Tanya Wanchek

Cost‐analysis of percutaneous pulmonary valve implantation compared to surgical pulmonary valve replacement

To perform cost evaluation and economic modeling of percutaneous pulmonary valve implantation (PPVI) compared to surgical revision.

Decisions to Initiate Involuntary Commitment: The Role of Intensive Community Services and Other Factors

OBJECTIVE This study examined the predictors of actions to initiate involuntary commitment of individuals experiencing a mental health crisis. METHODS Emergency services clinicians throughout Virginia completed a questionnaire following each face-to-face evaluation of individuals experiencing a mental health crisis. Over a one-month period in 2007, a total of 2,624 adults were evaluated. Logistic hierarchical multiple regression was used to analyze the relationship between demographic, clinical, and service-related variables and outcomes of the emergency evaluations. RESULTS Several factors predicted 84% of the actions taken to initiate involuntary commitment. These included unavailability of alternatives to hospitalization, such as temporary housing or residential crisis stabilization; evaluation of the client in a hospital emergency room or police station or while in police custody; current enrollment in treatment; and clinical factors related to the commitment criteria, including risk of self-harm or harm to others, acuity and severity of the crisis, and current drug abuse or dependence. CONCLUSIONS A lack of intensive community-based treatment and support in lieu of hospitalization accounted for a significant portion of variance in actions to initiate involuntary commitment. Comprehensive community services and supports for individuals experiencing mental health crises may reduce the rate of involuntary hospitalization. There is a need to enrich intensive community mental health services and supports and to evaluate the impact of these enhancements on the frequency of involuntary mental health interventions.

Dental Hygiene Regulation and Access to Oral Healthcare: Assessing the Variation across the US States

Regulations in many US states prevent dental hygienists (DHs) from fulfilling their potential to improve oral healthcare. Wing et al. found that stringent practice regulations lower DH wages and reduce access to care. We add licensure regulations to the analysis and estimate the simultaneous effect of licensure and practice restrictions on the DH labour market and access to care. The results are consistent with licensure restrictions reducing employment, practice restrictions reducing wages, and wage and employment rates jointly influencing the prevalence of dental office visits. These results suggest that in order to significantly improve access to oral healthcare, states need to consider how their entry and practice regulations interact to influence outcomes.

The Effect of Community Mental Health Services on Hospitalization Rates in Virginia

OBJECTIVE This study examined the relationship between the availability of mental health outpatient services provided by 40 publicly funded community service boards (CSBs) and the use of inpatient mental health treatment among Medicaid recipients. METHODS Three-year data were obtained for Medicaid recipients aged 18-64 from the Medicaid claims database for the Commonwealth of Virginia. Medicaid recipients who had a mental disorder diagnosis and who had received at least one community mental health service were included in the sample. A multivariate regression model was used for the analyses. RESULTS Of the 11,107 individuals included, 27% had schizophrenia-related disorders and 32% had affective psychoses; 60% were white and 37% were black; and the average age was 40.1±13.1 years. In this sample, greater use of outpatient mental health services, but not greater variety of services available, was correlated with fewer inpatient hospital days for mental health treatment (-1.0±.2 days of hospitalization). CONCLUSIONS Virginias CSBs provide a range of outpatient mental health services that are designed to enable individuals to remain in their community. The availability of community-based mental health services was correlated with lower rates of inpatient hospitalization for mental illness. More research, however, is needed to establish causality and to determine which services are most effective at reducing the need for inpatient care.

A survey of stakeholder knowledge, experience, and opinions of advance directives for mental health in Virginia.

An innovative Virginia health care law enables competent adults with serious mental illness to plan for treatment during incapacitating crises using an integrated advance directive with no legal distinction between psychiatric or other causes of decisional incapacity. This article reports results of a survey of 460 individuals in five stakeholder groups during the initial period of the law’s implementation. All respondents held favorable views of advance directives for mental health care. Identified barriers to completing and using advance directives varied by group. We conclude that relevant stakeholders support implementation of advance directives for mental health, but level of baseline knowledge and perception of barriers vary. A multi-pronged approach will be needed to achieve successful implementation of advance directives for mental health.

