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Background: Patients who left against medical advice (AMA) may be at higher risk for a hospital readmission if the unauthorized discharge was premature. The objective of this study is to examine the relationship between discharges AMA from nonfederal acute care hospitals and cardiovascular disease (CVD) hospital readmissions while addressing bias due to potential confounding, selection, and hospital-level clustering., Methods: This cross-sectional study used hospital discharge data covering the period between 2000 and 2005. The outcome variables captured readmissions for a CVD-related condition following an index CVD-related discharge. The covariate of interest was an indicator for a discharge AMA in the index hospitalization. The relationship between discharges AMA and 7-day, 31-day, and 180-day readmissions was examined using multivariate models with adjustment for clustering and selection bias., Results: The sample included 348,572 patients, of which 7001 (2%), 19,779 (6%), and 48,855 (14%) were readmitted within 7, 31, and 180 days, respectively. The percentage of patients who were readmitted (7 days; 31 days; 180 days) was higher among the AMA group versus the non-AMA group (2.2% vs. 1%, P < 0.002; 1.3% vs. 1%, P < 0.001; 1.2% vs. 1%, P = 0.02). The adjusted odds of a CVD-related readmission to the same hospital within 7 days, 31 days, and 180 days were 154% (P < 0.001), 51% (P < 0.001), and 19% (P = 0.004) higher, respectively, for patients who left AMA. Results were robust in examining readmissions to any hospital as well as corrections for observable selection bias through propensity score analysis., Conclusions: A discharge AMA among patients with a discharge diagnosis for CVD during the index hospitalization was predictive of CVD-related readmissions. The strength of the association between a discharge AMA and readmission was greatest within the first week after discharge.

Patients, clinicians, payers, and policymakers face an environment of significant evidentiary uncertainty as they attempt to achieve maximum value, or the greatest level of benefit possible at a given level of cost in their respective health care decisions. This is particularly true in the area of oncology, for which published evidence from clinical trials is often incongruent with real-world patient care, and a substantial portion of clinical use is for off-label indications that have not been systematically evaluated. It is this uncertainty in the knowledge of the clinical harms and benefits associated with oncology treatments that prevents postregulatory decision makers from making accurate assessments of the value of these treatments. Because of the incentives inherent in the clinical research enterprise, randomized control trials (RCTs) are designed for the specific purpose of regulatory approval and maximizing market penetration. The pursuit of these goals results in RCT study designs that achieve maximal internal validity at the expense of generalizability to diverse real-world patient populations that may have significant comorbidities and other clinically mitigating factors. As such, systematic reviews for the purposes of coverage and treatment decisions often find relevant and high-quality evidence to be limited or nonexistent. For a number of reasons, including frequent off-label use of medications and the expedited approval process for cancer drugs by the U.S. Food and Drug Administration, this situation is exacerbated in the area of oncology. This paper investigates the convergence of incentives and circumstances that lead to widespread uncertainty in oncology and proposes new paradigms for clinical research, including pragmatic clinical trials, methodological guidance, and coverage with evidence development. Each of these initiatives would support the design of clinical research that is more informative for postregulatory decision makers, and would therefore reduce uncertainty and provide greater confidence in conclusions about the value of these treatments.

Context: Given the shortage of kidneys available for transplantation, a community-based intervention trial was implemented to assess the impact of an educational program on patients' access to live donor kidney transplantation (LDKT)., Objective: To compare the short-term impact of a basic intervention and an enhanced intervention on patients' readiness to pursue LDKT. DEGISN: Baseline data and data from 1 week after interventions were analyzed., Participants: 214 transplant-eligible hemodialysis patients attending 14 dialysis facilities in Maryland, Virginia, and Pennsylvania., Interventions: In the basic intervention, 107 patients watched a 10-minute videotape on the experience of recipients and live donors of a kidney. In the enhanced intervention, 107 patients watched the same videotape and had a discussion with a health educator on the risks and benefits of LDKT, who could be a donor, and how to address the barriers they were encountering when seeking a live kidney donor., Main Outcome Measure: Patient reported whether they were considering LDKT, had talked with family or friends about LDKT, and had asked someone for a kidney., Results: Over half of transplant-eligible patients were not pursuing LDKT at baseline (64% in the basic intervention group, 61% in the enhanced intervention group). One week after the intervention, the odds of considering LDKT were higher among African Americans (odds ratio [OR], 2.28; confidence interval [CI], 1.22-4.25), younger patients (OR, 0.94; CI, 0.91-0.97), and patients who spent less time on dialysis (OR, 0.90; CI, 0.83-0.97). The odds of asking for a kidney were higher among African Americans (OR, 4.94; CI, 2.54-9.60) and patients who perceived they were in poor to fair health (OR, 3.30; CI, 1.12-9.67)., Conclusions: Although both interventions helped patients consider LDKT and ask for a kidney, more time and expanded educational content might be needed to facilitate patients' discussion about LDKT with their loved ones.

