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An altered colonic microbiota probably increases colorectal adenoma (CRA) and cancer (CRC) risk, but large, unbiased fecal collections are needed to examine the relationship of gut microbiota diversity and composition to colorectal carcinogenesis. This study assessed whether fecal immunochemical tests (FITs) from CRA/CRC screening may fulfill this requirement. Using FIT, self-collected by members of Kaiser Permanente Hawaii (KPH), as well as interspersed quality control (QC) specimens, DNA was extracted and amplified to generate 16S rRNA microbiome profiles rarified at 10,000 reads. CRA/CRC were diagnosed by colonoscopy and histopathology. Covariates were from electronic KPH records. Of 921 participants’ FIT devices, 538 (58%) yielded at least 10,000 rRNA reads and 1016 species-level variants mapped to 46 genera. Of the 538 evaluable participants, 63 (11.7%) were FIT-negative per protocol, and they were considered negative for CRA/CRC. Of the 475 FIT + participants, colonoscopy and pathologic review revealed that 8 (1.7%) had CRC, 71 (14.9%) had high-risk CRA, 107 (22.5%) had low-risk CRA, and 289 (60.8%) did not have CRA/CRC. Men were 2.27-fold [95% confidence interval (CI) 1.32–3.91] more likely than women to be FIT+ . Men also had 1.96-fold (CI 1.24–3.07) higher odds of low-risk CRA, with similar trends for high-risk CRA and CRC. CRA/CRC were not associated with overweight, obesity, diabetes, or antibiotic prescriptions in this study. QC analysis across 24 batches of FIT devices revealed QC outliers in four batches. With or without exclusion of the four QC-outlier batches, as well as lenient (1000-read) rarefaction, CRA/CRC had no consistent, statistically significant associations with fecal microbiome alpha diversity, beta diversity or genera relative abundance. CRA/CRC had expected associations with male sex but not with microbiome metrics. Fecal microbiome profiling using DNA extracted from at-home collected, re-used FIT devices is feasible, albeit with substantial challenges. Using FITs for prospective microbiome studies of CRA/CRC risk should consider the impact of the current findings on statistical power and requisite sample sizes.

Background To reduce costs and improve care, states are increasingly enrolling individuals with disabilities in Medicaid managed care. Many states allow or require adults who are dually eligible for Medicaid and Medicare to enroll in these plans. Objective This study (1) quantifies changes in enrollment by managed care arrangement for duals under age 65, between 2005 and 2008 and (2) compares enrollment and spending between dual eligibles and Medicaid-only beneficiaries. Methods We used Medicaid Analytic eXtract data to compare the Medicaid enrollment and spending for all-year, full-benefit dual eligibles ages 21–64 with that of Medicaid-only Supplemental Security Income (SSI) and disabled beneficiaries. The study population was classified into 9 types of managed care to quantify enrollment and calculate expenditures by year. Results Nationwide, the proportion of adult duals in managed care increased from 2005 to 2008, with the expansion of prepaid health plans (PHPs) (31.0%–46.6%), particularly behavioral health PHPs, driving the increase. In 2008, Medicaid-only disabled adults were three times as likely as dual adults to enroll in comprehensive managed care (CMC) (35.1% versus 11.7%). Average Medicaid expenditures per enrollee differed markedly by managed care arrangement and state. Conclusions From 2005 to 2008, there was little expansion of CMC among adult duals, while the use of PHPs to cover carved out services increased greatly. New federal initiatives aim to reduce barriers to enrolling duals into comprehensive, integrated managed care. With expanded enrollment, it will be important to monitor enrollment and evaluate whether integration improves care.

Evaluate the association of multimorbidity, primary health care model and possession of a private health plan with hospitalization.A population-based cross-sectional study with 1,593 elderly individuals (60 years old or older) living in the urban area of the city of Bagé, State of Rio Grande do Sul, Brazil. The outcome was hospitalization in the year preceding the interview. The multimorbidity was evaluated through two cut-off points (≥ 2 and ≥ 3). The primary health care model was defined by residence in areas covered by traditional care or by Family Health Strategy. The older adults mentioned the possession of a private health plan. We performed a gross and adjusted analysis by Poisson regression using a hierarchical model. The adjustment included demographic, socioeconomic, functional capacity disability and health services variables.The occurrence of overall and non-surgical hospitalization was 17.7% (95%CI 15.8-19.6) and 10.6% (95%CI 9.1-12.1), respectively. Older adults with multimorbidity were admitted to hospitals more often when to older adults without multimorbidity, regardless of the exhibition' form of operation. Having a private health plan increased the hospitalization by 1.71 (95%CI 1.09-2.69) times among residents in the areas of the Family Health Strategy when compared to elderly residents in traditional areas without a private health plan.The multimorbidity increased the occurrence of hospitalizations, especially non-surgical ones. Hospitalization was more frequent in older adults with private health plan and those living in Family Health Strategy areas, regardless of the presence of multiple diseases.Avaliar a associação da multimorbidade, modelo de atenção básica e posse de plano de saúde com hospitalização.Estudo transversal de base populacional com 1.593 idosos (60 anos ou mais) residentes na zona urbana do município de Bagé, Rio Grande do Sul. O desfecho foi a hospitalização no ano anterior à entrevista. A multimorbidade foi avaliada por meio de dois pontos de corte (≥ 2 e ≥ 3). O modelo de atenção básica foi definido pela residência em áreas cobertas pela atenção tradicional ou da Estratégia Saúde da Família. A posse de plano de saúde foi referida pelos idosos. Realizou-se análise bruta e ajustada por regressão de Poisson utilizando modelo hierarquizado. O ajuste incluiu variáveis demográficas, socioeconômicas, capacidades funcionais e de serviços de saúde.A ocorrência de hospitalização geral e não cirúrgica foi de 17,7% (IC95% 15,8-19,6) e 10,6% (IC95% 9,1-12,1), respectivamente. Idosos com multimorbidade hospitalizaram mais em comparação com os idosos sem multimorbidade, independentemente da forma de operacionalização da exposição. O plano de saúde aumentou em 1,71 (IC95% 1,09-2,69) vezes a internação hospitalar entre residentes nas áreas da Estratégia Saúde da Família em comparação aos idosos residentes nas áreas tradicionais sem plano de saúde.A multimorbidade aumentou a ocorrência de hospitalizações, principalmente aquelas não cirúrgicas. Idosos com plano de saúde e residentes em áreas de Estratégia Saúde da Família internaram mais, independentemente da presença de múltiplas doenças.

Gastroesophageal reflux disease (GERD) may link the obesity epidemic to an array of adverse health outcomes including chronic esophageal inflammation and, consequentially, to pathophysiological changes of the esophagus. Although obesity and GERD are associated in adults, data in children are scarce and inconclusive. The aim of this study is to investigate whether, similar to adults, obesity is associated with GERD in youth.For this population-based, cross-sectional study, measured weight and height and diagnosis of GERD were extracted from electronic medical records of 690 321 patients, aged 2-19 years, who were enrolled in an integrated prepaid health plan between 2007 and 2008. Weight class (normal weight, overweight, moderate and extreme obesity) was assigned based on body mass index-for-age.Overall, GERD was diagnosed in 1.5% of boys and 1.8% of girls (P0.001). Moderately and extremely obese children, aged 6-11 years, were more likely to have a diagnosis of GERD compared with normal weight (OR 1.16, 95% CI: 1.02-1.32 and 1.32, 95% CI: 1.13-1.56, respectively). Children aged 12-19 years showed similar associations (OR 1.16, 95% CI: 1.07-1.25 and 1.40, 95% CI: 1.28-1.52, respectively). These associations remained with adjustment for sex and race/ethnicity. By contrast, obesity was not related to increased odds for GERD in children aged 2-5 years of age.The association between childhood obesity and GERD may have important implications for their future risk of GERD-associated diseases, such as esophageal adenocarcinoma.

