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PubMed1992

Expanding employment-based health insurance: is small group reform the answer?

Nearly two-thirds of all uninsured workers are employed in firms with 100 or fewer employees. Making insurance more affordable and available to small groups is high on the political agenda. Efforts to reform the small group market include making insurance more available by restricting the use of medical underwriting to deny access, and compressing rates to make it more affordable for high-risk groups. Other reforms pursued at the state level have focused on reducing the price of insurance facing all small employers. My analysis suggests that these proposals will have limited success in reducing the number of uninsured. Short of compulsory insurance, significant changes will occur only when insurance is organized around larger purchasing groups and not small employers.

Commerce↗
PubMed2001

Care coordination and physical and behavioral service integration in managed care contracts: analysis and sample purchasing specifications.

This double Issue Brief on the issue of managed care contracts and care coordination has been prepared for the Substance Abuse and Mental Health Services Administration as part of a series that examines legal issues in managed care for persons with mental illness and addiction disorders. This Issue Brief is presented in two parts. Part 1 presents an analysis, based on managed care contract data bases developed by CHSRP, of the extent to which public and private group purchasers maintain agreements that specify care coordination as part of the standard of care for persons with co-occurring physical and/or behavioral illnesses and conditions. Part 2 sets forth sample purchasing specifications that are designed to establish care coordination as part of the standard of care.

Accreditation↗
PubMed2004

Guidelines for acute decompensated heart failure treatment.

OBJECTIVE: To describe the development of guidelines for the treatment of acute decompensated heart failure (ADHF) in the emergency department/observation unit (ED-OU) setting for hospitals that are part of a group purchasing organization (GPO). DATA SOURCES: A MEDLINE search (1966-March 2003) using the following search terms: cardiotonic agents; diuretic; dobutamine; heart failure, congestive; milrinone; natriuretic peptide, brain; nesiritide; nitroglycerin; vasodilator agents, was conducted. STUDY SELECTION AND DATA EXTRACTION: Relevant articles in the English language were identified. All randomized studies and meta-analyses for each category of drugs were included. DATA SYNTHESIS: A group consensus method was used to develop guidelines. An expert panel reviewed and revised the guidelines. The final guidelines were approved June 1, 2003, and are described here. They are organized based upon a patient's symptomatology at the time the diagnosis of ADHF is made. Patients with evidence of volume overload require intravenous diuretics and/or intravenous vasodilators to alleviate the symptoms of ADHF. Patients with signs and symptoms of low cardiac output require inotropic support to manage their ADHF. A timeline for diagnosis, treatment, reassessment, and disposition is provided and encourages an early, aggressive approach to treating patients with ADHF. CONCLUSIONS: Hospitalization for ADHF is common and costly. Consensus guidelines for the treatment of ADHF did not previously exist, resulting in inconsistent and inefficient treatment. Consequently, hospitals struggling with the treatment of ADHF may find these guidelines and the process by which they were developed useful.

Acute Disease↗
PubMed2006

Partnering to improve the supply chain.

Successful materials management extends far beyond the hospital walls. More than ever, effective materials managers are partnering with suppliers, distributors, manufacturers and group purchasing organizations to reduce costs, improve inventory control and increase operational efficiency. This requires partners who are intimately familiar with both the unique requirements of individual health care settings and best practices throughout the industry. Beyond achieving better balance-sheet results, this consultative approach ultimately leads to standardized, proven processes that help ensure quality care is delivered safely. Health Forum convened a group of health care executives and industry vendors Nov. 4, 2005, in Chicago to discuss hospital-vendor partnerships. The closed-door dialogue focused on how hospitals can work with vendors to improve operations. Health Forum would like to thank all of the participants for their open and candid discussion, as well as the sponsors for supporting this event.

Commerce↗
PubMed2004

Determination of the seroprevalence of Neospora caninum in feedlot steers in Alberta.

