The American health care system--expenditures

Special Issue on Global Health Disparities Focus on Cancer

Haeok Lee, PhD, RN, FAAN who is a Korean-American nurse scientist, received her doctor al degree from the Nursing Physiology Department, College of Nursing, University of California, San Francisco (UCSF), in 1993, and her post doctor al training from College of Medicine, UCSF. Dr. Lee worked at Case Western Reserve University and University of Colorado Health Sciences Center. She has worked at the UMass Boston since 2008. Dr. Lee has established a long-term commitment to minority health, especially Asian American Pacific Islanders, as a community leader, community health educator, and community researcher, and all these services have become a foundation for her community-based participatory research. Dr. Lee's research addresses current health problems framed in the context of social, political, and economic settings, and her studies have improved racial and ethnic data and developed national health policies to address health disparities in hepatitis B virus (HBV) infections and liver cancer among minorities. Dr. Lee's research, which is noteworthy for its theoretical base, is clearly filling the gap. Especially, Dr. Lee's research is beginning to have a favorable impact on national and international health policies and continuing education programs directed toward the global elimination of cervical and liver cancer-related health disparities in underserved and understudied populations.

Conundrums in health care reform: current experiences across the North Atlantic

OBJECTIVE

To assist stakeholders (policy makers, dentists and patients) implementing the Patient Protection and Affordable Care Act of 2010 in the United States by providing information on conundrums arising from previous policies of the UK Labour government and emergent policies of the recently elected Coalition Government.

METHODS

The authors provide a background to the development of National Health Service dental services contrasted with US provision. Considerations are given from the different perspectives of stakeholders involved (policy makers, dentists, and patients).

CONCLUSIONS

Policy makers must work under pressure for services to remain within boundaries of finite economic resources and what people are willing to pay for. The importance is stressed that they respond to public demands and workforce capability by clearly determining what the priorities should be, what services will be delivered, and defining responsibilities.

Global health and the global economic crisis

Although the resources and knowledge for achieving improved global health exist, a new, critical paradigm on health as an aspect of human development, human security, and human rights is needed. Such a shift is required to sufficiently modify and credibly reduce the present dominance of perverse market forces on global health. New scientific discoveries can make wide-ranging contributions to improved health; however, improved global health depends on achieving greater social justice, economic redistribution, and enhanced democratization of production, caring social institutions for essential health care, education, and other public goods. As with the quest for an HIV vaccine, the challenge of improved global health requires an ambitious multidisciplinary research program.

Workers' Compensation in the United States: cost shifting and inequities in a dysfunctional system

Workers' Compensation is a far more significant expense to the U. S. economy than is commonly recognized. The total annual cost of the health care and disability benefits in the United States is at least $300 billion. The health care costs shifted by employers to Medicare/Medicaid and the disability costs shifted to the Social Security system far exceed the total costs of all the state Workers' Compensation programs. Most of the responsibility for compensating disabled workers now resides in the federal government, not in the state system. Federal funding of Workers' Compensation is at least four times that of state programs. State and federal Workers' Compensation programs are a costly and inefficient segment of health care that should be included in any consideration of health care reform.

Deficits in EMTALA Knowledge Among Pediatric Physicians

OBJECTIVE

All US hospitals that participate in Medicare and Medicaid are regulated by the Emergency Medical Treatment and Active Labor Act (EMTALA). The law was enacted to prevent hospitals from turning away patients with emergency medical conditions. The law imposes specific obligations on hospitals and their physicians, and provides severe penalties for violations. The objective of this study was to evaluate hospital-based pediatric physicians' knowledge of these obligations and potential liabilities.

METHODS

A questionnaire was submitted to the active medical staff and pediatric subspecialty residents at a tertiary care pediatric hospital. The questionnaire collected demographic information and posed 12 questions, based on well-established EMTALA principles, which addressed specific EMTALA obligations and liabilities.

RESULTS

The questionnaire was returned by 123 of 332 (37%) potential participants. Twenty-four percent (n = 30) had never heard of EMTALA, 24% (n = 30) had only "heard of" the law, and 51% (n = 63) considered themselves "generally familiar" with EMTALA. No respondent correctly answered all 12 questions, and 13% (n = 16) answered all 12 questions incorrectly. The median score was 42%, with a range of 0% to 83% correct. Only 20% (n = 25) reported that they had ever received any EMTALA education. Prior EMTALA education was associated with a higher score (P = 0.001). Eighty percent (n = 98) expressed interest in attending a formal EMTALA education program.

CONCLUSIONS

Physicians at this pediatric hospital were strikingly unaware of their EMTALA obligations and potential liabilities. A specific educational program regarding EMTALA should be provided to hospital-based pediatric physicians to improve compliance with the law and reduce potential liabilities.

