RESUMEN
CONTEXT: Studies of selected populations suggest that not all persons infected with human immunodeficiency virus (HIV) receive adequate care. OBJECTIVE: To examine variations in the care received by a national sample representative of the adult US population infected with HIV. DESIGN: Cohort study that consisted of 3 interviews from January 1996 to January 1998 conducted by the HIV Cost and Services Utilization Consortium. PATIENTS AND SETTING: Multistage probability sample of 2864 respondents (68% of those targeted for sampling), who represent the 231400 persons at least 18 years old, with known HIV infection receiving medical care in the 48 contiguous United States in early 1996 in facilities other than emergency departments, the military, or prisons. The first follow-up consisted of 2466 respondents and the second had 2267 (65% of all surviving sampled subjects). MAIN OUTCOME MEASURES: Service utilization (<2 ambulatory visits, at least 1 emergency department visit that did not lead to hospitalization, at least 1 hospitalization) and medication utilization (receipt of antiretroviral therapy and prophylaxis against Pneumocystis carinii pneumonia). RESULTS: Inadequate HIV care was commonly reported at the time of interviews conducted from early 1996 to early 1997 but declined to varying degrees by late 1997. Twenty-three percent of patients initially and 15% of patients subsequently had emergency department visits that did not lead to hospitalization, 30% initially and 26% subsequently of those who had CD4 cell counts below 0.20 x 10(9)/L did not receive P carinii pneumonia prophylaxis, and 41% initially and 15% subsequently of those who had CD4 cell counts below 0.50 x 10(9)/L did not receive antiretroviral therapy (protease inhibitor or nonnucleoside reverse transcriptase inhibitor). Inferior patterns of care were seen for many of these measures in blacks and Latinos compared with whites, the uninsured and Medicaid-insured compared with the privately insured, women compared with men, and other risk and/or exposure groups compared with men who had sex with men even after CD4 cell count adjustment. With multivariate adjustment, many differences remained statistically significant. Even by early 1998, fewer blacks, women, and uninsured and Medicaid-insured persons had started taking antiretroviral medication (CD4 cell count adjusted P values <.001 to <.005). CONCLUSIONS: Access to care improved from 1996 to 1998 but remained suboptimal. Blacks, Latinos, women, the uninsured, and Medicaid-insured all had less desirable patterns of care. Strategies to ensure optimal care for patients with HIV requires identifying the causes of deficiency and addressing these important shortcomings in care.
Asunto(s)
Infecciones por VIH/economía , Infecciones por VIH/terapia , Encuestas de Atención de la Salud/estadística & datos numéricos , Servicios de Salud/estadística & datos numéricos , Adulto , Atención Ambulatoria/estadística & datos numéricos , Fármacos Anti-VIH/uso terapéutico , Estudios de Cohortes , Servicios Médicos de Urgencia/estadística & datos numéricos , Femenino , Costos de la Atención en Salud , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Modelos Estadísticos , Análisis Multivariante , Probabilidad , Factores Socioeconómicos , Estados UnidosRESUMEN
OBJECTIVE: To compare the appropriateness of coronary angiography and coronary artery bypass graft (CABG) use between the United States and Canada. DESIGN: Retrospective randomized medical record review. SETTING: All hospitals performing coronary angiography and/or CABG surgery in two Canadian provinces (Ontario and British Columbia); in New York State, 15 randomly selected hospitals that provide coronary angiography and 15 randomly selected hospitals that provide CABG surgery. PATIENTS: All patients were randomly selected. For coronary angiography, 533 patients in Canada and 1333 patients in New York were selected; for CABG, 556 patients in Canada and 1336 patients in New York were selected. MAIN OUTCOME MEASURES: Percentage of patients in each country who had coronary angiography or CABG for necessary, appropriate, uncertain, or inappropriate indications as rated by criteria developed separately in each country and the complications of those procedures. RESULTS: For coronary angiography, 9% of Canadian cases and 10% of New York cases were rated inappropriate using Canadian criteria compared with 5% and 4%, respectively, using US criteria. For CABG, 4% of Canadian cases and 6% of New York cases were rated inappropriate by Canadian criteria compared with 3% and 2%, respectively, using US criteria. A lower proportion of procedures were performed on persons aged 75 years or older in Canada than in New York for both coronary angiography (5% vs 11%; P < .001) and CABG (6% vs 14%; P < .001). Women were also represented in lower proportions among angiography cases in Canada than in New York (28% vs 35%; P = .023). Canadian patients with left main coronary disease waited significantly longer between angiography and CABG than did New York patients (P < .0001). CONCLUSIONS: Rates of inappropriate use of cardiac procedures were low in Canada and New York, which suggests that the regionalization of cardiac procedures that characterizes both health care systems contributes to better clinical decision making. Differences in the use of cardiac procedures among the elderly in the two countries merits further comparative examination.
