'AJ's Orbicularis Oris Stitch: A Novel and Simple Technique of Reconstructing Central Arch Mandibular Defects in Resource-Constrained Set Up'

Lip and oral cavity SCC account for 2nd highest incidence of cancers and 3rd most common cause of mortality from cancer in India. Reconstruction of defects of central arch invading cancers results in poor cosmetic and functional outcomes if free flaps are not used. 30 patients with Oral SCC in the age group 20-75 years requiring central arch segmental mandibulectomy were included. Reconstruction was done with pedicled bipaddled PMMC flap with 'AJ's orbicularis oris stitch' using Fiber wire. Patients were divided into 4 groups according to extent of lip and skin loss post excision of primary tumour. Patients were evaluated with subjective scores for drooling, oral competence and cosmesis. There were 4, 12, 9 and 5 patients in Group A, B, C and D respectively. Mean subjective scores using our technique for drooling, oral competence and cosmesis were 3.75/4,3.75/4 and 3.5/4 for group A, 3.45/4, 3.36/4 and 3.09/4 for group B, 2.8/4, 2.6/4 and 2.3/4 for group C defects and 2.5/4, 3/4 and 2.5/4 for group D defects respectively. Over all scores for all patients were 3.2/4, 3.14/4 and 2.84/4 for drooling, oral competence and cosmesis. This simple, quick and inexpensive technique of reconstruction of central mandibular arch defects can drastically improve cosmetic and functional outcomes in a resource restrained set up. However, long term results and comparison studies are required for standardisation of the technique.

Large Brown Tumour of Mandible with Bleeding as Initial Presentation: A Case Report

Brown Tumour or Osteitis fibrous cystic or Von-Recklinghausen disease of bone is a non-malignant condition due to abnormal metabolism of bones in hyperparathyroidism. Although pathognomonic of hyperparathyroidism, brown tumours are rare and only case reports are found in literature. We report a case of brown tumour of mandible with recurrent episodes of bleeding. A 46 year old male patient presented in emergency with bleeding from ulceroproliferative mass from left floor of mouth. After control of bleeding, radiological, laboratory and histopathological investigations were done that led to the diagnosis of brown tumour of mandible in the presence of parathyroid adenoma of left lower parathyroid gland. Left upper and lower parthyroidectomy was done with segmental resection of mandible with mass and titanium plating. Brown tumour of facial bones is a rare entity. Very rarely it can reach enormous sizes to cause bleeding. Although parathyroidectomy and correction of parathormone levels cause regression of small tumours, large brown tumours with complications should be managed with surgical resection and reconstruction.

Solitary endobronchial plasmacytoma-a rare differential of an endobronchial mass

Diagnostic dilemma, owing to the inconclusiveness of biopsy results, often leaves us with limited options to offer to the patients upfront, amongst the various armamentarium available. We hereby report a rare case of extramedullary plasmacytoma, whose diagnosis was established only on the final histopathology report with the aid of immunohistochemistry. A 50-year-old gentleman presented to our outpatient setup with computed tomography suggestive of a well-defined endobronchial mass occupying the left lower lobe bronchus. However, bronchoscopy and computed tomography-guided biopsies were inconclusive. After a routine metastatic workup, the patient underwent a left lower lobectomy following a provisional diagnosis of carcinoid on the frozen section. The final histopathology was solitary endobronchial plasmacytoma. Postoperative myeloma workup was within normal limits and the patient is doing well and disease free at 8 months of follow-up. This rare differential needs to be kept in mind while evaluating a case of well-defined endobronchial growth.

The role of cadaveric simulation in talus fracture research: A scoping review

BACKGROUND

Talus fractures are rare (<1% of all fractures), and their rarity limits the number of studies available to guide management. In instances such as this, cadaveric studies can play an important role. The purpose of this scoping review was to identify and describe the current body of literature on cadaveric studies of fractures of the talus.

METHODS

Through multiple electronic database searches (Medline, Embase, Scopus) we identified a broad body of cadaveric research into talus fractures, and these were classified into 4 main themes. Study characteristics were summarised along with any descriptive results and conclusions.

RESULTS

The search yielded 484 articles of which 19 met the inclusion criteria. They provide valuable insights into benefits and drawbacks of surgical approaches to the talus, particularly with regard to direct visualisation of anatomic reduction, and risks of neurovascular or tendon compromise. For talar neck fractures it is clear that cannulated screws offer superior fixation over plates, however, are inferior when considering anatomic reduction of the fracture. Direct visualisation of fracture reduction is far superior to intraoperative radiographic assessment, and mal-reduction leads to reduced subtalar joint range of motion, midfoot deformity, and increased joint contact pressures.

CONCLUSIONS

This study provides a summary of the existing literature surrounding the use of cadaver studies in fractures of the talus. We have identified gaps in the literature, particularly surrounding strength of fixation of new locking plate fixation techniques.