Developing sustainability: a new metaphor for progress

In this paper, we propose a new model for development, one that transcends the North-South dichotomy and goes beyond a narrow conception of development as an economic process. This model requires a paradigm shift toward a new metaphor that develops sustainability, rather than sustains development. We conclude by defending a 'report card on development' as a means for evaluating how countries perform within this new paradigm.

Advantages and Disadvantages of Single-Versus Multiple-Occupancy Rooms in Acute Care Environments

Private patient rooms have become the industry standard in the United States based on the assumption that they reduce the rate of hospital-acquired infections, facilitate patient care and management, and afford greater therapeutic benefits for patients. The objective of this article is to reviewand analyze the existing literature to identify the empirical evidence related to the advantages and disadvantages of single versus multiple-occupancy patient rooms in hospitals. Three substantive areas were identified for synthesis of the review: (a) first and operating cost of hospitals, (b) infection control, and (c) health care facility management and hospital design and therapeutic impacts. The analysis reveals that private patient rooms reduce the risk of hospital-acquired infections, allow for greater flexibility in operation and management, and have positive therapeutic impacts on patients. This review highlights the need to consider room occupancy issues along with other patient care issues and environmental and management policies.

Using the ecology model to describe the impact of asthma on patterns of health care

BACKGROUND

Asthma changes both the volume and patterns of healthcare of affected people. Most studies of asthma health care utilization have been done in selected insured populations or in a single site such as the emergency department. Asthma is an ambulatory sensitive care condition making it important to understand the relationship between care in all sites across the health service spectrum. Asthma is also more common in people with fewer economic resources making it important to include people across all types of insurance and no insurance categories. The ecology of medical care model may provide a useful framework to describe the use of health services in people with asthma compared to those without asthma and identify subgroups with apparent gaps in care.

METHODS

This is a case-control study using the 1999 U.S. Medical Expenditure Panel Survey. Cases are school-aged children (6 to 17 years) and young adults (18 to 44 years) with self-reported asthma. Controls are from the same age groups who have no self-reported asthma. Descriptive analyses and risk ratios are placed within the ecology of medical care model and used to describe and compare the healthcare contact of cases and controls across multiple settings.

RESULTS

In 1999, the presence of asthma significantly increased the likelihood of an ambulatory care visit by 20 to 30% and more than doubled the likelihood of making one or more visits to the emergency department (ED). Yet, 18.8% of children and 14.5% of adults with asthma (over a million Americans) had no ambulatory care visits for asthma. About one in 20 to 35 people with asthma (5.2% of children and 3.6% of adults) were seen in the ED or hospital but had no prior or follow-up ambulatory care visits. These Americans were more likely to be uninsured, have no usual source of care and live in metropolitan areas.

CONCLUSION

The ecology model confirmed that having asthma changes the likelihood and pattern of care for Americans. More importantly, the ecology model identified a subgroup with asthma who sought only emergent or hospital services.

Effect of difficulty affording health care on health status after coronary revascularization

BACKGROUND

An objective of the United States' Healthy People 2010 Initiative is to eliminate disparities based on socioeconomic status. We assessed the effect of difficulty affording health care on the health status (symptoms, function, and quality of life) of patients treated with percutaneous coronary intervention or CABG.

METHODS AND RESULTS

A consecutive, single-center cohort of 480 patients undergoing coronary revascularization received the Seattle Angina Questionnaire at the time of their procedure and at subsequent monthly intervals for 6 months. At baseline, patients who reported somewhat of a burden to a severe burden in affording health care had significantly lower scores on the Seattle Angina Questionnaire (mean+/-SD) with respect to angina (55+/-29 versus 68+/-25, P<0.0001), physical limitation (55+/-26 versus 72+/-24, P<0.0001), and quality of life (46+/-22 versus 56+/-22, P<0.0001) than those who did not perceive healthcare costs to be burdensome. Although both groups of patients improved after revascularization, poorer health status persisted among those with difficulty affording health care after percutaneous coronary intervention (6-month mean+/-SE: angina 79+/-2.5 versus 88+/-1.9, P=0.002; physical function 61+/-2.7 versus 80+/-2.0, P<0.0001; quality of life 67+/-2.4 versus 82+/-1.8, P<0.0001) but not after CABG (angina 91+/-2.5 versus 93+/-1.6, P=0.47; physical function 75+/-3.4 versus 81+/-2.2, P=0.13; quality of life 84+/-3.1 versus 84+/-2.0, P=0.81). Similar differences remained after adjustment for demographic and clinical characteristics.

CONCLUSIONS

Patients reporting difficulty affording health care have worse health status at the time of coronary revascularization. A persistent disparity exists after percutaneous but not surgical revascularization. Additional inquiry into the mechanism of this disparity is needed so that the goals of equitable health care, irrespective of treatment strategy, can be achieved.

