The impact of statistical adjustment on economic profiles of interventional cardiologists.

OBJECTIVES: The objective of this study was to identify preprocedure patient factors associated with percutaneous intervention costs and to examine the impact of these patient factors on economic profiles of interventional cardiologists. BACKGROUND: There is increasing demand for information about comparative resource use patterns of interventional cardiologists. Economic provider profiles, however, often fail to account for patient characteristics. METHODS: Data were obtained from Duke Medical Center cost and clinical information systems for 1,949 procedures performed by 13 providers between July 1, 1997, and December 31, 1998. Patient factors that influenced cost were identified using multiple regression analysis. After assessing interprovider variation in unadjusted cost, mixed linear models were used to examine how much cost variability was associated with the provider when patient characteristics were taken into account. RESULTS: Total hospital costs averaged $15,643 (median, $13,809), $6,515 of which represented catheterization laboratory costs. Disease severity, acuity, comorbid illness and lesion type influenced total costs (R(2) = 38%), whereas catheterization costs were affected by lesion type and acuity (R(2) = 32%). Patient characteristics varied significantly among providers. Unadjusted total costs were weakly associated with provider, and this association disappeared after accounting for patient factors. The provider influence on catheterization costs persisted after adjusting for patient characteristics. Furthermore, the pattern of variation changed: the adjusted analysis identified three new outliers, and two providers lost their outlier status. Only one provider was consistently identified as an outlier in the unadjusted and adjusted analyses. CONCLUSIONS: Economic profiles of interventional cardiologists may be misleading if they do not adequately adjust for patient characteristics before procedure.

Achieving optimal results with standard balloon angioplasty: can baseline and angiographic variables predict stent-like outcomes?

OBJECTIVES: To predict which patients might not require stent implantation, we identified clinical and angiographic characteristics associated with repeat revascularization after standard balloon angioplasty. BACKGROUND: Stents reduce the risk of repeat revascularization but are costly and may lead to in-stent restenosis, which remains difficult to treat. Identification of patients at low risk for repeat revascularization may allow clinicians to reserve stents for patients most likely to benefit. METHODS: Data from five interventional trials (5,146 patients) were pooled for analysis. We identified patients with optimal angiographic results (final diameter stenosis < or =30% and no dissection) after balloon angioplasty and determined the multivariable predictors of repeat revascularization. RESULTS: Optimal angiographic results were achieved in 18% of patients after angioplasty. The repeat revascularization rate at six months was lower for patients with optimal results (20% vs. 26%, p < 0.001) but still higher than observed in stent trials. Independent predictors of repeat revascularization were female gender (odds ratio [OR] 1.67, p = 0.01), lesion length > or =10 mm (OR 1.62, p = 0.03) and proximal left anterior descending coronary artery lesions (OR 1.62, p = 0.03). For the 8% of patients with optimal angiographic results and none of these risk factors, the repeat revascularization and target vessel revascularization rates were 14% and 8% respectively, similar to rates after stent implantation. Cost analysis estimated that $78 million per year might be saved in the U.S. with a provisional stenting strategy using these criteria compared with elective stenting. CONCLUSIONS: A combination of baseline characteristics and angiographic results can be used to identify a small group of patients at very low risk for repeat revascularization after balloon angioplasty. Provisional stenting for these low risk patients could substantially reduce costs without compromising clinical outcomes.

Transradial coronary stenting: comparison with femoral access closed with an arterial suture device.

