PMH15 Development of a Self-Administered Outcome Measure for use in an Outpatient Population of Individuals with Schizophrenia

Insurers' influence on patterns of care and disease management continues to be questioned in the U.S.
OBJECTIVE: To determine the effect managed care has on length of stay (LOS) and costs of inpatient management of schizophrenia in acute general hospitals.
METHODS: LOS and cost estimates were developed based on patient-level data from the 1996 Massachusetts discharge database. Analyses were limited to patients with a principal diagnosis of schizophrenia (based on ICD9 codes). Three populations were examined: an all payer group, a standard Medicaid coverage group, and those with a Medicaid-funded managed care plan (MMC). Unique patient identifiers enabled examination of annual admission frequency. All costs are reported in 1996 US$, adjusted appropriately for cost-to-charge ratios.
RESULTS: Of the 3,500 patients admitted for schizophrenia, 582 (17%) were covered by Medicaid and 419 (12%) by MMC. Overall, patients were admitted an average of 1.7 times in the year, with 67% having only one admission. The mean admission rate was 1.8 among Medicaid patients and 1.6 with MMC; a single admission occurred in 73% of the Medicaid group and 67% for MMC. The mean LOS was 14 days for the Medicaid group compared to 13.5 days for the all payer group and 12.3 days for those with MMC. Among those with only one admission, the differences increases: 16.4 days for the Medicaid group, 14.7 days for the all payer group, and 12.9 for the MMC group. Costs for this admission were correspondingly highest for standard Medicaid ($10,864) and lowest for MMC ($7,911).
CONCLUSION: The managed care approach decreases the length of stay and cost of inpatient management of schizophrenia. The appropriateness of these reductions remains unclear.     

DA7 Prospective, Naturalistic Outcomes Measurement: The Schizophrenia Care and Assessment Program (SCAP)

Traditional state Medicaid programs that adopt an open managed care model must adapt their oversight from a single drug formulary to multiple formularies. Following the workshop, participants should be able to identify and describe successful strategies for obtaining and analyzing data needed to evaluate appropriateness of multiple drug formularies. Practical experience with obtaining information and creating a database containing multiple formularies, procedures to incorporate analysis of drug therapy by disease sate, and different methods used to categorize drugs for evaluation will be presented. These will be demonstrated by comparing medications used for the treatment of peptic ulcer disease by Medicaid managed care formularies in the state of Tennessee. This workshop is intended for government and healthcare industry decision makers and others involved in quality control and improvement.     

Patterns of Medicaid eligibility: a sample of 408 Medi-Cal eligibles in San Francisco, California.

Medicaid expenditures per recipient have increased substantially in the past decade, even after controlling for medical care price inflation. In response to this Medicaid expenditure growth, various policies to encourage Medicaid enrollment in cost-effective health maintenance organizations (HMOs) are being considered, including guaranteed Medicaid eligibility for Medicaid eligibles enrolled in HMOs. This paper addresses several important questions about Medicaid eligibility that are essential to an analysis of guaranteed eligibility--the length of eligibility, turnover rates, and reasons individuals lose their Medicaid eligibility. We selected a stratified random sample of 408 eligibility case files for individuals eligible for Medicaid in San Francisco County during December 1977. Six aid categories are represented in this study: (1) Cash Grant AFDC; (2) Medically Needy Families; (3) Medically Needy Aged; (4) Medically Needy Disabled; (5) Medically indigent Adults; and (6) Medically indigent Children. We found that the majority of individuals remain eligible for Medicaid for long, uninterrupted spells, ranging from a median of 15 months (Medically Indigent Adults) to 40 months (Medically Needy Aged). A much smaller subset of eligible persons had relatively short spells and higher turnover; some of that turnover was due to failure to comply with income reporting requirements. We used data on length of eligibility to estimate the cost impact of 6 months' guaranteed eligibility (for months during which individuals would otherwise not have been eligible for Medicaid benefits). We also estimated the potential benefits (savings of HMOs relative to average fee-for-service expenditures) and the benefits of guaranteed eligibility appear to be greater than the costs.     

PCV18 The Impact of Acute Renal Failure on Cost in Elderly Patients with Congestive Heart Failure

Recent lipid therapy clinical trials confirm the treatment recommendations of the National Cholesterol Education Program (NCEP) and extend the proven benefits of primary and secondary prevention to women, elderly, and high risk patients with average cholesterol.
OBJECTIVE: The purpose of this study was to estimate and compare the size of the primary and secondary prevention population if lipid treatment recommendations were based on (1) the NCEP treatment guidelines and the baseline characteristics of (2) the primary prevention population in the West of Scotland Coronary Prevention Study (WOSCOPS) and the Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS), (3) the secondary prevention population in the Cholesterol and Recurrent Events (CARE) trial, and the Scandinavian Simvastatin Survival study (4S).
METHODS: Phase 1 data from the third National Health and Nutrition Examination Survey were used for analysis.
RESULTS: Following the current NCEP recommendations, 18.6 and 5.8 million adults would be candidates for primary prevention and secondary prevention intervention, respectively. If the treatment guidelines were based on the characteristics of the WOSCOPS or AFCAPS patients, the size of the primary prevention population would increase by 12.2 million to 30.8 million. Extending the recommendation based on the characteristics of the CARE or the 4S study patients would increase the secondary prevention population size by 2 million to 7.8 million.
CONCLUSION: Recent clinical trials suggest that more than 15% of U.S. adults would benefit from lipid-lowering therapy for primary and secondary prevention of heart disease. Cost-effectiveness evaluation of lipid-lowering strategies should be used as a guide to treatment decisions.     

