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1.
Ngaire Kerse Chris McLean Simon A. Moyes Kathy Peri Terence Ng Laura Wilkinson-Meyers Paul Brown Nancy Latham Martin Connolly 《Annals of family medicine》2014,12(6):514-524
PURPOSE
People are now living longer, but disability may affect the quality of those additional years of life. We undertook a trial to assess whether case finding reduces disability among older primary care patients.METHODS
We conducted a cluster-randomized trial of the Brief Risk Identification Geriatric Health Tool (BRIGHT) among 60 primary care practices in New Zealand, assigning them to an intervention or control group. Intervention practices sent a BRIGHT screening tool to older adults every birthday; those with a score of 3 or higher were referred to regional geriatric services for assessment and, if needed, service provision. Control practices provided usual care. Main outcomes, assessed in blinded fashion, were residential care placement and hospitalization, and secondary outcomes were disability, assessed with Nottingham Extended Activities of Daily Living Scale (NEADL), and quality of life, assessed with the World Health Organization Quality of Life scale, abbreviated version (WHOQOL-BREF).RESULTS
All 8,308 community-dwelling patients aged 75 years and older were approached; 3,893 (47%) participated, of whom 3,010 (77%) completed the trial. Their mean age was 80.3 (SD 4.5) years, and 55% were women. Overall, 88% of the intervention group returned a BRIGHT tool; 549 patients were referred. After 36 months, patients in the intervention group were more likely than those in the control group to have been placed in residential care: 8.4% vs 6.2% (hazard ratio = 1.32; 95% CI, 1.04–1.68; P = .02). Intervention patients had smaller declines in mean scores for physical health-related quality of life (1.6 vs 2.9 points, P = .007) and psychological health-related quality of life (1.1 vs 2.4 points, P = .005). Hospitalization, disability, and use of services did not differ between groups, however.CONCLUSIONS
Our case-finding strategy was effective in increasing identification of older adults with disability, but there was little evidence of improved outcomes. Further research could trial stronger primary care integration strategies. 相似文献2.
PURPOSE
Depression commonly accompanies diabetes, resulting in reduced adherence to medications and increased risk for morbidity and mortality. The objective of this study was to examine whether a simple, brief integrated approach to depression and type 2 diabetes mellitus (type 2 diabetes) treatment improved adherence to oral hypoglycemic agents and antidepressant medications, glycemic control, and depression among primary care patients.METHODS
We undertook a randomized controlled trial conducted from April 2010 through April 2011 of 180 patients prescribed pharmacotherapy for type 2 diabetes and depression in primary care. Patients were randomly assigned to an integrated care intervention or usual care. Integrated care managers collaborated with physicians to offer education and guideline-based treatment recommendations and to monitor adherence and clinical status. Adherence was assessed using the Medication Event Monitoring System (MEMS). We used glycated hemoglobin (HbA1c) assays to measure glycemic control and the 9-item Patient Health Questionnaire (PHQ-9) to assess depression.RESULTS
Intervention and usual care groups did not differ statistically on baseline measures. Patients who received the intervention were more likely to achieve HbA1c levels of less than 7% (intervention 60.9% vs usual care 35.7%; P <.001) and remission of depression (PHQ-9 score of less than 5: intervention 58.7% vs usual care 30.7%; P <.001) in comparison with patients in the usual care group at 12 weeks.CONCLUSIONS
A randomized controlled trial of a simple, brief intervention integrating treatment of type 2 diabetes and depression was successful in improving outcomes in primary care. An integrated approach to depression and type 2 diabetes treatment may facilitate its deployment in real-world practices with competing demands for limited resources. 相似文献3.
