Nurse Work Environment and Hospital-Onset Clostridioides difficile Infection

BACKGROUND

Clostridioides difficile is the leading cause of hospital-onset diarrhea and is associated with increased lengths of stay and mortality. While some hospitals have successfully reduced the burden of C. difficile infection (CDI), many still struggle to reduce hospital-onset CDI. Nurses-because of their close proximity to patients-are an important resource in the prevention of hospital-onset CDI.

OBJECTIVE

Determine whether there is an association between the nurse work environment and hospital-onset CDI.

METHODS

Survey data of 2016 were available from 15,982 nurses employed in 353 acute care hospitals. These data, aggregated to the hospital level, provided measures of the nurse work environments. They were merged with 2016 hospital-onset CDI data from Hospital Compare, which provided our outcome measure-whether a hospital had a standardized infection ratio (SIR) above or below the national average SIR. Hospitals above the average SIR had more infections than predicted when compared to the national average.

RESULTS

In all, 188 hospitals (53%) had SIRs higher than the national average. The odds of hospitals having higher than average SIRs were significantly lower, with odds ratios ranging from 0.35 to 0.45, in hospitals in the highest quartile for all four nurse work environment subscales (managerial support, nurse participation in hospital governance, physician-nurse relations, and adequate staffing) than in hospitals in the lowest quartile.

CONCLUSIONS

Findings show an association between the work environment of nurses and hospital-onset CDI. A promising strategy to lower hospital-onset CDI and other infections is a serious and sustained commitment by hospital leaders to significantly improve nurse work environments.

Preoperative Coil-Embolization of a Large, Myelon-Compressing Vertebral Metastasis Involving the Artery of Adamkiewicz

Background Metastatic spinal cord compression causes neurologic impairment and pain, potentially improved by decompression surgery at the risk of heavy intraoperative bleeding. Preoperative embolization carries the risk of nontarget embolization, potentially causing spinal ischemia. Current evidence indicates that knowledge of artery of Adamkiewicz (AKA) location and the amount of collateralization may help estimate the risk of postinterventional spinal cord injury.

Case Presentation In this case of a 73-year-old female patient with progression of a large, myelon-compressing vertebral metastasis of L1, protective, blood-flow-controlling occlusion of the proximal-most points of the AKA and segmental spinal arteries was safely performed prior to tumor embolization, surgical decompression, and tumor debulking.

Association of Registered Nurse Staffing With Mortality Risk of Medicare Beneficiaries Hospitalized With Sepsis

Question

Is registered nurse workload associated with mortality among Medicare beneficiaries who are admitted to an acute care hospital with a diagnosis of sepsis?

Findings

In this cross-sectional study of 1958 acute care hospitals and 702 140 Medicare beneficiaries with a diagnosis of sepsis, an increase in registered nurse hours per patient day was associated with a 3% decrease in 60-day mortality in these older adults, a finding that was statistically significant.

Meaning

The study results suggest that the hours of care provided by registered nurses is likely associated with the outcomes of patients with a diagnosis of sepsis.

Importance

Sepsis is a major physiologic response to infection that if not managed properly can lead to multiorgan failure and death. The US Centers for Medicare & Medicaid Services (CMS) requires that hospitals collect data on core sepsis measure Severe Sepsis and Septic Shock Management Bundle (SEP-1) in an effort to promote the early recognition and treatment of sepsis. Despite implementation of the SEP-1 measure, sepsis-related mortality continues to challenge acute care hospitals nationwide.

Objective

To determine if registered nurse workload was associated with mortality in Medicare beneficiaries admitted to an acute care hospital with sepsis.

Design, Setting, and Participants

This cross-sectional study used 2018 data from the American Hospital Association Annual Survey, CMS Hospital Compare, and Medicare claims on Medicare beneficiaries age 65 to 99 years with a primary diagnosis of sepsis that was present on admission to 1 of 1958 nonfederal, general acute care hospitals that had data on CMS SEP-1 scores and registered nurse workload (indicated by registered nurse hours per patient day [HPPD]). Patients with sepsis were identified based on 29 International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes. Data were analyzed throughout 2021.

Exposures

SEP-1 score and registered nurse staffing.

Main Outcomes and Measures

The patient outcome of interest was mortality within 60 days of admission. Hospital characteristics included number of beds, ownership, teaching status, technology status, rurality, and region. Patient characteristics included age, sex, transfer status, intensive care unit admission, palliative care, do-not-resuscitate order, and a series of 29 comorbid diseases based on the Elixhauser Comorbidity Index.

Results

In total, 702 140 Medicare beneficiaries (mean [SD] age, 78.2 [8.7] years; 360 804 women [51%]) had a diagnosis of sepsis. The mean SEP-1 score was 56.1, and registered nurse HPPD was 6.2. In a multivariable regression model, each additional registered nurse HPPD was associated with a 3% decrease in the odds of 60-day mortality (odds ratio, 0.97; 95% CI 0.96-0.99) controlling for SEP-1 score and hospital and patient characteristics.

Conclusions and Relevance

The results of this cross-sectional study suggest that hospitals that provide more registered nurse hours of care could likely improve SEP-1 bundle compliance and decrease the likelihood of mortality in Medicare beneficiaries with sepsis.

Urban-rural differences in healthcare utilization among beneficiaries in China's new cooperative medical scheme

BACKGROUND

The New Cooperative Medical Scheme (NCMS) is a voluntary social health insurance program launched in 2002 for rural Chinese residents where 80% of people were without health insurance of any kind. Over time, several concerns about this program have been raised related to healthcare utilization disparities for NCMS participants in urban versus rural regions. Our study uses 2015 national survey data to evaluate the extent of these urban and rural disparities among NCMS beneficiaries.

METHODS

Data for our study are based on the Chinese Health and Retirement Longitudinal Study (CHARLS) for 2015. Our 12,190-patient sample are urban and rural patients insured by NCMS. We use logistic regression analyses to compare the extent of disparities for urban and rural residence of NCMS beneficiaries in (1) whether individuals received any inpatient or outpatient care during 2015 and (2) for those individuals that did receive care, the extent of the variation in the number of inpatient and outpatient visits among each group.

RESULTS

Our regression results reveal that for urban and rural NCMS patients in 2015, there were no significant differences in inpatient or outpatient utilization for either of the dependent variables - 1) whether or not the patient had a visit during the last year, or 2) for those that had a visit, the number of visits they had. Patient characteristics: age, sex, employment, health status, chronic conditions, and per capita annual expenditures - all had significant impacts on whether or not there was an inpatient or outpatient visit but less influence on the number of inpatient or outpatient visits.

