How psychology can improve effectiveness and reduce costs of health services.

Contends that psychology can be used to prevent heart disease, cancer, accidents and violence, and respiratory disease through programs such as those designed to eliminate smoking, control obesity, reduce stress, and intervene when multiple risk factors are present. Psychological techniques—as useful and cost-saving companions to traditional medical treatments—can increase checkup visits and participation in health screening, improve adherence to medication schedules, aid recovery from surgery, and facilitate outpatient medical service delivery. Since 40–60% of physician visits are for nonmedical reasons that are psychological and behavioral in nature, psychologists can reduce medical care overutilization and unnecessary medical expenditures by offering less costly and more appropriate alternatives. Psychological interventions for health disorders include treatment for pain, asthma attacks not responsive to medical treatment, heart rate variability, gastrointestinal problems, skin disorders, and self-destructive behaviors. It is concluded that psychological procedures offer a means of reducing health care expenditures reliably. (4 p ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Trends in medical care costs--evolving market forces

Slower growth in medical care costs has been the culmination of lower inflation and significant changes to the U.S. health care system, primarily the movement toward managed care. National health expenditures rose just 4.4 percent in 1996 - the smallest growth since the beginning of the national health expenditure data series. This is also true for the 35 percent gain recorded during 1992-96. The medical care Consumer Price Index (CPI) rose just 2.8 percent in 1997 and was only one-half of a percentage point above the overall CPI. The reduction in spending growth is most evident in hospital expenditures, which clearly reflects the expansion of HMO enrollment in both the private and public sectors. While the issue of quality of care is receiving more attention, this is unlikely to alter the basic direction of health care in the near-term. Cost is likely to remain a dominant factor in shaping the market forces that have significantly changed the delivery and financing of health care. Although trending upward, growth in medical spending is expected to remain relatively moderate as we move into the next century.     

Benefit of a favorable cardiovascular risk-factor profile in middle age with respect to Medicare costs

BACKGROUND: People without major risk factors for cardiovascular disease in middle age live longer than those with unfavorable risk-factor profiles. It is not known whether such low-risk status also results in lower expenditures for medical care at older ages. We used data from the Chicago Heart Association Detection Project in Industry to assess the relation of a low risk of cardiovascular disease in middle age to Medicare expenditures later in life. METHODS: We studied 7039 men and 6757 women who were 40 to 64 years of age when surveyed between 1967 and 1973 and who survived to have at least two years of Medicare coverage in 1984 through 1994. Men and women classified as being at low risk for cardiovascular disease were those who had the following characteristics at the time they were initially surveyed: serum cholesterol level, <200 mg per deciliter (5.2 mmol per liter); blood pressure, < or =120/80 mm Hg; no current smoking; an absence of electrocardiographic abnormalities; no history of diabetes; and no history of myocardial infarction. We compared Medicare costs for the 279 men (4.0 percent) and 298 women (4.4 percent) who had this low-risk profile with those for the rest of the study group, who were not at low risk. Health Care Financing Administration charges for services to Medicare beneficiaries were used to estimate average annual health care costs (total costs, those for cardiovascular diseases, and those for cancer). RESULTS: Average annual health care charges were much lower for persons at low risk - the total charges for the men at low risk were less than two thirds of the charges for the men not at low risk ($1,615 less); for the women at low risk, the charges were less than one half of those for the women not at low risk ($1,885 less). Charges related to cardiovascular disease were lower for the low-risk groups of men and women than for those not at low risk (by $979 and $556, respectively), and charges related to cancer were also lower (by $134 and $189). CONCLUSIONS: People with favorable cardiovascular risk profiles in middle age had lower average annual Medicare charges in older age. Having optimal status with respect to major cardiovascular risk factors may result not only in greater longevity but also in lower health care costs.     

EEG source localization: implementing the spatio-temporal decomposition approach

The results of longitudinal studies in geriatric medicine were reviewed by referring to relatively recent publications. "Longidufinal studies" comprised not only cohort studies but also prospective case-control studies in the broad sense. Poor self-rated health, weight loss hypoalbuminemia, inability to perform activities of daily living, low levels of physical activity, and cognitive dysfunction, all of which could be manifestations of chronic diseases, might shorten longevity. Cardiomegaly or left ventricular hypertrophy on ECG were again found to be important risk factors for cardiovascular disease in the aged, because of their relation to atherosclerosis. There is no evidence regarding the contribution of hyperlipidemia to the risk of cardiovascular disease in the aged, although insulin resistance can increase serum triglyceride levels and reduced level of high-density lipoprotein cholesterol even in the aged. Mortality due to stroke and heart disease have been decreasing in most developed countries, and several recent community-based studies have also shown decreases in the incidence of cerebral stroke. Large-scale case-control studies on the pharmacological treatment of hyperlipidemia have resulted in both primary and secondary prevention of coronary heart disease. However, information concerning the effects of treatment for hyperlipidemia on coronary heart disease in the aged is limited. Results of large-scale case-control studies indicate that pharmacological treatment of elderly hypertensive patients can reduce cardiovascular morbidity and mortality, and angiotensin-converting enzyme inhibitors have recently been shown ot be useful.     

