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Steiner, Claudia

Authors: Coben J and Steiner CA.
Title: Hospitalization for Firearm-Related Injuries in the United States, 1997
Publication: American Journal of Preventive Medicine 24(1):1-8.
Date: 2003.
Abstract: Firearm-related injuries are a serious public health problem in the United States. Despite the magnitude of this problem, prior national estimates of nonfatal firearm-related morbidity have been limited to an emergency department-based surveillance system. The objective of this study was to assess and report the information available on firearm-related injuries in an existing national database, derived from hospital discharge data. Methods: Cross-sectional analysis of the 1997 Nationwide Inpatient Sample (NIS), a stratified probability sample of 1,012 nonfederal community hospitals from 22 States. The database was queried using E codes to identify firearm-related injuries. The software program SUDAAN was used to convert raw counts into weighted counts that represent national estimates and 95% confidence intervals. Results: An estimated 35,810 (95% CI: 32,615-38,947) cases nationwide were identified, of which 86% were male. Assault was the leading cause of firearm-related hospitalization, followed by unintentional injury. The mean length of stay (LOS) for patients with a firearm-related assault was 6 days. Seven percent of all firearm cases died during the hospitalization. The total estimated hospital charges for firearm-related injuries in the United States in 1997 was over $802 million and 29% of the patients admitted for this condition were uninsured. Conclusions: Firearm-related injuries rank highest among all conditions in the number of uninsured hospital stays, and the average LOS is much longer as compared with other medical conditions. National estimates derived from the NIS are consistent with previous estimates and NIS provides additional information not available from other data sources.
Topics: Cost, Hospitals, Public Policy, Statistics.

Authors: Steiner CA, Elixhauser A, and Schnaier J.
Title: The Healthcare Cost and Utilization Project: An Overview.
Publication: Effective Clinical Practice 5(3):143-51.
Date: 2002.
Abstract: Healthcare Cost and Utilization Project (HCUP)-a family of databases including the State Inpatient Databases (SID), the Nationwide Inpatient Sample (NIS), the Kids' Inpatient Database (KID), and the outpatient databases State Ambulatory Surgery Data (SASD) and State Emergency Department Data (SEDD). Multistate, inpatient (SID, NIS, KID) and outpatient (SASD, SEDD) discharge records on insured and uninsured patients. Partnership between the Agency for Healthcare Research and Quality (AHRQ) and public and private statewide data organizations. Selected data elements from inpatient and outpatient discharge records, including patient demographic, clinical, disposition and diagnostic/procedural information; hospital identification (ID); facility charges; and other facility information. Varies by database: NIS 1988-2000; SID 1995-2000; KID 1997 and 2000; SASD 1995-2000; and SEDD in pilot phase. Future data years anticipated for all datasets and back years for SID and SASD. UNITS OF ANALYSIS: Patient (in states with encrypted patient identification), physician, market, and state. Quality assessment, use and cost of hospital services, medical treatment variations, use of ambulatory surgery services, diffusion of medical technology, impact of health policy changes, access to care (inference), study of rare illness or procedures, small area variations, and care of special populations. Largest collection of all-payer, uniform, state-based inpatient and ambulatory surgery administrative data. Lacks clinical detail (e.g., stage of disease, vital statistics) and laboratory and pharmacy data. Ability to track patients across time and setting varies by state. Access available to all users who sign and abide by the Data Use Agreement. Application kits available at www.ahrq.gov/data/hcup. HCUPnet, an online interactive query tool, allows access to data without purchase (http://hcupnet.ahrq.gov/).
Topics: Hospitals, Methods.

