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1.  Different patient subgroup, different ranking? Which quality indicators do patients find important when choosing a hospital for hip- or knee arthroplasty? 
Patients are increasingly expected to become active, critical consumers in healthcare. They can use comparative healthcare information presented on websites to make informed choices for healthcare providers. However, the use of this information has been limited so far. An obstacle can be that the information is not perceived as relevant by patients. Presenting only the most important quality indicators might improve the usefulness of this information. The aim of this study was to explore which quality indicators different subgroups of patients find important when choosing a hospital for total hip arthroplasty (THA) or total knee arthroplasty (TKA).
In this explorative, cross-sectional study, questionnaires were distributed to 265 patients who underwent or had to undergo THA/TKA. Participants were asked to rank the importance of three types of quality indicators: patient experience indicators, clinical performance indicators, and indicators about hospital services. We used random effects regression analyses to assess the relative importance of the indicators in different subgroups of patients.
110 patients (response rate 41.5%) who underwent or had to undergo THA/TKA participated. Conduct of doctors, the presence of procedures to prevent adverse effects of thrombosis and information about the specialist area of orthopaedists were the most important patient experience indicator, clinical performance indicator and indicator about hospital services, respectively. We found a few differences between patient subgroups in the importance attached to the quality indicators.
This study provides a first insight into which quality indicators patients find important when choosing a hospital for THA/TKA, and shows that subgroups of patients differ in the value they attach to these indicators. More extended research is needed to establish the indicators that should at least be presented in succinct overviews of comparative healthcare information for patients choosing a hospital for THA/TKA.
PMCID: PMC3268112  PMID: 22050686
2.  Pain measurement as part of primary healthcare of adult patients with sickle cell disease 
The aim of this exploratory, cross-sectional study was to evaluate pain in sickle cell disease patients and aspects related to primary healthcare.
Data were obtained through home interviews. The assessment instruments (body diagram, Numerical Pain Scale, McGill Pain Questionnaire) collected information on the underlying disease and on pain. Data were analyzed using the Statistical Package for Social Sciences program for Windows. Associations between the subgroups of sickle cell disease patients (hemoglobin SS, hemoglobin SC, sickle β-thalassemia and others) and pain were analyzed using contingency tables and non-parametric tests of association (classic chi-square, Fisher's and Kruskal-Wallis) with a level of 5% (p-value < 0.05) being set for the rejection of the null hypothesis.
Forty-seven over 18-year-old patients with sickle cell disease were evaluated. Most were black (78.7%) and female (59.6%) and the mean age was 30.1 years. The average number of bouts of pain annually was 7.02; pain was predominantly reported by individuals with sickle cell anemia (hemoglobin SS). The intensity of pain (Numeric Pain Scale) was 5.5 and the quantitative index (McGill) was 35.9. This study also shows that patients presented a high frequency of moderately painful crises in their own homes.
According to these facts, it is essential that pain related to sickle cell disease is properly identified, quantified, characterized and treated at the three levels of healthcare. In primary healthcare, accurate measurement of pain combined with better care may decrease acute painful episodes and consequently minimize tissue damage, thus improving the patient's overall health.
PMCID: PMC3789433  PMID: 24106446
Hemoglobinopathies; Anemia, sickle cell; Pain measurement; Primary healthcare; Home visit
3.  Protein supplementation in strength and conditioning adepts: knowledge, dietary behavior and practice in Palermo, Italy 
It is known that supplement use is a widespread and accepted practice by athletes and people who attend commercial gyms. Little is known about protein supplement amongst people undertaking strength training in commercial gyms in Italy when compared to the US.
The purpose of this study was to examine the use of protein supplementation, alone or in association with other supplements, and dietary behavior amongst regular fitness center attendees in Palermo, Italy.
Resistance training information have been collected from 800 regular fitness center attendees for the initial analysis. A specific questionnaire was generated for the experimentation. Data were collected using a face-to-face interview method. Supplement users were then compared to the non users and analyzed using a one-way ANOVA, Kruskall-Wallis, chi-square test or exact test of Fisher when appropriate.
30.1% of the respondents use dietary supplements during their training as a believe it is the "way to gain muscles and strength". Whey protein shakes (50.0%) mixed with creatine and amino-acids (48.3%) were the most frequent choices amongst the users. A majority of the subjects (34.0%) appeared to rely on their gym instructors' advice for their intake; a lower proportion (13.0%) consulted physicians, while none of them consulted nutritionists. A high consumption of milk has been noticed in both users (67,7%) and non-users (52,8%); supplement non-users consumed significantly more snacks and bakery products than users per week (P < 0.001), while users consumed significantly more protein-rich foods (P < 0.01) with a particular preference for meat (48.0%).
A considerable number of regular strength training adepts consume protein supplements mixed with other products (mainly creatine and amino-acids). Limited numbers consult "dietary specialists" and rely mainly on their instructors. We emphasize on the importance of the dissemination of scientifically based information about supplementation in this environment and the promotion of updated educational programs for the instructors.
