Medical versus surgical treatment for low back pain: evidence and clinical practice.
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CONTEXT: Although low back pain is one of the most common health problems, it is still difficult to choose between surgical and medical treatment. OBJECTIVE: To examine the evidence of the efficacy of surgical and medical treatment of the two most common indications for spinal surgery for low back pain--lumbar disc herniation and spinal stenosis--and to assess geographic variation in the use of surgery for these conditions in the United States. METHODS: The MEDLINE database (1966-1999) was searched for all studies that compared surgical and medical treatments for low back pain. Data from the Health Care Financing Administration were used to examine geographic variation in spinal surgery rates for patients enrolled in Medicare (1996-1997). RESULTS: Eight observational studies and one randomized clinical trial were identified. In general, these studies suggest better short-term outcomes (e.g., functional status and employability) with surgery than with medical approaches, but they indicate that long-term results are similar with both types of treatment. Methodologic flaws in the observational studies, particularly selection bias, preclude definitive conclusions about relative efficacy. In 1996 and 1997, more than 98,000 Medicare enrollees had surgery for disc herniation or spinal stenosis. Among hospital referral regions, rates of surgery for disc herniation varied 8-fold, from 0.24 to 1.96 per 1000 Medicare enrollees, and rates of surgery for spinal stenosis varied 12-fold, from 0.29 to 3.34 per 1000 Medicare enrollees. CONCLUSIONS: The literature comparing the efficacy of surgical and medical treatment for low back pain is limited. Not surprisingly, the use of surgery for low back pain varies widely across the United States. To establish clinical consensus, we need better evidence about the efficacy of surgery. (+info)
Trends in the use of radical prostatectomy for treatment of prostate cancer.
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CONTEXT: The incidence of prostate cancer and rates of radical prostatectomy increased sharply in the Medicare population (men older than 65 years of age) after the introduction of prostate-specific antigen screening in the late 1980s. PRACTICE PATTERN EXAMINED: Trends in age-specific rates of use of radical prostatectomy in U.S. men between 1989 and 1995. DATA SOURCE: The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. RESULTS: Overall, rates of radical prostatectomy more than doubled between 1989 and 1992 (from 78 per 100,000 men to 206 per 100,000 men) but decreased by a third between 1992 and 1995 (to 146 per 100,000 men). The pattern in overall radical prostatectomy rates between 1992 and 1995, however, obscures changes that occurred for men in different age groups. Decreases in radical prostatectomy rates were most dramatic in elderly persons, dropping 51% in men 70 to 74 years of age and 71% in men 75 years of age or older. In contrast, rates in younger men continued to increase between 1992 and 1995, rising 42% in men 45 to 49 years of age and 18% in men 50 to 54 years of age. In each age group, trends in surgery rates mirrored trends in cancer detection rates. CONCLUSIONS: Surgical treatment of prostate cancer in older men is decreasing; however, surgery rates are increasing in younger men. These divergent trends reflect the pattern of prostate cancer detection in clinical practice. (+info)
Who is enrolled in for-profit vs. nonprofit Medicare HMOs?
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We compare the characteristics of enrollees in for-profit and nonprofit Medicare health plans using nationwide data from the 1996 Medicare Current Beneficiary Survey. We find few differences in overall health status, limitations in activities of daily living (ADLs), or history of chronic disease. However, older Americans enrolled in for-profit plans are substantially poorer and less educated than those enrolled in nonprofit plans, are more likely to have joined their plan recently, and are more likely to have joined a plan with the expectation of reducing their out-of-pocket health care costs. (+info)
What drives Medicare managed care growth?
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We conducted case studies of four markets--Los Angeles, New York City, Portland (OR), and Tampa-St. Petersburg--to learn more about why Medicare managed care develops differently across the country even when capitation rates are similar. Our analysis highlights the importance of prior managed care history, beneficiary characteristics, supplemental coverage patterns, the form of provider organization, practice patterns, care expectations, and other market characteristics to the development of Medicare managed care. Policymakers seeking to expand Medicare managed care need to go beyond national statistics to understand how local market forces affect its growth. (+info)
Medicare HMO withdrawals: what happens to beneficiaries?
