The economic burden of asthma: direct and indirect costs in Switzerland.
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Asthma mortality increased in Switzerland between 1980 and 1994. This study aimed to assess the economic burden of asthma in this country. Chart reviews were conducted for the last five patients seen for asthma in physician practices in 1996 and 1997. Direct expenditures and indirect costs for asthma-related morbidity were determined. A total of 589 patient charts were completely analysed, including 117 children's charts, obtained from 120 office-based physicians. The annual direct medical costs were CHF 1,778 and the mean annual indirect costs were CHF 1,019 per patient for all patients. The total estimated cost of asthma in Switzerland in 1997 was nearly CHF 1,252 million. Direct medical expenditures approached CHF 762 million, or 61% of the total. In 1997, the indirect costs for asthma were estimated to have exceeded CHF 490 million. Of these costs CHF 123 million (25%) was associated with morbidity and nearly CHF 368 million (75%) was associated with looking after asthmatic patients who had to be cared for at home. This study provides evidence that asthma is a major healthcare cost factor in Switzerland, amounting to approximately CHF 1,200 million per year. The data suggest that cost savings can be achieved by improving primary care for asthma in an ambulatory setting. (+info)
Systematic review of day hospital care for elderly people. The Day Hospital Group.
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OBJECTIVE: To examine the effectiveness of day hospital attendance in prolonging independent living for elderly people. DESIGN: Systematic review of 12 controlled clinical trials (available by January 1997) comparing day hospital care with comprehensive care (five trials), domiciliary care (four trials), or no comprehensive care (three trials). SUBJECTS: 2867 elderly people. MAIN OUTCOME MEASURES: Death, institutionalisation, disability, global "poor outcome," and use of resources. RESULTS: Overall, there was no significant difference between day hospitals and alternative services for death, disability, or use of resources. However, compared with subjects receiving no comprehensive care, patients attending day hospitals had a lower odds of death or "poor" outcome (0.72, 95% confidence interval 0.53 to 0.99; P<0.05) and functional deterioration (0.61, 0.38 to 0.97; P<0.05). The day hospital group showed trends towards reductions in hospital bed use and placement in institutional care. Eight trials reported treatment costs, six of which reported that day hospital attendance was more expensive than other care, although only two analyses took into account cost of long term care. CONCLUSIONS: Day hospital care seems to be an effective service for elderly people who need rehabilitation but may have no clear advantage over other comprehensive care. Methodological problems limit these conclusions, and further randomised trials are justifiable. (+info)
Efficiency and quality in the public and private sectors in Senegal.
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It is often argued that the private sector is more efficient than the public sector in the production of health services, and that government reliance on private provision would help improve the efficiency and equity of public spending in health. A review of the literature, however, shows that there is little evidence to support these statements. A study of government and non-governmental facilities was undertaken in Senegal, taking into account case mix, input prices, and quality of care, to examine relative efficiency in the delivery of health services. The study revealed that private providers are highly heterogeneous, although they tend to offer better quality services. A specific and important group of providers--Catholic health posts--were shown to be significantly more efficient than public and other private facilities in the provision of curative and preventive ambulatory services at high levels of output. Policies to expand the role of the private sector need to take into account variations in types of providers, as well as evidence of both high and low quality among them. In terms of public sector efficiency, findings from the study affirm others that indicate drug policy reform to be one of the most important policy interventions that can simultaneously improve efficiency, quality and effectiveness of care. Relationships that this study identified between quality and efficiency suggest that strategies to improve quality can increase efficiency, raise demand for services, and thereby expand access. (+info)
Prepaid capitation versus fee-for-service reimbursement in a Medicaid population.
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Utilization of health resources by 37,444 Medicaid recipients enrolled in a capitated health maintenance organization was compared with that of 227,242 Medicaid recipients enrolled in a traditional fee-for-service system over a 1-year period (1983-1984) in the state of Kentucky. Primary care providers in the capitated program had financial incentives to reduce downstream costs like specialist referral, emergency room use, and hospitalizations. The average number of physician visits was similar for both groups (4.47/year in the capitated program; 5.09/year in the fee-for-service system). However, the average number of prescriptions (1.9 versus 4.9 per year), average number of hospital admissions per recipient (0.11 versus 0.22 per year), and average number of hospital days per 1,000 recipients (461 versus 909 per year) were 5% to 60% lower in the capitated group than in the fee-for-service group. The Citicare capitated program resulted in a dramatic reduction in healthcare resource utilization compared with the concurrent fee-for-service system for statewide Medicaid recipients. (+info)
The validity and usage of resource utilization data among a group of primary care physicians.
