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Generic and disease-specific instruments have been used to assess health-related quality of life (HRQoL) in hemophilia. However, HRQoL measures also need to reflect patient preferences for various hemophilia health states. The goal of this project was to develop a disease-specific utility instrument that measures patient preferences for various health states unique to hemophilia. The visual analog scale (VAS) and the standard gamble (SG) methods were used. Study participants (n = 128) were tested and stratified into paediatric and adult groups. Test-retest reliability was demonstrated for both instruments, with r = 0.91 for the VAS and r = 0.79 for the SG. When comparing results by age group, statistically significant differences were observed between paediatric and adult participants with the SG instrument (P = 0.045), with older participants taking more risk overall. However, no significant differences based on age were seen when using the VAS (P = 0.636). Statistically significant differences were observed between the VAS and SG instruments within both the paediatric and adult groups (P < 0.0001). In general, the SG yielded higher preference scores than the VAS for the majority of health states. Results derived from the SG instrument indicate that age can influence patients' preferences regarding their state of health. This can have implications for considering treatment options based on the mean age of the population under consideration. Both instruments demonstrated reliability and validity indicating that they could be used to assess patient preferences in hemophilia. However, preference score differences indicate that the two measures may not be interchangeable.

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The purpose of this paper is to describe the temporal pattern of healthcare cost in two population-based samples of new cases of epilepsy from two different regions of the US, and show how it varies with seizure type and frequency. Epilepsy-related healthcare cost from onset through 4 years of follow-up was determined for two population-based incident samples from Houston, TX and Rochester, MN. Cases were identified over the period 1987-1991 and followed through 1994. Annual use and cost was calculated for the first through fourth year of treatment for each person in the combined samples to examine the temporal pattern of early treatment cost. A multivariate model was estimated to examine how seizure type and seizure frequency affect early treatment cost while controlling for location, age, gender, and ethnicity. Our estimates indicate high initial healthcare cost at onset for most patients followed by lower cost in subsequent years. The mean annual epilepsy-related healthcare cost per patient was $3157 for the first year, $702 for the second year, $471 for year three, and $411 for year four. Cost was significantly higher for groups whose seizures continued and were relatively frequent, but was not significantly different for groups with partial seizures as compared with primary generalized seizures. There was a 2.2-fold difference in 4-year cost between patients with a single seizure at onset and those having recurrent seizures at the rate of more than one per month, controlling for seizure type, age, gender, and ethnicity.

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OBJECTIVE: To develop a cost model that estimates the total and per case lifetime cost of bipolar disorder for 1998 incident cases in the US. STUDY DESIGN: Lifetime cost simulation model. PERSPECTIVE: Societal. METHODS: Age- and gender-specific incidence of bipolar disorder in 1998 was estimated by simulation based on existing prevalence data. The course of illness and mental health service cost of 6 clinically defined prognostic groups was estimated based on the research literature and the judgement of panels of experts. Excess cost of general medical care was estimated based on claims data from a large insurer. Indirect cost was projected including excess unemployment and reduced earnings reported in the National Comorbidity Survey. Comorbidity treatment and indirect cost related to alcohol (ethanol) and drug abuse was added based on a National Institute on Drug Abuse study. RESULTS: The present value of the lifetime cost of persons with onset of bipolar disorder in 1998 was estimated at 24 billion US dollars ($US). Average cost per case ranged from $US11,720 for persons with a single manic episode to $US624,785 for persons with nonresponsive/chronic episodes. CONCLUSION: The model indicates the potential cost savings of preventing a case of bipolar disorder and underscores the importance of achieving a stable outcome in new cases to limit the economic consequences of the disorder.

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PURPOSE: To provide 1995 estimates of the lifetime and annual cost of epilepsy in the United States using data from patients with epilepsy, and adjusting for the effects of comorbidities and socioeconomic conditions. METHODS: Direct treatment-related costs of epilepsy from onset through 6 years were derived from billing and medical chart data for 608 population-based incident cases at two sites in different regions of the country. Indirect productivity-related costs were derived from a survey of 1,168 adult patients visiting regional treatment centers. Direct costs separate the effects of epilepsy and comorbidity conditions. Indirect costs account for the effects of other disabilities and socioeconomic conditions on foregone earnings and household activity. The estimates were applied to 1995 population figures to derive national projections of the lifetime and annual costs of the disorder. RESULTS: The lifetime cost of epilepsy for an estimated 181,000 people with onset in 1995 is projected at $11.1 billion, and the annual cost for the estimated 2.3 million prevalent cases is estimated at $12.5 billion. Indirect costs account for 85% of the total and, with direct costs, are concentrated in people with intractable epilepsy. CONCLUSIONS: Direct costs attributable to epilepsy are below previous estimates. Indirect costs adjusted for the socioeconomic conditions of patients are above previous estimates. Findings indicate that epilepsy is unique in the large proportion of costs that are productivity-related, justifying further investment in the development of effective interventions.