Authors: Farquhar, C.M, Steiner, C.A.
Title: The Impact of Endometrial Ablation on Hysterectomy Rates in Women with Benign Uterine Conditions in the U.S.
Publication: International Journal of Technology Assessment in Health Care 2002, 18:3
Date: Summer 2002
Abstract: This study assesses the impact of endometrial ablation on the utilization of hysterectomy in women with benign uterine conditions. Data are from the State Inpatient Database and Ambulatory Surgery Database of the Healthcare Cost and Utilization Project (HCUP) for 6 States, 1990-97. Women who underwent hysterectomy and endometrial ablation and had benign uterine conditions were extracted using ICD-9 coding. Comparative rates, length of stay, total charges, age, payer, location of hospital and teaching status of the hospital for hysterectomy and endometrial ablation were studied. The rates of hysterectomy decreased in three States (Colorado 37 percent, Maryland 18 percent, New Jersey 11 percent), were static in two States (Connecticut and New York) and increased in one State (Wisconsin, 11 percent increase). In contrast, the rates for endometrial ablation have increased in all states. The ratio of hysterectomy to endometrial ablation rates fell in each state and in two States (New York and New Jersey) the rate of endometrial ablations was equivalent to the rate of hysterectomies during the eight years studied. The total combined rate for hysterectomy and endometrial ablation for women with benign uterine conditions for each state increased by more than 10 percent with the exception of Maryland which had an increase of only 4 percent, and Colorado which had a decline of 23 percent. In the six States studied, the diffusion of endometrial ablation has had a varying impact, although overall it appears ablation is an additive rather than substitutive technology.
Topics: Women, Hospitals

Authors: Farquhar C, Steiner C.
Title: Hysterectomy Rates in the United States 1990-1997
Publication: Obstetrics & Gynecology 99:229-34.
Date: 2002.
Abstract: This study assesses national hysterectomy rates, type of hysterectomy and other factors associated within the United States from 1990 to 1997. A descriptive statistical analysis of national discharge data was undertaken. Data from the Nationwide Inpatient Sample of HCUP (from which national estimates are generated based on a 20 percent stratified sample of U.S. community hospitals) were used for the 1990-97. All women who underwent hysterectomy were identified using ICD-9-CM procedure codes. Rates and type of hysterectomy, age of patients, length of stay, total hospital charges and diagnostic categories were determined. We found that the rates of hysterectomy have not changed significantly over 1990-97. Rates for hysterectomy in 1990 were 5.5 per 1,000 women and increased slightly by 1997 to 5.6 per 1,000 per women. It appears that introduction of alternative techniques for controlling abnormal uterine bleeding such as endometrial ablation have not had an impact on hysterectomy rates. The type of hysterectomy has changed, with laparoscopic hysterectomy (LAVH) accounting for 9.9 percent of cases by 1997, with a concomitant decline in abdominal hysterectomy but no substantial change in vaginal hysterectomy rates. Length of stay decreased and total charges increased for all types of hysterectomy. Vaginal hysterectomy and laparoscopic hysterectomy are associated with shorter length of stay than abdominal hysterectomy. Abdominal hysterectomy remains the most common procedure (63.0 percent in 1997).
Topics: Hospitals, Women.

Authors: Case C., Johantgen M., Steiner C.
Title: Outpatient Mastectomy: Clinical Payer and Geographical Influences.
Publication: Health Services Research 2001 Oct;36:5.
Abstract: This study was designed to determine: 1) the use of outpatient services for all surgical breast procedures for breast cancer, and 2) the influence of payer and state on the use of outpatient services for complete mastectomy, in light of state and federal length-of-stay, managed care legislation. All discharges from hospitals and ambulatory surgery centers for five States (Colorado, Connecticut, Maryland, New Jersey, and New York) and 7 years (1990-96) are examined using the Healthcare Cost and Utilization Project (HCUP). All women undergoing inpatient and outpatient complete mastectomy, subtotal mastectomy and lumpectomy for cancer were analyzed. Total age-adjusted rates and percent of outpatient complete mastectomy, subtotal mastectomy and lumpectomy are compared. Independent influence of state and HMO payer on likelihood of receiving an outpatient complete mastectomy is determined from multivariate models, adjusting for clinical (age <50, comorbidity, metastases, simple mastectomy, breast reconstruction) and hospital characteristics (teaching, ownership, urban). This study determined that lumpectomy an outpatient procedure, and subtotal mastectomy is becoming primarily outpatient. Complete mastectomy, while still primarily inpatient, is increasingly outpatient in some states. While clinical characteristics remain important, the state in which a woman receives her care and whether she has an HMO payer are strong determinants of whether she receives an outpatient complete mastectomy.
Topics: Women.

