTICIPANTS: Elderly patients (,65) who underwent surgery between 1991 and 2002 at the study hospitals. Cases were elderly patients with SSI; controls were elderly operative patients without SSI. Infection control practitioners prospectively identified patients. MEASUREMENTS: Data were collected retrospectively. Case patients who developed SSI were compared with control patients who did not develop SSI. RESULTS: Five hundred sixty-nine SSI cases were identified, and 589 uninfected controls were selected. In multivariate analysis, independent predictors of SSI included obesity (odds ratio (OR)=1.77, 95% confidence interval (CI)=1.34,2.32), chronic obstructive pulmonary disease (COPD) (OR=1.66, 95% CI=1.17,2.34), and a wound class classified as contaminated or dirty (OR=1.65, 95% CI=1.01,2.72). Having private insurance was associated with lower risk (OR=0.29, 95% CI=0.12,0.68). CONCLUSION: This study identified several independent predictors of SSI in older people, including comorbid conditions (COPD and obesity), perioperative variables (wound class), and socioeconomic factors (private insurance, which was associated with lower risk). The results from this study can be used to design and implement interventions for SSI prevention in high-risk older people. [source] Eclecticism in health services for developmental disordersJOURNAL OF PAEDIATRICS AND CHILD HEALTH, Issue 3 2000M McDowell Abstract: The term ,eclectic', as applied to health care for children with developmental disorders, portrays an individualized, adaptive service response to local constraints and pressures. While this may appear appropriate for the local setting, the end result is a broad diversity of health care approaches. This paper discusses three separate processes that interact at a local level, increasing the likelihood of an eclectic local model of health care for this population of children. The first process draws from the direct clinical work. Variable training, knowledge and skills among health care providers, in combination with differing beliefs around the nature of the problems and their management leads to health care which directly reflects the attributes of the local clinicians. A separate, second process fuelling variability is the differing models of departmental responsibility across Australia , which Government departments fund which aspect of care for children with disabilities. The final process relates to funding streams for health care. State public health, federal Medicare and private insurance all support health services for children with disabilities, with the financial incentives (budgets compared to fee-for-service) driving a divergence of practice. This paper concludes that the external political, administrative and financial frameworks within which health care is constructed will continue to promote clinical eclecticism to a degree that would probably be considered unacceptable in other areas of child health care. The solution can only arise from within the clinical work itself, with greater clarity of understanding around the nature of the disorders, the outcomes for which health care takes responsibility, and an increasing focus on an evidence based set of approaches towards achieving these. [source] Using Insurance Claims and Demographic Data for Surveillance of Children's Oral HealthJOURNAL OF PUBLIC HEALTH DENTISTRY, Issue 1 2004Keith E. Heller DDS ABSTRACT Objectives: This paper examines the utility of using private insurance and Medicaid dental claims as well as demographic data for assessing the oral health of children aged 5,12 years in Genesee County, Michigan, communities. Methods: Dental insurance claims data from Delta Plan of Michigan and Michigan Medicaid, plus demographic data from the 1990 US Census (percent poverty) and from the 1995 National Center for Educational Statistics (percent free or reduced lunch eligibility), were compared to findings from two school-based oral health surveys. These surveys were the 1995 Genesee County Oral Health Survey and the 1998,2001 Mott Children's Health Center oral health screenings. Data were analyzed using zip codes, representing communities, as the comparison unit. Statistical comparisons using correlation coefficients were used to compare the findings from the six data sets. Results: Using the insurance claims and school-based data, some communities consistently demonstrated high levels of dental caries or treatment for the primary dentition. The demographic measures were significantly associated with many of the primary dentition