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(1/751) Reliability of a hospital utilization review method in Turkey.

OBJECTIVE: To determine whether the Appropriateness Evaluation Protocol (AEP) is reliable in Turkey. METHODS: Three reviewers, two physicians and one nurse each reviewed 196 patient-days concurrently by using the AEP at three hospitals, two of which were teaching hospitals. Inter-reviewer reliability was assessed both for all cases reviewed (overall agreement), and for only those judged inappropriate by at least one reviewer (specific agreement). In addition, overall agreement between pairs of reviewers was evaluated by the Kappa statistic. RESULTS: The overall agreement between pairs of reviewers was very high: 93.4-95.9%, and it was similar between all pairs. The level of overall agreement was highly statistically significant: k=0.725-0.833, P<0.001. The specific agreement rates ranged from a low of 61.8% to a high of 75%. CONCLUSIONS: These results show, for the first time, that the AEP method is reliable in Turkey.  (+info)

(2/751) Audit of bronchial artery embolisation in a specialist respiratory centre.

OBJECTIVE: To audit the use of bronchial arteriography and embolisation for controlling haemoptysis. DESIGN: Retrospective review of radiological and clinical data. SETTING: Brompton and National Heart Hospitals. PATIENTS: 35 patients with severe pulmonary disease in whom 58 bronchial arteriograms were obtained between 1 January 1984 and 31 December 1989 with the intention of bronchial artery embolisation for controlling haemoptysis. MAIN MEASURES: Rate of technical success and cessation of haemoptysis; detailed evaluation of patients, particularly those with major haemoptysis (> 100 ml expectorated blood); and retrospective assessment of the appropriateness of the procedure in each. RESULTS: 58 procedures were performed, nine of which were unsuitable for detailed analysis. Nine procedures were for minor haemoptysis, which subsequently recurred, and 40 for recent major haemoptysis in 26 patients with cystic fibrosis (16) aspergilloma (six), bronchiectasis (three), and an unknown diagnosis (one). The median total volume of haemoptysis in the episode before the procedure was 680 ml (range 270-2200 ml). Embolisation was technically successful in 33/40 procedures, in 17 of which, however, major haemoptysis recurred within 10 days of the procedure, leaving 16 clinically and technically successful procedures in 15 patients. Five patients (three with aspergilloma, two with cystic fibrosis) died of haemoptysis despite attempted embolisation. CONCLUSION: Success rate of bronchial artery embolisation was 40%(16/40). IMPLICATIONS: Bronchial artery embolisation is probably not justified for minor haemoptysis or when performed more than one week after a major haemoptysis. Repeat arteriograms during a single period of haemoptysis are seldom useful. With these criteria 43% fewer procedures would have been performed with no loss of clinical benefit.  (+info)

(3/751) User charges in government health facilities in Kenya: effect on attendance and revenue.

In this paper we study demand effects of user charges in a district health care system using cross-sectional data from household and facility surveys. The effects are examined in public as well as in private health facilities. We also look briefly at the impact of fees on revenue and service quality in government facilities. During the period of cost-sharing in public clinics, attendance dropped by about 50%. This drop prompted the government to suspend the fees for approximately 20 months. Over the 7 months after suspension of fees, attendance at government health centres increased by 41%. The suspension further caused a notable movement of patients from the private sector to government health facilities. The revenue generated by user fees covered 2.4% of the recurrent health budget. Some 40% of the facilities did not spend the fee revenue they collected, mainly due to cumbersome procedures of expenditure approvals. The paper concludes with lessons from Kenya's experience with user charges.  (+info)

(4/751) Health services research in the English-speaking Caribbean 1984-93: a quantitative review.

Evaluating the effectiveness and efficiency of health services is important for all countries, especially those with limited resources. This study aimed to evaluate the volume and quality of health services research (HSR) conducted in one developing region, the English-speaking Caribbean. Data were abstracted from all 770 abstracts describing presentations at the annual scientific meetings of the Commonwealth Caribbean Medical Research Council for the decade 1984 to 1993. Of these, 341 abstracts were judged to report health services research and were from the English-speaking Caribbean. Hospital services were evaluated in 240 (70%) reports while primary health services were evaluated in only 90 (26%). Most hospital-based studies evaluated the use and outcome of medical and surgical services through the collection of case series and cohorts of cases, with a median sample size of 104 (interquartile range 38 to 320). Evaluations at primary level were more likely to evaluate need or demand for services, were more likely to report cross sectional surveys or randomized trials and included larger numbers of subjects (median 343, interquartile range 121 to 661). Patient-based measures of health status and measures of resource use were not often reported at either primary or secondary level. Estimation and hypothesis testing were infrequently employed in data analysis. A large proportion of the research presented could be classified as HSR but measures are needed to increase the motivation for research into primary care and to improve skills in HSR study design, conduct and analysis among those presently conducting research.  (+info)

(5/751) The fall and rise of cost sharing in Kenya: the impact of phased implementation.