PMCID: PMC3267647  PMID: 22206347
4.  Dutch healthcare reform: did it result in performance improvement of health plans? A comparison of consumer experiences over time 
Many countries have introduced elements of managed competition in their healthcare system with the aim to accomplish more efficient and demand-driven health care. Simultaneously, generating and reporting of comparative healthcare information has become an important quality-improvement instrument. We examined whether the introduction of managed competition in the Dutch healthcare system along with public reporting of quality information was associated with performance improvement in health plans.
Experiences of consumers with their health plan were measured in four consecutive years (2005-2008) using the CQI® health plan instrument 'Experiences with Healthcare and Health Insurer'. Data were available of 13,819 respondents (response = 45%) of 30 health plans in 2005, of 8,266 respondents (response = 39%) of 32 health plans in 2006, of 8,088 respondents (response = 34%) of 32 health plans in 2007, and of 7,183 respondents (response = 31%) of 32 health plans in 2008. We performed multilevel regression analyses with three levels: respondent, health plan and year of measurement. Per year and per quality aspect, we estimated health plan means while adjusting for consumers' age, education and self-reported health status. We tested for linear and quadratic time effects using chi-squares.
The overall performance of health plans increased significantly from 2005 to 2008 on four quality aspects. For three other aspects, we found that the overall performance first declined and then increased from 2006 to 2008, but the performance in 2008 was not better than in 2005. The overall performance of health plans did not improve more often for quality aspects that were identified as important areas of improvement in the first year of measurement. On six out of seven aspects, the performance of health plans that scored below average in 2005 increased more than the performance of health plans that scored average and/or above average in that year.
We found mixed results concerning the effects of managed competition on the performance of health plans. To determine whether managed competition in the healthcare system leads to quality improvement in health plans, it is important to examine whether and for what reasons health plans initiate improvement efforts.
PMCID: PMC2761896  PMID: 19761580
5.  Resource utilization and costs before and after total joint arthroplasty 
The purpose of this study was to compare pre- and post-surgical healthcare costs in commercially insured total joint arthroplasty (TJA) patients with osteoarthritis (OA) in the United States (U.S.).
Using a large healthcare claims database, we identified patients over age 39 with hip or knee OA who underwent unilateral primary TJA (hip or knee) between 1/1/2006 and 9/30/2007. Utilization of healthcare services and costs were aggregated into three periods: 12 months "pre-surgery," 91 days "peri-operative," and 3 to 15 month "follow-up," Mean total pre-surgery costs were compared with follow-up costs using Wilcoxon signed-rank test.
14,912 patients met inclusion criteria for the study. The mean total number of outpatient visits declined from pre-surgery to follow-up (18.0 visits vs 17.1), while the percentage of patients hospitalized increased (from 7.5% to 9.8%) (both p < 0.01). Mean total costs during the follow-up period were 18% higher than during pre-surgery ($11,043 vs. $9,632, p < 0.01), largely due to an increase in the costs of inpatient care associated with hospital readmissions ($3,300 vs. $1,817, p < 0.01). Pharmacotherapy costs were similar for both periods ($2013 [follow-up] vs. $1922 [pre-surgery], p = 0.33); outpatient care costs were slightly lower in the follow-up period ($4338 vs. $4571, p < 0.01). Mean total costs for the peri-operative period were $36,553.
Mean total utilization of outpatient healthcare services declined slightly in the first year following TJA (exclusive of the peri-operative period), while mean total healthcare costs increased during the same time period, largely due to increased costs associated with hospital readmissions. Further study is necessary to determine whether healthcare costs decrease in subsequent years.
PMCID: PMC3373371  PMID: 22443109
6.  Variations of care quality for infectious pulmonary tuberculosis in Taiwan: a population based cohort study 
BMC Public Health  2007;7:107.
Effective and efficient care is required to prevent the spread of infectious pulmonary tuberculosis (PTB). We attempted to compare care quality among different healthcare institutions in Southern Taiwan.
This study conducted population-based retrospective cohort design. One tuberculosis sanatorium, 2 medical centers, 11 regional hospitals, and 15 district hospitals and primary practitioners in the study area had reported tuberculosis cases, registered from January 1 to June 30 2003. Those cases with sputum positive PTB were followed 15 months after anti-tuberculosis treatment initiation. Meanwhile, Level of conformance with diagnostic guidelines, efficiency of diagnostic and treatment process, and treatment were measured as main outcome. Association was investigated using Chi-square tests, Kruskal Wallis tests, Mann-Whiteney U tests, and multiple logistic regression analysis to evaluate outcome differences among different levels of institutions.