Longitudinal Preterm Cerebellar Volume: Perinatal and Neurodevelopmental Outcome Associations

Impaired cerebellar development is an important determinant of adverse motor and cognitive outcomes in very preterm (VPT) infants. However, longitudinal MRI studies investigating cerebellar maturation from birth through childhood and associated neurodevelopmental outcomes are lacking. We aimed to compare cerebellar volume and growth from term-equivalent age (TEA) to 7 years between VPT (< 30 weeks' gestation or < 1250 g) and full-term children; and to assess the association between these measures, perinatal factors, and 7-year outcomes in VPT children, and whether these relationships varied by sex. In a prospective cohort study of 224 VPT and 46 full-term infants, cerebellar volumes were measured on MRI at TEA and 7 years. Useable data at either time-point were collected for 207 VPT and 43 full-term children. Cerebellar growth from TEA to 7 years was compared between VPT and full-term children. Associations with perinatal factors and 7-year outcomes were investigated in VPT children. VPT children had smaller TEA and 7-year volumes and reduced growth. Perinatal factors were associated with smaller cerebellar volume and growth between TEA and 7 years, namely, postnatal corticosteroids for TEA volume, and female sex, earlier birth gestation, white and deep nuclear gray matter injury for 7-year volume and growth. Smaller TEA and 7-year volumes, and reduced growth were associated with poorer 7-year IQ, language, and motor function, with differential relationships observed for male and female children. Our findings indicate that cerebellar growth from TEA to 7 years is impaired in VPT children and relates to early perinatal factors and 7-year outcomes.

Factors associated with treatment delays in pediatric refractory convulsive status epilepticus

OBJECTIVE

To identify factors associated with treatment delays in pediatric patients with convulsive refractory status epilepticus (rSE).

METHODS

This prospective, observational study was performed from June 2011 to March 2017 on pediatric patients (1 month to 21 years of age) with rSE. We evaluated potential factors associated with increased treatment delays in a Cox proportional hazards model.

RESULTS

We studied 219 patients (53% males) with a median (25th-75th percentiles [p₂₅-p₇₅]) age of 3.9 (1.2-9.5) years in whom rSE started out of hospital (141 [64.4%]) or in hospital (78 [35.6%]). The median (p₂₅-p₇₅) time from seizure onset to treatment was 16 (5-45) minutes to first benzodiazepine (BZD), 63 (33-146) minutes to first non-BZD antiepileptic drug (AED), and 170 (107-539) minutes to first continuous infusion. Factors associated with more delays to administration of the first BZD were intermittent rSE (hazard ratio [HR] 1.54, 95% confidence interval [CI] 1.14-2.09; p = 0.0467) and out-of-hospital rSE onset (HR 1.5, 95% CI 1.11-2.04; p = 0.0467). Factors associated with more delays to administration of the first non-BZD AED were intermittent rSE (HR 1.78, 95% CI 1.32-2.4; p = 0.001) and out-of-hospital rSE onset (HR 2.25, 95% CI 1.67-3.02; p < 0.0001). None of the studied factors were associated with a delayed administration of continuous infusion.

CONCLUSION

Intermittent rSE and out-of-hospital rSE onset are independently associated with longer delays to administration of the first BZD and the first non-BZD AED in pediatric rSE. These factors identify potential targets for intervention to reduce time to treatment.

Counting the cost of cancer: out-of-pocket payments made by colorectal cancer survivors

PURPOSE

Cancer places a significant cost burden on health services. There is increasing recognition that cancer also imposes a financial and economic burden on patients but this has rarely been quantified outside North America. We investigate out-of-pocket costs (OOPCs) incurred by colorectal (CRC) survivors in Ireland.

METHODS

CRC survivors (ICD10 C18-20) diagnosed 6-30 months previously were identified from the National Cancer Registry Ireland and invited to complete a postal questionnaire. Cancer-related OOPC for tests, procedures, drugs, allied medications and household management in approximately the year following diagnosis were calculated. Robust regression was used to identify predictors of OOPC; this was done for all survivors combined and stratified by age (<70 and ≥70 years) and employment status (working and not working) at diagnosis.

RESULTS

Four hundred ninety-seven CRC survivors completed questionnaires (response rate = 39%). Almost all (90%) respondents reported some cancer-related OOPC. The average total OOPC was €1589. Stage III at diagnosis was associated with significantly higher OOPCs than other stages in the all-survivor model, in those not working in the employment model and in those under 70 years in the age-stratified model. In all-survivor model, those under 70 also had higher OOPCs, as did those in employment. Having one or more children was associated with significantly lower OOPCs in those under 70 years.

CONCLUSIONS

Almost all CRC survivors incur cancer-related OOPCs; for some, these are not insignificant. Greater attention should be paid to the development of services to help survivors manage the financial and economic burden of cancer.

