Treatment Intensity (treatment + intensity)

Distribution by Scientific Domains


Selected Abstracts


Trends in Inpatient Treatment Intensity among Medicare Beneficiaries at the End of Life

HEALTH SERVICES RESEARCH, Issue 2 2004
Amber E. Barnato
Objective. Although an increasing fraction of Medicare beneficiaries die outside the hospital, the proportion of total Medicare expenditures attributable to care in the last year of life has not dropped. We sought to determine whether disproportionate increases in hospital treatment intensity over time among decedents are responsible for the persistent growth in end-of-life expenditures. Data Source. The 1985,1999 Medicare Medical Provider Analysis and Review (MedPAR) and Denominator files. Study Design. We sampled inpatient claims for 20 percent of all elderly fee-for-service Medicare decedents and 5 percent of all survivors between 1985 and 1999 and calculated age-, race-, and gender-adjusted per-capita inpatient expenditures and rates of intensive care unit (ICU) and intensive procedure use. We used the decedent-to-survivor expenditure ratio to determine whether growth rates among decedents outpaced growth relative to survivors, using the growth rate among survivors to control for secular trends in treatment intensity. Data Collection. The data were collected by the Centers for Medicare and Medicaid Services. Principal Findings. Real inpatient expenditures for the Medicare fee-for-service population increased by 60 percent, from $58 billion in 1985 to $90 billion in 1999, one-quarter of which were accrued by decedents. Between 1985 and 1999 the proportion of beneficiaries with one or more intensive care unit (ICU) admission increased from 30.5 percent to 35.0 percent among decedents and from 5.0 percent to 7.1 percent among survivors; those undergoing one or more intensive procedure increased from 20.9 percent to 31.0 percent among decedents and from 5.8 percent to 8.5 percent among survivors. The majority of intensive procedures in the United States were performed in the more numerous survivors, although in 1999 50 percent of feeding tube placements, 60 percent of intubations/tracheostomies, and 75 percent of cardiopulmonary resuscitations were in decedents. The proportion of beneficiaries dying in a hospital decreased from 44.4 percent to 39.3 percent, but the likelihood of being admitted to an ICU or undergoing an intensive procedure during the terminal hospitalization increased from 38.0 percent to 39.8 percent and from 17.8 percent to 30.3 percent, respectively. One in five Medicare beneficiaries who died in the hospital in 1999 received mechanical ventilation during their terminal admission. Conclusions. Inpatient treatment intensity for all fee-for-service beneficiaries increased between 1985 and 1999 regardless of survivorship status. Absolute changes in per-capita hospital expenditures, ICU admissions, and intensive inpatient procedure use were much higher among decedents. Relative changes were similar except for ICU admissions, which grew faster among survivors. The secular decline in in-hospital deaths has not resulted in decreased per capita utilization of expensive inpatient services in the last year of life. This could imply that net hospital expenditures for the dying might have been even higher over this time period if the shift toward hospice had not occurred. [source]


Driving forces behind increasing cardiovascular drug utilization: a dynamic pharmacoepidemiological model

BRITISH JOURNAL OF CLINICAL PHARMACOLOGY, Issue 6 2008
Helle Wallach Kildemoes
WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT , Several studies indicate that switch to more expensive drugs and increasing treatment intensity, rather than population ageing have been responsible for rising drug expenditures during the 1990s. , Little is known about the driving forces behind the increasing treatment intensity with cardiovascular drugs. WHAT THIS STUDY ADDS , This study provides a new pharmacoepidemiological method to analyse drug utilization trends, applying dispensing data at the individual level. , The suggested semi-Markov model allows for quantification of the influence of changing incidence, discontinuation and user mortality on rising treatment prevalence. , Increasing treatment incidence was the main driver behind rising treatment prevalence for most cardiovascular drug categories. , Whereas declining discontinuation drove some of the growth, declining mortality among drug users had little influence. AIMS To investigate the driving forces behind increasing utilization of cardiovascular drugs. METHODS Using register data, all Danish residents as of 1 January 1996 were followed until 2006. Cohort members were censored at death or emigration. Cardiovascular drug utilization on the individual level was traced, applying registered out-of-hospital dispensing. The impact of population ageing on cardiovascular drug utilization was investigated using standardized intensities and prevalences. Based on a three-state (untreated, treated and dead) semi-Markov model, we explored to what extent increasing treatment prevalence was driven by changing incidence, discontinuation and mortality. Expected treatment prevalences were modelled, applying stratum-specific cohort prevalence in 1996 along with incidence, discontinuation and drug user mortality either throughout 1996,2004 or at fixed 1996 levels. RESULTS Treatment prevalence (ages ,20 years) with cardiovascular drugs increased by 39% during 1996,2005 from 192.4 to 256.9 per 1000 inhabitants (95% confidence interval 256.5, 257.3). Treatment intensity grew by 109% from 272 to 569 defined daily doses 1000,1 day,1. Population ,middle-ageing' accounted for 11.5 and 20.3%, respectively. Increasing treatment incidence was the main driver of the rising treatment prevalence in most drug categories. Declining discontinuation drove some of the growth, declining drug user mortality less. Even with fixed incidence in the model, treatment prevalence continued to increase. CONCLUSIONS Age-related increases in treatment intensity and prevalence, rather than population ageing, drove the increasing treatment intensity with cardiovascular drugs. Increasing treatment prevalence in subgroups was primarily caused by increasing incidence. Due to pharmacoepidemiological disequilibrium, treatment prevalence will continue to grow even with unchanged incidence. [source]