Wells KB Tang L Miranda J Benjamin B Duan N Sherbourne CD 《Health services research》2008,43(6):1952-1974
Objective
To examine 9-year outcomes of implementation of short-term quality improvement (QI) programs for depression in primary care.Data Sources
Depressed primary care patients from six U.S. health care organizations.Study Design
Group-level, randomized controlled trial.Data Collection
Patients were randomly assigned to short-term QI programs supporting education and resources for medication management (QI-Meds) or access to evidence-based psychotherapy (QI-Therapy); and usual care (UC). Of 1,088 eligible patients, 805 (74 percent) completed 9-year follow-up; results were extrapolated to 1,269 initially enrolled and living. Outcomes were psychological well-being (Mental Health Inventory, five-item version [MHI5]), unmet need, services use, and intermediate outcomes.Principal Findings
At 9 years, there were no overall intervention status effects on MHI5 or unmet need (largest F (2,41)=2.34, p=.11), but relative to UC, QI-Meds worsened MHI5, reduced effectiveness of coping and among whites lowered tangible social support (smallest t(42)=2.02, p=.05). The interventions reduced outpatient visits and increased perceived barriers to care among whites, but reduced attitudinal barriers due to racial discrimination and other factors among minorities (smallest F (2,41)=3.89, p=.03).Conclusions
Main intervention effects were over but the results suggest some unintended negative consequences at 9 years particularly for the medication-resource intervention and shifts to greater perceived barriers among whites yet reduced attitudinal barriers among minorities. 相似文献4.
Leonie Heyworth Ronen Rozenblum James F. Burgess Jr Errol Baker Mark Meterko Debra Prescott Zeev Neuwirth Steven R. Simon 《Annals of family medicine》2014,12(4):324-330
PURPOSE
Shared medical appointments (SMAs) are becoming popular, but little is known about their association with patient experience in primary care. We performed an exploratory analysis examining overall satisfaction and patient-centered care experiences across key domains of the patient-centered medical home among patients attending SMAs vs usual care appointments.METHODS
We undertook a cross-sectional study using a mailed questionnaire measuring levels of patient satisfaction and other indicators of patient-centered care among 921 SMA and 921 usual care patients between 2008 and 2010. Propensity scores adjusted for potential case mix differences between the groups. Multivariate logistic regression assessed propensity-matched patients’ ratings of care. Generalized estimating equations accounted for physician-level clustering.RESULTS
A total of 40% of SMA patients and 31% of usual care patients responded. In adjusted analyses, SMA patients were more likely to rate their overall satisfaction with care as “very good” when compared with usual care counterparts (odds ratio = 1.26; 95% CI, 1.05–1.52). In the analysis of patient-centered medical home elements, SMA patients rated their care as more accessible and more sensitive to their needs, whereas usual care patients reported greater satisfaction with physician communication and time spent during their appointment.CONCLUSIONS
Overall, SMA patients appear more satisfied with their care relative to patients receiving usual care. SMAs may also improve access to care and deliver care that patients find to be sensitive to their needs. Further research should focus on enhancing patient-clinician communication within an SMA as this model of care becomes more widely adopted. 相似文献5.
David H. Thom Amireh Ghorob Danielle Hessler Diana De Vore Ellen Chen Thomas A. Bodenheimer 《Annals of family medicine》2013,11(2):137-144
PURPOSE
Peer health coaches offer a potential model for extending the capacity of primary care practices to provide self-management support for patients with diabetes. We conducted a randomized controlled trial to test whether clinic-based peer health coaching, compared with usual care, improves glycemic control for low-income patients who have poorly controlled diabetes.METHOD
We undertook a randomized controlled trial enrolling patients from 6 public health clinics in San Francisco. Twenty-three patients with a glycated hemoglobin (HbA1C) level of less than 8.5%, who completed a 36-hour health coach training class, acted as peer coaches. Patients from the same clinics with HbA1C levels of 8.0% or more were recruited and randomized to receive health coaching (n = 148) or usual care (n = 151). The primary outcome was the difference in change in HbA1C levels at 6 months. Secondary outcomes were proportion of patients with a decrease in HbA1C level of 1.0% or more and proportion of patients with an HbA1C level of less than 7.5% at 6 months. Data were analyzed using a linear mixed model with and without adjustment for differences in baseline variables.RESULTS
At 6 months, HbA1C levels had decreased by 1.07% in the coached group and 0.3% in the usual care group, a difference of 0.77% in favor of coaching (P = .01, adjusted). HbA1C levels decreased 1.0% or more in 49.6% of coached patients vs 31.5% of usual care patients (P = .001, adjusted), and levels at 6 months were less than 7.5% for 22.0% of coached vs 14.9% of usual care patients (P = .04, adjusted).CONCLUSIONS
Peer health coaching significantly improved diabetes control in this group of low-income primary care patients.Key words: peer coach, diabetes mellitus type 2, self care, primary health care, self-management support 相似文献6.
