Deborah Dobrez

Quality of life in patients with newly diagnosed chronic phase chronic myeloid leukemia on imatinib versus interferon alfa plus low-dose cytarabine: results from the IRIS Study.

PURPOSE Quality of life (QOL) outcomes in patients with chronic myeloid leukemia (CML) were evaluated in an international phase III study. PATIENTS AND METHODS Newly diagnosed patients with chronic phase CML were randomly assigned to imatinib or interferon alfa plus subcutaneous low-dose cytarabine (IFN+LDAC). Cross-over to the other treatment was permitted because of intolerance or lack of efficacy. Patients completed cancer-specific QOL (Functional Assessment of Cancer Therapy-Biologic Response Modifiers) and utility (Euro QoL-5D) questionnaires at baseline and during treatment (n = 1,049). The primary QOL end point was the Trial Outcome Index (TOI; a measure of physical function and well-being). Secondary end points included social and family well-being (SFWB), emotional well-being (EWB), and the utility score. Primary analyses were intention to treat with secondary analyses accounting for cross-over. RESULTS Patients receiving IFN+LDAC experienced a large decline in the TOI, whereas those receiving imatinib maintained their baseline level. Treatment differences at each visit were significant (P <.001) and clinically relevant in favor of imatinib. Mean SFWB, EWB, and utility scores were also significantly better for those patients taking imatinib. Patients who crossed over to imatinib experienced a large increase in TOI; significant (P <.001) differences were observed between patients who did and did not cross over in favor of imatinib. CONCLUSION Imatinib offers clear QOL advantages compared with IFN+LDAC as first-line treatment of chronic phase CML. In addition, patients who cross over to imatinib from IFN+LDAC experience a significant improvement in QOL compared with patients who continue to take IFN+LDAC.

Effect of mental health specialty care on antidepressant length of therapy.

OBJECTIVES Treatment of depression with medications and psychotherapy clearly is efficacious, but not all patients require such intensive therapy. In this report, we examine the costs and effects of dual treatment on a population of employees and their families with depression. We sought to determine the costs and length of medication treatment consequences of providing mental health specialty care to antidepressant-treated individuals. RESEARCH DESIGN AND SUBJECTS A quasi-experimental retrospective design was used to examine the administrative data of 2678 antidepressant users whose insurance claims are included in the MarketScan database. The primary measure used was joint cost-continuity of antidepressant medication. RESULTS Patients receiving concurrent psychotherapy were more likely to achieve length of antidepressant treatment consistent with current recommendations. The cost-consequence ratio for concurrent treatment was

Impact of Medicare's Prospective Payment System for Inpatient Rehabilitation Facilities on Stroke Patient Outcomes

4062/1% improvement in the number of adequately treated individuals. CONCLUSION Adding psychotherapy to treatment with medication appears to improve the efficacy of antidepressant treatment. The incremental costs suggest that it is a valuable addition in most cases and should be considered cost-effective.

Trends in perinatal regionalization and the role of managed care

Dobrez D, Heinemann AW, Deutsch A, Manheim L, Mallinson T: Impact of Medicares prospective payment system for inpatient rehabilitation facilities on stroke patient outcomes. Objective:To estimate the effect of Medicares prospective payment system for inpatient rehabilitation facilities on discharge functional status, community discharge, and length of stay. Design:Secondary analysis using data drawn from the American Medical Rehabilitation Providers Association subscription database. Eligible patients were Medicare and non-Medicare stroke patients discharged from inpatient rehabilitation facilities from 1998 through the first two quarters of 2006. Random effects panel data models were used to estimate the impact of prospective payment on motor and cognitive discharge function, the probability of discharge to the community and inpatient length of stay, controlling for patient, and facility characteristics. Results:The introduction of prospective payment was associated with small, statistically significant reductions in Functional Independence Measure discharge motor (−1.10) and cognitive (−0.15) scores and in the probability of discharge to the community (adjusted odds ratio: 0.87) for Medicare fee-for-service patients. Length of stay was substantially lower for both Medicare (−1.86 days) and (−2.16) non-Medicare fee-for-service patients. Conclusions:Further research is needed to determine whether the small reductions in patient function are persistent over time. This short-term evaluation of prospective payment system suggests minimal negative impact on stroke patient function at discharge because of the change in Medicare reimbursement but a decrease in likelihood of discharge to the community.

