Effects of socioeconomic status on access to invasive cardiac procedures and on mortality after acute myocardial infarction.
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BACKGROUND: Universal health care systems seek to ensure access to care on the basis of need rather than income and to improve the health status of all citizens. We examined the performance of the Canadian health system with respect to these goals in the province of Ontario by assessing the effects of neighborhood income on access to invasive cardiac procedures and on mortality one year after acute myocardial infarction. METHODS: We linked claims for payment for physicians' services, hospital-discharge abstracts, and vital-status data for all patients with acute myocardial infarction who were admitted to hospitals in Ontario between April 1994 and March 1997. Patients' income levels were imputed from the median incomes of their residential neighborhoods as determined in Canada's 1996 census. We determined rates of use and waiting times for coronary angiography and revascularization procedures after the index admission for acute myocardial infarction and determined death rates at one year. In multivariate analyses, we controlled for the patient's age, sex, and severity of disease; the specialty of the attending physician; the volume of cases, teaching status, and on-site facilities for cardiac procedures at the admitting hospital; and the geographic proximity of the admitting hospital to tertiary care centers. RESULTS: The study cohort consisted of 51,591 patients. With respect to coronary angiography, increases in neighborhood income from the lowest to the highest quintile were associated with a 23 percent increase in rates of use and a 45 percent decrease in waiting times. There was a strong inverse relation between income and mortality at one year (P<0.001). Each $10,000 increase in the neighborhood median income was associated with a 10 percent reduction in the risk of death within one year (adjusted hazard ratio, 0.90; 95 percent confidence interval, 0.86 to 0.94). CONCLUSIONS: In the province of Ontario, despite Canada's universal health care system, socioeconomic status had pronounced effects on access to specialized cardiac services as well as on mortality one year after acute myocardial infarction. (+info)
Hospitalist staffing requirements.
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CONTEXT: The use of hospitalists--physicians who spend a substantial portion of their time providing in-hospital care to the patients of primary care physicians--has been proposed as a way to decrease costs and increase the quality of inpatient care. COUNT: Number of full-time hospitalists. CALCULATIONS: Average daily census = annual admissions x length of stay divided by 365. Number of hospitalists = (average daily census divided by patients per hospitalist) + 1 extra hospitalist for night coverage. DATA SOURCES: The average number of patients per hospitalist was obtained from a National Association of Inpatient Physicians membership survey. A low estimate of 10 patients per hospitalist was used to account for the extra manpower needed for coverage during vacations and other time off. RESULTS: A hospital with 3000 admissions per year and an average length of stay of 5 days would have an average daily census of 41 patients and would need 5 full-time hospitalists. Hospitals with a lower patient volume would need fewer hospitalists and would probably need to find persons other than hospitalists to cover some nights and weekends. CONCLUSIONS: Simple calculations based on hospital admissions and length of stay can estimate the number of hospitalists required for adequate staffing. Requirements will vary with the hospitalists' workload; the patient case complexity; and the duties other than inpatient care that are required of hospitalists, such as consultations, skilled nursing facility coverage, quality improvement work, teaching, and research. (+info)
Hospital expenditures and utilization: the impact of HMOs.