The purpose of this study was to determine if closure of the femoral artery access site using a percutaneous arterial suture device (Perclose, Menlo Park, CA) in patients undergoing coronary stenting can result in the same benefits as seen with radial artery access. A total of 218 consecutive patients underwent coronary stenting (109 femoral, 109 radial) by investigators experienced with each technique. The two groups were matched in terms of sex, age, clinical presentation (50% acute), number of vessels and lesions stented, and lesion morphology. The relative costs of the femoral and radial procedures were examined using a decision analytic model and sensitivity analysis. The suture device was not used in 20/109 patients (18%) for anatomic reasons and failed to obtain hemostasis in 9/89 patients (10%). One radial patient had an occluded radial artery postprocedure, but this was recanalized at follow-up a month later. Primary success, procedural complications, postprocedure length of stay, and the percentage of patients discharged the same day were the same in both groups. Because of the added time to deploy Perclose, total procedure time was significantly longer in the femoral group (57 +/- 22 min femoral vs. 44 +/- 22 min radial, P < 0.01). Access site complications occurred only in the femoral group. More patients were ambulatory the same day of the procedure in the radial group (95% radial vs. 56% femoral, P < 0.01). The cost of the radial approach was substantially less than the femoral approach because of lower supply costs and fewer access complications. The transradial approach is a dominant strategy for coronary stenting, offering better outcomes at lower cost. Cathet. Cardiovasc. Intervent. 49:150-156, 2000.

Microsurgery costs and outcome.

Reliable information on cost and value in microsurgery is not readily available in the literature. Driving factors for cost, determinants of complications, and cost-reduction strategies have not been elucidated in this population, despite such progress in other areas of medicine. Clearly, the time-consuming and costly nature of this endeavor demands that appropriate indications and patient management be delineated; to operate proactively in this cost-conscious time, financial and outcome determinations are critical. One hundred seven consecutive free-tissue transfers performed from 1991 to 1994 by a single microsurgeon were studied. Retrospective chart review for clinical parameters was combined with analysis of hospital costs and professional charges. Operating room and anesthesia costs were based on a microcost analysis of actual operating room time, materials, labor, and overhead. Other patient level costs were generated by Transition 1, a hospital cost-accounting system. The following issues were addressed: (1) flap survival; (2) total costs and length of stay for all free flaps; (3) payments received from various insurers; (4) breakdown of operating room costs by labor, supplies, and overhead; (5) breakdown of inpatient costs by category; (6) additional costs of complications and takebacks; (7) factors associated with complications and flap takebacks; and (8) cost-reduction strategies. Mean free flap operating room costs (exclusive of professional fees) ranged among case types from $4439 to $6856 and were primarily a function of operating room times. Elective patient cases lasted a mean 440 minutes. There was a large disparity in reimbursement: private insurers covered hospital costs (not charges) completely, whereas Medicare paid 79 percent and Medicaid only 64 percent. Length of stay, operative procedures, and complications had the greatest influence on inpatient costs in this group of free flap patients. Potential cost savings as a result of possible practice changes (e.g., shortening intensive care unit stays and avoiding staged operations) can be predicted. This analysis has caused a revision in these institutions' practice patterns and lays the foundation for planned outcome studies in this population.

Acute and long-term cost implications of coronary stenting.

OBJECTIVES: We compared the acute and one year medical costs and outcomes of coronary stenting with those for balloon angioplasty (percutaneous transluminal coronary angioplasty) in contemporary clinical practice. BACKGROUND: While coronary stent implantation reduces the need for repeat revascularization, it has been associated with significantly higher acute costs compared with coronary angioplasty. METHODS: We studied patients treated at Duke University between September 1995 and June 1996 who received either coronary stent (n = 384) or coronary angioplasty (n = 159) and met eligibility criteria. Detailed cost data were collected initially and up to one year following the procedure. Our primary analyses compared six and 12 month cumulative costs for coronary angioplasty- and stent-treated cohorts. We also compared treatment costs after excluding nontarget vessel interventions; after limiting analysis to those without prior revascularization; and after risk-adjusting cumulative cost estimates. RESULTS: Baseline clinical characteristics were generally similar between the two treatment groups. The mean in-hospital cost for stent patients was $3,268 higher than for those receiving coronary angioplasty ($14,802 vs. $11,534, p < 0.001). However, stent patients were less likely to be rehospitalized (22% vs. 34%, p = 0.002) or to undergo repeat revascularization (9% vs. 26%, p = 0.001) than coronary angioplasty patients within six months of the procedure. As such, mean cumulative costs at 6 months ($19,598 vs. $19,820, p = 0.18) and one year ($22,140 vs. $22,571, p = 0.26) were similar for the two treatments. Adjusting for baseline predictors of cost and selectively examining target vessel revascularization, or those without prior coronary intervention yielded similar conclusions. CONCLUSIONS: In contemporary practice, coronary stenting provides equivalent or better one-year patient outcomes without increasing cumulative health care costs.

