Outpatient Physician Visits Research Articles

Cost and use of conservative management of lumbar disc herniation before surgical discectomy

Background Context Lumbar discectomy is one of the most common spine surgical procedures. With the exception of true emergencies (eg, cauda equina syndrome), lumbar discectomy is usually performed as an elective procedure after a prudent trial of nonoperative treatment. Although several studies have compared costs of definitive operative or nonoperative management of lumbar disc herniation, no information has been published regarding the cost of conservative care in patients who ultimately underwent surgical discectomy. Purpose The purpose of this study was to determine the financial costs (and relative distribution of those costs) associated with the nonoperative management of lumbar disc herniation in patients who ultimately failed conservative care and elected to undergo surgical discectomy. Study Design This is a retrospective database review. Patient Sample The sample comprises patients within the database who underwent lumbar discectomy. Outcome Measures The outcome measures were frequency of associated procedures and the costs of those procedures. Materials and Methods A search was conducted using a commercially available online database of insurance records of orthopedic patients to identify all patients within the database undergoing lumbar discectomy between 2004 and 2006. Patients were identified by American Medical Association Current Procedural Terminology code. The associated charge codes for the 90-day period before the surgery were reviewed and categorized as outpatient physician visits, imaging studies, physical therapy, injection, chiropractic manipulation, medication charges, preoperative studies, or miscellaneous charges. The frequency of each code and the percentage of patients for whom that code was submitted to the insurance companies were noted, as were the associated charges. Results In total, 30,709 patients in the database met eligibility criteria. A total of $105,799,925 was charged during the 90 days preoperatively, an average of $3,445 per patient. Average charge for discectomy procedure was $7,841. Charges for injection procedures totaled $16,211,246 or 32% of total charges, diagnostic imaging $15,648,769 (31%), outpatient visits $6,552,135 (13%), physical therapy visits $5,723,644 (11%), chiropractic manipulation $1,177,406 (2%), preoperative studies $426,976 (0.8%), medications $263,039 (0.5%), and miscellaneous charges $1,177,371 (2%). Conclusions Charges for preoperative care of patients with lumbar disc herniation are substantial and are split almost evenly between diagnostic charges (outpatient visits, imaging, laboratory studies, and miscellaneous) and therapeutic charges (injections, physical therapy, chiropractic manipulation, and medications). Although a large number of patients will ultimately require surgical intervention, given that many patients will improve with nonoperative therapy, a trial of conservative management is appropriate. Additional studies to identify patients who may ultimately fail nonoperative treatment and would benefit from early discectomy would be beneficial.

Close Companions at Church, Health, and Health Care Use in Late Life

This article studies whether there are age variations in the relationships between having a close companion friend at church, health, and outpatient physician visits. The data come from two waves of interviews in a nationwide survey of older adults. These data are analyzed with ordinary least squares multiple regression analyses. The findings reveal that older people who have a close companion friend in the place where they worship are more likely to rate their health in a favorable way over time. However, these health-related benefits emerge only among the oldest-old study participants. The data results further indicate that having a close friend at church is associated with fewer outpatient physician visits over time, but once again, the results are observed only among the oldest old. The results from this study provide preliminary insight into one way in which spiraling health care costs may eventually be curtailed.

Impact of Disease Progression On Healthcare Cost and Resource Utilization Among Follicular NHL Patients Treated within the US Oncology Network.

