To tell the truth: disclosing the incentives and limits of managed care.
As managed care becomes more prevalent in the United States, concerns have arisen over the business practices of managed care companies. A particular concern is whether patients should be made aware of the financial incentives and treatment limits of their healthcare plan. At present, managed care organizations are not legally required to make such disclosures. However, such disclosures would be advisable for reasons of ethical fidelity, contractual clarity, and practical prudence. Physicians themselves may also have a fiduciary responsibility to discuss incentives and limits with their patients. Once the decision to disclose has been made, the managed care organization must draft a document that explains, clearly and honestly, limits of care in the plan and physician incentives that might restrict the care a patient receives. (+info)
Tuberculin skin testing among economically disadvantaged youth in a federally funded job training program.
Low income, medically underserved communities are at increased risk for tuberculosis. Limited population-based national data are available about tuberculous infection in young people from such backgrounds. To determine the prevalence of a positive tuberculin skin test among economically disadvantaged youth in a federally funded job training program during 1995 and 1996, the authors evaluated data from medical records of 22,565 randomly selected students from over 100 job training centers throughout the United States. An estimated 5.6% of students had a documented positive skin test or history of active tuberculosis. Rates were highest among those who were racial/ethnic minorities, foreign born, and (among foreign-born students) older in age (p < 0.001). Weighted rates (adjusting for sampling) were 1.3% for white, 2.2% for Native American, 4.0% for black, 9.6% for Hispanic, and 40.7% for Asian/Pacific Islander students; rates were 2.4% for US-born and 32.7% for foreign-born students. Differences by geographic region of residence were not significant after adjusting for other demographic factors. Tuberculin screening of socioeconomically disadvantaged youth such as evaluated in this study provides important sentinel surveillance data concerning groups at risk for tuberculous infection and allows recommended public health interventions to be offered. (+info)
Effect of missing data on the estimate of average daily feed intake of growing pigs.
The effect of missing records for feed intake per day (FID) on the estimate of average daily feed intake (DFI) during the test period of individual pigs was studied. Data from 192 growing pigs tested with single-space computerized feeding stations during an average of 93 d were used. True DFI was computed by averaging FID records per pig, individually. A first- and third-degree polynomial and a nonlinear function were fit to FID records per pig to estimate DFI by averaging estimated FID records per pig, individually. The three functions showed small differences for goodness of fit. Missing FID records were simulated by random as well as period-wise deletions of FID records. The effect of missing FID records was judged on the Pearson correlation between true and estimated DFI. Deleting randomly up to 70% of FID records per pig before fitting each function reduced this correlation only from 1.00 to .96 for each function. Deleting 25 successive FID records (approximately 27% of records) before fitting reduced the correlation to values ranging from .92 to .96 and from .59 to .96 for the first- and third-order degree polynomial function, respectively, and from .80 to .97 for the nonlinear function. Using iteratively reweighted least squares regression methods to exclude undesirable effects of outlier values gave similar results for the effect of missing FID records on estimated DFI. Results imply that considering incorrect FID records as missing is a good alternative for adjusting incorrect data in combination with using functions to estimate DFI of growing pigs. Use of a first-degree polynomial function is recommended. Moreover, use of functions enables a more efficient use of feeding stations by recording feed intake data during only parts of the test period. (+info)
Evaluation of the completeness of cancer case ascertainment in the Seoul male cohort study: application of the capture-recapture method.
Since the completeness of case ascertainment is directly related to the validity of a study, the evaluation of completeness is an essential feature of a cohort study. To estimate the completeness of cancer case ascertainment during a three year period (Jan. 1, 1993, to Dec. 31, 1995) in which the Seoul Male Cohort was followed up, we applied capture-recapture method. Data were obtained from the cancer registries, medical records and death certificates, with cases identified from each source numbering 103, 105, and 38, respectively. After eliminating duplicate cases, the total number was 141, and by using a log-linear model, the number of cases not detected by any of the three data sources was estimated to be 16. For all cancers, the estimated completeness of follow-up was 89.9%. (+info)
Towards a multi-professional patient record--a study of the headings used in clinical practice.
This paper reports on the differences and similarities of headings used in patient records by Swedish health care professionals; nurses, occupational therapists, physiotherapists, dietitians, speech therapists, medical social workers and general practitioners. The background to the study is a national project where representatives from the different health care professions have worked together for two years in an effort to develop a multi-professional database of terms for the health care sector. The study reports on an analysis of the existing multi-professional lists of headings with respect to structure, degree of specialization, synonyms and homonyms. The study is descriptive in nature, gives a status report on the variety of headings used in clinical practice, provides necessary material for a normative approach focusing on a truly multiprofessional patient record in the future. (+info)
Medical student database development: a model for record management in a multi-departmental setting.
