Trends in percutaneous endoscopic gastrostomy placement in the elderly from 1993 to 2003.

OBJECTIVES: To investigate national trends in percutaneous endoscopic gastrostomy (PEG) tube placement for hospitalized elderly patients from 1993 to 2003. METHODS: Retrospective analysis of patients ≥ 65 years of age with PEG tube placement from 1993 to 2003 from the Nationwide Inpatient Sample (NIS) database was utilized to calculate PEG placement rates per 1000 people. RESULTS: Placement of PEG tube increased by 38% in elderly patients during the study period, from 2.71 procedures during hospitalization per 1000 people to 3.75 procedures during hospitalization per 1,000 people. Placement of PEG tube in patients with Alzheimer's dementia doubled (5%-10%) over the study period. CONCLUSION: Over a 10-year period, PEG tube use in hospitalized elderly patients increased significantly. More importantly, approximately 1 in 10 PEG tube placements occurred in patients with dementia.

Improving estimates of caregiver time cost and family impact associated with birth defects.

BACKGROUND: Birth defects impose substantial costs on both families and society because of medical, developmental, and special education needs. Caring for children with birth defects also may influence caregiver time and impact the family. However, the economic cost of caregiver time and other impacts on the family has received far less attention than traditional healthcare costs. METHODS: This study reviews the literature on measuring caregiver time costs and family impact in an economic framework. The economic framework involves translating caregiver time or difficulties into appropriate units such as cost or quality adjusted life years (QALYs). RESULTS: Despite the potential important contribution of caregiver time costs to the total cost estimate of birth defects, few studies estimate caregiver time costs related specifically to birth defects. Only two studies provide estimates of these costs. Recent work has investigated the impact of chronic illness on caregivers in QALY terms, but birth defects have not been studied. Several issues need to be addressed in both the estimation of caregiver time costs and family impact to improve cost estimates. CONCLUSIONS: Improved estimates of caregiver time costs and impact on the family will assist policy makers in allocating resources for the prevention and treatment of birth defects. Future research should investigate the economic costs of caregiver time and family impact associated with caring for children with birth defects.

Variation in therapy and outcome for pediatric head trauma patients.

OBJECTIVE: This study was undertaken to examine variation in therapies and outcome for pediatric head trauma patients by patient characteristics and by pediatric intensive care unit. Specifically, the study was designed to examine severity of illness on admission to the pediatric intensive care unit, the therapies used during the pediatric intensive care unit stay, and patient outcomes. DATA SOURCES AND SETTING: Consecutive admissions from three pediatric intensive care units were recorded prospectively (n = 5,749). For this study, all patients with an admitting diagnosis of head trauma were included (n = 477). Data collection occurred during an 18-month period beginning in June 1996. All of the pediatric intensive care units were located in children's hospitals, had residency and fellowship training programs, and were headed by a pediatric intensivist. METHODS: Admission severity was measured as the worst recorded physiological derangement during the period 1 yr old (16.1% vs. 6.1%; p = .002). Comparisons by insurance status indicated that observed mortality rates were highest for self-paying patients. However, patient characteristics were not associated with use of therapies or standardized mortality rates after adjustment for patient severity. There was significant variation in the use of paralytic agents, seizure medications, induced hypothermia, and intracranial pressure monitoring on admission across the three pediatric intensive care units. In multivariate models, only the use of seizure medications was associated significantly with reduced mortality risk (odds ratio = 0.17; 95% confidence interval = 0.04-0.70; p = .014). CONCLUSIONS: Therapies and outcomes vary across pediatric intensive care units that care for children with head injuries. Increased use of seizure medications may be warranted based on data from this observational study. Large randomized controlled trials of seizure prophylaxis in children with head injury have not been conducted and are needed to confirm the findings presented here.

Volume-outcome relationships in pediatric intensive care units.

