Medical care
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Randomized Controlled Trial Clinical Trial
The cost-effectiveness of a multifactorial targeted prevention program for falls among community elderly persons.
Falls and fall injuries are common-potentially preventable-causes of morbidity, functional decline, and increased health-care use among elderly persons. The current analyses, performed on data obtained as part of a randomized controlled trial conducted within a health maintenance organization, describe the costs of a multifactorial, targeted prevention program for falls, present total net health-care costs, estimate the cost per fall prevented, and describe acute fall-related health-care costs. ⋯ Consideration should be given toward incorporating and reimbursing the cost of fall-prevention programs within the usual health care of community-living elderly persons, particularly for those persons at high risk for falling.
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Randomized Controlled Trial Comparative Study Clinical Trial
Eliminating language barriers for non-English-speaking patients.
More than 31 million persons living in the United States do not speak English, therefore language discordance between the clinician and patient may hinder delivery of cost-effective medical care. A new language service was developed in which interpreters are trained in the skills of simultaneous interpretation commonly used at international conferences. The interpreters are linked from a remote site to headsets worn by the clinician and patient through standard communication wires. The service is called "remote-simultaneous interpretation," to contrast it with a traditional method of an interpreter being physically present at the interview and interpreting consecutively "proximate-consecutive interpretation." The aim of this study is to assess in a randomized protocol the quality of communication, interpretation, and level of patient, interpreter, and physician satisfaction with these two language services. ⋯ Using remote-simultaneous interpretation to improve the quality of communication in discordant-language encounters promises to enhance delivery of medical care for the millions of non-English-speaking patients in the United States.
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Many groups involved in health care are very interested in using external quality indices, such as risk-adjusted mortality rates, to examine hospital quality. The authors evaluated the feasibility of using mortality rates for medical diagnoses to identify poor-quality hospitals. ⋯ Although they may be useful for some surgical diagnoses, DRG-specific hospital mortality rates probably cannot accurately detect poor-quality outliers for medical diagnoses. Even collapsing to all medical DRGs, hospital mortality rates seem unlikely to be accurate predictors of poor quality, and punitive measures based on high mortality rates frequently would penalize good or average hospitals.
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Multicenter Study
Clinical predictors of functioning in persons with acquired immunodeficiency syndrome.
To help clinicians better assess and treat functional disabilities in persons with acquired immunodeficiency syndrome (AIDS), the authors estimate empirical relations among biologic and physiologic variables, symptoms, and physical functioning in persons with AIDS. The sample of 305 persons with AIDS for this cross-sectional analysis came from three sites in Boston, Massachusetts: a hospital-based group practice, a human immunodeficiency virus clinic at a city hospital, and a staff-model health maintenance organization. Physical functioning, 10 AIDS-specific symptoms, and mental health were assessed by interview. ⋯ In conclusion, symptom reports were strong predictors of physical functioning. Poorer mental health and weight loss were correlated consistently with worse symptoms, and not using zidovudine was correlated with worse neurologic and fever symptoms. These variables, and the others the authors identified, may represent mutable determinants of physical functioning in persons with AIDS, and potential targets for specific clinical interventions.
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Hospitalization rates for chronic medical conditions vary across small areas and are associated inversely with community income. The authors studied whether variation in hospitalization rates can be attributed to differences in physician practice style. Using census and hospital discharge data, hospitalization rates were calculated for asthma, congestive heart failure, and diabetes in 40 medical service areas in California. ⋯ However, in a multiple linear regression analysis that included community sociodemographic factors, physician practice style was not associated significantly with hospitalization rates. Physician practice style varies across areas, but does not explain variation in admission rates for chronic medical conditions after adjusting for community sociodemographic factors. Using methods such as practice guidelines or utilization review to re-set physicians' threshold for admission may not be effective in reducing hospitalizations for chronic medical conditions.