Personal Care Costs Research Articles

A RISK CLASSIFICATION SYSTEM FOR ELDERLY FALLS USING SUPPORT VECTOR MACHINE

Falls are a multi-factor problem that poses a serious risk to the elderly. Approximately, 60% of falls are caused by a number of known factors, including the environment, which accounts for approximately 25–45% of falling risk. Most of the remainder results from a lack of personal balance control. Falling can cause long-term disabilities in the elderly, sometimes resulting in lower quality of life, and is also associated with increased medical expenses and personal care costs. In this study, we developed a falling assessment system to evaluate and classify individuals into four graded falling risk groups. During the test, all subjects were required to wear a self-developed dynamic measurement system and to perform two balance tests: a “Timed Up and Go Test” and a “30-Second Chair Stand Test.” We obtained 29 characteristic parameters from the data recorded during these tests. Next, we performed group classification. Eigenvalues were normalized, and a principal component analysis (PCA) was performed. After identifying informative characteristic parameters, support vector machine (SVM) was used to classify individuals as members of one of the four falling risk groups. These included low-, moderate-, high-, and extreme-risk groups. Using unreduced data of the 29 characteristic parameters extracted from the two balance tests, the accuracy of the SVM classification in allocating individuals to the correct group was 97.5%. After PCA, the 29 characteristic parameters were reduced to eight principal components, and the SVM classification method using these eight principal components was 93.25%.

Living with severe multiple sclerosis: Cost-effectiveness of a palliative care intervention and cost of illness study

BackgroundLittle is known about the economic consequences of living with severe multiple sclerosis (SMS). AimsTo assess the cost-effectiveness of a home-based palliative approach (HPA) for people with SMS (pwSMS). To assess direct healthcare costs in this population. MethodsPwSMS from three Italian centers received (2:1 ratio) HPA or usual care over six months. Direct healthcare costs were collected on a monthly basis. Incremental cost-effectiveness was gauged from a national healthcare system (NHS) and a personal perspective, considering the Palliative Outcome Scale-Symptoms-MS (POS-S-MS) and the EuroQol five-dimension descriptive system quality-adjusted life years (EQ-5D-3L QALYs), both completed at baseline, after three and six months. ResultsOf 78 randomized pwSMS, 76 (50 HPA, 26 usual care) were analyzed. Mean QALYs were close to zero, and the mean group difference was -0.006 (95% CI -0.057 to 0.044). The mean baseline-adjusted cost difference was € -394 (95% confidence interval, CI -3,532 to 2,743). POS-S-MS cost-effectiveness showed a slight mean reduction of symptom burden (-1.9; 95% CI -1.1 to 5.0) with unchanged costs. Mean direct costs due to MS were € 23,195/year, almost equally distributed between NHS (€ 13,108) and pwSMS (€ 10,087). Personal care, medications and home rehabilitation accounted for 80% of total expenditures. Most personal care costs were covered by pwSMS, and these costs were 3/4 of pwSMS out-of-pocket. ConclusionsThe slight reduction of symptom burden produced by the HPA was not associated with an increase in costs. NHS and pwSMS almost equally sustained these costs. Trial registrationCurrent Controlled Trials ISRCTN73082124.

Cost of care for persons with dementia: using a discrete-time Markov chain approach with administrative and clinical data from the dementia service Centres in Austria

BackgroundThere is growing evidence that the cost for dementia care will increase rapidly in the coming years. Therefore, the objective of this paper was to determine the economic impact of treating clients with dementia in outpatient Dementia Service Centres (DSCs) and simulate the cost progression with real clinical and cost data.MethodsTo estimate the cost for dementia care, real administrative and clinical data from 1341 clients of the DSCs were used to approximate the total cost of non-pharmaceutical treatment and simulate the cost progression with a discrete-time Markov chain (DTMC) model. The economic simulation model takes severity and progression of dementia into account to display the cost development over a period of up to ten years.ResultsBased on the administrative data, the total cost for treating these 1341 clients of the DSCs came to 67,294,910 EUR in the first year. From these costs, 74% occurred as indirect costs. Within a five-year period, these costs will increase by 7.1-fold (16.2-fold over 10 years). Further, the DTMC shows that the greatest share of the cost increase derives from the sharp increase of people with severe dementia and that the cost of severe dementia prevails the cost in later periods.ConclusionThe DTMC model has shown that the cost increase of dementia care is mostly driven by the indirect cost and the increase of severity of dementia within any given year. The DTMC reveals also that the cost for mild dementia will decrease steadily over the time period of the simulation, whereas the cost for severe dementia increases sharply after running the simulation for 3 years.