Is the Individual Market More Than a Bridge Market? An Analysis of Disenrollment Decisions

The individual insurance market is perceived by many to provide primarily transition coverage, but there is limited research about how long people stay in this market and what affects their disenrollment decisions. We examine these issues using administrative records and survey data for those enrolled in the individual market in California. We conclude that there is less turnover in this market than is commonly believed. We find that economic factors and coverage characteristics are important in the decision to disenroll, but that perceptions about insurance and the health care system also affect this decision.

Changing trends in the UK management of upper GI bleeding: is there evidence of reduced UK training experience?

OBJECTIVE

The aim of this study was to evaluate UK trainee experience in endoscopy for acute upper gastrointestinal bleeding (AUGIB).

METHODS

Data was prospectively collected from all patients presenting to South Yorkshire Hospitals with AUGIB from September 2011 to December 2011 and compared with data from 1996. Concurrently, all gastroenterology trainees registered with the British Society of Gastroenterology were invited to respond to a web-based questionnaire regarding their experience in AUGIB management.

RESULTS

77% (589/766) of the patient cohort underwent endoscopy for AUGIB; 15% (90/589) were performed by trainees. 7.2% (9/125) of the out of hours endoscopy case load was performed by trainees; all were low-risk or medium-risk cases (pre-endoscopy Rockall score ≤4). During the study period, dual therapy was delivered by a trainee on only four occasions. Comparison with the 1996 cohort demonstrated a marked reduction in the number of trainee performed endoscopies (76% vs 15%; p<0.001). Questionnaires were returned by 51% (245/478) of British Society of Gastroenterology trainees. 81% (198/245) thought that <10% of the gastroscopies they had performed involved therapeutic intervention. 23% (57/245) felt they would not be competent in AUGIB endoscopy by completion of specialty training.

CONCLUSIONS

This study demonstrates the decline over time in trainee experience in AUGIB endoscopy. It also highlights a lack of trainee exposure to more challenging cases, out of hours endoscopy and therapeutic procedures. Furthermore, trainees are concerned that a level of competency may not be attained during specialty training. We advocate reviewing UK endoscopic training provision for AUGIB to ensure that experienced endoscopists are produced to meet future service needs.

Time costs associated with informal care for colorectal cancer: an investigation of the impact of alternative valuation methods

BACKGROUND

A societal perspective in economic evaluation necessitates that all resources associated with a disease or intervention should be valued; however, informal care time costs are rarely considered.

OBJECTIVE

We estimated time allocated to care by informal carers of colorectal cancer survivors; and investigated the impact of applying alternative valuation methods to this time.

METHODS

Colorectal cancer cases (ICD10 C18-C20) diagnosed 6-30 months previously and identified from the National Cancer Registry Ireland were invited to provide details of informal carers. Carers completed a postal questionnaire. Time estimates per week associated with hospital-related and domestic-related care activities were collected for two phases: diagnosis and initial treatment (initial 3 months) and ongoing care (previous 30 days). Seven valuation scenarios, based on variants of the opportunity cost approach (OCA), and the proxy good approach (PGA), were considered. The base-case was OCA with all carer time valued at the average national wage.

RESULTS

We received 154 completed questionnaires (response rate = 68 %). Average weekly time allocated to caring was 42.5 h in the diagnosis and initial treatment phase and 16.9 h in the ongoing care phase. Under the base-case, average weekly time costs were <euro>295 (95 % CI 255-344) for hospital-related activities and <euro>630 (95 % CI 543-739) for domestic-related activities in the diagnosis and initial treatment phase and <euro>359 (95 % CI 293-434) in the ongoing care phase. PGA estimates were 23 % below the base-case. Only one alternative scenario (occupation and gender-specific wages for carers in paid work and replacement wages for non-working carers) surpassed base-case costs, and the difference was modest.

CONCLUSIONS

Overall, significant time is associated with informal caring in colorectal cancer. Different time valuation methods can produce quite different cost estimates. A standardised methodology for estimating informal care costs would facilitate better integration of these into economic evaluations.

How much does it cost to care for survivors of colorectal cancer? Caregiver's time, travel and out-of-pocket costs

Purpose

Cancer treatment is increasingly delivered in an outpatient setting. This may entail a considerable economic burden for family members and friends who support patients/survivors. We estimated financial and time costs associated with informal care for colorectal cancer.

Methods

Two hundred twenty-eight carers of colorectal cancer survivors diagnosed on October 2007–September 2009 were sent a questionnaire. Informal care costs included hospital- and domestic-based foregone caregiver time, travel expenses and out-of-pocket (OOP) costs during two phases: diagnosis and treatment and ongoing care (previous 30 days). Multiple regression was used to determine cost predictors.

Results

One hundred fifty-four completed questionnaires were received (response rate = 68 %). In the diagnosis and treatment phase, weekly informal care costs per person were: hospital-based costs, incurred by 99 % of carers, mean = €393 (interquartile range (IQR), €131–€541); domestic-based time costs, incurred by 85 %, mean = €609 (IQR, €170–€976); and domestic-based OOP costs, incurred by 68 %, mean = €69 (IQR, €0–€110). Ongoing costs included domestic-based time costs incurred by 66 % (mean = €66; IQR, €0–€594) and domestic-based OOP costs incurred by 52 % (mean = €52; IQR, €0–€64). The approximate average first year informal care cost was €29,842, of which 85 % was time costs, 13 % OOP costs and 2 % travel costs. Significant cost predictors included carer age, disease stage, and survivor age.