A Cost Analysis of the Iowa Medicaid Primary Care Case Management Program

Objective. To determine the cost savings attributable to the implementation and expansion of a primary care case management (PCCM) program on Medicaid costs per member in Iowa from 1989 to 1997.
Data Sources. Medicaid administrative data from Iowa aggregated at the county level.
Study Design. Longitudinal analysis of costs per member per month, analyzed by category of medical expense using weighted least squares. We compared the actual costs with the expected costs (in the absence of the PCCM program) to estimate cost savings attributable to the PCCM program.
Principal Findings. We estimated that the PCCM program was associated with a savings of $66 million to the state of Iowa over the study period. Medicaid expenses were 3.8 percent less than what they would have been in the absence of the PCCM program. Effects of the PCCM program appeared to grow stronger over time. Use of the PCCM program was associated with increases in outpatient care and pharmaceutical expenses, but a decrease in hospital and physician expenses.
Conclusions. Use of a Medicaid PCCM program was associated with substantial aggregate cost savings over an 8-year period, and this effect became stronger over time. Cost reductions appear to have been mediated by substituting outpatient care for inpatient care.     

MHC5 The EuroQol in Parkinson''s Disease Research: Rated Current Health vs. Population-Derived Health State Preferences

The EuroQoL EQ-5D and MOS SF-36 are two generic quality of life measures that differ significantly in their design (the former being an index and the latter a profile). Both have been extensively used in evaluating interventions in acute disease. This study tested their comparative performance in a survey of patients with relapsing-remitting multiple sclerosis (MS).
METHODS: 309 patients with diagnosed relapsing-remitting MS were identified through the records of 5 specialist centers in North West England. Patients were contacted by telephone by a specialist MS nurse and asked to complete a set of questionnaires distributed by mail. The questionnaire booklet reproduced the English version of SF-36, together with the EQ-5D and a self completion form of the Barthel. Minimal additional background information was obtained from all respondents; 4 weeks following their completion of the initial booklet, a second identical booklet was sent to the first 200 initial respondents. Patients in this re-test sub-group were asked whether their health status had improved, deteriorated, or remained unchanged over the intervening period.
RESULTS: Of the 200 patients in the test/re-test subgroup, 144 (72%) replied on both occasions. Paired t-tests for the PCS, MCS, and general health perception scores on the SF-36 failed to generate comprehensive evidence of reliability. The weighted index form of the EQ-5D and the visual analogue scale self-ratings provided superior evidence of reliability. Standardized response means for both measures confirmed this general pattern.
CONCLUSION: EQ-5D performs satisfactorily as a generic measure of health-related quality of life in patients with MS.     

UT3 The EuroQoL EQ-5D: An Outcome Measure for use in Clinical and Economic Evaluation

The measurement of health outcomes is central to all evaluative studies. Clinical practice too is shaped by the need to monitor health status, and changes in health status. A prime requirement in most studies is the capacity to represent benefits (or disbenefits) in terms of a single, aggregate value. This property is typically absent from profile meausres that characterise health status in terms of separate dimension scores. EQ-5D is a generic measure that yields a single index value for health status based on self-reported problems on each of 5 dimensions-mobility, self care, usual activity, pain/discomfort, anxiety/depression. Utility weights for each of 245 health states are available. EQ-5D is one of a handful of measures recommended by the Washington Panel on Cost-Effectiveness. Elsewhere EQ-5D has received official sanction under the European Commission BIOMED programme and has been incorporated in the English National Health Survey. EQ-5D has rapidly been assimilated into clinical trials by many of the major pharmaceuticals. This workshop is designed to provide an overview of the development of EQ-5D, outlining the research proramme undertaken by the EuroQoL Group over the past 10 years; to report on its use in clinical and economic evaluation; and to detail its international take-up. It is expected that workshop attendees will be primarily researchers and analysts concerned with clinical and economic evaluation, particularly where international collaboration is involved. Thus far EQ-5D has been translated into more than 25 languages. Participation in the Workshop should provide sufficient exposure to enable all attendees to reach a balanced conclusion regarding the usefulness of EQ-5D.     