Using policy simulation to predict drug plan expenditure when planning reimbursement changes

BACKGROUND

Drug plan decision makers need accurate financial impact projections before the implementation of new drug policy initiatives. Tools for such projections need to have small margins of error and be based on methodology that is easy to communicate to stakeholders. Ad hoc methods typically used for financial impact projections by health plans are inadequate.

OBJECTIVE

To present a flexible tool for projecting the financial impact of drug policy changes based on historical dispensing data and simulation, and explore its validity using a recent example of a complex drug policy change in British Columbia, Canada.

METHODS

A policy simulator (SAS) program using a Web browser interface) was used to produce 3-year forecasts of expenditure (for the drug plan and for individual families) along with the number of patients who would pay more or less for their drugs (stratified by age and income level) for various proposed drug policies starting in 2003. Drug expenditure under each policy was simulated based on projections from prescription claim records of the British Columbia PharmaNet database of community pharmacy prescriptions from 1 January 2001 to 31 December 2001. The simulator selected a random 1% sample of British Columbia families (175,000 families) in the database. Once the new drug policy was selected and implemented, the accuracy of the predictions were tested by comparing the actual PharmaCare expenditure for the period 1 May 2003 to 31 March 2004 after implementation of the new drug policy with the final simulation made for this policy in February 2003, 2 months before the policy was implemented.

RESULTS

The policy simulation tool produced hundreds of variations for decision makers in the months before the final policy rules were decided upon. When compared with actual drug expenditure after policy implementation, it was found that the tool had predicted spending with <1% error for the first 11 months after introduction of the policy. As well as producing accurate expenditure forecasts for the insurer, the tool was able to predict how family out-of-pocket expenditure would be affected.

CONCLUSIONS

The simulator aided drug policy planning and communication. The tool provided rapid and accurate results that were communicated easily to decision makers. Such policy simulation can be applied to a wide range of health plans and policy changes.

The cost structure of lung tuberculosis in Germany

Although the total number appears to be decreasing, 7,886 new cases of tuberculosis (TB) were reported in Germany in 2001. Previous American publications reveal considerable differences in the costs caused by the disease. On the basis of the therapy guidelines of the Deutsches Zentralkomitee zur Bekampfung der Tuberkulose (DZK), this study estimates the mean direct outpatient and combined in- and outpatient costs of lung TB, together with the indirect costs of the disease on the basis of the most recent official health statistics. According to this, the mean outpatient costs per case were <euro>1,226 (adults) and <euro>785 (children under 15 years of age). The mean combined inpatient/outpatient costs ranged from <euro>14,301 (adults) to <euro>16,634 (children). These are joined by the mean costs of sick benefit amounting to <euro>2,088. The mean indirect costs per case were <euro>2,461. Consistent implementation of the recommendations of the German DZK is still necessary in order to reduce the significant economic impact of TB disease resulting in high health and socioeconomic costs.

Changing prescribing patterns and increasing prescription expenditures in Medicaid

PURPOSE

Prescription drug expenditures are the most rapidly growing component of total health care expenditures and particularly affect state Medicaid programs. We determined the extent to which increasing prescription price and changing prescribing patterns contribute to rising prescription expenditures in Medicaid.

METHODS

We conducted a claims-based analysis comparing annual prescription drug expenditures and prescribing patterns. Prescription drug and outpatient visit claims for all North Carolina Medicaid enrollees from 1998 through 2000 were included. We analyzed drugs individually by combining all prescriptions and expenditures for the same drug formulation, and we calculated the number of units dispensed per person-year of enrollment.

RESULTS

Prescription drug coverage for 1 person-year cost 503 dollars in 1998 and 759 dollars in 2000, for an annual increase of 22.8%. The average number of prescriptions filled per person-year increased from 13.0 in 1998 to 15.5 in 2000. Increased prescribing for 6 drugs accounted for more than 25% of the total increase in expenditures. The price for the 15 most expensive drugs increased an average of 4.1% annually.

CONCLUSIONS

Prices for existing drugs increased slightly during the study period, but the major cause of the increase in drug costs was an increase in the number of prescriptions for new and more expensive medications. Prescribing patterns in Medicaid differ somewhat from those in the private sector and partly reflect the population with low socioeconomic status and high health care needs that it serves. To help control rising prescription drug expenditures, efforts should be undertaken to improve appropriate and cost-effective prescribing.

Use of the case-crossover design to study prolonged drug exposures and insidious outcomes

PURPOSE

The case-crossover design was originally intended to study brief exposures with immediate and transient effects, and acute outcomes with abrupt onsets. We investigated whether case-crossover methods can be used to study prolonged exposures and insidious outcomes.