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OBJECTIVE: To evaluate the effectiveness, efficiency, and equity of behavioral healthcare and to guide an assessment of the current state of the art of behavioral health-oriented health services research. STUDY DESIGN: The framework is grounded in previous conceptual work by the authors in defining a prevention- and outcomes-oriented continuum of healthcare and in identifying and integrating the concepts and methods of health services research and policy analysis for assessing healthcare system performance. PATIENTS AND METHODS: The defining assumptions are that (1) the denominator for behavioral healthcare services must encompass a look at the population, not just the patients, who manifest behavioral health risks; and (2) the delivery system to address these needs must extend beyond acute, treatment-oriented services to include both primary prevention and aftercare services for chronic relapsing conditions. RESULTS: Current policy and practice in behavioral healthcare reveal the absence of a comprehensive, coordinated continuum of care; substantial variation in policy and financial incentives to encourage such development; and poorly defined or articulated outcome goals and objectives. The current state of the art of research in this area reflects considerable imprecision in conceptualizing and measuring the effectiveness, efficiency, and equity criteria. Further, these 3 criteria have not been examined together in evaluating system performance. CONCLUSIONS: The first era of behavioral healthcare focused on cost savings in managed care alternatives; the second is focusing on quality and outcomes; a third must consider the issues of equity and access to behavioral healthcare, especially for the most seriously ill and vulnerable, in an increasingly managed care-dominated public and private policy environment.

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Changes in treatment alternatives and the emphasis on cost containment and managed care have increased the interest in information on the cost of epilepsy. The last comprehensive cost study in the USA was in 1975. That study estimated the national cost of epilepsy at $3.6 billion for 2.1 million cases. On a per patient basis the 1975 figure represents $7440 in 1995 US dollars, $1150 (15%) for direct treatment-related costs and $6290 (85%) for indirect employment-related costs. Since then, various cost-of-illness (COI) studies in the USA and other countries have offered estimates ranging from $6000 to $15000 per patient per year, with percentages of direct and indirect cost varying greatly. To assist those interested in interpreting or producing cost information, this paper reviews the state of research on the cost of epilepsy and discusses several methodological issues. A comprehensive study begun in 1993 to update the 1975 estimates for the USA is also described. Recommendations are provided to stimulate discussion about the best methods to use in future research.

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Texas has a plan for statewide implmentation of Medicaid managed care by 2001. This article presents evidence from initial demonstration projects, which were implemented in 1993. The 1st-year experience is described and preliminary effects are examined in terms of reactions of clients and providers and changes in utilization patterns and costs of care. Results of the evaluation indicate implementation difficulties with several operational aspects of managed care, variable effects in terms of client and provider reaction to the reform, and little or no change in utilization patterns, but significant cost-savings to the state. Because of the implementation difficulties identified by the evaluation and the mixed results regarding effects, further research is recommended to determine the potential benefit of this reform.

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Motivated by the need for fundamental change, reform of the health care delivery system is continuing despite the recent failure of national initiatives. One aspect of this reform is the restructuring of managed care systems to include low-income, at-risk populations in their health delivery program: It is a move that threatens current "safety-net" providers, which already serve these populations with programs that combine public health and traditional primary care. This paper explores this potential conflict by providing a brief history and comparison of the main features of the community-oriented primary care (COPC) and health maintenance organization (HMO) models. The authors provide a frame-work that contrasts the structure, process, and outcome characteristics of these two models, delineating key similarities and differences. The frame-work is used in profiling a service delivery system model that integrates the two systems and in discussing issues related to operationalizing the proposed integration.