Asunto(s)
Angiografía Coronaria/estadística & datos numéricos , Puente de Arteria Coronaria/estadística & datos numéricos , Resultado del Tratamiento , Revisión de Utilización de Recursos/estadística & datos numéricos , Anciano , Colombia Británica , Angiografía Coronaria/mortalidad , Puente de Arteria Coronaria/mortalidad , Recolección de Datos , Femenino , Hospitales/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , New York , Ontario , Complicaciones Posoperatorias , Pautas de la Práctica en Medicina/estadística & datos numéricos , Evaluación de la Tecnología Biomédica , Revisión de Utilización de Recursos/métodosRESUMEN
OBJECTIVE: To develop and test a method for comparing the appropriateness of hysterectomy use in different health plans. DESIGN: Retrospective cohort study. SETTING: Seven managed care organizations. PATIENTS: Random sample of all nonemergency, non-oncological hysterectomies performed in the seven managed care organizations over a 1-year period. Patients who were not continuously enrolled in a plan for 2 years prior to their hysterectomy were excluded. MAIN OUTCOME MEASURES: Proportion of women undergoing hysterectomy in each plan for inappropriate clinical reasons according to ratings derived from a panel of managed care physicians. RESULTS: Overall, about 16% of women underwent hysterectomy for reasons judged to be clinically inappropriate. Only one plan had significantly more hysterectomies rated inappropriate compared with the group mean (27%, unadjusted). Adjusting for age and race did not affect the rankings of the plans and had little effect on the numeric results. CONCLUSION: The rates of inappropriate use of hysterectomies are similar to those for other procedures and vary to a small degree among health plans. This information may be useful to purchasers when they consider which health plans to offer their employees.
Asunto(s)
Sistemas Prepagos de Salud/normas , Mal Uso de los Servicios de Salud/estadística & datos numéricos , Histerectomía/estadística & datos numéricos , Revisión de Utilización de Recursos/estadística & datos numéricos , Adulto , Anciano , Femenino , Sistemas Prepagos de Salud/estadística & datos numéricos , Investigación sobre Servicios de Salud/organización & administración , Humanos , Persona de Mediana Edad , Garantía de la Calidad de Atención de Salud , Estudios Retrospectivos , Estados UnidosRESUMEN
We evaluated the effect of patients' comorbidity on the appropriateness of performing esophagogastroduodenoscopy or cholecystectomy. A nine-member national physician panel rated 1118 brief clinical scenarios for patients without comorbidity. Ratings were then repeated for patients with increasing degrees of comorbidity. As comorbidity changed from none to medium, 60% of those scenarios that were originally rated as appropriate for endoscopy and cholecystectomy remained appropriate. As high comorbidity was introduced, only 13% of such scenarios remained appropriate for endoscopy, while 33% remained appropriate for cholecystectomy. These findings suggest that, although clinical reasons for performing procedures are a powerful determinant of when they should be used, comorbidity is also important and needs to be included in any assessment of the appropriateness of procedure use.