DA2 The Role of Patient Registries in Disease Management and Outcomes Research

Although observational studies are a relatively inexpensive and rapid alternative to randomized controlled trials, critics argue that observational studies lack internal validity. For example, indication bias may limit the reliability of outcomes data from observational studies on the cost or safety of alternative pharmacotherapy. The workshop will focus on the novel use of data on prior medications to document the extent of confounding by indication. Current research on use of anti-hypertensive and antianginal medications in a Medicaid population will be used to illustrate recommended methods for designing and conducting observational studies. Topics covered will include assessing and classifying the duration and classes of prior medication history, sequencing of risk factors and adjusting for severity of disease. The on-going controversy over the safety of calcium channel blockers will be examined in light of evidence on confounding by indication. The presenters' own research will be used to explore the evidentiary basis for current claims and counter claims as well as the weakness of data on the key intervening variable-exposure to the study drugs. The workshop material is aimed at researchers with hands-on experience using administrative databases as well as industry sponsors of outcome studies. The workshop addresses the themes of enhancing the usefulness of outcomes research for providers and insurers by strengthening current methods for identifying and eliminating systematic biases.     

PMH2 Assessment of Health-Related Quality of Life During Treatment of Opiate Dependence using the Short Form-36

In the U.S., acute general hospitals increasingly provide treatment for patients with schizophrenia.
OBJECTIVE: To estimate the average annual cost of inpatient schizophrenia care per patient in an acute general hospital setting.
METHODS: Using ICD9 codes to identify disease and procedure-level data in five state (CA, FL, MA, MD, NC) acute care, all payer, discharge databases, an average cost per admission was estimated and combined with the frequency of admission calculated from the MA database to derive a mean annual acute care inpatient cost. Physician costs were calculated by applying 1997 Medicare fees to a resource use profile derived from the databases and published treatment recommendations. All costs are reported in 1997 US$, appropriately adjusted for medical inflation and cost-to-charge ratios.
RESULTS: Of 7.5 millions discharges, 73,000 were identified as having been admitted primarily due to schizophrenia. The average length of stay was 13.5 days, with 90% of time spent in a designated psychiatric bed. Over 90% were discharged within one month, most (∼80%) to home without documentation of further services. The mean cost per stay (including physician fees) was $8,963. Most (68%) patients had only one admission, and 96% had less than five in one year, leading to annual hospitalization cost per schizophrenic patient of $13,854.
CONCLUSIONS: Of schizophrenic patients admitted to an acute general hospital, the majority are admitted only once per year, spend their stay in a designated psychiatric unit bed, and are discharged within two weeks. Although these patients may have subsequent admissions to another type of inpatient facility, the majority are not transferred to such a facility at the time of discharge.     

PMH12 Texas Medication Algorithm Project: Feasibility Study of Implementing Medication Algorithms in the Public Mental Health Sector

In an era of cost containment, psychiatric drug formularies often limit choice of first-line selective serotonin reuptake inhibitors (SSRI) in the treatment of depression.
OBJECTIVES: Most patients in this study belong to one of three managed care systems with varying drug formularies. The purpose of this study was to describe treatment events and utilization of services by patients with depression initially prescribed one of three SSRIs in a "treatment as usal" setting.
METHODS: Patients with major depression were identified in the organization database. Retrospective chart reviews determined patient demographics, frequency of adverse events, attrition rate, and utilization of services over a six-month period following initiation of therapy.
RESULTS: One-hundred forty charts were reviewed. SSRIs were equally prescribed. The mean age of patients was 39.5, (sd = 14.1). Approximately 38% were Hispanic. Approximately 41% had prior SSRI therapy. Prescribes tended to follow restricted formularies but showed no preference with an open formulary. Chi-square analyses revealed that among the SSRIs, there was no difference in attribution or in reports that patients had at least one adverse effect. On average, patients received 2.3 prescriber visits during the initial six months of therapy, with no significant difference by SSRI.
CONCLUSIONS: Preliminary evidence suggests no difference in the number of outpatient prescriber visits, attrition rates, or reports of at least one adverse effect among the three SSRIs. Further analysis wil examine frequency of patients who switched from initial SSRI to another antidepressant. The results of this study are limited by small sample size, non-randomization of patients, and data derived from documentation in medical records. Future research will prospectively measure symptomatology of depression, along with utilization of services and treatment events.     

Enrolling in Medicaid through the National School Lunch Program: outcome of a pilot project in California schools

California has several health insurance programs for children. However, the system for enrolling into these programs is complex and difficult to manage for many families. Express Lane Eligibility is designed to streamline the Medicaid (called Medi-Cal in California) enrollment process by linking it to the National School Lunch Program. If a child is eligible for free lunch and the parents consent, the program provides two months of presumptive eligibility for Medi-Cal and a simplified application process for continuation in Medi-Cal. For those who are ineligible, it provides a referral to other programs. An evaluation of Express Lane shows that while many children were presumptively enrolled, nearly half of the applicants were already enrolled in Medi-Cal. Many Express Enrolled children failed to complete the full Medi-Cal enrollment process. Few were referred to the State Children's Health Insurance Program or county programs. Express Lane is less useful as a broad screening strategy, but can be one of many tools that communities use to enroll children in health insurance.