Objective: The objective of this retrospective study was to assess the evidence for racial differences in discharge disposition among patients hospitalized for stroke., Data: Hospital discharge data from the Maryland Health Services Cost Review Commission were used in the analysis. The data covered the period from January 2000 to September 2003., Study Design: Discharge-disposition categories were ordered such that higher numbers corresponded to less desirable outcomes: 1 = discharge to home; 2 = discharge to any medical care facility; 3 = death. We analyzed the influence of black race on the discharge disposition by estimating a partial proportional odds logit regression model that included demographic and clinical covariates., Data Extraction: The study inclusion criteria were 1) stroke (ICD9 431-434; 436-438) as a primary admission diagnosis and 2) patient race identified as black or white. Patients discharged against medical advice were excluded. The sample contained 51,564 stroke hospitalizations., Principal Findings: Based on the relative odds ratios (OR; 95% confidence interval [CI]), black males were more likely to be discharged to higher ranked (i.e., less desirable) discharge categories (OR = 1.66; CI 1.55-1.77) compared to white males. Black females were more likely to die (OR = 1.14; CI 1.02-1.28) and more likely either to die or to be discharged to medical care (OR = 1.38; CI 1.24-1.54) compared to white males., Conclusions: Blacks are at greater mortality risk following stroke hospitalizations and face less desirable discharge dispositions if they survive. These results are consistent with prior reports of lower survival rates among blacks and are robust to adjustments for various confounding factors.

Objective: To assess the effect of persistence of use of warfarin sodium, aspirin, or clopidogrel bisulfate on stroke recurrence in a Medicaid high-risk, largely female, African American population., Study Design: Prospective non-concurrent cohort, longitudinal data analysis of medical and pharmacy claims of stroke patients from Medicaid managed care organizations between January 1, 2001, and December 31, 2003., Methods: Cox proportional hazards models were used to predict the likelihood of avoiding a recurrence as a function of persistence of use of the initial medication (warfarin, aspirin, or clopidogrel) after stroke, adjusting for age, race, sex, hypertension and other comorbidities, and the pharmacotherapies prescribed. We used propensity scores to adjust for confounding by indication., Results: Among 925 stroke patients (64.6% female, 75.1% > or =50 years, and 57.8% African American), hypertension and heart disease were the most prevalent comorbidities (66.1% and 65.1%, respectively); most initial strokes were nonhemorrhagic. Persistence of use of warfarin, aspirin, or clopidogrel after stroke increased the likelihood of avoiding a recurrence (hazard ratio [HR], 1.57; 95% confidence interval [CI], 1.22-2.01). Having a hemorrhagic stroke initially (HR, 0.37; 95% CI, 0.18-0.74) or having heart disease (HR, 0.82; 95% CI, 0.67-1.01), hypertension (HR, 0.63; 95% CI, 0.51-0.79), or diabetes mellitus (HR, 0.74; 95% CI, 0.60-0.91) after an initial stroke significantly decreased the likelihood of avoiding a recurrence. Patient's age, race, sex, and urban residence did not significantly predict the likelihood of avoiding a recurrence., Conclusions: Persistence of use of the initial stroke preventive medication after stroke is effective in avoiding a recurrence. Hemorrhagic stroke, heart disease, hypertension, and diabetes increase the likelihood of a recurrence.