The combined effects of increasing demand for health services and declining real public resources have recently led many governments in the developing world to explore various health financing alternatives. Faced with a significant decline during the 1980s in its real per capita expenditures, the Kenya Ministry of Health (MOH) introduced a new cost sharing programme in December 1989. The programme was part of a comprehensive health financing strategy which also included social insurance, efficiency measures, and private sector development. Early implementation problems led to the suspension in September 1990 of the outpatient registration fee, the major revenue source at the time. In 1991, the Ministry initiated a programme of management improvement and gradual re-introduction of an outpatient fee, but this time as a treatment fee. The new programme was carried out in phases, beginning at the national and provincial levels and proceeding to the local level. The impact of these changes was assessed with national revenue collection reports, quality of care surveys in 6 purposively selected indicator districts, and time series analysis of monthly utilization in these same districts. In contrast to the significant fall in revenue experienced over the period of the initial programme, the later management improvements and fee adjustments resulted in steady increases in revenue. As a percentage of total non-staff expenditures, fiscal year 1993-1994 revenue is estimated to have been 37% at provincial general hospitals, 20% at smaller hospitals, and 21% at health centres. Roughly one third of total revenue is derived from national insurance claims. Quality of care measures, though in some respects improved with cost sharing, were in general somewhat mixed and inconsistent. The 1989 outpatient registration fee led to an average reduction in utilization of 27% at provincial hospitals, 45% at district hospitals, and 33% at health centres. In contrast, phased introduction of the outpatient treatment fee beginning in 1992, combined with somewhat broader exemptions, was associated with much smaller decreases in outpatient utilization. It is suggested that implementing user fees in phases by level of health facility is important to gain patient acceptance, to develop the requisite management systems, and to orient ministry staff to the new systems.  (+info)

(6/751) Use of PRISM scores in triage of pediatric patients with diabetic ketoacidosis.

Triage guidelines are needed to help in the decision process of intensive care unit (ICU) versus non-ICU admission for patients with diabetic ketoacidosis (DKA). Pediatric risk of mortality (PRISM) scores have long been used to assess mortality risk. This study assess the usefulness of the traditional PRISM score and adaptation of that score (PRISM-ED, which uses presentation data only) in predicting hospital stay in pediatric patients with DKA. PRISM and PRISM-ED were tested for correlation with length of stay and length of ICU stay. A medical record review was conducted for patients admitted to The Children's Hospital of Alabama with DKA during an 18-month period (n = 79). Two scores were calculated for each study entrant: PRISM using the worst recorded values over the first 24 hours and PRISM-ED using arrival values. Median scores, median test, and Spearman rank correlations were determined for both tests. Median PRISM scores were PRISM = 11 and PRISM-ED = 12; Median PRISM and PRISM-ED scores for patients admitted to the ICU were less than median scores among floor-admitted patients: [table: see text] Spearman rank correlations were significant for both scores versus total stay: PRISM, rs = 0.29; P = 0.009; PRISM-ED, rs = 0.60, P < 0.001. Also, correlations were significant for both scores versus ICU stay: PRISM rs = 0.22, P = 0.05; PRISM-ED, rs = 0.41, P < 0.001. Triage guidelines for ICU versus floor admission for DKA patients could have significant economic impact (mean ICU charge = $11,417; mean charge for floor admission = $4,447). PRISM scores may be an important variable to include in a multiple regression model used to predict the need for ICU monitoring.  (+info)

(7/751) Impact of managed care on quality of healthcare: theory and evidence.

Each strategy for managing healthcare risk has important and unique implications for the patient-provider relationship and for quality of care. Not only are different incentive structures created by different risk-sharing arrangements, but these incentives differ from those in a fee-for-service environment. With fee-for-service and traditional indemnity insurance, physicians have incentives to provide healthcare services of marginal value to the patient; under managed care, physicians have fewer incentives to provide marginally beneficial services. However, the impact of financial arrangements on quality of care remains ambiguous, because it depends on the strategic behavior of physicians with regard to their informational advantage over their patients. Using the framework of an agency theory model, we surveyed the current scientific literature to assess the impact of managed care on quality of care. We considered three different dimensions of quality of care: patient satisfaction, clinical process and outcomes of care measures, and resource utilization. Although we found no systematic differences in patient satisfaction and clinical process and outcomes between managed care and fee-for-service plans, resource utilization appears to be decreased under managed care arrangements. Given the strengths and weaknesses of fee-for-service and managed care, it is unlikely that either will displace the other as the exclusive mechanism for arranging health insurance contracts. Policy makers may be able to take advantage of the strengths of both fee-for-service and managed care financial arrangements.  (+info)

(8/751) Comparison of NHS and private patients undergoing elective transurethral resection of the prostate for benign prostatic hypertrophy.

OBJECTIVES: To compare the operative thresholds and clinical management of men undergoing elective transurethral resection of the prostate for benign prostatic hypertrophy in the NHS and privately. DESIGN: Cohort study of patients recruited by 25 surgeons during 1988. SETTING: Hospitals in Oxford and North West Thames regions. PATIENTS: Of 400 consecutive patients, 129 were excluded because of open surgery (nine), lack of surgeons' information (three), and emergency admission (117) and three failed to give information, leaving 268 patients, 214 NHS patients and 54 private patients. MAIN MEASURES: Sociodemographic factors, prevalence and severity of symptoms, comorbidity, general health (Nottingham health profile) obtained from patient questionnaire preoperatively and reasons for operating, and operative management obtained from surgeons perioperatively. RESULTS: NHS and private patients were similar in severity of symptoms and prevalence of urinary tract abnormalities. They differed in four respects: NHS patients' general health was poorer as a consequence of more comorbid conditions (49, 23% v 7, 13% in severe category); the condition had a greater detrimental effect on their lives (36, 17% v 2, 4% severely affected; p < 0.01); private patients received more personalised care more quickly and were investigated more before surgery, (29, 54% v 60, 20% receiving ultrasonography of the urinary tract); and NHS patients stayed in hospital longer (57, 27% v 3, 6% more than seven days; p < 0.001). CONCLUSIONS: Private patients' need for surgery, judged by symptom severity, was as great as that of NHS patients, and there was no evidence of different operative thresholds in the two sectors, but, judged by impact on lifestyle, NHS patients' need was greater.  (+info)