CONCLUSIONS

For both access to inpatient and outpatient facilities and the level of utilization of these facilities, our results reveal that both urban and rural NCMS patients have similar levels of resource utilization. These results from 2015 indicate that utilization angst about urban and rural disparities in NCMS patients do not appear to be a significant concern.

Trends in U.S. Community hospitalizations due to herpes zoster: 2001-2015

BACKGROUND

In 2007, based on decisions by the U.S. Advisory Committee on Immunization Practices, the CDC recommended a booster dose at 4-6 years in the varicella vaccine schedule. In 2008, a herpes zoster vaccine was recommended for use in persons age ≥60 years. The purpose of this study was to examine trends in herpes zoster hospitalization rates and assess the impact of both policy recommendations using U.S. hospital discharge data.

METHODS

Nationwide Inpatient Sample discharge data from 2001 to 2015 were used to identify primary or secondary herpes zoster diagnoses. Trends in annual total and age-specific herpes zoster hospitalization rates and average length of stay were examined. Average annual rates for the pre (2001-2005) and post (2012-2015)-zoster vaccine policy eras were compared. Absolute change in herpes zoster hospitalizations were calculated.

RESULTS

The rate difference of U.S. herpes zoster hospitalizations in the post vs. pre-zoster vaccine policy era was -1.9 per 100,000 population (6,200 fewer hospitalizations in 2015 than expected). Key age group rate differences: 0-3 years (-0.4 per 100,000; 50 fewer), 4-6 years (-0.6 per 100,000; 50 fewer), 7-14 years (-1.3 per 100,000; 400 fewer), 50-59 years (0.7 per 100,000; 300 more), 60-69 years (-2.5 per 100,000; 900 fewer), 70-79 years (-10.2 per 100,000; 2,000 fewer), 80+ years (-29.9 per 100,000; 3,600 fewer).

CONCLUSIONS

Reduction of wild-type varicella due to the 2-dose varicella vaccination recommendation may have impacted declining herpes zoster hospitalization rates among children ≤14 years. The 2008 herpes zoster vaccine may have impacted declining herpes zoster hospitalization rates for adults age ≥60 years despite vaccination coverage <31% by 2015.

California safety-net hospitals likely to be penalized by ACA value, readmission, and meaningful-use programs

The Affordable Care Act includes provisions to increase the value obtained from health care spending. A growing concern among health policy experts is that new Medicare policies designed to improve the quality and efficiency of hospital care, such as value-based purchasing (VBP), the Hospital Readmissions Reduction Program (HRRP), and electronic health record (EHR) meaningful-use criteria, will disproportionately affect safety-net hospitals, which are already facing reduced disproportionate-share hospital (DSH) payments under both Medicare and Medicaid. We examined hospitals in California to determine whether safety-net institutions were more likely than others to incur penalties under these programs. To assess quality, we also examined whether mortality outcomes were different at these hospitals. Our study found that compared to non-safety-net hospitals, safety-net institutions had lower thirty-day risk-adjusted mortality rates in the period 2009-11 for acute myocardial infarction, heart failure, and pneumonia and marginally lower adjusted Medicare costs. Nonetheless, safety-net hospitals were more likely than others to be penalized under the VBP program and the HRRP and more likely not to meet EHR meaningful-use criteria. The combined effects of Medicare value-based payment policies on the financial viability of safety-net hospitals need to be considered along with DSH payment cuts as national policy makers further incorporate performance measures into the overall payment system.

Index of cardiometabolic health: a new method of measuring allostatic load using electronic health records

OBJECTIVE

We developed a measure of allostatic load from electronic medical records (EMRs), which we named "Index of Cardiometabolic Health" (ICMH).

METHODS

Data were collected from participants' EMRs and a written survey in 2005. We computed allostatic load scores using the ICMH score and two previously described approaches.

RESULTS

We included 1865 employed adults who were 25-59 years old. Although the magnitude of the association was small, all methods of were predictive of SF-12 physical component subscales (all p < 0.001).

CONCLUSION

We found that the ICMH had similar relationships with health-related quality of life as previously reported in the literature.

Addressing Medicaid Expansion from the Perspective of Patient Experience in Hospitals

BACKGROUND

More Medicaid holders are entering the healthcare system consequential to Medicaid expansion. Their experience has financial consequences for hospitals and crucial implications for the provision of patient-centered care. This study examined how the hospital characteristics, especially the rates of Medicaid coverage and racial/ethnic minorities, impact the quality of inpatient care.

METHODS

Using data for years 2009-2011 for 870 observations of California hospitals, and data collected from patients via the Hospital Consumer Assessment of Healthcare Providers and Systems survey coupled with data from the Healthcare Cost and Utilization Project and American Hospital Association Annual Survey, we used a generalized estimating equation approach to evaluate patients' experience with hospital care. Our multivariate model includes a comprehensive set of characteristics capturing market, structural, process, and patient demographics associated with the patient's hospital stay.

RESULTS

The findings indicate that high concentrations of Medicaid patients in the hospital negatively impact the perceived patient experience. In addition, all things being equal, hospitals with higher concentrations of Hispanic, Black, and Asian patients received lower patient satisfaction results on 28 of the 30 regression coefficients capturing patient satisfaction, with 22 of the 30 negative coefficients statistically significant.

CONCLUSIONS

Hospitals serving higher concentrations of Medicaid patients and more racial/ethnic diverse patients experienced a less satisfactory patient experience than patients utilizing other payers or patients who were White. Our research magnifies the challenge for addressing the disparities that exist in healthcare. Further research is called for clarifying the underlying reasons for these disparities and the optimal strategies for addressing these problems.

Trends in U.S. hospitalizations and inpatient deaths from pneumonia and influenza, 1996-2011

BACKGROUND

To reduce excess morbidity and mortality of pneumonia and influenza (PI), the Advisory Committee on Immunization Practices has recommended the use of 7-valent pneumococcal conjugate vaccine (PCV7), and incrementally expanded the target group for annual influenza vaccination of healthy persons, to ultimately include all persons ≥6 months of age without contraindications as of the 2010-2011 influenza season. We aimed to capture broader epidemiologic changes by looking at PI collectively.

METHODS

Using interrupted time series, we evaluated the changes in the rates of PI hospitalization and inpatient death across three periods defined according to the changes in vaccination policy. We assessed linear trends adjusting for seasonality, sex, and age group, allowing for differential impact across age groups. PI hospitalizations were defined as a principal diagnosis of PI, or a principal diagnosis of sepsis or respiratory failure, accompanied by a secondary diagnosis of PI.

