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PubMed2002

Recent trends in workload, input costs, and expenditures in the Air Force Medical Service Direct Care System.

A study was conducted to examine the relationship between two types of trends in the Air Force Medical Service Direct Care System (AFMS/DCS): trends in expenditures, total and by categories; and trends in medical workload, defined as the sum of inpatient admissions and outpatient clinic visits. Expenditure and medical workload data were extracted from the Medical Expense and Performance Reporting System Executive Query System. Medical inflation data were obtained from the Bureau of Labor Statistics Producer Price Index series. Between fiscal years 1995 and 1999, the AFMS/DCS experienced a 21.2% decrease in medical workload, but total (nominal) expenditures declined only 3.6%. Of all expenditure categories, only inpatient medical care, outpatient medical care, and military-funded private sector care for active duty personnel (supplemental care) have any direct relationship with AFMS/DCS medical workload. Real expenditures for the three categories above decreased by 20.3% during the 5-year period. Accounting for inflation and considering only expenditures related to medical workload, these results suggest that the AFMS/DCS is spending approximately 20% less money to do approximately 20% less work.

Aerospace Medicine↗
PubMed2002

Major inequities between district health boards in referred services expenditure: a critical challenge facing the primary health care strategy.

AIMS: This study examines variation between district health boards (DHBs) in expenditure on referred services (ie, pharmaceutical and laboratory services), and compares the gap between budgets as determined by the primary care funding formula and actual expenditure on these services. It also analyses the relationship between population need factors and variation from equity. METHODS: Actual DHB referred services expenditure related to GPs for the period July to November 2001 was obtained from the Ministry of Health and compared with expected expenditure calculated from the funding formula. Percentage difference between actual and expected expenditure was calculated for each DHB. Data were also obtained relating to DHB populations (numbers with community services cards (CSCs), ethnicity, and scores by NZDep96 quintiles) and number of GPs. The data were used to calculate rates for these variables, which were then correlated with percentage variation from equity in DHB referred services expenditure. RESULTS: The analysis showed wide percentage variation from equity between DHBs, with Capital and Coast being 17.5% above and Tairawhiti 23.9% below equity. The analysis also showed a high and significant correlation between this inequity and four measures of disadvantage--population per GP, percentage with CSC, percentage of Maori, and NZDep96 scores--which, together, explained more than 50% of the total variation between DHBs. Population per GP was found to be the most significant predictor of variation. CONCLUSIONS: The inverse care law, ie, that those populations in greatest need are those least likely to receive the services they need, remains a dominant feature of New Zealand s primary care system. This is linked to the gross historical underfunding of access to primary care services. A major redistribution of primary care resources, including GPs, supported by much greater investment in better information and research and development, will be critical to the implementation of the government s Primary Health Care Strategy.

Clinical Laboratory Techniques↗
PubMed1992

Cigarette smoking and lifetime medical expenditures.

The cumulative impact of excess medical care required by smokers at all ages while alive outweighs shorter life expectancy, and smokers incur higher expenditures for medical care over their lifetimes than never-smokers. This accords with the findings by Manning et al. (1989) of positive lifetime medical care costs per pack of cigarettes, but disagrees with the results found by Leu and Schaub (1983, 1985) for Swiss males. The contradictory conclusions of the analyses are undoubtedly due to a large difference in the amount of medical care used by smokers relative to neversmokers in the United States and Swiss data. Excess expenditures increase with the amount smoked among males and females so that lifetime medical costs of male heavy smokers are 47 percent higher than for neversmokers when discounted at 3 percent. Each year more than one million young people start to smoke and add an extra $9 to $10 billion (in 1990 dollars discounted at 3 percent) to the nation's health care bill over their lifetimes. Given the smoking behavior, medical care utilization and costs of care, and population size embedded in the data used in this analysis, I have concluded that in the first five years from baseline the population of smokers aged 25 and over incurs excess medical expenditures totaling $187 billion, which is $2,324 per smoker. The excess cost of medical care associated with cigarette smoking is 18 percent of expenditures for hospital care, physicians' services, and nursing-home care required by all persons (smokers and neversmokers) aged 25 and over. In the absence of large and rapid changes in the values of the underlying parameters, $187 billion, 18 percent of medical expenditures, can be taken as the premium currently being paid every five years to provide medical care for the excess disease suffered by smokers. Even without the addition of any new smokers, the present value of the bill that will be incurred for excess medical care required by the current population of smokers over their remaining lifetimes is high. The civilian noninstitutionalized population of cigarette smokers in 1985 who are age 25 and older is expected to incur over its remaining lifetime excess medical expenditures of $501 billion, or $6,239 per smoker. It is possible that future changes beyond recent historical trends in the habits of those who currently smoke, such as reductions in the amount smoked, higher rates of quitting, whether occurring fortuitously or brought about by design, may result in lower costs of smoking than estimated.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed2005

[Catastrophic health expenditures in Mexico: comparative study by social exclusion level].