A study was conducted in Alberta to determine the seroprevalence of Neospora caninum in feedlot calves purchased from various auction markets throughout western Canada. Four feedlots (1 feedlot from each of the Airdrie and High River areas and 2 feedlots from the Strathmore area) were selected for sampling. At each feedlot, a random 10% sample of feedlot steer and bull calves entering the feedlot from September 2001 to December 2001 were enrolled in the study until there were a maximum of 500 animals enrolled per feedlot. Blood samples were collected from 1976 male animals at the time of entry to the 4 study feedlots. The animals represented 375 groups purchased from 70 sale points throughout British Columbia, Alberta, Saskatchewan, and Manitoba. Of the 1976 animals tested, 128 animals tested positive for antibodies to N. caninum. The prevalence and adjusted 95% confidence limits for N. caninum in beef calves on entrance to the feedlot in western Canada were 6.5% (95% CI, 5.1 to 8.2). There were no significant (P > or = 0.05) associations between the risk of treatment, the risk of designation as "chronic," and the risk of death and antibodies to N. caninum either before or after adjusting for feedlot, entry weight, entry date, and clustering of disease within lots at each feedlot. In addition, there was no significant (P > or = 0.05) association between serological status and feedlot entry weight or average daily gain. Note that there was no information available on feed conversion because the calves were mixed within existing commercial feedlot pens and the actual feed intake of each animal could not be determined. Adjustment for the concentration of antibodies to bovine viral diarrhea virus on arrival did not change any of the examined associations between N. caninum status and calf health or performance. The results of this study demonstrated that the prevalence of N. caninum in feedlot calves in western Canada was less than the prevalence reported in the United States. Additional studies are required to determine whether the inferior rate of gain and feed efficiency observed in the southern United States with animals testing positive for antibodies to N. caninum also occurs under the management conditions used in western Canada.

Alberta↗
PubMed1993

Association between availability of non-prescription beta 2 agonist inhalers and undertreatment of asthma.

OBJECTIVE: To determine whether the availability of beta 2 agonist inhalers without prescription leads to undertreatment of asthma. DESIGN: Cross sectional study of adequacy of treatment in asthmatic subjects who purchased beta 2 agonist inhalers and subjects who obtained inhalers by prescription. SETTING: Community pharmacies in New South Wales, Australia. SUBJECTS: 403 eligible consecutive asthmatic subjects aged 13 to 55 purchasing salbutamol metered dose inhalers over the counter or by prescription; 197 attended for follow up and spirometry and 139 returned 14 day symptom, peak flow, and medication diaries. MAIN OUTCOME MEASURES: Severity of asthma assessed on frequency of day time and night time wheezing, frequency of inhaler use, and peak expiratory flow rates. Adequacy of treatment according to published guidelines. RESULTS: Of the 139 patients who completed the diary 83, (60%) purchased their inhalers without prescription and 83 were undertreated. The characteristics of patients in the prescription and purchasing groups were similar. Multiple logistic regression analysis identified use of non-prescribed salbutamol as being associated with a 2.9-fold increase in the odds of undertreatment (95% confidence interval 1.3 to 6.8). Smoking increased the odds of undertreatment (3.3, 1.2 to 9.5) and use of a peak flow meter reduced the odds (0.11, 0.04 to 0.34). Adjustment for frequency of consultation made use of non-prescription salbutamol insignificant (1.4, 0.55 to 3.8). Attitudes to services provided by doctors and pharmacists were favourable and not associated with undertreatment. CONCLUSION: Over the counter purchase of salbutamol is associated with infrequent consultation with doctors and undertreatment of asthma.

Administration, Inhalation↗
PubMed1985

Challenges in purchasing and inventory control.

