Exercise rehabilitation improves functional outcomes and peripheral circulation in patients with intermittent claudication: a randomized controlled trial.

OBJECTIVE: To determine the effects of a 6-month exercise program on ambulatory function, free-living daily physical activity, peripheral circulation, and health-related quality of life (QOL) in disabled older patients with intermittent claudication. DESIGN: Prospective, randomized controlled trial. SETTING: University Medical (Center and Veterans Affairs Medical Center, Baltimore, Maryland. PARTICIPANTS: Thirty-one of 61 patients with Fontaine stage II peripheral arterial occlusive disease (PAOD) were randomized to exercise rehabilitation and 30 to usual-care control. Three patients from the exercise group and six patients from the control group dropped out, leaving 28 and 24 patients, respectively, completing the study in each group. INTERVENTION: Six months of exercise rehabilitation. MEASUREMENTS: Treadmill distance walked to onset of claudication and to maximal claudication, ambulatory function, peripheral circulation, perceived QOL, and daily physical activity. RESULTS: Compliance with the exercise program was 73% of the possible sessions. Exercise rehabilitation increased treadmill distance walked to onset of claudication by 134% (P < .001) and to maximal claudication by 77% (P < .001), walking economy by 12% (P = .003), 6-minute walk distance by 12% (P < .001), and maximal calf blood flow by 30% (P < .001). Changes in distance walked to maximal pain correlated with changes in walking economy (r = -.50, P = .013) and changes in maximal calf blood flow (r = .38, P = .047). Exercise rehabilitation increased accelerometer-derived daily physical activity by 38% (P < .001); this change correlated with the change in distance walked to maximal pain (r = .45, P = .020). These improvements were significantly better than the changes in the control group (P < .05). CONCLUSION: Improvements in claudication following exercise rehabilitation in older PAOD patients are dependent on improvements in peripheral circulation and walking economy. Improvement in treadmill claudication distances in these patients translated into increased accelerometer-derived physical activity in the community, which enabled the patients to become more functionally independent.

Obesity-related hospitalization costs to the U.S. Navy, 1993 to 1998.

The objective of this work was to estimate the cost to the U.S. Navy for obesity-related hospital admissions by examining (1) inpatient utilization associated with obesity; (2) the rank order, probability, and total facility costs of obesity-related diagnosis-related groups (DRGs); and (3) expected inpatient expenses. The frequency and probability of inpatient events in the Navy's active duty population were derived from the Department of Defense's Retrospective Case Mix Analysis System. Medicare-based facility costs per DRG were estimated. These measures were combined in a decision-analytic model. Expected facility costs per obesity-related admission for active duty Navy personnel increased by age group from $3,328 for 18 to 24 year olds to $5,746 for 45 to 64 year olds. The annual avoidable inpatient cost for the Navy was estimated to be $5,842,627 for the top 10 obesity-related DRGs. Improvements to the Navy Physical Readiness Program and other interventions that may reduce obesity, obesity-related health care use, and the public economic burden should be pursued.

Caregivers' unmet needs for support in caring for functionally impaired elderly persons: a community sample.

Few estimates have been made of the extent to which the needs of caregivers are met. In addition to the inadequate capacity of services, many caregivers lack adequate financial resources, social resources, or other means to access them. Caregivers who provide services to minority or poor elderly may be particularly needy since their care receivers tend to be less healthy and are less likely to use institutional facilities. To address this issue, the authors studied a community sample of 124 caregivers who identified correlates of their perceived unmet caregiver needs and their use of supportive services available for their caregiving. Results indicated that 51.8 percent of women and 67.4 percent of men reported needs for one or more community services that were not met. It was concluded that caregivers who are poor or who required financial assistance are at the highest risk for needing assistance while providing caregiving services. Community services may more effectively target potential needs of caregivers through routine screenings.

Cost-effectiveness of aerobic and resistance exercise in seniors with knee osteoarthritis.