Treatment intensity and regularity in early outpatient psychotherapy and its relation to outcome

CLINICAL PSYCHOLOGY AND PSYCHOTHERAPY (AN INTERNATIONAL JOURNAL OF THEORY & PRACTICE), Issue 6 2006
Susanne Kraft
The distribution of treatment sessions (number of interruptions, weeks without psychotherapy and number of sessions) during the first three months of psychodynamic psychotherapy (PD), cognitive behavioral therapy (CBT) and psychoanalytic psychotherapy (PAP) was analyzed prospectively over two years in a sample of 256 outpatients. Number of weeks without psychotherapy in early treatment was predicted by initial helping alliance in PD and by initial quality of interpersonal relations in CBT. Level of initial psychological or physical impairment showed no effect on distribution of sessions during early treatment. In PD and CBT, session distribution early in treatment did not predict subsequent course of improvement. Only in PAP did weeks without psychotherapy and number of sessions affect rate of symptom change, in that participants showed better outcome when treatment started continuously at a rather slow pace. Implications for psychotherapy practice and research are discussed. Copyright 2006 John Wiley & Sons, Ltd. [source]


Trends in Inpatient Treatment Intensity among Medicare Beneficiaries at the End of Life

HEALTH SERVICES RESEARCH, Issue 2 2004
Amber E. Barnato
Objective. Although an increasing fraction of Medicare beneficiaries die outside the hospital, the proportion of total Medicare expenditures attributable to care in the last year of life has not dropped. We sought to determine whether disproportionate increases in hospital treatment intensity over time among decedents are responsible for the persistent growth in end-of-life expenditures. Data Source. The 1985,1999 Medicare Medical Provider Analysis and Review (MedPAR) and Denominator files. Study Design. We sampled inpatient claims for 20 percent of all elderly fee-for-service Medicare decedents and 5 percent of all survivors between 1985 and 1999 and calculated age-, race-, and gender-adjusted per-capita inpatient expenditures and rates of intensive care unit (ICU) and intensive procedure use. We used the decedent-to-survivor expenditure ratio to determine whether growth rates among decedents outpaced growth relative to survivors, using the growth rate among survivors to control for secular trends in treatment intensity. Data Collection. The data were collected by the Centers for Medicare and Medicaid Services. Principal Findings. Real inpatient expenditures for the Medicare fee-for-service population increased by 60 percent, from $58 billion in 1985 to $90 billion in 1999, one-quarter of which were accrued by decedents. Between 1985 and 1999 the proportion of beneficiaries with one or more intensive care unit (ICU) admission increased from 30.5 percent to 35.0 percent among decedents and from 5.0 percent to 7.1 percent among survivors; those undergoing one or more intensive procedure increased from 20.9 percent to 31.0 percent among decedents and from 5.8 percent to 8.5 percent among survivors. The majority of intensive procedures in the United States were performed in the more numerous survivors, although in 1999 50 percent of feeding tube placements, 60 percent of intubations/tracheostomies, and 75 percent of cardiopulmonary resuscitations were in decedents. The proportion of beneficiaries dying in a hospital decreased from 44.4 percent to 39.3 percent, but the likelihood of being admitted to an ICU or undergoing an intensive procedure during the terminal hospitalization increased from 38.0 percent to 39.8 percent and from 17.8 percent to 30.3 percent, respectively. One in five Medicare beneficiaries who died in the hospital in 1999 received mechanical ventilation during their terminal admission. Conclusions. Inpatient treatment intensity for all fee-for-service beneficiaries increased between 1985 and 1999 regardless of survivorship status. Absolute changes in per-capita hospital expenditures, ICU admissions, and intensive inpatient procedure use were much higher among decedents. Relative changes were similar except for ICU admissions, which grew faster among survivors. The secular decline in in-hospital deaths has not resulted in decreased per capita utilization of expensive inpatient services in the last year of life. This could imply that net hospital expenditures for the dying might have been even higher over this time period if the shift toward hospice had not occurred. [source]