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More than 400,000 Medicare beneficiaries had to seek other insurance arrangements when their health maintenance organization (HMO) withdrew from Medicare at the end of 1998. According to a new survey of 1,830 involuntarily disenrolled Medicare beneficiaries, two-thirds subsequently enrolled in another Medicare HMO; one-third experienced a decline in benefits, and 39 percent reported higher monthly premiums. One in seven lost prescription drug coverage; about one in five had to switch to a new primary care doctor or specialist. Those with traditional Medicare by itself or with Medigap, the disabled under age sixty-five, the oldest old, and the near-poor experienced the greatest hardship after their HMO withdrew. (+info)
Associations among hospital capacity, utilization, and mortality of US Medicare beneficiaries, controlling for sociodemographic factors.
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OBJECTIVE: To explore whether geographic variations in Medicare hospital utilization rates are due to differences in local hospital capacity, after controlling for socioeconomic status and disease burden, and to determine whether greater hospital capacity is associated with lower Medicare mortality rates. DATA SOURCES/STUDY SETTING: The study population: a 20 percent sample of 1989 Medicare enrollees. Measures of resources were based on a national small area analysis of 313 Hospital Referral Regions (HRR). Demographic and socioeconomic data were obtained from the 1990 U.S. Census. Measures of local disease burden were developed using Medicare claims files. STUDY DESIGN: The study was a cross-sectional analysis of the relationship between per capita measures of hospital resources in each region and hospital utilization and mortality rates among Medicare enrollees. Regression techniques were used to control for differences in sociodemographic characteristics and disease burden across areas. DATA COLLECTION/EXTRACTION METHODS: Data on the study population were obtained from Medicare enrollment (Denominator File) and hospital claims files (MedPAR) and U.S. Census files. PRINCIPAL FINDINGS: The per capita supply of hospital beds varied by more than twofold across U.S. regions. Residents of areas with more beds were up to 30 percent more likely to be hospitalized, controlling for ecologic measures of socioeconomic characteristics and disease burden. A greater proportion of the population was hospitalized at least once during the year in areas with more beds; death was also more likely to take place in an inpatient setting. All effects were consistent across racial and income groups. Residence in areas with greater levels of hospital resources was not associated with a decreased risk of death. CONCLUSIONS: Residence in areas of greater hospital capacity is associated with substantially increased use of the hospital, even after controlling for socioeconomic characteristics and illness burden. This increased use provides no detectable mortality benefit. (+info)
Applying disease management strategies to Medicare.
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Medicare coverage begins for many when they have already developed one or more chronic diseases, and it often pays for the latest and costliest phases. Population-based disease modeling, patient screening, and monitoring would be appropriate interventions for chronic renal disease. Patients who have not yet advanced to end-stage renal disease would benefit from management of diabetes and hypertension, avoidance of nephrotoxic substances, and better preparation for dialysis. Administrative support could take the form of clinical guidelines, physician-led multidisciplinary teams, integrated delivery systems, provider and patient education, and new information technologies. Medicare reflects the long-term public perspective, and thus should further this new direction by supporting education, reimbursing for prevention efforts and allied health services, encouraging efficiency, and monitoring cost and quality outcomes. (+info)
The changing landscape of health care financing and delivery: how are rural communities and providers responding?
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Rural communities have not kept pace with the recent dramatic changes in health care financing and organization. However, the Medicare provisions in the Balanced Budget Act of 1997 will require rural providers to participate in the new systems. Case studies revealed the degree of readiness for change in six rural communities and charted their progress along a continuum, as reflected in three sets of activities: the development of networking; the creation of new strategies for managing patient care; and the adoption of new methods for contracting with health insurers. Some communities had constructed highly integrated systems, whereas others were just beginning to change their billing practices; a few were signing contracts for capitated care, in contrast to those that were resisting discounts in current fee structures. These six rural areas still have considerable ground to cover before their health care organization and financing reach the levels achieved by urban communities. (+info)