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PubMed2000

Implementation and evaluation of a clinical pathway for TRAM breast reconstruction.

Among strategies recently proposed to reduce practice variation, promote quality, and control costs in health care delivery, the concept of the clinical pathway has received considerable attention. Because transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction is a common and often costly intervention, this institution sought to evaluate cost and quality outcomes of a clinical pathways program for this procedure. The TRAM reconstruction clinical pathway was implemented in April of 1996 to standardize postoperative care in this patient population. Outcomes of consecutive pathway cases for the first 14 months of the program were assessed in a retrospective cohort design, by using all nonpathway TRAM cases from the 18 months immediately before pathway implementation as controls. Outcomes assessed included length of hospital stay, postoperative complications, total postoperative charges, and total postoperative costs in relative value units. Data on these dependent variables were collected from hospital charts and billing records. The effects of pathway implementation on the outcomes of interest were analyzed by using analysis of covariance to control for potential confounding by other independent variables, including surgical site (unilateral versus bilateral reconstructions), technique (pedicle versus free TRAMs), timing (immediate versus delayed reconstructions), and patient age. Finally, a comparison of variances in the outcomes of interest between the two groups was analyzed by using an Ftest. For all statistical tests, p values of < or = 0.05 were considered significant. Twenty-nine patients were treated in the TRAM pathway group, whereas the control population included 40 nonpathway patients. After implementation of the TRAM pathway, length of stay decreased from 6.0 to 5.2 days; total postoperative charges were reduced from $8587 to $7744; and total postoperative relative value unit utilization declined from 1686 to 1104. Analysis of covariance showed that the decreases in length of hospital stay and relative value units in the TRAM pathway were statistically significant (p = 0.05 and p = 0.007, respectively). By contrast, no significant increase in complications was observed after pathway implementation. Variability in the TRAM pathway group, as measured by SD, decreased significantly for both length of hospital stay (p = 0.039) and relative value units (p = 0.023). Implementation of the TRAM reconstruction clinical pathway resulted in significant declines in length of hospital stay and total costs. These decreases in resource utilization had no significant effect on postoperative complication rates. Although additional research is needed to further assess the impact of clinical pathways, this approach offers considerable promise for improving the cost-effectiveness of health care.

Adult↗
PubMedDate not supplied

Swedish models of health care reform: a review and assessment.

Resource constraints and the necessity to improve efficiency and effectiveness have provided challenges for the Swedish health care system during the 1990s. Whereas there are no comprehensive reforms of funding and organization, measures have been taken at both national and regional level to meet these challenges. Decentralization has been a core issue in long-term reforms and current changes can be seen as continuing this pattern. As a consequence different solutions are sought in the various county councils (locally elected self-government bodies financing and procuring health services). In about one third of these county councils some sort of purchaser-provider models have been introduced. Emerging evaluation reports claim that the models have succeeded in improving efficiency; making the system more patient-oriented; and enhancing cost-consciousness. The roles of politicians, managers and professionals are also more clear, according to the proponents. However, there are also problems with more difficulties in controlling costs, and with inadequate remuneration systems. Over time the purchaser-provider schemes have matured, developing from emphasizing short-term tendering, negotiations and detailed contracts to more comprehensive agreements based on mutual commitments to improve health services. Rhetoric has changed; competition has been replaced by co-operation. The lure of the market concept has diminished. Similarities can be seen between county councils with and without purchaser-provider models.

Ambulatory Care↗
PubMed1993

Quality of life. 2. Economic analysis of drug therapies.

In 1990, health care expenditures in the United States reached $666.2 billion, 12.2% of the gross domestic product (GDP). It is projected for the year 2000, the USA will spend $1.6 trillion for health care which will be comparable to 16.4% of that year's GDP. As a result of the rapid increase in costs of health care and limited resources available, patients, third-party payers and the government have initiated and implemented more rigid cost control measures. Economic analyses can help ensure the efficient use of health care dollars in areas such as drug therapy. The four methodologies available are cost-benefit analysis, cost-effectiveness analysis, cost-minimization analysis and cost-utility analysis. This article reviews methods and provides examples from the medical literature. These tools can assist care providers in determining which treatments are most cost-effective.