RESULTS

Overall annual rates of PI hospitalizations and inpatient deaths declined by 95 per 100,000 (95% CI: 45-145) and by 4.4 per 100,000 (95% CI: 0.9-7.8), respectively. This translates to 295,000 fewer PI hospitalizations and 13,600 fewer PI inpatient deaths than expected based on the average rates from 1996 through 1999. PI hospitalizations dropped the most among seniors aged 65+ by 487 per 100,000, followed by children aged <2, by 228 per 100,000. PI inpatient deaths declined most among seniors aged 65+, by 25.3 per 100,000.

CONCLUSIONS

In this nationally representative study, PI hospitalizations and inpatient deaths decreased in U.S. between 1996 and 2011. There is a temporal association with the introduction and widespread use of pneumococcal conjugate vaccines, and the expansion of the target group for annual influenza vaccination to include all persons ≥6 months of age, while it is difficult to attribute these changes directly to specific vaccines used in this era.

The Financial Effect of Value-Based Purchasing and the Hospital Readmissions Reduction Program on Safety-Net Hospitals in 2014: A Cohort Study

BACKGROUND

Medicare's value-based purchasing (VBP) and the Hospital Readmissions Reduction Program (HRRP) could disproportionately affect safety-net hospitals.

OBJECTIVE

To determine whether safety-net hospitals incur larger financial penalties than other hospitals under VBP and HRRP.

DESIGN

Cross-sectional analysis.

SETTING

United States in 2014.

PARTICIPANTS

3022 acute care hospitals participating in VBP and the HRRP.

MEASUREMENTS

Safety-net hospitals were defined as being in the top quartile of the Medicare disproportionate share hospital (DSH) patient percentage and Medicare uncompensated care (UCC) payments per bed. The differences in penalties in both total dollars and dollars per bed between safety-net hospitals and other hospitals were estimated with the use of bivariate and graphical regression methods.

RESULTS

Safety-net hospitals in the top quartile of each measure were more likely to be penalized under VBP than other hospitals (62.9% vs. 51.0% under the DSH definition and 60.3% vs. 51.5% under the UCC per-bed definition). This was also the case under the HRRP (80.8% vs. 69.0% and 81.9% vs. 68.7%, respectively). Safety-net hospitals also had larger payment penalties ($115 900 vs. $66 600 and $150 100 vs. $54 900, respectively). On a per-bed basis, this translated to $436 versus $332 and $491 versus $314, respectively. Sensitivity analysis setting the cutoff at the top decile rather than the top quartile decile led to similar conclusions with somewhat larger differences between safety-net and other hospitals. The quadratic fit of the data indicated that the larger effect of these penalties is in the middle of the distribution of the DSH and UCC measures.

LIMITATION

Only 2 measures of safety-net status were included in the analyses.

CONCLUSION

Safety-net hospitals were disproportionately likely to be affected under VBP and the HRRP, but most incurred relatively small payment penalties in 2014.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute.

Cost of intraocular lens versus contact lens treatment after unilateral congenital cataract surgery in the infant aphakia treatment study at age 5 years

PURPOSE

To analyze differences in the cost of treatment for infants randomized to primary intraocular lens (IOL) implantation versus optical correction with a contact lens (CL) after unilateral cataract surgery in the Infant Aphakia Treatment Study (IATS).

DESIGN

Retrospective cost analysis of a prospective, randomized clinical trial based on Georgia Medicaid reimbursement data as well as actual costs of supplies used during the study, adjusted for inflation.

PARTICIPANTS

The IATS is a multicenter (n = 12), randomized clinical trial comparing the optical treatment of aphakia with either primary IOL implantation (n = 57) or CL correction (n = 57) in 114 infants with unilateral congenital cataract.

INTERVENTION

One hundred fourteen infants underwent unilateral cataract surgery and were either corrected optically by primary IOL implantation at the time of surgery or were corrected with a CL after surgery.

MAIN OUTCOME MEASURES

The mean cost of cataract surgery and all additional surgeries, examinations, and supplies used up to 5 years of age.

RESULTS

The 5-year treatment cost of an infant with a unilateral congenital cataract corrected optically with an IOL was $27 090 versus $25 331 for a patient treated with a CL after initial cataract surgery. The total cost of supplies was $3204 in the IOL group versus $7728 in the CL group.

CONCLUSIONS

Unilateral cataract surgery in infancy coupled with primary IOL implantation is approximately 7% more expensive than aphakia and CL correction. Patient costs are more than double with CL versus IOL treatment.

The impact of electronic health records on workflow and financial measures in primary care practices

OBJECTIVE

To estimate a commercially available ambulatory electronic health record's (EHR's) impact on workflow and financial measures.

DATA SOURCES/STUDY SETTING

Administrative, payroll, and billing data were collected for 26 primary care practices in a fee-for-service network that rolled out an EHR on a staggered schedule from June 2006 through December 2008.

STUDY DESIGN

An interrupted time series design was used. Staffing, visit intensity, productivity, volume, practice expense, payments received, and net income data were collected monthly for 2004-2009. Changes were evaluated 1-6, 7-12, and >12 months postimplementation.

DATA COLLECTION/EXTRACTION METHODS

Data were accessed through a SQLserver database, transformed into SAS®, and aggregated by practice. Practice-level data were divided by full-time physician equivalents for comparisons across practices by month.

PRINCIPAL FINDINGS

Staffing and practice expenses increased following EHR implementation (3 and 6 percent after 12 months). Productivity, volume, and net income decreased initially but recovered to/close to preimplementation levels after 12 months. Visit intensity did not change significantly, and a secular trend offset the decrease in payments received.

CONCLUSIONS

Expenses increased and productivity decreased following EHR implementation, but not as much or as persistently as might be expected. Longer term effects still need to be examined.

Value drivers: an approach for estimating health and disease management program savings

Health and disease management (HDM) programs have faced challenges in documenting savings related to their implementation. The objective of this eliminate study was to describe OptumHealth's (Optum) methods for estimating anticipated savings from HDM programs using Value Drivers. Optum's general methodology was reviewed, along with details of 5 high-use Value Drivers. The results showed that the Value Driver approach offers an innovative method for estimating savings associated with HDM programs. The authors demonstrated how real-time savings can be estimated for 5 Value Drivers commonly used in HDM programs: (1) use of beta-blockers in treatment of heart disease, (2) discharge planning for high-risk patients, (3) decision support related to chronic low back pain, (4) obesity management, and (5) securing transportation for primary care. The validity of savings estimates is dependent on the type of evidence used to gauge the intervention effect, generating changes in utilization and, ultimately, costs. The savings estimates derived from the Value Driver method are generally reasonable to conservative and provide a valuable framework for estimating financial impacts from evidence-based interventions.

