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  • 1
    Language: English
    In: Population health management, December 2010, Vol.13(6), pp.325-30
    Description: Capacity constraints and efficiency considerations require that disease management programs identify patients most likely to benefit from intervention. Predictive modeling with available administrative data has been used as a strategy to match patients with appropriate interventions. Administrative data, however, can be plagued by problems of incompleteness and delays in processing. In this article, we examine the effects of these problems on the effectiveness of using administrative data to identify suitable candidates for disease management, and we evaluate various proposed solutions. We build prospective models using regression analysis and evaluate the resulting stratification algorithms using R² statistics, areas under receiver operator characteristic curves, and cost concentration ratios. We find delays in receipt of data reduce the effectiveness of the stratification algorithm, but the degree of compromise depends on what proportion of the population is targeted for intervention. Surprisingly, we find that supplementing partial data with a longer panel of more outdated data produces algorithms that are inferior to algorithms based on a shorter window of more recent data. Demographic data add little to algorithms that include prior claims data, and are an inadequate substitute when claims data are unavailable. Supplementing demographic data with additional information on self-reported health status improves the stratification performance only slightly and only when disease management is targeted to the highest risk patients. We conclude that the extra costs associated with surveying patients for health status information or retrieving older claims data cannot be justified given the lack of evidence that either improves the effectiveness of the stratification algorithm.
    Keywords: Health Promotion ; Models, Statistical ; Information Management -- Organization & Administration
    ISSN: 19427891
    E-ISSN: 1942-7905
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  • 2
    Language: English
    In: Patient Education and Counseling, October 2012, Vol.89(1), pp.184-190
    Description: To evaluate (PC), a program that employed lay health workers to motivate antiretroviral adherence among persons living with HIV with coverage from Indiana's high-risk insurance pool. Four hundred and forty nine participants living in the greater Indianapolis area were randomly allocated to treatment ( = 91) or control ( = 358) groups and followed for one year. Compared to control subjects, PC subjects were more likely to adhere to HIV medications (medication possession ratio adherence ≥0.95, OR = 1.83, = 0.046), and to achieve undetectable viral load (〈50 copies/mL, OR = 2.01, = 0.011) in the 12 months following introduction of PC. There were no significant differences observed between groups in any of self-reported health status indicators. Estimates suggest that PC clients were 16% more likely to have undetectable viral loads than clients in standard care. The incremental program cost was approximately $10,000 for each additional person who achieved an undetectable viral load. As persons living with HIV experience greater longevity and healthcare reform expands coverage to these high-risk populations, greater demands will be placed on the HIV-care workforce. Results suggest lay health workers may serve as effective adjuncts to professional care providers.
    Keywords: Lay Health Workers ; Medication Adherence ; HIV ; Medicine ; Public Health
    ISSN: 0738-3991
    E-ISSN: 1873-5134
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  • 3
    Language: English
    In: The Journal of infectious diseases, 01 June 2009, Vol.199(11), pp.1671-9
    Description: Haemophilus ducreyi causes chancroid, which facilitates transmission of human immunodeficiency virus type 1. To better understand the biology of H. ducreyi, we developed a human inoculation model. In the present article, we describe clinical outcomes for 267 volunteers who were infected with H. ducreyi. There was a relationship between papule formation and estimated delivered dose. The outcome (either pustule formation or resolution) of infected sites for a given subject was not independent; the most important determinants of pustule formation were sex and host effects. When 41 subjects were infected a second time, their outcomes segregated toward their initial outcome, confirming the host effect. Subjects with pustules developed local symptoms that required withdrawal from the study after a mean of 8.6 days. There were 191 volunteers who had tissue biopsy performed, 173 of whom were available for follow-up analysis; 28 (16.2%) of these developed hypertrophic scars, but the model was otherwise safe. Mutant-parent trials confirmed key features in H. ducreyi pathogenesis, and the model has provided an opportunity to study differential human susceptibility to a bacterial infection.
    Keywords: Chancroid -- Microbiology ; Haemophilus Ducreyi -- Pathogenicity
    ISSN: 0022-1899
    E-ISSN: 15376613
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  • 4
    Language: English
    In: Annals of the Rheumatic Diseases, 22 March 2007, Vol.66(3), p.394
    Description: To evaluate the risk factors for early radiographic changes of knee osteoarthritis.