Utilisation of Personal Care Services in Scotland: The Influence of Unpaid Carers

<strong>Context:</strong> Unpaid carers may have an influence on the formal care utilisation of the cared for. Whether this influence is positive or negative will have important implications for the costs of formal care provision. Scotland, where personal care services are free to all individuals aged 65+, provides an interesting context in which to study this relationship. Moreover, the Scottish government is unique in its collection of administrative data on all social care clients. <strong>Objective:</strong> To investigate how the presence of an unpaid carer influences personal care use by those aged 65+ in Scotland. <strong>Methods:</strong> Two-part models (2PMs) are estimated using Scotland’s Social Care Survey (SCS) for the years 2014–2016. An instrumental variable (IV) approach is also implemented to deal with endogeneity concerns. <strong>Findings:</strong> The results suggest that unpaid care complements personal care services. In particular, the presence of an unpaid carer is associated with an increase in weekly personal care hours by 1 hour and 14 minutes per week, on average, other things being equal. <strong>Limitations:</strong> Concerns are noted surrounding the generalisability of results and lack of information available on client need and unpaid carers, arising from the very nature of conducting research using administrative data. Nevertheless, the findings are robust to a variety of sensitivity checks. <strong>Implications:</strong> Complementarity between unpaid and paid care may imply that unpaid carers are encouraging service use or demanding services on behalf of the cared for. Thus, policy interventions aimed at incentivising unpaid care could in fact lead to increased personal care costs to local authorities. Having said that, the complementary relationship might suggest that unpaid carers are being supported in their role and this might reduce pressure on formal care services longer term. <strong>JEL codes:</strong> I11, I12, J14

Addressing Disparities in Alzheimer's Disease and African-American Participation in Research: An Asset-Based Community Development Approach.

Alzheimer's Disease and related dementias (ADRD) remain a worldwide burden to address for persons with ADRD, their family members, and others at risk. ADRD should be recognized as a public health priority (Barnes, 2019), particularly among African Americans for several reasons. Currently, African Americans have 2–4 times the risk of developing ADRD than non-Hispanic Whites (Barnes and Bennett, 2014; McDonough, 2017). Given the higher presence of co-morbid conditions and associated health disparities when comparing African Americans to other racial and ethnic groups (Dillworth-Anderson and Boswell, 2007; Hill et al., 2015), African Americans can have worse physical health and quality-of-life. These factors can also increase costs of care for persons with ADRD and their family members. African Americans could be further burdened by significantly higher costs of care than Whites (Gilligan et al., 2012) and lack of adequate insurance. Despite these disparities, African Americans are still underrepresented in ADRD research. Cultural and institutional barriers include primary reliance on passive recruitment strategies (e.g., postings, flyers, database recruitment) not tailored to communities of color, implicit bias, and mistrust of medical communities, academic institutions, and researchers (Ballard et al., 2010; Scharff et al., 2010; Williams et al., 2010; Shin and Doraiswamy, 2016). Investigator inclusion and participation criteria deemed more feasible for White participants (ex. Medical eligibility criteria, job restrictions, time, and financial requirements to go to study sites) also undermine or limit the participation of African Americans and other participants of color (Wendler et al., 2006; Konkel, 2015). Using asset-based community development (ABCD) approaches (Kretzmann and McKnight, 1993) can lead to improved access and delivery of care and ADRD knowledge among African Americans, increased social support for African-American caregivers and elders living with or at risk for ADRD, and increased African-American representation in neuroscience research. In this article, we describe the development and implementation of an ABCD approach for increasing African-American representation in the Wisconsin Registry for Alzheimer's Project (WRAP).

Expenditures for Persons Living With HIV Enrolled in Medicaid, 2006-2010.