survey measures. The demographic data were more useful in identifying communities with high levels of dental disease, particularly in the primary teeth, than the insurance claims data. Conclusions: When screening is not practical, readily available demographic data may provide valuable oral health surveillance information for identification of high-risk communities, but these data do not identify high-risk individuals. In these analyses, demographic data were more useful than dental insurance claims data for oral health surveillance purposes. [source] Natural Disaster Insurance and the Equity-Efficiency Trade-OffJOURNAL OF RISK AND INSURANCE, Issue 1 2008Pierre Picard This article investigates the role of private insurance in the prevention and mitigation of natural disasters. We characterize the equity-efficiency trade-off faced by the policymakers under imperfect information about individual prevention costs. It is shown that a competitive insurance market with actuarial rate making and compensatory tax-subsidy transfers is likely to dominate regulated uniform insurance pricing rules or state-funded assistance schemes. The model illustrates how targeted tax cuts on insurance contracts can improve the incentives to prevention while compensating individuals with high prevention costs. The article highlights the complementarity between individual incentives through tax cuts and collective incentives through grants to the local jurisdictions where risk management plans are enforced. [source] Health care utilization and expenditures for privately and publicly insured children with sickle cell disease in the United States,,PEDIATRIC BLOOD & CANCER, Issue 4 2009Mercy Mvundura PhD Abstract Background There are no current national estimates on health care utilization and expenditures for US children with sickle cell disease (SCD). Procedure We used the MarketScan® Medicaid Database and the MarketScan® Commercial Claims and Encounters Database for 2005 to estimate health services use and expenditures. The final samples consisted of 2,428 Medicaid-enrolled and 621 privately insured children with SCD. Results The percentage of children with SCD enrolled in Medicaid with an inpatient admission was higher compared to those privately insured (43% vs. 38%), yet mean expenditures per admission were 35% lower ($6,469 vs. $10,013). The mean number of emergency department (ED) visits was 49% higher for Medicaid-enrolled children compared to those with private insurance (1.36 vs. 0.91), but mean expenditures per ED visit were 28% lower. The mean number of non-ED outpatient visits was similar (12.6 vs. 11.5) but mean expenditures were 40% lower for the Medicaid-enrolled children ($3,557 vs. $5,908). The mean expenditures on drug claims were higher among those with Medicaid than private insurance ($1,049 vs. $531). Mean total expenditures for children with SCD enrolled in Medicaid were 25% lower than for privately insured children ($11,075 vs. $14,722). The samples were comparable with respect to SCD-related inpatient discharge diagnoses and use of outpatient blood transfusions. Conclusions Children with SCD enrolled in Medicaid had lower expenditures than privately insured children, despite higher utilization of medical care, which indicates lower average reimbursements. Research is needed to assess the quality of care delivered to Medicaid-enrolled children with SCD and its relation to health outcomes. Pediatr Blood Cancer 2009;53:642,646. Published 2009 Wiley-Liss, Inc. [source] Risiken im Lebenszyklus: Theorie und EvidenzPERSPEKTIVEN DER WIRTSCHAFTSPOLITIK, Issue 4 2005Axel Börsch-Supan Do we have the right institutions to cover these risks efficiently? We use the term "institutions" in a broad sense comprising individual saving, family help, private insurance and finally the state with its social insurance systems. Where and when do these institutions work efficiently and effectively? Where and when do they fail? What needs to be done to improve them? What does modern ,social risk management" look like? The article sketches the theoretical underpinnings of saving behavior, portfolio choice and insurance demand and collects the empirical evidence in order to draw economic policy conclusions. [source] Antivirals and antibiotics for influenza in the United States, 1995,2002PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 8 2005Jeffrey A. Linder MD Abstract Purpose To measure the rates of antiviral and antibiotic prescribing for patients diagnosed with influenza in the United States. Methods