Kouri EM Landrum MB Lamont EB Bozeman S McNeil BJ Keating NL 《Health services research》2012,47(2):783-793
Objective
Many veterans undergo cancer surgery outside of the Veterans Health Administration (VHA). We assessed to what extent these patients obtained care in the VHA before surgery.Data Sources
VHA-Medicare data, VHA administrative data, and Veterans Affairs Central Cancer Registry data.Study Design
We identified patients aged ≥65 years in the VHA-Medicare cohort who underwent lung or colon cancer resection outside the VHA and assessed VHA visits in the year before surgery.Principal Findings
Over 60% of patients in the VHA-Medicare cohort who received lung or colon cancer surgeries outside the VHA did not receive any care in VHA before surgery.Conclusions
Veterans’ receipt of major cancer surgery outside the VHA probably reflects usual private sector care among veterans who are infrequent VHA users. 相似文献7.
Higher Medicare SNF Care Utilization by Dual-Eligible Beneficiaries:
Can Medicaid Long-Term Care Policies Be the Answer?
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Momotazur Rahman Ph.D. Denise Tyler Ph.D. Kali S. Thomas Ph.D. David C. Grabowski Ph.D. Vincent Mor Ph.D. 《Health services research》2015,50(1):161-179
Objective
To examine outcomes associated with dual eligibility (Medicare and Medicaid) of patients who are admitted to skilled nursing facility (SNF) care and whether differences in outcomes are related to states'' Medicaid long-term care policies.Data Sources/Collection
We used national Medicare enrollment data and claims, and the Minimum Data Set for 890,922 community-residing Medicare fee-for-service beneficiaries who were discharged to an SNF from a general hospital between July 2008 and June 2009.Study Design
We estimated the effect of dual eligibility on the likelihood of 30-day rehospitalization, becoming a long-stay nursing home resident, and 180-day survival while controlling for clinical, demographic, socio-economic, residential neighborhood characteristics, and SNF-fixed effects. We estimated the differences in outcomes by dual eligibility status separately for each state and showed their relationship with state policies: the average Medicaid payment rate; presence of nursing home certificate-of-need (CON) laws; and Medicaid home and community-based services (HCBS) spending.Principal Findings
Dual-eligible patients are equally likely to experience 30-day rehospitalization, 12 percentage points more likely to become long-stay residents, and 2 percentage points more likely to survive 180 days compared to Medicare-only patients. This longer survival can be attributed to longer nursing home length of stay. While higher HCBS spending reduces the length-of-stay gap without affecting the survival gap, presence of CON laws reduces both the length-of-stay and survival gaps.Conclusions
Dual eligibles utilize more SNF care and experience higher survival rates than comparable Medicare-only patients. Higher HCBS spending may reduce the longer SNF length of stay of dual eligibles without increasing mortality and may save money for both Medicare and Medicaid. 相似文献8.
Allen J. Dietrich Jonathan N. Tobin Christina M. Robinson Andrea Cassells Mary Ann Greene Van H. Dunn Kimberly M. Falkenstern Rosanna De Leon Michael L. Beach 《Annals of family medicine》2013,11(4):335-343
PURPOSE
Health Plans are uniquely positioned to deliver outreach to members. We explored whether telephone outreach, delivered by Medicaid managed care organization (MMCO) staff, could increase colorectal cancer (CRC) screening among publicly insured urban women, potentially reducing disparities.METHODS
We conducted an 18-month randomized clinical trial in 3 MMCOs in New York City in 2008–2010, randomizing 2,240 MMCO-insured women, aged 50 to 63 years, who received care at a participating practice and were overdue for CRC screening. MMCO outreach staff provided cancer screening telephone support, educating patients and helping overcome barriers. The primary outcome was the number of women screened for CRC during the 18-month intervention, assessed using claims.RESULTS
MMCO staff reached 60% of women in the intervention arm by telephone. Although significantly more women in the intervention (36.7%) than in the usual care (30.6%) arm received CRC screening (odds ratio [OR] = 1.32; 95% CI, 1.08–1.62), increases varied from 1.1% to 13.7% across the participating MMCOs, and the overall increase was driven by increases at 1 MMCO. In an as-treated comparison, 41.8% of women in the intervention arm who were reached by telephone received CRC screening compared with 26.8% of women in the usual care arm who were not contacted during the study (OR = 1.84; 95% CI, 1.38, 2.44); 7 women needed to be reached by telephone for 1 to become screened.CONCLUSIONS
The telephone outreach intervention delivered by MMCO staff increased CRC screening by 6% more than usual care among randomized women, and by 15.1% more than usual care among previously overdue women reached by the intervention. Our research-based intervention was successfully translated to the health plan arena, with variable effects in the participating MMCOs. 相似文献9.
