Physician characteristics and the initiation of beta-adrenergic blocking agent therapy after acute myocardial infarction in a managed care population.

OBJECTIVE: To determine the association between physician characteristics and the use of beta-adrenergic blocking agents after acute myocardial infarction in a national managed care organization. STUDY DESIGN: Retrospective administrative data analysis. PARTICIPANTS AND METHODS: The study cohort consisted of 473 physicians who prescribed the medications and 578 patients who (1) experienced an acute myocardial infarction between January 1, 1995, and December 31, 1996, with at least 1 cardiac medication claim within 7 days of hospital discharge; (2) were not previously taking beta-adrenergic blocking agents; and (3) had none of several defined contraindications to the medication. Using multivariate models, we assessed the relation between physician characteristics and initiation of beta-adrenergic blocking agent therapy, controlling for patient characteristics and cardiac treatments. RESULTS: Sixty-two percent of patients filled a prescription for beta-adrenergic blocking agents within 7 days of hospital discharge. Physician characteristics, including specialty and region of hospitalization, were independently associated with the use beta-adrenergic blocking agents. Family practice physicians and other noninternists were much less likely than cardiologists to prescribe beta-adrenergic blocking agents. The other most important predictors of the use of beta-adrenergic blocking agents were region of hospitalization and patient age. CONCLUSIONS: Physician characteristics are associated with the use of beta-adrenergic blocking agents. Although there are opportunities to improve practice for all physicians, family practice physicians and noninternists have the most opportunity to improve.

Health literacy among Medicare enrollees in a managed care organization.

CONTEXT: Elderly patients may have limited ability to read and comprehend medical information pertinent to their health. OBJECTIVE: To determine the prevalence of low functional health literacy among community-dwelling Medicare enrollees in a national managed care organization. DESIGN: Cross-sectional survey. SETTING: Four Prudential HealthCare plans (Cleveland, Ohio; Houston, Tex; south Florida; Tampa, Fla). PARTICIPANTS: A total of 3260 new Medicare enrollees aged 65 years or older were interviewed in person between June and December 1997 (853 in Cleveland, 498 in Houston, 975 in south Florida, 934 in Tampa); 2956 spoke English and 304 spoke Spanish as their native language. MAIN OUTCOME MEASURE; Functional health literacy as measured by the Short Test of Functional Health Literacy in Adults. RESULTS: Overall, 33.9% of English-speaking and 53.9% of Spanish-speaking respondents had inadequate or marginal health literacy. The prevalence of inadequate or marginal functional health literacy among English speakers ranged from 26.8% to 44.0%. In multivariate analysis, study location, race/language, age, years of school completed, occupation, and cognitive impairment were significantly associated with inadequate or marginal literacy. Reading ability declined dramatically with age, even after adjusting for years of school completed and cognitive impairment. The adjusted odds ratio for having inadequate or marginal health literacy was 8.62 (95% confidence interval, 5.55-13.38) for enrollees aged 85 years or older compared with individuals aged 65 to 69 years. CONCLUSIONS: Elderly managed care enrollees may not have the literacy skills necessary to function adequately in the health care environment. Low health literacy may impair elderly patients' understanding of health messages and limit their ability to care for their medical problems.

Hospitalization and expenditures for the treatment of general medical conditions among the U.S. diabetic population in 1991.

Although the medical expenditures for the treatment of acute glycemic and chronic complications of diabetes are well documented, little is known about the costs of treating general medical conditions among persons with diabetes. Accordingly, data from the 1991 National Hospital Discharge Survey and the 1987 National Medical Expenditure Survey were used to estimate the risk of hospitalization for general medical conditions among middle-aged (45-64 yr) and elderly (> or = 65 yr) persons with diabetes and the associated in-patient expenditures attributable to diabetes in the United States. In 1991, there were 371,814 hospitalizations of middle-aged persons with diabetes and 712,725 hospitalizations of elderly persons with diabetes for treatment of general medical conditions. Both middle-aged and elderly persons with diabetes remained hospitalized longer than their nondiabetic peers (8.1 vs. 6.3 days and 10.1 vs. 8.9 days, respectively). Compared to their nondiabetic peers, middle-aged persons with diabetes were at greatest risk of hospitalization for peritonitis/intestinal abscess [relative risk, 13.1; 95% confidence interval (CI), 12.5-13.8] and respiratory failure (relative risk, 5.0; 95% CI, 4.9-5.1) and elderly persons with diabetes were at greatest risk of hospitalization for liver diseases (relative risk, 3.0; 95% CI, 2.9-3.0) and septicemia (relative risk, 2.8; 95% CI, 2.8-2.9). In-patient expenditures for the treatment of general medical conditions attributable to diabetes were estimated at +4.12 billion, nearly twice the in-patient expenditures incurred for the treatment of chronic complications of diabetes. These results demonstrate the disproportionate resources devoted to treating patients with diabetes for conditions that are neither acute glycemic nor chronic complications of diabetes.

Relative risk and economic consequences of inpatient care among patients with renal failure.

During the final phases of chronic renal disease, inpatient care comprises an enormous share of morbidity and direct medical costs. Using an attributable risk methodology, this study calculated inpatient resource utilization and associated costs for chronic renal failure (CRF) and ESRD. A national hospital survey was used to identify the 348,962 hospitalizations for patients with renal failure in 1991. Among persons under the age of 65, pre-ESRD CRF patients had the same number of hospitalizations (nearly 75,000) as ESRD patients. Age-adjusted relative risk calculations indicate that patients with renal failure experience greater inpatient morbidity compared with other populations with chronic, progressive diseases. For example, compared with persons with diabetes, ischemic heart disease, hypertension, and emphysema, renal patients were at significantly higher risk of hospitalization for congestive heart failure, pneumonia, sepsis, electrolyte disorders, and gastrointestinal hemorrhage. Overall, renal failure patients were ten times more likely to be hospitalized (relative risk, 10.0; 95% confidence interval, 10.00 to 10.04) and, on average, were hospitalized nearly 1 day longer (P < 0.01) compared with the non-renal failure population in 1991. As a result, the economic consequences of inpatient care for the treatment of renal failure were enormous. In 1991, 222,827 hospitalizations, 1.5 million days of inpatient care, and $2.2 billion were attributable to renal failure. Further studies that examine other components of direct medical costs (e.g., long-term care, outpatient care, and pharmaceuticals) as well as indirect costs associated with the treatment and care of renal failure patients are warranted.