Conclusion

Informal caregiving associated with colorectal cancer entails considerable time and OOP costs. This burden is largely unrecognised by policymakers, service providers and society in general. These types of studies may facilitate health decision-makers in better assessing the consequences of changes in cancer care organisation and delivery.

Electronic supplementary material

The online version of this article (doi:10.1007/s00520-013-1834-3) contains supplementary material, which is available to authorized users.

Inter-relationships between the economic and emotional consequences of colorectal cancer for patients and their families: a qualitative study

Background

While the evidence-base concerning the economic impact of cancer for patients and their families/carers has grown in recent years, there is little known about how emotional responses to cancer influence this economic impact. We investigated the economic costs of cancer in the context of patients’ emotions and how these both shaped the patient and family burden.

Methods

Health professionals from six hospitals invited patients diagnosed with colorectal cancer (ICD10 C18-C20) within the previous year to take part in the study. Semi-structured face-to-face interviews were conducted with patients and, where available, a family member. Interviews covered medical and non-medical costs incurred as a result of cancer and the impact of these on the lives of the patient and their family. Interviews were audio-recorded. Recordings were transcribed verbatim and these data were analysed qualitatively using thematic content analysis.

Results

Twenty-two patients with colorectal cancer (17 colon and 5 rectal; 14 women and 8 men) were interviewed; 6 were accompanied by a family member. Important cancer-related financial outlays included: travel and parking associated with hospital appointments; costs of procedures; increased household bills; and new clothing. Cancer impacted on employed individuals’ ability to work and depressed their income. The opportunity cost of informal care for carers/family members, especially immediately post-diagnosis, was a strong theme. All patients spoke of the emotional burden of colorectal cancer and described how this burden could lead to further costs for themselves and their families by limiting work and hindering their ability to efficiently manage their expenses. Some patients also spoke of how economic and emotional burdens could interact with each other. Support from employers, family/carers and the state/health services and patients’ own attitudes influenced this inter-relationship.

Conclusions

The economic impact of colorectal cancer on patients and their families is complex. This study suggests that the economic costs and the emotional impact of cancer are often related and can exacerbate each other, but that various factors can meditate this inter-relationship.

Depressive disorder moderates the effect of the FTO gene on body mass index

There is evidence that obesity-related disorders are increased among people with depression. Variation in the FTO (fat mass and obesity associated) gene has been shown to contribute to common forms of human obesity. This study aimed to investigate the genetic influence of polymorphisms in FTO in relation to body mass index (BMI) in two independent samples of major depressive disorder (MDD) cases and controls. We analysed 88 polymorphisms in the FTO gene in a clinically ascertained sample of 2442 MDD cases and 809 controls (Radiant Study). In all, 8 of the top 10 single-nucleotide polymorphisms (SNPs) showing the strongest associations with BMI were followed-up in a population-based cohort (PsyCoLaus Study) consisting of 1292 depression cases and 1690 controls. Linear regression analyses of the FTO variants and BMI yielded 10 SNPs significantly associated with increased BMI in the depressive group but not the control group in the Radiant sample. The same pattern was found in the PsyCoLaus sample. We found a significant interaction between genotype and affected status in relation to BMI for seven SNPs in Radiant (P<0.0057), with PsyCoLaus giving supportive evidence for five SNPs (P-values between 0.03 and 0.06), which increased in significance when the data were combined in a meta-analysis. This is the first study investigating FTO and BMI within the context of MDD, and the results indicate that having a history of depression moderates the effect of FTO on BMI. This finding suggests that FTO is involved in the mechanism underlying the association between mood disorders and obesity.

Profile of Live-born Infants of In-vitro Fertilisation

INTRODUCTION

The Army Hospital (R&R) is the only service hospital providing in-vitro fertilisation (IVF) facility. Neonatal characteristics of live-born infants at this centre over a two-year period are analyzed in this study.

METHODS

Data on 504 consecutive live-born IVF infants over a two-year period (01 Feb 2007 to 31 Jan 2009) were analysed.

RESULT

Of the 504 neonates, 190 (37.7%) were born by vaginal delivery, 156 (30.9%) by elective lower segment cesarean section (LSCS) and 127 (25.19%) following emergency LSCS. Maternal illness posing specific risk to the neonate was present in 165 out of 504 (32.7%). There were 239 (47.4%) preterm neonates. Males formed 51.8% of the cohort. Singletons accounted for 51.2%, while the rest (48.8%) were products of twin pregnancies. Small for gestational age neonates formed 22.6% (n = 114). A total of 20 (3.9%) infants had congenital malformations. There were 242 (48.1%) low birth weight neonates. A total of 128 (25.4%) neonates needed neonatal intensive care. Of the 504, there were 474 (94.1%) survivors while 30 (5.9%) did not survive. Twenty-nine (6.1%) neonates required readmission during the neonatal period.

