The authors recently published a meta-analysis of controlled trials of comprehensive geriatric assessment (CGA). The results supported the view that efficacy of CGA is strongly related to the patients, objectives, and...
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The authors recently published a meta-analysis of controlled trials of comprehensive geriatric assessment (CGA). The results supported the view that efficacy of CGA is strongly related to the patients, objectives, and basic design of CGA programs, and that particular program models and design features am associated with important health outcome improvements (e.g., survival, living at home, and functional improvement at follow-up). Present objectives include the outline of methods and how they were developed given the condition of the trial database and scientific context. Aspects of the approach, such as (a) survey of primary trialists to recover unpublished information and standardize data, (b) development of a program typology to guide the principal analysis, and (c) incorporation of program design features as covariates where statistical heterogeneity was detected, proved extremely useful and have implications for other systematic reviews of similarly complex primary trials of new health care technologies, health services, and organizational interventions.
A potential misinterpretation regarding measures of central tendency was identified in several health sciences textbooks presenting basic statistical procedures. The misinterpretation involves measures of central tend...
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A potential misinterpretation regarding measures of central tendency was identified in several health sciences textbooks presenting basic statistical procedures. The misinterpretation involves measures of central tendency derived from skewed unimodal sample distributions. The reviewed textbooks state or imply that in asymmetrical distributions the median is always located between the mode and mean. An example is presented illustrating the fallacy of this assumption. The mean and median will always be to the right of the mode in a positively skewed unimodal distribution and to the left of the mode in a negatively skewed distribution, but the order of the mean and median is impossible to predict or generalize. The assumption that the median always falls between the mode and mean in the calculation of coefficients of skewness has implications for the interpretation of health sciences research.
Although writing clear questions is accepted as a general goal in surveys, procedures to ensure that each key term is consistently understood are not routine. Researchers who do not adequately test respondent understa...
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Although writing clear questions is accepted as a general goal in surveys, procedures to ensure that each key term is consistently understood are not routine. Researchers who do not adequately test respondent understanding of questions must assume that ambiguity will not have a large or systematic effect on their results. Seven questions that were drawn from questions used in national health surveys were subjected to special pretest procedures and found to contain one or more poorly defined terms. When the questions were revised to clarify the definition of key terms, significantly different estimates resulted. The implication is that unclear terms are likely to produce biased estimates. The results indicate that evaluation of survey questions to identify key terms that are not consistently understood and defining unclear terms are ways to reduce systematic error in survey measurement.
This study examines the reliability and accuracy of ratings by general surgery residents of surgical faculty. Twenty-three of 33 residents anonymously and voluntarily evaluated 62 surgeons in June, 1988;24 of 28 resid...
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This study examines the reliability and accuracy of ratings by general surgery residents of surgical faculty. Twenty-three of 33 residents anonymously and voluntarily evaluated 62 surgeons in June, 1988;24 of 28 residents evaluated 64 surgeons in June, 1989. Each resident rated each surgeon on a 5-point scale for each of 10 areas of performance: technical ability, basic science knowledge, clinical knowledge, judgment, peer relations, patient relations, reliability, industry, personal appearance, and reaction to pressure. Reliability analyses evaluated internal consistency and interrater correlation. Accuracy analyses evaluated halo error, leniency/severity, central tendency, and range restriction. Ratings had high internal consistency (coefficient alpha = 0.97). Interrater correlations were moderately high (average Pearson correlation = 0.63 among raters). Ratings were generally accurate, with halo error most prevalent and some evidence of leniency. Ratings by chief residents had the least halo. Results were generally replicable across the two academic years. We conclude that anonymous ratings of surgical faculty by groups of residents can provide a reliable and accurate evaluation method, ratings by chief residents are most accurate, and halo error may pose the greatest threat to accuracy, pointing to the need for greater definition of evaluation items and scale points.
This paper provides an analysis of the effects of uncertainty on the demand for medical care using a simplified version of Grossman's human capital model of the demand for health. Two types of uncertainty are anal...
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This paper provides an analysis of the effects of uncertainty on the demand for medical care using a simplified version of Grossman's human capital model of the demand for health. Two types of uncertainty are analysed: the uncertainty surrounding the incidence of illness and the uncertainty surrounding the effectiveness of medical care. In the first the consumer's basic level of health is assumed to be a random variable; in the second the effectiveness of medical care is assumed to be random. Comparative static results are reported indicating the effects on the demand for medical care of both increases in the means of these distributions and mean-preserving spreads of the distributions.
Observational studies of demand for mental health services showed much greater use by those with more generous insurance, but this difference may have been due to adverse selection, rather than in response to price. T...
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Observational studies of demand for mental health services showed much greater use by those with more generous insurance, but this difference may have been due to adverse selection, rather than in response to price. This paper avoids the adverse selection problem by using data from a randomized trial, the RAND Health Insurance Experiment (HIE). Participating families were randomly assigned to insurance plans that either provided free care or were a mixture of first dollar coinsurance and free care after a cap on out-of-pocket spending was reached. We estimate the separate effects of coinsurance and the cap on the demand for episodes of outpatient mental health services. We find that outpatient mental health use is more responsive to price than is outpatient medical use, but not as responsive as most observational studies have indicated. Those with no insurance coverage would spend about one-quarter as much on mental health care as they would with free care. Coinsurance reduces the number of episodes of treatment, but has only a small effect on the duration and intensity of use within episodes. Users appear to anticipate exceeding the cap, and spend at more than the free rate after they do so.
This paper analyzes claims data from the RAND Health Insurance Experiment, which were grouped into episodes of treatment. The insurance plans in the experiment have coinsurance and a cap on out-of-pocket spending. Usi...
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This paper analyzes claims data from the RAND Health Insurance Experiment, which were grouped into episodes of treatment. The insurance plans in the experiment have coinsurance and a cap on out-of-pocket spending. Using new statistical techniques to adjust for the increased sickliness of those who exceed the cap, the effects of coinsurance on cost per episode and number of episodes are estimated. Cost sharing reduced the number of episodes but had little effect on cost per episode. People in the experiment responded myopically as their current insurance status changed through the year. The price elasticity of spending was about -0.2 throughout the range of coinsurance studied. When data permit it, the study of episodes complements analyses of annual medical spending by revealing more about how decisions to spend are made within the year.
This paper explores the trade-off between risk sharing and the incentives to consume increased medical care inherent in reimbursement insurance. The results for the theory of reimbursement insurance are compared with ...
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This paper explores the trade-off between risk sharing and the incentives to consume increased medical care inherent in reimbursement insurance. The results for the theory of reimbursement insurance are compared with those on Ramsey taxation. It is shown that there is a close formal analogy and interpretations are given.
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