The objective of this study was to estimate catastrophic healthcare expenditure in Brazil, using different definitions, and to identify vulnerability indicators. Data from the 2002-2003 Brazilian Household Budget Survey were used to derive total household consumption, health expenditure and household income. Socioeconomic position was defined by quintiles of the National Economic Indicator using reference cut-off points for the country. Analysis was restricted to urban households. Catastrophic health expenditure was defined as expenditure in excess of 10% and 20% of total household consumption, and in excess of 40% of household capacity to pay. Catastrophic health expenditure varied from 2% to 16%, depending on the definition. For most definitions, it was highest among the poorer. The highest proportions of catastrophic health expenditure were found to be in the Central region of Brazil, while the South and the Southeast had the lowest. Presence of an elderly person, health insurance and socioeconomic position were associated with the outcome, and coverage by health insurance did not protect from catastrophic health expenditure. O objetivo deste trabalho foi estimar o gasto catastrófico em saúde no Brasil e identificar indicadores de vulnerabilidade. Dados da Pesquisa de Orçamentos Familiares 2002-2003 foram utilizados para derivar consumo domiciliar total, despesa com saúde e renda domiciliar. Posição socioeconômica foi definida por meio de quintis do Indicador Econômico Nacional, usando pontos de corte de referência para o país. A análise se restringiu a domicílios urbanos. Gasto catastrófico em saúde foi definido como o gasto além de 10% e 20% do consumo domiciliar total e além de 40% da capacidade de pagar. Estimativas do gasto catastrófico em saúde variaram de 2% a 16%, dependendo da definição. Para a maioria delas, ele foi mais alto entre os pobres. A Região Centro-oeste apresentou as maiores proporções de gasto catastrófico em saúde, enquanto que o Sul e o Sudeste apresentaram as mais baixas. Presença de um idoso, plano privado de saúde e posição socioeconômica se associaram com o desfecho, sendo que a cobertura por plano de saúde não protegeu contra o gasto catastrófico em saúde.

Background Few health plans provide maintenance medication for opioid dependence. This study assessed the cost of treating opioid-dependent members in a commercial health plan and the impacts of methadone maintenance on costs of care. Methods Individuals with diagnoses of opioid dependence (two or more diagnoses per year) and at least 9 months of health plan eligibility each year were extracted from electronic health records for the years 2000 through 2004 (1,518 individuals and 2,523 observations across the study period—some individuals were in multiple years). Analyses examined the patterns and costs of health care for three groups of patients: (1) one or more methadone visits during the year (n = 1,298; 51%); (2) no methadone visits and 0 or 1 visits in the Addiction Medicine Department (n = 370; 15%); (3) no methadone visits and 2 or more visits in addiction medicine (n = 855; 34%). Results Primary care (86%), emergency department (48%) and inpatient (24%) visits were common. Mean total annual costs to the health plan were $11,200 (2004 dollars) per member per year. The health plan's costs for members receiving methadone maintenance were 50% lower ($7,163) when compared to those with two or more outpatient addiction treatment visits but no methadone ($14,157) and 62% lower than those with one or zero outpatient addiction treatment visits and no methadone treatment ($18,694). Conclusions Use of opioid maintenance services was associated with lower total costs of care for opioid-dependent members in a commercial health plan.

This study analyzed indicators for health behaviors and use of preventive services in two probabilistic samples of adults, one in 2003 (n = 13,757) and the other in 2010 (n = 12,983), with and without private health insurance in Greater Metropolitan Belo Horizonte, Minas Gerais State, Brazil. After adjusting for demographic variables, temporal variation, and source of care, there was a reduction in smoking prevalence, similar between individuals with and without private health insurance, from 2003 to 2010. During this same period the prevalence of excessive alcohol intake and sedentary lifestyle increased in both groups; with the same magnitude, there was a decrease in the prevalence of leisure-time physical activity. No changes were observed in the prevalence of blood pressure measurement, but the prevalence of cholesterol testing, mammogram, and Pap smear increased more sharply in individuals without health insurance.

Although states have had difficulty extending Medicaid managed care (MMC) to rural areas, rural models of capitated MMC are expected to grow in response to new federal regulations and the serious budget problems facing nearly all states. As such, understanding the effects of capitated MMC in rural settings is important for policy considerations.To evaluate the effects of capitated MMC on beneficiary access and use in rural Minnesota.We took advantage of delays in the timing of the introduction of MMC across rural counties in Minnesota to estimate the effects of managed care on adults and children under Medicaid using a difference-in-differences framework.We found that Minnesota's shift from fee-for-service Medicaid to MMC in its rural counties had little effect on access to health care for either adults or children.Because Minnesota reports that Medicaid costs under MMC are below expected costs under FFS Medicaid, it appears that the primary accomplishment of Minnesota's rural MMC initiative is one of cost savings: MMC provides the same access to care as FFS Medicaid, but at lower cost. With steep budget deficits in nearly all states, other states may want to consider Minnesota's rural MMC model as a mechanism for reducing their Medicaid costs.

Nonmelanoma skin cancer is the most common malignancy. Multiple therapies prevent recurrence but vary widely in cost. The most common therapies are local destruction, excision, and Mohs surgery (histologically guided tumor removal). Clinical variables that may affect treatment choices can be identified, but little is known about how clinicians choose among therapies.The objective of this study was to learn if variations exist in the treatment of nonmelanoma skin cancer in different practice settings.Prospective cohort study.Subjects consisted of consecutive patients with nonmelanoma skin cancer at a university-affiliated private dermatology practice and the dermatology clinic at the nearby affiliated Veterans Affairs (VA) medical center.We studied data from medical records and patient surveys.Overall, 1777 nonrecurrent nonmelanoma skin cancers were diagnosed in 1375 patients. Compared with the VA site, patients at the private site were younger, more likely to be female, and less likely to be poor, and their tumors were smaller and less likely to be on visible areas of the body. Treatments varied between the 2 sites (P0.001). The proportions of tumors treated at the private and VA sites, respectively, were 23% and 19% for destruction, 25% and 48% for excision, and 37% and 25% for Mohs surgery. In multiple clinical subgroups, Mohs surgery was more likely to be performed at the private site than at the VA. Moreover, in multivariable models controlling for clinical features that may have affected treatment choice, tumors at the private site were more likely than tumors at the VA to be treated with Mohs surgery (odds ratio, 2.39; 95% confidence interval, 1.54-3.70).Care for nonmelanoma skin cancer varied at 2 academic practice sites that are near each other and that share some clinician staff. These findings raise questions not only about overuse or underuse of procedures at the 2 sites, but also about systematic differences in patient preferences and/or physician incentives in prepaid and fee-for-service settings.

Background An optional capitation prepayment system has been implemented in Swedish dental care, supplementary to the traditional fee-for-service scheme within the Public Dental Service. The implementation of a new system may have a variety of preferred and adverse effects, arguably dependent on the individual patient’s attitudes, health beliefs and course of action. The aim of this study was to describe potential differences regarding socioeconomic and lifestyle factors, perceived oral health and attitudes towards oral health between patients in the two payment systems. Methods Questionnaire data were consecutively collected from 13,719 patients, who regularly attended 20 strategically selected clinics within the PDS in Region Västra Götaland, before they were offered the choice between the traditional and the new payment system. Results Capitation patients were more often female and well educated. They had healthier habits, were more motivated to follow self-care advice, more often judged their oral health to be very good and considered oral health to be very significant for their wellbeing. The results were statistically significant and described a gradient. Conclusions The more explicitly affirmative the answer, the more likely the patient was to choose the prepayment scheme. There appears to be a pattern of differences with respect to important individual views on oral health between patients choosing a capitation system or a fee-for-service system. These differences may be important when assessing outcomes in the new payment system and in public dental care.

