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Socioeconomic Factors, Urological Epidemiology and Practice Patterns
Urological Survey
Socioeconomic Factors, Urological Epidemiology and Practice Patterns Massachusetts Health Reform: Employer Coverage From Employees’ Perspective S. K. Long and K. Stockley Urban Institute, Washington, D. C. Health Aff (Millwood) 2009; 28: w1079 –w1087.
The national health reform debate continues to draw on Massachusetts’ 2006 reform initiative, with a focus on sustaining employer-sponsored insurance. This study provides an update on employers’ responses under health reform in fall 2008, using data from surveys of working-age adults. Results show that concerns about employers’ dropping coverage or scaling back benefits under health reform have not been realized. Access to employer coverage has increased, as has the scope and quality of their coverage as assessed by workers. However, premiums and out-of-pocket costs have become more of an issue for employees in small firms. Editorial Comment: The recently passed federal health care reform legislation bears some striking similarities to the 2006 Massachusetts health reform in that it strives to attain nearly universal health insurance coverage through expansion of employer based health insurance plans. To this end, we can use the Massachusetts experience as a model to predict what will happen as the proposed changes in federal law go into effect. This fascinating policy article describes the results of a health insurance survey sent to roughly 12,000 adults in the state of Massachusetts from 2006 to 2008. The authors note that roughly 90% of workers in Massachusetts received health insurance through work for the duration of the study period. They also note that it appeared that employers were actually loosening eligibility for health insurance for their workers. However, the most interesting findings of the survey were the impact of the legislation on employee insurance premiums. First, the average employee contribution for health insurance in Massachusetts was $1,000 for single coverage and $3,100 for family coverage (well above the national average of $788 for single coverage and $2,890 for family coverage). Also, contributions toward premiums appeared to be increasing for the employees who worked for small firms (fewer than 51 employees) during the study period. What does this all mean when extrapolated to a national level? First, insurance premiums likely will not decrease with the new legislation and it is possible they may increase. Additionally small businesses may have a difficult time providing affordable health insurance to their employees and will likely pass along costs to the employees. In short, someone has to pay for the proposed changes. The politicians have done all they can to avoid explicitly passing these costs off to health care consumers. However, in the end, whether through higher insurance premiums, higher co-payments or higher taxes, the consumer is appropriately going to bear the cost for assessing the health care system. David F. Penson, M.D., M.P.H.
0022-5347/10/1844-2094/0 THE JOURNAL OF UROLOGY® © 2010 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
2094
www.jurology.com
AND
RESEARCH, INC.
Vol. 184, 2094-2096, October 2010 Printed in U.S.A. DOI:10.1016/j.juro.2010.06.081
DIAGNOSTIC UROLOGY, URINARY DIVERSION AND PERIOPERATIVE CARE
Magnetic Resonance Imaging and Low Back Pain Care for Medicare Patients J. D. Baras and L. C. Baker Stanford University School of Medicine, Stanford, California Health Aff (Millwood) 2009; 28: w1133–w1140.
Magnetic resonance imaging (MRI) is a technology frequently used to evaluate low back pain, despite evidence that challenges the usefulness of routine MRI and the surgical interventions it may trigger. We analyze the relationship between MRI supply and care for fee-for-service Medicare patients with low back pain. We find that increases in MRI supply are related to higher use of both low back MRI and surgery. This is worrisome, and careful attention should be paid to assessing the outcomes for patients. Editorial Comment: These authors used data on patients with lower back pain in a 20% Medicare sample from 1998 to 2005. They linked these claims data to another data set on regional MRI availability. Their first analysis examined the relationship between MRI availability and MRI use through time. They noted that as more MRI units were added to a geographic area, more MRIs were performed. I would have expected this relationship. What is more surprising is that MRI availability strongly correlated with performance of lower back surgery, an intervention of questionable efficacy in the treatment of lower back pain. I was truly surprised by this finding and frankly a little unnerved to see that a downstream effect of increased use of advanced imaging is more surgical procedures being performed, at least for lower back pain. As urologists, we may think that this finding has little or no relevance to our practices but one need only consider the continued fascination of our specialty with new (and often unproved) technologies coupled with increasing use of MRI, computerized tomography and intensity modulated radiotherapy to realize that a similar analysis of certain urological conditions might yield similar unflattering results. David F. Penson, M.D., M.P.H.
Diagnostic Urology, Urinary Diversion and Perioperative Care Can Aviation-Based Team Training Elicit Sustainable Behavioral Change? H. C. Sax, P. Browne, R. J. Mayewski, R. J. Panzer, K. C. Hittner, R. L. Burke and S. Coletta Department of Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island Arch Surg 2009; 144: 1133–1137.
Objective: To quantify effects of aviation-based crew resource management training on patient safety-related behaviors and perceived personal empowerment. Design: Prospective study of checklist use, error self-reporting, and a 10-point safety empowerment survey after participation in a crew resource management training intervention. Setting: Seven hundred twenty-two-bed university hospital; 247-bed affiliated community hospital. Participants: There were 857 participants, the majority of whom were nurses (50%), followed by ancillary personnel (28%) and physicians (22%). Main Outcome Measures: Preoperative checklist use over time; number and type of entries on a Web-based incident reporting system; and measurement of degree of empowerment (1–5 scale) on a 10-point survey of safety attitudes and actions given prior to, immediately after, and a minimum of 2 months after training. Results: Since 2003, 10 courses trained 857 participants in multiple disciplines. Preoperative checklist use rose (75% in 2003, 86% in 2004, 94% in 2005, 98% in 2006, and 100% in 2007). Self-initiated reports increased from 709 per quarter in 2002 to 1481 per quarter in 2008. The percentage of reports related to environment as opposed to actual events increased from 15.9% prior
2095
Socioeconomic Factors, Urological Epidemiology and Practice Patterns Massachusetts Health Reform: Employer Coverage From Employees’ Perspective S. K. Long and K. Stockley Urban Institute, Washington, D. C. Health Aff (Millwood) 2009; 28: w1079 –w1087.