CONCLUSION

In our setting, neonates born following IVF appeared to be at increased risk of prematurity, multiple births and low birth weight. Proper obstetric and neonatal management can result in good neonatal outcomes.

How does health insurance affect the retirement behavior of women?

The availability of health insurance is a crucial factor in the retirement decision. Women are substantially less likely to have health insurance from their own employment. Using the Health and Retirement Study, we examine the role of employer-provided retiree health insurance in the retirement decisions of single women, and women in single-earner and dual-earner couples. We compare the effect of health insurance on female and male retirement. Our results show that retiree health insurance increases retirement for all groups except single men. We find suggestive evidence that the role of health insurance for women hinges on their husbands' labor force status.

Is employer-based health insurance a barrier to entrepreneurship?

The focus on employer-provided health insurance in the United States may restrict business creation. We address the limited research on the topic of "entrepreneurship lock" by using recent panel data from matched Current Population Surveys. We use difference-in-difference models to estimate the interaction between having a spouse with employer-based health insurance and potential demand for health care. We find evidence of a larger negative effect of health insurance demand on business creation for those without spousal coverage than for those with spousal coverage. We also take a new approach in the literature to examine the question of whether employer-based health insurance discourages business creation by exploiting the discontinuity created at age 65 through the qualification for Medicare. Using a novel procedure of identifying age in months from matched monthly CPS data, we compare the probability of business ownership among male workers in the months just before turning age 65 and in the months just after turning age 65. We find that business ownership rates increase from just under age 65 to just over age 65, whereas we find no change in business ownership rates from just before to just after for other ages 55-75. We also do not find evidence from the previous literature and additional estimates that other confounding factors such as retirement, partial retirement, social security and pension eligibility are responsible for the increase in business ownership in the month individuals turn 65. Our estimates provide some evidence that "entrepreneurship lock" exists, which raises concerns that the bundling of health insurance and employment may create an inefficient level of business creation.

Do patients bypass rural hospitals? Determinants of inpatient hospital choice in rural California

Rural hospitals play a crucial role in providing health care to rural Americans, a vulnerable and underserved population; however, rural hospitals have faced threats to their financial viability and many have closed as a result. This paper examines the hospital characteristics that are associated with patients choosing rural hospitals, and sheds light on the types of patients who depend on rural hospitals for care and, hence, may be the most harmed by the closure of rural hospitals. Using data from California hospitals, the paper shows that patients were more likely to choose nearby hospitals, larger hospitals, and hospitals that offered more services and technologies. However, even after adjusting for these factors, patients had a propensity to bypass rural hospitals in favor of large urban hospitals. Offering additional services and technologies would increase the share of rural residents choosing rural hospitals only slightly.

The role of product design in consumers' choices in the individual insurance market

OBJECTIVE

To evaluate the role of health plan benefit design and price on consumers' decisions to purchase health insurance in the nongroup market and their choice of plan.

DATA SOURCES AND STUDY SETTING

Administrative data from the three largest nongroup insurers in California and survey data about those insured in the nongroup market and the uninsured in California.

STUDY DESIGN

We fit a nested logit model to examine the effects of plan characteristics on consumer choice while accounting for substitutability among certain groups of products.

PRINCIPAL FINDINGS

Product choice is quite sensitive to price. A 10 percent decrease in the price of a product would increase its market share by about 20 percent. However, a 10 percent decrease in prices of all products would only increase overall market participation by about 4 percent. Changes in the generosity of coverage will also affect product choice, but have only small effects on overall participation. A 20 percent decrease in the deductible or maximum out-of-pocket payment of all plans would increase participation by about 0.3-0.5 percent. Perceived information search costs and other nonprice barriers have substantial effects on purchase of nongroup coverage.

CONCLUSIONS

Modest subsidies will have small effects on purchase in the nongroup market. New product designs with higher deductibles are likely to be more attractive to healthy purchasers, but the new benefit designs are likely to have only small effects on market participation. In contrast, consumer education efforts have a role to play in helping to expand coverage.

Individual health insurance within the family: can subsidies promote family coverage?

This paper examines the role of price in health insurance coverage decisions within the family to guide policy in promoting whole family coverage. We analyze the factors that affect individual health insurance coverage among families, and explore family decisions about whom to cover and whom to leave uninsured. The analysis uses household data from California combined with abstracted individual health plan benefit and premium data. We find that premium subsidies for individual insurance would increase family coverage; however, their effect likely would be small relative to their implementation cost.