The analyses included 421 patients. In comparison with patients receiving treatment at medical centers, regional hospitals, and district hospitals/primary practitioners, patients at the Chest Specialty Hospital were more likely to provide at least three sputum specimens (74.1% vs. 48.2%, 36.8%, and 50.0%), shorter workdays examining sputum smears (2.4 ± 2.4 days vs. 2.6 ± 2.1, 4.5 ± 3.1, and 3.5 ± 2.6 days), shorter interval between the first consultation and treatment (10.1 ± 18.3 days vs. 31.0 ± 53.6, 31.2 ± 70.4, and 25.4 ± 37.6 days), and a higher successful treatment rate (92.6% vs. 65.2%, 63.9%, and 68.0%). Furthermore, after adjusting age and gender, the patients treated by the pulmonologists and treated at Chest Specialty Hospital had significantly more successful treatment rate, of which odds ratios were 1.74 and 4.58 respectively.
Differences in care quality exist among different types of healthcare institutions and among individual physicians. The implementation of practice guidelines should contribute to an improvement in the care quality of the treatment and diagnosis of PTB.
PMCID: PMC1906756  PMID: 17562022
7.  Work related characteristics, work-home and home-work interference and burnout among primary healthcare physicians: A gender perspective in a Serbian context 
BMC Public Health  2011;11:716.
Little information exists on work and stress related health of medical doctors in non-EU countries. Filling this knowledge gap is needed to uncover the needs of this target population and to provide information on comparability of health related phenomena such as burnout across countries. This study examined work related characteristics, work-home and home-work interference and burnout among Serbian primary healthcare physicians (PHPs) and compared burnout levels with other medical doctors in EU countries.
Data were collected via surveys which contained Maslach Burnout Inventory and other validated instruments measuring work and home related characteristics. The sample consisted of 373 PHPs working in 12 primary healthcare centres. Data were analysed using t-tests and Chi square tests.
No gender differences were detected on mean scores of variables among Serbian physicians, who experience high levels of personal accomplishment, workload, job control and social support, medium to high levels of emotional exhaustion, medium levels of depersonalisation and work-home interference, and low levels of home-work interference. There were more women than men who experienced low job control and high depersonalisation. Serbian physicians experienced significantly higher emotional exhaustion and lower depersonalisation than physicians in some other European countries.
To diminish excessive workload, the number of physicians working in primary healthcare centres in Serbia should be increased. Considering that differences between countries were detected on all burnout subcomponents, work-related interventions for employees should be country specific. The role of gender needs to be closely examined in future studies as well.
PMCID: PMC3189139  PMID: 21943328
Burnout; Medical doctors; Gender differences; Work-Home and Home Work Interference; Job Characteristics
8.  Measuring the Value of Total Hip and Knee Arthroplasty: Considering Costs Over the Continuum of Care 
Controlling escalating costs of hip (THA) and knee arthroplasty (TKA) without compromising quality of care has created the need for innovative system reorganization to inform sustainable solutions.
The purpose of this study was to inform estimates of the value of THA and TKA by determining: (1) the data sources data required to obtain costs across the care continuum; (2) the data required for different analytical perspectives; and (3) the relative costs across the continuum of care.
Within the context of a pragmatic randomized controlled trial comparing alternative care pathways, we captured healthcare resource use: (1) 12 months before surgery; (2) inpatient; (3) acute recovery; and (4) long-term recovery 3 and 12 months postsurgery. We established a standardized costing model to reflect both the healthcare payer and patient perspectives.
Multiple data sources from regional health authorities, administrative databases, and patient questionnaire were required to estimate costs across the care continuum. Inpatient and acute care costs were approximately 60% of the total with the remaining 40% incurred 12 months presurgery and 12 months postsurgery. Regional health authorities bear close to 60%, and patient costs are approximately 30% of the mean total costs, most of which were incurred after the acute inpatient stay.
To fully understand the value of an orthopaedic intervention such as THA and TKA, a broader perspective than one limited to the payer should be considered using a standardized measurement framework over a relevant time horizon and from multiple viewpoints to reflect the substantial patient burden and support sustainable improvement over the care continuum.
Level of Evidence
Level III, economic and decision analyses study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC3293965  PMID: 21863395
To examine and compare the factors causing long waiting lists for non-urgent surgery in public (Ministry of Health, military, and teaching) and private hospitals in the city of Riyadh, Saudi Arabia, and to examine the relationship between the personal characteristics of the respondents (surgeons) and the surgery-delay experience.
Material and Methods:
The instrument used in this study was a self-administered questionnaire. Out of 500 distributed questionnaires 320 valid responses were returned. Data were collected from 14 public and private hospitals in Riyadh City. Frequencies and percentages; Mann-Whitney; Kruskall-Wallis one way ANOVA; Chi-square; Phi; and Cramers’ V tests were used in the statistical analysis..
Results show that seven factors were significantly important in causing long waiting lists. A significant difference with regard to the seriousness of this problem was found between the two types of hospitals.
This study shows that there is a significant difference in the seriousness of the problem between private and various types of public hospitals. Similar studies in different parts of the country are therefore recommended.
PMCID: PMC3437117  PMID: 23008580
Non-urgent surgery; waiting lists; and private; MOH; military; and teaching hospitals
10.  How do healthcare consumers process and evaluate comparative healthcare information? A qualitative study using cognitive interviews 
BMC Public Health  2009;9:423.