Costs of care for persons living with HIV have been high historically. Cost estimates based on data from 1 health care site may underestimate total expenditures; using insurance claims avoids this limitation. We used Medicaid claims data to comprehensively assess payments for care for persons living with HIV between 2006 and 2010. Five sites from the HIV Research Network (HIVRN) provided information on patients with Medicaid coverage. Medicaid data were obtained from the sites' states (MD, NY, and MA) and 3 surrounding states and matched to HIVRN medical record-based data. Individuals less than 18, those with Medicare, and those in Medicaid managed care plans were excluded. Medicaid and HIVRN data were compared to ascertain concordance in capturing any inpatient event and any antiretroviral (ART) medication use. Of 6892 unique HIVRN identifiers, 6196 (90%) were linked to Medicaid data. The analytic sample included 11,341 person-years of Medicaid claims data from 3695 individuals in fee-for-service (FFS) programs. The mean annual FFS payment for all services was $47,434; mean annual FFS payment for only medical services was $38,311. Concordance between Medicaid and HIVRN data was excellent for ART use, but HIVRN data did not record a substantial proportion of years in which Medicaid recorded inpatient use. Estimated Medicaid payment amounts in this study are higher than some previous estimates. More complete capture of expensive inpatient hospitalizations in Medicaid data may partially explain this finding. Although inpatient care and ART medications contribute the most, expenditures for nonmedical services are substantial.

The “Rising Tide” of dementia in Canada

Dementia is an umbrella term for a large class of brain disorders. The prevalence of dementia was estimated at 44.4 million people worldwide in 2013, and in the absence of any significant new scientific discovery, prevalence rates are estimated to increase to 75.6 million in 2030 and 135.5 million in 2050.1 Alzheimer’s disease is the most common irreversible form of dementia. It is a fatal, progressive and degenerative disease that destroys brain cells.2 The syndrome consists of a number of symptoms that include changes in memory, judgment, reasoning, mood, behaviour, communication abilities and the ability to function on a day-to-day basis. Rising Tide: The Impact of Dementia on Canadian Society3 is a report released by the Alzheimer Society in 2010 following 2 years of intensive study. It is the first study to estimate the health and economic burden of dementia in Canada over the next 30 years. It also reviews and makes recommendations on policy options to address this issue. The 5 main pillars are as follows: Provide support for family caregivers (family includes anyone in the supportive network of the individual). Emphasize risk reduction and early intervention. Build an integrated system of care. Strengthen and supplement Canada’s dementia workforce. Increase investment in dementia research. Approximately 747,000 Canadians are living with cognitive impairment including dementia.4 Additional statistics from Rising Tide are similarly compelling. Despite advancing age being the biggest risk factor for Alzheimer’s disease, more than 70,000 of those living with dementia are under the age of 65. Women make up 72% of those living with Alzheimer’s disease. Within a generation, incidences of new cases will increase from 1 every 5 minutes to 1 every 2 minutes. The total cost of care for persons with dementia was about $15 billion in 2008 in Canada; this is expected to rise to $153 billion in 2038.3 Moreover, long-term care beds are projected to have a shortfall of 157,000 in Canada by the year 2038. The number of older persons with dementia living at home is expected to steadily rise from 55% to 62%.3 All of these trends will require community or home-based care to become more responsive to the needs of those living with dementia. Pharmacists play a vital role in the health and overall well-being of all Canadians. Pharmacists are highly visible and regularly accessed by members of the community, forming long-standing relationships with their patients. They are trained to understand pharmacotherapy that can benefit or impair cognitive function, and they can monitor for progression and related issues such as medication adherence. However, like many health care professionals, pharmacists may feel ill-equipped to support the unique needs of people living with dementia and their families or caregivers. Simply put, many pharmacists are uncomfortable dealing with patients with dementia. This article is the first in a series that aims to identify roles, strategies and resources pharmacists can apply in daily practice in service of people with dementia.