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The use of individual resource utilization scores to compare primary care physicians (PCPs) has become more commonplace as managed care organizations (MCOs) increase their penetration into the US healthcare market. This study looks at the validity and usage of these scores among a group of PCPs within a multispecialty clinic that is part of an integrated managed care network. Personal interviews were conducted with PCPs; and reviews were done of the practice site paper charts, the computerized visit record system of the clinic and affiliated hospital, and the MCO-supplied resource utilization data on the 25 patients of each PCP on whom the most healthcare dollars were spent in 1995. As of October 1996, few PCPs had done more than a cursory review of their resource utilization data. None had identified the patients who use the most resources or developed any methods to proactively manage those patients with a history of high utilization. The clinic's communication systems alerted the PCPs less than 50% of the time when patients for whom they were responsible had high utilization of services. Patients appeared to be assigned to the incorrect PCP more than 20% of the time. All players in this managed care network--PCPs, clinic administration, and the MCO--must work together to improve the current system before resource utilization data are considered valid and are incorporated more fully into clinical practice. (+info)
The cost-effectiveness of ibutilide versus electrical cardioversion in the conversion of atrial fibrillation and flutter to normal rhythm.
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Atrial fibrillation and atrial flutter are cardiac rhythm disorders that are often symptomatic and may interfere with the heart's function, limiting its effectiveness. These arrhythmias are responsible for a large number of hospitalizations at a significant cost to the healthcare system. Electrical cardioversion (EC) is the most common nonpharmacologic intervention used to convert atrial fibrillation and atrial flutter to normal rhythm. Electrical cardioversion is highly successful in converting patients to normal rhythm; however, it is more traumatic and resource intensive than pharmacologic treatment. Recently, a new rapid-acting drug, ibutilide, was approved for the conversion of atrial fibrillation and atrial flutter. Ibutilide is administered through intravenous infusion and does not require anesthetization of the patient, as is required for EC. A decision-tree model was developed to estimate the cost-effectiveness of ibutilide therapy compared with EC therapy. Clinical outcomes were based on a phase III trial of ibutilide, and resource use was based on the literature and physician clinical judgment. A stepped conversion regimen of first-line ibutilide followed by EC for patients who fail to convert is less expensive and has a higher conversion rate than first-line EC. Sensitivity analysis shows that our results are robust to changes in cost and effectiveness estimates. (+info)
Private health care provision in developing countries: a preliminary analysis of levels and composition.
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While the importance of the private sector in providing health services in developing countries is now widely acknowledged, the paucity of data on numbers and types of providers has prevented systematic cross-country comparisons. Using available published and unpublished sources, we have assembled data on the number of public and private health care providers for approximately 40 countries. This paper presents some results of the analysis of this database, looking particularly at the determinants of the size and structure of the private health sector. We consider two different types of dependent variable: the absolute number of private providers (measured here as physicians and hospital beds), and the public-private composition of provision. We examine the relationship between these variables and income and other socioeconomic characteristics, at the national level. We find that while income level is related to the absolute size of the private sector, the public-private mix does not seem to be related to income. After controlling for income, certain socioeconomic characteristics, such as education, population density, and health status are associated with the size of the private sector, though no causal relationship is posited. Further analysis will require more complete data about the size of the private sector, including the extent of dual practice by government-employed physicians. A richer story of the determinants of private sector growth would incorporate more information about the institutional structure of health systems, including provider payment mechanisms, the level and quality of public services, the regulatory structure, and labour and capital market characteristics. Finally, a normative analysis of the size and growth of the private sector will require a better understanding of its impact on key social welfare outcomes. (+info)
Public hospital resource allocations in El Salvador: accounting for the case mix of patients.
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National hospitals in developing countries command a disproportionate share of medical care budgets, justified on the grounds that they have a more difficult patient case mix and higher occupancy rates than decentralized district hospitals or clinics. This paper empirically tests the hypothesis by developing direct measures of the severity of patient illness, hospital case-mix and a resource intensity index for each of El Salvador's public hospitals. Based on an analysis of inpatient care staffing requirements, national hospitals are found to receive funding far in excess of what case-mix and case-load considerations would warrant. The findings suggest that significant system-wide efficiency gains can be realized by allocating hospital budgets on the bases of performance-related criteria which incorporate the case-mix approach developed here. (+info)