Consumer-directed health care: early evidence about effects on cost and quality

Demand for consumer-directed health care (CDHC) is growing among purchasers of care, and early evidence about its effects is beginning to emerge. Studies to date are consistent with effects predicted by earlier literature: There is evidence of modest favorable health selection and early reports that consumer-directed plans are associated with both lower costs and lower cost increases. The early effects of CDHC on quality are mixed, with evidence of both appropriate and inappropriate changes in care use. Greater information about prices, quality, and treatment choices will be critical if CDHC is to achieve its goals.

Medical Abortion-An Alternative to Surgical Abortion

BACKGROUND

Termination of early pregnancy has traditionally been done surgically, but agents are now available which can terminate pregnancy if taken orally, vaginally or parenterally. We have used a combination of mifepristone and misoprostol for termination of early pregnancy.

MATERIAL AND METHOD

Fifty patients having amenorrhoea of upto 56 days with confirmed intrauterine pregnancy, were selected for medical termination of pregnancy. The patients were given tablet mifepristone (200mg) on day 1 and tablet misoprostol (400mcg) on day 3. On day 14, an ultrasound was done to confirm complete abortion.

RESULT

Majority 35 (70%) patients had amenorrhoea between 40 - 50 days. The duration of bleeding was less than 5 days in 12%, between 5 -10 days in 56%, 10 -13 days in 16% and greater than 14 days in 16%. In all patients with bleeding of more than 14 days ultrasonography confirmed intrauterine products & a suction evacuation was done. In this series there were no failures.

CONCLUSION

The combination of mifepristone and misoprostol is an effective method for termination of early pregnancy up to 56 days of amenorrhoea.

Consumer Decision Making In The Individual Health Insurance Market

This paper summarizes the results from a study of consumer decision making in California's individual health insurance market. We conclude that price subsidies will have only modest effects on participation and that efforts to reduce nonprice barriers might be just as effective. We also find that there is substantial pooling in the individual market and that it increases over time because people who become sick can continue coverage without new underwriting. Finally, we show that people prefer more-generous benefits and that it is difficult to induce people in poor health to enroll in high-deductible health plans.

Socioeconomic Status and Medical Care Expenditures in Medicare Managed Care

This study examined the effects of education, income, and wealth on medical care expenditures in two Medicare managed care plans. The study also sought to elucidate the pathways through which socioeconomic status (SES) affects expenditures, including preferences for health and medical care and ability to navigate the managed care system. We found that education, income, and wealth all affected medical care expenditures, although the effects of these variables differed across expenditure categories. Moreover, the effects of these SES variables were much smaller than the effects found in earlier studies of fee-for-service Medicare. The pathway variables also were associated with expenditures. Accounting for the pathways through which SES affects expenditures narrowed the effect of SES on expenditures; however, the change in the estimates was very small.

Comparing the urinary pancreolauryl ratio and faecal elastase-1 as indicators of pancreatic insufficiency in clinical practice

BACKGROUND

The urine pancreolauryl ratio (uPLR) and, more recently, the faecal pancreatic elastase-1, are widely used for the noninvasive diagnosis of exocrine pancreatic insufficiency. Both tests have previously been validated against 'gold standard' tests of pancreatic function, but their use in a clinical setting has never been directly compared.

METHODS

We performed a comparative study of the pancreolauryl ratio (PLR) and the faecal elastase-1 (FE-1) test in patients with a clinical suspicion for pancreatic insufficiency. The results were compared with the clinical response to pancreatic enzyme supplementation using pre-defined criteria.

RESULTS

Forty-five patients were enrolled in the study and 33 were given a trial of pancreatic enzyme supplementation. Twenty-four out of these 33 showed a positive clinical response to enzyme supplements. Of the 24 responders, 19 had positive FE-1 (<200 microg/g faeces), but only 12 had a positive uPLR (<20). There was a significant correlation between the FE-1 result and clinical response to enzyme supplements (p = 0.01), but not between the PLR and clinical response (p = 0.15).

CONCLUSIONS

FE-1 is a simpler test for the patient to perform and more accurately predicts the response to pancreatic enzyme supplementation in patients with chronic, unexplained diarrhoea with a clinical suspicion of pancreatic insufficiency than the PLR. This makes the FE-1 of greater use in clinical practice than the PLR.

Using contingent choice methods to assess consumer preferences about health plan design

INTRODUCTION

American insurers are designing products to contain health care costs by making consumers financially responsible for their choices. Little is known about how consumers will view these new designs. Our objective is to examine consumer preferences for selected benefit designs.

METHODS

We used the contingent choice method to assess willingness to pay for six health plan attributes. Our sample included subscribers to individual health insurance products in California, US. We used fitted logistic regression models to explore how preferences for the more generous attributes varied with the additional premium and with the characteristics of the subscriber.

RESULTS

High quality was the most highly valued attribute based on the amounts consumers report they are willing to pay. They were also willing to pay substantial monthly premiums to reduce their overall financial risk. Individuals in lower health were willing to pay more to reduce their financial risk than individuals in better health.