PURPOSE: The purpose of this study was to determine, in a randomized clinical trial of 439 individuals with knee osteoarthritis, the incremental cost-effectiveness of aerobic versus weight resistance training, compared with an education control intervention. METHODS: Cost estimates of the intervention were based upon the cost of purchasing from the community similar services to provide exercise or health education. Effect at 18 months was measured using several variables, including: self-reported disability score, 6-min walking distance, stair climb, lifting and carrying task, car task, and measures of pain frequency and pain intensity on ambulation and transfer. RESULTS: The total cost of the educational intervention was $343.98 per participant. The aerobic exercise intervention cost $323.55 per participant, and the resistance training intervention cost $325.20 per participant. On all but two of the outcome variables, the incremental savings per incremental effect for the resistance exercise group was greater than for the aerobic exercise group. CONCLUSION: The data obtained from this study suggest that, compared with an education control, resistance training for seniors with knee osteoarthritis is more economically efficient than aerobic exercise in improving physical function. However, the magnitude of the difference in efficiency between the two approaches is small.

Chronic disease self-management: improving health outcomes.

Chronic disease has become pandemic in the United States, and estimates are that it will affect 148 million people by the year 2030. Patients with chronic illnesses cost the health care system over three times more than individuals without chronic conditions. The US Department of Veterans' Affairs (VA) Sunshine HealthCare Network, composed of VA health care facilities in Florida and Puerto Rico, recognized that the needs of its increasing number of veterans with chronic diseases were unmet by traditional medical interventions. The Network implemented a chronic disease self-management pilot program to evaluate its value for the veteran population. Results of the pilot indicate that this program will make a positive, lasting change in the health status and quality of life for veterans with chronic disease.

Linking innovative nursing practice to health services research.

For many nurses, the first step toward becoming a nurse researcher is to obtain help to develop and conduct research that documents outcomes of their novel innovation. These opportunities to engage in health services research often require collaborating with trained researchers who may not have clinical backgrounds. Collaboration generates learning and sharing processes that can be rewarding on many levels. To understand the realities of the collaboration process, this article provides a case study as the authors recount their experiences.

The Kidney Outcomes Prediction and Evaluation (KOPE) study: a prospective cohort investigation of patients undergoing hemodialysis. Study design and baseline characteristics.

PURPOSE: The purpose of the Kidney Outcomes Prediction and Evaluation (KOPE) study, was to more fully characterize the end-stage renal disease (ESRD) population with respect to social, psychological, and clinical characteristics, and to prospectively study the biomedical, social, and psychological factors that influence a range of ESRD outcomes in a large observational study of black and white patients on hemodialysis. This paper focuses on the KOPE study design as well as characteristics of patients at baseline. METHODS: KOPE was a prospective cohort investigation of patients treated at four dialysis centers in Forsyth County, North Carolina. Participants were interviewed at the dialysis centers, semi-annually over a 3 1/2 year period. Prevalent cases who were being treated with hemodialysis at the initiation of the study were enrolled into KOPE. Incident cases were subsequently enrolled as they presented to the participating units for hemodialysis. A total of 304 prevalent and 162 incident cases were enrolled into the study. The baseline health and sociodemographic characteristics of KOPE participants reported in this paper were obtained from medical records and Southeast Kidney Council data. Laboratory values taken within a 30-day interval around the baseline interview are also reported. RESULTS: KOPE participants differ from national statistics on race, age, and gender. Differences between KOPE participants and patients living in the region, but who did not participate in the study, can be explained by our recruitment criteria. CONCLUSIONS: KOPE will enable the characterization of the ESRD population, identification of factors related to poor outcomes, and identification of opportunities for interventions to prevent death and morbidity.

Relationship between health status and utility measures in older claudicants.