Economic assessment of low-molecular-weight heparin (enoxaparin) versus unfractionated heparin in acute coronary syndrome patients: results from the ESSENCE randomized trial. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q wave Coronary Events [unstable angina or non-Q-wave myocardial infarction].

BACKGROUND: In the ESSENCE trial, subcutaneous low-molecular-weight heparin (enoxaparin) reduced the 30-day incidence of death, myocardial infarction, and recurrent angina relative to intravenous unfractionated heparin in 3171 patients with acute coronary syndrome (unstable angina or non-Q-wave myocardial infarction). No increase in major bleeding was seen. METHODS AND RESULTS: Of the 936 ESSENCE patients randomized in the United States, 655 had hospital billing data collected. For the remainder, hospital costs were imputed with a multivariable linear regression model (R2=.86). Physician fees were estimated from the Medicare Fee Schedule. During the initial hospitalization, major resource use was reduced for enoxaparin patients, with the largest effect seen with coronary angioplasty (15% versus 20% for heparin, P=.04). At 30 days, these effects persisted, with the largest reductions seen in diagnostic catheterization (57% versus 63% for heparin, P=.04) and coronary angioplasty (18% versus 22%, P=.08). All resource use trends seen in the US cohort were also evident in the overall ESSENCE study population. In the United States, the mean cost of a course of enoxaparin therapy was $155, whereas that for heparin was $80. The total medical costs (hospital, physician, drug) for the initial hospitalization were $11 857 for enoxaparin and $12620 for heparin, a cost advantage for the enoxaparin arm of $763 (P=.18). At the end of 30 days, the cumulative cost savings associated with enoxaparin was $1172 (P=.04). In 200 bootstrap samples of the 30-day data, 94% of the samples showed a cost advantage for enoxaparin. CONCLUSIONS: In patients with acute coronary syndrome, low-molecular-weight heparin (enoxaparin) both improves important clinical outcomes and saves money relative to therapy with standard unfractionated heparin.

The cost-effectiveness of a clinical pharmacist intervention among elderly outpatients.

We estimated the cost and cost-effectiveness of a clinical pharmacist intervention known to improve the appropriateness of drug prescribing. Elderly veteran outpatients prescribed at least five drugs were randomized to an intervention (105 patients) or control (103) group and followed for 1 year. The intervention pharmacist provided advice to patients and their physicians during all general medicine visits. Mean fixed and variable costs/intervention patient were $36 and $84, respectively Health services use and costs were comparable between groups. Intervention costs ranged from $7.50-30/patient/unit change in drug appropriateness. The cost to improve the appropriateness of drug prescribing is thus relatively low.

Impact of early discharge after coronary artery bypass graft surgery on rates of hospital readmission and death. The Ischemic Heart Disease (IHD) Patient Outcomes Research Team (PORT) Investigators.