Determinants Of Cost Of Care For Persons With Severe Hemophilia

BackgroundThe ability of a person with hemophilia to adhere to treatment recommendations aimed at preventing and controlling bleeding likely impacts clinical outcomes and resource utilization. Annual cost of replacement factor for persons with severe hemophilia on prophylaxis is estimated to be as high as $300,000 per year (Johnson KA and Zhou ZY. ASH Annual Meeting Educational Program. 2011; 413-418). Hemophilia care is optimized when delivered by a highly specialized hemophilia treatment center (HTC) (Soucie et al. Blood. 2000; 96: 437-442). Consolidation of care for persons with hemophilia from a large geographic region within an HTC results in demographic heterogeneity that may impact an individual's ability to adhere to treatment recommendations. Little is known regarding the impact of socio-demographic factors on treatment outcomes for persons with hemophilia. The purpose of this study was to identify disease-related, treatment-related and demographic variables that have a significant impact on morbidity and resource utilization. MethodsWe identified 69 persons with severe hemophilia treated at our HTC between June 2009 and June 2012. We collected data for the variables listed below in table 1. To assess morbidity and resource utilization, we collected data for total factor use, total outpatient cost, total inpatient cost, frequency of inpatient and outpatient encounters and length of stay when hospitalized. Risk factors were identified using linear regression. A subset analysis was performed to evaluate the impact of prophylaxis on patients without inhibitors. All statistical analyses were performed using STATA (version 12.0 College Station, TX). Statistical significance was defined as P < 0.05. ResultsAge and inhibitor status were the only variables to significantly impact cost in both inpatient and outpatient settings (Table 1). The statistically significant beneficial impact of prophylaxis was confirmed by subgroup analysis of patients without inhibitors with respect to number of hospitalizations and length of stay, but not total cost.Table 1Total CostTotal Outpatient CostTotal Inpatient CostVariableCoefficientP-valueCoefficientP-valueAge0-18 (Reference)$33,098.70$4,304.9619-24$41,229.180.569$1,206,743.000.04325-39$6,908.620.910$111,033.100.82440+$177,164.300.006$561,069.600.274RaceWhite (Reference)$84,293.73$159,972.60Non-White-$27,089.410.669$886,072.100.074Level of EducationHigh School (Reference)$103,974.60$363,663.60Post High School-$71,256.010.168-$105,655.900.797Distance<20 (Reference)$76,639.79$677,486.5020-39-$34,645.450.628-$536,091.800.34240-59$17,297.190.806-$339,293.800.540>60$24,235.240.727-$546,892.200.318Population Density<500 (Reference)$79,850.63$222,397.60500-1500$38,479.010.531-$111,211.200.344>1500-$35,152.900.548$438,733.900.454InhibitorNo (Reference)$42,779.31$12,317.91Yes$139,574.000.011$1,205,950.000.005HIV PositiveNo (Reference)$63,518.41$388,921.60Yes$90,111.220.165-$356,545.600.490HCV PositiveNo (Reference)$46,779.09$271,800.40Yes$93,181.170.070$158,450.700.700HBV PositiveNo (Reference)$63,683.04$236,377.60Yes$71,331.680.233$416,466.100.379Family HistoryNo (Reference)$75,939.89$79,381.42Yes$5,606.310.911$426,993.200.280Home TherapyNo (Reference)$79,683.84$63,368.37Yes-$540.950.995$288,644.900.678ProphylaxisNo (Reference)$136,291.60$855,492.40Yes-$91,628.240.070-$848,184.500.033ProductPlasma Derived (Reference)$126,870.50$31,583.86Recombinant-$98,638.070.135-$24,181.530.962Bypass$193,397.800.026$2,401,224.000.001Primary CaregiverNo (Reference)$115,912.00$560,892.00Yes-$87,373.200.078-$556,707.000.158 ConclusionsIdentifying and addressing potential barriers to care will likely reduce morbidity and cost for persons with hemophilia. Caregiver status and age are demographic variables that may contribute to poor medical adherence resulting in increased morbidity and cost of care for persons with severe hemophilia. Disclosures:No relevant conflicts of interest to declare.

Development of DEMQOL-U and DEMQOL-PROXY-U: generation of preference-based indices from DEMQOL and DEMQOL-PROXY for use in economic evaluation