Hospital readmissions are common and expensive, and there is little information on the problem in Colombia. The objective was to determine the frequency of 30-day all-cause hospital readmissions and associated factors. This was a retrospective analytical cohort study of 64,969 hospitalizations from January 2008 to January 2009 in 47 Colombian cities. 6,573 hospital readmissions, prevalence: 10.1% (men 10.9%, women 9.5%), 44.7%65 years of age. Hospital readmissions was associated with higher mortality (5.8% vs. 1.8%). There was an increase in the Hospital readmissions rate in patients with diseases of the circulatory system. Hospital readmissions was more likely in hematological diseases and neoplasms. Mean length of stay during the first readmission was 7 days in patients that were readmitted and 4.5 in those without readmission. Greater total cost of hospital readmissions (USA 21,998,275): 15.8% of the total cost of hospitalizations. Higher prevalence rates in referred patients (18.8%) and patients from the outpatient clinic (13.7%). Hospital readmissions is common and is associated with longer length of hospital stay and higher mortality and cost. Increased risk of hospital readmissions in men65 years, patients referred from other institutions, and in hematological diseases and neoplasms.

Objective: To present preliminary data on the health-related consequences for people with spinal cord injury (SCI) of participation in a prepaid, risk-based, managed care plan. Design: Baseline data from a longitudinal interview survey. Setting: Massachusetts. Participants: Subjects were 114 independently living adults with SCI recruited from 6 independent living centers and 2 managed care plans; 45 received care from a risk-based prepaid managed care plan and 69 from other sources. Main Outcomes: Self-reports of use of health services; self-assessments of health, health at interview versus 12 months earlier; hospital admissions; numbers of secondary conditions, and experiences of specific secondary conditions (eg, pressure ulcers, depression, fatigue, and chronic pain). Results: Persons in the managed care plan do not differ from their counterparts in terms of age, gender, education, level of SCI, number of comorbid conditions, activity of daily living profiles, household composition, and reliance upon health maintenance programs and routines (eg, bowel and bladder care). In terms of processes of care, they appear generally better-served. There also are a few differences in outcome that are statistically significant, or approach significance, and generally favor the managed care plan. Conclusion: Preliminary data suggest that thoughtfully and sensitively designed and implemented risk-based managed care may improve both access and outcomes.

To determine whether the incidence of multiple sclerosis (MS) varies by race/ethnicity in a multiethnic, population-based cohort.We conducted a retrospective cohort study of more than 9 million person-years of observation from the multiethnic, community-dwelling members of Kaiser Permanente Southern California health plan from January 1, 2008 to December 31, 2010. Incidence of MS and risk ratios comparing incidence rates between racial/ethnic groups were calculated using Poisson regression.We identified 496 patients newly diagnosed with MS who met McDonald criteria. The average age at diagnosis was 41.6 years (range 8.6-78.3 years) and 70.2% were women. The female preponderance was more pronounced among black (79.3%) than white, Hispanic, and Asian individuals with MS (67.8%, 68.1%, and 69.2%, respectively; p = 0.03). The incidence of MS was higher in blacks (10.2, 95% confidence interval [CI] 8.4-12.4; p0.0001) and lower in Hispanics (2.9, 95% CI 2.4-3.5; p0.0001) and Asians (1.4, 95% CI 0.7-2.4; p0.0001) than whites (6.9, 95% CI 6.1-7.8). Black women had a higher risk of MS (risk ratio 1.59, 95% CI 1.27-1.99; p = 0.0005) whereas black men had a similar risk of MS (risk ratio 1.04, 95% CI = 0.67-1.57) compared with whites.Our findings do not support the widely accepted assertion that blacks have a lower risk of MS than whites. A possible explanation for our findings is that people with darker skin tones have lower vitamin D levels and thereby an increased risk of MS, but this would not explain why Hispanics and Asians have a lower risk of MS than whites or why the higher risk of MS among blacks was found only among women.

Background . Using the medical records of a large, prepaid health plan, our purpose was to assess the accuracy of self-reported data on cancer detection practices and to evaluate any differences in accuracy between Hispanics and non-Hispanic whites. Methods . Data were collected on six procedures: mammography, clinical breast examination, Pap smear, sigmoidoscopy, fecal occult blood tests, and digital rectal examination. We audited the medical records of 815 randomly selected Hispanic and 483 non-Hispanic white members of the Kaiser Permanente Medical Care Program in Northern California. All responded to a telephone survey. Using a standardized form, we recorded any of the six target examinations that had been performed within 5 years of the telephone interview. We then compared the times of the most recent screening tests as reported in the telephone survey with those in the medical record. Results . For the 2 years before the telephone interview, self-reports for screening tests overestimated the actual rates at which these tests were performed as documented in the medical records. Lack of agreement between self-report and medical record audits was substantial for all screening procedures except sigmoidoscopy. Hispanic members had fewer procedures done for most tests, but the differences were not statistically significant. Overestimates in self-reported screening rates did not differ substantially between Hispanics and non-Hispanic whites. Conclusions . Self-reported data on early cancer detection procedures can substantially overestimate their occurrence among both non-Hispanic white and Hispanic populations. These findings confirm earlier findings for Pap smear and affect decisions on cancer prevention procedures that rely on the accuracy of self-reported data.

To investigate the association between frailty syndrome and cognitive performance in the older adults and the effect of schooling and age on this association.Data on frailty in older adults from Phase 1 of the FIBRA-RJ Study were analyzed, relating to 737 customers of a private health care provider, aged 65 and over, living in Rio de Janeiro, Southeastern Brazil, between January 2009 and January 2010. Data on socioeconomic and demographic characteristics, medical conditions and functional capacity were collected. Cognitive performance was assessed using the Mini-Mental State Examination (MMSE). Individuals who exhibited three or more of the following features were considered to be frail: unintentional weight loss (≥ 4.5 kg in the last year); feeling self-reported exhaustion, low grip strength, low physical activity level and slowness. The association between frailty and cognitive performance was evaluated using multivariate logistic regression, with adjustment for medical conditions, activities of daily living and socioeconomic variables. We evaluated the age and schooling as possible effect modifiers in this association.The frail subjects had a higher prevalence of low cognitive performance, compared to not frail or pre-frail, in the three age groups studied (65-74; 75-84; ≥ 85 years), p0.001. After adjustment, the association between frailty and cognitive performance was found among older adults individuals aged 75 and older, with an OR(adj)= 2.78 (95%CI 1.23;6.27) for those aged 75 to 84 and OR(adj)= 15.62 (95%CI 2.20;110.99) for 85 and older. The age variable was an effect modifier in the association between frailty and cognitive performance, χ²(5) = 806.97, p0.0001; the same was not the case with schooling.Frailty syndrome is associated with cognitive performance in the aging. Age proved to be an effect modifier in this association. The oldest patients showed a more significant association between the two phenomena.

To examine sociodemographic and epidemiological factors associated with private health insurance coverage in the elderly.A total of 2,143 individuals aged 60 years or more were interviewed in the city of São Paulo in 2000 and 2006. Having private health insurance was the dichotomous dependent variable. Independent variables included sociodemographic characteristics and self-reported health status. The proportions of the variables studied were described and a logistic regression model considering those variables significant at p0.05 was constructed.The elderly with private insurance coverage had significantly higher income and education. The elderly with no private insurance were screened less for cancer and more for respiratory diseases; they waited longer for appointments; they performed less medical tests; they reported fewer conditions and more falls and had a more negative self-rated health. The insured respondents reported lower vaccination rates and, among those hospitalized, 11.1% had their medical costs covered by the Brazilian National Health System (SUS) in 2000 and 17.9% in 2006. Osteoporosis was the single condition associated with private health insurance.The elderly with private insurance coverage had significantly higher income and education than those with no private coverage, and these differences were associated with service utilization and social determinants of health.