OBJECTIVE: To describe the differences in catastrophic health expenditures in five Mexican states. MATERIAL AND METHODS: This study included five states selected by convenience according to their social exclusion level. Household catastrophic health expenditures attributable to the three components of out of pocket health expenditures (ambulatory care, medication, and inpatient care) were calculated. RESULTS: The risk of impoverishment at the national level was greater in the most vulnerable households, namely, in the 20% poorest, rural, and uninsured households. Nevertheless, in states like Aguascalientes, Guerrero, Sinaloa, and Morelos the results were different. Over 70% of catastrophic health expenditures were attributable to medication and outpatient care expenditures in the poorest states. CONCLUSIONS: The differences found among states show that the implementation of local health policies to reduce catastrophic health expenditures should be based on evidence generated from analyses at the state level.

Adult↗
PubMed2005

Exploring the spatial pattern of mental health expenditure.

BACKGROUND: Recent years have witnessed growing interest in cross-sectional variations in municipality mental health expenditure. However, empirical work to date has not examined the links between such variability and demand and supply factors, particularly in the spatial domain. AIMS OF THE STUDY: The aim is to examine whether a local authority's spending decisions in the mental health field respond to neighbouring expenditure decisions. We explore a number of reasons why there might be interdependence between local authorities' decisions, labelling them the demonstrative, market leader, contextual, directive, shared resource and inducement effects. METHODS: Exploratory techniques from spatial data analysis are used to test for the existence of spatial structure. Drawing hypotheses from these initial exploratory analyses, we then adopt a reduced form demand and supply model, extended to incorporate possible policy interaction. The analysis of expenditure and cost variations has traditionally been based on regression models under the classical assumption that the observations are independent. But omitting the recognition that observations are interdependent might lead to erroneous statistical conclusions. Hence, we use spatial econometric techniques that explicitly take into account the potential interdependence of data in order to study the sources of spending variation between municipalities. RESULTS: The exploratory data analyses reveal the presence of positive significant spatial correlation. Per capita mental health spending distributes in clusters, with the highest concentrations in metropolitan areas such as Greater London, Greater Manchester and Birmingham. The estimated spatial regression models indicate that spatial autocorrelation characterises local expenditure decisions, consistent with some degree of policy interdependence between neighbouring municipalities. Comparing the results from our spatial model with those from a classical ('non-spatial') model suggests that the differences in the regression coefficients could be explained by the evident spatial pattern of the phenomenon, since the omission of the lagged dependent variable induces bias in the OLS estimates. IMPLICATIONS FOR HEALTH POLICIES: These results help central and local decision makers understand the factors that influence local spending levels, including variations between municipalities in their achievement of expenditure-related and perhaps other performance targets. The actual patterns of spatial interaction may well be more complex than simple contiguity (the structure assumed here), but there seems little doubt that positive interdependence is an important feature of decision making. IMPLICATIONS FOR FURTHER RESEARCH: Statistical interrogation of a panel dataset would allow exploration of both time-series and cross-municipality variation in mental health expenditure. Subsequent analysis would also benefit from more disaggregated data (e.g. at a census ward level) and the accompanying use of spatial multilevel techniques.

Adolescent↗
PubMed1992

Supply and demand factors in the determination of Medicare expenditures.

This article presents multivariate estimates of the effects of supply-side factors (e.g., provider reimbursement) and demand-side factors (e.g., beneficiary ability to pay) on state-level expenditures per enrollee in Medicare Part A and Part B. The results indicate that a 1 percent increase in elderly income significantly increases the propensity to use Medicare Part B services, resulting in a 0.45 percent increase in Part B expenditures per enrollee. By contrast, patients' ability to pay has a much weaker effect on Part A expenditures. Changes in provider reimbursement also exert a substantial effect on expenditures. A 1 percent rise in the Medicare Prevailing Charge Index raises Medicare Part B expenditures by 0.43 percent. Collectively, the findings of this study suggest that both limits on Medicare reimbursement to providers and increased beneficiary liability have substantial effects on Medicare costs. Whatever the merits of arguments for or against such controls, the responsiveness of Medicare expenditures to equal percentage changes in supply and demand factors appears to be of a similar order of magnitude.