Dementia is one of the most common and serious disorders in later life and the economic and personal cost of caring for people with dementia is immense. There is a need to be able to evaluate interventions in dementia using cost-effectiveness analyses, but the generic preference-based measures typically used to measure effectiveness do not work well in dementia. Existing dementia-specific measures can effectively measure health-related quality of life but in their current form cannot be used directly to inform cost-effectiveness analysis using quality-adjusted life-years as the measure of effectiveness. The aim was to develop two brief health-state classifications, one from DEMQOL and one from DEMQOL-Proxy, to generate health states amenable to valuation. These classification systems consisted of items taken from DEMQOL and DEMQOL-Proxy so they can be derived from any study that has used these instruments. In the first stage of the study we used a large, clinically representative sample aggregated from two sources: a sample of patients and carers attending a memory service in south London and a sample of patients and carers from other community services in south London. This included 644 people with a diagnosis of mild/moderate dementia and 689 carers of those with mild/moderate dementia. For the valuation study, the general population sample of 600 respondents was drawn to be representative of the UK general population. Households were sampled in urban and rural areas in northern England and balanced to the UK population according to geodemographic profiles. In the patient/carer valuation study we interviewed a sample of 71 people with mild dementia and 71 family carers drawn from a memory service in south London. Finally, the instruments derived were applied to data from the HTA-SADD (Study of Antidepressants for Depression in Dementia) trial. This was a complex multiphase study with four linked phases: phase 1 - derivation of the health-state classification system; phase 2 - general population valuation survey and modelling to produce values for every health state; phase 3 - patient/carer valuation survey; and phase 4 - application of measures to trial data. All four phases were successful and this report details this development process leading to the first condition-specific preference-based measures in dementia, an important new development in this field. The first limitation relates to the lack of an external data set to validate the DEMQOL-U and DEMQOL-Proxy-U classification systems. Throughout the development process we have made decisions about which methodology to use. There are other valid techniques that could be used and it is possible to criticise the choices that we have made. It is also possible that the use of a mild to moderate dementia sample has resulted in classification systems that do not fully reflect the challenges of severe dementia. The results presented are sufficiently encouraging to recommend that the DEMQOL instruments be used alongside a generic measure such as the European Quality of Life-5 Dimensions (EQ-5D) in future studies of interventions in dementia as there was evidence that they can be more sensitive for patients at the milder end of disease and some limited evidence that the person with dementia measure may be able to reflect deterioration. The National Institute for Health Research Health Technology Assessment programme.

Life Care Planning Projections for Individuals With Motor Incomplete Spinal Cord Injury Before and After Locomotor Training Intervention

We present a retrospective case series of 2 individuals with motor-incomplete spinal cord injury (SCI) to examine differences in lifetime cost estimates before and after participation in an intensive locomotor training (LT) program. Sections of a life care plan (LCP) were used to determine the financial implications associated with equipment, home renovations, and transportation for patients who receive LT. An LCP is a viable method of quantifying outcomes following any therapeutic intervention. The LCP cases analyzed were a 61-year-old woman and a 4½-year-old boy with motor-incomplete SCI and impairments classified by the American Spinal Injury Association Impairment Scale (AIS) as AIS D and AIS C, respectively. Each patient received an intensive outpatient LT program 3 to 5 days per week. The 61-year-old woman received 198 sessions over 57 weeks and the 4½-year-old boy received 76 sessions over 16 weeks. The equipment, home renovation, and transportation costs of an LCP were calculated before and after LT. Prior to the implementation of LT, the 61-year-old woman had estimated lifetime costs between $150,247.00 and $199,654.00. Following LT, the estimated costs decreased to between $2010.00 and $2446.00 (a decrease of $148,237.00 and $197,208.00). Similarly, the 4-year-old boy had estimated lifetime costs for equipment, home renovation, and transportation between $535,050.00 and $771,665.00 prior to LT. However, the estimated costs decreased to between $97,260.00 and $200,047.00 (a decrease of $437,790.00 and $571,618.00) following LT. The lifetime financial costs associated with equipment, home renovations, and transportation following a motor-incomplete SCI were decreased following an intensive LT program for the 2 cases presented in this article. The LCP, including costs of rehabilitation and long-term medical and personal care costs, may be an effective tool to discern cost benefit of rehabilitation interventions.