Self-referral of patients for electron-beam computed tomography to screen for coronary artery disease

As the availability of electron-beam CT increases, it is appropriate to question the balance among medical science, patient care, and profits. Broadening patients' sense of empowerment and promoting their autonomy are worthy goals within medicine. Breast-cancer screening with mammography is an example of a radiographic test used successfully in a diagnostic program based on self-referral. But the lessons of such a program, in which the distinction between the disease and the disease-free state is more easily recognized than is the case for age-dependent calcific arterial changes, are not easily extrapolated to screening for coronary disease. Currently, we are facing the possibility that market forces may increase interest in electron-beam CT beyond what is justified by its potential medical benefit. Well-designed clinical trials are required to define fully the appropriate indications for and limitations of electron-beam CT. Such trials will eventually clarify the medical applications of the technique and determine its suitability as a screening procedure for cardiovascular disease. Until then, the use of electron-beam CT, like that of all tests in medicine, should be based on a clearly defined rationale and should be coupled with a medical evaluation by a physician.     

The care of HIV-infected adults in the United States. HIV Cost and Services Utilization Study Consortium

BACKGROUND AND METHODS: In order to elucidate the medical care of patients with human immunodeficiency virus (HIV) infection in the United States, we randomly sampled HIV-infected adults receiving medical care in the contiguous United States at a facility other than military, prison, or emergency department facility during the first two months of 1996. We interviewed 76 percent of 4042 patients selected from among the patients receiving care from 145 providers in 28 metropolitan areas and 51 providers in 25 rural areas. RESULTS: During the first two months of 1996, an estimated 231,400 HIV-infected adults (95 percent confidence interval, 162,800 to 300,000) received care. Fifty-nine percent had the acquired immunodeficiency syndrome according to the case definition of the Centers for Disease Control and Prevention, and 91 percent had CD4+ cell counts of less than 500 per cubic millimeter. Eleven percent were 50 years of age or older, 23 percent were women, 33 percent were black, and 49 percent were men who had had sex with men. Forty-six percent had incomes of less than $10,000 per year, 68 percent had public health insurance or no insurance, and 30 percent received care at teaching institutions. The estimated annual direct expenditures for the care of the patients seen during the first two months of 1996 were $5.1 billion; the expenditures for the estimated 335,000 HIV-infected adults seen at least as often as every six months were $6.7 billion, which is about $20,000 per patient per year. CONCLUSIONS: In this national survey we found that most HIV-infected adults who were receiving medical care had advanced disease. The patient population was disproportionately male, black, and poor. Many Americans with diagnosed or undiagnosed HIV infection are not receiving medical care at least as often as every six months. The total cost of medical care for HIV-infected Americans accounts for less than 1 percent of all direct personal health expenditures in the United States.     

Detection and treatment of psychiatric illness in a general medical ward: a modified cost-benefit analysis

This article describes a prospective, randomized, controlled trial of screening and treatment for psychiatric disorder in medical in-patients. The study has assessed whether increased recognition of psychiatric disorder among medical in-patients improves clinical outcome and reduces the costs of care, and whether routine involvement of a psychiatrist in the assessment and care of medical in-patients with probable psychiatric disorder is superior to the efforts of the physicians alone. A total of 218 medical in-patients who scored over the screening threshold for psychiatric disorder on the General Health Questionnaire were randomly allocated to one of two intervention groups or a control group. Six months later their mental health, subjective health status, quality of life, and costs of care was reassessed. Mental health and quality of life at 6 months were similar in the two intervention groups and the control group. Patients whose physicians were told the results of the screening test had lower costs for subsequent admissions, but this was probably due to differences between the groups in terms of employment status. Treatments recommended by psychiatrists broke down when patients were discharged home, leading to inadequate treatment of psychiatric disorders. We have not been able to show that routine screening for psychiatric disorder produces any benefit, either in better outcome for patients or reduced costs for the NHS. Further research should: consider examining a more homogeneous group in terms of costs of care; screen only for disorders likely to respond to a specific treatment; and ensure that treatment recommendations are carried out.     