The purpose of this study was to examine the relationship between health status and health utility measures in 34 older claudicants and to determine which attributes of health status were significant predictors of health state valuation/preference. The MOS SF-36 was used to assess health status and the rating scale and multiattribute Health Utility Index (HUI) were used to assess utility scores. With regard to health status, the bodily pain and physical functioning subscales contributed the most to reductions in quality of life (QoL) with mean subscale scores substantially lower than reported population norms. Patients rated their health status approximately one-third below a state of perfect health on both utility measures. Moderate correlations were observed between the MOS SF-36 subscale scores and the HUI and rating scale scores. In multivariable regression models, physical functioning and mental health were the best predictors of HUI scores, whereas general health and vitality were the best predictors of rating scale scores. Approximately 50% of the variance in utility scores was explained by these attributes. This study provides further documentation that bodily pain and reductions in physical function contribute to reductions in QoL in older patients with intermittent claudication. Other attributes of health status, however, notably psychological distress, were predictive of patients' preference for health states. Recognized constructs of physical and mental health explained the substantial variation in the utility/preference assessment in this population. Furthermore, these data are consistent with those reported in the Dutch Iliac Stent Trial.

The economic impact of psoriasis increases with psoriasis severity.

BACKGROUND: Psoriasis treatments are known to be costly, but little is known about the financial impact of psoriasis and the way in which it relates to the severity of the disease. OBJECTIVE: This study was performed to obtain an estimate of the treatment costs faced by patients with psoriasis. METHODS: A total of 578 anonymous mail surveys were distributed to patients with psoriasis; 318 surveys were returned (55%). Psoriasis severity was assessed with the previously validated Self-Administered Psoriasis Area Severity Index (SAPASI). RESULTS: The total and out-of-pocket expenses to care for psoriasis were correlated with psoriasis severity (r = 0.26, p = 0.0001). There were no sex (p = 0.9) or racial (p = 0.4) differences in total expenditures. Severity was correlated with how bothersome to the patient was the cost of treatment (r = 0.30, p = 0.0001), the time required for treatment (r = 0.38, p = 0.0001), and the time lost from work (r = 0.23, p = 0.0001). Lower quality of life at work and in money matters also correlated with severity of psoriasis. Higher family income was associated with less time spent caring for psoriasis and less interference with work around the home. CONCLUSION: As expected, the expenses caring for psoriasis are greater for patients with more severe disease. These costs and other financial implications are associated with lower quality of life for patients with more severe psoriasis.

Economic value of caregiver effort in maintaining long-term ventilator-assisted individuals at home.

OBJECTIVE: To estimate the economic value of caregivers' efforts in maintaining ventilator-assisted individuals at home. DESIGN: Nonexperimental, cross-sectional survey. SETTING: Households of home-based ventilator-assisted individuals residing in 37 states. PARTICIPANTS: Caregivers of 1404 ventilator-assisted individuals; 277 (19.7%) responses were received. OUTCOME MEASURES: The Home Ventilator Care Cost and Utilization Survey and the Modified Katz Index. METHODS: The economic value of caregiver effort was estimated deterministically by opportunity cost, aggregated market value, and aggregated replacement cost and estimated stochastically by ordinary least squares regression. Cost of formal home care services was estimated with the Medicare Schedule of Limits for Home Health Agency Costs. Estimates of total cost of home care for each method of valuing caregiver effort were calculated by summing the cost of formal home care services with the value of caregiver effort. RESULTS: The average monthly cost of formal home care services was estimated to be $6411 (SD, $8490; median, $2006; range, $0 to $38,607). After adding various values of caregiver effort to the cost of formal home care services, the average cost of home care increases by $960 to $12,483, depending on the method used to calculate the value of the caregiver's time; the median total cost of home care increased by $1403 to $17,793. Data also showed that, depending on the figure used to estimate the cost of long-term care and which method was used to calculate caregiver value, home care was more expensive for at least 4.6% of ventilator-assisted individuals and for as many as 36.7%. CONCLUSIONS: The incorporation of the caregiver's time value into cost estimates did not substantially reduce the proportion of patients for whom home care was the least expensive alternative, except when caregiver effort was valued at a registered nurse's wage rate. However, the methods used to place an economic value on caregiver effort did not take into consideration the long-term economic impact on caregivers who reduce their work hours or forego employment or educational opportunities, nor did they take into account the lost wages of the ventilator-assisted individual or the extent to which the caregiver was financially dependent on the ventilator-assisted individual.

Financial performance among adult day centers: results of a national demonstration program.