Abstract 4543Follicular non-Hodgkin's Lymphoma (f-NHL) is a common type of b-cell lymphoma, accounting for approximately 30% of all NHL cases and 70% of indolent lymphomas. The purpose of this project was to estimate the economic cost of progression for patients with f-NHL treated in the outpatient community setting.Using US Oncology's iKnowMed electronic medical record (EMR) system, we identified and characterized f-NHL patients who received care within the US Oncology network between July 1, 2006 and February 29, 2008. It is estimated that the NHL patients with documented care in iKnowMed represent approximately 5-6 % of all newly diagnosed NHL patients in the United States. Patients were divided into two cohorts depending on whether they experienced disease progression during the study catchment period. Patients were then characterized with respect to relevant demographic and clinical characteristics and were followed over a 6 month period. Costs were estimated based on outpatient claims and were normalized to unadjusted 2007 Medicare reimbursement rates. To estimate the incremental cost of progression, costs per patient-month were compared between patients who did and did not experience disease progression. Multiple regression modeling techniques were employed to describe the impact of progression on healthcare cost after adjusting for potential confounders. Finally, to further explore the economic burden of disease progression, we compared resource utilization as measured by frequency of outpatient physician visits, chemotherapy infusion visits, laboratory procedures, and acute care visits.A total of 1,002 f-NHL patients were identified- 204 patients experienced disease progression and 798 did not. Patients who progressed were more likely to have been diagnosed with advanced stage disease and with 4+ positive lymph nodes and also tended to have a worse performance status and less favorable lab values (elevated LDH and low Hgb) at the study index date. Overall crude costs were significantly higher for patients following disease progression compared to patients without progression (difference = $2,647 per patient-month; p<0.001). Patients who progressed have significantly higher costs for outpatient visits, chemotherapy infusions, other medications, laboratory procedures and minor procedures. In a multivariable regression model controlling for significant clinical factors such as performance status, hemoglobin level, and number of positive lymph nodes, disease progression remained significantly associated with a greater than 200% increase in total cost. When we compared frequency of billed services by progression status, we found that patients with disease progression had significantly higher frequencies of outpatient physician visits and laboratory procedures compared to patients without progression and were more likely to receive intensive chemotherapy regimens and to be admitted to the hospital and/or ER.Using linked EMR and claims data, this retrospective study highlights and quantifies the economic costs of progression among patients with f-NHL treated within the outpatient community-based setting. Results of this study suggest that efforts to delay disease progression may provide substantial economic benefits in addition to the previously demonstrated improvements in clinical outcomes and patient quality of life.Table 1Outpatient Costs by Progression StatusCostCP - CNP*No Progression (NP) (n=798)Progression (P) (n=204)Cumulative CostUS$US$US$Month 12,1225,9613,839Month 22,88310,6107,727Month 33,55314,56611,013Month 44,21917,45913,240Month 54,69519,48214,787Month 65,16521,49616,331Cost per Patient- MonthUS$US$US$Total9653,6122,647Outpatient visits4010262Chemotherapy**7322,5541,822Other medication108715607Labs122917Minor Procedures3107*p<0.001 for all cost differences;**Includes immunotherapy Disclosures:Reyes:Genentech Inc: Employment, Equity Ownership.

Effect of depression on health care utilization in patients with end-stage renal disease treated with hemodialysis

Background and objectives Depression is regarded as the most common psychiatric abnormality in patients on hemodialysis (HD) for end-stage renal disease (ESRD). Although several studies have demonstrated a relationship between depression and utilization of health care in ESRD and other chronic illnesses in developing countries, such evidence from hemodialysis patients is lacking in Iran. This study aims to investigate the effect of depression on health care utilization among Iranian hemodialysis patients. Design A longitudinal study. Setting Baqiyatallah Hospital (Tehran, Iran) between 2005 and 2006. Patients Of the 70 enrolled hemodialysis patients, 68 finished the study including 19 depressed and 49 non-depressed ones according to the Hospital Anxiety and Depression Scale (HADS). Measurements The subjects' health care utilization in a six-month period was prospectively assessed by recording the hospital admission and home nurse visits, outpatient physician visits, and patients' emergency department visits for any medical reason. The results were subsequently compared between the study groups. Results A higher hospital admission rate (94.7% vs. 55.1%, p = .002; Pearson's chi-square test) as well as a higher likelihood of emergency department visits (73.7% vs. 40.8%, p = 0.002; Pearson's chi-square test) was seen in depressed patients. The frequencies of the other types of health care utilization were not statistically different between the two groups ( p > 0.05, Pearson's chi-square test). Conclusion Depression in hemodialysis patients is associated with higher rate of hospital admission, and prospective studies should be conducted to assess whether treatment of depression will decrease health care utilization in these patients.

Are German patients burdened by the practice charge for physician visits ('Praxisgebuehr')? A cross sectional analysis of socio-economic and health related factors.