Improving psychotherapeutic medication prescribing in Florida: implementation of the Florida Medicaid Drug Therapy Management Program (MDTMP)

This paper describes a program that was established by Florida Medicaid to improve the quality of prescribing of psychotherapeutic medications. It relates the process used for defining quality medication treatment including the definitions of unusual psychotherapeutic medication indicators (UPMI). It details the results of analysis of FY 2007-2008 pharmacy claims data using these indicators that enabled the Program to identify practices and prescribers that required targeted interventions. The most frequently triggered UPMI for adults involved the use of 2 or more antipsychotics for greater than 60 days; high doses of psychotherapeutic medications was the indicator most frequently triggered for children closely followed by the use of 2 or more antipsychotics for more than 45 days. Prescriptions that triggered UPMI were concentrated in a small number of prescribers. These results led to the Program focusing on these high frequency practices and on the prescribers most associated with them. They also led to the implementation of new quality improvement initiatives like the implementation of a psychiatric telephone consultation line for pediatricians who are treating children with serious emotional disturbances who do not have access to child psychiatrists.

Antipsychotic polypharmacy prescribing patterns and costs in the Florida adult and child Medicaid populations

The rapid growth in the use of antipsychotic medications and their related costs have resulted in states developing programs to measure, monitor, and insure their beneficial relevance to public program populations. One such program developed in the state of Florida has adopted an evidence-based approach to identify prescribers with unusual psychotherapeutic prescription patterns and track their utilization and costs among Florida Medicaid patients. This study reports on the prescriber prescription and cost patterns for adults and children using three measures of unusual antipsychotic prescribing patterns: (1) two antipsychotics for 60 days (2AP60), (2) three antipsychotics for 60 days (3AP60), and (2) two antipsychotics for 90 or more days (2AP90). We find that over the four-year study period there were substantial increases in several aspects of the Florida Medicaid behavioral drug program. Overall, for adults and children, patient participation increased by 29 percent, the number of prescriptions grew by 30 percent, and the number of prescribers that wrote at least one prescription grew 48.5 percent, while Medicaid costs for behavioral drugs increased by 32 percent. But the results are highly skewed. We find that a relatively small number of prescribers account for a disproportionately large share of prescriptions and costs of the unusual antipsychotic prescriptions. In general, the top 350 Medicaid prescribers accounted for more than 70 percent of the unusual antipsychotic prescriptions, and we find that this disparity in unusual prescribing patterns appears to be substantially more pronounced in adults than in children prescribers. For just the top 13 adult and children prescribers, their practice patterns accounted for 11 percent to 21 percent of the unusual prescribing activity and, overall, these 13 top prescribers accounted for 13 percent of the total spent on antipsychotics by the Florida Medicaid program and 9.3 percent of the total expenditure by the state for all drugs. Our findings suggest that a strategy to monitor and ensure patient safety and prescribing patterns that targets a relatively small number of Medicaid providers could have a substantial benefit and prove to be cost effective.

Cost of intraocular lens versus contact lens treatment after unilateral congenital cataract surgery: retrospective analysis at age 1 year

PURPOSE

To describe the differences in treatment costs for infants randomized to contact lens correction versus primary intraocular lens (IOL) implantation after unilateral cataract surgery in the Infant Aphakia Treatment Study (IATS).

DESIGN

Retrospective cost analysis of a prospective, randomized clinical trial based on Georgia Medicaid data and the actual costs of supplies used.

PARTICIPANTS

The IATS is a randomized, multicenter (n=12) clinical trial comparing treatment of aphakia with a primary IOL or contact lens in 114 infants with unilateral congenital cataract.

INTERVENTION

Infants underwent cataract surgery with or without placement of an IOL.

MAIN OUTCOME MEASURES

The mean cost of cataract surgery and all additional surgeries, examinations, and supplies used up to 12 months of age.

RESULTS

The mean cost of treatment for a unilateral congenital cataract with primary IOL implantation was $14 752 versus $10 726 with contact lens correction. The initial cataract surgery accounted for approximately 50% of the treatment costs for both groups. Contact lens costs accounted for 15% ($1600/patient) in the aphakic group, whereas glasses costs represented only 4% ($535/patient) in the IOL group. The increased costs in the IOL group were primarily due to the higher cost of cataract surgery in this group ($7302 vs. $5357) and the cost of additional operations.

CONCLUSIONS

For IATS patients up to 12 months of age, cataract surgery coupled with IOL implantation and spectacle correction was 37.5% (∼$4000) more expensive than cataract surgery coupled with contact lens correction.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

The impact of the individual mandate and Internal Revenue Service Form 990 Schedule H on community benefits from nonprofit hospitals

In response to a growing concern that nonprofit hospitals are not providing sufficient benefit to their communities in return for their tax-exempt status, the Internal Revenue Service (IRS) now requires nonprofit hospitals to formally document the extent of their community contributions. While the IRS is increasing financial scrutiny of nonprofit hospitals, many provisions in the recently passed historical health reform legislation will also have a significant impact on the provision of uncompensated care and other community benefits. We argue that health reform does not render the nonprofit organizational form obsolete. Rather, health reform should strengthen the nonprofit hospitals' ability to fulfill their missions by better targeting subsidies for uncompensated care and potentially increasing subsidized health services provision, many of which affect the public's health.

The financial and nonfinancial costs of implementing electronic health records in primary care practices

The incentives in the American Recovery and Reinvestment Act to expand the "meaningful use" of electronic health record systems have many health care professionals searching for information about the cost and staff resources that such systems require. We report the cost of implementing an electronic health record system in twenty-six primary care practices in a physician network in north Texas, taking into account hardware and software costs, as well as the time and effort invested in implementation. For an average five-physician practice, implementation cost an estimated $162,000, with $85,500 in maintenance expenses during the first year. We also estimate that the HealthTexas network implementation team and the practice implementation team needed 611 hours, on average, to prepare for and implement the electronic health record system, and that "end users"-physicians, other clinical staff, and nonclinical staff-needed 134 hours per physician, on average, to prepare for use of the record system in clinical encounters.

An evaluation of the influence of primary care team functioning on the health of Medicare beneficiaries

In service industries other than health care, unit employees who report a favorable service climate--characterized by commitment to a team concept and intrateam interactions that are supportive, collegial, and collaborative--have high levels of consumer satisfaction and work unit productivity. The authors evaluated whether similar primary care team (PCT) functioning influenced the short-term future health (SF-36) of elderly Medicare beneficiaries (N = 991) in a group model managed care organization (MCO). PCT functioning was assessed by surveys of practitioners and support staff on the MCO's 14 primary care practices and included measures of perceived task delegation, role collaboration, patient orientation, and team ownership. On average, patient physical and emotional health declined over 2 years. Medicare beneficiaries empanelled to relatively high functioning PCTs had significantly better physical and emotional health at 2 years following baseline assessment than those empanelled to relatively low functioning PCTs.

