To assess the accuracy of information in an administrative database (Canadian Institute for Health Information; CIHI) compared with the hospital record for patients undergoing knee replacement (KR).
A stratified random sample of 185 KR recipients from 5 Ontario hospitals were chosen. Their hospital records and corresponding CIHI files were compared to assess percent complete agreement, false negative (FN) and false positive (FP) rates for demographic data, procedures, and diagnoses.
Of 185 records, 175 (95%) were reviewed. Percent complete agreement was greater than 94% for each of patient demographics and procedures (mean FN rates: 0%; mean FP rates: 0-5%). For comorbidities and complications, although mean percent complete agreement was high, and FP rates were low, mean FN rates were 63% for specific comorbid conditions and 70% for organ systems.
High FN rates have been found in documentation of comorbidities and in-hospital complications for CIHI data compared with the hospital record. Under-coding of comorbidities and in-hospital complications has potential implications for researchers using administrative databases.
New technology is a major determinant of total healthcare costs. The assessment of alternative technologies from a cost-effectiveness perspective is important, although other considerations may finally determine which technology is used. The alternatives of extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrostolithotomy (PCNL) for the treatment of renal stone disease were compared by studying 1000 cases of ESWL and 133 cases of PCNL using a noncontemporaneous cohort study with PCNL representing the earlier cohort. The effectiveness, defined by success and stone-free rates, was higher with PCNL than with ESWL (96% success vs. 70%); PCNL was also accompanied by a lower burden of additional therapy, whereas ESWL had a higher retreatment rate. From the perspective of a third-party payer, total costs per case of ESWL ($2,746) were lower than those of PCNL ($4,087), but the figure varies with the annual volume. These represent the costs for complete treatment of a patient, including the costs of alternative technology such as PCNL or ureteroscopy that may ultimately be necessary in a patient initially managed by ESWL. The cost for a single ESWL treatment was $2,226 (at a volume of 1000 cases per year), but this increased to $2,746 when costs of retreatment and alternative treatment were prorated to each patient treated. The relative contribution of capital costs to the total cost of ESWL was always less than total professional fees and was only 12% at a volume of 2000 cases/year. Therefore ESWL is less expensive but it is also less effective in rendering patients stone-free.
To compare, in a Canadian health care setting, the costs and consequences of 3 strategies of misoprostol prophylaxis for osteoarthritis patients: prophylaxis for all patients taking nonsteroidal antiinflammatory drugs (NSAIDs), for no patients taking NSAIDs, and for only elderly patients (age > or = 60) taking NSAIDs.
We designed a decision-analysis model which incorporated costs (estimated with ulcer patient profiles and medical records), review, and probabilities (estimated from a companion meta-analysis, selected literature review, and Ontario Ministry of Health Statistics). Effectiveness was defined as the number of episodes of gastric ulceration requiring hospitalization or outpatient management that were averted by each strategy.
On average, prophylaxis cost an additional $650 for every additional gastrointestinal event prevented. Prophylaxis for elderly NSAID users was cost saving if the ulcer complication rate in this group exceeds 1.2%, or if either the charges for outpatient ulcer treatment exceed $2,000, or the 3-month price of misoprostol is
Rheumatologists from 4 countries, representing 8 rheumatology centers, tested 3 systemic lupus erythematosus (SLE) disease activity indices: the SLE Disease Activity Index (SLEDAI) from Toronto; the Systemic Lupus Activity Measure (SLAM) from Boston and the British Isles Lupus Assessment Group (BILAG) for their reproducibility and validity in the assessment of real patients. Seven patients representing a spectrum of disease manifestations and activity were each examined by 4 of 7 observers from all centers except Toronto, using a Youden square design. Each observer completed all 3 indices and a category rating scale for disease activity on each of the 4 patients seen. All 3 indices detected differences among patients. There was no detectable observer effect among the 7 observers with each of the 3 indices. There was a detectable order effect with the SLAM. The 3 indices are comparable and reproducible for evaluating disease activity in SLE.