Caring for the chronically ill: a vital subject for medical education

The growing prevalence of chronic illness will be the predominant challenge to the American health care system in the coming century. Patients with chronic conditions account for three fourths of U.S. health care expenditures, and considerable growth of these costs is likely as the population ages. Despite the enormity of this problem, the management of chronic illness has received little attention in undergraduate and graduate medical education. This paper describes the competencies required to develop curricula in the management of chronic illness.     

Liver transplantation and bile analysis: a parallel evolution

We hypothesized that women employees working in a hospital environment would be particularly attuned to aspects of personal health, well-being, and disease prevention. We performed an observational study at a local hospital, offering free assessments in its outpatient women's wellness screening program to women employees aged 39-60 years. Data from the first 60 women to enroll in the program are presented as a test of our hypothesis. Undiagnosed hypertension, abnormal lipid profiles, glucose intolerance, alcohol abuse, abnormal cervical cytology, breast masses, depression, or combinations of these were found in 49 of the 60 women. Twenty-one women were obese. Most women with abnormal findings did not follow specific personalized recommendations for remedial follow-up, including referral to a specialist. An important percentage of midlife women employees at this hospital exhibited unhealthful personal behaviors, had unrecognized disease, and did not use recommended health screening practices. The data emphasize the benefit for employees who participate in medical facility worksite health promotion programs.     

Psychologist–physician partnership in a medical specialty screening clinic.

Describes the development of a headache screening clinic in which psychologists participate with neurologists in the initial patient evaluation, using brief screening questionnaires and interviews. The majority of patients assessed in this clinic experienced clinically significant emotional distress, although only a minority of these patients felt a need for psychological intervention. By combining psychological screening with initial medical evaluation, emotionally disturbed individuals who present with physical complaints can be rapidly identified and their defensiveness about referral for psychological/psychiatric intervention can be minimized. Psychologists' psychometric screening instruments and their interviewing skills can contribute significantly to optimal utilization of health care services. Three case examples are given. (19 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment of hypertension in the presence of coexisting medical conditions

Treating hypertension reduces morbidity and mortality. Unfortunately, hypertension often exists in patients with other medical conditions. In these patients, the selection of an antihypertensive agent is often influenced by the presence of the coexisting condition. Conversely, the treatment of the coexisting medical condition may be influenced by the presence of hypertension. Given the vast array of antihypertensive medications available today, appropriate treatment of both hypertension and coexisting conditions can be achieved with careful selection of medications. This review discusses factors to consider when treating elderly patients with hypertension with the following coexisting conditions: dyslipidaemia, glucose intolerance, sexual dysfunction, cardiovascular disease, pulmonary disease, renal disease and neuropsychiatric disorders. Hypothyroidism, hyperthyroidism and various states of high cardiac output may cause hypertension. These conditions should be identified, since they are often treatable with subsequent resolution of the hypertension.     

Blood flow resistance during hemodilution: effect of plasma composition

To explore the extent of cross-border care seeking among Canadians, we analyzed the growth and distribution of Ontario Health Insurance Plan expenditures for medical care services provided in the United States to Ontario residents from 1987 to 1995. Although total out-of-province spending is low relative to in-province spending, there is evidence of cross-border care seeking for cardiovascular and orthopedic procedures, mental health services, and cancer treatments. However, combined with a preliminary investigation of cross-border patient care seeking using nonpublic funding sources, these analyses do not support the perception of widespread cross-border medical care seeking by Ontario residents.     

Quantification and rejection of ocular artifacts in auditory evoked fields in schizophrenics

PURPOSES: To determine what factors affect medical expenditure for the aged insured by the National Health Insurance among secondary medical care areas. METHOD: The original data of municipalities were combined and converted into the data of secondary medical areas. The original data included medical expenditure of the aged in 1994, medical supply factors per 100,000 population (numbers of doctors, numbers of general beds in hospitals, numbers of clinics, etc.) and socio-economic factors (income, proportion of employees for three sectors of industries, population density, average size of family, etc.). Medical expenditures for inpatients and outpatients were used separately as independent variables. The medical supply and socio-economic factors have been used as dependent variables. Multiple regression models were applied to clarify the differences in the contributing factors between inpatient and outpatient. RESULTS: 1. The maximum inpatient and outpatient medical expenditures for the aged are respectively 4 times and 2.6 times more expensive than minimum expenditures among secondary medical care areas. 2. The numbers of beds, income per capita, numbers of doctor, average size of family, proportion of employees for third level industry and income accounted for 57.4% of variance in inpatient medical expenditure of the aged. 3. The proportion of employees for first level industry, the numbers of beds and average members of family accounted for 21.4% of variance in outpatient medical expenditure of the aged. 4. Medical expenditure for inpatients related with medical supply and socioeconomic factors differently from that of outpatients.     