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OBJECTIVE: To determine whether hospital utilization and expenditures have declined more rapidly in metropolitan statistical areas (MSAs) with high health maintenance organization (HMO) penetration compared with MSAs with low HMO penetration. STUDY DESIGN: Levels and rates of change in hospital expenditures and hospital utilization in MSAs with varying levels of HMO penetration (1982 to 1996) were compared in a natural experiment. METHODS: MSAs were grouped into 4 categories based on HMO penetration rates in 1996. Levels and rates of change in hospital admission rates, hospital inpatient days, emergency room visits, total expenditures per capita, and expenditures per adjusted inpatient day from 1982 to 1996 were compared. A first-difference multivariate model was evaluated for 1993 to 1996. RESULTS: At the MSA level, the rates of change in hospital utilization and hospital expenditures varied only modestly with the level of HMO penetration. Changes in hospital admission rates did not vary systematically with HMO penetration rates except in the 1993 to 1996 period, when MSAs with the highest HMO penetration had the largest decline. Reductions in hospital days per capita and expenditures per day did not vary systematically by level of HMO penetration. Emergency room days declined most rapidly in the MSAs with the highest HMO penetration in the 1982 to 1993 period and were similar in the 1993 to 1996 period. Hospital expenditures per capita showed the greatest association with managed care penetration. They averaged 1.6% slower annual growth in MSAs with high versus low HMO penetration in the 1982 to 1996 period. CONCLUSIONS: This national study using data from 1982 to 1996 suggests that the effects of HMO penetration on hospital expenditures and hospital utilization at the MSA level are small (generally less than 1% per year). (+info)
Reliability study of the European appropriateness evaluation protocol.
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OBJECTIVE: To help to co-ordinate and harmonize research on utilization review in Europe, the US Appropriateness Evaluation Protocol (f inverted question markEP) was adapted for use in the European setting. The aim of this paper is to assess the reliability of the European version of the AEP (EU-AEP). DESIGN: Nineteen English-language medical records were reviewed by a physician reviewer from each of six participating countries: Austria, France, Italy, Spain, Switzerland and the UK. Each of the six reviewers was asked to assess the appropriateness of the 19 admissions and 31 hospitalization days (19 admission days and 12 randomly selected days of hospital stay, excluding days of discharge) using the revised review instrument. To evaluate inter-rater reliability, the kappa statistic was used to measure overall and pair-wise agreement for the assessment of appropriateness of admission and of day of care, respectively. RESULTS: For admission, the overall kappa statistic among the six reviewers was 0.64, with kappa values for each pair of reviewers in the range 0.46-0.86. For day of care, the kappa was 0.59, with pair-wise kappa coefficients in the range 0.25-0.95. CONCLUSION: The observed agreement could be considered substantial, especially if the fact that medical records were hand-written in a language native to only one of the reviewers is considered. Besides all the study limitations, this finding provides at least preliminary support for the application of the EU-AEP as a reliable instrument in the European setting, including application in comparative studies involving two or more countries. (+info)
Population-based study of relationships between hospital volume of prostatectomies, patient outcomes, and length of hospital stay.
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BACKGROUND: Despite the large number of prostatectomies performed annually, few data exist regarding relationships between the volume of prostatectomies handled by a hospital, the length of a patient's stay in the hospital, and patient outcomes. We examined the effect of hospital prostatectomy volume and changes in the hospital volume on patient outcomes and the length of a patient's stay. METHODS: We collected data on 101 604 prostatectomies from Medicare claims filed from 1991 through 1994. By use of logistic regression and analysis of variance, we examined relationships between hospital load of prostatectomies, length of a patient's hospital stay, surgical complications, readmission rate, and mortality rate in a 30-day period following surgery. Statistical tests were two-sided. RESULTS AND CONCLUSIONS: Cross-sectional analyses revealed that, compared with high-volume hospitals, low-volume, medium-low-volume, and medium-high-volume hospitals had higher relative risks of readmission by 30% (95% confidence interval [CI] = 21%-39%), 16% (95% CI = 7%-25%), and 8% (95% CI = -1% to 17%), respectively; higher relative risks of serious complications by 43% (95% CI = 37%-48%), 25% (95% CI = 19%-31%), and 9% (95% CI = 3%-15%), respectively; and higher relative risks of mortality by 51% (95% CI = 25%-77%), 43% (95% CI = 17%-69%), and 42% (95% CI = 16%-68%), respectively. The mean length of a patient's stay in a low-volume hospital was 9% longer than that in a high-volume hospital (8.51 days [95% CI = 8.47-8.56] versus 7.81 days [95% CI = 7.77-7.85]; P for trend across all volume categories =.0001). Within-hospital longitudinal analyses revealed that hospitals with a relative increase in prostatectomy volume had a 57% greater reduction in the length of a patient's stay compared with those with a relative decrease in volume (P =.005). Changes in prostatectomy volume did not affect the frequency of complications, mortality, and readmission. These findings suggest that an increase in a given hospital's prostatectomy volume may facilitate a decrease in the length of a patient's stay without an adverse impact on patient outcomes. (+info)
Integrated knowledge-based functions in a hospital cancer registry--specific requirements for routine applicability.
