Hospital spending in the United States and Canada: a comparison.
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Aged↗
Biomedical subjects
L L Roos
Publications and source records attributed to L L Roos.
Software for health care analysts: a modular approach.
The many concerns about the cost and quality of health care suggest the need to facilitate planners' using existing data bases for utilization review, program evaluation, and technology assessment. Despite both the availability of relevant data and widespread improvements in computing power, integrated computer software to permit analyses by nonspecialists has not previously been developed. This paper discusses the features of a health policy information system which aids working with hospital discharge abstracts, medical claims, cancer registries, and vital statistics files. Analyses of small area utilization, length of stay, in-hospital mortality, and readmissions are facilitated by this package. This information system, named the Health Applications System, includes an analysis module, three information management modules, and a set of record linkage modules. The modules were developed using the macroprocessor in the fourth-generation SAS system. Features of the software and their implications for data analysis are discussed.
Data Interpretation, Statistical↗
Simplifying record linkage: software and strategy.
Although the methodology of record linkage is fairly well developed, there is a need for less expensive methods and simpler software to facilitate trying out different tactics to generate good linkages. The present work has built on a fourth generation language SAS (Statistical Analysis System) with accompanying macroprocessor, to develop a user-friendly and flexible system for both exact and probabilistic matching. The major features of the LINKS system are presented and illustrated using 1979-1984 information from the Manitoba Health Services Commission (MHSC) registry file with the Canadian Mortality Data Base. Initial runs with exact, then probabilistic, matching linked approximately 91% of the Vital Statistics records to corresponding MHSC records. Subsequent modification of parameters improved the linkage to 95%.
Database Management Systems↗
Using administrative data for longitudinal research: comparisons with primary data collection.
This paper discusses the advantages and disadvantages of using administrative data for longitudinal research, focusing on loss to follow-up. Comparisons between research relying on primary data collection and that using data bases are made. After development of a suitable framework, follow-up in several well-known projects based on primary data collection (the Seven Countries project on coronary heart disease, the Massachusetts research on long-term care and the Pittsburgh clinical trial of tonsillectomy) is compared with follow-up using the Health Services Commission data base in Manitoba, Canada. Overall follow-up in the Manitoba research compares favorably with participation and follow-up rates in other studies based on primary data collection. Initial nonresponse and nonlocation are major problems with studies using primary data; failure to locate earlier respondents in subsequent waves results in a wide range of overall response rates. Data bases do not require researchers to contact individuals and hence follow-up is simplified. Eight year follow-up rates in the Manitoba data base are almost always over 80% and often over 90%. Because records can be flexibly summarized for each individual over time, data bases facilitate certain types of longitudinal studies which would be difficult, if not impossible, to perform using other methodologies. If the desired data are available and recorded with acceptable accuracy, administrative data banks hold considerable promise for the health care researcher.
Adolescent↗
Using insurance claims to measure health status: the Illness Scale.
Health insurance systems are generating large numbers of claims filed by physicians and hospitals for reimbursement and accounting purposes. This paper describes and evaluates a measure of health status derived from physician and hospital claims filed for a sample of older Canadians during 1970-1977. Information on the number, type, and seriousness of reported diagnoses and the number and duration of hospitalizations and surgeries during each year were combined to generate annual Illness Scales ranging from 0 to 24. Alpha coefficients, measures of internal consistency, were between 0.82 and 0.84. Consistent with high validity, Illness Scale scores increased with age, were significantly associated with other health measures, and were strongly predictive of death and hospitalization in the following year. The ability to develop valid and reliable health status measures from insurance claims substantially expands the potential use of these data for research and evaluation.
Age Factors↗
Monitoring adverse outcomes of surgery using administrative data.
In this article, we document a stabilization in adverse outcomes associated with hysterectomies, cholecystectomies, and prostatectomies performed between 1972-73 and 1982-83 in Manitoba, Canada. The proportion of surgery performed by high-volume surgeons and by surgical specialists increased slightly over the decade. However, given the already low rates of adverse outcomes, these changes did not translate into significant decreases in the postoperative mortality rate or in the rate of related hospital readmissions. Reducing the proportion of adverse outcomes would be facilitated by identifying institutions with poorer than expected outcomes.