In this concluding installment in a multipart series, issues that should be considered in the improvement of hospital pharmacy purchasing and inventory control systems are presented. Pharmacists must be aware of possible variation in bioavailability among different formulations of the same drug and evaluate new vendors critically. Hospital pharmacists and industry representatives should strive for a cooperative relationship by fostering ongoing dialogue. Pharmacists must continue to demand competitive bid prices on generically equivalent products of equal quality. Firm contact prices cannot be expected if product use estimates are unreliable. It is unethical to encourage additional price reductions on competitive products after a formal bid has been received. Institutions should limit their participation to one group purchasing organization or wholesaler for the competitive bid process. Inventory management through methods such as ABC analysis, economic-order quantities, calculated optimum reorder points, and other quantitative measurements should become commonplace. The use of data processing systems and devices can enable pharmacists to become more proficient at pharmaceutical purchasing and inventory control. The acquisition and distribution of pharmaceuticals in health-care institutions require good management to capture the opportunities in this area for pharmacy to contribute to fiscally sound health care.

Drug Industry↗
PubMed1986

Medical equipment purchasing: how can it be made efficient and economical?

Over the years, hospital purchasing groups have been able to realize significant savings for their member hospitals on a variety of supplies. One area where they have weak historically, however, is in capital equipment; specifically, advanced diagnostic and clinical hardware. Authors Dillman and Holzman suggest reasons for this weakness and recommend some possible solutions.

Capital Expenditures↗
PubMedDate not supplied

Pharmacy formularies in integrated health systems.

Formulary management implications are described for an Oklahoma integrated health system comprising 14 acute care facilities, numerous owned medical practices, and a fledgling HMO. A systemwide pharmacy director has yet to be appointed; however, the position of pharmacy operations management for the Oklahoma City area has been created. A physician group has been formed that is expected to address system-wide pharmacy and therapeutics (P&T) committees and formulary strategies. Currently P&T committee activities take place at the individual hospital level. The hospitals do not have restrictive formularies. An overall formulary system would likely be patterned after the largest hospital's system, including a formal approval process in which a P&T subcommittee reviews drug use outside established guidelines and the P&T committee asks the appropriate medical department to address the problem. For ambulatory care, the HMO has contracted with a pharmacy benefit manager (PBM), and there is no coordination of formulary efforts between the PBM and health system entities. Although this and other problems remain to be resolved, some standardization of drug use has begun. Also, all entities in the system use the same purchasing group and plan to use the same information system. Drug use among hospitalized patients in this integrated health system is influenced by the usage guidelines established at the largest hospital, and drug use among ambulatory managed care patients is influenced by an external PBM.

Ambulatory Care↗
PubMed1995

Reporting and using health plan performance information in Massachusetts.

BACKGROUND: In 1993, 27 corporate and government health care purchasers formed the Massachusetts Healthcare Purchaser Group (MHPG). Sixteen health plans submitted 1992 data on six clinical indicators-mental health inpatient days per patient and inpatient readmission, blood pressure screening, prenatal care, mammography screening, cesarean section (C-section) rates, and asthma admission rates-developed in an earlier pilot effort in response to the quality portion of MHPG's "Cost/Quality Challenge." DATA COLLECTION AND ANALYSIS: Detailed data specifications developed in the pilot to ensure uniform data collection were used, with a requested sample size for chart-reviewed measures of 220. A "clinically significant average range" was defined. Health plan performance was summarized for each indicator in a report released in March 1994. REPORTING OF CLINICAL INDICATOR RESULTS: For the six indicators, each plan had a unique pattern of variation from the average range. For prenatal care, mammography, and hypertension, many plans had opportunities for improvement. SURVEY OF PURCHASERS: Most of the purchasers MHPG surveyed in October 1994 about their assessment and use of the Cost/Quality Challenge Report found it useful. RESPONSES TO THE REPORT: To promote quality improvement activities among health plans, MHPG showed purchasers how to pursue performance issues with health plans, held a Best Practice Forum on C-section, and created a follow-up endeavor, the Coordinated Purchasing Initiative. SUMMARY AND CONCLUSIONS: In spite of potential problems posed by technical deficiencies, costs of data acquisition and quality efforts, and unintended effects of public reporting, purchaser/plan initiatives such as the Cost/Quality Challenge can provide valuable information to purchasers.

Adolescent↗
PubMed2006

Syneture stainless STEEL suture. A collective review of its performance in surgical wound closure.