CA7-04: Costs of Care for Persons with Opioid Dependence in Two Integrated Health Systems

Background/AimsOpioid dependence is a growing public health concern and results in high costs to individuals, health care systems, and society. Recent legislation allowing expansion of buprenorphine for replacement therapy use in general medical care settings may increase access to care for opioid dependence, but little is known about its impact on services utilization and commercial health systems costs. In this retrospective cohort study, we examined how the introduction of buprenorphine affected the pattern of medical care and addiction medicine (AM) services provided to patients with opioid dependence and associated costs.MethodsUsing electronic health records, we identified individuals with two or more diagnoses of opioid dependence per year from 2000 through 2008 in two large non-profit, integrated health systems (System A: N=4,425; System B: N=7122) and assessed health system utilization and costs.ResultsIn both health systems and across the study period, the number of opioid-dependent persons increased considerably and the use of buprenorphine for opioid dependence treatment increased steadily. In System A, those receiving buprenorphine plus AM counseling had significantly higher costs than those receiving methadone plus AM counseling (Z= ?9.22, p<.001), and significantly lower costs than those with little or no AM counseling (Z=2.81, p=.005). There were no differences in costs between those receiving buprenorphine plus AM counseling and those with AM counseling only (Z=1.30, p=.192). The treatment group by period interaction (?2 = 9.66, df=3, p=.022) was significant, with costs decreasing over time in the buprenorphine plus AM counseling group and increasing over time in all other groups. In System B, costs were significantly lower for the buprenorphine plus AM counseling group than for the group with little or no AM counseling (Z= ?5.14, p<.001) and higher than for the group with AM counseling only (Z=5.56, p=.001). The treatment group by period interaction was not significant (?2 =1.23, df=2, p=.540).DiscussionBuprenorphine treatment is emerging as a viable alternative to other AM treatment approaches for persons with opioid dependence. Results of this study provide further evidence that buprenorphine treatment can be provided at a similar cost to alternative strategies in private integrated health systems.

A randomized controlled trial of a community nurse‐supported hospital discharge programme in older patients with chronic heart failure

To evaluate the effectiveness and cost-effectiveness of a community nurse-supported hospital discharge programme in preventing hospital re-admissions, improving functional status and handicap of older patients with chronic heart failure. Randomized controlled trial; 105 hospitalized patients aged 60 years or over with chronic heart failure and history of hospital admission(s) in previous year were randomly assigned into intervention group (n = 49) and control group (n = 56) for six months. Intervention group subjects received community nurse visits before discharge, within seven days of discharge, weekly for four weeks, then monthly. Community nurse liaised closely with a designated specialist in hospital and were accessible to subjects during normal working hours. Control and intervention group subjects were followed up in the same specialist medical clinics. Primary outcome was the rate of unplanned re-admission at six months. Secondary outcomes were number of unplanned re-admissions, six-minute walking distance, London Handicap Scale and public health care and personal care costs. At sixth months, the re-admission rates were not significantly different (46 vs. 57% in control subjects, p = 0.233, Chi-square test). But the median number of re-admissions tended to lower in the intervention group (0 vs. 1 in control group, p = 0.057, Mann Whitney test). Intervention group subjects had less handicap in independence (median change 0 vs. 0.5 in control subjects, p = 0.002, Mann Whitney test), but there was no difference in six-minute walking distance. There was no significant group difference in median total public health care and personal care costs. Community nurse-supported post-discharge programme was effective in preserving independence and was probably effective in reducing the number of unplanned re-admissions. The cost benefits to public health care were not significant. Older chronic heart failure patients are likely to benefit from post-discharge community nurse intervention programmes. More comprehensive health economic evaluation needs to be undertaken.

Palliative care for patients with cancer: district nurses’ experiences

This paper reports a study exploring district nurses' experiences of providing palliative care for patients with cancer and their families. There is an increasing demand for palliative care in the community, as many patients wish to die at home. District nurses are central to providing palliative care in the community, but there is a dearth of literature on district nurses' experiences in palliative care. A Husserlian phenomenological approach was adopted with a purposive sample of 25 female district nurses. Data were collected using unstructured, tape-recorded interviews and analysed using Colaizzi's seven stages of data analysis. Four themes were identified: the communication web; the family as an element of care; challenges for the district nurse in symptom management and the personal cost of caring. District nurses' experiences of providing palliative care to family units was challenging but rewarding. The emotive nature of the experience cannot be under-estimated, as many district nurses were touched by the varying situations. Whilst acknowledging the need to maintain an integrated approach to care, district nurses should be identified as the key workers in the complex situation of palliative care.

Cost of fetal alcohol spectrum disorders.