OBJECTIVES: This study examined the impact of early hospital discharge on short-term clinical outcomes of elderly patients treated with coronary artery bypass graft surgery (CABG) in the United States in 1992. BACKGROUND: Protocols that encourage earlier discharge of patients who have had CABG have been implemented across the country. Although delivery of efficient care benefits both patients and providers, premature discharge can adversely affect clinical outcomes, resulting in increased hospital readmissions and higher long-term costs. METHODS: We examined the prevalence of early discharge (postoperative length of stay < or = 5 days) among 83,347 non-health maintenance organization (HMO) Medicare patients who underwent CABG in the United States in 1992. Using logistic regression models, we identified patient characteristics associated with early discharge and obtained risk-adjusted rates of death and readmission or death for postoperative lengths of stay between 4 and 14 days. RESULTS: In 1992, 6% of Medicare patients undergoing CABG were discharged within 5 days of the operation. The prevalence of early discharge varied considerably among states, ranging from 1% to 21%. Patients discharged early tended to be younger and male and have fewer comorbid illnesses. Risk-adjusted rates of death and death or cardiovascular readmission were lowest among patients discharged early. CONCLUSIONS: As of 1992, early discharge of elderly patients treated with CABG in non-HMO settings was not associated with higher 60-day rates of death or readmission. This suggests that physicians were able to identify low risk candidates for early discharge. Variation across the nation in early discharge rates, along with the percentage of patients without major risk factors for adverse outcomes, suggests that higher rates of early discharge might be safely achieved.

Geographic variation in resource use for coronary artery bypass surgery. IHD Port Investigators.

OBJECTIVES: The purpose of this study was to examine the national variability in patient-level cost and length of stay for coronary artery bypass grafting (CABG) in Medicare patients. METHODS: Retrospective multivariate regression analysis was done using Medicare administrative files and American Hospital Association files. Patients in the study had an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure code for CABG, with accompanying 1990 procedure data, in the Medicare Provider Analysis and Review File (n = 92,449). RESULTS: Outcome measures used were inpatient cost (exclusive of professional fees) and inpatient length of stay associated with bypass admission. The national average cost of bypass surgery was $22,847 (median $18,783), with an accompanying average length of stay of 16 days (median 13 days). Multivariate regression analysis revealed that patient-level cost and length of stay were related to clinical, demographic, hospital, and regional characteristics (R2 = 25% and 16%, respectively). After accounting for these characteristics at the patient level, considerable variation among states persisted in both cost and length of stay. In addition, states with similar adjusted lengths of stay varied widely with respect to adjusted cost. No relation was found at the state level between level of resource use and either procedural mortality or 60-day mortality/readmission rates. CONCLUSIONS: Considerable variability exists among states in patient-level cost and length of stay for CABG surgery, after adjusting to the extent possible for clinical, demographic, hospital, and regional characteristics. The lack of association at the state level between resource use and rates of mortality and hospital readmission suggests that costs could be reduced in many areas of the United States without compromising quality of care.

Five-year performance trends for older exercisers: a hierarchical model of endurance, strength, and flexibility.

OBJECTIVE: To examine 5-year trends in measures of physical performance, and the impact of disease upon performance, in three domains: cardiovascular fitness, musculo-skeletal strength, and flexibility among older adults participating in a medically supervised exercise program. DESIGN: Longitudinal analyses of data obtained in an observational cohort study. SETTING: Department of Veterans Affairs Medical Center in Durham, North Carolina. PARTICIPANTS: Seventy-three community-dwelling veterans between 64 and 90 years of age. INTERVENTION: Voluntary participation in a medically supervised outpatient exercise program meeting 3 days per week for 90 minutes per session. MAIN OUTCOME MEASURES: Changes over time in cardiovascular fitness, musculoskeletal strength, and flexibility. RESULTS: Forty-nine percent of the original study participants remained in the program for a full 5 years. They had lower baseline rates of cardiorespiratory and musculoskeletal diseases than did the dropouts. Dropouts were significantly more impaired in baseline measures of cardiovascular fitness (P = .038) and strength (P = .007). Changes over time for cardiovascular fitness and strength were similar. Only linear (P < .05) and quadratic time (P < .001) were significant. Only linear time was significant for measures of flexibility (P < .05). Baseline cardiorespiratory disease, baseline musculoskeletal disease, and interaction terms were not significant. Overall, measures of physical performance demonstrated gradual improvement for 2 to 3 years, followed by a gradual decline in performance irrespective of baseline disease status. CONCLUSION: Older adults who exercise regularly, including those with multiple chronic diseases, can achieve significant gains in measures of physical performance, and these gains can be sustained for 2 to 3 years.

A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy.