Momotazur Rahman David C. Grabowski Orna Intrator Shubing Cai Vincent Mor 《Health services research》2013,48(4):1279-1298
Objective
To estimate the effect of a nursing home''s share of residents with a serious mental illness (SMI) on the quality of care.Data Sources
Secondary nursing home level data over the period 2000 through 2008 obtained from the Minimum Data Set, OSCAR, and Medicare claims.Study Design
We employ an instrumental variables approach to address the potential endogeneity of the share of SMI residents in nursing homes in a model including nursing home and year fixed effects.Principal Findings
An increase in the share of SMI nursing home residents positively affected the hospitalization rate among non-SMI residents and negatively affected staffing skill mix and level. We did not observe a statistically significant effect on inspection-based health deficiencies or the hospitalization rate for SMI residents.Conclusions
Across the majority of indicators, a greater SMI share resulted in lower nursing home quality. Given the increased prevalence of nursing home residents with SMI, policy makers and providers will need to adjust practices in the context of this new patient population. Reforms may include more stringent preadmission screening, new regulations, reimbursement changes, and increased reporting and oversight. 相似文献10.
Shanthi Mendis S Claiborne Johnston Wu Fan Olulola Oladapo Ali Cameron Mohammed F Faramawi 《Bulletin of the World Health Organization》2010,88(6):412-419
Objective
To evaluate a simple cardiovascular risk management package for assessing and managing cardiovascular risk using hypertension as an entry point in primary care facilities in low-resource settings.Methods
Two geographically distant regions in two countries (China and Nigeria) were selected and 10 pairs of primary care facilities in each region were randomly selected and matched. Regions were then randomly assigned to a control group, which received usual care, or to an intervention group, which applied the cardiovascular risk management package. Each facility enrolled 60 consecutive patients with hypertension. Intervention sites educated patients about risk factors at baseline and initiated treatment with hydrochlorothiazide at 4 months in patients at medium risk of a cardiovascular event, according to a standardized treatment algorithm. Systolic blood pressure change from baseline to 12 months was the primary outcome measure.Findings
The study included 2397 patients with baseline hypertension: 1191 in 20 intervention facilities and 1206 in 20 control facilities. Systolic and diastolic blood pressure decreased more in intervention patients than in controls. However, at 12 months more than half of patients still had uncontrolled hypertension (systolic blood pressure > 140 mmHg and/or diastolic blood pressure > 90 mmHg). Behavioural risk factors had improved among intervention patients in Nigeria but not in China. Only about 2% of hypertensive patients required referral to the next level of care.Conclusion
Even in low-resource settings, hypertensive patients can be effectively assessed and managed in primary care facilities. 相似文献11.