Severe mental illness and HIV-related medical and neuropsychiatric sequelae

Medical and neuropsychiatric sequelae of HIV infection present a spectrum of diagnostic and treatment challenges to mental health clinicians. Both HIV and the many opportunistic infections that manifest in patients due to their immunocompromised state also can affect the central nervous system (CNS). Thus, mental health clinicians need to be familiar with the diagnosis and management of HIV-related medical and psychiatric complications. This article provides an overview of the CNS-related manifestations resulting from HIV disease, including HIV-related dementia, psychotic disorders, delirium, CNS opportunistic infections and tumors, systemic abnormalities, psychoactive substances, and the adverse effects of certain medical treatments. Treatment strategies for individuals with HIV disease and comorbid severe mental illness are outlined and recommendations for future research are offered.     

Heparin-induced thrombocytopenia

Seen from a societal perspective, the health gains that might result from prostate screening are too uncertain to justify the substantial associated costs and adverse health effects. Clinicians who rely on observational screening studies to justify current screening practices should be aware of the potential biases that render conclusions suspect. Medical history documents numerous cases of medical interventions that appeared reasonable at the time, but ultimately proved worthless and even harmful. Before embarking on an ambitious screening program for prostate cancer, clinicians should demand that five basic criteria are satisfied: (1) that prostate cancer is a significant health burden, (2) that screening can identify localized disease, (3) that tests used in screening programs have acceptable performance among the population being tested, (4) that the potential for cure is greater among patients with screen-detected disease, and (5) that screen-detected patients have improved health outcomes compared with those who are not screened. Randomized trials provide the best methodology for determining the efficacy of screening and treatment. Clinicians are often too quick to credit medical intervention for successful outcomes and blame tumor biology for disease progression. Furthermore, when faced with a decision of administering or withholding therapy, physicians generally wish to err on the side of having done everything possible. Data modeling can provide critical insights concerning these issues using currently available information. Three recently published models suggest that the overall benefit to a population of men screened for prostate cancer can be measured in days of additional time of life gained, not months or years. Furthermore, models suggest that a substantial number of men need to undergo treatment in order to avert a single cancer death. The costs of implementing a screening program are enormous and deflect resources away from alternative uses, such as increased basic science funding to identify a cure for this disease. Therefore, based on the evidence presented, I believe that without more substantial data supporting the efficacy of screening programs, screening for prostate cancer is neither appropriate nor cost-effective.     

Impact of prior and current alcohol use on use of services by patients with depression and chronic medical illnesses

OBJECTIVE: Alcohol use often co-occurs with other major chronic conditions, but its effect on health care utilization in this context is not understood. This study examines the impact of alcohol consumption on health care use by patients with chronic medical conditions or depression, or both. DATA SOURCES/STUDY SETTING: Data came from the Medical Outcomes Study, an observational study of patients from the offices of general medical providers and mental health specialists in three U.S. cities. STUDY DESIGN: Longitudinal data spanning four years for outpatient general medical visits and outpatient mental health visits were analyzed using a two-part model to assess the impact of alcohol use disorder, problem drinking, and current and past alcohol consumption on health care use by patients, controlling for patient demographics and health status. DATA COLLECTION/EXTRACTION METHODS: Data were collected from 2,546 adult patients with hypertension, diabetes, heart disease (congestive heart failure or myocardial infarction), and/or current major depression or subthreshold depression using periodic, self-report surveys detailing health care utilization and health status information. PRINCIPAL FINDINGS: Current alcohol consumption increases outpatient doctor visits, and problems related to current drinking decrease outpatient mental health visits. CONCLUSIONS: Patterns of alcohol consumption have an impact on both mental health and overall health care use by patients with chronic medical conditions or depression.     

Resources in medical research

The biennial national statistical surveys of research and development expenditure, based on OECD guidelines, contribute to the knowledge base for Norwegian research policy. This article outlines the resources for research and development in the medical sciences, with emphasis on the higher education sector. This sector, which includes university hospitals, performs about 75% of medical research in Norway (medical research in industry not included) while the remaining 25% is performed in research institutes in the institute sector. In 1995, current expenditure for medical research amounted to 1,240 million Norwegian kroner, 930 million in the higher education sector and 310 million in the institute sector. From 1993 to 1995, there was a small increase in real terms in resources for medical research in universities and colleges paid for over institutional budgets, while there was no growth in externally funded research. Over the 25-year period 1970-1995, the growth in expenditures for medical research was higher than for the natural sciences, but lower than for the humanities and the social sciences. Comparisons between the Nordic countries show that investments in medical research in Norway is much lower than in Denmark or Sweden.