Aged↗
PubMed1991

Disaggregated annual health services expenditures: their predictability and role as predictors.

Risk-based capitation payments are among the fastest growing modes of reimbursement for health insurance. There is ongoing debate about whether the usual underwriting factors such as age and sex are sufficient for establishing annual premiums. This study examines the predictability of disaggregated annual services expenditures and their potential as predictors. The results show that outpatient services are generally more predictable than inpatient services. According to elasticity calculations, prior-year own-expenditures are the strongest predictors of annual expenditures. Of the own-expenditure elasticities, those pertaining to total and outpatient charges are the largest. Among prior year cross-expenditure elasticities, outpatient drug and outpatient office visit expenditures are the greatest.

Adolescent↗
PubMed1995

Expenditure on health research in South Africa, 1991/1992.

OBJECTIVE: To determine expenditure on health research in South Africa in 1991/1992. DESIGN: Data from the financial statements of large statutory councils conducting research in South Africa, as well as other relevant reports, particularly the Department of National Education's (NATED) survey of research institutions, were analysed. RESULTS: A total of R198.7 million was spent on health research in 1991/1992, 56.1% by the tertiary education sector and 20.7% by the Medical Research Council. Only 1.1% of expenditure on health was spent on research. Less than 9% of health research expenditure by tertiary educational institutions is classified within the category of 'comprehensive medicine' (which includes community health, epidemiology and nutrition), whereas 82% of expenditure by autonomous government institutions is so classified. CONCLUSIONS: Given that expenditure on health research in South Africa is relatively low by international standards, an increase in expenditure by both the public and private sectors should be considered. Given the scarcity of research resources, there should be adequate planning, co-ordination, and particularly prioritisation of resource allocations, so that research can be directed towards addressing the country's health needs.

Health Expenditures↗
PubMed1994

Nursing home financing reform: how would it affect expenditures for nursing home care?

There are a number of proposals to expand substantially public financing of nursing home care. Included among the major elements of these proposals are front-end benefits limited to three or six months, back-end benefits with waiting periods of one or two years, and coverage of all nursing home days with or without substantial income-related cost sharing. Using data from the 1987 National Medical Expenditure Survey, this paper simulates the effect of these proposed changes in nursing home financing on public expenditures, Medicaid expenditures, and private expenditures (in total and by marital status and income group). The incentive for increased use of nursing home care also is examined. A short front-end benefit, the least expensive option in terms of public expenditures, increases public expenditures by $1 billion to $2 billion in 1987. Comprehensive coverage of all nursing home days increases public costs by $9 billion to $10 billion dollars, depending on the cost-sharing arrangement. There is wide variation in the range of plausible estimates because of uncertainty about the effect of increased public coverage of nursing home care on utilization.

Costs and Cost Analysis↗
PubMed1986

Energy expenditure in malnourished patients with colorectal cancer.

To evaluate energy expenditure in patients who have colorectal cancer with varying stages of disease and to examine the possible determinants of energy expenditure in a group of patients with cancer who have the same type of tumor, we studied 73 patients with biopsy proven and pathologically staged adenocarcinomas of the colon and rectum. Resting energy expenditure (REE) was measured by indirect calorimetry and compared with predicted energy expenditure (PEE), which was calculated from the Harris-Benedict formulas. Nutritional and tumor characteristics were examined. Forty-nine percent of patients had abnormal REE (normal = PEE +/- 10%). One quarter of the patients were hypometabolic (REE less than 90% PEE). The abnormalities persisted despite normalization of REE to metabolic body size (kg0.75) or predicted values based on weight, height, age, and sex. There were no differences in nutritional status, as judged by the percent of weight loss and visceral protein levels, between those patients in the hypometabolic, normometabolic, or hypermetabolic categories, and there were no significant relationships between energy expenditure and the tumor burden. The mean duration of disease in the normometabolic group was 4.5 months, while the hypometabolic and hypermetabolic groups had mean durations of 9.5 and 14.2 months, respectively. The tumor site and duration of the disease are important variables in studies of energy expenditure in patients with cancer.

Adenocarcinoma↗
PubMed1989

Errors in estimating energy expenditure in critically ill surgical patients.