To date, online public healthcare reports have not been effectively used by consumers. Therefore, we qualitatively examined how healthcare consumers process and evaluate comparative healthcare information on the Internet.
Using semi-structured cognitive interviews, interviewees (n = 20) were asked to think aloud and answer questions, as they were prompted with three Dutch web pages providing comparative healthcare information.
We identified twelve themes from consumers' thoughts and evaluations. These themes were categorized under four important areas of interest: (1) a response to the design; (2) a response to the information content; (3) the use of the information, and (4) the purpose of the information.
Several barriers to an effective use of comparative healthcare information were identified, such as too much information and the ambiguity of terms presented on websites. Particularly important for future research is the question of how comparative healthcare information can be integrated with alternative information, such as patient reviews on the Internet. Furthermore, the readability of quality of care concepts is an issue that needs further attention, both from websites and communication experts.
PMCID: PMC2785792  PMID: 19930564
11.  Association between Health Service Use and Multiplex Genetic Testing 
The identification of genetic variants associated with common disease is accelerating rapidly. “Multiplex tests” that give individuals feedback on large panels of genetic variants have proliferated. Availability of these test results may prompt consumers to use more healthcare services.
To examine whether offers of multiplex genetic testing increases healthcare utilization among healthy patients aged 25–40.
1,599 continuously insured adults aged 25–40 were surveyed and offered a multiplex genetic susceptibility test (MGST) for eight common health conditions.
Main Outcome Measure
Healthcare utilization from automated records was compared in 12 month pre- and post-test periods among persons who completed a baseline survey only (68.7%), those who visited a study Web site but opted not to test (17.8%), and those who chose the MGST (13.6%).
In the pre-test period, persons choosing genetic testing used an average of 1.02 physician visits per quarter compared to 0.93 and 0.82 for the other groups (p<0.05). There were no statistically significant differences by group in the pre-test use of any common medical tests or procedures associated with four common health conditions. When changes in physician and medical test/procedure use in the post-test period were compared among groups, no statistically significant differences were observed for any utilization category.
Persons offered and completing multiplex genetic susceptibility testing used more physician visits prior to testing, but testing was not associated with subsequent changes in use. This study supports that multiplex genetic testing offers can be provided directly to patients in such a way that use of health services are not inappropriately increased.
PMCID: PMC3424345  PMID: 22595941
genetic susceptibility; delivery of health care; genetic testing; genetic counseling
12.  Informal caregivers of persons with dementia, their use of and needs for specific professional support: a survey of the National Dementia Programme 
BMC Nursing  2010;9:9.
This paper describes both the use of and needs for informal caregivers of people with dementia, based on a questionnaire survey organized within the National Dementia Programme in the Netherlands. The National Dementia Programme is a quality collaborative of the Dutch Alzheimer's Association, the Institute of Quality of Healthcare (CBO) and the Knowledge Centre on Ageing (Vilans), instigated by the Ministry of Health, Welfare and Sport, to improve integrated care for people with dementia and their informal caregivers. The support needs of informal caregivers are important to improve caregiver well-being and delaying institutionalization of the person with dementia.
In the period April 2006 - January 2007, the National Dementia Programme questionnaire was completed by 984 informal caregivers. Descriptive statistics were used to analyze the use of and needs for additional professional support by informal caregivers. Chi-square tests were used to assess the relationships between characteristics of the caregivers (spouses, sons/daughters, sons/daughters in-law) and support needs on one hand and to assess the relationship between the living situation of the person with dementia (living at home or living in a nursing home or home for the elderly) and support needs on the other hand.
Almost all informal caregivers (92.6%) received some professional support. However, two thirds (67.4%) indicated they had one or more needs for additional professional support. Informal caregivers often need additional professional advice about what to do when their relative is frightened, angry of confused. Spouses reported different needs than sons or daughters (in-law): spouses relatively often need emotional support and sons or daughters (in-law) more often need information and coordination of dementia care.
Most of the informal caregivers report that they need additional information and advice, e.g. about how to cope with behavioral problems of their relative, about the progression of the illness trajectory, emotional support and coordination of dementia care. Future support programmes, e.g. in the field of case management, should address the specific needs of informal caregivers.
PMCID: PMC2901350  PMID: 20529271
13.  Quality of life in gynecologic cancer survivors compared to healthy check-up women 
Journal of Gynecologic Oncology  2011;22(2):103-109.
The primary objective of this study was to compare quality of life of disease-free patients after therapy for gynecologic malignancies at follow-up in comparison with healthy check-up patients. Our second objective was to assess correlation between demographic data, disease and treatment factors and quality of life scores.
Patients completed the Functional Assessment of Cancer Therapy-General (FACT-G) quality of life questionnaire at least 6 months after treatment for a gynecologic malignancy. Responses were compared to unmatched healthy women who were seen for standard gynecologic screening examinations. Statistical calculation was done using chi-squared tests, Wilcoxon rank-sum, and Kruskal-Wallis one-way analysis and Spearman rank correlations. Factors associated with FACT-G scores were evaluated using univariate and multivariate analyses.
