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Biomedical subjects

D Z Louis

Publications and source records attributed to D Z Louis.

At least 19 recordsLinked to original sources
PubMed1999

Impact of a DRG-based hospital financing system on quality and outcomes of care in Italy.

OBJECTIVE: To examine potential changes in quality of care associated with a recent financing system implementation in Italy: in 1995, hospital financing reform implemented in Italy included the introduction of a DRG-based hospital financing system with the goals of controlling the growth of hospital costs and making hospitals more accountable for their productivity. DATA SOURCES: Hospital discharge abstract data from 1993 through 1996 for all hospitals (N=32) in the Friuli-Venezia-Giulia region of Italy. Regional population data were used to calculate rates. STUDY DESIGN: Changes between 1993 and 1996 in hospital admissions, length of stay, mortality rates, severity of illness, and readmission rates were studied for nine common medical and surgical conditions: appendicitis, diabetes mellitus, colorectal cancer, cholecystitis, bronchitis/chronic obstructive pulmonary disease (COPD), bacterial pneumonia, coronary artery disease, cerebrovascular disease, and hip fracture. PRINCIPAL FINDINGS: The total number of ordinary hospital admissions decreased from 244,581 to 204,054 between 1993 and 1996, a population-based decrease of 17.3 percent (p<.001). The mean length of stay decreased from 9.1 days to 8.8 days, resulting in a 21.1 percent decrease in hospital bed days (p<.001). Day hospital use increased sevenfold from 16,871 encounters in 1993 to 108,517 encounters in 1996. The largest decrease in hospital admissions among study conditions was a 41 percent decrease for diabetes (from 2.25 per 1,000 in 1993 to 1.31 in 1996, p<.001). For eight of the nine conditions, severity of illness increased. Differences between severity-adjusted expected and observed in-hospital mortality rates were small. CONCLUSIONS: Observed trends showed a decrease in ordinary hospital admissions, an increase in day hospital admissions, and a greater severity of illness among hospitalized patients. There was little or no change in mortality and readmission rates. Administrative data can be used to track changes in patterns of care and to identify potential quality problems deserving further review.

Diagnosis-Related Groups↗
PubMed1997

Sedative-hypnotic use by the elderly: effects on hospital length of stay and costs.

Sedative-hypnotic medications are often used to treat anxiety and sleep disorders, although they may not be used appropriately. Relationships between hospital length of stay (LOS), costs, and levels of sedative-hypnotic use were examined. Charts of 856 elderly patients were reviewed for sedative hypnotic use and categorized into three groups: those whose use exceeded Health Care Financing Administration (HCFA) guidelines, those who used sedative-hypnotic medications but did not exceed HCFA guidelines, and those who did not receive any sedative-hypnotic medications. Patients whose sedative-hypnotic use exceeded guidelines had longer LOS (21.5 exceeding guidelines vs. 12.3 within guidelines vs. 6.7 no use, p < or = .001) and higher costs ($29,245 exceeding guidelines vs. $15,219 within guidelines vs. $7,516 no use, p < = or .001.) Even after controlling for severity of illness and comorbid conditions, differences in LOS and costs persisted. This study indicates that sedative-hypnotic medications are frequently prescribed to elderly patients, often in doses exceeding proposed guidelines, and are associated with longer hospital stays and higher hospital costs.

Age Factors↗
PubMed1997

Variation in hospital use and avoidable patient morbidity.

OBJECTIVES: To determine whether geographical areas with relatively low overall hospitalization rates have higher population-based rates of admission of patients with advanced stages of disease. METHODS: Age- and sex-standardized hospital admission rate were calculated for the residents of the 80 Local Health Units in Lombardia, Italy. Using the Disease Staging classification, advanced stage admissions were identified for six common medical and surgical conditions, which it was presumed would reflect untimely hospital admission. Standardized rates of advanced stage admissions were compared in areas with overall high hospitalization rates (high-use areas). RESULTS: Hospitalization at advanced stages of disease in the low-use areas were significantly higher for the six conditions combined (55.9 vs 43.0 per 100,000; P = 0.005), and for external hernia, appendicitis and uterine fibroma, but not for bacterial pneumonia, diverticular disease and peptic ulcer. For the six study conditions combined, residents of overall low-use area were 30% more likely to be admitted with advanced stages of disease. CONCLUSION: Low overall hospitalization rates were found to be associated with greater severity of illness at hospitalization and potentially avoidable morbidity for some conditions. Policies aimed at curbing unnecessary hospital admission should consider preserving access for appropriate treatment.

Acute Disease↗
PubMed1997

Bridging the gap between managed care and academic medicine: an innovative fellowship.