Simultaneous vs sequential bilateral cataract surgery for infants with congenital cataracts: Visual outcomes, adverse events, and economic costs

OBJECTIVES

To compare the incidence of adverse events and visual outcomes and to compare the economic costs of sequential vs simultaneous bilateral cataract surgery for infants with congenital cataracts.

METHODS

Retrospective review of simultaneous vs sequential bilateral cataract surgery for infants with congenital cataracts who underwent cataract surgery when 6 months or younger at our institution.

RESULTS

Records were available for 10 children who underwent sequential surgery at a mean age of 49 days for the first eye and 17 children who underwent simultaneous surgery at a mean age of 68 days (P = .25). We found a similar incidence of adverse events between the 2 treatment groups. Intraoperative or postoperative complications occurred in 14 eyes. The most common postoperative complication was glaucoma. No eyes developed endophthalmitis. The mean (SD) absolute interocular difference in logMAR visual acuities between the 2 treatment groups was 0.47 (0.76) for the sequential group and 0.44 (0.40) for the simultaneous group (P = .92). Payments for the hospital, drugs, supplies, and professional services were on average 21.9% lower per patient in the simultaneous group.

CONCLUSIONS

Simultaneous bilateral cataract surgery for infants with congenital cataracts is associated with a 21.9% reduction in medical payments and no discernible difference in the incidence of adverse events or visual outcomes. However, our small sample size limits our ability to make meaningful comparisons of the relative risks and visual benefits of the 2 procedures.

Disparities in use of a personal health record in a managed care organization

OBJECTIVE

Personal health records (PHRs) can increase patient access to health care information. However, use of PHRs may be unequal by race/ethnicity.

DESIGN

The authors conducted a 2-year cohort study (2005-2007) assessing differences in rates of registration with KP.org, a component of the Kaiser Permanente electronic health record (EHR).

MEASUREMENTS

At baseline, 1,777 25-59 year old Kaiser Permanente Georgia enrollees, who had not registered with KP.org, responded to a mixed mode (written or Internet) survey. Baseline, EHR, and KP.org data were linked. Time to KP.org registration by race from 10/1/05 (with censoring for disenrollment from Kaiser Permanente) was adjusted for baseline education, comorbidity, patient activation, and completion of the baseline survey online vs. by paper using Cox proportional hazards.

RESULTS

Of 1,777, 34.7% (616) registered with KP.org between Oct 2005 and Nov 2007. Median time to registering a KP.org account was 409 days. Among African Americans, 30.1% registered, compared with 41.7% of whites (p < 0.01). In the hazards model, African Americans were again less likely to register than whites (hazard ratio [HR] = 0.652, 95% CI: 0.549-0.776) despite adjustment. Those with baseline Internet access were more likely to register (HR = 1.629, 95% CI: 1.294-2.050), and a significant educational gradient was also observed (more likely registration with higher educational levels).

CONCLUSIONS

Differences in education, income, and Internet access did not account for the disparities in PHR registration by race. In the short-term, attempts to improve patient access to health care with PHRs may not ameliorate prevailing disparities between African Americans and whites.

Influence of Source and Type of Admission on In-Hospital Mortality for Coronary Artery Bypass Surgery Patients:

BACKGROUND

Hospitals identify the type of coronary artery bypass graft (CABG) surgery admission as routine, urgent, or emergency, and identify CABG admissions as elective, from another hospital, from a long-term healthcare facility, and an admission that results from an emergency room visit. No research has analyzed the importance of these admission characteristics on CABG outcomes.

METHODS

Using the Nationwide Inpatient Sample data from the Healthcare Cost and Utilization Project database for 1998 through 2002, 1.7 million CABG admissions are analyzed using descriptive and logistic regression techniques to evaluate the extent of differences in in-hospital CABG mortality rates by the type of admission and the source of admission.

RESULTS

While there has been 22% decline over our 5-year study period regardless of the source or type of admission, we find that a 2.5-fold difference exists in the in-hospital CABG mortality rates among categories that distinguish the type of admission and the source of admission in the nation's hospital. In 2002, CABG admissions that are routine elective-surgeries have a CABG mortality rate of 1.49%, while urgent CABG admissions from a long-term care facility have an in-hospital mortality rate that is 3.64%.

CONCLUSIONS

While significant progress has been made lowering in-hospital CABG mortality, sizable differences still remain among the types and sources of CABG admissions. Clinical trial research on CABG patients where the end points include mortality need to be especially mindful of the potential differences and distortions in their data that can be generated due to these various sources of hospital admissions.

Improved Intermediate Clinical Outcomes From Participation in a Diabetes Health Education Program

Diabetes self-management education programs are an essential strategy for improving health behaviors of adults with diabetes and, therefore, intermediate clinical outcomes. We conducted a retrospective observational study using a case:control design to estimate the impact of participation in a diabetes health education program on glycemic and lipid levels, accounting for nonrandom participation of adults with diabetes in the program ("regression to the mean"). Adults with diabetes in a group-model managed care organization who attended the diabetes health education program during the period January 1, 2003, through June 30, 2004 ("participants"), were randomly matched with 4 adults with diabetes who did not participate ("nonparticipants"). Participants (N=1991) and nonparticipants (N=7964) were matched on age group, gender, mean hemoglobin A1c (Hb A1c) (or low-density lipoprotein) in the 6 months prior to the class (or randomly selected index month for nonparticipants), and primary care practice where the patients received regular care. On average, participants had significantly (P < .05) worse glycemic and lipid levels in the 6 months prior to participation compared to nonparticipants. Participation in the diabetes education program significantly improved glycemic and lipid levels between baseline and follow-up periods above the improvement attributable to regression to the mean. For example, nonparticipants with baseline Hb A1c levels greater than 10.0% had improved Hb A1c levels of -1.7% (P < .01); however, among participants, mean Hb A1c levels improved an additional -1.6% (P < .01). Overall, the evidence suggests that participation in a multifactorial diabetes health education program significantly improved glycemic and lipid levels in the short-term, particularly among participants with extremely adverse Hb A1c or low-density lipoprotein levels prior to participation.