Eight hundred and seventy patients were recruited. The median time since therapy was 61 months (range, 6 to 173 months). The overall FACT-G scores were higher in the patient group than in the healthy group (p<0.05). The scores of each subscale measuring physical, functional, social/family and emotional well-being were also higher in the patient group (p<0.05). Multivariate analysis revealed correlation between Eastern Cooperative Oncology Group performance status, educational level, care giver, presence of economic problems and FACT-G scores.
The quality of life scores were higher in gynecologic cancer patients after treatment. And the factors that associated with the higher score in the patient group are having husband as a caregiver, no financial problem, Eastern Cooperative Oncology Group score 0 or 1 and having high school or higher education.
PMCID: PMC3152750  PMID: 21860736
Quality of life; Functional Assessment of Cancer Therapy-General; Gynecologic cancer
14.  Physician performance information and consumer choice: a survey of subjects with the freedom to choose between doctors 
Quality & safety in health care  2004;13(2):98-101.
Background: Increasing efforts have been made to provide information to help consumers to select a healthcare provider, but the public release of hospital performance data has had only a limited impact on consumer choice.
Objectives: To understand the experience of consumers in searching for physician performance information and to investigate the potential impact on their propensity to change doctors if hypothetically provided with physician specific performance information.
Design: A nationwide telephone interview survey using a structured questionnaire.
Setting: The survey was conducted in Taiwan, a country with a universal health insurance programme where residents are free to choose between physicians for any medical consultation.
Participants: 4015 adults aged over 20 years contacted by random digit dialling telephone calls.
Main outcome measures: Subjects were asked (1) if they have ever compared the quality of care provided by physicians in their area; (2) if they would consult a performance report if it was available; and (3) if they would change doctors on the basis of information provided in the report.
Results: Approximately half the subjects had made comparisons between doctors; 73% stated that they would consult a performance report if it was available, and 77% were prepared to change doctors if their doctor performed badly in the report.
Conclusions: Providing physician specific performance reports to the public may be viewed favourably by consumers of health care and have a significant impact on physician selection and hence quality improvement.
PMCID: PMC1743817  PMID: 15069215
15.  Correlates of Depression at Baseline Among African Americans Enrolled in Cardiac Rehabilitation 
To compare baseline psychosocial characteristics of African Americans entering phase 2 cardiac rehabilitation who have depression symptoms at or above threshold (Center for Epidemiological Studies Depression Scale [CES-D] score ≥16) with those who do not (CES-D score <16).
A nonrandom sample of 112 men and women (n = 78 without depression, n = 34 with depression) was recruited through local phase 2 cardiac rehabilitation programs. Data were obtained by a structured interview and brief physical examination using several reliable and valid instruments. Chi-square tests, Kruskal-Wallis 2-sample tests, Spearman rank correlation coefficients, and logistic regression models were used for analyses.
We found that 30% of the participants were above the depression symptom threshold. Demographic characteristics were not significantly different between individuals at or above threshold and those below threshold. However, depressed individuals above threshold were more likely to be dissatisfied with their neighborhoods (P = .01) and had lower optimism scores (P < .0001), higher stress scores (P < .0001), lower adaptive coping scores (P = .05), and higher problematic coping scores (P < .01) than their counterparts who were below threshold. In the logistic regression model, the odds of being above the depression symptom threshold increased with stress (P < .001) and decreased with optimism (P = .03); none of the other psychosocial characteristics had an independent effect on depression symptoms.
At baseline, African Americans starting phase 2 cardiac rehabilitation with depression symptoms at or above threshold had more stress and fewer stress resilience factors. Assessing depression and stress resilience factors is important and may lead to more active participation in cardiac rehabilitation once enrolled, as well as optimal cardiovascular health outcomes.
PMCID: PMC3932305  PMID: 19158584
African Americans; cardiac rehabilitation; depression; stress
16.  Effects of Seasonal Variations on the Outcome of Coronary Artery Bypass Graft Surgery 
Background: For all the reports on the association between seasons and coronary artery disease, there is a paucity of information on the possible effects of seasonal variations on the outcome of patients after coronary artery bypass grafting surgery (CABG). The aim of this study was to assess the short-term outcome of post-CABG patients in the four different seasons to find any correlation between seasonal variations and the outcome of such patients.
Methods: Data on patients who underwent cardiac surgery between 2007 and 2009 were analyzed. In-hospital mortality, length of Intensive Care Unit (ICU) stay, and length of hospital stay in the four different seasons were considered as outcome measures. The EuroSCORE was calculated for all the patients, and the Kruskal-Wallis, Mann-Whitney, Student t, and chi square tests were used as appropriate.