OBJECTIVES: This paper describes the financial performance (defined as percent of total expenses covered by net operating revenue) of 16 adult day centers participating in a national demonstration program on day services for people with dementia, including examination of possible predictors of financial performance. METHODS: Participating sites submitted quarterly financial and utilization reports to the National Program Office. Descriptive statistics summarize the factors believed to influence financial performance. RESULTS: Sites averaged meeting 35% of expenses from self-pay and 29% from government (mainly Medicaid) revenue, totaling 64% of all (cash plus in-kind) expenses met by operating revenue. Examination of center characteristics suggests that factors related to meeting consumer needs, such as being open a full day (i.e., 7:30 am to 6:00 pm) rather than shorter hours, and providing transportation, may be related to improved utilization and, thus, improved financial performance. Higher fees were not related to lower enrollment, census, or revenue. CONCLUSIONS: Adult day centers are able to achieve financial viability through a combination of operating (i.e., fee-for-service) and non-operating revenue. Operating revenue is enhanced by placing emphasis on consumer responsiveness, such as being open a full day. Because higher fees were not related to lower utilization, centers should set fees to reflect actual costs. The figure of 64% of expenses met by operating revenue is conservative inasmuch as sites included in-kind revenue as expenses in their budgeting calculations, and percent of cash expenses met by operating revenue would be higher (approximately 75% for this group of centers).

Rural and urban differences in mortality among Americans 55 years and older: analysis of the National Longitudinal Mortality Study.

Previous research on rural and urban differences in risk of mortality has been inconclusive. This article used data from the National Longitudinal Mortality Study to establish whether all-cause mortality risk among persons 55 years and older varies by degree of urbanization, controlling for the potential sociodemographic confounders of age, gender, race/ethnicity, education, income, and marital status. Using the Cox Proportional Hazards Regression Procedure, the authors found that persons living in the most rural locales and those living in rural communities in standard metropolitan statistical areas (SMSAs) have the lowest risk of mortality, while those living in SMSA central cities had the highest risk of dying during the study period. The protective effect of rural residence declines in older age cohorts.

Use of subdermal contraceptive implants in a community-based family planning program. Experience after two years.

PIP: In North Carolina, the Rutherford County Family Planning Council obtained funds from a special grant for levonorgestrel implants for women not eligible for medical assistance benefits. The Council approved the following approaches to promoting responsible sexual behavior and preventing unwanted pregnancy: creation of an interagency council to monitor the program, education in the schools on responsible sexual behavior, establishment of an information-sharing network for social service agencies, and expanded, low-cost or free family planning services. During 1992-1993, clinicians at the county health department and in private practices inserted implants in 287 women aged 13-37 living mainly in Rutherford County but also in McDowell and Polk counties. A survey was also conducted in the public high school to obtain self-assessment and information about family planning from female adolescents. Age distribution of the acceptors of the contraceptive implants was 40% for 13-19 year olds (the initiative's target group), 34% for 21-25 year olds, and 32% for 18-20 year olds (32%). The two-year insertion rate for women aged 10-19 was 17.3/1000 compared to 20.8/1000 for women aged 20-29. The implantation rate was greatest among 18-25 year olds and lowest among women aged 26 and older. The method of payment for implantation was medical assistance in 69% of cases and a philanthropic foundation for women not eligible for medical assistance in 29% of cases. 8% had the implants removed during the study period. The leading reason for removal was psychological distress (25%), followed by headaches (20.8%), desire to conceive (16.7%), bleeding (12.5%), and medical contraindication (12.5%). The interval between implantation and removal ranged from less than 3 months to more than 12 months. 2.3% of the female high school students used implants. Among the 596 students who were sexually active, 4.2% used implants, 1.85% used a diaphragm, 27.5% used condoms, and 15% used oral contraceptives. The implant acceptors attended 65% of scheduled 3-month follow-up visits.^ieng

Use of GnRH agonist before hysterectomy: a cost simulation.