Syneture (division of U.S. Surgical, division of Tyco Healthcare, Norwalk, Connecticut, USA) STEEL sutures are monofilament stainless steel sutures composed of 316L stainless steel conforming to ASTM Standard F138 grade 2 (" Stainless steel bar and wire for surgical implant"). STEEL sutures meet all requirements established by the United States Pharmacopeia (USP) for nonabsorbable surgical sutures. Steel sutures are for use in abdominal wound closure, intestinal anastomosis, hernia repair, sternal closure, and skin closure. They are attached to the following types of surgical needles: Roto-Grip Needles and SCC Needle. The sutures and needles are packaged in a Mylar/Tyvek outer envelope. The purposes of this clinical review are two fold. First, we will report the performance of the Syneture STEEL suture product in the largest studies of suture performance ever reported in the literature. In addition, we will provide comprehensive information from the surgical literature that highlights the unique benefits of stainless steel sutures for the following wound closure techniques: sternal fixation, abdominal wound repair, inguinal hernia repair, and skin wound closure. Consorta Inc. (Rolling Meadows, Illinois), a leading healthcare resource management group purchasing organization, and Syneture, jointly with a clinician task force, designed a reproducible surgical evaluation program for needles and sutures in a large cooperative of healthcare systems. Because of the subjective nature of the more commonly used suture selection techniques, a nonexperimental observational study approach was designed to replace perception of performance characteristics with actual clinical experience. In a report involving 19 Consorta shareholder hospitals, they discussed the preliminary part (Phase I) of a large nonexperimental observational study of the clinical performance of surgical needles and sutures. Performance characteristics of the sutures and needles produced by Syneture that were evaluated in 3407 surgical procedures included packaging/ease of opening, needle strength and sharpness, tissue drag, knot security, tensile strength, clinically acceptable determinations, and clinically unacceptable determinations. In this preliminary study, the surgeons concluded that the needles and sutures were clinically acceptable in 98.1% of the evaluations. Armed with this favorable experience, we wanted to expand this observational study to an entirely new group of shareholder hospitals that had a larger number of participating hospitals (Phase I, 19 hospitals; Phase II, 42 hospitals). This more than doubling of hospital observational base dramatically increased the number of patients and performance evaluations. In the Phase II expanded program involving 42 hospitals, the number of patients (8939) and the number of evaluations (25,545) were more than twofold the preliminary study. In the phase I multicentric evaluation of Syneture surgical sutures, the performance of 9266 sutures was evaluated. Of these performance evaluations, 130 evaluations focused on Syneture STEEL sutures. The surgeons were especially pleased by the performance of this suture product, with 129 Syneture STEEL products being judged as clinically acceptable in their performance. Only one Syneture STEEL suture was judged to be unacceptable in its performance, resulting in a 99.2% acceptability rating. In the expanded phase II evaluation of Syneture suture products, the performance evaluation involved 25,545 surgical suture evaluations. The performance of Syneture STEEL sutures was judged in 215 cases. Of these product performance evaluations, 207 were judged to be clinically acceptable in their performance (96.3%). It is important to emphasize that the phase I and phase II observational studies evaluated the performance of other sutures besides monofilament steel sutures. These comprehensive suture and needle performance evaluations included the following additional sutures: Plain Gut, Mild Chromic Gut, Chromic Gut, DEXON II, DEXON S, MAXON, BIOSYN, SOFSILK, SURGILON, BRALON, MONOSOF, DERMALON, SURGIDAC, POLY-SORB, TI.CRON, SURGIPRO, SURGIPRO II, NOVAFIL, VASCUFIL, and FLEXON. Finally, we provide a collective review of the literature that shows the reliable performance of monofilament stainless steel sutures in the following wound closure techniques: sternal fixation, abdominal wound closure, inguinal hernia repair, and skin wound closure.

Humans↗
PubMed1980

Implementation of Canadian Standards Association Z168.3-M 1980 Anaesthetic Gas Machine Standard: the Manitoba experience.