Results: Of a total of 402 patients, who underwent CABG during the mentioned period, 292 patients were male (M/F ratio=2.65). There were no differences in terms of mean age, sex ratio, and mean EuroSCORE of the patients between the seasons. The mean length of ICU stay was significantly more in the spring than that of the other seasons (P<0.001), while the difference between the four seasons regarding the mean length of hospital stay did not constitute statistical significance (P=0.22). No effect of seasonal variations was found for the lengths of ICU and hospital stay in the presence of the EuroSCORE after multiple logistic regression analysis (P=0.278, 0.431).
Conclusion: Psychological mood changes caused by regional cultural differences rather than environmental factors should be considered in the optimal management of patients after CABG.
PMCID: PMC3700053  PMID: 23825887
Coronary artery bypass graft; Seasonal variations; Iran
The Iowa Orthopaedic Journal  2011;31:173-180.
The purpose of this study was to examine the demographic and hospitalization characteristics of children hospitalized with lower extremity fractures in the United States in 2006.
Children aged 0 to 20 years with a diagnosis of lower extremity fracture in the 2006 Healthcare Cost and Utilization Project Kids’ Inpatient Database (KID) were included. Lower extremity fractures were defined by International Classification of Diseases, 9th Revision, Clinical Modification codes 820-829 under “Injury and Poisoning (800-999).” Patient demographic and hospitalization-related data were analyzed by chi-square testing and unbalanced analysis of variance.
There were more boys than girls with lower extremity fractures and 53% had private insurance as their primary payer. About one half of the children were between the ages of 13 and 20 years, but all ages were represented from age 0 to 20. White children accounted for 56%. Urban hospitalizations accounted for 93% of cases and 66 percent of admissions were to teaching hospitals. All patients had an average length of stay (LOS) 4.04 days, and infant patients had the longest average LOS of 5.46 days. The average number of diagnoses per patient was 3.07, and the average number of procedures per patient was 2.21. The average charge per discharge was $35,236, and the oldest patients had the largest average charge of $41,907. The average number of comorbidities increased with increasing patient age. There was a 55.6% greater mortality risk in non-teaching hospitals than in teaching hospitals and there was at least ten times the mortality risk in rural hospitals than in urban hospitals.
This study provides an understanding of the demographic and hospitalization characteristics of children with lower extremity fractures in the United States in 2006. This information may be useful in implementing measures to help prevent similar injuries in the future. Further research is required to determine causality of the associations found including increased mortality risk for this population at rural and non-teaching hospitals.
PMCID: PMC3215132  PMID: 22096438
18.  How would mental health parity affect the marginal price of care? 
Health Services Research  2001;35(6):1207-1227.
OBJECTIVE: To determine the impact of parity in mental health benefits on the marginal prices that consumers face for mental health treatment. DATA SOURCES/DATA COLLECTION: We used detailed information on health plan benefits for a nationally representative sample of the privately insured population under age 65 taken from the 1987 National Medical Expenditure Survey (Edwards and Berlin 1989). The survey was carefully aged and reweighted to represent 1995 population and coverage characteristics. STUDY DESIGN: We computed marginal out-of-pocket costs from the cost-sharing benefits described by policy booklets under current coverage and under parity for various mental health treatment expenditure levels using the MEDSIM health care microsimulation model developed by researchers at the Agency for Healthcare Research and Quality. Descriptive analyses and two-limit Tobit regression models are used to examine how insurance generosity varies across individuals by demographic and socioeconomic characteristics. Our analyses are limited to a description of how parity would change the marginal incentives faced by consumers under their existing plan's cost-sharing arrangements for mental and physical health care. We do not attempt to simulate how parity might affect the level of benefits, including whether benefits are offered at all, or the level of managed care that affects the actual benefits that plan members receive. Rather, we focus only on the nominal benefits described in their policy booklets. PRINCIPAL FINDINGS: Our results show that as of 1995 parity coverage would substantially reduce the share of mental health expenditures that consumers would pay at the margin under their existing plan's cost-sharing provisions, with larger changes for outpatient care than for inpatient care. Because current mental health coverage generally becomes less generous as expenditures rise, while coverage for other medical care becomes more generous (due to stop-loss provisions), the difference in incentives between current mental health coverage and the assumed parity coverage widens as total expenditure grows. We also find that the impact of parity on marginal incentives would vary greatly across the privately insured population. CONCLUSIONS: Based on the large variation in the impact of parity on marginal incentives across the population under current plan cost-sharing arrangements, changes in the demand for mental health treatment will likely also vary across the population.
PMCID: PMC1089187  PMID: 11221816
19.  Gender differences in HIV disease progression and treatment outcomes among HIV patients one year after starting antiretroviral treatment (ART) in Dar es Salaam, Tanzania 
BMC Public Health  2013;13:38.
We investigated gender differences in treatment outcome during first line antiretroviral treatment (ART) in a hospital setting in Tanzania, assessing clinical, social demographic, virological and immunological factors.
We conducted a cohort study involving HIV infected patients scheduled to start ART and followed up to 1 year on ART. Structured questionnaires and patients file review were used to collect information and blood was collected for CD4 and viral load testing. Gender differences were assessed using Kruskal-Wallis test and chi-square test for continuous and categorical data respectively. Survival distributions for male and female patients were estimated using the Kaplan-Meier method and compared using Cox proportional hazards models.