CONTEXT: Pediatric intensive care units (PICUs) have expanded nationally, yet few studies have examined the potential impact of regionalization and no study has demonstrated whether a relationship between patient volume and outcome exists in these units. Documentation of an inverse relationship between volume and outcome has important implications for regionalization of care. OBJECTIVES: This study examines relationships between the volume of patients and other unit characteristics on patient outcomes in PICUs. Specifically, we investigate whether an increase in patient volume improves mortality risk and reduces length of stay. DESIGN AND SETTING: A prospective multicenter cohort design was used with 16 PICUs. All of the units participated in the Pediatric Critical Care Study Group. Participants. Data were collected on 11 106 consecutive admissions to the 16 units over a 12-month period beginning in January 1993. MAIN OUTCOME MEASURES: Risk-adjusted mortality and length of stay were examined in multivariate analyses. The multivariate models used the Pediatric Risk of Mortality score and other clinical measures as independent variables to risk-adjust for illness severity and case-mix differences. RESULTS: The average patient volume across the 16 PICUs was 863 with a standard deviation of 341. We found significant effects of patient volume on both risk-adjusted mortality and patient length of stay. A 100-patient increase in PICU volume decreased risk-adjusted mortality (adjusted odds ratio:.95; 95% confidence interval:.91-.99), and reduced length of stay (incident rate ratio:.98; 95% confidence interval:.975-.985). Other PICU characteristics, such as fellowship training program, university hospital affiliation, number of PICU beds, and children's hospital affiliation, had no effect on risk-adjusted mortality or patient length of stay. CONCLUSIONS: The volume of patients in PICUs is inversely related to risk-adjusted mortality and patient length of stay. A further understanding of this relationship is needed to develop effective regionalization and referral policies for critically ill children.

Relationship of illness severity and length of stay to functional outcomes in the pediatric intensive care unit: a multi-institutional study.

OBJECTIVE: The purpose of this study was to establish relationships between illness severity, length of stay, and functional outcomes in the pediatric intensive care unit (PICU) by using multi-institutional data. We hypothesized that a positive relationship exists between functional outcome scores, severity of illness, and length of stay. DESIGN: The study used a prospective multicentered inception cohort design. SETTING: The study was conducted in 16 PICUs across the United States that were member institutions of the Pediatric Critical Care Study Group of the Society of Critical Care Medicine. PATIENTS: In total, 11,106 patients were assessed, representing all admissions to these intensive care units for 12 consecutive months. MEASUREMENTS: Functional outcomes were measured by the Pediatric Overall Performance Category (POPC) and Pediatric Cerebral Performance Category (PCPC) scales. Both scales were assessed at baseline and discharge from the PICU. Delta scores were formed by subtracting baseline scores from discharge scores. Other measurements included admission Pediatric Risk of Mortality scores, age, operative status, length of stay in the PICU, and diagnoses. Interrater reliability was assessed by using a set of ten standardized cases on two occasions 6 months apart. MAIN RESULTS: Baseline, discharge, and delta POPC and PCPC outcome scores were associated with length of stay in the PICU and with predicted risk of mortality (p < .01). Incorporation of baseline functional status in multivariate length of stay analyses improved measured fit. Mild baseline cerebral deficits in children were associated with 18% longer PICU stays after controlling for other patient and institutional characteristics. Moderate and severe baseline deficits for both the POPC and PCPC score predict increased length of stay of between 30% and 40%. On the standardized cases, interrater consensus was achieved on 82% of scores with agreement to within one neighboring class for 99.7% of scores. CONCLUSIONS: These data establish current relationships for the POPC and PCPC outcome scales based on multi-institutional data. The reported relationships can be used as reference values for evaluating clinical programs or for clinical outcomes research.

Alcoholism treatment offset effects: an insurance perspective.

This study investigates whether alcoholism treatment costs are offset by reductions in other medical treatment costs by comparing people treated for alcoholism with a matched comparison group. The alcoholism treatment group is defined by diagnoses of alcohol dependence, abuse, or psychoses from health insurance claims field between January 1980 and June 1987. A comparison sample was matched on age, gender, and insurance coverage. In this primarily methodological study, expected costs for nonalcoholism treatments were calculated from standardized regressions. Offset effects were measured from the insurer's perspective through differences in expected total nonalcoholism treatment costs in the periods preceding and following alcoholism treatment. Members of the alcoholism treatment group were more likely than the comparison group to be hospitalized and to need other (nonalcoholism) medical treatment, thus incurring higher total costs. Offset effects emerged for patients with alcohol abuse and without mental psychosis comorbidities.