Because there is little information about the efficacy of home occupational therapy, we decided to assess the effects of a home service on patients with rheumatoid arthritis. 105 patients aged 18-70 years, on stable medical therapy, were randomised to receive a 6-week comprehensive programme of occupational therapy (experimental group, 53 patients) or to receive no such treatment (control group, 52). At 6 weeks, control patients received the experimental regimen, and experimental patients were continued on treatment as needed up to 12 weeks. Outcomes were measured at baseline, 6, and 12 weeks with a global functional capacity score (functional score). At 6 weeks the functional score for the experimental group was significantly higher than that for the control group (mean difference = 8.1, 95% Cl 1.7 to 15.8, p = 0.012). Control patients at 12 weeks showed a similar improvement to experimental patients at 6 weeks, and between 6 and 12 weeks the experimental patients were stable. Occupational therapy leads to a statistically significant and clinically important improvement in function in patients with rheumatoid arthritis.
Data on musculoskeletal disorders (complaints), collected as part of the Canada Health Survey were analyzed. Sixteen percent of those sampled reported having arthritis, rheumatism or back, limb or joint disorders with a greater prevalence among females and in the older population. In 21% this was associated with limitation of activity with an average of 11 disability days/person/year. Serious back disorders were reported in 4.4% of the population. While the majority of health consultations (53%) were with a physician, a substantial number (34%) were with chiropractors.
To compare the measurement properties over time of five generic health status assessment techniques.
Five health status measures were completed on two occasions by a sample of workers with musculoskeletal disorders. They included the SF-36, Nottingham Health Profile, Health Status Section of the Ontario Health Survey (OHS), Duke Health Profile, the Sickness Impact Profile and a self-report of change in health between tests.
Subjects were accrued from a work site (within one week of injury) (n = 53), physiotherapy clinics (four weeks after injury), (n = 34), and a tertiary level rehabilitation center (more than four weeks after injury) (n = 40).
Intraclass correlation coefficients (ICC) derived from nonparametric one-way analysis of variance were used for test-retest reliability in those who had not changed (n = 49). Various responsiveness statistics were used to evaluate responsiveness in those who claimed they had a positive change in health (n = 45) and in those who would have been expected to have a positive change (n = 79).
Of the 127 subjects recruited, 114 completed both questionnaires (89.8%). In the subjects who reported no change in health, analysis of targeted dimensions (overall scores, physical function, and pain) demonstrated acceptable to excellent test-retest reliability in all but the Duke Health Profile. In subjects with change in health, the SF-36 was the most responsive measure (moderate to large effect sizes [0.55-0.97] and standardized response means ranging between 0.81 and 1.13).
The results suggest that the SF-36 was the most appropriate questionnaire to measure health changes in the population studied. The selection of a health status measure must be context-specific, taking into account the purpose and population of the planned research.
To examine back and neck hospitalizations in the Province of Ontario and Washington State. Because of their different organization and financing, there has been considerable interest in comparing healthcare systems in Canada and the United States. Features of healthcare systems might be expected to result in greater variations in care for elective than urgent conditions.
Automated hospital discharge databases.
Previously developed algorithms were used to identify surgical and nonsurgical hospitalizations for back and neck problems in the administrative databases. We compared overall rates of hospitalization and lengths of hospital stay in Ontario and Washington as well as small area variations within the province and state.
Surgical back and neck hospitalizations were three times as common in Washington, but medical hospitalizations were twice as common in Ontario. Provincial lengths of stay were longer for both surgical and nonsurgical hospitalizations. Admission rates varied substantially and significantly among small areas in both Washington and Ontario. Variations in hospital length of stay were greater in Ontario, particularly for nonsurgical back and neck hospitalizations.
The two jurisdictions had very different patterns of hospital utilization for one of the most common health problems seen by physicians. Our results suggest that the global controls on hospital budgets and access to technology in Ontario were associated with lower rates of surgery, higher rates of hospital-based medical care, and longer lengths of stay. They also indicate that the utilization review process in Washington was associated with lower small area variation rates for medical back care.