National trends and determinants of hospitalization costs and lengths-of-stay for uterine fibroids procedures

Uterine fibroid admissions in the nation's hospitals have grown more than 20 percent over the past five years. Substantial variations exist in inpatient treatment patterns. In spite of this dramatic growth, there are no national studies of the hospital costs associated with the treatment of uterine fibroids in the hospital setting. Using 11 years of data (1993-2003) from the Healthcare Cost and Utilization Project, a nationally representative 20 percent sample of the nation's inpatient admissions, trends in hospital charges, costs, and lengths of stay (LOSs) are reported. For 2001 to 2003, determinants of hospital costs and LOS for inpatients with a primary diagnosis of uterine fibroids were analyzed using univariate analyses and regression techniques. Hysterectomies for women with a primary diagnosis of uterine fibroids have in-hospital costs of over $1.5 billion. Among the major procedures for treating uterine fibroids, in 2003, total abdominal hysterectomy had the longest LOS, averaging 2.9 days with a mean cost of $6331. In contrast, the treatment with the shortest LOS, 1.72 days, was laparoscopically assisted vaginal hysterectomy but it had the highest mean costs of $7108. In 2003, supracervical hysterectomies and myomectomies had mean costs of $6809 and $6707, respectively. Multivariate results show that patient characteristics and structural aspects of the hospital are strong predictors of lengths of stay and cost per day but there are major differences across some of the surgical procedures. Although the patient characteristics-insulin-dependent, non-insulin dependent diabetes, obesity, morbid obesity, smoker, hypertension, congestive heart failure, chronic obstructive pulmonary disease-all have significant impacts on LOS and cost per day for some of the major uterine fibroid treatments, they are not consistent. Compared with white women, black, Hispanic, and Asian/Pacific Island women all had higher lengths of stay and costs per day. Bedsize and teaching status are generally positively associated with lengths of stay and costs per day; for-profit status always had a significant positive association with LOS and cost per day. Hospital costs for treating women with uterine fibroids are continuing to grow. Further research on the determinants of the resource utilization could be helpful in predicting and alleviating these costs and improving patient care.

Disparities in race/ethnicity and gender in in-hospital mortality rates for coronary artery bypass surgery patients

BACKGROUND

While dramatic progress has been made lowering in-hospital mortality for coronary artery bypass graft surgery (CABG), few comprehensive studies have been done that include Caucasian, African-American, Hispanic and Asian-American/Pacific-Islander CABG inpatients and simultaneously evaluate the influence of gender. This study, analyzing five years of national data for 1.2 million CABG admissions, examines trends in in-hospital CABG mortality rates for gender and four racial/ethnic categories for CABG patients.

METHODS

Using data from the Health Care Utilization Project (HCUP) for 1998-2002, 1.2 million CABG admissions were analyzed using descriptive and logistic regression analyses to evaluate the extent of the disparities in in-hospital CABG mortality rates. HCUP is a sample of nearly 1,000 hospitals from 35 states designed by the Agency for Healthcare Research and Quality (AHRQ) to approximate a 20% stratified sample of the nation's community hospitals: approximately 94% of all hospital discharges in the United States.

RESULTS

Although significant progress has been made in recent years in lowering in-hospital CABG mortality, after controlling for relevant patient and socioeconomic factors, female CABG patients, regardless of their racial/ethnic group, still experience significantly higher in-hospital mortality rates than their male counterparts. Additionally, among these racial and ethnic groups, black CABG patients, whether male or female, continue to experience significantly worse in-hospital mortality rates than other races/ethnicities.

CONCLUSIONS

The declines in CABG in-hospital mortality rates have not been equal across race/ethnicity and gender.

The frequency and incremental cost of major complications among medicare beneficiaries receiving implantable cardioverter-defibrillators

OBJECTIVES

We aimed to quantify the frequency and nature of early complications after implantable cardioverter-defibrillator (ICD) implantation in general practice, and estimate the incremental costs of those complications to the health care system.

BACKGROUND

Cardioverter-defibrillator implantation rates are rising quickly. Little has been published regarding the outcomes and costs of these procedures in unselected populations.

METHODS

Using Medicare Provider Analysis and Review (MedPAR) files, we identified 30,984 admissions containing procedure codes for new ICD or cardiac resynchronization therapy defibrillator implantation in fiscal year 2003. The frequencies of eight complicating diagnoses during these admissions were determined. Length of stay (LOS) and total hospital costs, derived using whole-hospital cost to charge ratios, were calculated for each admission. The incremental effects of any and each complication on LOS and hospital cost were estimated in multivariable models, adjusting for demographic factors and comorbid conditions.

RESULTS

The mean cost for all admissions was 42,184 dollars (median 37,902 dollars) with mean LOS of 4.7 days (median 2.0 days). One or more complications were coded in 10.8% of admissions, most commonly "mechanical complication of the ICD" and hemorrhage/hematoma. The occurrence of any complication increased adjusted LOS by 3.4 days and costs by 7,251 dollars. Each of the individual complications was associated with highly significant increases in both LOS (1 to 10 days) and hospital cost (5,000 dollars to 20,000 dollars).

CONCLUSIONS

In fiscal 2003, 10.8% of Medicare patients undergoing cardioverter-defibrillator implantation experienced one or more early complications, associated with significant increases in LOS and costs. Efforts to reduce these complications could have significant clinical and financial benefits.

Hospital resources consumed in treating complications associated with percutaneous coronary interventions

Nearly 9.5% of all Medicare beneficiaries who undergo a percutaneous coronary intervention (PCI) procedure develop > or =1 of 7 acute complications. This study used 2 approaches (regression analysis and propensity-matched samples) to estimate the cost of selected complications, based on administrative data from 335,477 Medicare beneficiaries who underwent PCI during a hospitalization in fiscal year 2002. Selected complications included hospital mortality, emergency/urgent coronary artery bypass surgery, postoperative stroke, acute renal failure, vascular complications, septicemia, and adult respiratory distress syndrome. The observed average cost of a PCI hospitalization for patients who did not develop complications was 13,861 dollars +/- 9,635 dollars, with an average length of stay of 3.0 +/- 3.2 days, compared with 26,807 dollars +/- 27,596 dollars and 8.0 +/- 8.9 days for patients who did develop complications. Estimates of the adjusted incremental hospital cost of treating any acute complication except death varied from a high of 33,030 dollars for patients who developed septicemia to a low of 4,278 dollars for those who developed vascular complications, whereas estimates of the incremental length of stay ranged from a high of 12.3 days for patients who had septicemia to a low of 1.8 days for patients who had vascular complications. In conclusion, we found that the incremental hospital resources that are consumed to treat patients with acute PCI complications are large compared with the cost of an uncomplicated PCI hospitalization.

A comparison of self-selectivity corrections in economic evaluations and outcomes research

OBJECTIVE

Two alternative selectivity correction methods have been widely applied in the health economics literature: the sample selection model (SSM) and the multipart model (MPM). The difference between these two approaches results from their initial assumptions about the distribution of error terms. Because the distributional assumptions cannot be theoretically verified, the usefulness of the methods can only be evaluated by real world comparison. This article reviews and empirically tests the two alternative selectivity correction methods to give a reality-based evaluation.