BackgroundIn 2004, a practice charge for physician visits ('Praxisgebuehr') was implemented in the German health care system, mainly in order to reduce expenditures of sickness funds by reducing outpatient physician visits. In the statutory sickness funds, all adults now have to pay € 10 at their first physician visit in each 3 month period, except for vaccinations and preventive services. This study looks at the effect of this new patient fee on delaying or avoiding physician visits, with a special emphasis on different income groups.MethodsSix representative surveys (conducted between 2004 and 2006) of the Bertelsmann Healthcare Monitor were analysed, comprising 7,769 women and men aged 18 to 79 years. The analyses are based on stratified analyses and logistic regression models, including a focus on the subgroup having a chronic disease.ResultsTwo results can be highlighted. First, avoiding or delaying a physician visit due to this fee is seen most often among younger and healthier adults. Second, those in the lowest income group are much more affected in this way than the better of. The multivariate analysis in the subgroup of respondents having a chronic disease shows, for example, that this reaction is reported 2.45 times more often in the lowest income group than in the highest income group (95% CI: 1.90–3.15).ConclusionThe analyses indicate that the effects of the practice charge differ by socio-economic group. It would be important to assess these effects in more detail, especially the effects on health care quality and health outcomes. It can be assumed, however, that avoiding or delaying physician visits jeopardizes both, and that health inequalities are increasing due to the practice charge.

Health care utilization of patients with chronic obstructive pulmonary disease and lung cancer in the last 12 months of life

Previous studies have documented similar levels of end-of-life symptom burden for lung cancer and chronic obstructive pulmonary disease (COPD) patients, yet there has been little comparison of health care utilization during this period. This study contrasts health care utilization by people with COPD and those with lung cancer in the 12 months prior to death. We performed a retrospective cohort study of 1098 patients who died in 2004 with a cause of death recorded as COPD or lung cancer using administrative health data. Our outcomes of interest included acute, long-term and home care service utilization. The study population was 42% female with a mean age of 77 years (S.D.=11). In the last 12 months of life, decedents with COPD were more likely to be institutionalized in a LTC setting (41% vs. 12.5%, p<0.05) and to receive long-term home care (26% vs. 9.7%, p<0.05), but were much less likely to receive palliative care in hospital (47.6% vs. 5.1%, p<0.001) or at home (37.4% vs. 2.8%, p<0.05) than people with lung cancer. In contrast, decedents with lung cancer made greater use of acute care services than those with COPD in that they were more likely to be hospitalized (94.2% vs. 80.4%, p<0.05) and had longer median LOS (7.0 vs. 5.7 days, p<0.05) than those with COPD. No differences in the number of out-patient physician visits were noted. Patterns of end-of-life health care utilization differ significantly between people with lung cancer and those with COPD. Further research is needed to establish need and determine gaps in services to better address the needs of people dying with COPD.

Hospital admissions and primary care attendances for nonulcer dyspepsia, reflux oesophagitis and peptic ulcer in Scotland 1981–2004

The aim of this study was to assess the recent time trends of oesophageal disorders, nonulcer dyspepsia, gastric and duodenal ulcer in the light of such risk factors as age, sex, deprivation and urban versus rural residence. The Scottish National Health Service provided diagnostic data on all admissions to all Scottish hospitals from 1981 to 2004 and patient visits to general practitioners (GP) from 1998 to 2004. In the last quarter of a century in Scotland, there were sevenfold increases in annual hospitalizations for dyspepsia (from 900 to 6000 per million population) and for oesophageal disorders (from 500 to 3700). Annual hospitalisations for gastric and duodenal ulcer changed from 590 to 1100 and from 1400 to 1130 per million population, respectively. The variation of hospital admissions for dyspepsia among various Scottish regions closely matched the variation of deprivation among them. GP contacts for dyspepsia (27 600 per million population) and oesophageal disorders (10,000) were common compared with relatively infrequent contacts for gastric ulcer (500) and duodenal ulcer (1200). Dyspepsia showed a rise of GP contacts with increasing scores of deprivation. This rise occurred similarly among urban and rural residents and applied to data for each individual year between 1998 until 2004. None of the other diagnoses showed any clear-cut correlation with grade of deprivation. Gastric and duodenal ulcer are relatively rare causes for hospital admission as well as outpatient physician visits. Their former predominant role in upper gastrointestinal disease has been replaced by gastro-oesophageal reflux disease and nonulcer dyspepsia, both increasing sevenfold in the last quarter of a century.