Cost-Benefit Analysis↗
PubMed1994

Cost analyses of prostate cancer screening: frameworks for discussion. Investigators of the American Cancer Society-National Prostate Cancer Detection Project.

Our recent cost analysis of prostate cancer early detection evaluated the economic performance of various prostate specific antigen (PSA) screening approaches, detected marginal cost variations with time and used a benefit-cost calculation as a framework for further discussion. Receiver operator characteristic analysis initially suggested an optimal test performance for PSA of 2 to 3 ng./ml. when used alone and at approximately 3 ng./ml. in combination with digital rectal examination. However, lower PSA decision levels require cost justifications. Marginal cost analysis demonstrated markedly decreased use of digital rectal examination by year 3 due to significantly lower sensitivity for incident cancer. The benefit-cost equation acknowledges that many parameters of cost and probability are not definitive to date yet illustrated major points for discussion. The cost parameters most sensitive to incremental change in decreasing order are the specificity of the screening test, benefits obtained from early therapy and prevalence of the disease. Discussions about improving the likelihood of overall benefit for the United States population should focus on these parameters, as well as social and ethical implications. If we assume minimized future expenditures for terminal cancer care via decreases in therapy choices or coverage, no economic benefit for screening exists. If we also assume that potential costs to society are not roughly approximated by any benefits, we may engender inappropriate attempts at cost reduction by effectively discouraging screening in the highest risk groups. Perhaps the greatest immediate cost control issue is the marked increase in prostate cancer detection in the oldest age groups who have the least likelihood of mortality or morbidity benefits. Current cost savings may be possible with improved public health education about the appropriateness of early detection in the oldest age groups or those with significant preexisting medical conditions.

American Cancer Society↗
PubMed1996

The ethical dilemmas of the Oregon health plan.

Escalating health care costs place our country at an economic disadvantage in the world marketplace. Currently, a mixture of rationing methods in the health care system limits access to control costs. Federal and state moneys fund the state Medicaid programs. States on limited budgets often tighten eligibility to far below the poverty level; those with benefits get unlimited care and those without get none. The state of Oregon has a different idea: Medicaid covers everyone below the poverty level but limits services to those with the "best cost-to-benefit ratio." Many people consider the distribution and finance of health care an ethical issue. The Oregon plan raises some ethical concerns and several arguments. The federal government waived Title XIX of the Social Security Act to allow implementation of the plan. Many providers believe universal access is important; however, the drive to see more patients may limit visit time.

Decision Making, Organizational↗
PubMedDate not supplied

Survey on AIDS, fear and infection control: attitudes affecting management decisions.

As a result of increased public concern about AIDS and dental treatment, dental professionals need to cope with legislative reactions, increased infection control costs, patient anxiety and vigilance on the part of law enforcement agencies regarding compliance with "universal precautions." Recommendations abound for educating patients about dental office infection control to allay irrational fears and market dental office asepsis, but few studies quantitatively measure these needs or address the behavioral concerns patients have about AIDS infection related to dental care. In this investigation, dental patients were surveyed to determine their beliefs, attitudes and behaviors regarding AIDS and dental office infection control. Several important educational caveats were identified. This paper considers these challenges and provides patient education and practice management recommendations consistent with a preventive focus on allaying dental patients' fears while building more successful dental practices.

Adult↗
PubMed1980

Regulating the bed supply in nursing homes.

Federal and state regulation of capital expenditures has been advanced as a means both to ensure rational allocation of resources and to control costs. But evidence drawn from eight states suggests that limiting the supply of nursing home beds ("certificate of need"), without refining conflicting standards of eligibility, quality control, and reimbursement policies (Medicaid and "rate-setting"), effectively discriminates against persons most in need of medical care. Alternative strategies for achieving economy, equity, and efficiency are explored.

Certificate of Need↗
PubMed1992

Health care for all: a crisis of cost and access. A roundtable discussion: Part 1.

Primary care physicians are feeling the impact of a healthcare system in crisis. Many Americans have no health insurance, paperwork is consuming more and more of physicians' time, and concerns about controlling costs seem to overshadow the value of medical decision-making. Medicare protects the elderly, but low reimbursement fees act as a disincentive to accepting them as patients. Although there is a general consensus that reforms are needed, there are many different opinions on how this should be achieved. In this first part of a three-part roundtable discussion, seven experts in the fields of aging, medicine, and government discuss flaws in our current system and factors that are interfering with reform.