METHODS

We conducted a case-crossover study of 8220 patients aged > or = 65 years enrolled in several health benefits programs in New Jersey during the period between 1991 and 1995. All had episodes of central nervous system (CNS) adverse events (e.g., delirium). Drug exposures were assessed during case time periods and control time periods lasting 1, 2, 3, or 4 months. Exposures included 3 active regimens with established deleterious CNS effects (corticosteroids, digoxin, and opiates) and 2 inactive regimens without such effects (multivitamins and statins).

RESULTS

In conditional logistic regression models, significantly elevated risks were observed for all three active drugs, regardless of which time windows were used. The magnitude of these risks generally increased with longer time windows. No significantly increased risks were observed for the 2 inactive drugs, regardless of the window duration.

CONCLUSIONS

These results suggest that with lengthened exposure assessment windows, case-crossover methods may be useful for studying exposures with prolonged effects and outcomes with insidious onsets.

What's behind the health expenditure trends?

In this paper, we review the literature on a number of the potential explanations for the rise in health care expenditures in the United States: the aging population, the costs of dying, technology, physician incomes, administrative costs, prescription drugs, managed care, and the underfunding of public health. Our goal is not to pass definitive judgment on the force(s) driving health care costs, but rather to make the reader a more educated consumer of these widely cited data. We place special emphasis on how health expenditures are measured and the inherent weaknesses in the methodology. We find that frequently it is difficult to accurately estimate how individual forces influence total health care expenditures. Moreover, we conclude that interpreting the causes of the rise in expenditures goes beyond simple observations of trends and depends on how we value various segments and aspects of health and health care.

Variation in the ecology of medical care

BACKGROUND

We wanted to quantify how the location in which medical care is delivered in the United States varies with the sociodemographic characteristics and health care arrangements of the individual person.

METHODS

Data from the 1996 Medical Expenditures Panel Survey (MEPS) were used to estimate the number of persons per 1,000 per month in 1996 who had at least 1 contact with physicians' offices, hospital outpatient departments, or emergency departments, hospitals, or home care. These data were stratified by age, sex, race, ethnicity, household income, education of head of household, residence in or out of metropolitan statistical areas, having health insurance, and having a usual source of care.

RESULTS

Physicians' offices were overwhelmingly the most common site of health care for all subgroups studied. Lacking a usual source of care was the only variable independently associated with a decreased likelihood of care in all 5 settings, and lack of insurance was associated with lower rates of care in all settings but emergency departments. Generally, more complicated patterns emerged for most sociodemographic characteristics. The combination of having a usual source of care and health insurance was especially related to higher rates of care in all settings except the emergency department.

CONCLUSION

Frequency and location of health care delivery varies substantially with sociodemographic characteristics, insurance, and having a usual source of care. Understanding this variation can inform public consideration of policy related to access to care.

Methods for estimating and comparing VA outpatient drug benefits with the private sector

OBJECTIVES

To estimate and compare Veterans Health Administration (VA) expenditures for outpatient pharmaceuticals for veterans at six VA facilities with hypothetical private sector costs.

METHODS

Using the VA Pharmacy Benefits Management Strategic Health Care Group (PBM) database, we extracted data for all dispensed outpatient prescriptions from the six study sites over federal fiscal year 1999. After extensive data validation, we converted prescriptions to the same units and merged relevant VA pricing information by National Drug Code to Redbook listed average wholesale price and the Medicaid maximal allowable charge, where available. We added total VA drug expenditures to personnel cost from the pharmacy portion of that medical center's cost distribution report.

RESULTS

Hypothetical private sector payments were $200.8 million compared with an aggregate VA budget of $118.8 million. Using National Drug Code numbers, 97% of all items dispensed from the six facilities were matched to private sector price data. Nonmatched pharmaceuticals were largely generic over-the-counter pain relievers and commodities like alcohol swabs. The most commonly prescribed medications reflect the diseases and complaints of an older male population: pain, cardiovascular problems, diabetes, and depression or other psychiatric disorders.

CONCLUSIONS

Use of the VA PBM database permits researchers to merge expenditure and prescription data to patient diagnoses and sentinel events. A critical element in its use is creating similar units among the systems. Such data sets permit a deeper view of the variability in drug expenditures, an important sector of health care whose inflation has been disproportionate to that of the economy and even health care.

Methods for estimating private sector payments for VA acute inpatient stays

OBJECTIVES

To describe methods for estimating hypothetical private sector payments for Veterans Health Administration (VA) acute inpatient stays.

METHODS

We assumed all VA hospitalizations would have occurred under a hypothetical VA system that paid private sector providers but had the current benefit package for VA patients. We compared aggregate budgets for VA inpatient care (less physician salaries) at six VA hospitals over federal fiscal year 1999 to aggregated hypothetical private sector payments developed using VA diagnosis-related groups matched to metropolitan-based average Medicare payments. Counts of care came from the VA's statistical analysis system (SAS) inpatient files. Inpatient stays with both medical or surgical and psychiatric or rehabilitation care were counted as two stays. An external auditor conducted three reviews of VA coding practices during the study year, and the appropriateness of admissions was examined using a commercial utilization review tool.

