An analysis of the heterogeneity of U.S. nursing home patients

Research has shown that the nursing home patient population is quite heterogeneous in terms of both individual patient characteristics and service needs. Furthermore, existing administrative classifications do a poor job of representing this heterogeneity. As a consequence we have conducted an analysis of the individual and service characteristics of two types of patients represented in the National Nursing Home Survey of 1977 (i.e., patients whose primary source of payment was Medicare and patients whose primary payment source was not Medicare). In this analysis we identified patterns of individual characteristics within the two patient groups and showed how these patterns related to their service needs. The logic of the model permitted us both to establish patterns of characteristics within the two payment types and to examine the implications of individual heterogeneity remaining in the classification. This makes the methodology useful both as a research tool for understanding the nature of the nursing home population and as a tool for studying the consequences of various classification schemes for questions of identifying service patterns and needs as well as the evaluation of policy options.

Predictors of stroke outcome

Findings from several studies of stroke victims indicate that consistent negative predictors of outcome are significant perceptual or cognitive dysfunction, prior stroke, delay in initiating rehabilitation therapy, the presence of nystagmus, and poor motivation. Factors associated with a good prognosis after rehabilitation include early return of voluntary movements, bladder control, high intelligence and feeding skills.

A comparison of digital subtraction angiography and noninvasive testing in the diagnosis of cerebrovascular disease

Among the 1,892 patients who underwent cerebrovascular digital subtraction angiography at our hospital over the past 18 months, there was a subgroup of 34 patients (65 carotid arteries) for whom noninvasive cerebrovascular test results and standard cerebral arteriograms were also available. These patients were reviewed retrospectively and the ability of both methods to detect hemodynamically significant lesions, defined as a greater than 50 percent reduction in the diameter of the carotid artery, was determined using the arteriograms as the "gold standard." Noninvasive cerebrovascular tests had a sensitivity of 81 percent, a specificity of 95 percent, a positive predictive value of 92 percent, a negative prediction value of 88 percent, and an overall accuracy of 89 percent. Digital subtraction angiography had a sensitivity of 84 percent, a specificity of 92 percent, a positive predictive value of 88 percent, a negative predictive value of 89 percent, and an overall accuracy of 89 percent. If the four cases of hemodynamically significant stenosis of the carotid siphon not detected by digital subtraction angiography had been considered as false-negatives, its sensitivity would have been reduced to 72 percent. In patients with hemispheric cerebral ischemia, we found noninvasive cerebrovascular tests neither necessary nor cost-effective. Digital subtraction angiography, on the other hand, often provided definitive diagnostic information in such patients if the intracranial circulation was well defined and the extracranial lesion corresponded to the patients' symptoms. Noninvasive cerebrovascular testing was the safest and most cost-effective technique for screening patients with asymptomatic bruits, atypical, nonhemispheric cerebral symptoms, and those who have undergone carotid endarterectomy. If the noninvasive cerebrovascular test result was positive or equivocal, digital subtraction angiography was performed to localize the responsible lesion and exclude carotid occlusion.

Why admit stroke patients to hospital?

Stroke patients consume nearly one-twentieth of all National Health Service resources, and much of this is attributable to the admission of patients with acute strokes to hospital. However, patients rarely need to be admitted for diagnostic or therapeutic reasons, and rehabilitation given in hospital is sometimes inappropriate. The major reason for admission relates to nursing during the acute illness, yet this could be done at home in more cases than at present. It is suggested that rehabilitation services should be more readily available to patients at home, so that fewer need to be admitted and so that those admitted can return home sooner. This might lead to a more appropriate rehabilitation, less anxiety and depression in the patient and his family, and a more efficient use of limited resources.

Prevalence of stroke and its sequelae

A population-based stroke incidence study was carried out in a defined urban area of Melbourne in 1978-1979. From the incidence data, and survival curves to two years, estimates have been made of the prevalence of stroke, the prevalence of stroke survivors in different places of care, and the prevalence of stroke-related disability in an Australian community.