The Province of Manitoba Anaesthetic Machine Program, completed in June 1980, accommodated Canadian Standards Association Standard Z168.3-M 1980. "Continuous Flow Inhalation Anesthetic Apparatus (Anesthetic Machines) for Medical Use". The goal of the program was to have all anaesthetic machines in hospitals in the province with the same basic design and safety features: "oxygen right"; characteristic oxygen knob profile; oxygen supply pressure failure device and alarm; standardized "oxygen flush" mechanism; pipeline inlets and pressure gauges; uniform color coding; standardized common gas outlet; pin indexed cylinder yokes; descriptive labels concerning safety devices; check valves within machine piping. Open group-purchase tenders were invited for both machine upgrading and replacement. Of 212 machines surveyed, 127 were upgraded (cost $100,000), 65 were replaced (cost $175,000), three were already satisfactory, and 17 were no longer required and were removed permanently from service. The Manitoba Program provided a satisfactory solution to a most important problem.

Anesthesia, Inhalation↗
PubMed1997

Quality assessment and tracking results of cardiac surgery.

Long-standing efforts to assess quality in medical care have been intensified by the striking expansion of managed care plans. Agencies such as the Joint Commission on Accreditation of Health Care Organizations and the National Committee on Quality Assurance have formalized the evaluation of health plan quality using criteria of structure, process, and outcome. A review of attempts to apply these criteria to individual physicians and to disease-specific interventions such as myocardial revascularization demonstrates the great difficulty of reliable quality assessment in this evolving surgical field. Cardiac surgeons must continue their work in deriving valid socioeconomic and clinical conclusions from The Society of Thoracic Surgeons and Veterans Affairs databases. This may prevent the precipitate adoption of newer treatment methods driven by entrepreneurial technology companies and large group purchasers of care. These entities tend to focus on economics rather than patient welfare. New technologies may also delude patients into insisting on treatment featuring short-term convenience and comfort despite less satisfactory long-term results. "Black box" methodology providing practice profiles and physician report cards must have critical validation.

Cardiac Surgical Procedures↗
PubMed1998

Comprehensive health data systems spanning the public-private divide: the Massachusetts experience.

As systems of health care delivery have evolved from claims-based fee-for-service to capitated or managed care, with its emphasis on cost-effectiveness, quality, and performance measurement, some states have begun to experiment with new ways to collect, organize, and share health information. In many cases, the drivers of these changes have been purchasers of health care, including large and small private employers and public agencies such as Medicaid. One of the results of these changes is the increased interest in the sharing of health information, between health plans and employers, and, in some instances, between private plans and public agencies such as public health. Massachusetts, which has one of the highest rates of managed care penetration in the United States, has brought together the various parties involved in the collection and utilization of health information, to craft agreements on standards and protocols that will allow the sharing of health data. While much of the activity involves business transactions between private sector health plans, the Department of Medical Assistance (Medicaid) has joined with its private sector purchasing partners in demanding cost-effective, high-quality care; it is these demands that have helped stimulate the need to reorganize previously proprietary health information systems. The activities of two public-private coalitions, the Massachusetts Healthcare Purchaser Group and the Massachusetts Health Data Consortium, have been critical in initiating and supporting the complex processes that have led to significant changes in state-based systems of health information.

Health Maintenance Organizations↗
PubMedDate not supplied

Institutional decision-making to select patient care devices: identifying venues to promote patient safety.

Many medical errors that involve drug infusion devices are related to classic interface problems. Although manufacturers are becoming increasingly aware of human factors design considerations, many devices that are currently on the market are still sub-optimal for human use. This places significant responsibility for device selection on institutional purchasing groups. Theories of naturalistic decision-making point to many potential strengths and pitfalls of group decision-making processes that may affect the final outcome. This paper describes a retrospective analysis of decision-making process for infusion pump selection in a large hospital and focuses on factors related to patient safety. Through a series of detailed interviews and a study of relevant documentation we characterized the nature of the decision-making, patterns of communication, and the roles of different participants. Findings show that although the process involves a number of different professional groups and committees, the information flow among them is restricted. This results in inadequate representation of critical device usability considerations in the decision-making process. While all participants view device safety as an important consideration in the selection process, administrators (who are the final decision-makers) tend to equate safety with technical accuracy and reliability, paying less attention to the role of human factors in safe device use. Findings suggest that collaborative communication technology and automated evidence-based guidelines could provide support to institutional decision-making, ensuring that the process is efficient, effective, and ultimately safe for the patients.