The national health reform debate continues to draw on Massachusetts’ 2006 reform initiative, with a focus on sustaining employer-sponsored insurance. This study provides an update on employers’ responses under health reform in fall 2008, using data from surveys of working-age adults. Results show that concerns about employers’ dropping coverage or scaling back benefits under health reform have not been realized. Access to employer coverage has increased, as has the scope and quality of their coverage as assessed by workers. However, premiums and out-of-pocket costs have become more of an issue for employees in small firms. Editorial Comment: The recently passed federal health care reform legislation bears some striking similarities to the 2006 Massachusetts health reform in that it strives to attain nearly universal health insurance coverage through expansion of employer based health insurance plans. To this end, we can use the Massachusetts experience as a model to predict what will happen as the proposed changes in federal law go into effect. This fascinating policy article describes the results of a health insurance survey sent to roughly 12,000 adults in the state of Massachusetts from 2006 to 2008. The authors note that roughly 90% of workers in Massachusetts received health insurance through work for the duration of the study period. They also note that it appeared that employers were actually loosening eligibility for health insurance for their workers. However, the most interesting findings of the survey were the impact of the legislation on employee insurance premiums. First, the average employee contribution for health insurance in Massachusetts was $1,000 for single coverage and $3,100 for family coverage (well above the national average of $788 for single coverage and $2,890 for family coverage). Also, contributions toward premiums appeared to be increasing for the employees who worked for small firms (fewer than 51 employees) during the study period. What does this all mean when extrapolated to a national level? First, insurance premiums likely will not decrease with the new legislation and it is possible they may increase. Additionally small businesses may have a difficult time providing affordable health insurance to their employees and will likely pass along costs to the employees. In short, someone has to pay for the proposed changes. The politicians have done all they can to avoid explicitly passing these costs off to health care consumers. However, in the end, whether through higher insurance premiums, higher co-payments or higher taxes, the consumer is appropriately going to bear the cost for assessing the health care system. David F. Penson, M.D., M.P.H.
0022-5347/10/1844-2094/0 THE JOURNAL OF UROLOGY® © 2010 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
2094
www.jurology.com
AND
RESEARCH, INC.
Vol. 184, 2094-2096, October 2010 Printed in U.S.A. DOI:10.1016/j.juro.2010.06.081
DIAGNOSTIC UROLOGY, URINARY DIVERSION AND PERIOPERATIVE CARE
Magnetic Resonance Imaging and Low Back Pain Care for Medicare Patients J. D. Baras and L. C. Baker Stanford University School of Medicine, Stanford, California Health Aff (Millwood) 2009; 28: w1133–w1140.
Magnetic resonance imaging (MRI) is a technology frequently used to evaluate low back pain, despite evidence that challenges the usefulness of routine MRI and the surgical interventions it may trigger. We analyze the relationship between MRI supply and care for fee-for-service Medicare patients with low back pain. We find that increases in MRI supply are related to higher use of both low back MRI and surgery. This is worrisome, and careful attention should be paid to assessing the outcomes for patients. Editorial Comment: These authors used data on patients with lower back pain in a 20% Medicare sample from 1998 to 2005. They linked these claims data to another data set on regional MRI availability. Their first analysis examined the relationship between MRI availability and MRI use through time. They noted that as more MRI units were added to a geographic area, more MRIs were performed. I would have expected this relationship. What is more surprising is that MRI availability strongly correlated with performance of lower back surgery, an intervention of questionable efficacy in the treatment of lower back pain. I was truly surprised by this finding and frankly a little unnerved to see that a downstream effect of increased use of advanced imaging is more surgical procedures being performed, at least for lower back pain. As urologists, we may think that this finding has little or no relevance to our practices but one need only consider the continued fascination of our specialty with new (and often unproved) technologies coupled with increasing use of MRI, computerized tomography and intensity modulated radiotherapy to realize that a similar analysis of certain urological conditions might yield similar unflattering results. David F. Penson, M.D., M.P.H.
Diagnostic Urology, Urinary Diversion and Perioperative Care Can Aviation-Based Team Training Elicit Sustainable Behavioral Change? H. C. Sax, P. Browne, R. J. Mayewski, R. J. Panzer, K. C. Hittner, R. L. Burke and S. Coletta Department of Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island Arch Surg 2009; 144: 1133–1137.
Objective: To quantify effects of aviation-based crew resource management training on patient safety-related behaviors and perceived personal empowerment. Design: Prospective study of checklist use, error self-reporting, and a 10-point safety empowerment survey after participation in a crew resource management training intervention. Setting: Seven hundred twenty-two-bed university hospital; 247-bed affiliated community hospital. Participants: There were 857 participants, the majority of whom were nurses (50%), followed by ancillary personnel (28%) and physicians (22%). Main Outcome Measures: Preoperative checklist use over time; number and type of entries on a Web-based incident reporting system; and measurement of degree of empowerment (1–5 scale) on a 10-point survey of safety attitudes and actions given prior to, immediately after, and a minimum of 2 months after training. Results: Since 2003, 10 courses trained 857 participants in multiple disciplines. Preoperative checklist use rose (75% in 2003, 86% in 2004, 94% in 2005, 98% in 2006, and 100% in 2007). Self-initiated reports increased from 709 per quarter in 2002 to 1481 per quarter in 2008. The percentage of reports related to environment as opposed to actual events increased from 15.9% prior
2095