PURPOSE: To evaluate the effect of sustained clinical pharmacist interventions involving elderly outpatients with polypharmacy and their primary physicians. PATIENTS AND METHODS: Randomized, controlled trial of 208 patients aged 65 years or older with polypharmacy (> or = 5 chronic medications) from a general medicine clinic of a Veterans Affairs Medical Center. A clinical pharmacist met with intervention group patients during all scheduled visits to evaluate their drug regimens and make recommendations to them and their physicians. Outcome measures were prescribing appropriateness, health-related quality of life, adverse drug events, medication compliance and knowledge, number of medications, patient satisfaction, and physician receptivity. RESULTS: Inappropriate prescribing scores declined significantly more in the intervention group than in the control group by 3 months (decrease 24% versus 6%, respectively; P = 0.0006) and was sustained at 12 months (decrease 28% versus 5%, respectively; P = 0.0002). There was no difference between groups at closeout in health-related quality of life (P = 0.99). Fewer intervention than control patients (30.2%) versus 40.0%; P = 0.19) experienced adverse drug events. Measures for most other outcomes remained unchanged in both groups. Physicians were receptive to the intervention and enacted changes recommended by the clinical pharmacist more frequently than they enacted changes independently for control patients (55.1% versus 19.8%; P <0.001). CONCLUSIONS: This study demonstrates that a clinical pharmacist providing pharmaceutical care for elderly primary care patients can reduce inappropriate prescribing and possibly adverse drug effects without adversely affecting health-related quality of life.

Outcomes of coronary artery bypass graft surgery in 24,461 patients aged 80 years or older.

BACKGROUND: Coronary artery bypass graft surgery is increasingly common in patients of age > or = 80 years. Single-institution reviews have cited a wide range of mortality results after bypass surgery in this age group, in part because of limited sample sizes. Using claims data, we examined recent national trends in the use and outcomes of bypass surgery in the very elderly. METHODS AND RESULTS: From an examination of Medicare data from 1987 through 1990, we identified 24,461 patients of age > or = 80 years who underwent bypass surgery. We compared surgical outcomes in these patients with those in Medicare patients of age 65 to 70 years. We found that the national use of bypass surgery in patients of age > or = 80 years increased 67% between 1987 and 1990. Compared with patients of age 65 to 70 years, the very elderly had significantly longer postoperative hospital stays (mean, 14.3 versus 10.4 days), higher charges (mean, $48,200 versus $38,000), and greater costs (mean, $27,200 versus $21,700). In-hospital (11.5% versus 4.4%), 1-year (19.3% versus 7.9%), and 3-year mortality rates (28.8% versus 13.1%) after bypass surgery were also significantly higher in patients of age > or = 80 years compared with younger patients. Although their initial surgical risk was high, octogenarians who underwent bypass surgery had a long-term survival rate similar to that of the general US octogenarian population. CONCLUSIONS: The use of bypass surgery in patients of age > or = 80 years in increasing. These very elderly patients face high surgical risks and accumulate significant hospital expenses. Further research is indicated to determine whether the long-term benefits from bypass surgery in the very elderly outweigh the increased procedural risks.

A nurse-coordinated intervention for primary care patients with non-insulin-dependent diabetes mellitus: impact on glycemic control and health-related quality of life.