DISCUSSION/CONCLUSION

Consumers may prefer tiered-benefit designs to those that involve overall increases in cost sharing. More consumer information is needed to help consumers better evaluate the costs and benefits of their insurance choices.

Subsidies and the demand for individual health insurance in California

OBJECTIVE

To estimate the effect of changes in premiums for individual insurance on decisions to purchase individual insurance and how this price response varies among subgroups of the population.

DATA SOURCE

Survey responses from the Current Population Survey (http://www.bls.census.gov/cps/cpsmain.htm), the Survey of Income and Program Participation (http://www.sipp.census.gov/sipp), the National Health Interview Survey (http://www.cdc.gov/nchs/nhis.htm), and data about premiums and plans offered in the individual insurance market in California, 1996-2001.

STUDY DESIGN

A logit model was used to estimate the decisions to purchase individual insurance by families without access to group insurance. This was modeled as a function of premiums, controlling for family characteristics and other characteristics of the market. A multinomial model was used to estimate the choice between group coverage, individual coverage, and remaining uninsured for workers offered group coverage as a function of premiums for individual insurance and out-of-pocket costs of group coverage.

PRINCIPAL FINDINGS

The elasticity of demand for individual insurance by those without access to group insurance is about -.2 to -.4, as has been found in earlier studies. However, there are substantial differences in price responses among subgroups with low-income, young, and self-employed families showing the greatest response. Among workers offered group insurance, a decrease in individual premiums has very small effects on the choice to purchase individual coverage versus group coverage.

CONCLUSIONS

Subsidy programs may make insurance more affordable for some families, but even sizeable subsidies are unlikely to solve the problem of the uninsured. We do not find evidence that subsidies to individual insurance will produce an unraveling of the employer-based health insurance system.

Managing care: utilization review in action at two capitated medical groups

Despite widespread concern about denials of coverage by managed care organizations, little empirical information exists on the profile and outcomes of utilization review decisions. This study examines the outcomes of nearly a half-million coverage requests in two large medical groups that contract with health plans to deliver care and conduct utilization review. We found much higher denial rates than those previously reported. Denials were particularly common for emergency care and durable medical equipment. Retrospective requests were nearly four times more likely than prospective requests were to be denied, and when prospective requests were denied, it was more likely because the service fell outside the scope of covered benefits than because it was not medically necessary.

Employment Transitions And Continuity of Health Insurance: Implications For Premium Assistance Programs

We use data from two nationwide panel surveys to explore whether premium assistance programs can provide stable insurance for low-income children. We estimate that low-income children who are newly enrolled in an employer-group plan would keep that coverage longer than similar children keep newly acquired public insurance. We conclude that group coverage could provide a source of insurance for eligible low-income children that is more stable than public insurance. However, only one-third of low-income uninsured children have access to group insurance, and most low-income children with access to a group plan are enrolled in it. Thus, premium assistance programs are difficult to target effectively, and other programs are necessary to reach the majority of uninsured children.

Practice characteristics and HMO enrollee satisfaction with specialty care: an analysis of patients with glaucoma and diabetic retinopathy

BACKGROUND

The specialist's role in caring for managed care patients is likely to grow. Thus, assessing the correlates of patient satisfaction with specialty care is essential.

OBJECTIVE

To examine the association between characteristics of eye care practices and satisfaction with eye care among working age patients with open-angle glaucoma (OAG) or diabetic retinopathy (DR). SUBJECTS/STUDY SETTING: A total of 913 working age patients with OAG or DR enrolled in six commercial managed care health plans. The patients were treated in 144 different eye care practices.

STUDY DESIGN

We used a patient survey to obtain information on patient characteristics and satisfaction with eye care, measured by scores on satisfaction subscales of the 18-item Patient Satisfaction Questionnaire. We used a survey of eye care practices to obtain information on practice characteristics, including provider specialties, practice organization, financial features, and utilization and quality management systems. We estimated logistic regression models to assess the association of patient and practice characteristics with high levels of patient satisfaction.

PRINCIPAL FINDINGS

Treatment in a practice with a glaucoma specialist (for OAG patients) or a retina specialist (for DR patients) was associated with higher satisfaction, whereas treatment in a practice that obtained a high proportion of its revenues from capitation payments or in a group practice where providers obtained a high proportion of their incomes from bonuses was associated with lower satisfaction.

CONCLUSIONS

Many eye care patients prefer to be treated by specialists with expertise in their conditions. Financial arrangement features of eye care practices also are associated with patient satisfaction with care. The most likely mechanisms underlying these associations are effects on provider behavior and satisfaction, which in turn influence patient satisfaction. Managed care plans and provider groups should aim to minimize the negative impact of managed care features on patient satisfaction.

Patterns of care for open-angle glaucoma in managed care

OBJECTIVES

To describe patterns of care for primary open-angle glaucoma (POAG) and assess conformance with the American Academy of Ophthalmology's Preferred Practice Pattern (PPP).