Fetal alcohol syndrome (FAS) is a common identifiable teratogenic cause of mental retardation, neurological deficit, mental disorders, and developmental disabilities. Accurate estimates of the cost of care for persons with FAS are essential for appropriate funding of health care, developmental disabilities services, special education, and other service systems, as well as prioritizing funding of public health prevention efforts. The cost of care for individuals with FAS can be conceptualized as the annual cost of care for one person or a population, or as the lifetime cost of care for an individual. Annual cost estimates for the United States range from $75 million in 1984 to $4.0 billion in 1998. Estimates of lifetime cost vary from $596,000 in 1980 to $1.4 million in 1988. After adjustments for changes in inflation and population, 2002 estimates of total annual cost and lifetime cost are higher. FAS is increasingly being recognized as a large public health problem with high potential for the prevention of future cases and for the prevention of excess disability and premature mortality in persons who are affected. Each day, from 6-22 infants with FAS are born in the United States, and as many as 87-103 more are born with other impairments resulting from prenatal alcohol exposure. Updated and improved cost data on FAS should be a research priority.

Use and costs of ambulatory care services among Medicare enrollees with schizophrenia.

The objective of this study was to identify predictors of the use and cost of ambulatory care services among Medicare recipients with schizophrenia. The design was a cross-sectional analysis of Medicare claims in 1991. The study subjects were a 5 percent random sample of all persons in the United States who had at least one Medicare service claim in 1991 and who were diagnosed as having schizophrenia in any care setting. Outcome measures included use and cost of any ambulatory care service, individual therapy, psychiatric somatotherapy, group therapy, or family therapy. For nearly 25 percent of the total sample of 12,440, no claims were filed for ambulatory care services in 1991. The mean+/-SD number of ambulatory care visits during the year was 7.9+/-21. The most frequently used type of therapy was individual therapy (5+/-14 visits). The mean+/-SD yearly cost of care for persons who received ambulatory care services was $470+/-$1,028. Among persons under 65 years of age, Caucasians were about 1.5 times as likely as African Americans to have received an ambulatory care service and 1.3 times as likely to have received individual therapy. Persons who were 65 or older were less likely to have received any service. Among service recipients, costs of care were lower for African Americans and for older people. The use of Medicare-funded ambulatory care services by persons with schizophrenia varied by race and age. Further investigation is required to determine whether subgroups of individuals who do not have additional insurance coverage or access to services are receiving substandard care.

Analysis of incremental and total direct costs of health care for persons with diabetes by type of diabetes with age and sex matched controls

Analysis of incremental and total direct costs of health care for persons with diabetes by type of diabetes with age and sex matched controls

The personal cost of caring

Caring Costs: an apt name for the alliance of voluntary bodies striving to achieve improved financial support for carets. The publication of its recent report on the many hardships carets face in looking after relatives at home coincided with the launch of similar publications from other bodies, including the Alzheimer’s Disease Society.

Financing Health Care for Persons with HIV Infection: Guidelines for State Action

Financing health care for persons with HIV infection is an increasing burden on states and their taxpayers. The major problems of state policy in the 1990s are how to organize and finance both early detection of infection and preventive drug treatment for persons without symptoms and how to provide a full range of health and social services for infected persons whose life expectancy is unknown. This article first describes the shift in the perceptions of HIV infection from a plague to a chronic disease and the implications of this shift for state government. Then it places the history of financing for health care in the context of general health care financing policy during the past decade. Next it describes the history of state action to finance care for HIV infection, especially the use of of Medicaid Waivers, problems of state financing for expensive prescription drugs, and state initiatives, especially in California, Michigan, New Jersey and New York. Finally, the article presents seven policy questions that states should consider in deciding what, if any, legislation or regulations to enact in order to organize treatment and pay some or all of the costs of care for persons with HIV infection.

Nursing and caring: a personal construct theory study of some nurses' self-perceptions.

This report outlines the results of a survey of trained nurses' perceptions about themselves as professional carers. Twenty-five nurses of charge nurse grade were interviewed using Kelly's personal construct theory and repertory grid technique. Nurses were asked to elicit eight bipolar constructs and to rate eight elements, including a 'myself as a carer' element and an 'ideal self as a carer' element, on a seven-point rating scale. A simple difference score was calculated to measure the degree of discrepancy between these two elements. Observed differences were assumed to be indicative of the need for personal change. Differences emerged for each of the 25 informants. Some possible explanations for these findings are provided, in particular the personal cost of caring for the carer is emphasized. Further research in this area must take account of this new finding.