Authors: Elixhauser A, Yu K, Steiner C, et al.
Title: Hospitalization in the United States. HCUP Factbook No. 1
Publication: Rockville (MD): AHRQ.
Date: 2000
Abstract: A new report by AHRQ shows that over a third of all hospital patients are initially seen in the emergency department before being admitted. This figure includes 40 percent of all hospitalized children and 55 percent of the very old (80 and older). According to the report, which is based on 1997 data from AHRQ's Nationwide Inpatient Sample, the number one cause of hospital admission through the emergency room was pneumonia. Half of the other top 10 conditions for the admission of emergency room patients involved heart conditions. The other leading conditions for admission through the emergency department were stroke, chronic obstructive lung disease (emphysema or chronic bronchitis), asthma and blood infection (septicemia). The report also provides statistics on the age and gender of hospitalized patients; leading reasons for hospital admission overall and by age; hospital charges; lengths of stay; in-hospital mortality; patients who leave against medical advice; and types of locations to which patients are discharged. The Nationwide Inpatient Sample—the AHRQ database used to develop the report—contains about 7 million records, making it one of the largest publicly available databases for research and policy analysis and the only one that provides information on total hospital charges for all patients, regardless of their type of insurance or other payment source. Users can preview NIS data through HCUPnet, an interactive software tool. HCUPnet can be used to query the database and selected State hospital databases that participate in AHRQ's Healthcare Cost and Utilization Project (HCUP).
Topics: Hospitals.
Availability: AHRQ Publication No. 00-0031 is available from the AHRQ Publications Clearinghouse.

Authors: Gross P, Steiner C, Bass E, Powe N
Title: Relation between prepublication release of clinical trials results and the practice of carotid endarterectomy.
Publication: JAMA 284:2886-93.
Date: December 13, 2000
Abstract: This article determined whether prepublication release of carotid endarterectomy trail results via National Institutes of Health Clinical Alerts were associated with a prompt change in patient care that was consistent with the new medical evidence. The study uses several years of data from seven States (NY, CA, PA, FL, CO, IL, and WI) that participate in the Healthcare Cost and Utilization Project. Findings include that the prepublication dissemination of Cost-effectiveness analysis trial results with clinical alerts was associated with prompt and substantial changes in medical practice. However, the results were extrapolated to patients and settings not directly supported by the trials.
Topics: Hospitals, public policy.
Availability: AHCPR Publication No. 01-R017 is available from the AHRQ Publications Clearinghouse.

Author: Elixhauser A, Steiner CA.
Title: Hospital Inpatient Statistics, 1996
Publication: Rockville (MD): AHCPR.
Date: 1999
Abstract: This publication provides descriptive statistics for U.S. hospital inpatient stays in 1996 using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. National estimates are provided for all discharges by principal diagnosis and by principal procedure. Statistics are presented on the number of discharges, mean length of stay, mean charges, charges in quartiles (25th, 50th, and 75th percentiles), percent who died in the hospital, percent male, and mean age. The statistics in this publication can be used to assess the processes and outcomes of care for diagnoses and procedures in U.S. hospitals. For example, among the most frequent conditions are coronary atherosclerosis with over 1.4 million stays and pneumonia with over 1.2 million stays. Among the longest mean lengths of stay were those for short gestational age, low birth weight, and fetal growth retardation (23 days), infant respiratory distress syndrome (22 days), late effects of cerebrovascular disease (15 days) and paralysis (16 days). The highest mean total charges were seen for organ transplantation ($191,000) and tracheostomy ($148,000). Diagnoses and procedures are categorized using the Clinical Classifications Software (CCS), a system for collapsing diagnosis and procedure codes into clinically meaningful categories.
Topics: Hospitals, Methods.
Availability: AHCPR Publication No. 99-0034 is available from the AHRQ Publications Clearinghouse.