    Keywords: BMI, Body Mass Index ; Gee, Generalised Estimating Equations ; Jsn, Joint Space Narrowing ; Jsw, Joint Space Width ; K&L, Kellgren and Lawrence ; Rct, Randomised Controlled Trial ; Womac, Western Ontario and Mcmaster Universities ; Radiology ; Degenerative Joint Disease ; Musculoskeletal Syndromes ; Osteoarthritis ; Clinical Diagnostic Tests ; Radiology (Diagnostics)
    ISSN: 0003-4967
    ISSN: 00034967
    E-ISSN: 1468-2060
    E-ISSN: 14682060
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  • 5
    In: Annals of Internal Medicine, July 15, 1997, Vol.127(2), p.97(8)
    Description: Background: The quadriceps weakness commonly associated with osteoarthritis of the knee is widely believed to result from disuse atrophy secondary to pain in the involved joint. However, quadriceps weakness may be an etiologic factor in the development of osteoarthritis. Objective: To explore the relation between lower-extremity weakness and osteoarthritis of the knee. Design: Cross-sectional prevalence study. Setting: Population-based, with recruitment by random-digit dialing. Participants: 462 volunteers 65 years of age or older. Measurements: Radiographs of the knee were graded for the presence of osteoarthritis. Knee pain and function were assessed with the Western Ontario and McMaster Universities Arthritis Index, the strength of leg flexors and extensors was assessed with isokinetic dynamometry, and lower-extremity lean tissue mass was assessed with dual-energy x-ray absorptiometry. Results: Among participants with osteoarthritis, quadriceps weakness, but not hamstring weakness, was common. The ratio of extensor strength to body weight was approximately 20% lower in those with than in those without radiographic osteoarthritis. Notably, among women with tibiofemoral osteoarthritis, extensor weakness was present in the absence of knee pain and was seen in participants with normal lower-extremity lean mass (extensor strength, 30.1 lb-ft for those with ostecarthritis and 34.8 lb-ft for those without osteoarthritis; P [is less than] 0.001).After adjustment for body weight, age, and sex, lesser quadriceps strength remained predictive of both radiographic and symptomatic osteoarthritis of the knee (odds ratio for prevalence of osteoarthritis per 10 lb-ft loss of strength, 0.8 [95% Cl, 0.71 to 0.90] for radiographic osteoarthritis and 0.71 [Cl, 0.51 to 0.87] for symptomatic osteoarthritis). Conclusion: Quadriceps weakness may be present in patients who have osteoarthritis but do not have knee pain or muscle atrophy; this suggests that the weakness may be due to muscle dysfunction. The data are consistent with the possibility that quadriceps weakness is a primary risk factor for knee pain, disability, and progression of joint damage in persons with osteoarthritis of the knee.
    Keywords: Osteoarthritis -- Development And Progression ; Knee -- Abnormalities ; Muscle Strength -- Measurement ; Thigh Muscles
    ISSN: 0003-4819
    E-ISSN: 15393704
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  • 6
    In: Medical Care, 2009, Vol.47(2), pp.154-160
    Description: BACKGROUND:: Disease management programs have grown in popularity over the past decade as a strategy to curb escalating healthcare costs for persons with chronic diseases. OBJECTIVES:: To evaluate the effect of the Indiana Chronic Disease Management Program (ICDMP) on the longitudinal changes in Medicaid claims statewide. RESEARCH DESIGN:: Phased implementation of a chronic disease management program in 3 regions of the state. Fourteen repeated cohorts of Medicaid members were drawn over a period of 3.5 years and the trends in claims were evaluated using a repeated measures model. SUBJECTS:: A total of 44,218 Medicaid members with diabetes and/or congestive heart failure in 3 geographic regions in Indiana. RESULTS:: Across all 3 regions and both disease classes, we found a flattening of cost trends between the pre- and post-ICDMP-initiation periods. This change in the slopes was significant for all of the models except for congestive heart failure in southern Indiana. Thus, the average per member claims paid was increasing at a faster rate before ICDMP but slowed once the program was initiated. To distinguish shorter and longer-term effects related to ICDMP, we estimated annual slopes within the pre- and post-ICDMP- time periods. A similar pattern was found in all regions: claims were increasing before ICDMP, flattened in the years around program initiation, and remained flat in the final year of follow-up. CONCLUSIONS:: This analysis shows that the trend in average total claims changed significantly after the implementation of ICDMP, with a decline in the rate of increase in claims paid observed for targeted Medicaid program populations across the state of Indiana.