METHODS

Using a randomized sample of patients as the "gold standard," the SSM and MPM are applied to a nonrandomized sample of patients with an identical set of dependent and independent variables. By comparing the actual estimates of the two methods, we evaluate the robustness of the two approaches.

RESULTS

The results show that neither method is empirically robust in replicating the results of the randomized trial. There is no consistent pattern in the coefficients from either selectivity-correction method for replicating the coefficients in the randomized sample.

CONCLUSIONS

Researchers should be cautious in applying these correction methods, and any conclusions based on these approaches may need to be qualified.

Inpatient surgical treatment patterns for patients with uterine fibroids in the United States, 1998-2002

OBJECTIVE

To analyze the impact of patient and organizational characteristics on surgical treatment patterns for patients with uterine fibroids.

METHODS

Unadjusted means and percentages were calculated from a population-based inpatient sample (HCUPNIS). Multiple logistic regression analysis was used to estimate the prevalence odds ratios for the association of uterine fibroid treatments and covariates of interest.

RESULTS

More than 1.2 million patients with a primary diagnosis of uterine fibroids were treated from 1998 to 2002. Of these, 84.4% received a hysterectomy and 12.3% received a myomectomy. Total abdominal hysterectomy was the most common procedure. The number of supracervical hysterectomies increased 18.1% over the five-year period. Black women and Asians/Pacific Islanders were more likely than white women to receive a myomectomy. All types of hysterectomies were more common in Medicaid patients compared with private/HMO patients. With the exception of patients in ZIP codes with a median income of <$25,000 per year, an inverse relationship was identified between income and hysterectomy rates.

CONCLUSIONS

The management of uterine fibroids appears to differ across a variety of socioeconomic factors and institutional characteristics. This study suggests that additional research should be conducted to assess the impact of nonclinical factors on treatment decisions for patients with uterine fibroids.

Patient Satisfaction With Primary Care

OBJECTIVE

The objective of this study was to evaluate the association of patient satisfaction with type of practitioner attending visits in the primary care practice of a managed care organization (MCO).

STUDY DESIGN

We conducted a retrospective observational study of 41,209 patient satisfaction surveys randomly sampled from visits provided by the pediatrics and adult medicine departments from 1997 to 2000. Logistic regression, with practitioner and practice fixed effects, of patient satisfaction versus dissatisfaction was estimated for each of 3 scales: practitioner interaction, care access, and overall experience. Models were estimated separately by department. Independent variables were type of practitioner attending the visit and other patient and visit characteristics.

RESULTS

Adjusted for patient and visit characteristics, patients were significantly more likely to be satisfied with practitioner interaction on visits attended by physician assistant/nurse practitioners (PA/NPs) than visits attended by MDs in both the adult medicine and pediatrics practices. Patient satisfaction with care access or overall experience did not significantly differ by practitioner type. In adult medicine, patients were more satisfied on diabetes visits provided by MDs than by PA/NPs. Otherwise, patient satisfaction for the combined effects of practitioner type and specific presenting condition did not differ.

CONCLUSIONS

Averaged over many primary care visits provided by many physicians and midlevel practitioners, patients in this MCO were as satisfied with care provided by PA/NPs as with care provided by MDs.

Use of midlevel practitioners to achieve labor cost savings in the primary care practice of an MCO

OBJECTIVE

To estimate the savings in labor costs per primary care visit that might be realized from increased use of physician assistants (PAs) and nurse practitioners (NPs) in the primary care practices of a managed care organization (MCO).

STUDY SETTING/DATA SOURCES

Twenty-six capitated primary care practices of a group model MCO. Data on approximately two million visits provided by 206 practitioners were extracted from computerized visit records for 1997-2000. Computerized payroll ledgers were the source of annual labor costs per practice from 1997-2000.

STUDY DESIGN

Likelihood of a visit attended by a PA/NP versus MD was modeled using logistic regression, with practice fixed effects, by department (adult medicine, pediatrics) and year. Parameter estimates and practice fixed effects from these regressions were used to predict the proportion of PA/NP visits per practice per year given a standard case mix. Least squares regressions, with practice fixed effects, were used to estimate the association of this standardized predicted proportion of PA/NP visits with average annual practitioner and total labor costs per visit, controlling for other practice characteristics.

RESULTS

On average, PAs/NPs attended one in three adult medicine visits and one in five pediatric medicine visits. Likelihood of a PA/NP visit was significantly higher than average among patients presenting with minor acute illness (e.g., acute pharyngitis). In adult medicine, likelihood of a PA/NP visit was lower than average among older patients. Practitioner labor costs per visit and total labor costs per visit were lower (p<.01 and p=.08, respectively) among practices with greater use of PAs/NPs, standardized for case mix.

CONCLUSIONS

Primary care practices that used more PAs/NPs in care delivery realized lower practitioner labor costs per visit than practices that used less. Future research should investigate the cost savings and cost-effectiveness potential of delivery designs that change staffing mix and division of labor among clinical disciplines.

Colorectal cancer screening, 1997-1999: role of income, insurance and policy

BACKGROUND

Receipt of age-appropriate cancer screens can lead to reduced incidence and mortality. Yet, low-income and uninsured experience barriers to screening. This paper examines colorectal cancer rates by income, racial and insured groups 1997 and 1999. These years focus on changes pre/post a 1998 policy change for Medicare beneficiaries that reduced their out-of-pocket costs for colorectal screening.

METHODS

The 1997 and 1999 Behavioral Risk Factor Surveillance System (BRFSS) survey is used to examine changes in age-appropriate fecal-occult blood testing (FOBT), flexible sigmoidoscopy screens. Differences in the odds that Medicare beneficiaries, relative to private insured, receive screens pre/post 1998 are examined using multivariate logit models.

RESULTS

Average rates of sigmoidoscopy increased significantly during 1997-1999 but remain below desired levels. While Medicare beneficiaries are more likely than privately insured to be screened, gaps between low- versus high-income groups in both Medicare and non-Medicare populations remain. The 1998 Medicare policy change was associated with a significant increase in the odds of screening among low-income (<$25,000) Medicare beneficiaries.

CONCLUSIONS

Policy makers should consider reasons for continued low colorectal screening rates among all insured groups. Barriers such as patient perceptions and physician advice should be considered along with the vulnerability that low income and lack of insurance imposes.

Methods for the economic and quality of life supplement to the cilostazol for RESTenosis (CREST) trial

OBJECTIVE

To determine economic and quality of life outcomes for the Cilostazol for RESTenosis (CREST) trial, which is investigating the efficacy of cilostazol vs. placebo in preventing post-stent restenosis.

DESIGN

CREST is a prospective, multicenter, randomized, placebo-controlled, double-blind trial.