We performed a retrospective analysis of visits to ambulatory clinics and emergency departments in the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) with a diagnosis of influenza that occurred in seven influenza seasons between 1 October 1995 and 31 May 2002 (n,=,1216). Results There were an estimated 22 million visits (95%CI, 17,26 million visits) with a diagnosis of influenza to community ambulatory clinics (88% of visits), hospital ambulatory clinics (3%) and emergency departments (9%) in the United States between the 1995,1996 and the 2001,2002 influenza seasons, inclusive. The sample was 63% adults, 44% male and 84% white. Physicians prescribed antivirals in 19% of visits and antibiotics not associated with an antibiotic-appropriate diagnosis in 26% of visits. In multivariable modeling, independent predictors of antiviral prescribing were adult age (OR, 2.1; 95%CI, 1.1,4.0) and Medicare insurance (OR, 0.1 compared to private insurance; 95%CI, 0.0,0.6). Antiviral prescribing was marginally associated with influenza season (OR, 1.2 per influenza season; 95%CI, 1.0,1.4). Independent predictors of antibiotic prescribing were influenza season (OR, 0.8 per influenza season; 95%CI, 0.7,0.9), male sex (OR, 0.6; 95%CI, 0.4,0.9), adult age (OR, 2.3; 95%CI, 1.2,4.2) and emergency department visits (OR, 0.5 compared to community ambulatory visits; 95%CI, 0.3,0.8). Conclusions Physicians prescribed antiviral medications to 19% of patients they diagnosed with influenza; the proportion that would have been clinically appropriate is unknown. In contrast, physicians prescribed apparently inappropriate antibiotics to 26% of these same patients, a rate that, encouragingly, decreased over time. Copyright © 2005 John Wiley & Sons, Ltd. [source] Health care utilization of carpenters with substance abuse-related diagnosesAMERICAN JOURNAL OF INDUSTRIAL MEDICINE, Issue 2 2003Hester J. Lipscomb PhD Abstract Background Persons in the construction trades in the US have high rates of alcohol and substance abuse. We had the unique opportunity to evaluate health care utilization through private insurance and workers' compensation for a group of carpenters at high risk of injury and substance abuse. Methods We identified a cohort of union carpenters. Their claims for medical care through union insurance and workers' compensation, and appropriate measures of time at risk were documented. Using methods of indirect standardization, we compared utilization and costs between carpenters with and without alcohol and substance-abuse related diagnoses (ASRD). Results Through private insurance, those with ASRD had 10% higher outpatient utilization and 2.1 times higher rates of hospitalizations for injury care; 2.6 times higher rates of outpatient care; and 2.9 times higher inpatient admissions for non-injury care. Individuals with ASRD had only modestly increased rates (10%) of outpatient utilization through workers' compensation. Conclusions These findings support the need for alcohol and drug abuse prevention and treatment services for this workforce. Operationalizing this among highly mobile workforces, such as the construction trades, is a challenge. While not intending to minimize the problems of alcohol or substance abuse on the job among carpenters, the focus of prevention should not necessarily be in the workplace. Am. J. Ind. Med. 43: 120,131, 2003. © 2003 Wiley-Liss, Inc. [source] Treatment Variation by Insurance Status for Breast Cancer PatientsTHE BREAST JOURNAL, Issue 2 2008Natalie Coburn MD Abstract:, Few studies have examined the relationship of insurance status with the presentation and treatment of breast cancer. Using a state cancer registry, we compared tumor presentation and surgical treatments at presentation by insurance status (private insurance, Medicare, Medicaid, or uninsured). Student's t -test, Chi-square test, and ANOVA were used for comparison. P-values reflect a comparison to insured patients. From 1996 to 2005, there were 6876 cases of invasive breast cancer with either private (n = 3975), Medicare (n = 2592), Medicaid (n = 193), or no insurance (n = 116). The median age (years) at presentation was 55 for private, 76 for Medicare, 54 for Medicaid and 54 for uninsured. The mean and median tumor size (mm) were 18.5 and 15 for private; 20.9 and 15 for Medicare; 24.2 and 18 for Medicaid; and 29.5 and 17 for uninsured, respectively; (p < 0.001 for all). Fewer women with Medicare and Medicaid presented with node negative breast cancers: private, 73.4% node negative; Medicare, 