Numerous challenges face academic medicine in the era of managed care. This environment is stimulating the development of innovative educational programs that can adapt to changes in the healthcare system. The U.S. Quality Algorithms Managed Care Fellowship at Jefferson Medical College is one response to these challenges. Two postresidency physicians are chosen as fellows each year. The 1-year curriculum is organized into four 3-month modules covering such subjects as biostatistics and epidemiology, medical informatics, the theory and practice of managed care, managed care finance, integrated healthcare systems, quality assessment and improvement, clinical parameters and guidelines, utilization management, and risk management. The fellowship may serve as a possible prototype for future post-graduate education.

Algorithms↗
PubMed1996

Sedative-hypnotic use and increased hospital stay and costs in older people.

OBJECTIVE: To assess the relationship between sedative-hypnotic (S/H) utilization, severity of illness, length of stay, and hospital costs among older patients admitted to a tertiary care university hospital. DESIGN: Retrospective review of computerized hospital and pharmacy data bases. SUBJECTS: A total of 856 older consecutive medical and surgical admissions from November 1993 to March 1994. MEASUREMENTS: Sedative/hypnotic utilization in accord with the Health Care Financing Administration (HCFA) guidelines for S/H use in nursing homes. Jefferson Disease Staging to estimate severity of illness. Hospital records to obtain demographic characteristics, length of stay, and hospital costs. RESULTS: Patients whose S/H use exceeded HCFA guide lines, compared with those within the guidelines and those receiving no drugs, had longer lengths of stay (21.5 days vs 12.3 days vs 6.7 days, P < .001), increased hospital costs ($29,245 vs $15,219 vs $7,516, P < .001). and greater severity of illness (245.8 vs 189.5 vs 148.5, P < .001). S/H use exceeding and within HCFA guidelines were associated with increased length of stay (both P < .0001) and hospital costs (both P < .0001). CONCLUSIONS: Older hospitalized patients receiving S/H have greater severity of illness, longer lengths of stay, and higher hospital costs compared with other patients. S/H use, and, in particular, S/H use exceeding the HCFA guidelines, are associated with increased hospital stay and cost.

Aged↗
PubMed1996

Patterns of hospital care and physician perspectives from an Italian, Japanese, and USA hospital.

Many studies have compared different countries' health care systems at the macro level. Less has been done to analyze care provided for patients with specific diseases and to compare physician attitudes concerning factors that influence patient care. This study compares severity of illness and length of hospital stay for patients admitted for diabetes mellitus, cholecystitis, or appendicitis at three teaching hospitals in Italy, Japan, and the United States. Physicians caring for patients with these diseases were surveyed to assess their opinions of the adequacy of resources available at their hospital, perceived administrative pressures concerning resource use, and interactions with patients and their families that relate to admission and discharge decisions. The severity of the patient mix was consistently higher in the U.S. hospital than in the Italian or Japanese hospitals. Controlling for diagnosis, severity of illness, surgery, age, and presence of co-morbid conditions, the U.S. hospital consistently had the shortest stays and the Japanese hospital the longest. Japanese physicians were more likely than U.S. or Italian physicians to report insufficient resources, such as nurses, to provide quality care, but less likely to report administrative pressures interfering with patient care. Differences in hospital utilization may reflect variation in clinical practices, availability of resources, barriers to access to care, organizational differences at the national and hospital level, and patient and family preferences.

Adult↗
PubMed1995

Severity-adjusted differences in hospital utilization by gender.

Gender-based differences in hospital use may result from biological differences or may suggest problems of access to health services and quality of care. We hypothesized that there should be no difference in hospital care between men and women, given the same diagnosis. Hospitalizations were characterized by severity of illness, as this may indicate the timeliness of hospital care. Hospitalizations may be too late (with higher severity of illness) resulting in long stays and high costs, or too early (with lower severity of illness) resulting in care that could be given in alternative treatment settings. Three abdominal conditions were examined which could be misdiagnosed or confused with other diseases involving the female reproductive system: appendicitis, diverticulitis, and cholecystitis. The National Hospital Discharge Survey (NHDS) was used for analysis. Disease staging was used to assign a severity of illness indicator, ranging from stage 1 (conditions with no complications) to stage 3 (multiple site involvement, poor prognosis). For each disease, the percentage of discharges and the age-adjusted discharge rate per 1000 population was examined by stage of illness and gender. For appendectomy, there was a significantly greater percentage of men at stage 1 (lower severity) compared to women (73% versus 67%). For diverticular disease, women had higher proportions of stage 2/3 discharges than men for both medical and surgical hospitalizations. For cholecystitis, women had a greater percentage of hospitalizations at stage 1 than men, notably for surgical treatment (63% compared with 38%), although more men were admitted at stage 2 for both medical and surgical treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic Tests, Routine↗
PubMed1994

Physicians' responsibilities and outcomes of medical care.