OBJECTIVE: To examine the impact of a nurse-coordinated intervention delivered to patients with non-insulin-dependent diabetes mellitus between office visits to primary care physicians. DESIGN: Randomized, controlled trial. SETTING: Veterans Affairs general medical clinic. PATIENTS: 275 veterans who had NIDDM and were receiving primary care from general internists. INTERVENTION: Nurse-initiated contacts were made by telephone at least monthly to provide patient education (with special emphasis on regimens and significant signs and symptoms of hyperglycemia and hypoglycemia), reinforce compliance with regimens, monitor patients' health status, facilitate resolution of identified problems, and facilitate access to primary care. MEASUREMENTS: Glycemic control was assessed using glycosylated hemoglobin (GHb) and fasting blood sugar (FBS) levels. Health-related quality of life (HRQOL) was measured with the Medical Outcomes Study SF-36, and diabetes-related symptoms were assessed using patients' self-reports of signs and symptoms of hyper- and hypoglycemia during the previous month. MAIN RESULTS: At one year, between-group differences favored intervention patients for FBS (174.1 mg/dL vs 193.1 mg/dL, p = 0.011) and GHb (10.5% vs 11.1%, p = 0.046). Statistically significant differences were not observed for either SF-36 scores (p = 0.66) or diabetes-related symptoms (p = 0.23). CONCLUSIONS: The intervention, designed to be a pragmatic, low-intensity adjunct to care delivered by physicians, modestly improved glycemic control but not HRQOL or diabetes-related symptoms.

Assessing health-related quality of life in elderly outpatients: telephone versus face-to-face administration.

OBJECTIVE: While health-related quality of life (HRQOL) is increasingly being used as an outcome in clinical trials, it is unknown whether HRQOL assessments are influenced by the method of administration. Within the context of a randomized, controlled trial evaluating a pharmacist intervention for elderly outpatients prescribed at least five medications, we compared telephone and face-to-face administration of the SF-36, a widely used HRQOL measure. DESIGN: Survey. SETTING: General Medicine Clinic, Veterans Affairs Medical Center. PATIENTS: At entry, participants in the randomized trial received continuous care from a general medicine clinic physician, were > or = 65 years of age, and were prescribed > or = 5 regularly scheduled medications. Patients were excluded if they were cognitively impaired and had no caregiver available to participate in the study as a proxy or if they resided in a nursing home. MEASUREMENTS: Subjects completed the SF-36 by telephone at closeout and face-to-face at clinic visits within 1 month (mean = 16.7 days). MAIN RESULTS: Telephone administration required significantly less time than face-to-face interviews (10.2 vs 14.0 minutes, P < 0.001). Although systematic differences between modes of administration were generally small, there were substantial nonsystematic discrepancies for all eight SF-36 scales (mean absolute difference scores ranged from 10.8 to 30.1). Discrepancies were greatest for emotional role functioning, physical role functioning, social functioning, and bodily pain; these four scales also demonstrated low to moderate correlations (.33 to .58). CONCLUSIONS: The two modes of administration may not produce interchangeable results. Researchers should be cautious when mixing modes of administration to elderly patients.

The relationship between glycemic control and health-related quality of life in patients with non-insulin-dependent diabetes mellitus.

The relationship between glycemic control and health-related quality of life was examined in patients with non-insulin-dependent diabetes mellitus (NIDDM). Within the context of a randomized controlled trial, 275 patients with NIDDM receiving primary care from a Veteran's Administration general medical clinic were enrolled and monitored for 1 year. Glycemic control (glycosylated hemoglobin levels) and health-related quality of life (Medical Outcomes Study Short-Form 36-item Health Survey [SF-36]) were assessed at baseline and at 1 year. Multivariate regression modeling using baseline and change scores during a 1-year period did not find a linear or curvilinear relationship between glycosylated hemoglobin and SF-36 scores (P = .15); this was true even after controlling for five covariates identified a priori (insulin use, number of diabetic complications, duration of diabetes, education, number of hyper-, or hypoglycemic episodes during the preceding month). Health services researchers and clinicians alike need to be aware that these two important outcomes may not be directly related. This lack of association could contribute to the high noncompliance rates observed among patients prescribed complex diabetic regimens. Unless patients perceive a benefit from following such regimens, good glycemic control may continue to be an elusive therapeutic goal, especially in patients with long-standing disease.

The Gerofit Program: a VA innovation.

In 1986 Gerofit, an exercise and health promotion program for older veterans, was established. This paper describes the program in detail by summarizing the patient assessment protocol, the exercise program, and program evaluation, as well as observational outcomes for up to 5 years of follow-up. Our data suggest that exercise provides older veterans with beneficial gains in function that are maintained for 5 years.

