Potential effect of authorization bias on medical record research.

OBJECTIVE: To analyze the influence of recent changes in Minnesota statutes that generally require prior authorization for use of medical records for research from patients who received medical care after Jan. 1, 1997. MATERIAL AND METHODS: In this Mayo Clinic Institutional Review Board-approved study, we obtained a stratified random sample of patients encountered at Mayo Clinic Rochester during the period 1994 through 1996 and estimated the proportion willing to provide the general authorization. On the basis of data from administrative files, we then compared demographic, diagnostic, and utilization characteristics for patients who provided authorization and those who did not. RESULTS: Overall, 3.2% (95% confidence interval, 2.4 to 4.0%) of the study subjects declined authorization. If patients not responding to requests for authorization were also considered to have refused, the overall refusal rate would be 20.7% (95% confidence interval, 18.5 to 22.9%). Women were somewhat more likely to refuse authorization than were men (4.0% versus 2.4%; P = 0.067), and patients younger than 60 years were more likely to refuse than were older patients (5.4% versus 1.2%; P<0.001). Patients residing more than 120 miles from Rochester were much less likely to decline authorization than were local residents (2.1% versus 5.8%; P = 0.001). Patients with prior diagnoses that might be considered more sensitive such as mental disorders, infectious diseases, and reproductive problems also were more likely to refuse authorization. CONCLUSION: These data demonstrate that laws requiring written authorization for research use of the medical record could result in substantial biases in etiologic and outcome studies, the direction and magnitude of which may vary from topic to topic. Clinicians should be prepared to enter the discussion to help inform patients and legislators of the potential hazards of laws that restrict access to medical records for research purposes.

Health care utilization in multiple sclerosis: a population-based study in Olmsted County, MN.

OBJECTIVE: The authors sought to determine acute ambulatory- and hospital-billed charges for the Olmsted County, Minnesota Multiple Sclerosis (MS) Disability Prevalence Cohort and compare them to those incurred by the general population. METHODS: Billed charges for 155 people with clinically definite or laboratory-supported MS were compared with those of age- and gender-matched non-MS controls. Billing data, including all inpatient and outpatient acute and rehabilitative medical care charges over a 5-year period surrounding a December 1, 1991 prevalence date, were analyzed. Data were correlated with level of disability using the Minimal Record of Disability for MS. RESULTS: Median total annual billed charges for most individuals with MS, including those with less severe ($1,277) and relapsing-remitting illness ($1,348), did not differ from those for controls ($1,327, p=0.075). Only those with severe MS (22.6%) had median annual medical charges higher than controls ($5,440, p < 0.001). Male patients with MS had higher median annual total charges ($2,353) than male controls ($762, p=0.003). Total charges for female patients with MS ($1,440) were not different from those for female controls ($1469). Median annual outpatient charges were 15% more for the MS group ($1,418) than for controls ($1,231). Patients with MS had a mean of 0.2 hospital admissions annually compared with 0.1 annual admissions per control patient. Among variables collected on persons with MS, the Expanded Disability Status Scale was the strongest predictor of level of charges (p < 0.001). CONCLUSION: Acute ambulatory- and hospital-billed charges for most patients with MS do not differ from those of the general population.

Direct medical costs unique to people with arthritis.

OBJECTIVE: We report the results of a population based analysis of all health services used and charges incurred over a one-year period among a community based cohort of persons with a diagnosis of arthritis [including both osteoarthritis (OA) and rheumatoid arthritis (RA)] compared to a similar cohort of individuals from the same community who have never had a diagnosis of arthritis (NA), to examine the attributable costs of this chronic condition. METHODS: The unique resources of the Rochester Epidemiology Project were used to assemble the arthritis prevalence cohorts and the population based control cohort. The Olmsted County Health Care Utilization and Expenditures Database was used to collect information on health services utilization and charges. RESULTS: The average direct medical charges for the RA, OA, and NA cohorts were $3,802.05, $2,654.51, and $1,387.83, respectively (age and sex adjusted, p < 0.0001 for both the RA vs NA and OA vs NA comparisons). The median charges for these 3 groups were $1,050.00, $663.55, and $232.04 for the RA, OA, and NA groups, respectively (age and sex adjusted p < 0.0001 for both the RA vs NA and OA vs NA comparisons). These analyses indicated that, compared to the NA cohort both the OA and the RA prevalence cohorts incurred statistically significantly more charges, not only for the musculoskeletal disease care, but also for the care of numerous other conditions including respiratory, cardiovascular, gastrointestinal, neurological, and psychiatric conditions; and for general medical care. Individuals with arthritis (both OA and RA) also incurred statistically significantly more charges for diagnostic and therapeutic procedures, in-hospital care, imaging studies, physician services, equipment, and laboratory studies. Use of prescription medications was statistically significantly more common in the RA and OA groups compared to NA (96.3, 96, and 83%, respectively; age and sex adjusted p = 0.006 for the OA vs NA comparison and p = 0.015 for RA vs NA). CONCLUSION: These results emphasize the importance of considering all health services utilization (rather than only disease specific use) when estimating the economic effect of a chronic illness such as arthritis.