RESULTS

For 30,518 inpatient discharges, hypothetical payments were $188 million, compared with the VA budget of $171 million. Fifteen of the 25 most frequent diagnosis-related groups in the VA were also in the top 25 for Medicare in 1998 and 1999. Audits established that the overall financial impact of VA coding problems was similar to that in the private sector.

DISCUSSION

Differences in organization, practice, and incentives limit estimates of the financial impact of shifting VA acute inpatient care to the private sector.

Improving physicians' knowledge of the costs of common medications and willingness to consider costs when prescribing

OBJECTIVES

To determine the effectiveness of an educational intervention designed to improve physicians' knowledge of drug costs and foster willingness to consider costs when prescribing.

DESIGN

Pre- and post-intervention evaluation, using physicians as their own controls.

SETTING

Four teaching hospitals, affiliated with 2 residency programs, in New York City and northern New Jersey.

PARTICIPANTS

One hundred forty-six internal medicine house officers and attendings evaluated the intervention (71% response rate). Of these, 109 had also participated in a pre-intervention survey.

INTERVENTION

An interactive teaching conference and distribution of a pocket guide, which listed the average wholesale prices of over 100 medications commonly used in primary care

MEASUREMENTS AND MAIN RESULTS

We administered a written survey, before and 6 months after the intervention. Changes in attitudes and knowledge were assessed, using physicians as their own controls, with Wilcoxon matched-pairs signed-rank tests. Eighty-five percent of respondents reported receiving the pocket guide and 46% reported attending 1 of the teaching conferences. Of those who received the pocket guide, nearly two thirds (62%) reported using it once a month or more, and more than half (54%) rated it as moderately or very useful. Compared to their baseline responses, physicians after the intervention were more likely to ask patients about their out-of-pocket drug costs (22% before vs 27% after; P <.01) and less likely to feel unaware of drug costs (78% before vs 72% after; P =.02). After the intervention, physicians also reported more concern about the cost of drugs when prescribing for patients with Medicare (58% before vs 72% after; P <.01) or no insurance (90% before vs 98% after; P <.01). Knowledge of the costs of 33 drugs was more accurate after the intervention than before (P <.05).

CONCLUSION

Our brief educational intervention led to modest improvements in physicians' knowledge of medication costs and their willingness to consider costs when prescribing. Future research could incorporate more high-intensity strategies, such as outreach visits, and target specific prescribing behaviors.

Medical students' attitudes toward persons with disability: a comparative study

OBJECTIVES

To investigate first-year medical students' attitudes toward persons with disability and to examine whether gender and a background in disability determine attitudes toward persons with disability.

DESIGN

A cross-sectional survey.

SETTING

University settings in the United States and Canada.

PARTICIPANTS

Ninety first-year medical students (US, n=46; Canada, n=44) were surveyed.

INTERVENTION

Medical students given 3 surveys.

MAIN OUTCOME MEASURES

Attitude Toward Disabled Persons (ATDP) Scale, Scale of Attitudes Toward Disabled Persons (SADP), and Rehabilitation Situations Inventory (RSI).

RESULTS

There were no differences between the medical student groups from the United States and Canada. Compared with norms, medical students overall have more positive attitudes on the ATDP. Their attitudes were less positive on the SADP and on its optimism-human rights subscale. On the RSI, they were less comfortable with sexual situations and depression. Male medical students held poorer attitudes as scored than female medical students. Those with a background in disability were more comfortable dealing with challenging rehabilitation situations. Comfort with challenging rehabilitation situations showed significant differences across levels of experience but not gender. The more positive medical students' attitudes are toward persons with disability, the more likely they are to be comfortable with challenging rehabilitation situations.

CONCLUSION

First-year medical students from the United States and Canada held similar attitudes and had less positive attitudes than SADP norms. Gender and background in disability influenced attitudes. Male medical students were more likely to hold negative attitudes. Specific educational experiences need to promote more positive attitudes.

Modifying provider behavior: a low-tech approach to pharmaceutical ordering

OBJECTIVE

To determine if a clinically structured, paper-based prescription form can modify pharmaceutical prescribing behavior without restricting physician freedom to select the most appropriate medication for an individual patient.

DESIGN

Uncontrolled, nonrandomized, time series design.

SETTING

The urgent care clinic of a university-affiliated, county-supported hospital that provides care for underserved, vulnerable populations.

PATIENTS

Patients (N = 2189) who had a prescription written at the intervention site during the study.