Investigation of Air Pollution and Cardiovascular Disease in a Population-Based Cohort

ISEE-712 Objective: As part of the Border Air Quality Study, we used Canada's universal healthcare administrative databases to assess the relationship between air pollution and cardiovascular disease (CVD). We investigated the relationship between air pollution and CVD among groups with predisposing medical conditions and high-risk populations. Materials and Methods: The cohort includes all Greater Vancouver Regional District residents, 45 to 84 years of age as of January 1, 1999, who lived there since January 1, 1994. Predisposing conditions were monitored from January 1, 1994 to December 31, 1998. Hospitalization and outpatient physician visit records were used to obtain information on clinical diagnoses for each individual. Six-digit residential postal codes were used to assign exposure. Outcomes of interest included acute coronary syndrome (ACS, ICD-9:410, 411), chronic coronary syndrome (CCS, ICD-9:413, 414, 429.2), hypertension (HTN, ICD-9:401-405), congestive heart failure (CHF, ICD-9:428), diabetes (DM, ICD-9:250). Neighborhoods socioeconomic status (SES) was obtained from the 1996 and 2001 Census. Results: The cohort consisted of 559,110 subjects and was followed until December 2003. Cumulative prevalence 1994–1998 for ACS, CCS, CHF, HTN, and DM were 29.8, 78.9, 13.8, 228.5, and 79.6 per 1000 people. Incidences in 1999 for these outcomes were 6.2, 12.5, 5.0, 27.7, and 10.5 per 1000 people. Age, gender, and SES were considered as potential confounders. Exposures were measured as mean monthly concentrations based on inverse distance weighting of hourly ambient monitoring data (CO, NO, NO2, PM10, PM2.5, O3, SO2) and were also estimated for NO, NO2, PM2.5, black carbon, and wood smoke using land use regression models. Analyses will be conducted using Poisson regression. Conclusions: This large cohort will allow us to examine the relationship between air pollution and CVD among various subpopulations, while controlling for potential confounders at the individual level.

Youth and Young Adults With Cerebral Palsy: Their Use of Physician and Hospital Services

Young NL, Gilbert TK, McCormick A, Ayling-Campos A, Boydell K, Law M, Fehlings DL, Mukherjee S, Wedge JH, Williams JI. Youth and young adults with cerebral palsy: their use of physician and hospital services. Objectives To examine patterns of health care utilization among youth and young adults who have cerebral palsy (CP) and to provide information to guide the development of health services for adults who have CP. Design This study analyzed health insurance data for outpatient physician visits and hospital admissions for a 4-year period. Setting Six children’s treatment centers in Ontario, Canada. Participants The sample included 587 youth and 477 adults with CP identified from health records. Youths were 13 to 17 years of age, and adults were 23 to 32 years of age at the end of the data range. Interventions Not applicable. Main Outcome Measures We computed the annual rates of outpatient physician visits and hospitalizations per 1000 persons and compared these with rates for the general population. Results Annual rates of outpatient physician visits were 6052 for youth and 6404 for adults with CP, 2.2 times and 1.9 times higher, respectively, than rates for age-matched peers ( P<.01). Specialists provided 28.4% of youth visits but only 18.8% of adult visits. Annual hospital admission rates were 180 for youth and 98 for adults with CP, 4.3 times and 10.6 times higher, respectively, than rates for age-matched peers ( P<.01). Conclusions It appears that youth and adults with CP continue to have complex care needs and rely heavily on the health care system. Comprehensive services are essential to support their health as they move into youth and adulthood. However, there appear to be gaps in the adult health care system, such as limited access to specialist physicians.