Author: Elixhauser A, Steiner CA.
Title: Most common diagnoses and procedures in U.S. community hospitals.
Publication: Rockville (MD): AHCPR.
Date: 1999
Abstract: This publication provides information on the most frequent diagnoses and procedures for hospital inpatients. It helps to answer questions such as "What are the most common reasons for hospitalization in the United States?" "Which procedures are most frequently performed?" "For what conditions is this procedure used?" and "How is this condition treated?" The analysis is based on data for U.S. hospital inpatient stays in 1996 using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. For each of the 100 most frequently performed principal procedures, the authors list the 5 principal diagnoses most commonly recorded on the discharge abstract. Similarly, for each of the 100 most frequent principal diagnoses treated in hospitals, the authors list the 5 principal procedures most commonly performed. For each diagnosis-procedure combination, information on in-hospital mortality and mean and median length of stay and total charges is provided. This publication can be used to evaluate the variety of diagnoses associated with a given procedure and the variations in treatment for particular diagnoses. In addition, it provides information on variations in length of stay, total charges, and in-hospital mortality among diagnosis-procedure combinations.
Topics: Hospitals, Statistics.
Availability: AHCPR Publication No. 99-0046 is available from the AHRQ Publications Clearinghouse.

Author: Friedman B, Jee J., Steiner C, et al.
Title: Tracking the State Children's Health Insurance Program with hospital data: National baselines, State variations, and some cautions.
Publication: Med Care Res Rev 56(4):440-55.
Date: 1999
Abstract: State and Federal agencies are concerned with the impact of the State Children's Health Insurance Program (SCHIP) on the health care of enrolled children. As part of a broad program evaluation, and at relatively low cost, analysts can track data on hospital admissions for ambulatory care sensitive (ACS) conditions. This article uses hospital data for 19 states to calculate baseline ACS rates and to discuss trends and cross-state variations just prior to the start of SCHIP. A few cautions and limitations are discussed. An unexpected result in the explorations was a substantial increase in the rate of ACS admissions for self-pay and Medicaid-enrolled children during the period of 1990-1995. During that same period, the admission rate for other insured children fell by more than a third. The comparisons across states are meant to be illustrative; they do reveal a relationship between the rate of asthma admissions and the proportion of self-pay plus Medicaid-enrolled cases.
Topics: Children, Hospitals, Insurance, Medicaid.
Availability: AHRQ Pub. No. 00-R009 is available from the AHRQ Publications Clearinghouse.

Author: Friedman B, Steiner C.
Title: Does managed care affect the supply and use of ICU services?
Publication: Inquiry 1999 Spring;(36):68-77.
Date: 1999
Abstract: In two States that differ greatly in hospital ownership and history of regulation, we find that the services per ICU user are less for managed care patients than for other privately insured. In Massachusetts, the differences across payers disappear for hospitals where the total supply of ICU is low in relation to expected demand. In both States, admission to ICU is not significantly different between managed care and other privately insured.
Topics: Hospitals, Managed Care, Medical Decisionmaking, Markets.

Authors: Elixhauser A, Steiner C, Harris D, et al.
Title: Comorbidity measures for use with administrative data.
Publication: Med Care 36(1):8-27.
Date: 1998
Abstract: When using administrative data, pre-existing conditions (or comorbidities) are handled analytically by stratifying patients into groups: those with coexisting medical conditions and those without. Employing separate binary indicators for discrete conditions, or summarizing comorbidity information into an index or score provides a single parameter for measuring multiple comorbidities. Since comorbidities affect outcomes differently among different patient groups, comorbidities probably should not be simplified as an index. The authors developed a comprehensive set of 30 comorbidity measures for use with administrative inpatient databases to control for a broad array of patients underlying pre-existing conditions in many types of studies. The comorbidities were associated with substantial increases in length of stay, hospital charges, and mortality both for heterogeneous and homogeneous disease groups. The authors point out several comorbidities that are important predictors of outcomes, yet are not commonly measured. These include: mental disorders, drug and alcohol abuse, obesity, coagulopathy, weight loss, and fluid and electrolyte disorders.
Topics: Hospitals, Methods.
Availability: AHCPR Publication No. 98-R013 is available from the AHRQ Publications Clearinghouse.