Cholecystectomy↗
Health care utilization in the years prior to death.
The impact of an aging population on the health care system is a primary speculative concern for health policy. Unique data from a large sample of 4,263 decedents aged 45 years and over in Manitoba, Canada, describe actual utilization in the four years prior to death: all hospitalizations, nursing home stays, and ambulatory physician contacts. Total expenditures associated with dying do increase with age, but even among the very elderly many deaths have few expenditure consequences. Apocalyptic scenarios for the health care system may be premature.
Aged↗
The art and science of record linkage: methods that work with few identifiers.
Increasing use of administrative records for research purposes has led to the need to develop methods for linking records. Linkage of the data from the Manitoba Health Services Commission (MHSC) with Canadian Vital Statistics records was done to verify Manitoba deaths, to measure degree of agreement between the two data sets, and to link "cause of death" information from Vital Statistics back to medical histories. A multi-stage approach to matching was adopted. Individual records matching perfectly across a number of relevant variables in the two files were selected first, reducing the number of records going through the probability matching to manageable proportions. Overall, almost 96% of the MHSC records were well matched with Vital Statistics records. Both uses of the matched data and various ways to confirm data quality are discussed.
Humans↗
Centralization, certification, and monitoring. Readmissions and complications after surgery.
Research on adverse outcomes following common surgical procedures has suggested the importance of hospital and surgeon variables. Policy directions depend on which factors are important in influencing patient outcomes and what sorts of policies are feasible. Focusing on where a given procedure is performed highlights a concern for centralization; emphasizing who should perform a particular operation implies physician certification. Finally, monitoring involves identifying particular hospitals that appear to have relatively poor (or relatively good) results. This paper analyzes patient, surgeon, and hospital characteristics associated with serious postdischarge complications of hysterectomy, cholecystectomy, and prostatectomy in patients age 25 and over in Manitoba, Canada, following surgery during 1974 through 1976. The three procedures differ markedly in the ease of prediction of the probability of complications and in the predictive importance of patient, hospital, and physician variables. The predictors worked fairly well for cholecystectomy, somewhat less well for hysterectomy, and not well at all for prostatectomy. Hospital variables were not generally important in the multiple logistic regressions. After controlling for case mix and type of surgery, physician surgical experience was found to account for relatively large differences (almost two to one) in the probability of patient complications following cholecystectomy. Cholecystectomy might be a candidate for certification because of the epidemiology of the operation. As of the mid-1970s, a substantial proportion of the cholecystectomies were being performed by physicians with comparatively little ongoing experience with this type of procedure. Moreover, a monitoring perspective identified one hospital with a significantly higher postcholecystectomy complication rate, even after physician experience was taken into account. Both identifying which procedures should be attended to and focusing on problems following surgery are important beyond Manitoba and highly relevant to such American requirements as Peer Review Organizations. Methods of increasing the efficiency of using claims data for quality assurance studies are outlined.
Cholecystectomy↗
Using computers to identify complications after surgery.
We used the Health Services Commission data from Manitoba, Canada to identify complications resulting from hysterectomy, cholecystectomy, and prostatectomy which led to hospital readmissions. For each procedure, two specialists independently judged whether the readmissions were for surgery-related complications on the basis of liberally interpreted literature guidelines. Then, each pair of physicians met to resolve differences; only complications agreed upon by physicians were retained in our computer-based analysis. The analysis was done in three steps: algorithms were developed using guidelines from the literature, physician input, and 1974 hospital claims; these were then modified using 1975 data; finally, the algorithms were tested with 1976 data. The computerized algorithms developed were compared with the clinical decisions of physician panels. The results showed high specificity, sensitivity, and predictive value. Given the increasing availability of routinely collected data bases, the possibilities for inexpensively monitoring the outcomes of different providers and institutions are appealing. More extensive validation and application of the methodology to a greater number of procedures are necessary to implement such a program.
Cholecystectomy↗
Aging and the demand for health services: which aged and whose demand?
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Aged↗
Using health care: rural/urban differences among the Manitoba elderly.
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Aged↗
Surgical rates and mortality. A correlational analysis.
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Adult↗
When surgical rates change. Workload and turnover in Manitoba, 1974-1978.
