Evaluation results from prospective drug utilization review: Medicaid demonstrations.

In 1992 HCFA awarded two cooperative agreements for demonstrations of prospective drug utilization review (PDUR). Iowa tested an on-line prospective drug utilization review (OPDUR) system. Washington tested payments to pharmacists for providing non-dispensing "cognitive services" (CS). In this article the authors report on an evaluation of these demonstrations and on three assessments of retrospective drug utilization review (RDUR) interventions. The evaluation failed to detect effects of either State PDUR demonstration on the frequency of drug problems, utilization of prescription drugs and other health services, and clinical outcomes. However, the State RDUR interventions had immediate effects on prescribing physicians.

Drug use and prescribing problems in four state Medicaid programs.

In this article the authors present population-level prevalence rates for 61 specific drug-related problems occurring in three State Medicaid programs (Maryland, Iowa, and Washington) from 1989 through 1996 and a fourth (Georgia) from 1994 through 1996. The findings represent the first application of a consistent drug utilization review (DUR) screener program to Medicaid data across States. The study finds major differences in DUR failure rates among the four States with the lowest rates in Georgia and the highest in Washington. Only Iowa showed any population-level reduction in DUR failure rates during the study period, however, rates for community-dwelling elderly fell in most States.

Adherence to antihypertensive medications across the life span.

Although treatment for hypertension is readily available, poor control of hypertension is a major health problem frequently manifested in late life. Researchers believe that one of the major causes of uncontrolled hypertension is failure to take medication as directed. In this preliminary study, the medication-taking behaviors of 48 adults diagnosed with hypertension, ranging in age from 35 to 87, were recorded for 2 months with credit card-sized bar-code scanners. The social-cognitive model (Park, 1992) for understanding medication adherence, which proposes that medication adherence is governed by both beliefs and cognitive factors, was used as a basis for this research. Therefore, measures of health behaviors, attitudes about health and medication taking, and cognitive function were recorded, as well as blood pressure readings. The main findings were that (a) the oldest-old and groups of middle-aged adults were the most nonadherent, whereas the young-old were more likely to adhere than the other age groups; (b) high blood pressure readings predicted adherence to antihypertensive medications; and (c) medication beliefs influenced adherence in some situations.

Effect of age on event-based and time-based prospective memory.

The magnitude of age differences on event- and time-based prospective memory tasks was investigated in 2 experiments. Participants performed a working memory task and were also required to perform either an event- or time-based prospective action. Control participants performed either the working memory task only or the prospective memory task only. Results yielded age differences on both prospective tasks. The age effect was particularly marked on the time-based task. Performance of the event-based prospective task, however, had a higher cost to performance on the concurrent working memory task than the time-based task did, suggesting that event-based responding has a substantial attentional requirement. The older adults also made a significant number of time-monitoring errors when time monitoring was their sole task. This suggests that some time-based prospective memory deficits in older adults are due to a fundamental deficit in time monitoring rather than to prospective memory.

Managing access: extending Medicaid to children through school-based HMO coverage.

This study explores how a health maintenance organization's (HMO) capacity and incentives to manage care might be used to improve access. In the early 1990s, the Florida Healthy Kids (FHK) demonstration extended Medicaid-like HMO coverage to indigent children in the public schools of Volusia County, Florida. The study finds that uninsured student months in area public schools were likely reduced by one-half. Utilization and cost levels for these indigent enrollees proved to be indistinguishable from commercial clients; and measures of access, utilization, and satisfaction for enrollees were in line with (and in some cases, superior to) non-enrollees with private insurance. Overall, these results suggest the value of using schools as a medium for providing coverage, and the importance of taking deliberate steps to manage access to reduce non-financial barriers to care.

The effects of hospice coverage on Medicare expenditures.

This article reports on the findings of a study of the effects of the hospice program on Medicare Part A expenditures during the first three years of the program. The analysis compared treatment costs between hospice beneficiaries and nonbenefit patients with diagnosis of malignant cancer during their last seven months of life. It was estimated that during the first three years of the hospice program, Medicare saved $1.26 for every dollar spent on Part A expenditures. While the methodology included use of data from Medicare claims to adjust for confounding factors, including self-selection bias, our estimated savings might still have been overstated due to persistent selection effects. The extent of savings also varied according to the hospice's organization. Freestanding hospices, in contrast to those affiliated with either a hospital, nursing home, or home health agency, achieved the greatest savings by utilizing home care more extensively. However, we note that payment rates are increasing and the limits on the benefit period are being lifted, making it possible that the savings related to the hospice program found in this study will not continue. Of greater importance may be the long-term access and quality effects engendered by the benefit's preference for home care.

An alternative in terminal care: results of the National Hospice Study.