Severity of Chronic Pain Affects Health Care Utilization After Kidney Transplantation

Background While the association between chronic pain and high health care utilization is a known issue in the general population, this relation has not been well studied among kidney transplantation patients. Methods The subjects were first-time kidney transplant recipients engrafted between 2003 and 2006 and 6 months to 5 years postoperatively. Using SF-36 Bodily Pain Scale, patients were categorized in three groups: group I, those with scores over 66.6; group II, between 66.6 and 33.3; and group III, over 33.3. The subjects’ health care utilization was prospectively assessed by recording the number of hospital admission days and the frequency of home nurse visits, outpatient physician visits, and emergency department visits for any medical reason in a 6-month period. Results A stepwise increase in the frequency of patients admitted to the hospital ( P = .017), and those referred to emergency departments ( P = .007) was correlated with greater severity of pain in the three groups. However, the frequency of patients having outpatient physician visits ( P = .30) or home nurse visits ( P = .387) did not vary significantly. Similarly, with increased pain severity, an increase was observed in the number of emergency department visits ( P = .005) and duration of hospital stays ( P = .049), but not in the number of home nurse ( P = .890) or physician visits ( P = .112). Conclusion The severity of pain seems to increase the amount of health care use among kidney transplant patients. To minimize associated costs, appropriate pain rehabilitation programs are suggested.

Substance Abuse and Dependence Treatment in Outpatient Physician Offices, 1997–2004

Objective: To examine patient, physician, and visit characteristics associated with treatment for substance abuse during outpatient physician visits. Methods: Secondary data was obtained from the 1997–2004 National Ambulatory Medical Care Survey. Results: A substance abuse diagnosis was recorded in. 9% of general and family practice visits,. 8% of internal medicine visits, and 5.1% of psychiatry visits. Multivariable logistic regression found that women, elderly, non-White, and established patients were less likely to be given a substance abuse diagnosis. Conclusion: Increased screening, particularly of existing patients, may lead to decreased gender, age, and racial disparities in diagnosis and treatment.

Comparisons of Rosiglitazone Versus Pioglitazone Monotherapy Introduction and Associated Health Care Utilization in Medicaid-Enrolled Patients with Type 2 Diabetes Mellitus

Background: Outcomes in patients with type 2 diabetes mellitus (DM) can differ based on the antidiabetic medication that is used. Thiazolidinediones (TZDs) are a newer class of agents used for the treatment of type 2 DM. No previous study has compared health care utilization associated with the 2 TZDs on the market. Objective: The objective of this study was to compare health care utilization and costs associated with initiation of treatment with either rosiglitazone or pioglitazone by Medicaid-enrolled patients with type 2 DM. Methods: This was a retrospective data analysis comparing cohorts of patients with type 2 DM starting a new antidiabetic medication in terms of hospitalizations, emergency department visits, outpatient physician visits, and health care costs reimbursed by the North Carolina Medicaid program. The perspective adopted in this analysis was that of the third-party payer (ie, the North Carolina Medicaid program). Patients starting rosiglitazone between July 1, 2001, and June 30, 2002, were compared with patients starting pioglitazone during the same period. The patients were followed up for 30 months to examine the difference in health care utilization over time. Multivariate regression techniques were employed for comparisons between the 2 different antidiabetic therapies. Results: A total of 1705 patients with type 2 DM were identified and included in the final cohort. There were 660 patients (mean [SD] age, 49.0 [10.2] years) in the rosiglitazone arm and 1045 patients (mean [SD] age, 49.1 [10.5] years) in the pioglitazone arm. Multivariate analysis showed that the rosiglitazone monotherapy group was associated with a 12.2% decrease in the mean number of hospitalizations, a 10.4% decrease in the mean number of emergency department visits, and a 7.3% decrease in total health care costs compared with the pioglitazone monotherapy group (all, P < 0.05). This study only looked at patients who used the same drug for the entire follow-up period. It did not account for drug switching or addition of a new drug to an existing therapy. Conclusions: Introduction of rosiglitazone was associated with a decreased number of hospitalizations, emergency department visits, and total health care costs compared with pioglitazone. The utilization of oral antidiabetic agents, with documented clinical and economic benefits, should continue to be advocated to reduce avoidable medical care utilization and to improve patient outcomes in this population.

A Review of the Economic Burden of Pleural and Pericardial Effusions in Cancer Patients.