Indirect and nonmedical costs among people with rheumatoid arthritis and osteoarthritis compared with nonarthritic controls.

OBJECTIVE: Compared to rheumatoid arthritis (RA), osteoarthritis (OA) is considered much more benign and much less costly. We sought to describe the economic effects of RA and OA, in terms of the indirect and nonmedical expenditures, compared to nonarthritic controls. METHODS: Using our unique population based data resources, we developed a model for estimating and comparing disease specific costs among 2 randomly selected, community based samples of 200 patients each with RA and OA and a control group of 200 individuals from the same community who do not have arthritis. Data were collected using a pretested postal survey. Age and sex adjusted comparisons were conducted across the 3 groups, and predictors of cost and utilization were identified using logistic regression modeling. RESULTS: There were 123, 116, and 94 respondents among the RA, OA, and nonarthritis groups, respectively. The average age and the female-to-male ratios were higher in the OA and RA groups compared to the nonarthritis group. Patients with RA and OA required 3 times more days of care for their conditions compared to nonarthritics (p < 0.0001) and incurred significantly more expenditures for home or child care (p = 0.01) and other services (p = 0.001) (i.e., medical equipment, assistive devices, or home remodeling) compared to nonarthritics. In addition, patients with RA were significantly more likely to have lost their job or to have retired early due to their illness (p = 0.001); were the most likely to have reduced their work hours or stopped working entirely due to their illness (p = 0.003); and were 3 times more likely to have had a reduction in household family income than either individuals with OA or those without arthritis (p = 0.0001). Fifteen percent of respondents with RA were unable to get a job because of their illness, while 3% of respondents with OA and only 1% of nonarthritic respondents reported this experience (p = 0.001). Logistic regression analysis revealed that functional status and pain score, as well as the presence of either RA or OA, were significant predictors of cost and health services utilization. CONCLUSION: Disease specific indirect and nonmedical costs for OA are substantial and approach those for RA. This has important societal implications, given the high prevalence of OA.

A cost-utility analysis of misoprostol prophylaxis for rheumatoid arthritis patients receiving nonsteroidal antiinflammatory drugs.

OBJECTIVE: To determine the cost-utility of low-dose misoprostol prophylaxis in rheumatoid arthritis (RA) patients treated with nonsteroidal antiinflammatory drugs (NSAIDs). METHODS: Prospectively collected, population-based data on 57 RA patients' preferences (obtained using the category scaling and time trade-off techniques), charge data from a consecutive, population-based cohort of 36 RA patients with NSAID-related gastric ulcer, and literature-derived probability estimates were incorporated into a decision analysis model. RESULTS: Probabilistic sensitivity analysis using 10,000 Monte Carlo simulations demonstrated that, on average, prophylaxis resulted in modest additional costs and no additional quality-of-life benefits. At best, the incremental cost per quality-adjusted life year gained was $9,333. At worst, prophylaxis reduced quality of life. Prophylaxis was cost-saving if the ulcer complication rate was > 1.5%, or if the 3-month price of misoprostol was < or = $95. CONCLUSION: Whereas prophylaxis may be cost-saving among high-risk NSAID users, from some patients' perspective, it reduces quality of life. Although these data may not be generalizable to other clinical populations, they illustrate the importance of incorporating patient preferences into economic evaluations.

Patient preferences for nonsteroidal antiinflammatory drug related gastrointestinal complications and their prophylaxis.

We conducted a pilot study examining the relative preferences for various nonsteroidal antiinflammatory drug associated adverse gastrointestinal events and misoprostol prophylaxis for these events. Thirty patients with rheumatoid arthritis volunteered to participate. A trained nurse interviewer administered the structured pretested interview. Respondents rated 18 hypothetical health states on a category rating scale with anchors at 0 (immediate death) and 100 (full health for life). Linear contrasts were created to test the null hypotheses of equal preferences, using t tests for correlated means. Our results suggest that respondents place a high value on the avoidance of (in order of decreasing importance) surgery, hospitalization, prophylaxis induced diarrhea and uncomplicated ulcer requiring outpatient treatment. The avoidance of ulcer symptoms (primarily dyspepsia) and the inconvenience of an additional medication taken 4 times daily (in the absence of diarrhea) appeared to be substantially less important from these patients' perspective. Further work is underway to confirm these preliminary findings.

The Olmsted County Benchmark Project: primary study findings and potential implications for corporate America.

Since 1965, expenditures for medical care in the United States have increased 10-fold. As a result, corporate outlays for health benefits have skyrocketed. Employers have instituted various cost-containment measures based in part on reports of wide variations in rates of utilization and the assumption that unnecessary or inappropriate utilization of medical care contributes to increasing costs. Frequently, however, employers lack adequate means for identifying sources of variation or for evaluating its appropriateness. In this article, we report on a project in which hospital utilization among several US corporate populations was compared with that for a geographically defined benchmark population to assist employers in the assessment of their rates of utilization and expenditures and to identify specific areas that merit further investigation. Our findings illuminate the difficulties in constructing valid rates from medical-care claims data and emphasize potential biases due to problems of comparability between populations. We also address the potential value of such comparison for helping corporations identify areas in which cost-containment efforts may be most effective and yet not jeopardize the quality of medical care.