Response to health insurance by previously uninsured rural children.

OBJECTIVE: To examine the healthcare utilization and costs of previously uninsured rural children. DATA SOURCES/STUDY SETTING: Four years of claims data from a school-based health insurance program located in the Mississippi Delta. All children who were not Medicaid-eligible or were uninsured, were eligible for limited benefits under the program. The 1987 National Medical Expenditure Survey (NMES) was used to compare utilization of services. STUDY DESIGN: The study represents a natural experiment in the provision of insurance benefits to a previously uninsured population. Premiums for the claims cost were set with little or no information on expected use of services. Claims from the insurer were used to form a panel data set. Mixed model logistic and linear regressions were estimated to determine the response to insurance for several categories of health services. PRINCIPAL FINDINGS: The use of services increased over time and approached the level of utilization in the NMES. Conditional medical expenditures also increased over time. Actuarial estimates of claims cost greatly exceeded actual claims cost. The provision of a limited medical, dental, and optical benefit package cost approximately $20-$24 per member per month in claims paid. CONCLUSIONS: An important uncertainty in providing health insurance to previously uninsured populations is whether a pent-up demand exists for health services. Evidence of a pent-up demand for medical services was not supported in this study of rural school-age children. States considering partnerships with private insurers to implement the State Children's Health Insurance Program could lower premium costs by assembling basic data on previously uninsured children.

Differences in pediatric ICU mortality risk over time.

OBJECTIVES: To compare pediatric intensive care unit (ICU) mortality risk using models from two distinct time periods; and to discuss the implications of changing mortality risk for severity systems and quality-of-care assessment. DATA SOURCES AND SETTING: Consecutive admissions (n = 10,833) from 16 pediatric ICUs across the United States that participate in the Pediatric Critical Care Study Group were recorded prospectively. Data collection occurred during a 12-mo period beginning in January 1993. METHODS: Data collection for the development and validation of the original Pediatric Risk of Mortality (PRISM) score occurred from 1980 to 1985. The original PRISM coefficients were used to calculate mortality probabilities in the current data set. Updated estimates of mortality probabilities were calculated, using coefficients from a logistic regression analysis using the original PRISM variable set. Quality-of-care tests were performed using standardized mortality ratios. RESULTS: Risk of mortality from pediatric ICU admission improved considerably between the two periods. Overall, the reduction in mortality risk averaged 15% (p < .001). Analysis of mortality risk by age indicated a large improvement for younger infants. The mortality risk for infants <1 mo improved by 39% (p < .001). Mortality risk improved by 28% (p < .001) for infants between 1 and 12 mos. Analysis of mortality risk by principal diagnosis indicated substantial improvement in respiratory diseases, including respiratory diseases developing in the perinatal period. The mortality risk for respiratory diseases improved by 45% (p < .001). The improvement in mortality risk substantially deteriorated the calibration of the original PRISM severity system (p < .001). As a result of changing mortality risk, the standardized mortality ratios across the 16 pediatric ICUs demonstrated substantial disparities, depending on the choice of models. CONCLUSIONS: This study documents differences in pediatric ICU risk of mortality over time that are consistent with a general improvement in the quality of pediatric intensive care. Despite continued widespread use of the original PRISM, recent improvements in pediatric ICU quality of care have negated its usefulness for many intended applications, including quality-of-care assessment.

A number-needed-to-treat analysis of the use of respiratory syncytial virus immune globulin to prevent hospitalization.