SETTING

20 clinical sites; the Emory Center for Outcomes Research (ECOR) will serve as the economic and data coordinating center.

PATIENTS

705 patients (>18 years) who have undergone successful, uncomplicated placement of an intracoronary stent in a native coronary artery.

INTERVENTION

Cilostazol (100 mg twice daily) or placebo for 6 months.

OUTCOME MEASURES

COSTS

Primary endpoint, total direct medical costs at 6 months; secondary endpoints, initial hospital costs and follow-up costs. QOL: Health-related quality of life (QOL) will be assessed using the EQ-5D and the Seattle Angina Questionnaire at baseline and at 1, 3, and 6 months. Cost-effectiveness analysis: Preliminary data show that cilostazol is clinically superior to placebo and if the mean cost for the cilostazol arm is higher than that for placebo, cost-effectiveness analysis will be determined for the cost per episode of restenosis prevented, the cost per episode of major clinical and angiographic endpoints averted, and the cost per quality-adjusted life-years gained.

Economic analysis of a transesophageal echocardiography-guided approach to cardioversion of patients with atrial fibrillation

OBJECTIVES

The aim of this study was to compare the relative cost of a transesophageal echocardiography (TEE)-guided strategy versus conventional strategy for patients with atrial fibrillation (AF) >2 days duration undergoing electrical cardioversion over an eight-week period.

BACKGROUND

The Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) trial found no difference in embolic rates between the two approaches. However, the TEE-guided strategy had a shorter time to cardioversion and a lower rate of composite bleeding. While similar clinical efficacy was concluded, the relative cost of these two strategies has not been explored.

METHODS

Two economic approaches were employed in the ACUTE trial. The first approach was based on hospital charge data from complete hospital Universal Billing Code of 1992 forms, a detailed hospital charge questionnaire, or imputation. Regression analysis was used to investigate the added cost of adverse events. The second economic approach involved the development of an independent analytic model simulating treatment and actual ACUTE outcome costs as a validation of clinically derived data. Sensitivity analysis was performed on the analytic model to investigate the potential range in cost differences between the strategies.

RESULTS

A total of 833 of the 1,222 patients were enrolled from 53 U.S. sites; TEE-guided (n = 420) and conventional (n = 413). At eight-week follow-up, total mean costs did not significantly differ between the two groups, respectively (6,508 dollars vs. 6,239 dollars; difference of 269 dollars; p = 0.50). Cumulative costs were 24% higher in the conventional group, primarily due to increased incidence of bleeding and hospital costs associated with bleeding. A separate analytic model showed that treatment costs were higher for the TEE-guided strategy, but outcome costs were higher for the conventional strategy. Sensitivity analysis of the analytic model illustrated that varying the incidence and cost of major bleeding and the cost of TEE had the greatest impact on cost differences between the two groups.

CONCLUSIONS

In patients with AF >2 days duration undergoing electrical cardioversion, the TEE-guided group showed little difference in patient costs compared with the conventional group. The TEE strategy had higher initial treatment costs but lower outcome-associated costs. Cumulative costs were 24% higher in the conventional group, primarily due to bleeding. The TEE-guided strategy is an economically feasible approach compared with the conventional strategy.

Current status and outcomes of coronary revascularization 1999 to 2002: 148,396 surgical and percutaneous procedures

BACKGROUND

Current practice, trends, and early outcomes in patients undergoing surgical and percutaneous coronary interventions (PCI) are changing and subject to speculation.

METHODS

148,396 consecutive patients in 69 HCA, Inc hospitals who underwent either PCI or coronary artery bypass grafting (CABG) were tracked in the HCA Casemix Database from 1999 through the first quarter of 2002. Comorbid conditions, procedures, complications, and outcome variables were defined through International Classification of Diseases, Ninth Revision coding. Odds ratios (OR) for death and other procedure-related complications were estimated using logistic regression adjusting for age, sex, and 31 other patient clinical and procedural characteristics.

RESULTS

Now 65.4% of all coronary revascularization is by PCI with a 6.8% annual rate of increase whereas CABG volume is declining by 1.9% per year. However the majority of these changes occurred between 1999 and 2000 with only small changes in the last 3 years. Coronary artery bypass grafting is still utilized primarily for multivessel disease (3.38 bypasses per patient) whereas PCI is predominately (83%) still limited to single-vessel intervention. Unadjusted mortality rates over the full 13-quarter period were 1.25% for PCI and 2.63% for CABG (p < 0.001), with PCI rates remaining constant and CABG mortality declining. Twenty-three percent of CABG is performed off pump with a lower mortality than conventional on-pump CABG (2.37% versus 2.69%, p < 0.001). Percutaneous coronary intervention patients have lower mortality (OR 0.51), and fewer acute renal failure (OR 0.39), neurologic (OR 0.12), and cardiac (OR 0.16) complications than CABG patients (p < 0.001).

CONCLUSIONS

Interventions for coronary artery disease continue to rise primarily due to an increase in PCI. The volume of PCI continues to increase relative to CABG. Although adverse outcomes are higher after CABG, the proportion of multivessel disease treated is greater. The difference in adverse outcomes between CABG and PCI remains small and continues to decline.

Preventive care: female cancer screening, 1996-2000

BACKGROUND

Low-income and uninsured women have lower odds of receiving age-appropriate cancer screens that can detect cancers earlier and reduce morbidity/mortality. A key question is whether federal/state public health programs aimed at increasing screening and other public policies (e.g., welfare reform, managed care) have affected their receipt of these preventive services.

METHODS

Data from the Behavioral Risk Factor Surveillance System (BRFSS) were used to estimate the effects of public programs, income, and insurance status on the odds that women received mammography, clinical breast examination (CBE), or Papanicolaou (Pap) smears from 1996 to 2000. State fixed-effects models are estimated. Effects of the age (measured in years) of states' National Breast and Cervical Cancer Early Detection Programs (NBCCEDPs) and level of federal funding are presented.

RESULTS

Adjusted odds of uninsured women reporting female cancer screens were lower than for those privately insured, and did not change between 1996 and 2000 despite welfare reform and increasing numbers of uninsured. The age of states' NBCCEDPs were associated with increased odds of mammography, CBE, and Pap smear screens for non-elderly women. For example, the aging of a state's program from 0 to 5 years was associated with an increase in the percentage of women receiving mammography from 52.7% to 55.1%.

CONCLUSIONS

Despite efforts to increase screening among low-income uninsured women, their average rates remain below those with higher incomes and/or insurance. However, initiation and maintenance of the states' NBCCEDPs over long periods is associated with increased screening. After accounting for program age, increased federal dollars are associated with slight increases in screening for women aged >65.