Incidence and duration of hospitalizations among persons with AIDS: an event history approach.
(1/224)
OBJECTIVE: To analyze hospitalization patterns of persons with AIDS (PWAs) in a multi-state/multi-episode continuous time duration framework. DATA SOURCES: PWAs on Medicaid identified through a match between the state's AIDS Registry and Medicaid eligibility files; hospital admission and discharge dates identified through Medicaid claims. STUDY DESIGN: Using a Weibull event history framework, we model the hazard of transition between hospitalized and community spells, incorporating the competing risk of death in each of these states. Simulations are used to translate these parameters into readily interpretable estimates of length of stay, the probability that a hospitalization will end in death, and the probability that a nonhospitalized person will be hospitalized within 90 days. PRINCIPAL FINDINGS: In multivariate analyses, participation in a Medicaid waiver program offering case management and home care was associated with hospital stays 1.3 days shorter than for nonparticipants. African American race and Hispanic ethnicity were associated with hospital stays 1.2 days and 1.0 day longer than for non-Hispanic whites; African Americans also experienced more frequent hospital admissions. Residents of the high-HIV-prevalence area of the state had more frequent admissions and stays two days longer than those residing elsewhere in the state. Older PWAs experienced less frequent hospital admissions but longer stays, with hospitalizations of 55-year-olds lasting 8.25 days longer than those of 25-year-olds. CONCLUSIONS: Much socioeconomic and geographic variability exists both in the incidence and in the duration of hospitalization among persons with AIDS in New Jersey. Event history analysis provides a useful statistical framework for analysis of these variations, deals appropriately with data in which duration of observation varies from individual to individual, and permits the competing risk of death to be incorporated into the model. Transition models of this type have broad applicability in modeling the risk and duration of hospitalization in chronic illnesses. (+info)
Need to measure outcome after discharge in surgical audit.
(2/224)
OBJECTIVE: To assess the accuracy of outcome data on appendicectomy routinely collected as part of a surgical audit and to investigate outcome in the non-audited period after discharge. DESIGN: Retrospective analysis of audit data recorded by the Medical Data Index (MDI) computer system for all patients undergoing emergency appendicectomy in one year; subsequent analysis of their hospital notes and notes held by their general practitioners for patients identified by a questionnaire who had consulted their general practitioner for a wound complication. SETTING: One district general hospital with four consultant general surgeons serving a population of 250,000. PATIENTS: 230 patients undergoing emergency appendicectomy during 1989. MAIN MEASURES: Comparison of postoperative complications recorded in hospital notes with those recorded by the MDI system and with those recorded by patients' general practitioners after discharge. RESULTS: Of the 230 patients, 29 (13%) had a postoperative complication recorded in their hospital notes, but only 14 (6%) patients had these recorded by the MDI system. 189 (82%) of the patients completed the outcome questionnaire after discharge. The number of wound infections as recorded by the MDI system, the hospital notes, and notes held by targeted patients' general practitioners were three (1%), eight (3%), and 18 (8%) respectively. None of 12 readmissions with complications identified by the hospital notes were identified by the MDI system. CONCLUSIONS: Accurate audit of postoperative complications must be extended to the period after discharge. Computerised audit systems must be able to relate readmissions to specific previous admissions. (+info)
The diagnostic and treatment approach to two common conditions by the physician members of a community health maintenance organization.
(3/224)
We retrospectively collected data from one community managed care organization on all ambulatory care patients initially diagnosed with pneumonia or acute bronchitis from October, 1, 1992, to March 31, 1993, and from November 1, 1993, to January 31, 1994. We considered treatment to be successful when patients did not return for any related service within 15 days of initial diagnosis. We identified 2,490 episodes of illness, 85.7% which were acute bronchitis and 14.3% which were pneumonia. Overwhelmingly, physicians approached these conditions empirically (no diagnostic test); just 8.6% of patients had a diagnostic test during the 15-day episode of illness. Two-hundred twenty-nine of the episodes (9.2%) were apparently related to initial diagnoses, as they occurred during the 15-day period. More branded prescriptions (vs. generic) were dispensed during these related episodes. One patient was hospitalized and 19 patients used the emergency room either for first or subsequent visits. Empiric treatment is associated with effective diagnosis and therapy in ambulatory care patients with acute bronchitis and pneumonia. It remains unclear, however, if this strategy is the most cost-effective or if it leads to the most effective utilization of services. (+info)
Pharmacoeconomic analysis of selected antibiotics in lower respiratory tract infection.