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The background of the presented work is the design, realization, and routine use of integrated knowledge-based functions in the context of a hospital cancer registry. The first field of application was supporting registrars to detect data inconsistencies and incompleteness timely during the documentation process. Especially, we focused on the acceptance of the administrator of the underlying information system and on the phenomenon of duplicate and outdated messages. These aspects are specific for integrated knowledge based functions and a precondition for obtaining a routine applicability and acceptance. (+info)
Epidemics of diarrhea caused by a clindamycin-resistant strain of Clostridium difficile in four hospitals.
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BACKGROUND: Large outbreaks of diarrhea caused by a newly recognized strain of Clostridium difficile occurred in four hospitals located in different parts of the United States between 1989 and 1992. Since frequent use of clindamycin was associated with the outbreak in one of the hospitals, we examined the resistance genes of the epidemic-strain isolates and studied the role of clindamycin use in these outbreaks. METHODS: Case-control studies were performed at three of the four hospitals to assess the relation of the use of clindamycin to C. difficile-associated diarrhea. All isolates of the epidemic strain and representative isolates of other strains identified during each outbreak were tested for susceptibility to clindamycin. Chromosomal DNA from these representative isolates was also analyzed by dot blot hybridization and amplification with the polymerase chain reaction (PCR) with the use of probes and primers from a previously described determinant of erythromycin resistance - the erythromycin ribosomal methylase B (ermB) gene - found in C. perfringens and C. difficile. RESULTS: In a stratified analysis of the case-control studies with pooling of the results according to the Mantel-Haenszel method, we found that the use of clindamycin was significantly increased among patients with diarrhea due to the epidemic strain of C. difficile, as compared with patients whose diarrhea was due to nonepidemic strains (pooled odds ratio, 4.35; 95 percent confidence interval, 2.02 to 9.38; P<0.001). Exposure to other types of antibiotics or hospitalization in a surgical ward was not significantly associated with the risk of C. difficile-associated diarrhea due to the epidemic strain. All epidemic-strain isolates were highly resistant to clindamycin (minimal inhibitory concentration, >256 microg per milliliter). DNA hybridization and PCR analysis showed that all these isolates had an ermB gene, which encodes a 23S ribosomal RNA methylase that mediates resistance to macrolide, lincosamide, and streptogramin antibiotics. Only 15 percent of the nonepidemic strains were resistant to clindamycin. CONCLUSIONS: A strain of C. difficile that is highly resistant to clindamycin was responsible for large outbreaks of diarrhea in four hospitals in different states. The use of clindamycin is a specific risk factor for diarrhea due to this strain. Resistance to clindamycin further increases the risk of C. difficile-associated diarrhea, an established complication of antimicrobial use. (+info)
Therapeutic drug monitoring in a developing country: an overview.
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Therapeutic Drug Monitoring (TDM) was introduced in India in the mid and late 1980s and the last 10 years have seen it grow, together with the growth of separate Clinical Pharmacology departments. The TDM service in the country is broadly of two types: in large teaching hospitals where the service is available through departments of Clinical Pharmacology, and in the private sector, where drug estimations are done by clinical biochemistry departments with minimal interpretation. This article is based on literature review and our own experiences over a 10 year period in a department of Clinical Pharmacology. It focuses on the evolution of TDM, its problems such as lack of funding, special aspects such as the impact of ethnic differences, nutritional deficiencies, quality of medicines and availability of generic products; its utility as a research tool and its future. (+info)