INTERVENTION

Four-phase interventions lasting 2 weeks each, with a washout period between each phase, consisting of: (1). collection of baseline data utilizing the traditional prescription blank, (2). introduction of the pre-formatted prescription form, (3). use of the pre-formatted prescription form with medication cost added, and (4). pre-formatted prescription form with target drug (ranitidine) removed.

MEASUREMENTS AND MAIN RESULTS

Physicians were less likely to prescribe ranitidine compared to cimetidine after the introduction of the cost information (P <.01) and again after the removal of ranitidine from the pre-formatted prescription form (P <.001).

CONCLUSIONS

A structured, paper-based prescription order form can shift prescribing practices without inhibiting physicians' ordering freedom.

The effect of drug co-payment policy on the purchase of prescription drugs for children with infections in the community

A cross-sectional study was conducted to investigate the influence of the co-payment policy in a community setting on the purchase of prescription medications for children with acute infections. Data for all purchased medications prescribed for children with an acute infectious disease were gathered from a pediatric health care center over a 6-week period. Parents of the sick children and controls were interviewed by telephone, using a short sociodemographic questionnaire, and were asked to state their reasons for not purchasing (either partially or completely) necessary medications, primarily antibiotics. Of the 779 children who received a prescription for antibiotics during the 6-week period, 162 (20.7%) failed to take the complete course of antibiotic treatment. One hundred and one parents of these children (62.3%) were interviewed, of whom 30 (29.7%) claimed that the main reason for not buying the full course of antibiotic medication was the cost. This group is characterized by low income, overcrowded housing conditions and a large quantity of prescription medications. The cost of prescribed medication under the co-payment policy is a serious barrier to the purchase of prescribed medication for children with acute infections in the primary care setting. The policy has a particularly deleterious effect in under-privileged populations and is in contradiction with the proclaimed principles of justice and equality underlying the obligatory Israeli National Israeli Health Insurance Law and similar laws in other western countries.

How sociodemographics, presence of oncology specialists, and hospital cancer programs affect accrual to cancer treatment trials

PURPOSE

We chose to examine the impact of socioeconomic factors on accrual to National Cancer Institute (NCI)-sponsored cancer treatment trials.

PATIENTS AND METHODS

We estimated the geographic and demographic cancer burden in the United States and then identified 24,332 patients accrued to NCI-sponsored cancer treatment trials during a 12-month period. Next, we examined accrual by age, sex, geographic residence, health insurance status, health maintenance organization market penetration, several proxy measures of socioeconomic status, the availability of an oncologist, and the presence of a hospital with an approved multidisciplinary cancer program.

RESULTS

Pediatric patients were accrued to clinical trials at high levels, whereas after adolescence, only a small percentage of cancer patients were enrolled onto clinical trials. There were few differences by sex. Black males as well as Asian-American and Hispanic adults were accrued to clinical trials at lower rates than white cancer patients of the same age. Overall, the highest observed accrual was in suburban counties. Compared with the United States population, patients enrolled onto clinical trials were significantly less likely to be uninsured and more like to have Medicare health insurance. Geographic areas with higher socioeconomic levels had higher levels of clinical trial accruals. The number of oncologists and the presence of approved cancer programs both were significantly associated with increased accrual to clinical trials.

CONCLUSION

We must work to increase the number of adults who enroll onto trials, especially among the elderly. Ongoing partnership with professional societies may be an effective approach to strengthen accrual to clinical trials.

Community-based case management: a model for outcome-based research for non-institutionalized elderly

Medical treatment and research has changed subsequent to a paradigm shift in fiscal management strategies for health care. The demand for greater fiscal and clinical accountability in health care has resulted in more bureaucratic control of physicians, health care providers and health care delivery. Institutional-based care has been deferred to community-based care, and outcomes-based measurement of treatment interventions are becoming the benchmark of effective care. The increase in our elderly population's numbers and longevity of life, combined with fiscal and clinical constraints, invite a potential health care delivery crisis for our noninstitutionalized elderly. Interdisciplinary programs, such as community-based case management, that promote the health and well-being of our noninstitutionalized elderly can be an effective response to this crisis. However, the need for empirical evidence of their effectiveness is essential.

Reflections and recommendations on research ethics in developing countries

The debate on the ethics of international clinical research involving collaboration with developing countries has achieved a high profile in recent years. Informed consent and universal standards have been most intensively debated. Exploitation and lack of adequate attention to justice in the distribution of risks/harm and benefits to individuals and communities have to a lesser extent been addressed. The global context in which these debates are taking place, and some of the less obvious implications for research ethics and for health are discussed here to broaden understanding of the complexity of the debate. A wider role is proposed for research ethics committees, one that includes an educational component and some responsibility for audit. It is proposed that new ways of thinking are needed about the role of research ethics in promoting moral progress in the research endeavour and improving global health.