(4/224)
An interactive pharmacoeconomic model was designed to evaluate the effects of clinical response and adverse drug events on the comparative cost and cost-effectiveness of a relatively new antibiotic, clarithromycin, compared with those of six other antibiotics used to treat community-acquired lower respiratory tract infection. The cost and cost-effectiveness analyses were based don 12 randomized, double-blind, controlled clinical trials conducted between 1987 and 1992 in regionally distributed outpatient clinics in the United States. The trials enrolled a total of 2377 patients. Of the 2377, 1102 patients were treated for acute exacerbation of chronic bronchitis, 591 for pneumonia, and 201 for either of the two conditions. Safety data for one of the antibiotics was obtained from a trial of patients with sinusitis (N = 483). The antibiotics included in the analysis were amoxicillin/clavulanate, ampicillin, cefaclor, cefixime, cefuroxime, clarithromycin, and erythromycin. The main outcome measures were the costs of resources to achieve a clinical response, costs related to managing adverse drug events, and costs of antibiotic treatment from the perspective of managed care. The mean total cost per episode ranged from approximately $137 to $267. The drug acquisition cost typically contributed a small amount to the overall cost. For the cost-effectiveness analysis, in which complication-free cure was used as a proxy for patient satisfaction, the range of mean cost per complication-free cure varied from approximately $307 for clarithromycin to $612 for cefaclor. When ranked from most to least cost-effective, the order was as follows: clarithromycin, cefixime, amoxicillin/clavulanate, erythromycin, cefuroxime, ampicillin, and cefaclor. The costs associated with clinical management (including treatment failure) and managing adverse drug events significantly contribute to the total cost and cost-effectiveness of antibiotics in the outpatient setting. Cost-effectiveness analyses are valuable in analyzing the various costs associated with the treatment of lower respiratory tract infection (acute exacerbation of chronic bronchitis or pneumonia) and may be useful tools for physicians managing patients, members of pharmacy and therapeutics committees developing formularies, and medical staff implementing practice guidelines. (+info)
Differences in costs of treatment for foot problems between podiatrists and orthopedic surgeons.
(5/224)
We examined charge data for health insurance claims paid in 1992 for persons under age 65 covered by a large California managed care plan. Charge and utilization comparisons between podiatrists and orthopedic surgeons were made for all foot care and for two specific foot problems, acquired toe deformities and bunions. Podiatrists provided over 59% of foot care services for this commercial population of 576,000 people. Podiatrists charged 12% less per individual service than orthopedists. However, podiatrists performed substantially more procedures per episode of care and treated patients for longer time periods, resulting in 43% higher total charges per episode. Hospitalization was infrequent for all providers, although podiatrists had the lowest rates. In a managed care setting in which all providers must adhere to a preestablished fee schedule, regardless of specialty, the higher utilization by podiatrists should lead to higher overall costs. In some cases, strong utilization controls could offset this effect. We do not know if the utilization difference is due to actual treatment or billing differences. Further, we were unable to determine from the claims data if one specialty had better outcomes than the other. (+info)
Gastrointestinal illness in managed care: healthcare utilization and costs.