OBJECTIVES: Pleural and pericardial effusions can lead to severe outcomes. Cancer accounts for an estimated 40% of all pleural effusions. About half of the effusions diagnosed in cancer patients are malignant, while the rest are nonmalignant and may occur as complications of the cancer treatments themselves. Pleural and pericardial effusions are associated with increased morbidity and mortality as well as high healthcare costs. The objective of this study was to review the economic burden of pleural and pericardial effusions in cancer patients.METHODS: A systematic search of the English-language medical literature published between 1990 and 2006 was conducted. Additional publications and conference proceedings were retrieved from the article bibliographies and included in the review. Articles selected include prospective or retrospective studies specifically designed to examine burden of illness, direct medical costs, indirect costs, or cost drivers associated with pleural or pericardial effusions in cancer patients. All original costs were reported, with adjusted figures (to 2006 US dollars) presented in parentheses using the medical care component of the consumer price index from the US Bureau of Labor Statistics.RESULTS: Of 15 studies identified, 11 met selection criteria and were reviewed in detail. Seven references reported data on costs associated with pleural or pericardial effusions in cancer patients. The cost per episode of pleural effusion ranged from $3,391 (2006 US $4,387) for outpatient treatment with pleural catheter to $20,996 ($37,341) for talc pleurodesis. The most common treatment for malignant pleural effusion is chest tube insertion and drainage with instillation of a sclerosing agent. Key cost drivers for significant pleural effusions included operating room costs, surgeon fees, and drugs such as sclerosing agents. Resources used for management of low grade pleural effusions include chest x-rays, physician outpatient visits, diuretics, and corticosteroids. For the treatment of pericardial effusion, the costs of performing pericardiocentesis and a pericardial window procedure were estimated to be $4,446 and $14,641 (2006 US$), respectively. Cost components for pericardial effusions, depending on treatment modality selected, included echocardiogram (3–10%), intensive care unit (17–56%), sclerosant (1–4%), surgeon fees (28–29%), anesthesia fees (20%), and operating room costs (31%).CONCLUSIONS: Pleural and pericardial effusions lead to significant direct medical costs, contributing to the total cost of care among patients treated for cancer. These costs should be included in the economic evaluation of therapies that increase the risk of pleural and pericardial effusions. Given the scarcity of published analyses in this area, additional research is warranted to better understand the burden of pleural and pericardial effusions.

Investigation of Air Pollution and Otitis Media in a Population-based Birth Cohort

P-727 Introduction: Middle ear infection, or otitis media, is one of the most common childhood diseases in the developed world and its incidence is increasing. It is presently the second most common reason children receive prescription medication. Due to increasing antibiotic resistance in otitis media pathogens, the public health focus has shifted from treatment to prevention for the management of this disease. Environmental tobacco smoke (ETS) is an accepted risk factor but ambient air pollution has not been thoroughly investigated. We hypothesize that ambient air pollutants can influence development of otitis media through suppression of the immune system. Due to the multi-factorial nature of otitis media it is important that a study investigating this disease adequately control for potential confounders. As part of the Border Air Quality Study (BAQS) we took advantage of Canada's universal healthcare administrative databases and linked multiple datasets to control for potential confounders during investigation of this hypothesis in a population-based cohort. Methods: The study population was identified using postal code and date of birth from the vital statistics registry. These individual-level data were linked, by personal health number, to hospitalization and outpatient physician visit records to obtain information on clinical diagnoses (ICD-9 codes: 381, 381.0, 382, 382.0, 382.9). The date and billing status of each file entry was used to collect additional confounder information. These files were further linked with a perinatal database to ascertain breastfeeding initiation and the smoking status of both parents. Exposure histories were linked to each child based on their residential address (six-digit postal code) and neighborhood socioeconomic indicators were obtained from the 2001 Canadian Census. Results: We created a database of exposure, health outcome and risk factor data for every child born in the southwestern British Columbia study area from January 1999–December 2000 (n=59,917; 48.5% female). Age, gender, ethnicity (First Nations status), season, parity, ETS, non-breastfeeding and socioeconomic status were all considered in the analysis as potential confounders. There was complete two year follow-up for 87% of the cohort. Exposures were measured as mean monthly concentrations based on inverse distance weighting of hourly ambient monitoring data (CO, NO/NO2, PM10, PM2.5, O3, SO2) and were also estimated for traffic-related air pollution and wood smoke using land use regression models. Discussion: This database has enabled us to conduct the first population-based study examining the relationship between air pollution and otitis media while controlling for many potential confounders at the individual level.