Hospice is a program of supportive services for terminally ill patients and their families, provided either at home or in designated inpatient settings, which is purported to improve patient and family quality of life at lower cost than conventional terminal care. The National Hospice Study was a multi-site, quasi-experimental study to compare the experiences of terminal cancer patients and their families in hospices with those of similar patients and families receiving conventional terminal care. The results indicate that, although care is different in hospices, e.g. lesser utilization of aggressive interventional therapy and diagnostic testing, patients' quality of life is similar in the hospice and conventional care systems with the exception of pain and symptom control, which may be better in the inpatient hospice setting. Hospice patients are more likely to die at home and their families are satisfied with that outcome. Otherwise, no consistent superiority of family outcome was associated with the hospice approach. The cost of hospice care is less than that of conventional terminal care for patients in hospices without inpatient facilities, but the cost of hospice appears to be equivalent to conventional care for patients in hospices having beds.

Influence of creep feeding and weaning on brush border enzyme activities in the piglet small intestine.

The activities of the enterocyte brush border enzymes lactase (beta-D galactoside galactohydrolase, EC 3.2.1.23) and sucrase (sucrose alpha-D glucohydrolase, EC 3.2.1.48) were measured at set percentage lengths along the small intestines of 112 piglets killed between 21 and 32 days of age. The influences on these activities of consumption of creep feed and of weaning were recorded. Weaning at three weeks old resulted in large, rapid reductions in lactase activity at most sites along the small intestine; sucrase activity declined temporarily and then recovered. Minimum values were recorded about four to five days after weaning. Similar changes were observed whether or not creep feed was consumed before weaning. Continued consumption of creep feed by unweaned pigs over the 21 to 32 day period also produced small but significant reductions in lactase activities. The large loss of digestive enzyme activities at brush borders in weaned animals coincided with a reduced ability to absorb xylose and to checks in growth rate in otherwise healthy piglets.

Cost savings in hospice: final results of the National Hospice Study.

Medicare inpatient and home care costs over the last year of life of terminal cancer patients served in two types of hospices and in conventional care (CC) were compared as a part of the National Hospice Study (NHS). Both home care (HC) and hospital-based (HB) hospice patients had lower costs in the last month of life than did CC patients. HC patients substituted home care for inpatient care, yielding cost savings for lengths of hospice stay of up to 1 year. Although HB patients added home care to relatively high levels of inpatient care, their ancillary costs per inpatient day were significantly lower than those of CC patients. Thus, HB costs over the last year of life were also somewhat less than those of CC. The size of the savings associated with hospice care is sensitive to the type of hospice and the length of stay distribution of patients served; patients served longer have significantly higher costs in the last year of life.

Patient predictors of hospice choice. Hospital versus home care programs.

Research findings indicate cost savings associated with home care hospices, while hospital-based hospices can be as expensive as conventional care. Based on National Hospice Study data, this article identifies the characteristics of patients admitted to hospital-based and home care hospices in those areas of the country where a choice of hospice model was possible. Multivariate logistic regression indicates that the significant discriminating factors between the two patient populations relate to the availability of supportive care at home and the severity of nursing care problems at the time of hospice entry. Reinforcing selected pre-existing differences, an examination of prehospice had longer episodes of care than was the case for home care hospice patients.

Coliform numbers in the stomach and small intestine of healthy pigs following weaning at three weeks of age.

In 60 weaned and 52 unweaned pigs, aged between 21 and 32 days, the number of coliform organisms in the gastric contents was found to be related to their pH value. The contents were generally more acidic in the weaned animals and contained fewer coliforms. Haemolytic coliform organisms were never identified among selected isolates examined from the gastric contents although in weaned animals the haemolytic enterotoxigenic Escherichia coli serotype 0149: K91, K88a,c (Abbotstown strain) was commonly recovered from the intestines. After weaning, this strain appeared to colonize the anterior small intestine from lower down the tract, and its presence was associated with an increase in the total coliform count at the site from which it was isolated. Rotaviruses were also more commonly detected in the intestinal contents of weaned than unweaned pigs, but their appearance after weaning appeared to be preceded by the proliferation of haemolytic E. coli. The presence of either or both of these potentially enteropathogenic organisms never induced diarrhoea, and although faecal water content increased significantly after weaning, this occurred independently of the presence of both agents.

What does hospice cost?

