J. Michael McWilliams, MD; Ellen Meara, PhD; Alan M. Zaslavsky, PhD; John Z. Ayanian, MD, MPP
JAMA. 2007;298(24):2886-2894.
Context Uninsured near-elderly adults, particularly thosewith cardiovascular disease or diabetes, experience worse healthoutcomes than insured adults. However, the health benefits ofproviding insurance coverage for uninsured adults have not beenclearly demonstrated.
Objective To assess the effect of acquiring Medicare coverageon the health of previously uninsured adults.
Design and Setting We conducted quasi-experimental analysesof longitudinal survey data from 1992 through 2004 from thenationally representative Health and Retirement Study. We comparedchanges in health trends reported by previously uninsured andinsured adults after they acquired Medicare coverage at age65 years.
Participants Five thousand six adults who were continuouslyinsured and 2227 adults who were persistently or intermittentlyuninsured from ages 55 to 64 years.
Main Outcome Measures Differential changes in self-reportedtrends after age 65 years in general health, change in generalhealth, mobility, agility, pain, depressive symptoms, and asummary measure of these 6 domains; and adverse cardiovascularoutcomes (all trend changes reported in health scores per year).
Results Compared with previously insured adults, previouslyuninsured adults reported significantly improved health trendsafter age 65 years for the summary measure (differential changein annual trend, +0.20; P = .002) and several componentmeasures. Relative to previously insured adults with cardiovasculardisease or diabetes, previously uninsured adults with theseconditions reported significantly improved trends in summaryhealth (differential change in annual trend, +0.26; P = .006),change in general health (+0.02; P = .03), mobility(+0.04; P = .05), agility (+0.08; P = .003),and adverse cardiovascular outcomes (–0.015; P = .02)but not in depressive symptoms (+0.04; P = .32). Previouslyuninsured adults without these conditions reported differentialimprovement in depressive symptoms (+0.08; P = .002)but not in summary health (+0.10; P = .17) or anyother measure. By age 70 years, the expected difference in summaryhealth between previously uninsured and insured adults withcardiovascular disease or diabetes was reduced by 50%.
Conclusion In this study, acquisition of Medicare coveragewas associated with improved trends in self-reported healthfor previously uninsured adults, particularly those with cardiovasculardisease or diabetes.
Ongoing efforts to increase colorectal cancer (CRC) screening rates have raised concerns that these exams may be overused, thereby subjecting patients to unnecessary risks and wasting healthcare resources.
OBJECTIVE
Our aim was to measure overuse of screening and surveillance colonoscopies among average-risk adults, and to identify correlates of overuse.
DESIGN, SETTING, AND PARTICIPANTS
Our approach was a retrospective cohort study using electronic health record data for patients 50–65 years old with no personal history of CRC or colorectal adenomas with an incident CRC screening colonoscopy from 2001 to 2010 within a multispecialty physician group practice.
MAIN OUTCOME MEASURES
We measured time to next screening or surveillance colonoscopy and predictors of overuse (exam performed more than one year earlier than guideline recommended intervals) of colonoscopies.
KEY RESULTS
We identified 1,429 adults who had an incident colonoscopy between 2001 and 2010, and they underwent an additional 871 screening or surveillance colonoscopies during a median follow-up of 6 years. Most follow-up screening colonoscopies (88 %) and many surveillance colonoscopies (49 %) repeated during the study represented overuse. Time to next colonoscopy after incident screening varied by exam findings (no polyp: median 6.9 years, interquartile range [IQR]: 5.1–10.0; hyperplastic polyp: 5.7 years, IQR: 4.9–9.7; low-risk adenoma: 5.1 years, IQR: 3.3–6.3; high-risk adenoma: 2.9 years, IQR: 2.0–3.4, p < 0.001). In logistic regression models of colonoscopy overuse, an endoscopist recommendation for early follow-up was strongly associated with overuse of screening colonoscopy (OR 6.27, 95 % CI: 3.15–12.50) and surveillance colonoscopy (OR 13.47, 95 % CI 6.61-27.46). In a multilevel logistic regression model, variation in the overuse of screening colonoscopy was significantly associated with the endoscopist performing the previous exam.
CONCLUSIONS
Overuse of screening and surveillance exams are common and should be monitored by healthcare systems. Variations in endoscopist recommendations represent targets for interventions to reduce overuse.KEY WORDS: colorectal cancer screening, colonoscopy, overuse, efficiency相似文献
The objective of this study was to determine how patient preferences guide the course of palliative chemotherapy for advanced colorectal cancer.
METHODS:
Eligible patients with metastatic colorectal cancer (mCRC) were enrolled nationwide in a prospective, population‐based cohort study. Data were obtained through medical record abstraction and patient surveys. Logistic regression analysis was used to evaluate patient characteristics associated with visiting medical oncology and receiving chemotherapy and patient characteristics, beliefs, and preferences associated with receiving >1 line of chemotherapy and receiving combination chemotherapy.
RESULTS:
Among 702 patients with mCRC, 91% consulted a medical oncologist; and among those, 82% received chemotherapy. Patients ages 65 to 75 years and aged ≥75 years were less likely to visit an oncologist, as were patients who were too sick to complete their own survey. In adjusted analyses, patients aged ≥75 years who had moderate or severe comorbidity were less likely to receive chemotherapy, as were patients who were too sick to complete their own survey. Patients received chemotherapy even if they believed that chemotherapy would not extend their life (90%) or that chemotherapy would not likely help with cancer‐related problems (89%), or patients preferred treatment focusing on comfort even if it meant not living as long (90%). Older patients were less likely to receive combination first‐line therapy. Patient preferences and beliefs were not associated with receipt of >1 line of chemotherapy or combination chemotherapy.
PURPOSE: Prior studies have documented variation in breast cancer treatment and care that does not follow guideline recommendations, particularly for elderly women. We assessed whether consultation with a medical oncologist before surgery was associated with use of definitive surgery, axillary node dissection, and type of surgery. METHODS: We conducted a retrospective cohort study of a population-based sample of 9,630 women aged > or = 66 years diagnosed with breast cancer during 1995 to 1996. We measured the adjusted proportion visiting a medical oncologist before surgery, identified factors associated with such visits, and assessed the association between visits with a medical oncologist and use of definitive surgery (mastectomy or breast-conserving surgery with radiation v breast-conserving surgery without radiation); axillary dissection; and breast-conserving surgery versus mastectomy among women undergoing definitive surgery. RESULTS: Nineteen percent of women visited a medical oncologist before surgery; these women were younger, more often had larger or more poorly differentiated cancers, had more comorbid illnesses, and were treated more often at a teaching hospital (all P <.05). Women who saw a medical oncologist before surgery were more likely than others to undergo definitive surgery (adjusted odds ratio [OR], 1.28; 95% CI, 1.05 to 1.56) and axillary dissection (adjusted OR, 1.44; 95% CI, 1.19 to 1.73), but less likely to undergo breast-conserving surgery among women undergoing definitive surgery (OR, 0.84; 95% CI, 0.75 to 0.95). CONCLUSION: Elderly women who consulted with a medical oncologist before surgery were more likely to receive guideline-recommended care. Additional research is needed allow a better understanding of the quality and content of discussions that elderly women have with various providers about breast-conserving surgery and mastectomy. 相似文献
