Jeffrey S. Harman

Health Utilization and Cost Impact of Childhood Constipation in the United States

OBJECTIVE To estimate the total health care utilization and costs for children with constipation in the United States. STUDY DESIGN We analyzed data from 2 consecutive years (2003 and 2004) of the Medical Expenditure Panel Survey (MEPS), a nationally representative household survey. We identified children who either had been reported as constipated by their parents or had received a prescription for laxatives in a given year. Outcome measures were service utilization and expenditures. RESULTS The MEPS database included a total of 21 778 children age 0 to 18 years, representing 158 million children nationally. An estimated 1.7 million US children (1.1%) reported constipation in the 2-year period. No differences with respect to age, sex, race, and socioeconomic status were found between the children with constipation and those without constipation. The children with constipation used more health services than children without constipation, resulting in significantly higher costs:

Effort in Phone Survey Response Rates: The Effects of Vendor and Client-Controlled Factors

3430/year vs

Trends in women's health services by type of physician seen: data from the 1985 and 1997-98 NAMCS.

1099/year. This amounts to an additional cost for children with constipation of

Barriers to Evaluation and Wait Listing for Kidney Transplantation

3.9 billion/year. CONCLUSIONS This study demonstrates that childhood constipation has a significant impact on the use and cost of medical care services. The estimated cost per year is 3 times than that in children without constipation, which likely is an underestimate of the actual burden of childhood constipation.

A 'weight-listing' paradox for candidates of renal transplantation?

This article presents a model using data from 205 telephone surveys conducted in the same survey lab over a three-year period. The model demonstrates that while response rates are partly a function of variables reflecting effort, they are also affected by contextual variables often not under the survey vendors control. Significant factors that affected response rates included the salience of the survey to the population, the survey length, the type of sample (listed vs random-digit dialing), minutes per piece of sample (effort), and the amount of time the survey was in the field. A ten-minute increase in survey length results in a 7% decrease in the response rate. An increase of one day in the field per one hundred cases (fielding time) results in a 7% increase in the response rate. An increase of one interviewer minute devoted to each piece of sample released results in a 2.2% increase in overall response rates and a 3.4% increase in random-digit dialing response rates.

The influence of comorbid chronic medical conditions on the adequacy of depression care for older americans

As managed care enrollment has increased, controversy has arisen about the role of internists (IM), family physicians (FP), and obstetrician/gynecologists (ob/gyns) in the provision of womens health care. Efforts to improve training in womens health needs have also increased. Yet it is unclear how these trends have affected practice. We used the National Ambulatory Medical Care Survey (NAMCS), a nationally representative sample of office-based medical visits, to examine by physician specialty a) trends in the proportion of visits for womens health care and b) the content of nonillness care. Between 1985 and 1997-98, market share of reproductive health services increased for IMs (e.g., from 3.7% to 10.5% of contraceptive visits, p <.05) and decreased for FPs (from 30.5% to 20.5% for contraceptive visits, p <.05). Ob/Gyns increased their share of womens health care visits, with reproductive health visits increasing from 56.2% to 65.9% (p <.0001). The trend in hormone replacement therapy visits differed, with nonsignificant gains in market share for IMs and decreases for ob/gyns. Nonillness care (1997-98 data only) differed predictably by specialty, with IMs and FPs more often providing cholesterol screening while ob/gyns more often provided reproductive health services. Compared with IMs and FPs, ob/gyns were more likely to counsel women on reproductive health topics and equally likely to counsel on general health topics, but additional time spent in counseling was lower. Specialty differences in the provision of womens health services continue, though the scope of care provided by IMs has broadened. Still, women are unlikely to obtain a full range of preventive services in a single nonillness visit. Ensuring adequate coordination among physicians providing primary care to women continues to be a critical concern.

Trends in mental health and chronic condition visits by children presenting for care at U.S. emergency departments.