79.5% (p < 0.001); Medicaid, 60.9% (p < 0.001); and uninsured, 58% (p = 0.005). Significantly more uninsured women had no surgical treatment of their breast cancer: 15.5% versus 4.3% for private (p < 0.001). Among women with non-metastatic T1/T2 tumors, 71.5% with private insurance underwent breast-conserving surgery (BCS), compared with 64.2% of Medicare (p < 0.001), 65% of Medicaid (p = 0.097), and 65.4% of uninsured (p = 0.234). The rate of reconstruction following mastectomy was higher for private insurance (36.6%), compared with Medicare (3.8%, p < 0.0001), Medicaid (26.1%, p = 0.31), and uninsured (5.0%, p = 0.0038). The presentation of breast cancer in women with no insurance and Medicaid is significantly worse than those with private insurance. Of concern are the lower proportions of BCS and reconstruction among patients who are uninsured or have Medicaid. Reduction of disparities in breast cancer presentation and treatment may be possible by increasing enrollment of uninsured, program-eligible women in a state-supported screening and treatment program. [source] US Health Care Reform and Transplantation, Part II: Impact on the Public Sector and Novel Health Care Delivery SystemsAMERICAN JOURNAL OF TRANSPLANTATION, Issue 10 2010D. A. Axelrod The Patient Protection and Affordable Care Act passed in 2010 will result in dramatic expansion of publically funded health insurance coverage for low-income individuals. It is estimated that of the 32 million newly insured, 16 million will obtain coverage through expansion of the Medicaid Program, and the remaining 16 million will purchase coverage through their employer or newly legislated insurance exchanges. While the Act contains numerous provisions to improve access to private insurance as discussed in Part I of this analysis, public sector coverage will significantly be affected. The cost of health care reform will be borne disproportionately by Medicare, which faces nearly $500 billion in cuts to be identified by a new independent board. Transplant centers should be concerned about the impact of the reform on the financial aspects of transplantation. In addition, this legislation also utilizes the Medicare Program to drive reform of the health care delivery system, by encouraging the development of integrated Accountable Care Organizations, experimentation with new ,models' of health care delivery, and expanded support for Comparative Effectiveness Research. Transplant providers, including transplant centers and physicians/surgeons need to lead this movement, drawing on our experience providing comprehensive multidisciplinary care under global budgets with publically reported outcomes. [source] Care of the Chronically Ill at Home: An Unresolved Dilemma in Health Policy for the United StatesTHE MILBANK QUARTERLY, Issue 4 2007KAREN BUHLER-WILKERSON The problems of caring for patients with disabling illnesses who neither get well nor die are not new. Such patients have always required assistance at home from family, benevolent volunteers, or paid caregivers. Despite two centuries of experimentation, however, no agreement exists concerning the balance between the public and private resources to be allocated through state funding, private insurance, and family contributions for the daily and routine care at home for chronically ill persons of all ages. This article examines these issues and the unavoidable tensions between fiscal reality and legitimate need. It also uses historical and policy analyses to explain why home care has never become the cornerstone for caring for the chronically ill. [source] Impact of Medicare Coverage on Disparities in Access to Simultaneous Pancreas and Kidney TransplantationAMERICAN JOURNAL OF TRANSPLANTATION, Issue 12 2009J. K. Melancon In the setting of disparities in access to simultaneous pancreas and kidney transplantation (SPKT), Medicare coverage for this procedure was initiated July 1999. The impact of this change has not yet been studied. A national cohort of 22 190 type 1 diabetic candidates aged 18,55 for kidney transplantation (KT) alone or SPKT was analyzed. Before Medicare coverage, 57% of Caucasian, 36% of African American and 38% of Hispanic type 1 diabetics were registered for SPKT versus KT alone. After Medicare coverage, these proportions increased to 68%, 45% and 43%, respectively. The overall increase in SPKT registration rate was 27% (95% CI 1.16,1.38). As expected, the increase was more substantial in patients with Medicare primary insurance than those with private insurance (Relative Rate 1.18, 95% CI 1.09,1.28). However, racial disparities were unaffected by this policy change (African American vs. Caucasian: 0.97, 95% CI 0.87,1.09; Hispanic vs. Caucasian: 0.94, 95% CI 0.78,1.05). Even after Medicare coverage, African Americans and Hispanics had almost 30% lower SPKT registration rates than their Caucasian counterparts (95% CI 0.66,0.79 and 0.59,0.80, respectively). Medicare coverage for SPKT succeeded in increasing access for patients with Medicare, but did not affect the substantial racial disparities in access to this procedure. [source] Trends of spinal fusion surgery in Australia: 1997 to 2006ANZ JOURNAL OF SURGERY, Issue 11 2009Ian Andrew Harris Abstract Background:, This study aims to explore the trend in spine fusion surgery in Australia over the past 10 years, and to explore the possible influence of health insurance status (private versus public) on the rate of surgery. Methods:, Data pertaining to the rate of lumbar spine fusion from 1997 to 2006 were collected from Inpatient Statistics Collection of NSW Health, Medicare Australia Statistics and the Australian Bureau of Statistics. Data on total hip and total knee arthroplasties were collected to provide a comparator. Results:, The number of publicly performed spinal fusion procedures increased by 2% from 1997 to 2006. In comparison, privately performed spinal fusion procedures increased by 167% over the same 10-year period. In 2006, spine fusion surgery was 10.8 times more likely to be done in the private sector than in the public sector, compared with corresponding figures of 4.2 times and 3.0 times for knee replacement and hip replacement, respectively. Waiting list data showed no increase in demand for spine fusion surgery in the public sector. Conclusion:, There is a disproportionately high rate of lumbar spine fusion surgery performed in the private sector, given the rate of private insurance. The rate of increase was found to be higher than that for hip or knee arthroplasty procedures. Possible explanations for this difference include: over-servicing in the private sector, under-servicing in the public sector, differences in medical referral patterns, surgeon and patient preferences and financial incentives. [source] Preoperative prediction of long-term outcome following laparoscopic fundoplicationANZ JOURNAL OF SURGERY, Issue 7 2002Colm J. O'Boyle Background: Although long-term outcomes following laparoscopic fundoplication for gastro-oesophageal disease have now been reported as very satisfactory, a small, but important, minority of patients are unhappy with the outcome, often due to recurrent reflux symptoms or new-onset dysphagia. In this study, we sought to establish whether various parameters that can be determined before surgery, can predict the long-term outcome of surgery. Methods: Data collected prospectively were evaluated to determine factors that were associated with outcome at 5 years following laparoscopic fundoplication. Inclusion criteria were complete preoperative assessment data and 5-year follow-up data. Data examined included information on preoperative age, sex, weight, home address, health insurance status, duration of reflux symptoms, previous surgery, operating surgeon, endoscopy and 24-h pH monitoring. In addition, lower oesophageal sphincter resting and residual relaxation pressures were evaluated before and after surgery. The postoperative symptoms of heartburn and dysphagia, as well as overall satisfaction 5 years following surgery was determined using a 0,10 visual analogue scale. The association of the pre- and perioperative factors and outcome at 5 years was determined by univariate and linear regression analysis. Results: Two hundred and sixty-two patients from an overall experience of over 1000 laparoscopic anti-reflux procedures met the entry criteria. There was no association between patient address, age, weight, duration of symptoms, the presence of endoscopically proven oesophagitis, operating surgeon, the necessity for conversion to an open procedure, change in lower oesophageal sphincter residual relaxation pressure and the outcome parameters. Using univariate analysis, a higher heartburn score was associated with previous abdominal surgery, female sex, no private health insurance, and a normal preoperative 24-h pH study. A higher dysphagia score was associated with a normal preoperative pH study, a postoperative increase in lower oesophageal sphincter resting pressure of more than 6 mmHg, and previous abdominal surgery. Overall satisfaction