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To monitor the growth of the health-care sector in Texas, we made annual estimates of aggregate health spending in 1989 and 1990 and compared them with estimates from prior years and with national trends. Expenditures are grouped by total spending, spending by the state government, and distribution of payment. To achieve data that could be compared with national figures, we followed the methods used by the federal government to estimate national health spending. Results indicate a return to the rapid rates of growth experienced in the early 1980s. Possible explanations for some major trends in spending and in sources of payment are provided. Basic features of recent efforts to contain costs are addressed and related to the trends.

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A model of the clinical course of epilepsy from onset until remission or death has been developed for six prognostic groups, including survival, use and cost of medical care, and time lost from work and housekeeping. The model has been used to generate preliminary estimates of the lifetime cost of epilepsy for a cohort of persons diagnosed in 1990 in the United States. The distribution of incident cases among prognostic groups is derived from epidemiologic studies of prognosis in epilepsy. Direct cost is estimated by multiplying nationally representative unit costs by the expected type and frequency of medical care use. The latter were derived by an expert panel, based on inferences from existing literature and on their own clinical experiences. Indirect cost is estimated based on lost earnings associated with projections of restricted activity days, excess unemployment, and excess mortality. Total lifetime cost in 1990 dollars of all persons with epilepsy onset in 1990 was estimated at $3.0 billion, with indirect cost accounting for 62% of the total. Cost per patient ranged from $4,272 for persons with remission after initial diagnosis and treatment to $138,602 for persons with intractable and frequent seizures. Antiepileptic drug (AED) treatment is the most costly category of service. Different assumptions about the amount and type of drug administration cause major changes in overall cost estimates.

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Population-based hospitalization rates for preventable conditions are derived for a low-income population in Galveston County, Texas using discharge data from four area hospitals and demographic data from the U.S. Census. Comparisons are made with similar rates for the general populations of two eastern states (Maryland and Massachusetts) and New York City. Results support the hypothesis that low-income persons lack access to primary care, leading to higher rates of hospitalization for preventable conditions. Alternative explanations for differences found are examined.

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Expenditures for health care in Texas during 1988 totaled $32.4 billion. Health spending by category of service and sources of payment was estimated and compared with estimates for prior years and with national trends. Texas differed from the nation as a whole in average annual increases in total spending, the percentage of spending for prepayment and administration, and the percentage of spending paid by consumers, the federal government, and private insurance. Proposed expansions in insurance coverage for the large proportion of uninsured Texans will probably require strong efforts to contain costs.

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Direct and indirect costs of cancer for Texas are estimated for 1988 and are compared to costs for 1980. The distribution of these costs by age group and type of cancer is presented and discussed. Conceptual and methodological issues underlying the estimates are explained to assist the reader in interpretation. The authors conclude that future collection of more specific data at the state level would greatly assist policymakers dealing with cancer issues.

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Rationales for government regulation in the weight loss industry are developed on the basis of the concepts of market failure and potential harm to consumers. Evidence shows that consumers face problems in judging the quality of the industry's products and services, and they lack adequate protection against possible harm. The pros and cons of a variety of public and private strategies are examined for correcting these deficiencies. Recommendations are suggested for strengthening existing government regulations and expanding research.

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Total, per capita, and state government health spending by category of service for 1987 were estimated along with the distribution of spending by sources of payment. Definitions, methods, and sources of data are similar to those used by the US Health Care Financing Administration in estimating national health care expenditures and payments. Comparisons are made with prior-years' spending and with estimates of spending at the national level. Spending and financing patterns are identified and possible explanations are discussed.

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The future earnings of male Texans dying of AIDS in 1987 were estimated using: national earnings profiles; earnings derived from occupations listed on death certificates; and earnings reported by persons with AIDS who responded to a survey. Mortality cost estimates using the two sources of actual earnings differed by a modest amount in comparison to the estimate using national earnings profiles.

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A cost-effectiveness analysis was conducted to determine the relative efficacy of nine primary health care projects serving low income persons in urban and rural areas of Texas. The projects were created as part of a government program to provide services in medically underserved areas of the state by contracting with local public and private providers. While they vary widely in terms of sponsoring organizations, service strategy, and scope of services, the projects share a similar goal of providing an array of basic medical and preventive care services to the poor. This study compares the average cost per encounter for diagnosis/treatment, emergency, family planning, and preventive health screening services provided by the various projects during the first year of operation. After adjusting for differences in input prices and patient volume, the cost differences are examined and related to organizational model and personnel mix. Those projects with the highest ratio of nonphysician to physician practitioners proved more cost-effective, as did those projects following the public clinic model of service delivery.

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