(6/224)
Identification of inefficiencies is a first step to improving the quality of gastrointestinal (GI) care at the most reasonable cost. This analysis used administrative data to examine the healthcare utilization and associated costs of the management of GI illnesses in a 2.5 million-member private managed care plan containing many benefit designs. An overall incidence of 10% was found for GI conditions, with a preponderance in adults (patients older than 40 years) and women. The most frequently occurring conditions were abdominal pain, nonulcer peptic diseases, lower GI tract diseases, and other GI tract problems. These conditions, along with gallbladder/biliary tract disease, were also the most costly. Claims submitted for care during GI episodes averaged $17 per member per month. Increasing severity of condition was associated with substantial increases in utilization and costs (except for medication use). For most GI conditions, approximately 40% of charges were for professional services (procedures, tests, and visits) and 40% of charges were for facility admissions. The prescription utilization analysis indicated areas where utilization patterns may not match accepted guidelines, such as the low use of anti-Helicobacter pylori therapy, the possible concomitant use of nonsteroidal anti-inflammatory drugs in patients with upper GI diseases, and the use of narcotics in treating patients with lower GI disease and abdominal pain. Also, there was no clear relationship between medication utilization and disease severity. Thus, this analysis indicated that GI disease is a significant economic burden to managed care, and identified usage patterns that potentially could be modified to improve quality of care. (+info)
The impact of reimbursement changes for intracoronary stents on providers and Medicare.
(7/224)
CONTEXT: New Medicare reimbursement policies will move stents into a different diagnosis-related group (DRG) than conventional balloon angioplasty (percutaneous transluminal coronary angioplasty [PTCA]). OBJECTIVE: To examine the financial impact on hospitals and Medicare of these planned changes, taking into account costs, reimbursement, and the cost-offset effect of prevented complications. DESIGN: The economic impact of proposed reimbursement changes was modeled by using a retrospective clinical and economic data set from a single institution. PATIENTS AND METHODS: A total of 421 consecutive interventional cases from 1996 were examined by using actual cost data. The new, proposed revenues were assigned to these cases. From the hospitals' perspective, the focus was on contribution margin (the difference between revenues and costs), risk adjusted for case-mix severity. From Medicare's perspective, the focus was on expenditures. Various assumptions were adopted for two clinical variables: the effectiveness of stents in preventing the major PTCA-related complications of myocardial infarction and coronary artery bypass graft surgery and the relative proportions of myocardial infarction and coronary artery bypass graft surgery in the mix of complications. Under current Medicare DRG policies, coronary artery bypass graft surgery is highly profitable for hospitals, whereas myocardial infarction as a complication of PTCA has a negative financial impact. RESULTS: Under the new Medicare reimbursement policies, hospitals experience higher profitability with stents than with conventional PTCA under most assumed levels of clinical effectiveness and mixes of myocardial infarction and coronary artery bypass graft surgery. For Medicare, under most circumstances (including percentages of stent use and levels of clinical effectiveness that represent contemporary practice) stents lead to greater expenditures. CONCLUSIONS: Medicare reimbursement changes will substantially realign previously misaligned financial and clinical incentives for hospitals. The immediate effect on hospitals will be to enhance profitability, whereas the effect on Medicare will be to increase expenditures. (+info)
Allocative efficiency in the use of health resources in Portugal.
(8/224)
BACKGROUND: This is the first time that a resource allocation technique based on a marginal met need approach has been used in Portugal, and the objective of the study is to attain the improvement of allocative efficiency. METHODS: The utilities of health states with and without treatment have been measured using the rating scale technique and a cost-utility analysis has been made. The value resulting from multiplying the avoided days of incapacity by a weight, on a scale from zero to one, has been considered as an indicator of utility corresponding to the difference between a health state with and without treatment. This study has been carried out using the main causes of morbidity from the National Health Survey, 1987, at a regional level. A sample of 150 local authorities was considered to be sufficient. A second objective of this study was to carry out a cost-utility analysis for the main causes of declared morbidity. RESULTS: This analysis has shown that the ratio of cost-utility is highest for hypertension, followed by influenza, asthma and digestive ill-functioning. Pharyngitis-amygdalitis, cold, osteoarthrosis, chronic bronchitis, spondylous arthrosis and diabetes are the illnesses with a more favourable cost-utility ratio which, in a rational resource allocation, should be treated first. CONCLUSIONS: So that an increase in the allocative efficiency could be achieved, a transfer of resources between regions is required up to the point at which the use of these resources would be equally efficient. Resources should be transferred from two regions - Interior Centre Region and Littoral Lisbon Region - towards all the other regions, in particular the Interior North Region. (+info)