Health Care Utilization and Expenditures for Children with Autism: Data from U.S. National Samples

Little is known about the use of medical services by children who have autism (ASD). Provide nationally representative data for health service utilization and expenditures of children with ASD. Cross-sectional survey using the Medical Expenditure Panel (MEPS), and National (Hospital) Ambulatory Medical Care Surveys (N(H)AMCS). A total of 80 children with ASD were identified from N(H)AMCS (weighted sample size (wss) 186,281), and 31 (wss 340,158) from MEPS. They had more outpatient visits, physician visits, and medications prescribed than children in general. They spent more time during physician visits than other children. Annual expenses for children with autism spectrum disorder (6,132 dollars) were more than for other children (860 dollars). Children with ASD have a substantial burden of medical illness.

Differences in Access to Outpatient Medical Care for Black and White Adults in the Rural South

We compared black and white adults in the rural South on multiple indicators of access to outpatient medical care and assessed whether any differences might be explained by group differences in socioeconomic situations or proximity to medical resources. Cross-sectional telephone survey. Survey respondents were 1237 black and 2158 white adults from 113 rural counties in 6 southern states. Blacks and whites were compared on a variety of commonly used survey measures of access, some followed in the Healthy People 2010 Initiative. Access comparisons were adjusted for age, gender, and health status and then reassessed with adjustments for individual socioeconomic indicators and county medical resources: physician-to-population ratios, the presence of hospitals and federally qualified health centers, and urban adjacency. Compared with whites, blacks reported similar or higher use of outpatient services over the previous year, including the likelihood of having had an outpatient physician visit and regular checkup. Nevertheless, blacks more often reported forgoing needed care, encountering various barriers, and experiencing dissatisfaction with some aspects of care. Adjusting for socioeconomic factors generally reduced but did not eliminate black-white access differences, whereas adjusting for county medical care resources did not affect measured group differences. Blacks and whites in the rural South report similar use rates of outpatient medical care, but blacks more often report unmet needs, barriers to care, and dissatisfaction with care. Beyond socioeconomic differences, black versus white differences in sites of care, the quality of care received, the quality of interactions with providers, and expectations for their care may explain group reported access differences.

Access to Health Care Services for the Disabled Elderly

To determine whether difficulty walking and the strategies persons use to compensate for this deficit influenced downstream Medicare expenditures. Secondary data analysis of Medicare claims data (1999-2000) for age-eligible Medicare beneficiaries (N=4,997) responding to the community portion of the 1999 National Long Term Care Survey (NLTCS). Longitudinal cohort study. Walking difficulty and compensatory strategy were measured at the 1999 NLTCS, and used to predict health care use as measured in Medicare claims data from the survey date through year-end 2000. Respondents to the 1999 community NLTCS with complete information on key explanatory variables (walking difficulty and compensatory strategy) were linked with Medicare claims to define outcome variables (health care use and cost). Persons who reported it was very difficult to walk had more downstream home health visits (1.1/month, p<.001), but fewer outpatient physician visits (-0.16/month, p<.001) after controlling for overall disease burden. Those using a compensatory strategy for walking also had increased home health visits/month (0.55 for equipment, 1.0 for personal assistance, p<.001 for both) but did not have significantly reduced outpatient visits. Persons reporting difficulty walking had increased downstream Medicare costs ranging from 163 US dollars to 222 US dollars/month (p<.001) depending upon how difficult walking was. Less than half of the persons who used equipment to adapt to walking difficulty had their difficulty fully compensated by the use of equipment. Persons using equipment that fully compensated their difficulty used around 300 US dollars/month less in Medicare-financed costs compared with those with residual difficulty. Difficulty walking and use of compensatory strategies are correlated with the use of Medicare-financed services. The potential impact on the Medicare program is large, given how common such limitations are among the elderly.

Variability in Measures of Health Outcomes in Sickle Cell Disease (SCD) Patients with Access to Comprehensive Care Centers.