Factors influencing the long-term success of periurethral collagen therapy in the office

OBJECTIVE: To describe trends in regionalization of perinatal care and identify factors that predict the extent of regionalization. METHODS: Data were drawn for four states for every year between 1989 and 1998. Panel data models estimated the effect of managed care enrollment on site of delivery for low, very low, and extremely low birth weight neonates. RESULTS: Strong evidence for regionalization over time was observed for North Carolina and Illinois, with little change in site of delivery in Washington. A shift from level III to level II hospitals was observed for low and very low birth weight neonates in California. Although managed care enrollment increased substantially in all four states, managed care had no effect on site of delivery; that is, the effect of managed care was near zero and not statistically significant in any state. CONCLUSION: Evidence supports the delivery of high-risk neonates at tertiary care centers. Despite changes in site of delivery, the percentages of very low birth weight neonates delivered at level III hospitals were substantially lower than the goal of 90% set by Healthy People 2010. Financial pressures introduced by managed care cannot be blamed for the failure to meet this goal. LEVEL OF EVIDENCE: II-2

Managed care and perinatal regionalization in Washington State.

IntroductionGlutaraldehyde crosslinked bovine collagen has been used for periurethral bulking for the treatment of urodynamic stress incontinence since 1989 with variable success. A retrospective study was undertaken to evaluate the factors involved in the long-term success of glutaraldehyde crosslinked bovine collagen used for periurethral bulking in the office.MethodsPatients were followed objectively with stress testing after receiving periurethral collagen injection in the office under local anesthesia. Repeat injections were done as necessary during their follow-up appointments. The “success” group was defined as those women who demonstrated negative stress tests for over 1 year following their first injection.ResultsNineteen of 184 women (10.3%) demonstrated negative stress tests for over 1 year following only one initial injection of glutaraldehyde crosslinked collagen. Their success lasted a mean of 829 days up to the time of follow-up.ConclusionPrior anti-incontinence surgery was the one factor analyzed that showed a trend toward this long lasting success. No other factors were predictive of negative stress tests for over 1 year. Prior anti-incontinence surgery seems to represent a factor involved in the long-term success of periurethral bulking in the office with glutaraldehyde crosslinked bovine collagen for the treatment of urodynamic stress incontinence.

Impact of Mental Disorders on Cost and Reimbursement for Patients in Inpatient Rehabilitation Facilities

OBJECTIVE To determine if an association exists between managed care penetration and perinatal deregionalization in Washington State. METHODS The proportions of low birth weight (LBW) and very low birth weight (VLBW) deliveries were tabulated for each hospital in Washington State for the years 1989, 1993 and 1996. Level of perinatal care, degree of health maintenance organization (HMO) penetration, and maternal demographic characteristics including age, race, smoking, and Medicaid status were derived from state and national databases. Multiple linear regression analysis was performed for each hospital level to evaluate the association between change in proportion of LBW and VLBW deliveries and change in HMO penetration per hospital between each of the 3 years. RESULTS From 1989 through 1993, the proportion of LBW deliveries significantly declined at level III hospitals and rose at level I and II hospitals. This trend reversed between 1993 and 1996. Very low birth weight deliveries demonstrated more limited and somewhat contrary results, significantly decreasing, then increasing in level I hospitals, and significantly increasing in level III hospitals from 1989 to 1993. After controlling for changes in maternal characteristics over time, changes in HMO penetration at the hospital level were not significantly associated with an increasing proportion of LBW or VLBW deliveries at nonlevel III hospitals. In some analyses, increasing HMO penetration actually was significantly associated with decreasing LBW and VLBW deliveries at nonlevel III hospitals. CONCLUSION Despite continued growth in HMOs throughout the state, the trend toward deregionalization in Washington State noted in the early 1990s has not continued. At the hospital level, the increasing presence of HMOs is not significantly associated with perinatal deregionalization.

Eliciting Social Preference Weights for Functional Assessment of Cancer Therapy-Lung Health States

OBJECTIVE To determine whether comorbid mental disorders affect inpatient rehabilitation facility (IRF) costs and to examine the extent to which Medicares prospective payment system reimbursement sufficiently covers those costs. DESIGN Secondary analysis of Medicare IRF Patient Assessment Instrument files and Medicare Provider and Review files. Payment was compared with costs for patients with and without reported mood, major depression, substance use, or anxiety disorders. The relationships among payment group assignment, comorbidity-related adjustments in payment, and the presence of mental disorders were estimated. SETTING IRFs (N=1334) in the United States. PARTICIPANTS Medicare fee-for-service beneficiaries (N=1,146,799) discharged from IRFs from 2002 to 2004. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE IRF costs. RESULTS Mental disorders were reported for 13% of the Medicare fee-for-service beneficiaries. After controlling for payment group and comorbidity classifications, patients with mood, major depression, or anxiety disorders had significantly greater costs of

Impact of Urinary Incontinence on Rehabilitation Outcomes in Inpatient Rehabilitation Facilities

433,

Estimating the Cost of Developmental and Behavioral Screening of Preschool Children in General Pediatric Practice

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