Of 234 patients recruited in this study, 70% were females. At baseline, women had significantly lower education level; lower monthly income, lower knowledge on ARV, less advanced HIV disease (33% women; 47% men started ART at WHO stage IV, p = 0.04), higher CD4 cell count (median 149 for women, 102 for men, p = 0.02) and higher BMI (p = 0.002). After 1 year of standard ART, a higher proportion of females survived although this was not significant, a significantly higher proportion of females had undetectable plasma viral load (69% women, 45% men, p = 0.003), however females ended at a comparable CD4 cell count (median CD4, 312 women; 321 men) signifying a worse CD4 cell increase (p = 0.05), even though they still had a higher BMI (p = 0.02). The unadjusted relative hazard for death for men compared to women was 1.94. After correcting for confounding factors, the Cox proportional hazards showed no significant difference in the survival rate (relative hazard 1.02).
We observed women were starting treatment at a less advanced disease stage, but they had a lower socioeconomical status. After one year, both men and women had similar clinical and immunological conditions. It is not clear why women lose their immunological advantage over men despite a better virological treatment response. We recommend continuous follow up of this and more cohorts of patients to better understand the underlying causes for these differences and whether this will translate also in longer term differences.
PMCID: PMC3623886  PMID: 23320567
20.  Risk-adjusted capitation based on the Diagnostic Cost Group Model: an empirical evaluation with health survey information. 
Health Services Research  1999;33(6):1727-1744.
OBJECTIVE: To evaluate the predictive accuracy of the Diagnostic Cost Group (DCG) model using health survey information. DATA SOURCES/STUDY SETTING: Longitudinal data collected for a sample of members of a Dutch sickness fund. In the Netherlands the sickness funds provide compulsory health insurance coverage for the 60 percent of the population in the lowest income brackets. STUDY DESIGN: A demographic model and DCG capitation models are estimated by means of ordinary least squares, with an individual's annual healthcare expenditures in 1994 as the dependent variable. For subgroups based on health survey information, costs predicted by the models are compared with actual costs. Using stepwise regression procedures a subset of relevant survey variables that could improve the predictive accuracy of the three-year DCG model was identified. Capitation models were extended with these variables. DATA COLLECTION/EXTRACTION METHODS: For the empirical analysis, panel data of sickness fund members were used that contained demographic information, annual healthcare expenditures, and diagnostic information from hospitalizations for each member. In 1993, a mailed health survey was conducted among a random sample of 15,000 persons in the panel data set, with a 70 percent response rate. PRINCIPAL FINDINGS: The predictive accuracy of the demographic model improves when it is extended with diagnostic information from prior hospitalizations (DCGs). A subset of survey variables further improves the predictive accuracy of the DCG capitation models. The predictable profits and losses based on survey information for the DCG models are smaller than for the demographic model. Most persons with predictable losses based on health survey information were not hospitalized in the preceding year. CONCLUSIONS: The use of diagnostic information from prior hospitalizations is a promising option for improving the demographic capitation payment formula. This study suggests that diagnostic information from outpatient utilization is complementary to DCGs in predicting future costs.
PMCID: PMC1070345  PMID: 10029506
21.  Direct-to-Consumer Genetic and Genomic Testing: Preparing Nurse Practitioners for Genomic Healthcare 
Rapidly emerging technologies make it possible for consumers to acquire information that is intended to explain their inherited susceptibility to disease and facilitate tailored healthcare services through direct-to-consumer (DTC) marketing of personal genetic (PG) and personal genomic (PGM) testing. However, the health benefits and risks associated with these technologies are largely unknown. Consumers will turn to their healthcare providers, including nurse practitioners, to interpret test results and seek guidance on how to use these test results for medical decision-making. Nurse practitioners will need to constantly update their practice skills in response to advances in genomic technology that create new expectations among patients and lead to substantial changes in healthcare delivery.
PMCID: PMC2995214  PMID: 21132113
direct-to-consumer marketing; nurse practitioner; personal genetic testing; personal genomic testing
22.  The discriminative power of patient experience surveys 
Comparisons of patient experiences between providers are increasingly used as an index of performance. The present study describes the ability of patient experience surveys to discriminate between healthcare providers for various patient groups and quality aspects, and reports the sample sizes required for reliable (comparisons of) provider scores.
The consumer quality index is a family of surveys that are tailored to specific patient groups. Data was used from patients who underwent cataract surgery, patients who underwent hip or knee surgery, patients suffering from spinal disc herniation and patients suffering from varicose veins. Multi-level regression models were fitted to assess the proportion of variance in patient experiences that is attributable to providers for various quality aspects.
The proportion of variance in patient experiences that is attributable to providers varied from 0.001 to 0.054. The required sample size for reliable estimates at the provider level varied from 41 to 1967 per provider. Differences in discriminative power between patient groups and/or quality aspects were inconsistent, with one exception: for all groups, the discriminative power of experiences regarding change in physical functioning was particularly limited.