Jeph Herrin Ph.D. Justin St. Andre M.A. Kevin Kenward Ph.D. Maulik S. Joshi Dr.P.H. Anne‐Marie J. Audet M.D. M.Sc. Stephen C. Hines Ph.D. 《Health services research》2015,50(1):20-39
Objective
To examine the relationship between community factors and hospital readmission rates.Data Sources/Study Setting
We examined all hospitals with publicly reported 30-day readmission rates for patients discharged during July 1, 2007, to June 30, 2010, with acute myocardial infarction (AMI), heart failure (HF), or pneumonia (PN). We linked these to publicly available county data from the Area Resource File, the Census, Nursing Home Compare, and the Neilsen PopFacts datasets.Study Design
We used hierarchical linear models to assess the effect of county demographic, access to care, and nursing home quality characteristics on the pooled 30-day risk-standardized readmission rate.Data Collection/Extraction Methods
Not applicable.Principal Findings
The study sample included 4,073 hospitals. Fifty-eight percent of national variation in hospital readmission rates was explained by the county in which the hospital was located. In multivariable analysis, a number of county characteristics were found to be independently associated with higher readmission rates, the strongest associations being for measures of access to care. These county characteristics explained almost half of the total variation across counties.Conclusions
Community factors, as measured by county characteristics, explain a substantial amount of variation in hospital readmission rates. 相似文献12.
Paul Bray Doyle M. Cummings Susan Morrissey Debra Thompson Don Holbert Kyle Wilson Eric Lukosius Robert Tanenberg 《Annals of family medicine》2013,11(2):145-150
PURPOSE
Rural low-income African American patients with diabetes have traditionally poorer clinical outcomes and limited access to state-of-the-art diabetes care. We determined the effectiveness of a redesigned primary care model on patients’ glycemic, blood pressure, and lipid level control.METHODS
In 3 purposively selected, rural, fee-for-service, primary care practices, African American patients with type 2 diabetes received point-of-care education, coaching, and medication intensification from a diabetes care management team made up of a nurse, pharmacist, and dietitian. In 5 randomly selected control practices matched for practice and patient characteristics, African American patients received usual care. Using univariate and multivariate adjusted models, we evaluated the effects of the intervention on intermediate (median 18 months) and long-term (median 36 months) changes in glycated hemoglobin (hemoglobin A1c) levels, blood pressure, and lipid levels, as well as the proportion of patients meeting target values.RESULTS
Among 727 randomly selected rural African American diabetic patients (368 intervention, 359 control), intervention patients had a significantly greater reduction in mean hemoglobin A1c levels at intermediate (−0.5 % vs −0.2%; P <.05) and long-term (−0.5% vs −0.10%; P <.005) follow-up in univariate and multivariate models. The proportion of patients achieving a hemoglobin A1c level of less than 7.5% (68% vs 59%, P <.01) and/or a systolic blood pressure of less than 140 mm Hg (69% vs 57%, P <.01) was also significantly greater in intervention practices in multivariate models.CONCLUSION
Redesigning care strategies in rural fee-for-service primary care practices for African American patients with established diabetes results in significantly improved glycemic control relative to usual care.Key words: diabetes, improved outcomes, African Americans, delivery redesign, rural, patient-centered medical homes 相似文献13.
Effects of the Ten Percent Cap in Medicare Home Health Care on Treatment Intensity and Patient Discharge Status
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Objective
To estimate the effect of the 10 percent cap introduced to Medicare home health care on treatment intensity and patient discharge status.Data Sources
Medicare Denominator, Medicare Home Health Claims, and Medicare Provider of Services Files from 2008 through 2010.Study Design
We used agency-level variation in the proportion of outlier payments prior to the implementation of the 10 percent cap to identify how home health agencies adjusted the number of home health visits and patient discharge status under the new law.Principal Findings
Under the 10 percent cap, agencies dramatically decreased the number of service visits. Agencies also dropped relatively healthy patients and sent sicker patients to nursing homes.Conclusions
The drastic reduction in the number of service visits and discontinuation of relatively healthy patients from home health care suggest that the 10 percent cap improved the efficiency of home health services as intended. However, the 10 percent cap increased other types of health care expenditures by pushing sicker patients to use more expensive health services. 相似文献14.