    Keywords: Medicine ; Public Health;
    ISSN: 0025-7079
    E-ISSN: 15371948
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  • 7
    In: Archives of Internal Medicine, August 8, 1994, Vol.154(15), p.1721(9)
    Description: 〈p〉BACKGROUND: Acute hospitalizations represent substantial financial liability to closed health care systems. Among hospitalized patients, those with repeated admissions are high-cost users. Most managed care plans employ case management to control hospital use. This technique attempts to detect and fulfill unmet medical and social needs, intensify postdischarge care, identify and mobilize effective community services, and enhance primary care access. Despite the popularity of case management to control hospital use, few trials have examined its efficacy. METHODS: We conducted a randomized controlled trial of an intervention of case managers at a university-affiliated Veterans Affairs medical center. Six hundred sixty-eight patients aged 45 years or older who were discharged from the general medicine inpatient service, who had access to a telephone, and who received primary care at the hospital's clinics were randomized to the intervention (N=333) and control (N=335) groups. Within 24 hours of discharge, case managers mailed educational materials and access information to intervention patients, and within 5 days they called to review and resolve unmet needs, early warning signs, barriers to keeping appointments, and any readmissions. Case managers contacted intervention patients if they made no visits for 30 days. This resulted in a total of 6260 patient—case manager contacts. Control and intervention patients were followed up for 12 months. RESULTS: Intervention patients had more frequent visits per patient per month to the general medicine clinic (0.30±0.23 vs 0.26±0.22, P=.008), but we detected no significant differences between groups in nonelective readmissions, readmission days, or total readmissions. CONCLUSIONS: Frequent contacts for education, care, and accessibility by case managers using protocols were ineffective in reducing nonelective readmissions.(Arch Intern Med. 1994;154:1721-1729)〈/p〉
    Keywords: Medical Case Management -- Models ; Hospital Admission And Discharge ; Veterans Hospitals
    ISSN: 0003-9926
    E-ISSN: 15383679
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  • 8
    Language: English
    In: Arthritis and rheumatism, January 2002, Vol.46(1), pp.109-13
    Description: To estimate the reproducibility of the semiflexed metatarsophalangeal (MTP) view in repeat radiographic examinations of the knee of subjects with osteoarthritis (OA) with respect to radioanatomic alignment of the medial tibial plateau and the central x-ray beam and the precision of measurements of minimum medial tibiofemoral joint space width (JSW). Thirty-eight subjects with definite knee OA underwent 2 semiflexed MTP examinations on the same day. Radioanatomic alignment of the medial tibial plateau and the x-ray beam (distance between anterior and posterior margins of the plateau) was measured manually (Lequesne method). Manual measurements of the JSW in repeat radiographs also were obtained. The reproducibility of JSW measurements was estimated by the method of Bland and Altman. Only 29% of the initial semiflexed MTP radiographs exhibited satisfactory radioanatomic alignment (intermargin distance 〈 or =1 mm). However, intermargin distances in initial and repeat radiographs were highly correlated (r = 0.86, P 〈 0.01). In 89% of knees, the intermargin distance in the first examination was reproduced (+/- 1 mm) in the second examination. The standard error of measurement (mean of within-knee standard deviations of repeat JSW values) was 0.30 mm. The magnitude of discrepancy between repeat measurements of JSW was related positively to overall radiographic severity of knee OA (P 〈 0.05). The semiflexed MTP protocol affords highly reproducible radioanatomic positioning of the knee, although misalignment of the medial tibial plateau and the x-ray beam occurs in 〉70% of cases. Precision of measurement of JSW in the semiflexed MTP view approaches that associated with fluoroscopically assisted positioning protocols. However, the consequences of poor, albeit reproducible, alignment of the knee in serial semiflexed MTP radiographs in longitudinal studies of OA progression are currently unknown.