Canada↗
PubMed2001

The use of a resource-based relative value scale (RBRVS) to determine practice expense costs: a novel technique of practice management for the vascular surgeon.

Vascular surgeons have had to contend with rising costs while their reimbursements have undergone steady reductions. The use of newer accounting techniques can help vascular surgeons better manage their practices, plan for future expansion, and control costs. This article reviews traditional accounting methods, together with activity-based costing (ABC) principles that have been used in the past for practice expense analysis. The main focus is on a new technique-resource-based costing (RBC)-which uses the widely available Resource-Based Relative Value Scale (RBRVS) as its basis. The RBC technique promises easier implementation as well as more flexibility in determining true costs of performing various procedures, as opposed to more traditional accounting methods. It is hoped that RBC will assist vascular surgeons in coping with decreasing reimbursement.

Humans↗
PubMed1994

Health care paper chase, 1993: the cost to the nation, the states, and the District of Columbia.

The U.S. health care payment system is an elaborate and increasingly wasteful paper chase. This article presents new state-by-state estimates of health care administrative costs in the United States, and savings that could be realized with single-payer reform. In 1993, health care bureaucracy will consume 24.7 cents of every health care dollar, a total of $232.3 billion. Administration's share of health spending is up from 23.9 percent in 1987, and from 21.9 percent in 1983. Reducing the cost of administration to Canadian levels by adopting a single-payer health care system would cut U.S. health care bureaucracy by more than half (50.7 percent), saving at least $117.7 billion in 1993. The savings achievable with a single-payer system could fund universal access for the uninsured and improve benefits for the tens of millions of Americans who currently have only partial coverage, without any increase in overall health spending. Reform measures such as electronic billing, insurance industry consolidation, and increased competition (including "managed competition") would save little or nothing on administration. Only a single-payer reform that incorporates the "macro-management" approach to cost control, as in Canada, can achieve significant administrative savings.

Cost Savings↗
PubMed2001

Cost recovery beds in public hospitals in Indonesia.

A policy of allowing public hospitals to provide some better quality, higher priced hospital beds for those able to pay was introduced as government policy in Indonesia after 1993. A study was conducted in 1998 in three public hospitals in East Java to investigate if the policy objective of cost-recovery was being achieved. Hospital revenue from these commercial beds was less than both the recurrent and total costs of providing them in all three hospitals, but exceeded recurrent costs minus staff salaries in two hospitals. One reason for the low cost-recovery ratios was that between 55% and 66% of the revenue was used as staff incentives, mostly to doctors. This was more than the maximum of 40% stipulated in the policy. The high proportions of total revenue going to staff were a result of hospital management having set bed fees too low. The policy may be contributing to the retention of doctors within public sector employment; however, it is not achieving its stated objective, especially over the longer term where full recovery of salaries and investment costs needs to be considered. Public hospitals that wish to invest in commercial beds need effective management and accounting systems so as to be able to monitor and control costs and set fees at levels that recoup the costs incurred. Further research is required to determine if this form of public-private mix has negative effects on equity and access for poorer patients.

Accounting↗
PubMed2005

The costs of caring for patients in a tertiary referral Australian Intensive Care Unit.

We determined the direct cost of an Intensive Care Unit (ICU) bed in a tertiary referral Australian ICU and the cost drivers thereof, by retrospectively analysing a number of prospectively designed Hospital- and Unit-specific electronic databases. The study period was a financial year, from 1 July 2002 to 30 June 2003. There were 1615 patients occupying 5692 fractional occupied bed days at a total cost of A dollar 15,915,964, with an average length of stay of 3.69 days (range 0.5-77, median 1.06, interquartile range 2.33). The main cost driver not incorporated into this analysis was blood products (paid for centrally). The average costs of an ICU day and total stay per patient were A dollar 2670 and A dollar 9852 respectively. Staff-related charges were 68.76%, with consumables related expenditure making up 19.65%, clinical support services 9.55% and capital equipment 2.04%. Overtime charges and nursing agency staff were 19.4% of staff-related charges (2.9% for agency staff), 3.9% lower than expenditure associated with full-time employment charges, such as pension and leave. The emergency nature of ICU means it is difficult to accurately set a nursing establishment to cater for all admissions and therefore it is hard to decide what is an acceptable percentage difference between agency/overtime costs compared with the costs associated with full-time staff appointments. Consumable expenditure is likely to increase the most with new innovation and therapies. Using protocol driven practices may tighten and control costs incurred in ICU.