Notes
Cites: Am J Public Health. 1983 Apr;73(4):389-956219588
Cites: JAMA. 1985 Jul 19;254(3):371-54009864
Cites: Lancet. 1987 May 23;1(8543):1185-92883497
Cites: N Engl J Med. 1988 Feb 4;318(5):291-3002961994
Cites: Am J Prev Med. 1987 Mar-Apr;3(2):101-93132956
Cites: Health Serv Res. 1990 Feb;24(6):741-712312306
Cites: Annu Rev Public Health. 1991;12:141-561828670
Cites: J Bone Joint Surg Am. 1992 Apr;74(4):536-431583048
Cites: Med Care. 1992 May;30(5):461-51583923
Cites: QRB Qual Rev Bull. 1992 Mar;18(3):98-1071603577
Cites: JAMA. 1992 Aug 19;268(7):907-111640622
Cites: Spine (Phila Pa 1976). 1992 Jul;17(7):817-251386943
Cites: N Engl J Med. 1993 Mar 18;328(11):772-88437598
Cites: JAMA. 1993 Apr 7;269(13):1661-68455299
Cites: Med Care. 1993 Aug;31(8):711-88336510
Cites: Health Aff (Millwood). 1993 Summer;12(2):130-98375808
Cites: Spine (Phila Pa 1976). 1993 Oct 1;18(13):1728-358235855
Cites: Med Care. 1993 Dec;31(12):1106-188246640
Cites: Spine (Phila Pa 1976). 1994 Jun 1;19(11):1201-68073310
Cites: J Spinal Disord. 1995 Feb;8(1):1-77711364
Cites: Health Serv Res. 1995 Apr;30(1):27-427721583
Cites: JAMA. 1996 May 8;275(18):1410-68618366
Cites: N Engl J Med. 1997 May 22;336(21):1500-59154770
To determine which second line agents Canadian and US rheumatologists use to treat patients with active rheumatoid arthritis (RA).
A one page survey was sent by fax or mail to all 263 members of the Canadian Rheumatology Association and 320 members of the American College of Rheumatology (10% random sample weighted by region) known to practice adult rheumatology. The survey asked for first and second treatment preferences in patients with (1) aggressive RA; (2) moderate RA; and (3) aggressive RA failing a trial of methotrexate (MTX) 25 mg.
Altogether 231 (87.8%) Canadian and 230 (71.7%) US rheumatologists responded, and 214 responses in each survey were analyzable. In aggressive RA. MTX was the drug of first choice of most Canadian (68.7%) and US (78.5%) rheumatologists. Intramuscular gold was a drug of first choice for 14.5 and 1.9% of Canadians and Americans, respectively. 93.9% of Canadian and 90.2% of US respondents preferred single agents for the treatment of moderate RA. Among US rheumatologists. no clear leader emerged as a single agent alternative for the management of aggressive RA unresponsive to MTX. Most said they would use combination (38.3%) or triple (23.8%) therapy involving MTX plus sulfasalazine and/or hydroxychloroquine. 52.3% of Canadians preferred single agent therapy, with 34.6% choosing gold as an alternative to MTX.
Canadian and US rheumatologists preferred MTX for the treatment of aggressive RA. Canadian rheumatologists saw a small but significant role for intramuscular gold. No single agent emerged as a clear alternative to MTX among US rheumatologists.
Patients' ratings of the severity and importance of items are often used to select items for health status instruments. The purpose of this study was to compare six different methods of combining severity-importance ratings. Two different patient groups separately rated the importance and severity of their complaints; (i) 76 patients with upper-extremity disorders rated 70 upper-extremity-related questions; and (ii) 86 patients with hip arthrosis rated 22 questions relating to their hip problem. The rank ordering of the items using the six different methods in the two populations were very similar (tau(bi) = 0.91 and 0.87, respectively). Furthermore, the six methods when used to choose 30 upper-extremity items shared 25 items in common and shared 9 (of 10) hip items in the second group. In conclusion, the results of item reduction were not affected by the method of creating importance-severity ratings.