This study explored the association between headache response and return to functioning, and identified migraine-associated symptoms related to functional status and acceptability of migraine treatment as reported by patients. Data from migraineurs enrolled in the active arms of a randomized, double-blind, parallel group, placebo-controlled, clinical trial were analysed. The relationships between headache response and functional response, and clinical factors and treatment acceptability were assessed using chi(2) tests of proportions and logistic regressions. A greater proportion of patients with headache response at 0.5 h were functioning at 0.5, 1 and 2 h compared with patients who did not attain a headache response at 0.5 h (P < 0.0001). These patients also were more likely to find their treatment acceptable (P < 0.05). The results suggest a direct temporal relationship among the key determinants of migraine resolution. Rapid headache response is associated with faster return to functioning; rapid headache and functional responses are significant attributes of treatment acceptability.

Background: Cancer is the second leading cause of death in the United States and a major contributor to healthcare expenditure. There are few studies examining disparities in treatment costs. Studies that do exist are dominated by the cost of hospital care., Methods: Utilizing Maryland Medicaid administrative claims data, a retrospective cohort, design was employed to examine disparities in ambulatory treatment costs of breast, colorectal and prostate cancer treatment by region, race and gender. We report mean and median results by each demographic category and test for the statistical significance of each. Lorenz curves are plotted and Gini coefficients calculated for each type of cancer., Results: We do not find a consistent trend in ambulatory costs across the three cancers by traditional demographic variables. Lorenz curves indicate highly unequal distributions of costs. Gini coefficients are 0.687 for breast cancer, 0.757 for colorectal cancer and 0.774 for prostate cancer., Conclusion: Significant variation in nonhospital-based expenditures exists for breast, colorectal and prostate cancers in a population of homogeneous socioeconomic status and uniform insurance entitlement. Observed individual-level disparities are not consistent across cancers by region, race or gender, but the majority of this low-income population receives very little ambulatory care.

This study evaluated the economic impact of a policy change in adult Maryland Medicaid dental benefits that eliminated reimbursements to dentists. We examined all claims for 2 years before and after the change. Reimbursements to dentists fell to zero from their preenactment period annual rate of US 7.6 million dollars; other care settings simultaneously generated an additional US 232,470 dollars savings during the postenactment period. Medicaid's goal to reduce costs was achieved; however, disadvantaged patients may have been confused by the policy change and likely suffered poorer health outcomes and paid for treatment out of pocket, found free clinics, or received free care from generous dentists.

Out-of-pocket drug spending per patient rose 25 percent in 2001 for the privately insured nonelderly in Maryland, outpacing the 10 percent increase in total drug spending per patient. Prescription drug use patterns changed little in response to a 30 percent rise in copayments, with the number of prescriptions per patient decreasing by 3 percent, and the proportion of generic drugs remaining steady. About 23 percent of patients spent less than 50 dollars on drugs in 2001, while 21 percent spent more than 700 dollars. Findings suggest that a greater proportion of the economic burden of prescription drugs in coming years will be borne by those who use them.

Background: Given previous reports of variations in prevalence of cancer in low-income individuals, we sought to determine if disparities in cancer prevalence existed in a similarly-insured Medicaid population., Methods: Using Maryland Medicaid administrative claims data, prevalence rates of lung, colorectal, breast, and prostate cancers were calculated for Maryland Medicaid recipients who were continuously eligible during the period from January 1, 2000 to December 31, 2000. Chi-squared tests were used to test the differences across subgroups. Cancer prevalence data were age-adjusted using Maryland Medicaid enrollees as the standard population., Results: The care prevalence rates for lung, colorectal, breast, and prostate cancers were 75/10,000, 63/10,000, 92/10,000, and 45/10,000, respectively. These rates were 1.2 to 5.2 times those reported at the national level. Generally, higher cancer prevalence rates in certain racial groups in Maryland Medicaid were consistent with previous studies. Regional differences in cancer prevalence existed for each cancer studied., Conclusions: Limiting our study sample to a population of uniformly low socioeconomic individuals did not eliminate the disparity in prevalence rates between blacks and whites. Different patterns of racial disparity across regions reported by previous researchers might be due to small area variation in addition to socioeconomic status.