Understanding the properties of aerobic sludge granules as hydrogels

BIOTECHNOLOGY & BIOENGINEERING, Issue 5 2009
Thomas Seviour
Abstract Aerobic sludge granules are larger, denser microbial aggregates than activated sludge flocs with a smoother and more regular surface, which facilitates greater wastewater treatment intensity. Factors important in their growth are still poorly understood, which is an impediment to the construction and operation of full-scale aerobic sludge granule processes. Data in this article obtained with granules treating an abattoir wastewater provide evidence that aerobic sludge granules are hydrogels. The results also demonstrate a method for characterizing macromolecular associations. The rheological profile of these granules was found to be analogous with that of typical polymer gels. Water uptake or swelling reflects an equilibrium between granule elastic modulus and osmotic pressure, whereby uptake is increased by reducing solute concentration or the elastic modulus. A weakening of the extracellular polymeric substance (EPS) matrix as demonstrated with mechanical spectroscopy was induced by several environmental factors including temperature, pH and ionic strength. Uniform and elastic deformation was observed at low strain. Enzymatic degradation studies indicate that proteins and ,-polysaccharides were the major granule structural materials. The aerobic sludge granules in the current study were therefore protein,polysaccharide composite physical hydrogels. While aerobic sludge granules treating an abattoir wastewater are used as a case study, many of the fundamental principles detailed here are relevant to other granulation processes. The paradigm established in this study can potentially be applied to better understand the formation of aerobic sludge granules and thus overcome a hurdle in the acceptance of aerobic sludge granulation as an alternative to more traditional wastewater treatment processes. Biotechnol. Bioeng. 2009;102: 1483,1493. 2008 Wiley Periodicals, Inc. [source]


Driving forces behind increasing cardiovascular drug utilization: a dynamic pharmacoepidemiological model

BRITISH JOURNAL OF CLINICAL PHARMACOLOGY, Issue 6 2008
Helle Wallach Kildemoes
WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT , Several studies indicate that switch to more expensive drugs and increasing treatment intensity, rather than population ageing have been responsible for rising drug expenditures during the 1990s. , Little is known about the driving forces behind the increasing treatment intensity with cardiovascular drugs. WHAT THIS STUDY ADDS , This study provides a new pharmacoepidemiological method to analyse drug utilization trends, applying dispensing data at the individual level. , The suggested semi-Markov model allows for quantification of the influence of changing incidence, discontinuation and user mortality on rising treatment prevalence. , Increasing treatment incidence was the main driver behind rising treatment prevalence for most cardiovascular drug categories. , Whereas declining discontinuation drove some of the growth, declining mortality among drug users had little influence. AIMS To investigate the driving forces behind increasing utilization of cardiovascular drugs. METHODS Using register data, all Danish residents as of 1 January 1996 were followed until 2006. Cohort members were censored at death or emigration. Cardiovascular drug utilization on the individual level was traced, applying registered out-of-hospital dispensing. The impact of population ageing on cardiovascular drug utilization was investigated using standardized intensities and prevalences. Based on a three-state (untreated, treated and dead) semi-Markov model, we explored to what extent increasing treatment prevalence was driven by changing incidence, discontinuation and mortality. Expected treatment prevalences were modelled, applying stratum-specific cohort prevalence in 1996 along with incidence, discontinuation and drug user mortality either throughout 1996,2004 or at fixed 1996 levels. RESULTS Treatment prevalence (ages ,20 years) with cardiovascular drugs increased by 39% during 1996,2005 from 192.4 to 256.9 per 1000 inhabitants (95% confidence interval 256.5, 257.3). Treatment intensity grew by 109% from 272 to 569 defined daily doses 1000,1 day,1. Population ,middle-ageing' accounted for 11.5 and 20.3%, respectively. Increasing treatment incidence was the main driver of the rising treatment prevalence in most drug categories. Declining discontinuation drove some of the growth, declining drug user mortality less. Even with fixed incidence in the model, treatment prevalence continued to increase. CONCLUSIONS Age-related increases in treatment intensity and prevalence, rather than population ageing, drove the increasing treatment intensity with cardiovascular drugs. Increasing treatment prevalence in subgroups was primarily caused by increasing incidence. Due to pharmacoepidemiological disequilibrium, treatment prevalence will continue to grow even with unchanged incidence. [source]