BACKGROUND AND OBJECTIVES Many factors have been shown to be associated with ESRD patient placement on the waiting list and receipt of kidney transplantation. Our study aim was to evaluate factors and assess the interplay of patient characteristics associated with progression to transplantation in a large cohort of referred patients from a single institution. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We examined 3029 consecutive adult patients referred for transplantation from 2003 to 2008. Uni- and multivariable logistic models were used to assess factors associated with progress to transplantation including receipt of evaluations, waiting list placement, and receipt of a transplant. RESULTS A total of 56%, 27%, and 17% of referred patients were evaluated, were placed on the waiting list, and received a transplant over the study period, respectively. Older age, lower median income, and noncommercial insurance were associated with decreased likelihood to ascend steps to receive a transplant. There was no difference in the proportion of evaluations between African Americans (57%) and Caucasians (56%). Age-adjusted differences in waiting list placement by race were attenuated with further adjustment for income and insurance. There was no difference in the likelihood of waiting list placement between African Americans and Caucasians with commercial insurance. CONCLUSIONS Race/ethnicity, age, insurance status, and income are predominant factors associated with patient progress to transplantation. Disparities by race/ethnicity may be largely explained by insurance status and income, potentially suggesting that variable insurance coverage exacerbates disparities in access to transplantation in the ESRD population, despite Medicare entitlement.

Ethnic and Regional Differences in Primary Care Visits for Attention-Deficit Hyperactivity Disorder

Research suggests that end‐stage renal disease patients with elevated body mass index (BMI) have superior outcomes on dialysis. In contrast, low and high BMI patients represent the highest risk cohorts for kidney transplant recipients. The important question remains concerning how to manage transplant candidates given the potentially incommensurate impact of BMI by treatment modality. We conducted a retrospective analysis of waitlisted and transplanted patients in the United States from 1990 to 2003. We constructed Cox models to evaluate the effect of BMI on mortality of waitlisted candidates and identified risk factors for rapid weight change. We then assessed the impact of weight change during waitlisting on transplant outcomes. Decline in BMI on the waiting list was not protective for posttransplant mortality or graft loss across BMI strata. Substantial weight loss pretransplantation was associated with rapid gain posttransplantation. The highest risk for death was among listed patients with low BMI (13–20 kg/m2, adjusted hazard ratio = 1.47, p < 0.01). Approximately one‐third of candidates had a change in BMI category prior to transplantation. While observed declines in BMI may be volitional or markers of disease processes, there is no evidence that candidates have improved transplant outcomes attributable to weight loss. Prospective trials are needed to evaluate the efficacy of weight loss protocols for candidates of kidney transplantation.

Physician office visits of adults for anxiety disorders in the United States, 1985–1998

Objectives: To assess the effect of the co‐occurrence of four common chronic medical conditions (hypertension, diabetes mellitus, arthritis, heart disease) on the probability of receiving adequate depression treatment.

Psychiatric diagnosis in children and adolescents with obesity-related health conditions.

Objective. The purpose of this study was to compare the burden of mental health disorders to the burden of other chronic care conditions as measured by emergency department (ED) visits by children with respect to prevalence rates, time trends, and hospital admission rates. Methods. Data from the 1995–2001 National Hospital Ambulatory Medical Care Survey were used to assess the number of visits to emergency departments by children with a diagnosis of a mental health or chronic condition, a mental health-related reason for the visit, or a prescription or continuation of psychotropic medication. Results. From 1995 to 2001, there was an increase in the proportion of visits by children with mental health problems. During the same period, the proportion of visits by children with chronic illness appeared stable. Overall, mental health diagnoses made up approximately 5% of all U.S. emergency department visits by children, similar to the percentage of total visits for other chronic conditions (5.2%). Approximately 15% of visits in both the mental health and chronic condition groups ended in hospital admission compared to less than 5% in the overall group of ED visits by children. Conclusions. The burden of mental health related visits to U.S. EDs is growing at a faster rate than visits related to chronic conditions. Visit intensity, hospital admission, and medication utilization is just as intense as that for chronic conditions. Promoting provider mental health training and restructuring the ED visit to allow for rapid mental health assessment and immediate onsite or contiguous mental health care may be one way to improve outcomes for families and to position the ED as part of a larger integrated system of effective mental illness care.