Assessing head-injury survivors of motor vehicle crashes at discharge from trauma care

OBJECTIVES

This study examines the needs at discharge from acute care to home of trauma patients with head injuries resulting from motor vehicle crashes.

DESIGN

A retrospective case series was conducted by using the 1997 trauma registry to identify eligible adults. Selected variables were abstracted from medical records and hospital databases.

RESULTS

Thirty-four cases were reviewed. At discharge, rehabilitative needs associated with musculoskeletal injury, brain injury, skin integrity, and pain management were identified, with 55% of patients having needs in two or more domains. Although all patients were referred for follow-up appointments, only 62% of patients returned for trauma-related follow-up within this institution. After initial hospitalization, twenty-four percent of patients were seen in the emergency department, and 6% had trauma-related readmissions.

CONCLUSIONS

This study documents the multidimensional needs of this group of survivors of motor vehicle trauma with head injury who were discharged to home. Findings suggest that mobility skills were formally assessed more often than either self-care skills or cognition, possibly resulting in an underestimate of the amount of disability experienced by this group. There seems to be a gap in continuity of care from hospital to the outpatient setting as evidenced by missed follow-up appointments. Models for continuity-focused trauma care with rehabilitative components are needed.

Midwives and HIV antibody testing: identifying the key factors for achieving the targets

A questionnaire study was designed to assess whether differences in knowledge and attitudes to HIV infection existed between midwives working in areas of higher and lower HIV prevalence, and the extent to which this influenced the uptake of HIV antibody testing by their clients. The response rate was 75% (219/292). Midwives in an area of a higher HIV prevalence had significantly greater experience with HIV-positive mothers, were more confident with HIV-related issues and were less judgemental in their attitudes than midwives in an area of lower HIV prevalence. However, midwives who had been offering HIV testing for more than 2 years were significantly less likely to achieve an HIV antibody test uptake rate of more than 75% than those who had been offering testing for less than 2 years, 35% (95% confidence interval [CI]: 22.2-48.6%) vs 67% (95% CI: 56.3-76.0%), respectively. This demonstrates the need for regular updating of midwives about HIV antibody testing.

From delegation to specialization: nurses and clinical trial co-ordination

This paper considers an area of clinical research that has been delegated by physician-researchers to nurses and others in the United States, that of clinical trials co-ordination. It uses interviews with nurse trial co-ordinators to explore the occupational processes by which the boundaries of work enactment and the definition of work have been established by nurses and others. It then discusses the occupational processes that have been established to formalize a role for nurses in clinical research. It raises the question of (and offers speculation on) whether specialization alone will distinguish nursing from other occupational groups engaged in clinical research work.

Organizational context and taxonomy of health care databases

An understanding of the organizational context and taxonomy of health care databases is essential to appropriately use these data sources for research purposes. Characteristics of the organizational structure of the specific health care setting, including the model type, financial arrangement, and provider access, have implications for accessing and using this data effectively. Additionally, the benefit coverage environment may affect the utility of health care databases to address specific research questions. Coverage considerations that affect pharmacoepidemiologic research include eligibility, the nature of the pharmacy benefit, and regulatory aspects of the treatment under consideration.

Professional integrity in the age of managed care: views of physicians

At the end of 1997, one quarter of the American public used health maintenance organizations. This paper reports findings on physicians' perspectives on the role of managed care in their professional practices. The research data come from mailed surveys to physicians who are selected from the Cigna Directory of Physicians practicing in the State of Ohio. Subjects were asked to explain what managed care meant to them, and how long they have been practicing medicine. Questions also focused on professional autonomy, quality of care and career aspirations for the future. The results from the study suggest that managed care has had a negative impact on how physicians practice medicine. Several of our respondents reported that they are playing the role of a "double agent" and feel a sense of frustration in doing so. The degree of antipathy toward managed care differs between primary care physicians and specialists.

Making sense of outpatient pharmacy management. How to control pharmacy costs while delivering quality care

Pharmacy brings together some of the major themes ushering US healthcare into the 21st century: concern about iatrogenesis, patient consumerism, resurgence of healthcare costs, and wide disparity in access to flourishing technology.

Clinical ethics revisited: responses

This series of responses was commissioned to accompany the article by Singer et al , which can be found at . If you would like to comment on the article by Singer et al or any of the responses, please email us on editorial@biomedcentral.com .

Paying the piper: the crisis in chronic care

The current article reviews the broad outlines of the crisis in chronic care with emphasis on Southern California, a region where the powerful forces buffeting health and long term care have reached gale force intensity. The article argues that a partial solution to the crisis lies in flexible local partnerships among patients, families, providers, and payers focused on helping the chronically ill cope with the tasks of daily life. Such partnerships would emphasize supportive care, prevention, family preservation, assistive devices, and family income supplementation through facilitation of productive work, aspects of chronic care neglected by current financing and service delivery practices. A case example, the Southern California-based Partners in Care Foundation's Family Care Network, illustrates these essential components of a revitalized, responsive chronic care system.