Trends in elderly hospitalization and readmission rates for a geographically defined population: pre- and post-prospective payment.

To address the paucity of patient-level data regarding the effectiveness of Medicare's prospective payment system (PPS), we conducted a population-based study of inpatient hospitalizations among individually identified elderly residents of Olmsted County, Minnesota, 1970-1987. A 4.3% increase in total days of care/1000 population from 2,652/1,000 in 1970 to 2,766/1,000 in 1980 was followed by a 9.8% decline from 1980 to 1987 (2,495/1,000). The decline was due primarily to a 13.4% decrease in mean length stay (9.7 days in 1980 to 8.4 days in 1987). The number of hospitalizations/1,000 Olmsted County elderly in 1980 was already below 1987 U.S. figures and did not exhibit the decline evidenced nationally between 1980 and 1987. A 4.6% decline in the proportion of county residents age 65-74 years who were hospitalized (174/1,000 in 1980 to 166/1,000 in 1987) was offset by an 8.3% increase for persons age greater than or equal to 75 (252/1,000 to 273/1,000) and by a 5.7% increase in the number of hospitalizations per individual hospitalized for persons age 65-74 years (1.34 to 1.42). Using a time-dependent Cox model, which adjusted for differences in patients characteristics between years, there was a significantly higher risk of readmission within 14 days in 1987 vs 1980 (hazard ratio (HR) = 1.33, 95% confidence interval (CI) = 1.05-1.70). The difference between years was no longer evident at 30 or 60 days (HR = 0.84, 95% CI = 0.63-1.11 between 15 and 30 days; HR = 1.12, 95% CI = 0.84-1.49 between 31 and 60 days). This study suggests that initial effects of PPS on utilization may be temporary and that more research is needed to appreciate the impact of cost-containment on patient outcome.

Assessment of prediction of mortality by using the APACHE II scoring system in intensive-care units;.

Some investigators have suggested that information on quality of care in intensive-care units (ICUs) may be inferred from mortality rates. Specifically, the ratio of actual to predicted hospital mortality (A/P) has been proposed as a valid measure for comparing ICU outcomes when predicted mortality has been derived from data collected during the first 24 hours of ICU therapy with use of a severity scoring tool, APACHE II (acute physiology and chronic health evaluation). We present a comparison of mortality ratios (A/P) in four ICUs under common management, in two hospitals within a single institution. Significant differences in A/P were detected for nonoperative patients (0.99 versus 0.67;P = 0.014) between the two hospitals. This variation was traced to uneven representation of a subset of patients who had chronic health problems related to diseases that necessitated admission to the hematology-oncology or hepatology service. No differences in A/P were seen between the two hospitals for operative patients or for nonoperative patients on services other than hematology-oncology or hepatology. Thus, differences in A/P detected by using the APACHE II system not only may reside in operational factors within the ICU organization but also may be related to weaknesses in the APACHE II model to measure factors intrinsic to the disease process in some patients. We suggest that case-mix must be examined in detail before concluding that differences in A/P are caused by differences in quality of care.

Altering residency curriculum in response to a changing practice environment: use of the Mayo internal medicine residency alumni survey.

To elicit the opinions of practicing internists who had graduated from a single internal medicine residency program about the adequacy of their training and its relevance to their medical practice, we mailed a survey to 1,342 physicians who had spent at least 1 year in the Mayo internal medicine residency training program. Of this group, 703 alumni (52%) responded to the survey, 532 of whom were currently practicing internal medicine. Our detailed analysis was based on responses from these 532 and, for some aspects of evaluation, on the 121 general internists who had completed residency training after 1970. Of the respondents, 42% spent more than 80% of their time in general medicine, and 53% had at least some subspecialty practice; 55% were involved in teaching, 20% in some research, and 37% in various administrative duties. In 27%, all patient-care activities involved primary care, an increase from 18% in a 1979 survey and 9% in 1972. Of those who were subspecialists, 67% spent more than half their time in subspecialty practice. Of those who were trained after 1970, 90% were board certified. Most respondents thought that their training in the internal medicine subspecialties was adequate, that additional procedure training was needed in joint aspiration, line placement, and flexible sigmoidoscopy, and that many allied medical areas were important to their practice and necessitated additional training. Although virtually all respondents assessed their inpatient training as adequate, only 42% were fully satisfied with their outpatient training. Alumni surveys can be useful in restructuring a residency program to meet the needs of the trainees.

Disposition at discharge and 60-day mortality among elderly people following shorter hospital stays: a population-based comparison.

This study examines whether shorter hospital stays following the introduction of Medicare's Prospective Payment System have been accompanied by increased mortality or an increased rate of discharge to nursing homes. An examination of hospitalizations for all elderly residents of Olmsted County, MN (N = 5,854) for 1980, 1985, and 1987 demonstrates significant increases in 60-day mortality and nursing home transfers after this system began. These increases, however, are largely explained by differences in risk factors other than length of stay, such as patient age, gender, disease severity, and complexity.