The National Survey of Stroke. Economic impact

The estimated economic costs of stroke in 1976 amounted to $7,363,784,000 (based on a 6 percent gross, or 4 percent net, discount rate). Almost half were direct costs, the majority of these were related to inpatient hospital and nursing facility care. Only about six percent of the total were morbidity costs, and the remaining fifty percent consisted of mortality costs, stated in terms of the present value of future earnings. Direct costs include charges by short-term hospitals, extended care facilities, physicians and other medical and allied health personnel, and the costs of aids and appliances. Indirect costs include both morbidity and mortality costs. These costs are distributed as follows. [Formula: see text].

The incidence and economic costs of cancer, motor vehicle injuries, coronary heart disease, and stroke: a comparative analysis

The economic impact of disease and injury has most often been calculated by examining the costs associated with the prevalence of the impairments in the reference year. An alternative accounting approach is to assign all disease costs to the year of incidence, an approach which entails present-valuing to the year of incidence both health care expenditures and lost productivity. The incidence approach is the more appropriate for gauging the economic gains achievable through prevention, immediate rehabilitation, and arresting progression. Incidence-based costs have been estimated for the United States in 1975 for cancer, coronary heart disease, motor vehicle injuries, and stroke. A noteworthy finding is the relative economic importance of motor vehicle injuries, which frequently have been overlooked in the ordering of public health expenditure priorities. After cancer, which generated approximately $23.1 billion in present-valued costs in 1975 (discounted at 6 per cent), motor vehicle injuries and coronary heart disease constitute the next most expensive conditions--having generated estimated annual costs of $14.4 billion and $13.7 billion, respectively. Stroke, at $6.5 billion, follows in economic importance.

Outcome and cost for stroke patients in academic and community hospitals. Comparison of two groups referred to a regional rehabilitation center

Patients transferred to a regional stroke rehabilitation center from academic hospital centers (124 patients) and from community hospital centers (315 patients) were compared for outcome and cost of treatment. The two groups were matched for Amended International Classification of Diseases diagnostic category, age, sex, distribution of weakness, types of neurological deficits, time from the onset of the stroke symptoms to admission to the rehabilitation unit, and the concurrence of major medical problems thought to contribute to cerebrovascular disease. There was no statistically significant difference in functional outcome or length of stay, but acute health care costs for patients treated in community hospitals were about 50% less.

Computed tomography in patients with cerebrovascular disease: impact of a new technology on patient care

The medical care of 157 patients with suspected cerebrovascular disease was analyzed to assess the impact of the new technology, computed tomography (CT) of the brain, on the care of these patients. A cohort of patients admitted before installation of CT was compared to two cohorts admitted after installation of CT. Length of hospital stay, speed of diagnostic workup, treatment, and discharge plans were not significantly different. Discharge diagnoses were more specific after installation of CT. Lumbar punctures and radionuclide brain scans were used less frequently, but utilization of other diagnostic studies was unchanged. Aggregate charges for diagnostic procedures actually increased in both after-CT groups. In this study, addition of CT to the neurodiagnostic armamentarium resulted in little demonstrable improvement in the care of these patients with cerebrovascular disease but did increase the cost of evaluation. This is unlike the situation for patients with brain tumors, where CT was shown to improve care while not increasing cost. These results may help guide the use of CT by physicians caring for patients with cerebrovascular disease and suggest that health planners not use all patients with cerebrovascular disease in estimating need for CT.

Efficacy of computed tomography of the head in changing patient care and health costs: a retrospective study

Detailed analysis of all neurologic and neurosurgical admissions at Johns Hopkins Hospital for 6 months prior to the second 6 months after installation of a CT head scanner was undertaken in an attempt to identify the effect CT had on health care decisions, costs, and morbidity. Data showed decreased cost of more than $2,000 per patient and shorter length of stay by 7 days in patients with extracerebral collections, and more than $2,500 and 8 days reduction in patients with tumors after CT was in use. A group matched by computer for age, diagnosis, and physician showed decreased costs of more than $2,000 and shortened stay by more than 3 days per hospitalization. Increased costs were shown in patients with cerebrovascular disease after CT. Change in method of workup with fewer invasive studies for all patients (P less than .001) and significant increases in cost of diagnostic workup were demonstrated (P less than .001). There was no change in morbidity and mortality between the two groups. These data suggest that CT of the head may reduce cost and length of hospitalization in certain patient groups and frequently alters patient workup.