Market structure and performance: evaluating the U.S. health system reform

First, U.S. health system evolution over the last several years is assessed and found to be in line with what could be anticipated from economic theory. The immature market appears to be giving way to the concentration and the oligopolies of the mature market. This is explained in a manner accessible to non-economists. Next, the performance of market competition as a vehicle for health system reform is assessed in the areas of cost containment, quality of care, access, research/education and social mission. Overall, results have not measured up to promise. Market competition has not succeeded in bringing U.S. health care costs in line with those of other industrialized countries. There is no evidence of sustained quality improvement. Market based reform has not expanded health insurance coverage but has rather, directly or indirectly, increased the number of underinsured and uninsured Americans. Medical research and education have suffered and medicine's social mission has declined. These failures could probably have been anticipated, in advance, had policy makers carefully examined economic theory concerning market evolution. While these are some reasons to be hopeful for market performance in the future there are also potential pitfalls. Non-market oriented policy alternatives for health system reform are worth considering based on the experiences of the states and other countries.

Medical ethos and social responsibility in clinical medicine

The medical profession will face many challenges in the new millenium. As medicine looks forward to advances in molecular genetics and the prospect of unprecedented understanding of the causes and cures of human disease, clinicians, scientists, and bioethicists may benefit from reflection on the origins of the medical ethos and its relevance to postmodern medicine. Past distortions of the medical ethos, such as Nazism and the Tuskegee Syphilis Study, as well as more recent experience with the ethical challenges of employer-based, market-driven managed care, provide important lessons as medicine contemplates the future. Racial and ethnic disparities in health status and access to care serve as reminders that the racial doctrines that fostered the horrors of the Holocaust and the Tuskegee Syphilis Study have not been removed completely from contemporary thinking. Inequalities in health status based on race and ethnicity, as well as socioeconomic status, attest to the inescapable reality of racism in America. When viewed against a background of historical distortions and disregard for the traditional tenets of the medical ethos, persistent racial and ethnic disparities in health and the prospect of genetic engineering raise the specter of discrimination because of genotype, a postmodern version of "racist medicine" or of a "new eugenics." There is a need to balance medicine's devotion to the well-being of the patient and the primacy of the patient-physician relationship against the need to meet the health care needs of society. The challenge facing the medical profession in the new millennium is to establish an equilibrium between the responsibility to ensure quality health care for the individual patient while effecting societal changes to achieve "health for all."

The benefits of HMO community benefits programs

Managed care is becoming the dominant mode of health care coverage, and health maintenance organizations (HMOs) are playing a key role in the delivery of health care within the evolving, cost-competitive system. However, in this cost-cutting arena, do HMOs have responsibility for health services to communities which extends beyond their enrolled populations? Do HMO community benefits programs have significant impact on the uninsured or the related problem of paying for uncompensated care? The Massachusetts Attorney General believed so and developed the first set of voluntary guidelines in the nation for HMOs to follow in developing community benefits programs. This study reports on the initial year of the program and raises important policy questions regarding the responsibility HMOs have to the communities apart from the population they contract with, and the extent to which communities benefit from HMO community benefits programs.

Using standardized patients to measure quality: evidence from the literature and a prospective study

BACKGROUND

Use of standardized patients for evaluating the clinical skills of medical students and medical trainees is commonplace. This has encouraged the use of standardized patients to evaluate the quality of physician practice in outpatient settings. However, there may be substantive differences between observing student performance and evaluating whether the provision of care meets defined quality criteria.

OBJECTIVES

This study had two primary objectives: (1) to review studies that use standardized patients to evaluate physician performance and (2) to ascertain directly whether standardized patients could be useful in assessing quality of outpatient care.

METHODS

A comprehensive literature review of studies that used standardized patients to assess physician performance was conducted. A prospective study that included 20 physicians at two outpatient settings and 27 actor patients assessed quality of care using eight clinical cases divided into five clinical domains, each of which had explicit criteria checklists based on widely accepted guidelines.

RESULTS

The literature review identified five important issues: developing scenarios, selecting explicit criteria, standardizing standardized patient training, creating subterfuges, and ensuring reliability and validity of measures. In the study, trained standardized patients were able to assess physician practice accurately for common medical conditions, using proven criteria linked to health outcomes. The detection rate was 3%. There was no performance variation between actors for seven of the eight cases.

CONCLUSIONS

Using standardized patients to measure the quality of care is practical and feasible. The major methodological challenge is incorporating observable evidence-based criteria into realistic scripts and objective checklists. The major logistical challenge is obtaining and maintaining undetected entry into physicians' offices.