    Keywords: Arthrography -- Standards ; Knee Joint -- Diagnostic Imaging ; Metatarsophalangeal Joint -- Diagnostic Imaging ; Osteoarthritis, Knee -- Diagnostic Imaging
    ISSN: 0004-3591
    E-ISSN: 15290131
    Source: MEDLINE/PubMed (U.S. National Library of Medicine)
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  • 9
    Language: English
    In: Arthritis & Rheumatism, January 2002, Vol.46(1), pp.100-108
    Description: OBJECTIVETo evaluate the effectiveness of tidal irrigation (TI) in comparison with a well-matched sham irrigation (SI) procedure as a treatment for knee osteoarthritis (OA). METHODSOne hundred eighty subjects with knee OA were randomized to receive TI or SI, with clinical followup over the ensuing 12 months. The primary outcomes of interest were change in pain and function, as measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Subjects and the nurse assessor were blinded, and success of blinding was assessed. RESULTSAlthough the study groups were otherwise comparable, the baseline WOMAC pain and physical functioning scores were higher (worse) in the SI group. After adjustment for baseline, there were no differences between the effects of
    Keywords: Aged–Administration & Dosage ; Anti-Inflammatory Agents, Non-Steroidal–Adverse Effects ; Debridement–Methods ; Double-Blind Method–Diagnosis ; Female–Therapy ; Follow-Up Studies–Adverse Effects ; Gout–Methods ; Humans–Methods ; Male–Methods ; Middle Aged–Methods ; Osteoarthritis, Knee–Methods ; Pain Measurement–Methods ; Therapeutic Irrigation–Methods ; Treatment Failure–Methods ; Abridged ; Anti-Inflammatory Agents, Non-Steroidal;
    ISSN: 0004-3591
    E-ISSN: 1529-0131
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  • 10
    Language: English
    In: Arthritis & Rheumatism, August 2001, Vol.44(8), pp.1786-1794
    Description: OBJECTIVEPrevious studies of knee osteoarthritis (OA) have yielded variable estimates of the rate of joint space narrowing (JSN) in the standing anteroposterior (AP) radiograph, due largely to longitudinal changes in the alignment of the medial tibial plateau (MTP) and x-ray beam. To characterize this bias, we examined serial radiographs of subjects with knee OA in population-based and clinical OA cohorts from 3 locations in the United States and the United Kingdom. METHODSRadiographic features of knee OA (e.g., osteophytosis, JSN) and MTP alignment in 428 OA knees were evaluated by consensus of 2 readers. Alignment was considered satisfactory if the anterior and posterior margins of the MTP were superimposed within 1 mm. Readers were blinded to subject identity, and films were read in random order. The minimum medial joint space width was also measured manually (standard error of repeated measurements 0.20 mm) in serial knee images. RESULTSOnly 14% of serial radiographs exhibited alignment of the MTP in both images. In OA knees with satisfactory alignment in both images, the mean rate of JSN over 2-3 years (0.26 mm/year) was significantly larger (P = 0.004) than that in OA knees with misalignment in 1 or both radiographs and was 86% more rapid than the mean JSN in all OA knees. Moreover, the within-group standard deviation of JSN was significantly smaller among knees with reproduced alignment of the MTP than in knees in which misalignment occurred in 1 or both images (P = 0.006). CONCLUSIONPoor standardization of knee positioning in serial standing AP radiographs in previous studies of OA progression has obscured the rate and variability of articular cartilage loss in subjects with knee OA. True JSN (i.e., JSN that is not attributable to longitudinal changes in the alignment of the MTP with the x-ray beam in serial radiographic examinations) may occur more rapidly, and with less between-subject variability, than that previously thought to be characteristic of knee OA.
    Keywords: Aged–Diagnostic Imaging ; Cohort Studies–Diagnostic Imaging ; Diagnostic Errors–Pathology ; Disease Progression–Methods ; Female–Methods ; Humans–Methods ; Male–Methods ; Menisci, Tibial–Methods ; Osteoarthritis, Knee–Methods ; Radiography–Methods ; Abridged;
    ISSN: 0004-3591
    E-ISSN: 1529-0131
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