Patterns of care for early stage bladder cancer,,

CANCER, Issue 11 2010
Seth A. Strope MD
Abstract BACKGROUND: Early stage bladder cancer is a heterogeneous disease with a variable risk of progression and mortality. Uncertainty surrounding the optimal care for these patients may result in a mismatch between disease risk and treatment intensity. METHODS: Using Surveillance, Epidemiology, End Results-Medicare data, we identified patients diagnosed with early stage bladder cancer (n = 24,980) between 1993 and 2002. We measured patients' treatment intensity by totaling all Medicare payments made for bladder cancer in the 2 years after diagnosis. Using multiple logistic regression, we assessed relationships between clinical characteristics and treatment intensity. Finally, we determined the extent to which a patient's disease risk matched with their treatment intensity. RESULTS: The average per capita expenditures increased from $6,936 to $7,642 over the study period (10.2% increase; P < .01). This increase was driven by greater use of intravesical therapy (2.6 vs 3.7 instillations per capita, P < .01) and physician office visits (3.0 vs 4.8 visits per capita, P < .01). Generally, treatment intensity was appropriately aligned with many clinical characteristics, including age, comorbidity, tumor stage, and grade. However, treatment intensity matched disease risk for only 55% and 49% of the lowest and highest risk patients, respectively. CONCLUSIONS: The initial treatment intensity of early stage bladder cancer is increasing, primarily through greater use of intravesical therapy and office visits. Treatment intensity matches disease risk for many, but up to 1 in 5 patients may receive too much or too little care, suggesting opportunities for improvement. Cancer 2010. 2010 American Cancer Society. [source]


Secondary or concomitant neoplasms among adults diagnosed with acute lymphoblastic leukemia and treated according to the LALA-87 and LALA-94 trials

CANCER, Issue 12 2007
Emmanuelle Tavernier MD
Abstract BACKGROUND. Second malignant neoplasms are a serious complication after successful treatment of childhood acute lymphoblastic leukemia (ALL). Although treatment intensity and outcome were not comparable, with improvements in survival it is important to evaluate the rate and the type of second neoplasms in adults with ALL. METHODS. The data from the GET-LALA group were analyzed. A cohort of 1494 patients, aged 15 to 60 years and enrolled in 2 successive multicenter protocols between 1987 and 2002, was observed to determine the incidence of second neoplasms and associated risk factors. The median follow-up from diagnosis was 6 years. RESULTS. By February 2005 secondary or concomitant neoplasms were documented in 23 patients, including 9 acute myeloid leukemias (AML) or myelodysplasias (MDS), 4 non-Hodgkin lymphomas (NHL), 5 skin tumors, and 5 other solid tumors (1 lung cancer, 1 tongue carcinoma, 1 thymoma, 1 condrosarcoma, 1 histiocytosis). Neoplasms developed 0.5 to 13.8 years (median, 4.5 years) after the diagnosis of ALL. There were 22 patients in first remission and 1 was in second remission. The overall cumulative risk of secondary neoplasms was 2.1% at 5 years, 4.9% at 10 years, and 9.4% at 15 years. The cumulative risk of developing a second hematologic malignancy was 1.8% at 5 years, 2.2% at 10 years, 3.3% at 18 years; that of developing a solid tumor was 0.2% at 5 years, 2.8% at 10 years, 6.2% at 15 years. The development of secondary neoplasm was not associated with the use of any specific cytotoxic agent. However, the risk of skin tumor increased with radiation dose and transplantation (P = .01). Overall survival (OS) after the diagnosis of a second malignant neoplasm was 55% at 10 years. However, the median OS in patients developing AML/MDS was 5.7 months. CONCLUSIONS. The data document that adult ALL survivors are at an increased risk of later malignancy. The risk of secondary or concomitant neoplasm appeared higher than that of childhood ALL previously reported in the literature. Considering the low survival rate of this large unselected adult ALL cohort (32% at 10 years) as compared with that observed in childhood ALL, the risk of second malignancy remains underestimated. Larger series with long-term follow-up are necessary, as well as methods of screening and identification of patients at increased risk. Cancer 2007. 2007 American Cancer Society. [source]


Management of isolated rectal bleeding in newborn infants: comparison of two time periods

ACTA PAEDIATRICA, Issue 2 2010
Ayala Maayan-Metzger
Abstract Aim:, To demonstrate the differences in treatment of isolated rectal bleeding (IRB) by comparing two study time period groups and to evaluate whether decreased treatment intensity increased complications during the follow-up period. Methods:, Retrospective recording of medical charts of 307 neonates with IRB during two time periods. Results:, The rate of IRB in both period groups was similar among term and near-term infants, but significantly lower among preterm infants in the later period study group. The rate of breast milk feeding among preterm infants increased significantly in the later compared with the early group. Duration of antibiotic treatments and feeding cessation was significantly shortened in the late period study as compared with the early period. The rates of recurrent episodes of IRB among preterm infants were similar in the early and late period groups. No infant developed necrotizing enterocolitis within the episode of isolated rectal bleeding. Conclusions:, Decreased treatment duration to 1 day of nil per os and 2 days of antibiotics was not associated with increased rates of deterioration to severe clinical conditions, nor to recurrent episodes of isolated rectal bleeding. [source]