Kenneth J. Smith Cindy L. Bryce Heather E. Hsu Mark S. Roberts M. Kaye Kramer Trevor J. Orchard Gretchen A. Piatt Miriam C. Seidel Janice C. Zgibor 《Preventing chronic disease》2010,7(5)
Introduction
We assessed the cost-effectiveness of a community-based, modified Diabetes Prevention Program (DPP) designed to reduce risk factors for type 2 diabetes and cardiovascular disease.Methods
We developed a Markov decision model to compare costs and effectiveness of a modified DPP intervention with usual care during a 3-year period. Input parameters included costs and outcomes from 2 projects that implemented a community-based modified DPP for participants with metabolic syndrome, and from other sources. The model discounted future costs and benefits by 3% annually.Results
At 12 months, usual care reduced relative risk of metabolic syndrome by 12.1%. A modified DPP intervention reduced relative risk by 16.2% and yielded life expectancy gains of 0.01 quality-adjusted life-years (3.67 days) at an incremental cost of $34.50 ($3,420 per quality-adjusted life-year gained). In 1-way sensitivity analyses, results were sensitive to probabilities that risk factors would be reduced with or without a modified DPP and that patients would enroll in an intervention, undergo testing, and acquire diabetes with or without an intervention if they were risk-factor–positive. Results were also sensitive to utilities for risk-factor–positive patients. In probabilistic sensitivity analysis, the intervention cost less than $20,000 per quality-adjusted life-year gained in approximately 78% of model iterations.Conclusion
We consider the modified DPP delivered in community and primary care settings a sound investment. 相似文献15.
Arash Rashidian Hossein Joudaki Elham Khodayari-Moez Habib Omranikhoo Bijan Geraili Mohamad Arab 《Bulletin of the World Health Organization》2013,91(12):942-949
Objective
To assess the effects on hospital utilization rates of a major health system reform – a family physician programme and a social protection scheme – undertaken in rural areas of the Islamic Republic of Iran in 2005.Methods
A “tracer” province that was not a patient referral hub was selected for the collection of monthly hospitalization data over a period of about 10 years, beginning two years before the rural health system reform (the “intervention”) began. An interrupted time series analysis was conducted and segmented regression analysis was used to assess the immediate and gradual effects of the intervention on hospitalization rates in an intervention group composed of rural residents and a comparison group composed of urban residents primarily.Findings
Before the intervention, the hospitalization rate in the rural population was significantly lower than in the comparison group. Although there was no significant increase or decline in hospitalization rates in the intervention or comparison group before the intervention, after the intervention a significant increase in the hospitalization rate – of 4.6 hospitalizations per 100 000 insured persons per month on average – was noted in the intervention group (P < 0.001). The monthly increase in the hospitalization rate continued for over a year and stabilized thereafter. No increase in the hospitalization rate was observed in the comparison group.Conclusion
The primary health-care programme instituted as part of the health system reform process has increased access to hospital care in a population that formerly underutilized hospital services. It has not reduced hospitalizations or hospitalization-related expenditure. 相似文献16.
PURPOSE
Research demonstrates an association between the geographic concentration of primary care clinicians and mortality in the area, but there is limited evidence of a mortality benefit of primary care at the individual patient level. We examined whether patient-reported access to selected primary care attributes, including some emphasized in the medical home literature, is associated with lower individual mortality risk.METHODS
We analyzed data from 2000–2005 Medical Expenditure Panel Survey respondents aged 18 to 90 years (N = 52,241), linked to the National Death Index through 2006. A score was constructed from 5 yes/no items assessing whether the respondent’s usual source of care had 3 attributes: comprehensiveness, patient-centeredness, and enhanced access. Scores ranged from 0 to 1 (higher scores = more attributes). We examined the association between the primary care attributes score and mortality during up to 6 years of follow-up using Cox survival analysis, adjusted for social, demographic, and health-related characteristics.RESULTS
Racial/ethnic minorities, poorer and less educated persons, individuals without private insurance, healthier persons, and residents of regions other than the Northeast reported less access to primary care attributes than others. The primary care attributes score was inversely associated with mortality (adjusted hazard ratio = 0.79; 95% confidence interval, 0.64–0.98; P = .03); supplementary analyses showed mortality decreased linearly with increasing score.CONCLUSIONS
Greater reported patient access to selected primary care attributes was associated with lower mortality. The findings support the current interest in ensuring that patients have access to a medical home encompassing these attributes. 相似文献17.