Exports and legal institutions: exploring the connection in transition economies

Secure property rights, established through court enforcement of contracts, are widely acknowledged to be fundamental to economic exchange. Despite their essential function, weak legal and judicial institutions remain the norm across much of Eastern European and former Soviet Union. Barzel (2002) hypothesizes that the value of contract trade, as opposed to relationships and reputation, increases as products travel further and are more costly to inspect. Combining Barzels theory with the high cost of searching for foreign buyers (Rauch, 1999), this article presents evidence that international trade played a significant role in the emergence of institutions. Search costs influence the potential to export value-added, or complex, products. The level of potential complex exports in turn influences the intensity with which businesses lobby for more credible legal and juridical institutions. Both a micro-level model and empirical evidence provide evidence consistent with an endogenous link between exports and legal and judicial institutions.

When Would a Metal-Backed Component Become Cost-Effective Over an All-Polyethylene Tibia in Total Knee Arthroplasty?

The importance of cost control in total knee arthroplasty is increasing in the United States secondary to both changing economic realities of healthcare and the increasing prevalence of joint replacement. Surgeons play a critical role in cost containment and may soon be incentivized to make cost-effective decisions under proposed gainsharing programs. The purpose of this study is to examine the cost-effectiveness of all-polyethylene tibial (APT) components and determine what difference in revision rate would make modular metal-backed tibial (MBT) implants a more cost-effective intervention. Markov models were constructed using variable implant failure rates and previously published probabilities. Cost data were obtained from both our institution and published United States implant list prices, and modeled with a 3.0% discount rate. The decision tree was continued over a 20-year timeframe. Using our institutional cost data and model assumptions with a 1.0% annual failure rate for MBT components, an annual failure rate of 1.6% for APT components would be required to achieve equivalency in cost. Over a 20-year period, a failure rate of >27% for the APT component would be necessary to achieve equivalent cost compared with the proposed failure rate of 18% with MBT components. A sensitivity analysis was performed with different assumptions for MBT annual failure rates. Given our assumptions, the APT component is cost-saving if the excess cumulative revision rate increases by <9% in 20 years compared with that of the MBT implant. Surgeons, payers, and hospitals should consider this approach when evaluating implants. Consideration should also be given to the decreased utility associated with revision surgery.

Use of Longer Periods of Temporary Detention to Reduce Mental Health Civil Commitments

OBJECTIVE This study examined whether lengthening the holding period for an individual experiencing a mental health crisis under a temporary detention order (TDO) can reduce the number and length of post-TDO involuntary hospital commitments. METHODS Data from the Virginia Court System were matched to the Commonwealth of Virginia Medicaid claims database for July 1, 2008, through March 30, 2009. The final data set included 500 Medicaid recipients who had a mental health diagnosis and at least one TDO during the study period. Covariates included sex, race, age, primary diagnosis, and Community Service Board serving the individual. Logistic and multivariate regression models were used. RESULTS Longer TDO periods were correlated with an increased probability of a dismissal of the commitment petition rather than hospitalization after a TDO. Among individuals who were hospitalized, longer TDO periods were correlated with an increased likelihood of voluntary hospitalization, rather than involuntary commitment, and shorter hospitalizations, although the net care time (TDO period plus post-TDO hospitalization) increased for individuals whose TDO length was greater than 24 hours. CONCLUSIONS Longer TDO periods were correlated with shorter hospital stays and fewer involuntary commitments. These findings support previous work showing that short TDO periods provide insufficient time to stabilize and evaluate individuals. More research is needed to establish a causal link between TDO length and health outcomes.

The Demand for Public Adjudication and Private Arbitration

There are a number of seemingly unrelated puzzles in the institutional and administrative structure of our legal system, such as why do courts not charge parties the full cost of adjudication, why courts adopt a system of stare decisis in the nineteenth century, and why the government refuse to expand the number of property forms for certain assets, such as real property. This article looks comprehensively at how these features of our modern legal system work together to achieve the governments goal of maximizing the positive externalities of litigation, while relegating lower valued disputes to other means of dispute settlement.