METHODS

We obtained administrative, survey, and eye care records data on 395 working-age patients with POAG enrolled in 6 managed care plans between 1997 and 1999. We assessed processes of care at the initial and follow-up visits, control of intraocular pressure (IOP), intervals between visits and visual field tests, and adjustments in therapy.

RESULTS

We found high rates of performance on most recommended processes during initial evaluations, although only 53% of patients received an optic nerve head photograph or drawing and only 1% had a target IOP level documented. Recommended processes were performed at 80% to 97% of follow-up visits. Using loose criteria for control, IOP was controlled in 66% of follow-up visits for patients with mild glaucoma and 52% of visits for patients with moderate to severe glaucoma. Intervals between visits and visual field tests were generally consistent with PPP recommendations. Adjustments in therapy were more likely with worse control of IOP, although adjustments occurred in only half of visits where the IOP was 30 mm Hg or higher.

CONCLUSIONS

Our study suggests that, in many respects, patients with POAG are receiving care that is consistent with the PPP. However, care is falling short on several key aspects, and POAG may be undertreated relative to standards for IOP control established in recent clinical trials.

Health insurance for workers who lose jobs: implications for various subsidy schemes

A number of proposals have been made to help laid-off workers purchase health insurance. We use data from the 1996 Medical Expenditure Panel Survey to profile the insurance status of workers who left a job. Our descriptive analysis suggests that it might be difficult to design policies that target those who would otherwise be uninsured and that large subsidies might be needed to help laid-off workers.

Does an exercise and incontinence intervention save healthcare costs in a nursing home population?

OBJECTIVES

To determine whether an intervention that combines low-intensity exercise and incontinence care offsets some of its costs by reducing the incidence of selected health conditions in nursing home residents.

DESIGN

Randomized, controlled trial with the incidence and costs of selected, acute conditions compared between a 6-month baseline and an 8-month intervention phase.

SETTING

Four nursing homes.

PARTICIPANTS

One hundred ninety incontinent, long-stay nursing home residents.

INTERVENTION

Low-intensity, functionally oriented exercise and incontinence care were provided every 2 hours from 8:00 a.m. to 4:00 p.m. for 5 days a week for 8 months.

MEASUREMENTS

Predefined acute conditions hypothesized to be related to physical inactivity, incontinence, or immobility were abstracted from residents' medical records by blinded observers during a 6-month baseline period and throughout the 8-month intervention. Conditions included those in the dermatological, genitourinary, gastrointestinal, respiratory and cardiovascular systems; falls; pain; and psychiatric and nutritional disturbances. Costs were determined using Current Procedural Terminology Center and Medicare allowable cost reimbursement at a rate of 80%.

RESULTS

The intervention group had significantly better functional outcomes than the control group (strength, mobility endurance, urinary and fecal incontinence) and a reduction of 10% in the incidence of the acute conditions, which was not significant. There were no significant differences between groups in the cost of assessing and treating these acute conditions between baseline and intervention.

CONCLUSION

The intervention, which is consistent with federal and clinical practice guidelines, significantly improved functional outcomes but did not reduce the incidence and costs of selected acute health conditions. The cost of implementing these labor-intensive interventions for frail nursing home residents will have to be justified based on functional and quality-of-life outcomes and are unlikely to be offset by savings in medical care costs in this population.

Trends And Variability In Individual Insurance Products In California

This paper examines recent trends in benefits and premiums for individual health insurance products purchased by Californians. There is much variability in the coverage available in the individual insurance market, with correspondingly wide variability in premiums. Despite concerns about increased consumer cost sharing, the average share of health spending covered by these products has remained constant between 1997 and 2002. Whether this trend can continue in the face of higher health costs is unclear.

Racial and ethnic differences in public and private medical care expenditures among aged Medicare beneficiaries

This study examines the current allocation of medical care expenditures among non-Hispanic white, non-Hispanic black, and Hispanic seniors who are Medicare beneficiaries. Analyses of both "need-based" and "demand-based" perspectives found that white, black, and Hispanic seniors in similar health had similar total annual expenditures for medical care. The groups did, however, differ substantially in the distribution of expenditures between public and private sources of payment. Notably, racial and ethnic differences in public and private expenditures all but vanished when socioeconomic variables and health insurance coverage were included in the analyses. The findings suggest that public sources of payment for medical care services, especially public supplementary coverage have helped to eliminate racial and ethnic gaps in expenditures.

Medicare calibration of the clinically detailed risk information system for cost

The clinically detailed risk information system for cost (CD-RISC) contains definitions for several hundred severity-adjusted conditions that can be used to predict future health care costs. We develop a prospective Medicare CD-RISC model using a 5-percent sample of Medicare beneficiaries and data that contain 1996 diagnostic information and 1997 annualized costs. The CD-RISC model has a hierarchical structure that implies that only the most expensive condition-severity variable within a body system affects payments. This minimizes incentives to game the system by entering multiple related codes for the same condition. The R2 for the CD-RISC model is 11 percent.