with the outcome at 5 years was higher among male patients, private patients, patients who had a hiatus hernia, and patients who had an abnormal preoperative pH study. Linear regression analysis confirmed that private insurance, male sex, and the absence of previous abdominal surgery, were the strongest predictors of an improved heartburn score, whereas male sex and private health insurance were the strongest predictors of greater satisfaction with the overall outcome. Conclusions: There are parameters that can be assessed before or during laparoscopic Nissen fundoplication that correlate with late outcome parameters. In particular, male patients and those from higher socioeconomic groups appear to have a better long-term outcome. [source] North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) and the National Hospital Ambulatory Medical Care Survey (NHAMCS): Comparison of Emergency Department DataACADEMIC EMERGENCY MEDICINE, Issue 3 2009Anne M. Hakenewerth MS Abstract The North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) is a near-real-time database of emergency department (ED) visits automatically extracted from hospital information system(s) in the state of North Carolina. The National Hospital Ambulatory Medical Care Survey (NHAMCS) is a retrospective probability sample survey of visits to U.S. hospital EDs. This report compares data from NC DETECT (2006) with NHAMCS (2005) ED visit data to determine if the two data sets are consistent. Proportions, rates, and confidence intervals (CIs) were calculated for ED visits by age and gender; arrival method and age; expected source of payment; disposition; hospital admissions; NHAMCS top 20 diagnosis groups and top five primary diagnoses by age group; International Classifications of Disease, 9th revision, Clinical Modification (ICD-9-CM) primary diagnosis codes; and cause of injury. North Carolina DETECT captured 79% of statewide ED visits. Twenty-eight persons for every 100 North Carolina residents visited a North Carolina ED that reports to NC DETECT at least once in 2006, compared to 20% nationally. Twenty-seven percent of ED visits in North Carolina had private insurance as the expected payment source, compared with 40% nationwide. The proportion of injury-related ED visits in North Carolina is 25%, compared to 36.4% nationally. Rates and proportions of disease groups are similar. Similarity of NC DETECT rates and proportions to NHAMCS provides support for the face and content validity of NC DETECT. The development of statewide near-real-time ED databases is an important step toward the collection, aggregation, and analysis of timely, population-based data by state, to better define the burden of illness and injury for vulnerable populations. [source] Cancer treatment cost in the United States,,CANCER, Issue 14 2010Has the burden shifted over time? Abstract BACKGROUND: There has not been a comprehensive analysis of how aggregate cancer costs have changed over time. The authors present 1) updated estimates of the prevalence and total cost of cancer for select payers and how these have changed over the past 2 decades; and 2) for each payer, the distribution of payments by type of service over time to assess whether there have been shifts in cancer treatment settings. METHODS: Pooled data from the 2001 through 2005 Medical Expenditure Panel Survey and the 1987 National Medical Care Expenditure Survey were used for the analysis. The authors used an econometric approach to estimate cancer-attributable medical expenditures by payer and type of service. RESULTS: In 1987, the total medical cost of cancer (in 2007 US dollars) was $24.7 billion. Private payers financed the largest share of the total (42%), followed by Medicare (33%), out of pocket (17%), other public (7%), and Medicaid (1%). Between 1987 and the 2001 to 2005 period, the total medical cost of cancer increased to $48.1 billion. In 2001 to 2005, the shares of cancer costs were: private insurance (50%), Medicare (34%), out of pocket (8%), other public (5%), and Medicaid (3%). The share of total cancer costs that resulted from inpatient admissions fell from 64.4% in 1987 to 27.5% in 2001 to 2005. CONCLUSIONS: The authors identified 3 trends in the total costs of cancer: 1) the medical costs of cancer have nearly doubled; 2) cancer costs have shifted away from the inpatient setting; and 3) the share of these costs paid for by private insurance and Medicaid have increased. Cancer 2010. Published 2010 by American Cancer Society. [source] | ||||||||||||||||||||||