BACKGROUND: The federal government and many states have published hospital-specific data on resource use and outcomes of care. Both Pennsylvania and New York State have published data that identify physicians by name. These data are being released without a clear understanding of physicians' responsibilities and the impact of their behavior on patient outcomes. They also lack the clinical specificity necessary for appropriate comparisons of outcomes or processes of care. This article proposes a model for defining the responsibilities of physicians in providing medical care and describes a clinically specific approach to classifying patients for evaluation studies. A PROPOSED MODEL: Physicians' responsibilities require that they act as clinicians, managers, and teachers. Outcomes are affected by many factors--the practices of the individual physician, the contributions of the patient, the setting in which care is provided, and the social and physical environment. To enable clinically specific comparisons to be made, an approach to defining biological severity of illness based on the dimensions of location, etiology, and severity of the problem is described. CONCLUSION: Public release of data concerning quality of medical care implies a responsibility for the quality of the data being presented. Research needs to be performed to improve measurement tools, new personnel need to be adequately trained, and data that have clinical and statistical validity need to collected and analyzed.

Community-Institutional Relations↗
PubMed1991

Clinical outcomes management and disease staging.

Clinical outcomes management includes multiple approaches for evaluating and improving the quality and cost effectiveness of medical care. The usefulness of outcomes assessments depends, in part, on how well the clinical issues have been specified and whether the analyses are sensitive to the diverse clinical characteristics of the patients receiving the medical care in question. Measures of severity of illness and, in particular, Disease Staging, have an important role in outcomes assessment by classifying diseases along dimensions that have prognostic significance. This article reviews current applications of Disease Staging for outcomes assessment and management.

Clinical Protocols↗
PubMed1990

The problem of late hospitalization: a quality and cost issue.

Emphasis on controlling health-care costs has led to many activities aimed at avoiding medically unnecessary hospitalizations. Much less attention has been given to patients hospitalized in advanced stages of illness and the impact of these late admissions on cost and quality of care. A panel of physicians developed criteria to categorize hospital admissions into one of three groups--early, timely, or late--based on the timing of the initial hospitalizations of patients admitted with any one of 14 diagnoses. Over a period of one year (fiscal year 1984) the criteria were applied retrospectively to 2,713 patients admitted to either of two hospitals. Twenty-one percent of the admissions studied in one hospital and 19% in the other were judged to occur later than was desirable. The mean length of stay for late hospitalizations exceeded that for timely hospitalizations by 11.1 days at one hospital and by 7.5 days at the other (p less than .01). Similar patterns were observed in analyzing the 14 diseases individually and in an analysis of hospital charges at the one hospital where charge data were available. In-hospital mortality rates for patients with a principal diagnosis of bacterial pneumonia were over ten times greater for those admitted late than for those whose admissions were timely (39.0% versus 3.8%, p less than .001, at one hospital; 28.9% versus 2.1%, p less than .001, at the other). While not all late hospitalizations are avoidable, the authors believe that the analysis of late hospitalization patterns is an important part of any effort that can be made to reduce them.

Costs and Cost Analysis↗
PubMed1984

Staging of disease. A case-mix measurement.

Measurement of illness severity is required to evaluate diagnostic efficiency of physicians, assess quality of care, understand utilization of health services, design clinical trials, and reimburse hospitals on the basis of output. "Staging" is a method for measuring severity of specific, well-defined diseases. Staging defines discrete points in the course of individual diseases that are clinically detectable, reflect severity in terms of risk of death or residual impairment, and possess clinical significance for prognosis and choice of therapeutic modality. Medical staging criteria have been developed for 420 diagnoses and converted into "coded" criteria for the major diagnostic coding systems. Coded criteria can be efficiently applied to computerized hospital discharge abstracts to derive a comprehensive case-mix classification system. Uses of staging in epidemiologic, case-mix, and utilization analyses are illustrated for diabetes mellitus.

Adult↗
PubMed1984

Disease staging: implications for hospital reimbursement and management.

The current patient classification schemes used in case-mix reimbursement are not fully sensitive to variations in resource consumption that are associated with differential disease severity. Disease staging is a clinically based measure of severity that uses objective medical criteria to assess the stage of disease progression. Its availability in automated form increases its ease of implementation in hospital reimbursement and management. Results of recent studies demonstrate that staging is a useful case-mix reimbursement and management tool that explains significant variation in cost per discharge within current diagnosis-related groups.

Costs and Cost Analysis↗