We analyzed switches between prepaid and fee-for-service health care plans among depressed outpatients in the longitudinal part of the Medical Outcomes Study. Patients of mental health specialists in fee-for-service plans had the lowest adjusted rate of plan switching (8.1%), compared to fee-for-service general medical patients (13.5%) and prepaid patients of both types of providers (10.1% to 11.7%). Although there were no substantial differences in initial sickness by payment system among enrolled patients, differing switching rates by provider specialty and payment system indicated biased selection over time. In addition, we found that married, nonwhite, and wealthier individuals were significantly more likely to leave fee-for-service than prepaid care plans. We analyzed whether system switching had an effect on patient satisfaction and outcomes. None of the results were highly significant, but the power of the data to analyze this issue was limited. Nevertheless, it appears that patients switching from prepaid to fee-for-service may be at risk for poorer functioning outcomes, although there was no similar effect on mental health status.

To analyze clinical outcomes of patients on hemodialysis linked to health care plan provider.Cohort study of hemodialysis events in Belo Horizonte, MG, Southeastern Brazil, between 2004 and 2008, based on records from health care plan provider databases. The independent variables were: sex, age, time between first appointment with nephrologist and starting hemodialysis, type of first vascular access, diabetes mellitus, length of time spent in hospital/year of treatment and death.time between starting hemodialysis and death and length of time spent in hospital/year of treatment7.5 days. Statistical analysis was carried out using Pearson's Chi-squared test in the univariate analysis for the outcomes 'death' and 'length of time spent in hospital/year of treatment'; the Kaplan-Meier method was used to analyze survival; the Cox model and Poisson regression were used for risk of death and chance of length of time spent in hospital/year of treatment7.5 days. The Business Intelligence tool and Stata(r) 10.0 software were used to extract data.There were 311 patients on hemodialysis included in the study, with a mean age of 62 (sd 16.6 years), of whom 55.5% were male. Prevalence increased 160% during the period in question. Survival analysis showed a higher mortality among older patients, patients that did not consult a nephrologists, those whose first vascular access was using a temporary catheter, those with diabetes mellitus, those admitted to hospital within a month of beginning hemodialysis. The Cox model showed that a higher risk of death was associated with age, diabetes mellitus, not consulting a nephrologists and those that were hospitalized within a month of beginning hemodialysis. Greater length of time spent in hospital/year of treatment was not associated with sex or diabetes. According to Poisson regression, the variables were not significant.Assessment by a specialist before starting hemodialysis decreases the risk of death in cases of chronic kidney disease, whereas the presence of diabetes and being hospitalized within a month of beginning hemodialysis are markers of risk of death.

To analyze the prevalence of elderly users' satisfaction with dental care and associated factors.Cross-sectional study conducted with 495 elderly individuals aged 65-74 years, without cognitive impairment according to the Mini-Mental State Examination, who used dental services of the municipality of Montes Claros (Southeastern Brazil) from 2008 to 2009. A two-stage cluster, complex probability sample was used. Trained/ calibrated professionals and students conducted tests and household interviews using handheld computers with software developed for this purpose. In the statistical analysis, with correction by design effect, PASW® Statistics 18.0 was utilized. To identify associations between satisfaction and the factors of interest, Poisson regression was conducted, estimating the prevalence ratio and the 95% confidence interval (PR / 95%CI).Overall, 91.4% of the elderly were satisfied. Greater satisfaction was found among users of services of the Sistema Único de Saúde (SUS - Brazil's National Health Service) (PR = 1.07; 95%CI 1.01;1.12); those who had access to information on how to avoid oral problems (PR = 1.09; 95%CI 1.02;1.16); those who did not use medicines (PR = 1.05; 95%CI 1.00;1.10); and those who rated the appearance of their teeth and gums as excellent or good (PR = 1.13; 95%CI 1.00;1.28).The elderly who access the service offered by SUS have greater satisfaction with dental treatment, as well as those who do not use medicines, those with better self-perception of the aesthetics of teeth and gums and those who have more access to information about how to prevent oral problems. Therefore, health care policies in the SUS have been presenting positive results.

Background Population-based data on the demographics and clinical characteristics of patients with multiple unrelated drug class intolerances noted in their medical records are lacking. Objectives To provide population-based drug "allergy" incidence rates and prevalence, and to identify individuals with multiple drug intolerance syndrome (MDIS) defined by 3 or more unrelated drug class "allergies," and to provide demographic and clinical information on MDIS cases. Methods Electronic medical record data from 2,375,424 Kaiser Permanente Southern California health plan members who had a health care visit and at least 11 months of health care coverage during 2009 were reviewed. Population-based drug "allergy" incidence rates and prevalence were determined for 23 unrelated medication classes. Results On January 1, 2009, 478,283 (20.1%) health plan members had at least one reported "allergy." Individuals with a history of at least 1 "allergy" and females, in general, reported higher population-based new "allergy" incidence rates. Multiple drug intolerance syndrome was present in 49,582 (2.1%). The MDIS cases were significantly older, 62.4 ± 16.1 years; heavier, body mass index 29.3 ± 7.1; and likely to be female, 84.9%, compared with average health plan members. They had high rates of health care utilization, medication usage, and new drug "allergy" incidence. They sought medical attention for common nonmorbid conditions. Conclusions Multiple drug intolerance syndrome is in part iatrogenic. It is associated with overweight elderly women who have high rates of health care and medication usage. Urticarial syndromes only explain a small fraction of MDIS cases. Multiple drug intolerance syndrome is associated with anxiety, but not predominately with immunoglobulin E (IgE)-mediated allergy or life-threatening illness. Multiple drug intolerance syndrome can be managed by medication avoidance and judicious rechallenge.

To examine how enrollment in high-deductible health plans (HDHPs) affects use of well-child visits relative to traditional plans, when preventive care is exempt from the deductible.Pre-post comparison between groups.We selected children aged18 years enrolled in a large Massachusetts health plan through employers offering only 1 type of plan. Children were in traditional plans for a 12-month baseline period between 2001 and 2004, then were either switched by a decision of the parent's employer to an HDHP or kept in the traditional plan (controls) for a 12-month follow-up period. Preventive and other office visits were exempt from the deductible and subject to copayments, as in traditional plans. The primary outcome was whether the child received well-child visits recommended for the 12-month period. Using generalized linear mixed models, we compared the change in receipt of recommended well-child visits between baseline and follow-up for the HDHP group relative to controls.We identified 1598 children who were switched to HDHPs and 10,093 controls. Between baseline and follow-up, the mean proportion of recommended well-child visits received by HDHP children decreased slightly from 0.846 to 0.841, and from 0.861 to 0.855 for controls. In adjusted models, there was no significant difference in the change in probability that recommended well-child visits were received by HDHP children compared with controls (P = .69).Receipt of recommended well-child visits did not change for children switching from traditional plans to HDHPs that exempt preventive care from the deductible.

This article has two objectives: to quantify the access and utilization of services received by chronically mentally ill Medicaid recipients, and to compare service utilization and access under prepayment and fee-for-service (FFS) payment. The study setting is Hennepin County (Minneapolis), Minnesota, where 35 percent of Medicaid recipients were randomly assigned to receive services from prepaid plans. An algorithm was developed to identify recipients with chronic mental illness, resulting in 739 study participants, split approximately evenly between prepayment and FFS Medicaid. Data were collected through in-person surveys at baseline, and after 1 year. We found slight improvements in the majority of access measures studied and no significant decreases in the use of inpatient or outpatient services for enrollees in prepaid health plans. The results support efforts to expand the use of prepaid health plans to meet the needs of non-institutionalized chronically mentally ill Medicaid beneficiaries.