Student records flow through medical school offices at a rapid rate. Much of this data is often tracked on paper, spread across multiple departments. The Medical Student Informatics Group at the University of Utah School of Medicine identified offices and organizations documenting student information. We assessed departmental needs, identified records, and researched database software available within the private sector and academic community. Although a host of database applications exist, few publications discuss database models for storage and retrieval of student records. We developed and deployed an Internet based application to meet current requirements, and allow for future expandability. During a test period, users were polled regarding utility, security, stability, ease of use, data accuracy, and potential project expansion. Feedback demonstrated widespread approval, and considerable interest in additional feature development. This experience suggests that many medical schools would benefit from centralized database management of student records. (+info)
Epidemiological studies on the 1967-1968 foot-and-mouth disease epidemic: the reporting of suspected disease.
From an analysis of the telephone reports in ten FMD Control Centres in the West Midlands, the veterinary officers' reports on each outbreak, the farm patrol reports and the daily number of outbreaks announced on the 17.50 h B.B.C. T.V. News, it would appear that the reporting of suspected outbreaks was indirectly related to the local disease activity. Private veterinary practitioners reported older cases of FMD at the beginning and end of the epidemic than in the middle. (+info)
Using routine data to complement and enhance the results of randomised controlled trials.
BACKGROUND: Randomised controlled trials (RCTs) are widely accepted as the best way to assess the outcomes and safety of medical interventions, but are sometimes not ethical, not feasible, or limited in the generalisability of their results. In such circumstances, routinely available data could help in several ways. Routine data could be used, for example, to conduct 'pseudo-trials', to estimate likely outcomes and required sample size to help design and conduct trials, or to examine whether the expected outcomes observed in an RCT will be realised in the general population. OBJECTIVES: The project was undertaken to explore how routinely assembled hospital data might complement or supplement RCTs to evaluate medical interventions: in contexts where RCTs are not feasible for defining the context and design of an RCT for assessing whether the benefits indicated by RCTs are achieved in wider clinical practice. METHODS: The project was based on the system of linked Scottish morbidity records, which cover 100% of acute hospital care episodes and statutory death records from 1981 to 1995. Three case studies were undertaken as a way of investigating the utility of these records in different applications. First, an attempt was made to analyse the link between the timing of surgery for subarachnoid haemorrhage (SAH) and subsequent outcomes (a question not easily susceptible to RCT design). A subsample was derived by excluding patients for which a diagnosis of SAH may not have been established or that may not have been admitted to a neurosurgical unit, and the data were assessed to attempt to inform the design of a trial of early versus late surgery. Transurethral prostatectomy (TURP), the second case study, has become the surgery of choice for benign prostatic hyperplasia without systematic assessment of its effectiveness and safety, and an RCT would now be considered unethical. However, there is a need to investigate long-term effects and the influence of co-morbidities on outcomes. A retrospective comparison of mortality and re-operation following either open prostatectomy (OPEN) or TURP was, therefore, undertaken. Patients for whom it was not possible to establish the initial procedure were excluded. The third case study compared coronary artery bypass grafting (CABG) with percutaneous transluminal angioplasty (PTCA) for coronary revascularisation. RCTs have been conducted in limited patient subgroups with short follow-up periods. A meta-analysis of RCTs could be augmented by routine data, which are available for large populations. This would allow assessment of subgroup effects, and outcomes over a long period. A subgroup of patients was therefore constructed for whom relevant routine data were available and who reflected the entry criteria for major RCTs, thus enabling a comparison between the results expected from this subgroup and those of the general population. RESULTS AND CONCLUSIONS: The uses of routine data in these contexts had strengths and weaknesses. The SAH study suggested a means of assessing outcomes and survival rates following haemorrhage, which could have value in informing the design of more precise trials and in evaluating changes in outcome following the introduction of new treatments such as embolisation. However, the potential of the data was not realised because their scope and content were insufficient. For example, lack of data on the time of onset of symptoms and patients' conditions at hospital admission made it difficult to establish the link between timing of surgery and the outcome, and there was insufficient information on patients' conditions at discharge to enable a comparison of outcomes. The prostatectomy study was able to address questions not answered by RCT literature because the large number of cases it included allowed exploration of subgroup effects. (ABSTRACT TRUNCATED) (+info)