Authors: Elixhauser A, Steiner C, Whittington C, et al.
Title: Clinical classifications for health policy research. Hospital inpatient statistics, 1995.
Publication: Rockville (MD): AHCPR.
Date: 1998
Abstract: This Research Note provides descriptive statistics for U.S. hospital inpatient stays in 1995 using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. National estimates are provided for all discharges by principal diagnosis and by principal procedure. Statistics are presented on the number of discharges, mean length of stay, mean charges, charges in quartiles, percent who died in the hospital, percent male, and mean age. Diagnoses and procedures are categorized using the Clinical Classifications for Health Policy Research (CCHPR), a system for collapsing diagnosis and procedure codes into clinically meaningful categories.
Topics: Hospitals, Methods.
Availability: AHCPR Publication No. 98-0049 is available from the AHRQ Publications Clearinghouse.

Authors: Sills E, Saini J, Steiner C, et. al.
Title: Abdominal hysterectomy practice patterns in the United States.
Publication: International Journal of Gynecology and Obstetrics 1998:63;277-83.
Date: 1998.
Abstract: This article describes the nationwide practice trends for two principal techniques of abdominal hysterectomy in the United States, total abdominal (TAH) and supracervical hysterectomy (SCH). The study uses data form the Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project, 1991-94. The study concludes that the national rates of TAH and SCH changed significantly in the Unites States from 1991 to 1994, with TAH declining and SCH increasing. The mix of cases continues to reflect a strong preference for TAH. The data also demonstrated that SCH was more expensive.
Topics: Women, hospitals.
Availability: AHCPR Publication No. 98-R053 is available from the AHRQ Publications Clearinghouse.

Authors: Steiner C, Elixhauser A.
Title: Managed care, technology assessment and coverage of medical technology.
Publication: Today's Internist 39:22-7.
Date: 1998.
Abstract: This article summarizes the results of three surveys in which pharmaceutical directors, medical directors, and other decisionmakers in MCOs responded to questions about coverage of medical technology. Researchers conducted these surveys in the past several years and have published the results in several journals.
Topics: Managed Care, Medical Decisionmaking.
Availability: AHCPR Publication No. 98-R038 is available from the AHRQ Publications Clearinghouse.

Authors: Elixhauser A, Luce B, Steiner C.
Title: Cost-effectiveness analysis, medical technology assessment, and managed care organizations.
Publication: In Policy Issues in Pharmaceutical Cost-Effectiveness Research: AEI Press.
Date: 1997
Abstract: Managed care organizations (MCOs) face an onslaught of criticism amid widespread concern that they deny access to potentially valuable but expensive medical technologies. Increasingly, technology assessment incorporates cost-effectiveness and cost-benefit analysis as an integral part of the assessment process, making the examination of the relationship between costs of the outcomes an important contributor to the evaluation of technologies. How do managed care organizations make decisions about which technologies to employ and which to reject and about appropriate use of specific technologies? What information is used in this decision that affects the health and well-being of patients and the costs of medical care? To what extent does formal technology assessment and cost-effectiveness analysis play a role in this decisionmaking process? Exploring these issues will help to identify what is known about the use of technology assessment and cost-effectiveness analysis in MCOs and how this use differs from other segments of the health care industry, and will help to identify gaps in the information base on medical technology.
Topics: Managed Care, Medical Decisionmaking, Methods.