This paper aims to describe health insurance coverage among different types of workers in Brazil. Health insurance coverage and labor market insertion are used to define homogeneous groups of workers. The Grade of Membership method is used to build a typology of workers. The database was the Brazilian National Household Survey (PNAD) for 1998 and 2003, including a health survey. Five worker profiles were defined. The key variables were: health insurance coverage, schooling, and work status. The main findings show a positive association between health insurance coverage, income from work, and trade union membership.

The paper exposes the changes in rules of price readjustment of health plans by age thresholds and demographic changes observed between 1998 and 2008. By calculating aging indicators and building population pyramids, it assesses whether the demographic changes coupled with the regulation caused any alteration in young people subscribing to supplementary healthcare plans. The indicators reveal the aging trend of beneficiaries of health plans, especially among those contracted individually, and also that this has not resulted in young people quitting supplementary healthcare plans.

The incidence of reoperation and mortality after prostatectomy was studied in 8,219 men who underwent surgical treatment for benign prostatic hypertrophy between 1976 and 1987 while they were members of the Kaiser Permanente Medical Care Program, Northern California Region. The vast majority (94.5%) received transurethral prostatectomy (TURP). The cumulative 8-year probability of a second prostatectomy was 7.6% after TURP and 2.1% after open prostatectomy. The risk of mortality associated with transurethral prostatectomy relative to open prostatectomy was 1.6 (95% confidence interval 1.2, 2.1) 8 years postsurgery. The increased risk of mortality associated with transurethral prostatectomy was most prominent during the first 5 years postsurgery (relative risk 1.8, 95% confidence interval 1.3, 2.5) and declined to 1.1 (95% confidence interval 0.8, 1.6) for deaths occurring after the first 5 years. The finding of an increased risk of mortality associated with transurethral prostatectomy is consistent with other studies and is unexplained.

Objective Although depression is one of the most common problems of medical and psychiatric outpatients, it has not been clear whether the extent of medical comorbidity among depressed patients varies across major types of clinical settings in which depressed patients receive care--especially by type of treating clinician (general medical versus mental health specialty) or type of payment for services (prepaid versus fee-for-service). Methods The authors examined these issues using data on 1,152 adult outpatients with current depressive symptoms and a lifetime history of unipolar depressive disorder who received care in one of three health care delivery systems in three U.S. sites. Results Depressed patients had a similarly high prevalence (64.9%-71.0%) of any of eight common chronic medical conditions whether they were seen in the general medical or specialty mental health sector; however, those visiting medical clinicians had a significantly higher prevalence of the two most common chronic medical conditions, hypertension and arthritis. Among depressed patients with hypertension, those visiting the general medical sector were more likely to be taking antihypertensive medication than were those visiting the mental health specialty sector. Type of payment (prepaid versus fee-for-service) was unrelated to either prevalence or severity of comorbid medical conditions, suggesting that the typical depressed patient in all types of practices studied had medical comorbidity. Conclusions These data suggest that clinicians in all health care settings must be prepared to encounter chronic medical conditions and complaints in the depressed patients who visit them.

To assess health coverage of elderly people receiving supplementary health care and these users' sociodemographic characteristics.Descriptive study of elderly population living in Brazil and in the states of São Paulo and Rio de Janeiro in 2006. Data was collected from the National Supplementary Care Beneficiary Information System and the National Household Sample Survey. The following variables were studied: gender, age, distribution by federal unit, category of health insurance, type of contract and plan segmentation.Higher coverage of the general population was seen in the age groups 70-79 years (26.7% and 80 years and more (30.2%). Of those aged 80 years and more, 33% had private health plans among women and 25.9% among men. Nearly 80% of health insurance beneficiaries were living in southeastern and southern Brazil, of which 55% were in Rio-São Paulo axis. Health maintenance organizations covered a higher proportion of younger compared to elderly population (39% and 34.5%, respectively) and self-management care plans covered a significantly higher proportion of elderly compared to younger population in Brazil (22.8% and 13.8%, respectively).Elderly health care coverage was significantly high and age groups over 70 years showed the highest coverage rates among the Brazilian population, especially among women.

To describe the pattern of health services utilization by young adults.Longitudinal study in Pelotas (Southern Brazil), in which the individuals were identified at birth in 1982 and followed up until 23 years of age. The outcome was defined by information collected about visits to health professionals that were attended in the year before the interview, between 2004 and 2005. The places where the visits occurred were categorized as public, private or belonging to health plan systems. Descriptive analyses were carried out for utilization and type of health service. Poisson Regression was employed in the adjusted analysis.Of the interviewees, 72.0% visited health professionals in the year before the interview; 86.2% (95% CI 84.7;87.7) of the women and 59.3% (95% CI 57.3;61.3) of the men. Even when gynecological visits were excluded, the women still attended more visits than the men, 68.4% (95% CI 66.4;70.4). Health services utilization was more frequent among interviewees of better socioeconomic level. A difference of lower use in relation to non-white skin color was observed only among male youths. There were differences regarding the type of professional visited by men and women and also according to family income. Men and women used more frequently the public system, the health plan system and, in a smaller proportion, the private system.The socioeconomic situation influenced the utilization and the type of health service, with men and women classified as 'poor at the moment', which indicates lower utilization of services. Such socioeconomic differences may indicate difficulties in the access to the health system.

The main objective was to assess how group premiums can help poor people in the informal economy prepay for health care services.A comparative approach was adopted to study four groups of informal economy operators (cobblers, welders, carpenters, small scale market retailers) focusing on a method of prepayment which could help them access health care services. Two groups with a total of 714 operators were organized to prepay for health care services through a group premium, while the other two groups with a total of 702 operators were not organized to prepay through this approach. They prepaid through individual premium, each operator paying from his or her sources. Data on the four groups which lived in the same city was collected through a questionnaire and focus group discussions. Data collected was focused on health problems, health seeking behaviour and payment for health care services. Training of all the groups on prepaid health care financing based on individual based premium payment and group based premium payment was done. Groups were then free to choose which method to use in prepaying for health care. Prepayment through the two methods was then observed over a period of three years. Trends of membership attrition and retention were documented for both approaches.Data collected showed that the four groups were similar in many respects. These similarities included levels of education, housing, and social services such as water supplies, health problems, family size and health seeking behaviour. At the end of a period of three years 76% of the members from the two groups who chose group premium payment were still members of the prepayment health scheme and were receiving health care. For the two groups which opted for individual premium payment only 15% of their members were still receiving health care services at the end of three years.Group premium is a useful tool in improving accessibility to health care services in the poorer segments of the population especially the informal economy operators

Background We established a male, multiethnic cohort primarily to study prostate cancer etiology and secondarily to study the etiologies of other cancer and non-cancer conditions. Methods/Design Eligible participants were 45-to-69 year old males who were members of a large, prepaid health plan in California. Participants completed two surveys on-line or on paper in 2002 – 2003. Survey content included demographics; family, medical, and cancer screening history; sexuality and sexual development; lifestyle (diet, physical activity, and smoking); prescription and non-prescription drugs; and herbal supplements. We linked study data with clinical data, including laboratory, hospitalization, and cancer data, from electronic health plan files. We recruited 84,170 participants, approximately 40% from minority populations and over 5,000 who identified themselves as other than heterosexual. We observed a wide range of education (53% completed less than college) and income. PSA testing rates (75% overall) were highest among black participants. Body mass index (BMI) (median 27.2) was highest for blacks and Latinos and lowest for Asians, and showed 80.6% agreement with BMI from clinical data sources. The sensitivity and specificity can be assessed by comparing self-reported data, such as PSA testing, diabetes, and history of cancer, to health plan data. We anticipate that nearly 1,500 prostate cancer diagnoses will occur within five years of cohort inception. Discussion A wide variety of epidemiologic, health services, and outcomes research utilizing a rich array of electronic, biological, and clinical resources is possible within this multiethnic cohort. The California Men's Health Study and other cohorts nested within comprehensive health delivery systems can make important contributions in the area of men's health.