From a statistical point of view, the discriminative power appears limited. The sample sizes required for reliable estimates are often substantial and deserve careful consideration when setting up measurements. Future research should evaluate the discriminative power by validating differences between providers in patient experiences with other indices and should explore other, more sensitive measures of patient experiences regarding treatment-related changes in physical functioning.
PMCID: PMC3292538  PMID: 22145965
23.  Patients Are Satisfied with Advanced Practice Physiotherapists in a Role Traditionally Performed by Orthopaedic Surgeons 
Physiotherapy Canada  2010;62(4):298-305.
Purpose: To measure and compare patient satisfaction with follow-up care in advanced practice physiotherapist (APP) and orthopaedic surgeon clinics for patients following total hip or knee replacement.
Method: Consecutive patients attending either an APP-led or a surgeon-led review clinic were surveyed using a modified nine-item satisfaction questionnaire based on the Visit-Specific Satisfaction Instrument (VSQ-9). Chi-square analyses were used to examine differences in patient characteristics and type of visit. Independent t-tests were used to examine potential differences in patient satisfaction.
Results: Of the 123 participants, more than half were aged 65 years or older. Chi-squared analyses revealed no significant difference in participant characteristics (gender, age, and overall health status) between the two different types of clinics. There was a significant difference (χ24=12.49, p=0.014) in the distribution of the timing of follow-up appointments. There was no significant difference between the groups in mean overall patient satisfaction scores on the modified VSQ-9 (p=0.34) nor in the mean of the sum of the seven items related to the service provider (p=0.85). Satisfaction scores for most of the service-provider items were above 90/100.
Conclusion: Patients are highly satisfied with the care provided by APPs in follow-up clinics after joint replacement. Evaluation of the patient perspective is essential to any new role involving a shift in traditional practice boundaries.
PMCID: PMC2958073  PMID: 21886368
extended scope; hip and knee arthroplasty; osteoarthritis; instrument validity; questionnaire; arthroplastie de la hanche ou du genou; arthrose; instrument de validation; portée étendue; questionnaire
24.  Consumer evaluation of complaint handling in the Dutch health insurance market 
How companies deal with complaints is a particularly challenging aspect in managing the quality of their service. In this study we test the direct and relative effects of service quality dimensions on consumer complaint satisfaction evaluations and trust in a company in the Dutch health insurance market.
A cross-sectional survey design was used. Survey data of 150 members of a Dutch insurance panel who lodged a complaint at their healthcare insurer within the past 12 months were surveyed. The data were collected using a questionnaire containing validated multi-item measures. These measures assess the service quality dimensions consisting of functional quality and technical quality and consumer complaint satisfaction evaluations consisting of complaint satisfaction and overall satisfaction with the company after complaint handling. Respondents' trust in a company after complaint handling was also measured. Using factor analysis, reliability and validity of the measures were assessed. Regression analysis was used to examine the relationships between these variables.
Overall, results confirm the hypothesized direct and relative effects between the service quality dimensions and consumer complaint satisfaction evaluations and trust in the company. No support was found for the effect of technical quality on overall satisfaction with the company. This outcome might be driven by the context of our study; namely, consumers get in touch with a company to resolve a specific problem and therefore might focus more on complaint satisfaction and less on overall satisfaction with the company.
Overall, the model we present is valid in the context of the Dutch health insurance market. Management is able to increase consumers' complaint satisfaction, overall satisfaction with the company, and trust in the company by improving elements of functional and technical quality. Furthermore, we show that functional and technical quality do not influence consumer satisfaction evaluations and trust in the company to the same extent. Therefore, it is important for managers to be aware of the type of consumer satisfaction they are measuring when evaluating the handling of complaints within their company.
PMCID: PMC3250957  PMID: 22085762
25.  Haptic Feedback Can Provide an Objective Assessment of Arthroscopic Skills 
The outcome of arthroscopic procedures is related to the surgeon’s skills in arthroscopy. Currently, evaluation of such skills relies on direct observation by a surgeon trainer. This type of assessment, by its nature, is subjective and time-consuming. The aim of our study was to identify whether haptic information generated from arthroscopic tools could distinguish between skilled and less skilled surgeons. A standard arthroscopic probe was fitted with a force/torque sensor. The probe was used by five surgeons with different levels of experience in knee arthroscopy performing 11 different tasks in 10 standard knee arthroscopies. The force/torque data from the hand and tool interface were recorded and synchronized with a video recording of the procedure. The torque magnitude and patterns generated were analyzed and compared. A computerized system was used to analyze the force/torque signature based on general principles for quality of performance using such measures as economy in movement, time efficiency, and consistency in performance. The results showed a considerable correlation between three haptic parameters and the surgeon’s experience, which could be used in an automated objective assessment system for arthroscopic surgery.
Level of Evidence: Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC2504651  PMID: 18213507

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