Background: Hypertension is one of the most frequently diagnosed chronic medical conditions in the United States and imposes a substantial financial and social burden on Americans., Objective: The aim of this study was to compare the cost of health care resources for hypertensive patients taking analgesics stratified by having controlled versus uncontrolled hypertension., Methods: This was a retrospective, database analysis of data for managed-care patients in Maryland and Washington, DC, recorded from February 1, 1999, to July 31, 2001. Hypertensive patients who were taking analgesics were stratified by their hypertension control status using a claims-based algorithm. Annualized costs and differences in annualized costs calculated for the periods before and after the initiation of analgesics were compared by patient hypertension control status., Results: Of the 9805 patients in the study (mean [SD] age, 49.8 [12.04] years), 2523 (25.73%) were categorized as having uncontrolled hypertension. The mean total annualized costs differed significantly between the controlled and uncontrolled hypertension groups by 2568 dollars (P < 0.001). The annualized costs for emergency-department visits and hospitalizations for uncontrolled hypertensive patients exceeded those for controlled hypertensive patients by 9.3% and 28.0%, respectively. The differences between the postindex- and preindex-period costs for health care resources were 1972 dollars with controlled hypertension and 2961 dollars with uncontrolled hypertension (P < 0.001). The results of linear regression, after adjustments were made for preindex costs and other covariates, indicated that patients with uncontrolled hypertension had significantly increased billed annualized costs (P < 0.001)., Conclusions: These data suggest that the costs of health care resources were significantly higher for analgesic users with uncontrolled hypertension than for analgesic users with controlled hypertension. A considerable proportion of the cost differential was directly attributable to hypertension-related treatment care.

Background: Projecting future breast cancer treatment expenditure is critical for budgeting purposes, medical decision making and the allocation of resources in order to maximise the overall impact on health-related outcomes of care. Currently, both longitudinal and cross-sectional methodologies are used to project the economic burden of cancer. This pilot study examined the differences in estimates that were obtained using these two methods, focusing on Maryland, US Medicaid reimbursement data for chemotherapy and prescription drugs for the years 1999-2000., Methods: Two different methodologies for projecting life cycles of cancer expenditure were considered. The first examined expenditure according to chronological time (calendar quarter) for all cancer patients in the database in a given quarter. The second examined only the most recent quarter and constructed a hypothetical expenditure life cycle by taking into consideration the number of quarters since the respective patient had her first claim., Results: We found different average expenditures using the same data and over the same time period. The longitudinal measurement had less extreme peaks and troughs, and yielded average expenditure in the final period that was 60% higher than that produced using the cross-sectional analysis; however, the longitudinal analysis had intermediate periods with significantly lower estimated expenditure than the cross-sectional data., Conclusions: These disparate results signify that each of the methods has merit. The longitudinal method tracks changes over time while the cross-sectional approach reflects more recent data, e.g. current practice patterns. Thus, this study reiterates the importance of considering the methodology when projecting future cancer expenditure.

Background: The growing shortage of organs available for transplantation has resulted in an increased use of living donors for kidney transplantation. The laparoscopic nephrectomy is a new procedure used to remove kidneys from donors. The study objective was to explore the attitudes of recipients and donors toward living donor kidney transplantation and the impact of the laparoscopic donor nephrectomy on donors' and recipients' acceptance of living donor kidney transplantation., Methods: Tailored self-administered questionnaires were mailed to kidney donors, potential donors, recipients and potential recipients who visited the University of Maryland School of Medicine Division of Transplantation between January 1998 and May 2001., Results: The laparoscopic donor nephrectomy helped recipients and potential recipients with their decision to accept a kidney from a living donor (recipients: 53% strongly agreed, 36% agreed; potential recipients: 42% strongly agreed, 46% agreed). To a lesser extent, the laparoscopic donor nephrectomy assisted donors and potential donors with their decision to donate (donors: 19% strongly agreed, 20% agreed; potential donors: 20% strongly agreed, 20% agreed). Potential recipients and recipients identified 2 barriers to accepting living donor kidney transplantation: they were unwilling to accept a kidney if it meant this would financially burden their donors, and they worried that their donors might succumb to a future kidney problem., Conclusion: Overall, the study found a positive attitude toward living donor kidney transplantation and laparoscopic donor nephrectomy. This new surgical procedure seemed to positively influence recipients and potential recipients to accept a kidney. In contrast, it had less impact on donors' and potential donors' willingness to give their kidney.