To assess the direct cost during hospitalization for an osteoporotic hip fracture in Brazilian private health care system, by health plan companies' perspective.We conducted a cross-sectional and retrospective study on costs of medical resources in patients above 50 years with an osteoporotic hip fracture, under hospital treatment, between July 2003 and June 2004. The study sample was collected from electronic claims databases of patients enrolled in Brazilian health plans.There were 129,611 patients with osteoporosis diagnosis. The incidence of osteoporotic hip fracture was 4.99% (women). The mean length of hospital stay was 9.21 days (2.13 days in ICU). The total mean cost of hospitalization was R$ 24,000. The largest cost component was attributable to medical device (61%). The economic burden of osteoporotic hip fracture to health plan companies was estimated in R$ 12 million.The costs of treating osteoporotic hip fracture are substantial in Brazilian private health care system. This study highlights the savings to health plan companies if an osteoporotic hip fracture can be avoided.

Introduction Preventive screening is widely recognized as a key component of cost-effective, high-quality health care. Even so, national screening for cancer, diabetes, and cholesterol falls far short of U.S. Preventive Services Task Force recommendations. Although evidence has shown that reminder programs improve preventive screening rates, this study is one of the first to examine the characteristics of health plan members who respond to screening reminders. Methods The study sample included active members of a large health plan in Hawaii who were identified by an algorithm as not having received one or more recommended screenings based on age and sex criteria (2000–2003) for breast cancer (n = 44,331), cervical cancer (n = 73,875), colon cancer (n = 131,860), diabetes (n = 86,216), and cholesterol (n = 54,843). Statistical analyses were conducted using Cox proportional hazard and logistic regression models. In the proportional hazard models, reminder letters were treated as time-varying exposures. Hazard ratios, or rate ratios, were used to examine the relationship between health plan member and physician characteristics and the likelihood of responding to the reminders. The effects of additional or multiple reminders among health plan members receiving more than one reminder were examined in multivariable regression models. Results The impact of health plan member characteristics and number of office visits on the response to reminders varied among the five health-screening types. Health plan members responded better to reminders for diabetes screening than for colon cancer screening. Members sent their second annual reminders were less likely to obtain screening than members sent their first reminder. Members receiving their third (or more) annual reminder were especially recalcitrant. Conclusion Our findings suggest that the response to reminders differs according to patient characteristics. In particular, targeted interventions may be needed to encourage screening for younger and healthier members whose response rate to reminders was low. Further research is needed to determine how health plans can best reach members who do not respond to patient reminders.

This study analyzes data from the World Health Survey (WHS) conducted in 2003, with a sample of 5,000 individuals 18 years and older. Some 24.0% of the interviewees had private health insurance, and the main variables associated with private coverage were number of household assets, age, level of education, formal employment, living in municipalities with more than 50,000 inhabitants, and good self-rated health. The socioeconomic profiles of needs for and use of health services in the population covered by private health plans are different, confirming the findings of other studies reporting that this population segment as a whole presents better health conditions and greater use of services as compared to the population without private coverage, even after adjusting for socio-demographic variables and self-rated health. The WHS data also suggest that individuals with private health plans do not always use their insurance to pay for services, except in the case of mammograms. Esse estudo analisa os dados da Pesquisa Mundial de Saúde (PMS), realizada em 2003, em uma amostra de 5 mil indivíduos com 18 anos ou mais. Cerca de 24,0% dos indivíduos entrevistados têm seguro privado de saúde, sendo que os fatores associados à posse do plano são o número de bens, idade, escolaridade, ter emprego formal, residir em municípios com menos de 50 mil habitantes e referir boa auto-avaliação do estado de saúde. Os perfis sócio-demográficos de necessidades e uso de serviços de saúde da população coberta por plano de saúde são distintos, confirmando os achados de outros trabalhos que referem que esse segmento populacional como um todo apresenta melhores condições de saúde e um maior uso de serviços em relação à população não coberta por seguro de saúde, mesmo após o controle por variáveis sócio-demográficas e a auto-avaliação do estado de saúde. Os dados da PMS também sugerem que pessoas cobertas por plano de saúde nem sempre utilizam o plano para pagamento de serviços, excetuando-se o caso da mamografia.

In March 2004 the U.S. Food and Drug Administration (FDA) warned physicians and patients regarding increased risk of suicide with 10 newer antidepressant drugs. Available data leave considerable uncertainty regarding actual risk of suicide attempt and death by suicide during antidepressant treatment. The authors used population-based data to evaluate the risk of suicide death and serious suicide attempt in relation to initiation of antidepressant treatment.Computerized health plan records were used to identify 65,103 patients with 82,285 episodes of antidepressant treatment between Jan. 1, 1992, and June 30, 2003. Death by suicide was identified by using state and national death certificate data. Serious suicide attempt (suicide attempt leading to hospitalization) was identified by using hospital discharge data.In the 6 months after the index prescription of antidepressant treatment, 31 suicide deaths (40 per 100,000 treatment episodes) and 76 serious suicide attempts (93 per 100,000) were identified in the study group. The risk of suicide attempt was 314 per 100,000 in children and adolescents, compared to 78 per 100,000 in adults. The risk of death by suicide was not significantly higher in the month after starting medication than in subsequent months. The risk of suicide attempt was highest in the month before starting antidepressant treatment and declined progressively after starting medication. When the 10 newer antidepressants included in the FDA advisory were compared to older drugs, an increase in risk after starting treatment was seen only for the older drugs.The risk of suicide during acute-phase antidepressant treatment is approximately one in 3,000 treatment episodes, and risk of serious suicide attempt is approximately one in 1,000. Available data do not indicate a significant increase in risk of suicide or serious suicide attempt after starting treatment with newer antidepressant drugs.

Background: A large number of headache sufferers with features of migraine fail to meet criteria for strict migraine (SM; migraine with or without aura) but do meet criteria for probable migraine (PM). Objectives: To estimate the prevalence of PM, to compare the epidemiologic profiles of SM and PM, and to assess the disability and impact on the health-related quality of life (HRQoL) of these patients. Methods: Computer-assisted telephone interviews in a sample recruited from a mixed model health maintenance organization were used. SM, PM, and control subjects were identified. Also assessed were demographic features, disability, HRQoL, and depression. Results: The 1-year prevalence for SM was 14.7% (19.2% in women and 6.6% in men); for PM, it was 14.6% (15.9% in women, 12.6% in men). Most subjects with PM (82%) did not meet the associated symptom criteria for migraine. HRQoL was reduced in the PM, SM, and all migraine (AM; SM and PM pooled together) groups compared with controls. The proportion of subjects with high disability was elevated in PM (13%), SM (31%), and AM (22%) groups vs controls (3.7%; p Conclusions: Within a health plan, probable migraine is a prevalent form of migraine, with symptom and epidemiologic profiles that overlap with strict migraine. Although strict migraine prevalence was consistent with previous studies, a probable migraine prevalence higher than previously reported was found, perhaps reflecting a difference between health plan and population samples.