OBJECTIVE: To evaluate the potential savings in cost of care derived from performing vaginal hysterectomies instead of abdominal hysterectomies in selected women with fibroid uteri equivalent in size to a 14-18 week gestation. METHODS: Women 35-46 years of age undergoing hysterectomy for fibroid uteri were selected to allow application of conversion rates gained in a separate randomized study using leuprolide acetate depot 3.75 mg. Statewide public data for North Carolina's hospital discharges provided relative rates of hospital charges and leiomyomas for all hysterectomies, by age. Professional charges were omitted from the analysis. Estimated savings were projected to the national level. RESULTS: During 1992 in North Carolina, 18,110 inpatient hysterectomies were performed for women of all ages; 28.1% of these were for uterine leiomyomas. For women 35-46 years old (12.7% of all hysterectomies), there were 1904 abdominal and 390 vaginal hysterectomies; the mean total charge for abdominal hysterectomy was $5590, and $4732 for the vaginal alternative. These statewide data provide missing elements to allow a national estimate of the potential savings of using GnRH agonist preoperatively. The projected national savings, if 1987 utilization data are used, was $4.6 million, nearly 1.4% of the inpatient charges. The 1992 value of these savings is $6.7 million. CONCLUSION: The use of preoperative GnRH agonist therapy before hysterectomy for patients with a uterine size equivalent to a 14-18 week gestation represents a significant cost-saving alternative, increasing the use of vaginal hysterectomy and resulting in potential savings in direct inpatient medical care charges.

Mortality in the uninsured compared with that in persons with public and private health insurance.

OBJECTIVE: To compare mortality in persons with employer-provided health insurance, Medicare, Medicaid, military health benefits, other private health insurance, and no health insurance, before and after adjustment for income and employment status. DESIGN: Cohort study using national survey data containing information on social, economic, and demographic factors and health insurance, with deaths identified through matching to the National Death Index resulting in a mortality follow-up period of 5 years. SETTING: Noninstitutionalized population of the United States. PARTICIPANTS: Approximately 150,000 respondents to national surveys conducted by the US Bureau of the Census (Current Population Surveys), aged 25 to 64 years. RESULTS: After adjustment for age and income, persons with Medicare and Medicaid had the highest mortality in comparison with those with employer-provided insurance, with relative risks generally greater than 2. With adjustment for age and income, persons without insurance had higher mortality than those with employer-provided insurance, with relative risks of 1.2 for white men and 1.5 for white women. These relationships held after adjustment for employment status, with the working uninsured showing mortality between 1.2 and 1.3 times higher than that of the working insured. Mortality was higher in those with lower incomes after adjustment for insurance status. Those with annual income of $10,000 or less per year had mortality about two times that of persons with incomes greater than $25,000 per year. CONCLUSION: Mortality was lowest in employed persons with employer-provided health insurance. The higher mortality in those with public insurance or with no insurance reflects an indeterminate mix of selection on existing health status and access to medical care.

Dermatologic services provided to children and adolescents by primary care and other physicians in the United States.

To determine the frequency and types of pediatric dermatologic problems encountered by primary care physicians, dermatologists, and other physicians, we examined data from the 1990 National Ambulatory Medical Care Survey, a continuing study of physician practice in the United States. In 1990, 163.3 million physician office visits were made by patients 18 years of age or younger for all diagnoses; of these, 126.2 million were to primary care physicians. Among visits to these providers, a primary, secondary, or tertiary cutaneous concern or diagnosis was recorded in 12.3 million visits (9.7%). Of these patients with a primary cutaneous concern, 68% of visits were made to primary care physicians, 21% to dermatologists, and 10% to other physicians. For encounters in which primary care physicians reported a primary dermatologic diagnosis (9.6 million visits, 7.6%), the majority of diagnoses (86-93%) were in one of five categories: skin infections, dermatitis, parasitic infestations, acne, or urticaria. This analysis demonstrates the great frequency with which cutaneous disease occurs in ambulatory medicine, and reinforces the importance of dermatologic education in the training of primary care physicians.

Mass mammography screening: using an information system to track participation and identify target populations.