Authors: Friedman B, Steiner C, Scott J.
Title: Rationing of an expensive technology in the U.S.: Hospital intensive care in two States, 1992.
Publication: In Governments and Health Systems: Implications of Differing Involvements, edited by Chinitz JCD. Sussex, England: John Wiley and Sons, Ltd.
Date: 1997
Abstract: A discussion of public and payer policies and descriptive review of variations in use of ICU services for adult, non-emergency, non-surgical patients. Once admitted to a hospital, most people with public and private insurance are protected against the extra out-of-pocket expense for the ICU. Therefore, some amount of rationing can be desirable if patients demand service that has very low benefit relative to the high resource costs of production. Many payers do give physicians and hospitals incentives to provide less ICU care than patients and ideal agents would demand. The variations in use suggest that rationing is more a function of hospital characteristics and performance variables than of patient characteristics.
Topics: Hospitals, Medical Decisionmaking, Public Policy.

Authors: Steiner C, Powe N, Anderson G, et al.
Title: Technology coverage decisions by health care plans and considerations used by medical directors for coverage decisions.
Publication: Med Care 35(5):1-18.
Date: 1997
Abstract: This study provides results from a national survey of indemnity and HMO payers regarding coverage decisions for new medical technology. The influence of payer type, size, and ownership on coverage of different laser technologies and types of considerations used to make decisions is examined. This article demonstrates variation in coverage across indemnity and HMO payers, and for-profit and indemnity plans covered more individual laser technologies.
Topics: Managed Care, Medical Decisionmaking.
Availability: AHCPR Publication No. 97-R068 is available from the AHRQ Publications Clearinghouse.

Authors: Powe N, Steiner C, Anderson G, et al.
Title: Awareness of providers' use of new medical technology by private health care plans in the United States.
Publication: International Journal of Technology Assessment in Health Care 2:367-76.
Date: 1996
Abstract: In this study of 231 indemnity and HMO payers, the authors studied whether medical directors are aware when a new technology is getting used in procedures for which claims are submitted, the factors alerting them to such use, and the factors prompting them to make a specific coverage decision for the technology. The authors also examined the association between payer type, size and ownership, and each of those outcomes. The study demonstrates that payers overall are not aware when new technology is being used, although HMO payers demonstrate increased awareness as compared to indemnity payers. Payers are most often prompted to make a specific coverage decision if the technology is viewed as experimental.
Topics: Managed Care, Medical Decisionmaking.
Availability: AHCPR Publication No. 96-R118 is available from the AHRQ Publications Clearinghouse.

Authors: Steiner C, Powe N, Anderson G.
Title: Coverage decisions for medical technology by managed care: Relationship to organizational and physician payment characteristics.
Publication: American Journal of Managed Care 1996;2(10):1321-31.
Date: 1996
Abstract: This article presents results of a national survey of HMO medical directors regarding coverage decisions for new medical technology. This study investigates the influence of HMO organizational structure and method of physician payment on aspects of managed care plans' decisions to cover new medical technologies. The study demonstrates managed care plans use cost-effectiveness in decisionmaking, and plans' decreased use of cost considerations as financial risk-sharing with physicians increased.
Topics: Managed Care, Medical Decisionmaking, Methods.

Authors: Steiner C, Powe N, Anderson G, et al.
Title: The review process used by health care plans in the U.S. when evaluating new medical technology for coverage.
Publication: Journal of General Internal Medicine 5(11):294-302.
Date: 1996
Abstract: This study provides results from a national survey of indemnity and HMO payers regarding the process of establishing coverage for new medical technology. The study examines the actual review process, final decision authority, sources and evidence used for coverage decisions. The influence of payer type, size, and ownership on the coverage process is examined as well. Indemnity payers were likely to assert medical directors should be responsible for final decisionmaking. Barriers to optimal decisionmaking included lack of timely effectiveness and cost-effectiveness data.
Topics: Managed Care, Medical Decisionmaking.
Availability: AHCPR Publication No. 96-R120 is available from the AHRQ Publications Clearinghouse.

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