OBJECTIVES: To estimate how many infants in selected high-risk subgroups would require treatment with respiratory syncytial virus immune globulin (RSV-IG) to avoid 1 hospital admission and to determine whether this is economically justified. DESIGN: Cost-benefit analysis. Data from 3 randomized controlled trials of RSV-IG are used to estimate the number needed to treat to prevent 1 hospital admission for respiratory syncytial virus infection. The threshold number needed to treat is computed according to a formula incorporating costs and benefits of RSV-IG prophylaxis. Estimates of the willingness to pay were obtained from a sample of 39 health care providers (35 physicians and 4 nurses). MAIN OUTCOME MEASURES: The number needed to treat to prevent 1 hospital admission for respiratory syncytial virus infection. The threshold number needed to treat that would balance costs with benefits. RESULTS: More than 16 (95% confidence interval, 12.5-23.8) infants would need to be treated with RSV-IG to avoid 1 hospital admission for respiratory syncytial virus infection, ranging from 63 for premature infants without chronic lung disease to 12 (confidence interval, 6.3-100.0) for infants with bronchopulmonary dysplasia. A sensitivity analysis of the costs and values of hospital admission for respiratory syncytial virus infection and RSV-IG treatment resulted in a weak recommendation against the treatment of infants with bronchopulmonary dysplasia and strong recommendations that the costs and risks of RSV-IG treatment outweigh the benefits for the combined sample of infants and premature infants without lung disease. CONCLUSIONS: The number-needed-to-treat procedures offer a method to assess evidence of treatment effects and decision rules for whether to accept treatment recommendations. Under plausible assumptions, treatment with RSV-IG is not recommended for infants without lung disease. Institutions can examine cost and benefit assumptions that best fit their own practice setting.

Rural Arkansas physicians and telemedicine technology: attitudes in communities receiving equipment.

OBJECTIVE: To assess physician attitudes toward the usefulness, effectiveness, and expected use of telemedicine, as well as interest in learning about the technology. METHODS: A survey instrument assessing attitudes toward each of the four objective domains was mailed to 46 physicians at six hospitals affiliated with the Rural Hospital Program of the University of Arkansas for Medical Sciences. Binomial probability methods were used to analyze the responses. RESULTS: The survey achieved a response rate of 59% (27/46). Physician responders agreed that telemedicine would be useful in improving patient care quality but would not be useful in improving the financial position of the hospital or in lowering patient-borne costs. Physicians were evenly split on the effectiveness and expected utilization of telemedicine for patient consults. There was significant interest in learning more about telemedicine applications. CONCLUSION: Barriers to utilization of telemedicine by physicians may remain even under a new reimbursement system unless referring physicians are convinced of the benefits to the community as well the clinical effectiveness of the technology.

U.S. public school enrollment-based health insurance initiatives and America's uninsured.

This article reviews current literature on school enrollment-based health insurance programs underway or pending in the United States. This model of affordable family health insurance delivery was first proposed in a 1988 New England Journal of Medicine Sounding Board article, but only a few states--Arkansas, Florida, New Hampshire, and Texas--have begun public sector-driven programs in the 1990s that use school enrollment as a pooling mechanism to purchase group insurance policies from the private sector. Public support of this model is strong, interest is currently growing, and other states, including North Carolina and Iowa, are exploring or have enacted legislation that supports establishment of school enrollment-based health insurance programs. After summarizing these public-sector initiatives, additional information is presented on uninsuredness in America; risk factors for uninsuredness among children; and national public and private initiatives in child health insurance using eligibility criteria other than or including school enrollment that were examined by the GAO in 1994/95.

The effects of mental health factors on ambulatory care visits by rural teens.

This study sought to determine the effects of mental health variables on rural adolescents' use of ambulatory health care services and whether these effects varied across common outpatient settings. Using a cross-sectional survey design, 2,297 adolescents who attended public schools in grades 7 through 12 in one isolated rural Mississippi River Delta county were assessed via a standardized health behavior survey. This self-report measure inquired about relevant health behaviors such as alcohol use, depressive symptoms, and health service use. The students' mean age was 15 years and 58 percent of the sample were black. Approximately 11 percent of the sample reported symptoms of depression, 16.5 percent reported problem drinking, and slightly fewer than 6 percent reported both. After controlling for predisposing, enabling, and need factors, the reporting of depressive symptoms, problem drinking, or both was related to an increased number of outpatient visits in three of four sites examined. However, differences among sites were observed. These data suggest that mental health problems are associated with increased visits to ambulatory settings, and these problems affect service use differentially. Thus, effective interventions and better linkages between ambulatory settings and mental health providers may reduce unnecessary use.