A cost-effectiveness analysis of hepatitis B vaccine in predialysis patients.

OBJECTIVE: Our objective was to assess the cost effectiveness of hepatitis B vaccine in predialysis patients. DATA SOURCES: Costs were calculated from estimated rates of health services use and unit costs of resource use. Efficacy data were based on probability estimates from the medical literature and included vaccination response rates, anticipated hepatitis B virus (HBV) infection rates, and outcomes from HBV. STUDY DESIGN: Costs and effectiveness of HBV vaccination was modeled with a decision tree constructed to analyze three vaccination strategies for patients with renal insufficiency: vaccine given prior to dialysis, vaccine given at time of dialysis, and no vaccine. Sensitivity analyses were performed to assess the effect of varying important clinical and cost variables. DATA COLLECTION/EXTRACTION METHODS: All analyses were based on efficacy and cost estimates derived from the medical literature. Analyses were conducted with the aid of SMLTREE software. PRINCIPAL FINDINGS: The number of patients requiring vaccination per case of HBV prevented was higher for dialysis patients (625 vaccinees/case prevented) than for predialysis patients (434 vaccinees/case prevented). The cost-effectiveness ratios were $25,313/case of HBV prevented for vaccination at the time of dialysis and $31,111 for the predialysis vaccine. When a higher HBV infection rate (based on clinical trial data) was substituted in the analysis, the cost effectiveness of a predialysis vaccination strategy improved to $856 per case prevented. Results were sensitive to the cost of the vaccine and the incidence of HBV infection in dialysis patients. For the predialysis strategy to become cost saving, the price of the vaccine would have to decrease from $114 to $1.50, or the incidence of infection would have to increase from 0.6 percent to 38 percent, holding all other variables constant. CONCLUSIONS: Additional HBV infection can be prevented by immunizing predialysis patients, but the cost is high. Decisions concerning vaccination policy should be influenced by local prevalence of HBV infection.

Expenditures in caring for patients with dementia who live at home.

OBJECTIVES: Given the national interest in progressive dementia, we estimated expenditures incurred in caring for dementia patients who live at home. METHODS: Primary caregivers of 264 patients from a university-based memory disorders clinic were interviewed at baseline and asked to keep service use diaries for 6 months; 141 caregivers who returned the diaries are the focus of this report. We examined both formal and informal services (distinguished by whether money was exchanged) and associated expenditures. RESULTS: Neither caregivers returning diaries nor their patients differed at baseline from those not returning diaries and their patients. Expenditures incurred over 6 months were extensive for both formal ($6986) and informal ($786) services. Out-of-pocket expenditures were high (e.g., in-home companion or sitter, adult day care, visiting nurse). Multivariable analyses indicated that patients with more severe symptoms of dementia and families with higher incomes reported significantly higher expenditures. CONCLUSIONS: The expense of caring for patients with progressive dementia living at home may be higher than previously estimated and frequently involves expenses paid directly by patients and their families.

Social service interventions for caregivers of patients with dementia: impact on health care utilization and expenditures.

OBJECTIVES: An intervention, which had as its primary goal the enhancement of compliance to social work recommendations, was shown to produce extremely high rates of compliance. This report addresses the secondary objective of the study: to evaluate the impact of the intervention on short-term (ie, 6-month) health services utilization and expenditures. DESIGN: Randomized controlled trial. SETTING: University-based memory disorders clinic. PARTICIPANTS: Caregivers of patients with progressive memory disorders. MAIN OUTCOME MEASURES: Service utilization and expenditures. RESULTS: The intervention did not have a statistically significant impact on utilization of either health care or community resources. The intervention group had $903 less expenditures during the study period, a difference that did not achieve statistical significance. The results were consistent when controlling for caregiver characteristics that differed at baseline. CONCLUSIONS: Although the intervention was successful in enhancing compliance with recommendations, more intensive interventions may be required to increase subsequent service utilization. Future investigations may wish to target the appropriateness of services used over a period longer than 6 months.