Thirty-one critically ill surgical patients were receiving central parenteral nutrition. All were intubated, and 29 were receiving mechanical ventilatory support. Nutritional and metabolic data were recorded at the time of indirect calorimetry. Measured energy expenditure (MEE) was compared with predictions of basal energy expenditure (BEE) and calculated energy expenditure, defined as the product of BEE and a stress factor estimated by the nutrition support service to account for severity of illness and activity. The MEE was significantly greater than the BEE and significantly less than the calculated energy expenditure. The estimated stress factor was significantly greater than the actual MEE/BEE ratio, and the correlation between these values was poor. Clinical assessment may overestimate energy expenditure in critically ill patients because of the apparent degree of illness used to determine the stress factor. Bedside indirect calorimetry may be useful to assess more accurately energy expenditure and optimize nutritional support.

Adolescent↗
PubMed1999

Daily energy expenditure across the course of lactation among urban Bangladeshi women.

Measures of energy intake of lactating women in developing countries show that intakes are often lower than those recommended by international bodies, while fat-mass losses are often substantially less than the 3-4 kg used in the calculations of recommendations, suggesting that physiological adaptation must be commonplace among such women. The cost of lactation may be met by reduction in energy expenditure, including reduced physical activity, as well as by mobilization of bodily soft tissue. However, daily energy expenditure of lactating women has been shown to increase across the course of lactation among women in a rural population in the Philippines and an urban population in India, with a decline in body weight across the course of lactation in both studies. In the present study, total daily energy expenditure and anthropometric body composition were measured longitudinally in 68 mothers from a poor urban area of Dhaka, Bangladesh, at 0, 1, 2, 4, and 8 months of lactation, to determine whether the increasing energy expenditure across lactation observed elsewhere also occurs in Bangladeshi women. In addition, the extent to which an extended period of lactation was accompanied by weight and body fat change in these women was determined. Energy expenditure by heart-rate monitoring and activity report, and body composition from anthropometry was carried out four times across the 8-month period of lactation. A small decline in body fat mass and a significant increase in total energy expenditure across this period were observed, confirming similar observations elsewhere in the developing world.

Adult↗
PubMed1984

Energy expenditure estimation in recipients of marrow transplants.

The resting metabolic expenditure of seven allogeneic marrow transplant patients supported by total parenteral nutrition was monitored by respiratory indirect calorimetry using a portable apparatus with a plexiglass canopy. The averaged measurements of resting metabolic expenditure using indirect calorimetry were highly correlated with calculated basal energy expenditures, ideal body weights, fat-free weights, and actual body weights. No consistent correlation was demonstrated between resting metabolic expenditure and body temperature. It is concluded that indirect calorimetry using a portable system is feasible and that measurements of energy expenditure so obtained correlate well with calculated estimates employing the basal energy expenditure equation.

Adult↗
PubMed1993

Measurements of total energy expenditure provide insights into the validity of dietary measurements of energy intake.

The quantification of errors inherent in methods of measuring dietary intake has been handicapped by the absence of independent markers for testing their validity. The doubly labeled water technique permits a precise measure of energy expenditure in free-living persons. Because energy expenditure must equal energy intake in populations in energy balance, this technique may be used to validate the assessment of energy intake. A series of studies demonstrated good agreement between mean energy intake and mean energy expenditure when food intake was recorded by observers or when it was self-reported by normal-weight, self-selected, highly motivated volunteer subjects using weighed records. However, in randomly recruited men and women, energy intake by weighed records was 82% and 81%, of energy expenditure, respectively, indicating underestimation of habitual intake. Men and women in the lowest third of reported intake recorded energy expenditure of only 69% and 61%, respectively. Reported intake of obese and previously obese women was only 73% and 64% of expenditure, whether measured by weighed record or by diet history, confirming suspicions that these subjects misrepresented their intake. Acceptable weighed records were obtained from 7- and 9-year-olds whereas 15- and 18-year-olds underestimated intake. Diet histories taken from the same children tended to overestimate intake. These studies suggest that, ideally, all dietary studies should include independent measures of validity.

Adolescent↗
PubMed1994

Appropriate interpretation of indirect calorimetry for determining energy expenditure of patients in intensive care units.

Energy expenditure varies with patient agitation. We asked whether energy expenditure determined from 5 minutes of measurement with less than 5% variation in minute-to-minute measurements (short mean) was similar to energy expenditure determined from a longer measurement period (long mean; average duration: 31 minutes). The difference between the short mean and the long mean was less than 5% for 42 of 47 patients in intensive care units; the difference was more than 10% for 2 patients. We also generated a statistical model simulating energy expenditure measurement variations of 5% to 20%, and calculated the necessary measurement durations required to achieve a 3% error in measurement. The statistical model showed that for energy expenditure variations of 5%, 10%, 15%, and 20%, the necessary durations of measurement to achieve a 3% error were 3, 9, 16, and 25 minutes, respectively. We conclude that energy expenditure may be determined using the mean of a 5-minute period of measurement if variation in that measurement is less than 5%. Larger variation requires longer periods of measurement.