The aim of this cross sectional study was to investigate whether holding a private health plan affects the consumption of medical services (hospitalization and visits to a doctor) and use of medications by older adults. All residents in Bambuí town (Minas Gerais, Brazil) aged > or = 60 years (n = 1,742) were selected. From these, 92.2% were interviewed and 85.9% were examined (blood tests and physical measurements). After adjustments for counfounders, those under exclusive public coverage (n = 1,296), compared with those holding a private health plan (n = 310), presented some evidence of having worse health status, reported less visits to a doctor, and used a small number of prescribed medications. The main explanation for the aged holding a private health plan was economic, not health. Even though those who had only public health coverage complained more in relation to medical care (70.9%), an important proportion of the aged with a private health care plan presented some kind of complaint (45.2%). Another worrying factor was the difficulty to acquire medication because of financial problems (47.2 and 25.2% reported, respectively). Further investigations are needed to verify whether our results can be generalized to other communities of the country.

Cost concerns may inhibit emergency medical services (EMS) use. Novel tax-based and subscription prepayment programs indemnify patients against the cost of EMS treatment and transport. We determine whether the presence of (or enrollment in) prepayment plans increase EMS use among patients with acute chest discomfort, particularly those residing in low-income areas, those lacking private insurance, or both.This study uses a subset of baseline data from the REACT trial, a multicenter, randomized controlled community trial designed, in part, to increase EMS use. The sample includes 860 consecutive noninstitutionalized patients (30 years old) presenting with nontraumatic chest discomfort to hospital emergency departments in 4 Oregon/Washington communities. The association between prepayment systems and EMS use was analyzed using multivariable logistic regression.Overall EMS use was 52% (n=445). Among EMS users, 338 (75%) were subsequently admitted to the hospital and 110 (25%) were released from the ED. Prepayment was not associated with increased EMS use in the overall patient sample. However, patients residing in low-income census block groups (median annual income$30,000) were 2.6 times (95% confidence interval [CI] 1.4 to 4.8) more likely to use EMS when a prepayment system was available than when no system was present. No association was noted among higher-income block group residents. Among low-income block group residents lacking private insurance, prepayment systems were associated with 3.8 times (95% CI 1.2 to 13.4) greater EMS usage.Economic considerations may affect EMS system utilization among underinsured and low-income patients experiencing a cardiac event. Prepayment systems may increase EMS utilization among these groups.

This study examines the impact of a mental health carve-out program in Utah on mental health status of Medicaid beneficiaries with schizophrenia. Three community mental health centers contracted to provide mental health care for all Medicaid beneficiaries in their service areas under managed care arrangements, while beneficiaries in the remainder of the state remained under traditional Medicaid. A pre-post evaluation was utilized, with a contemporaneous control group of Utah Medicaid beneficiaries with schizophrenia under traditional Medicaid. From 1991 to 1994, the average beneficiary's mental health status improved, but the improvement was less under the carve-out program than under traditional fee-for-service Medicaid. The difference was the greatest for beneficiaries with the worst mental health status at baseline, with effects growing over time. Medicaid beneficiaries with schizophrenia experienced less improvement in mental health status under a carve-out arrangement for mental health care compared to what would have happened under traditional Medicaid.

Article-at-a-Glance Background and purpose "Americans as Health Care Consumers: The Role of Quality Information," a nationally representative telephone survey of 2,006 adults, designed by the Henry J. Kaiser Family Foundation (Kaiser) and the Agency for Health Care Policy and Research (AHCPR) of the U.S. Department of Health and Human Services, was presented at the Kaiser/AHCPR conference "Value and Choice: Providing Consumers with Information on the Quality of Care" in Arlington, Virginia, October 29–30, 1996. The survey was conducted by Princeton Survey Research Associates between July 16 and September 5, 1996, and has a margin of error of plus or minus 3 percentage points. Results The survey found that Americans value quality but that the use of quality indicators is likely to be only one factor in their decision making, given their reliance on and preference for quality information from their physicians, friends, and family. A plurality (42%) chose having high quality of care as their most important concern, but only 39% reported seeing information comparing health plans, and only about one-third of that group said they used this information themselves to make decisions. The following are possible explanations for why consumers don't use information on quality in making health care decisions: ■They trust friends, families, and physicians about all other sources for advice; ■They do not (at the time of the survey) have many health plan choices to make; or ■They lack familiarity with comparative health care quality information.

BACKGROUND: The research community relies heavily on measures of healthcare utilization from household surveys to understand health seeking choices and to evaluate interventions in developing countries. Such measures are known to suffer from recall problems but there is limited evidence of whether the method of data collection affects evaluation findings. We compared the results of a randomized trial of free healthcare using utilization data from two sources. METHODS: Data are from a study in Ghana, in which 2,194 households containing 2,592 children under 5 y old were randomized into a prepayment scheme providing free primary and some referral care, or to a control group whose families paid user fees for healthcare. Data on morbidity and health seeking behaviour were collected using a standard household survey administered at endline and a pictorial diary given to households over a six month period, collected at monthly intervals. RESULTS: Self-reported measures of morbidity and healthcare utilization were substantially lower in the household survey than the pictorial diary when the recall period was over a month. Introducing free healthcare had a positive effect on primary care visits based on the pictorial diary and a non-significant negative effect according to the household survey. Using any clinic visit in the past month as the outcome, the difference in the effect of free care between the two data collection methods was 3.6 percentage points (p = 0.078). CONCLUSIONS: The findings raise methodological concerns about measures of healthcare utilization from household surveys, particularly in the evaluation of health financing interventions.

This study compares severity of depression for patients of general medical clinicians, psychiatrists, and nonphysician therapists receiving prepaid or fee-for-service care. Cross-sectional severity comparisons were conducted among 715 outpatients with current major depression or dysthymia, by independent assessment. Severity was assessed by counts of current and lifetime depressive symptoms, prognostic and treatment response indicators, and global measures of psychological and physical sickness. Patients of psychiatrists were the most psychologically ill, patients of nonphysician therapists were intermediate, and general medical patients were least ill; but even in the general medical sector, depression severity was at least ill; but even in the general medical sector, depression severity was at least moderate. No differences in global physical sickness by specialty remained after demographic adjustment. General medical patients whose depression had been detected were only slightly sicker than undetected cases. Type of payment was not consistently related to either psychological or physical aspects of sickness, and payment did not interact with specialty. Mental health specialists, especially psychiatrists, encountered more severely depressed patients, but patients in all sectors were sick enough to warrant treatment. Even undetected patients in the general medical sector were relatively sick, raising questions about gatekeeper policies. There was no evidence of a greater severity gradient by specialty in prepaid care. Because payment was unrelated to severity, treatment implications are similar under prepaid and fee-for-service care. Implications for clinical practice, public policy, and outcomes research design are discussed.

To examine differences in the quality of primary care delivered in prepaid and fee-for-service (FFS) health care systems.Longitudinal study of 1208 adult patients with chronic disease whose health insurance was through a traditional indemnity (FFS) plan, an independent practice association (IPA), or a health maintenance organization (HMO). Both IPA and HMO represent prepaid care systems. Patient- and physician-provided information was obtained by self-administered questionnaires.A total of 303 physician offices (family medicine, general internal medicine, endocrinology, or cardiology) in solo and group practices in three US cities.Seven indicators of primary care quality--accessibility (financial and organizational), continuity, comprehensiveness, coordination, and accountability (interpersonal and technical) of care. Performance on each was evaluated in FFS, IPA, and HMO settings. Analyses controlled for patient and physician characteristics.Financial access was highest in prepaid systems. Organizational access, continuity, and accountability were highest in the FFS system. Coordination was highest and comprehensiveness was lowest in HMOs.The results mark notable differences in core dimensions of primary care quality in each of three payment systems and raise questions regarding the associated cost inefficiencies and outcomes of care. In the current health care delivery reform climate, these findings call for consideration of the relative strengths and weaknesses of each system. We suggest strategies for elevating performance in each.