Decision Making, Organizational↗
PubMed2002

Epidemiological and nutritional transition in Mexico: rapid increase of non-communicable chronic diseases and obesity.

OBJECTIVE: The objective of this paper is to characterise the epidemiological and nutritional transition and their determinants in Mexico. DESIGN: Age-adjusted standardised mortality rates (SMRs) due to acute myocardial infarction (AMI), diabetes mellitus and hypertension were calculated for 1980-1998. Changes in the prevalences of overweight and obesity in women and children and of dietary intake from 1988 to 1999 were also used in the analysis. Quantities of food groups purchased by adult equivalent (AE) and food expenditures away from home between 1984 and 1989 were used to assess trends. All information was analysed at the national and regional levels, and by urban and rural areas. RESULTS: SMR for diabetes, AMI and hypertension increased dramatically parallel to obesity at the national and regional levels. Fat intake in women and the purchase of refined carbohydrates, including soda, also increased. DISCUSSION: The results suggest that obesity is playing a role in the increased SMRs of diabetes, AMI and hypertension in Mexico. Total energy dietary intake and food purchase data could not explain the rise in the prevalence of obesity. The increases in fat intake and the purchase of refined carbohydrates may be risk factors for increased mortality. Information on physical activity was not available. CONCLUSION: SMRs due to diabetes, hypertension and AMI have increased dramatically in parallel with the prevalence of obesity; therefore actions should be taken for the prevention of obesity. Reliable information about food consumption and physical activity is required to assess their specific roles in the aetiology of obesity.

Acute Disease↗
PubMed2001

Governance and autonomy in alternatives to hospital care.

Older people with complex illness and disability should have the same equitable opportunities and safeguards for treatment and care as do younger people. These should be based on needs, likely health gain and personal preference. Comprehensive assessment and goal setting, with monitoring of progress and outcomes, should be an integral feature of alternatives to hospital care, wherever they are provided. To satisfy the principles of clinical governance the development of innovative intermediate rehabilitative and long-term care programmes may require more time and expertise than small purchasing groups can reasonably provide. Pooled health and care budgets managed in partnership by larger providers may offer a solution. There is an urgent need for pilot projects to inform development.

Aged↗
PubMed1996

Formularies in integrated health systems: Fallon Healthcare System.

Formulary management implications in a Massachusetts integrated health system consisting of a physician group practice clinic, an HMO, a hospital, a long-term care facility, a physician-hospital organization, a home care agency, and a clinical laboratory are described. Two formularies govern drug therapy for most patients in the system. The formulary of the group practice (Fallon Clinic) is used for 180,000 patients covered by the HMO. The formulary of Saint Vincent Hospital influences drug use in the hospital and the system's long-term care facility. Both formularies require formal review before a drug is added and have structured processes for nonformulary requests. Entities in the health system are still being integrated at the operational level. The system does not have a formal position on integration of the formularies, but information exchange and collaboration occur because of overlap in the membership of the committees that approve the two formularies. Formulary decision-making has been coordinated to account for systemwide needs (for example, enoxaparin was not added to the hospital's formulary because of concerns about continuity of drug therapy after discharge, and the hospital's formulary includes the oral agents on the clinic's formulary). The systems uses one group-purchasing organization and one wholesaler; one person negotiates separate contracts for the hospital and the clinic. System coordination of formulary management has had little effect on daily activities of the pharmacy staff. Drug use among ambulatory patients in this integrated health system is influenced by the clinic's formulary, and drug use among patients in the hospital and subacute care beds is influenced by the hospital's formulary.

Cost Savings↗