APACHE↗
PubMed2000

Economic justification of antimicrobial management programs: implications of antimicrobial resistance.

The relationship between the problem of antimicrobial resistance and efforts to control antimicrobial costs is explored. Antimicrobial drug management typically centers around controlling costs and controlling antimicrobial resistance. Selection of therapeutic alternatives without adherence to a well-developed program or without a rationale based on data from the medical literature may promote antimicrobial resistance. Attempts to select alternatives can produce cost shifting rather than cost containment. The annual cost associated with antimicrobial resistance in the United States is estimated to be as high as $47 billion. In one study, patients with bacteremia caused by methicillin-resistant Staphylococcus aureus had an average length of stay 2.7 days longer than patients with susceptible strains and a mean cost of care that was $3500 higher. Infection control is one of the most important duties of health care practitioners. Given today's prevailing reimbursement structure, hospitals with high rates of nosocomial and resistant infections are likely to lose money. A basic problem with the current approach to controlling resistance is that the two most common strategies, highly restrictive formularies and drug cycling, work in opposition. Antimicrobial management programs should be directed at ensuring the most appropriate use of antimicrobials rather than focusing on limiting choices.

Anti-Bacterial Agents↗
PubMed1978

[Health services as a study object: preconditions, principles, applications].

The call for more research in health care delivery has increased with the rising cost of medical care. Since the end of the fifties, a new research direction is identifying itself primarily in the Anglo-Saxon literature: Health Services Research. Examples discussed include results of Health Services Research regarding the diffusion of medical technology and the mechanisms to control costs of health services. These and similar results from special studies on average length of stay and utilization of hospital beds show that Health Services Research should develop from primarily descriptive studies into an analytical and experimental discipline in order to provide clues to the pressing problems of the delivery of medical care.

Costs and Cost Analysis↗
PubMed1994

Assuring the affordability of Canada's health care system.

Canada's health care system is challenged by a crisis of affordability. A sluggish economy and substantial federal, provincial, and territorial debt have caused health care spending, in spite of a good record of cost control, to consume nearly 10% of Canada's gross domestic product, largely due to a denominator effect. Issues identified as warranting further investigation as potential approaches to further reducing cost in order to match available resources include therapeutic effectiveness, drug use, hospital utilization, manpower planning, consumer access, and population approaches to improving health status. An important role exists for clinical investigators to contribute to health care reform.

Canada↗
PubMedDate not supplied

The heart failure pandemic: changing patterns, costs, and treatment strategies.

Heart failure is the most important public health problem in cardiovascular medicine, and is increasing in both prevalence and expense. Programs that use an interdisciplinary team to improve outpatient treatment and prevent hospitalizations will help improve care and control costs. But the most important long-term strategy for dealing with the heart failure pandemic is more aggressive primary and secondary prevention.

Adult↗
PubMed1990

Optimum allocation of samples in strata-matching case-control studies when cost per sample differs from stratum to stratum.

We investigate the allocation of samples over strata in case-control studies with consideration of sampling costs. We consider two situations, typical of strata-matched case-control studies. Subject to a fixed total cost we derived optimum allocations that maximize the asymptotic efficiency of Cochran's test, that is, minimize the variance of the maximum likelihood estimator of the common odds ratio when the common odds ratio is one. Our results show that the standard design with equal numbers of cases and controls in each stratum is inefficient when costs per control differ greatly from stratum to stratum. We show that the optimum design suggested in this paper is robust for values of the odds ratio common in epidemiologic studies.

Case-Control Studies↗
PubMed1977

PSRO: issues in health care policy.

Enactment of the law regarding Professional Standards Review Organizations (PSROs) represents a major shift in health care policy in the United States. PSRO is an experiment in developing a national quality assurance system. It raises issues of quality versus cost control, professional versus public accountability, and confidentiality. These issues must be examined critically by social workers.

Confidentiality↗

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