Objective: To evaluate self-reported use of cancer screening tests by Latino and Anglo prepaid health plan members, we conducted telephone interviews about the knowledge of, use of, and reason for Papanicolaou (Pap) smear, clinical breast examination, mammogram, rectal examination, fecal occult blood test, and sigmoidoscopy. Methods: Cross-sectional telephone survey of randomly selected Kaiser Permanente Medical Care Program members in San Francisco and Alameda Counties, California. A total of 844 Latinos (432 men and 412 women) and 510 Anglos (208 men and 302 women), between 35 and 74 years of age, completed the interview. Results: Overall, 97.4% of Latinas reported having had at least one Pap smear compared with 99.7% of Anglo women; 90% in each group reported a Pap smear within 3 years. A clinical breast examination within 2 years was reported by 87% of Latina and 90% of Anglo women. Seventy-six percent of Latina and 85% of Anglo women aged 35 years or more reported having had at least one mammogram; and 65% of Latina and 75% of Anglo women reported a mammogram within 2 years. Among members 40 to 74 years of age, a lower proportion of Latinos compared with Anglos reported having had at least one digital rectal examination (67% vs 80%) and one fecal occult blood test (46% vs 54%); among those 50 to 74 years of age, fewer Latinos reported at least one sigmoidoscopy (29% vs 41%). After adjusting for age, education, employment, perceived health status, marital status, and county of residence, Latinos were significantly less likely to report having had at least one digital rectal examination (odds ratio; 0.60,95% confidence interval, 0.45,0.79), fecal occult blood test (odds ratio, 0.77; 95% confidence interval, 0.59-1.01), and sigmoidoscopy (odds ratio, 0.70; 95% confidence interval, 0.52,0.95). After adjusting for the same variables, Latinos were more likely than Anglos to claim forgetfulness/carelessness (75% vs 60%; odds ratio, 1.84; 95% confidence interval, 1.41-2.40) as a reason for not obtaining cancer screening tests. Conclusion: These data suggest that, within this prepaid health plan without direct financial barriers to cancer screening services, Latinos are less likely than Anglos to obtain selected recommended cancer screening tests. (Arch Intern Med. 1994;154:1073-1081)

Context Depression co-occurring with diabetes mellitus is associated with higher health services costs, suggesting that more effective depression treatment might reduce use of other medical services. Objective To evaluate the incremental cost and cost-effectiveness of a systematic depression treatment program among outpatients with diabetes. Design Randomized controlled trial comparing systematic depression treatment program with care as usual. Setting Primary care clinics of group-model prepaid health plan. Patients A 2-stage screening process identified 329 adults with diabetes and current depressive disorder. Intervention Specialized nurses delivered a 12-month, stepped-care depression treatment program beginning with either problem-solving treatment psychotherapy or a structured antidepressant pharmacotherapy program. Subsequent treatment (combining psychotherapy and medication, adjustments to medication, and specialty referral) was adjusted according to clinical response. Main Outcome Measures Depressive symptoms were assessed by blinded telephone assessments at 3, 6, 12, and 24 months. Health service costs were assessed using health plan accounting records. Results Over 24 months, patients assigned to the intervention accumulated a mean of 61 additional days free of depression (95% confidence interval [CI], 11 to 82 days) and had outpatient health services costs that averaged $314 less (95% CI, $1007 less to $379 more) compared with patients continuing in usual care. When an additional day free of depression is valued at $10, the net economic benefit of the intervention is $952 per patient treated (95% CI, $244 to $1660). Conclusions For adults with diabetes, systematic depression treatment significantly increases time free of depression and appears to have significant economic benefits from the health plan perspective. Depression screening and systematic depression treatment should become routine components of diabetes care.

Background: To assess how current policy trends may affect the use of counseling for depression, we examined the variation in the use of counseling and usual clinician counseling style for depression across specialty sectors (psychiatry, psychology, and general medicine) and reimbursement type (fee-for-service or prepaid). Methods: Three types of observational data from the RAND Medical Outcomes Study: (1) patient-reported demographics, depressive symptoms, clinical status, and perceptions about participation style; (2) clinician reports of counseling during specific patient encounters; and (3) clinician reports of the usual counseling and interpersonal style across patients who were seen in a practice. Results: While almost all depressed patients who were being treated by mental health specialists received brief counseling for at least 3 minutes, less than half of the depressed patients in the general medical sector received such counseling—even for those patients with a current depressive disorder. Counseling rates were lower under prepaid than fee-for-service care in general medical practices. Psychiatrists relied more on psychodynamic approaches, and psychologists relied more on behavioral therapies relative to each other, but both specialty groups provided longer sessions and used more formal psychotherapeutic techniques (eg, interpretation) than did general medical clinicians. Clinicians who were treating more patients who had prepaid plans reported a lower proclivity for face-to-face counseling, and they spent less time when they were counseling patients compared with clinicians who were treating more patients who had fee-forservice plans; however, these differences were not large. Conclusion: The use of counseling in the usual care for depression varied by both specialty and payment system, while the usual clinician counseling style differed markedly by specialty, but only slightly by payment system.

Objective: To compare change over time in symptoms of depression and limitations in role and physical functioning of patients receiving prepaid or fee-for-service care within and across clinician specialties. Method: Observational study of change in outcomes over 2 years for 617 depressed patients of psychiatrists, psychologists, other therapists, and general medical clinicians in three urban sites in the United States. Results: Psychiatrists treated psychologically sicker patients than other clinicians in all payment types. Among psychiatrists' patients, those initially receiving prepaid care acquired new limitations in role/physical functioning over time, while those receiving fee-for-service care did not. This finding was most striking in independent practice associations but varied by site and organization. Patients of psychiatrists were more likely to use antidepressant medication than were patients of other clinicians, but among psychiatrists' patients, there was a sharp decline over time in the use of such medication in prepaid compared with fee-for-service care. Outcomes did not differ by payment type for depressed patients of other specialty groups, or overall. Conclusion: Depressed patients of psychiatrists merit policy interest owing to their high levels of psychological sickness. For these patients, functioning outcomes were poorer in some prepaid organizations. The nonexperimental evidence favors (but cannot prove) an explanation based on care received, such as a reduction in medications, rather than on preexisting sickness differences.

OBJECTIVE: To prospectively compare inpatient and outpatient utilization rates between prepaid (PPD) and fee-for-service (FFS) insurance coverage for patients with chronic disease. DATA SOURCE/STUDY SETTING: Data from the Medical Outcomes Study, a longitudinal observational study of chronic disease patients conducted in Boston, Chicago, and Los Angeles. STUDY DESIGN: A four-year prospective study of resource utilization among 1,681 patients under treatment for hypertension, diabetes, myocardial infarction, or congestive heart failure in the practices of 367 clinicians. DATA COLLECTION/EXTRACTION METHODS: Insurance payment system (PPD or FFS), hospitalizations, and office visits were obtained from patient reports. Disease and severity indicators, sociodemographics, and self-reported functional status were used to adjust for patient mix and to compute expected utilization rates. PRINCIPAL FINDINGS: Compared to FFS, PPD patients had 31 percent fewer observed hospitalizations before adjustment for patient differences (p = .005) and 15 percent fewer hospitalizations than expected after adjustment (p = .078). The observed rate of FFS hospitalizations exceeded the expected rate by 9 percent. These results are not explained by system differences in patient mix or trends in hospital use over four years. Half of the PPD/FFS difference in hospitalization rate is due to intrinsic characteristics of the payment system itself. CONCLUSIONS: PPD patients with chronic medical conditions followed prospectively over four years, after extensive patient-mix adjustment, had 15 percent fewer hospitalizations than their FFS counterparts owing to differences intrinsic to the insurance reimbursement system.