Rachel M. Werner M.D. Ph.D. Anne Canamucio M.S. Judy A. Shea Ph.D Gala True Ph.D. 《Health services research》2014,49(4):1329-1347
Objective
To evaluate the effect of medical home implementation on primary care delivery in the Veterans Health Administration (VHA).Data Sources/Study Setting/Study Design
We link interview-based qualitative data on medical home implementation to quantitative outcomes from VHA clinical encounter data. We use a longitudinal analysis with provider fixed effects (taking advantage of variation in timing of implementation and allowing each provider to serve as a control for him or herself) to test whether patient-aligned care team (PACT) implementation was associated with changes in organizational processes and patient outcomes.Principal Findings
Among 683 PCPs, caring for 321,295 patients, the uptake of eight of nine PACT structural changes significantly increased from July 2010 to June 2012 as did the percentage of primary care appointments occurring by telephone and hospital discharges contacted within 2 days of discharge. We found that PACT implementation was associated with significant improvements in 2-day post-hospital discharge contact, but not primary care visits occurring by telephone or within 3 days of the requested date. We found no association between medical home implementation and rates of emergency department use by patients.Conclusions
Medical home implementation at the VHA resulted in large changes in the structure of care but few changes in patient-level outcomes. These results highlight both the complexity of studying the effect of the medical home as well as implementing this model to change primary care delivery. 相似文献18.
Etsuji Okamoto 《Journal of epidemiology / Japan Epidemiological Association》2013,23(4):262-269
Background
Evidence is lacking on whether health guidance for metabolic syndrome reduces health care expenditures. The author used propensity-score matching to evaluate the effects of health guidance on health care expenditure.Methods
Men who did and did not receive health guidance from a health insurance society (approximately 60 000 covered lives) were matched (n = 397 respectively) using propensity scores. Health insurance claims were compared using cumulative health care expenditures for metabolic syndrome-related outpatient medical care and drug costs for the period from the initial consultation to 3 years later.Results
No difference was observed between intervention and control groups in cumulative outpatient charges or drug costs related to metabolic syndrome. However, regression analysis using the Tobit model showed that health guidance resulted in a small, nonsignificant reduction in health care expenditure.Conclusions
Health guidance for metabolic syndrome did not reduce outpatient charges or drug costs related to metabolic syndrome during the 3-year period after the intervention. Findings from Tobit regression suggest that health guidance might eventually result in savings, but this hypothesis remains untested.Key words: health guidance, health insurance claims, propensity-score matching, PDM (proportional distribution method), metabolic syndrome 相似文献19.
Mark Aaron Unruh Ph.D. David C. Grabowski Ph.D. Amal N. Trivedi M.D. M.P.H. Vincent Mor Ph.D. 《Health services research》2013,48(5):1617-1633
Objective
To evaluate the effect of Medicaid bed-hold policies on hospitalization of long-stay nursing home residents.Data Sources
A nationwide random sample of long-stay nursing home residents with data elements from Medicare claims and enrollment files, the Minimum Data Set, the Online Survey Certification and Reporting System, and Area Resource File. The sample consisted of 22,200,089 person-quarters from 754,592 individuals who became long-stay residents in 17,149 nursing homes over the period beginning January 1, 2000 through December 31, 2005.Study Design
Linear regression models using a pre/post design adjusted for resident, nursing home, market, and state characteristics. Nursing home and year-quarter fixed effects were included to control for time-invariant facility influences and temporal trends associated with hospitalization of long-stay residents.Principal Findings
Adoption of a Medicaid bed-hold policy was associated with an absolute increase of 0.493 percentage points (95% CI: 0.039–0.946) in hospitalizations of long-stay nursing home residents, representing a 3.883 percent relative increase over the baseline mean.Conclusions
Medicaid bed-hold policies may increase the likelihood of hospitalization of long-stay nursing home residents and increase costs for the federal Medicare program. 相似文献20.
Stephen M. Shortell Ph.D. M.P.H. M.B.A. Sean R. McClellan Ph.D. Patricia P. Ramsay M.P.H. Lawrence P. Casalino M.D. Ph.D. Andrew M. Ryan Ph.D. M.A. Kennon R. Copeland Ph.D. M.S. 《Health services research》2014,49(5):1519-1536