The mortality of children less than 5 years of age with SCD has decreased substantially and now is similar to that of children without SCD. However the impact of comprehensive care on health outcomes of SCD has not been fully evaluated. This study compared the medical care utilization and mortality in children and adults with SCD in four regions in the state of Tennessee with variable access to a comprehensive sickle cell center (CSCC). This is a retrospective longitudinal study of a cohort of patients with SCD enrolled in TennCare, Tennessee's Medicaid managed health care program, from January 1995 to December 2002. Children and adults who had at least one inpatient or two outpatient physician visit claims, at least 30 days apart, listing an International Classification of Diseases, Ninth Revision, Clinical Modification code for SCD (homozygous, SC, sickle beta thalassemia) constituted the cohort. TennCare data linked to Tennessee vital records were used to define the population and identify the outcomes. One of the four large urban counties in Tennessee has a CSCC. The patients were assigned to one of four regions based on the area of residence on the day of their hospitalization or outpatient visit: Area 1a- urban county where CSCC is located, Area 1b- counties surrounding the CSCC area, Area 2: 3 urban counties which include large academic medical centers, Area 3- the remainder of Tennessee counties. Rates of hospitalizations, outpatient and emergency department (ED) visits, and deaths were compared in the four regions of the state. The cohort included 2102 patients with a total of 11,814 person-years (py). 58% of patients resided in area 1a, 9% in area1b, 19% in area 2 and 14% in area 3. 59% were females and 49% were older than 20 years. 14% were younger than 5 years. The following figure shows the rates of hospitalizations, ED and outpatient visits and deaths in 4 regions. Among children less than 5 years of age the rate of hospitalization was highest in area 1a (p<0.001). ED and outpatient visits for children were highest in area 3, (p<0.001). Among adults, 20 years or older, the rates of hospitalization and ED visits were highest in area 3, (p<0.001). The outpatient visits were highest in area1b (p<0.001). There was no significant difference in the death rates in the four regions. Males had significantly higher death rates in all regions (p<0.001). Trend analysis over 8 years showed a significant trend for increased rates of ED and outpatient visits in all regions (p<0.001) and deaths in area 2 (p=0.014). No clear pattern of improved outcomes as measured by hospitalizations, ED and outpatient visits and deaths are identified in relation to access to a CSCC or large academic medical centers. Area of residence may not affect care for SCD. Alternatively, there may be selective distribution of sicker patients in these areas based on their need for care. [Display omitted]

Racial Differences in Health Care Use among Medicare Only and Dual Eligibles

It has been an important financial issue in the U.S. Medicare expenditures that health care expenses of Medicaid-Medicare dual eligibles (MMDE) are much higher than those of Medicare only beneficiaries (MOB). This paper compares health care use and health status of MMDEs and MOBs who are either Afro-American or white recipients. Using total health care use information from the Medical Expenditure Panel Survey (MEPS) 2000, we find that the proportion of dual eligibles with chronic health conditions is higher by 4% than that of the Medicare only beneficiaries and that dual eligibles make more frequent uses of various health care services. The number of office-based physician visits and outpatient physician visits are higher for Afro-American dual eligibles than white dual eligibles. This finding seems to be contributed to by relatively high medical needs among dual eligibles. Higher utilization of agency-related home health services among Afro-American dual eligibles than among white dual eligibles is considered as a consequence of different ethnicity-specific responses to insurance coverage.

Cost of Alzheimer's disease in a developing country setting

To evaluate the economic impact of AD in Denizli, Turkey. This observational study was conducted with 42 AD patients and their primary caregivers. During the initial interview, demographic data and medical histories were collected with questionnaires. For an observational period of 15 days, data on time spent for patient care were collected using standard forms. Calculations on direct cost (e.g. per day medication, outpatient physician visits during the last 3 months), indirect cost (e.g. time spent for care by caregiver for daily living (ADL) and instrumental activity of daily living (IADL)) were made by summing up and taking averages of the appropriate items. ANOVA, and linear regressions were the methods for comparisons. The primary caregivers of the patients mainly were their children and/or spouses. The maximum mean time spent (h/week) was 21.0 (17.5) for severely damaged cognition. The average annual cost per case was between $1,766 [95% Confidence Intervals (CI); 1.300-2.231] and $4,930 (95% CI; 3.3714-6.147). The amount of caregiver cost was the most significant item in the overall cost and it showed an increase with the declining cognitive function of patients. Daily medication cost reflected the same pattern. In contrast, cost of outpatient physician was the lowest among the patients with the worst cognition. These results suggest that recently AD has become a significant cost for developing countries. This pilot study gives an idea of the cost of AD in developing countries where determining the actual cost can be difficult.