Background: Combined mortality rates for pneumonia and influenza suggest that the 2 conditions represent the sixth leading cause of death in the United States. The total cost of pneumonia, including indirect costs, was estimated to be approximately $23 billion per year in 1994., Objective: The objective of this study was to assess variables that may be significantly associated with the cost of treating patients hospitalized with community-acquired pneumonia (CAP). We also assessed the impact of treatment guidelines for management of CAP (developed by managed care plans) on total costs., Methods: Patients in 3 managed care plans who were hospitalized with a primary or secondary diagnosis of CAP in Maryland and Washington, DC, between January 1, 1997, and April 30, 1997, or between January 1, 1998, and April 30, 1998, were identified based on International Classification of Diseases, Ninth Revision codes. Clinical data were abstracted from patients' medical charts by nurses, and billing data were acquired from these plans. A retrospective data analysis was carried out using billing data from 3 managed care plans and clinical data from hospitals associated with the plans. A multivariate regression model was developed using the natural logarithm of cost as the dependent variable. Independent variables that were studied included severity of illness, days in the intensive care unit (ICU), triage per guidelines, drug therapy per guidelines, mortality, and managed care plan identifiers., Results: The charts of 569 patients were assessed. The mean age of the study sample was 75.3 years. ICU days (P < 0.001), mortality, and drug therapy (both P < 0.01) per guidelines significantly affected costs. As expected, an increase in the number of ICU days led to an increase in costs. However, patients who received drug therapy recommended by the guidelines had significantly lower costs than patients not treated according to the guidelines (P = 0.001)., Conclusions: The findings of this study suggest that guidelines for CAP management, such as those developed by managed care plans, may help reduce costs by minimizing unnecessary ICU admissions and appropriately managing patients with CAP.

Background: Pain from toothaches represents a significant problem. People lacking access to private dental services may use hospital emergency departments, or EDs. In 1993, Maryland eliminated Medicaid reimbursement to dentists for adult emergency services., Methods: The authors used the change in Medicaid policy that eliminated dentist reimbursement to establish two study periods. Data tapes describing patients' use of EDs were obtained from the Maryland Medicaid Management Information System. A total of 3,639 people visited EDs for dental problems sometime during the four-year study period., Results: After controlling for age, race and sex, the authors found that the rate of ED claims was 12 percent higher in the postchange period than in the prechange period. Comparisons between periods show significant rate increases during the postchange period for men, whites, African-Americans and patients aged 21 through 44 years and 45 through 64 years., Conclusions: The change in Medicaid policy that eliminated dentist reimbursement and participation in the program appears to have increased the use of EDs for the treatment of dental problems. Practice Implications. Many EDs lack dental services and are not capable of providing definitive treatment. When definitive treatment is not provided, this pattern of care may be repeated if patients are forced to return for treatment.

Objective: The aim of this study was to evaluate the association of age, race, and comorbid illness with procedures and complications in hospitalized patients with invasive carcinoma of the cervix in a statewide population-based database over a 3-year period., Methods: Hospitalizations were classified into homogeneous subgroups based on a diagnosis of invasive cervical cancer. Cancer-related complications and comorbid diseases were evaluated. chi(2) and t tests determined differences in means or proportions. Linear regression techniques were applied to build models for hospitalization charges and lengths of stay (LOS)., Results: There were 1009 admissions. The mean age was 49.5, with a median age of 46 (21-100, SD 15.4). Of the total, 606/1009 (60%) were white, 354/1009 (35%) were African-American (AA), and 5% were "other" races. AAs were more likely to have Medicaid or be uninsured (44% vs 23%, P = 0. 001) and were more likely to be admitted for an emergency (unadjusted odds ratio (OR) = 1.6; 1.2-2.2), to have a comorbid illness (P = 0.001), to be admitted for a cancer-related complication (P = 0.036), to be admitted for a transfusion (P = 0. 01), and to be admitted for radiation therapy rather than surgery (P = 0.001). The following were associated with LOS and higher hospital costs: emergency admissions for complications of cancer, comorbid illness, and older age., Conclusions: Racial differences exist in patterns of admission, type of therapy, and severity of illness; however, there were no differences in charges or LOS for similar procedures. The large percentage of African-Americans uninsured or insured by government-supported programs indicates the potential impact of public policy on the care of these patients. Socioeconomic status rather than phenotypic appearance may be a more important determinant of outcome., (Copyright 2000 Academic Press.)