This research analyzes the changes in individual physician surgical workload and accompanying changes in surgical rates in Manitoba, Canada between 1974 and 1978. Data covering essentially all operations on provincial residents age 25 years and older were analyzed using information from the health insurance data base. The most dramatic change was a 50% rise in outpatient surgery. An overall pattern of increased specialization seemed to be emerging; surgeons' surgical workloads were gradually growing while those of general practitioners were slowly declining. Changes in the frequency of several common surgical procedures were due much more to changes in workload of physicians remaining in the same hospital service area throughout the 1974-1978 period than to turnover (older physicians leaving practice and newer physicians coming in).
Adult↗
Assessing existing technologies: the Manitoba study of common surgical procedures.
An overview of the Manitoba study of common surgical procedures is presented. The research is oriented toward describing and explaining the outcomes of nine relatively common procedures, using longitudinal data from the Manitoba Health Services Commission's population registry, medical claims, and physician claims. The research approach recognizes differences among surgical procedures, tailoring the analyses to specific characteristics of a given procedure. At the same time, this article describes the efforts made to achieve economies of scale in organizing the data base and writing the computer programs. The strategy used for assessing surgical risks and benefits is described at some length. Health services utilization before and after surgery is compared across small areas with widely differing surgical rates. Comparisons between surgical and other groups are suggested. The wealth of data permits a number of different types of studies. One study deals with patterns of surgical practice, types of operations performed, and risk characteristics of patients brought to surgery in areas with differing surgical rates. High-risk patients residing in high-rate areas are more likely to be operated upon than their counterparts in low-rate areas. A second study found that hysterectomy is apparently being used in situations where women have high rates of contact with the health care system before surgery; their rates of contact after surgery are almost as high. Ongoing activities in the research project are outlined.
Epidemiologic Methods↗
Building individual histories with registries. A case study.
This study concentrates on utilizing registries and assessing their quality for population-based research. A method of successive comparisons is used to develop and update a summary record of coverage (length of time on the registry) and mortality for each individual in the Manitoba Health Services Commission data base. Various ways to ascertain the accuracy of the summary records are discussed. These techniques are validated by efforts to follow over an 8-year period 4,794 individuals interviewed in 1971 as part of ongoing research on the Manitoba elderly. Ninety-seven percent of the total elderly sample (and 99% of those successfully matched with interviewees) were traced over 8 years. Deaths recorded on hospital claims but not on the master registry and possible unrecorded out-of-hospital deaths are outstanding problems with the Manitoba data base. Further checks against 1970-1977 vital statistics information in the Canadian Mortality Data Base will be made.
Data Collection↗
Supply, workload and utilization: a population-based analysis of surgery in rural Manitoba.
This paper explores the relationships among physician supply, workload (output per physician), and utilization (physician services per capita) in rural Manitoba. Surgery taking place within a patient's home area and that taking place outside this area are discussed. Longitudinal and cross-sectional analyses are compared. Although the average surgeon does more surgical procedures than does the average general practitioner, the number of procedures performed varies greatly within each specialty. Individual physician workloads remained fairly stable over time when a surgically active physician moved into an area, while population utilization increased 17 per cent. When such physicians left an area, the surgical workloads of the physicians increased significantly (18.7 per cent) while population utilization stayed essentially the same. Both physician workload and surgical utilization in control areas increased gradually (between 6 and 7 per cent) over the period studied. Several models of physician behavior were investigated using data on individual procedures as well as overall figures. A model emphasizing the importance of physician discretion appeared to provide the best fit with the data.
Economics, Medical↗
Issues in studying ancillary services.
This paper examines several approaches to studying ancillary services usage. The likely generalizability of results provides one criterion for picking site, study population and conditions studied. Breaking up such an aggregate figure as mean annual ancillary services charges per patient into its component parts helps identify the different contributors to high cost practice patterns. Potential differences in case mix are noted as providing the most severe threat to interpreting variation in ancillary services use across practitioners and practice settings. Strategies for dealing with case mix problems include: focusing on specific diseases and specific specialities, stratifying within diagnostic categories, using multiple comparisons and multivariate analysis, pairing of visits and episodes and applying small area techniques.
Costs and Cost Analysis↗