This paper presents the preliminary results of the economic analyses of the National Hospice Study (NHS), mandated by the United States Congress to investigate the implications of including hospice services in Medicare. Data were collected over an 18-month period from approximately 4,000 patients receiving hospice and conventional terminal care in 25 hospices and 12 conventional care sites. Subsequent analysis may lead to changes in the specific results, and some of the differences may be due to confounding variables that cannot be adjusted for. According to these data, hospital based (HB) hospice costs per day are 44 per cent higher than home care (HC) hospice costs per day ($95 versus $66, respectively). In addition, per patient hospice costs are 24 per cent more for patients enrolled in HB than in HC hospices ($5,890 versus $4,758, respectively). The proportional difference between HB and HC in cost per patient is smaller than the cost per day difference due to the shorter average HB length of stay, 62.3 days compared to 72.5 days for HC. Regarding the cost savings of hospice compared to conventional care, HC hospice costs are lower than conventional care costs regardless of length of stay. However, HB costs seem lower than conventional care costs only for patients with lengths of stay less than two months. Hospice and conventional care patients appear to differ with respect to predisposition toward intensive health care utilization. When this difference is explored more thoroughly in subsequent analyses, the estimated cost differential between hospice and conventional care may change.

Hospital payroll costs, productivity, and employment under prospective reimbursement.

This paper reports preliminary findings from the National Hospital Rate-Setting Study regarding the effects of State prospective reimbursement (PR) programs on measures of payroll costs and employment in hospitals. PR effects were estimated through reduced-form equations, using American Hospital Association Annual Survey data on over 2,700 hospitals from 1969 through 1978. These tests suggest that hospitals responded to PR by lowering payroll expenditures. PR also seems to have been associated with reductions in full-time equivalent staff per adjusted inpatient day. However, tests did not confirm the hypothesis that hospitals reduce payroll per full-time equivalent staff as a result of PR.

Radiologic observations of gastric mixing and emptying of food in growing pigs.

The stomachs of 10 Large White x Landrace pigs were examined radiographically from weaning (at 26 to 28 days of age) until 6 or 16 weeks of age. Conventional radiographs were taken and observations were made with a television chain and 35-mm cinecamera linked to an image intensifier. Before radiography, each animal was fed its normal diet that contained a barium sulfate suspension and/or radio-opaque pellets. The basic pattern of motility in the major chamber of the pig's stomach was similar to that described in animals with a simple stomach. Type II peristaltic waves were clearly identified as indentations of the body of the stomach that moved towards the pyloric antrum, which became circular as it filled with digesta. A terminal antral contraction then occurred, the antrum decreased in diameter, and the ingesta and barium sulfate either entered the duodenum or were returned to the body of the stomach. Liquids and finely ground food left the stomach more rapidly than did the radio-opaque pellets that were retained for up to 44 hours. The radio-opaque pellets demonstrated the movement of ingesta within the gastric lumen and showed that ingesta was retropulsed into the body of the stomach by the terminal antral contraction. In 4 pigs, barium and ingesta were present in the 2nd chamber of the stomach, the gastric diverticulum. In 1 pig, a movement of the diverticulum was observed on a single occasion.

The level of distribution of carbohydrases in the small intestine mucosa of pigs from 3 weeks of age to maturity.

1. The levels of the brush-border enzymes sucrase (sucrose glucohydrolase, EC 3.2.1.48), isomaltase (oligo-1,6-glucosidase, EC 3.2.1.10), maltases 2 and 3 (glucoamylase, EC 3.2.1.3), lactase (beta-galactosidase, EC 3.2.1.23) and trehalase (EC 3.2.1.28) and adsorbed pancreatic alpha-amylase (EC 3.2.1.1) have been measured at twenty-one positions along the small intestines of eighty-four pigs of different ages ranging from 3 weeks to 4.5 years. The state of dilation of the intestine at the sampling points was noted. 2. The levels of sucrase and isomaltase increased with age throughout the age-range studied. Trehalase and the glucoamylases increased with age up to 200--300 d of age. Lactase decreased with age over the whole age range. 3. For the pigs above 10 weeks of age, the distribution pattern of the brush-border enzymes along the intestine did not change with age. Each enzyme had a characteristic distribution curve, with low values at the proximal and distal ends and a peak which was proximal in the instance of lactase and trehalase and approximately mid-way along the gut with sucrase, isomaltase and the glucoamylases. 4. The pattern of distribution of the brush-border enzymes altered with age in the piglets, but approached the adult pattern by 8 weeks. 5. Piglets weaned at 3 weeks had higher levels of sucrase, isomaltase and glucoamylases at 5 weeks than piglets left on the sow. At 8 weeks of age the piglets weaned at 3 weeks still had higher sucrase and isomaltase levels than those on the sow. 6. There was a very close correlation between the sucrase and isomaltase levels, and between the maltase 2 and maltase 3 levels in all the samples, and a fairly close correlation between all these four enzymes. 7. The level of alpha-amylase increased with age but showed no regular distribution pattern, its irregular fluctuations being related to the presence or absence of dilation of the intestine at the time of slaughter rather than to the position along the intestine.