Calorimetry, Indirect↗
PubMed2006

Caloric expenditure in the morbidly obese using dual energy X-ray absorptiometry.

Total caloric expenditure is the sum of resting energy expenditure (REE) and caloric expenditure during physical activity. In this study, we examined total caloric expenditure in 25 morbidly obese patients (body mass index>or=35 kg/m(2)) using dual energy X-ray absorptiometry (DXA) scanning and cardiorespiratory exercise testing. Our results show average REE for all individuals was 2027+/-276 kcal/d and mean net caloric expenditure during 30 min of exercise was 115+/-16 kcals. Assuming the mean of all input values, a strict 1500 kcal/d diet combined with 150 min per wk of structured physical activity, the projected weight change was -7% (8.8+/-6.2 kg) for 6 mo. We conclude that morbidly obese individuals should be able to achieve only a modest weight loss by following minimal national guidelines. These data suggest that more aggressive energy expenditure and caloric restriction targets for long periods of time are needed to result in significant weight loss in this population.

Absorptiometry, Photon↗
PubMed2004

Energy expenditure, nutrition status, and body composition in children with cystic fibrosis.

OBJECTIVE: Undernutrition is a frequent complication in patients with cystic fibrosis (CF). Elevated energy requirements have been found to be 4% to 33% higher than in controls in some studies. Whether or not this is caused by a primary defect or energy metabolism is still a matter of controversy. To this end, we assessed energy expenditure, nutrition status, and body composition of clinically stable CF outpatients. METHODS: Fifteen clinically stable CF patients, ages 2 to 15 y, were paired with 15 healthy control children. Measurements consisted of anthropometry and body composition. Plasma tocopherol, retinol, and hair zinc content were measured. Resting energy expenditure was determined by indirect calorimetry. Physical activity and dietary intake were recorded by recall methods. RESULTS: Two children were nutritionally at risk according to the weight/height index, eight were normal, three were overweight, and two were obese. Body composition was similar in both groups. Zinc, tocopherol, and retinol levels were low in three, two, and three patients, respectively. Resting energy expenditures were 4.7 MJ/d (1127 +/- 220 kcal/d) in CF children and 4.63 MJ/d (1108 +/- 191 kcal/d) in control children (P = not significant). Physical activity level was sedentary in 86.6% of CF patients; the rest had a light physical activity pattern. Energy intake represented 141% of the estimated daily energy expenditure. CONCLUSIONS: Non-oxygen-dependent CF children, without acute respiratory infection, had resting energy expenditures comparable to those of matched controls. Total energy expenditure was similar to or slightly lower than that in healthy children. Dietary recommendations for CF patients need to be reassessed.

Adolescent↗
PubMed2002

Energy intake and energy expenditure: a controlled study comparing dietitians and non-dietitians.

BACKGROUND: Underreporting of food intake has been commonly observed. We hypothesized that experience with recording dietary information might increase the accuracy of the records. To test this hypothesis, we compared energy intake and energy expenditure in dietitians-who are experienced in recording food intake-with those of non-dietitians, whose only exposure to training to record food was in the context of this trial. SUBJECTS/SETTING: Subjects for this study were 10 female registered dietitians and 10 women of comparable age and weight who were not dietitians. DESIGN: This study compared the energy intake obtained from 7-day food records with energy expenditure measured over the corresponding 7-day period using doubly labeled water. STATISTICAL ANALYSIS: Data were compared by an analysis of variance METHODS: All subjects were trained to provide a 7-day weighed food intake record. Energy expenditure was measured with doubly labeled water over the 7 days when the weighed food intake record was obtained. A total of 10 dietitians and a control of group of 10 women of similar age and weight were recruited for this study. Participants were told that the goal was to record food intake as accurately as possible, because it would be compared with the simultaneous measurement of energy expenditure determined by doubly labeled water. RESULTS: The energy expenditure of the dietitians and controls were not different (2,154+/-105 [mean+/- standard error of the mean] kcal/day for dietitians and 2,315 +/- 90 kcal/ day for controls). The dietitians underreported their energy intake obtained from the food records by an average of 223 +/- 116 kcal/day, which was not different from their energy expenditure. Participants in the control group, as hypothesized, significantly underreported their energy intake (429 +/- 142 kcal/day, P < .05). CONCLUSION: Dietitians estimated their energy intake more accurately than non-dietitians, suggesting that familiarity with and interest in keeping food records may lead to more reliable estimates of energy intake.

Adult↗