This article describes the 1991 American Cancer Society Greater Tampa Bay Breast Screening Program and an information system developed to track participants from the point of inquiry to mammography results. Information from three sources was linked to create a comprehensive data base, including participant demographics, mammography history, perceived risks of breast cancer, barriers to mammography, and mammography results. This comprehensive data base allowed investigators to describe the 11,134 participants and to assess the program's impact. The analysis suggested that women older than 65 years are underrepresented in this voluntary program. Black women were less likely to participate, as were women in lower income and education groups. To reduce mortality effectively, leaders of mass screening programs need to develop creative strategies for reaching these high-risk groups. Effective information systems can identify program weaknesses and track the impact of changes.

Office-based physician services provided by dermatologists in the United States in 1990.

Published epidemiologic data regarding dermatologic practice may no longer be current. The National Ambulatory Medical Care Survey conducted in 1990 provides a comprehensive assessment of ambulatory medical practice including patient demographics, chief and secondary complaints, diagnoses, and drug treatments prescribed. Many specialties including dermatology were represented in the sampling technique. The database was reviewed for descriptive aspects of visits to dermatologists surveyed. Using standardized weighting techniques, we estimated the total number of physician visits. Dermatologists had an estimated 24.0 million patient encounters in 1990. Dermatologists treated a disproportionately large number of female and younger patients. After adjusting for their proportion of the population, Asians and Whites had greater numbers of dermatologic encounters than Blacks and Native Americans. Patients had two or more complaints 27.2% of the time, and received two or more diagnoses 28.9% of the time. The most common complaints accounting for 49.7% of visits included "pimples," "rash," "discoloration," "skin lesion," "wart," and "skin growth." The most common diagnoses, accounting for 52.7% of all encounters, were acne, keratosis, wart, dermatitis or eczema, benign neoplasm, and malignant neoplasm. This paper presents demographic information, chief and secondary complaints, and chief and secondary diagnoses of patients visiting dermatologists in the United States in 1990. Whites and Asian or Pacific Islanders have increased utilization of services compared with Blacks and Native Americans or Eskimos; this disparity correlates with median family income.

Response to the National Cancer Institute Alert. The effect of practice guidelines on two hospitals in the same medical community.

BACKGROUND: Despite the recent increase in medical practice guideline development and dissemination, physician compliance with the guidelines has often been low. Previous research has suggested that physicians at hospitals with low volumes of cases and weakened financial status were more likely to omit indicated diagnostic testing or appropriate treatment. The authors sought to determine whether differences in compliance to a widely disseminated set of guidelines would exist even among the most dominant hospital providers within the same medical community. METHODS: Two hospitals, together providing nearly half of the cancer surgery within a metropolitan area, were studied for their compliance to the May 1988 National Cancer Institute (NCI) Clinical Alert regarding adjuvant therapy after primary treatment for node negative breast cancer. A case series consecutive collection of 549 women treated at the study hospitals for 2 years before and two years after the Alert determined those patients who had received any form or combination of adjuvant therapy after primary surgical treatment (lumpectomy or modified radical mastectomy). RESULTS: Following modified radical mastectomy, for women age 50 and older, the university hospital (U) provided adjuvant therapy to a higher percentage of patients than the community hospital (C) both before (25.6% versus 4.7%, P < 0.005) and after (58.9% versus 23.2%, P < 0.001) the Alert. For women younger than 50 years of age, the two hospitals were equally likely to provide adjuvant therapy both before and after the Alert. Following lumpectomy, hospital U increased the percentage of women receiving adjuvant therapy following the Alert in women younger than 50 years of age (25-75.8%, P < 0.001) and in women age 50 and older (33.3-56.5%, P < 0.025). Hospital C provided no adjuvant therapy before or after the Alert. Preferences for breast conserving surgical treatment were significantly (P < 0.001) different with hospital U performing a higher percentage of lumpectomies than hospital C both before (50.9% versus 14.9%) and after (57.6% versus 16.8%) the Alert. CONCLUSIONS: Significant differences in compliance with practice guidelines may be found even among the most dominant hospital providers of cancer services within the same medical community. The role of the surgeon in referring patients to the oncologist greatly influences the ultimate provision of adjuvant therapy. Strategies for enhancing compliance should be considered integral to the process of guideline development.