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PubMedDate not supplied

Cost per service differentials in local health departments.

An emerging issue in health care is the relative efficiency with which local health departments provide their services. The problem is complicated by the fact that many factors may contribute to variations in efficiency. We have developed a framework for analyzing such variations across departments, using cost per service (CPS) as the measure of efficiency. The approach is illustrated with data from all 82 county or district health departments in North Carolina. CPS levels can be differentially affected by selected uncontrollable characteristics of the serviced population. Thus, when used to evaluate departmental performance, or to determine reimbursement rates, the CPS must be adjusted for relevant exogenous factors. Our method of cluster analysis accounts "naturally" for these factors, thereby allowing for development of policy decisions more responsive to actual health department circumstances.

Direct Service Costs↗
PubMed2004

Complete versus culprit vessel percutaneous coronary intervention in multivessel disease: a randomized comparison.

BACKGROUND: The purpose of this study was to compare the safety, efficacy, and costs of complete versus "culprit" vessel revascularization in multivessel coronary artery disease treated with percutaneous coronary interventions (PCI). METHODS: Patients with multivessel disease and an identified culprit vessel were randomly assigned to complete revascularization of vessels > or =50% stenoses (n = 108) versus revascularization limited to the culprit vessel (n = 111). The primary end point, major adverse cardiac events (MACE), were defined as cardiac or noncardiac death, myocardial infarction, need for coronary artery bypass graft surgery, and repeat PCI up to 1 year. RESULTS: Despite equal MACE at 24 hours (6.3% vs 7.4%), strategy success was higher in the culprit vessel than in the complete revascularization group (93.7% vs 81.5%, P =.007). MACE rates at 1 month (14.4% vs 9.3%), 1 year (32.4% vs 26.9%), and 4.6 +/- 1.2 years (40.4% vs 34.6%) were similar in both groups. Repeat PCI was performed more often in the culprit vessel group (31.2% vs 21.2%, P =.06). A lower consumption of medical material was associated with lower procedural costs in the culprit vessel group (5784 vs 7315 Euros; P <.001). However, between 1 year and the end of follow-up, costs had equalized in both groups. CONCLUSIONS: Complete versus culprit vessel revascularization in multivessel coronary disease treated with PCI was associated with a lower strategy success rate, similar MACE rates, and initially higher costs. However, over the long term, more repeat PCIs were conducted in patients treated by culprit revascularization only, mostly because of the need to treat lesions initially left untreated. As a consequence, incremental costs had equalized within 1 year. The decision of whether to perform culprit vessel or complete revascularization can be made on an individual basis.

Adult↗
PubMed2003

Costs of chronic bronchitis and COPD: a 1-year follow-up study.

OBJECTIVE: This study attempted to determine the total direct costs derived from the management of chronic bronchitis and COPD in an ambulatory setting through a prospective, 1-year, follow-up study. METHOD: A total of 1,510 patients with chronic bronchitis and COPD were recruited from 268 general practices located throughout Spain. Patients were followed up for 1 year. All direct medical costs incurred by the cohort and related to their respiratory disease were quantified. Costs were calculated for patients with confirmed COPD according to the degree of severity of airflow obstruction. RESULTS: The global mean direct yearly cost of chronic bronchitis and COPD was $1,876. The cost generated by patients with COPD was $1,760, but the cost of severe COPD ($2,911) was almost double that of mild COPD ($1,484). Hospitalization costs represented 43.8% of costs, drug acquisition costs were 40.8%, and clinic visits and diagnostic tests represented only 15.4% of costs. CONCLUSION: This is the first prospective follow-up study on a large cohort of patients with chronic bronchitis and COPD aimed at quantifying direct medical costs under usual clinical practice in the community. Costs of chronic bronchitis and COPD were almost twofold those reported for asthma. Patterns of COPD management in the community differ from those recommended in guidelines. COPD represents a great health-care burden in developed countries, and aging of the population and continuing smoking habits predict that it will continue to do so in the future.

Aged↗
PubMed2006

Prospective payments in a regional trauma center: the case for recognition of the transfer patient in diagnostic related groups.

BACKGROUND: Transfer patients (TP) differ from patients transported directly from the field (DP) by virtue of their complexity and delays to definitive care, factors that might impact on costs and resource utilization and aggravate the adverse selection that already threatens TC reimbursement. METHODS: This is a retrospective cohort study where patients admitted to a Level I trauma center were classified as a TP or DP. Crude and adjusted total costs, complications, length of stay, and proportion of DRG outliers were compared across the two cohorts. RESULTS: Among 8,665 patients, 40% were transferred. TP were more likely to be DRG outliers (15% versus 10%, p < 0.001). Costs in 65% of the DRGs were higher in the TP. Rates of complications and length of stay were significantly greater in the TP. CONCLUSION: There are systematic differences in resource consumption between transferred patients and patients transported directly from the field. These differences render conventional DRG-based mechanisms of reimbursement inadequate, suggesting a need for recognition of the transfer patient as a distinct entity by payers.

Adult↗
PubMed2006

Cost of depression of adults in Taiwan.

OBJECTIVE: To estimate the direct cost of depression in Taiwanese adults for the years 2000-2002. METHODS: The medical claims database of the National Health Bureau was analyzed and the cost of treating adults (>15 years of age) with the diagnosis of depression was calculated. RESULTS: The total direct medical costs of adult depression in the three years 2000, 2001, and 2002 were approximately US dollars 93 million, US dollars 117 million, and US dollars 140million, respectively. CONCLUSION: The cost of depression increased continuously over the period from 2000-2002. However, the percentage of patients receiving treatment did not increase steadily over the same time period with treatment rates of 1.5% in 2000, 2.3% in 2001, and 2.0% in 2002. The recent annual prevalence of depression in Taiwan has been estimated at 4-5%. Thus, the Taiwanese health authority spends an annual average of US dollars 116.6 million to treat depression (1.2% of total national expenses). In sum, the treatment of depression, while costly, deserves greater attention by public health officials in order to avoid the already significant burden of this disease on both patients and society. Future research will therefore require more accurate statistical data in order to assess the effects of depression-related burdens on individuals and society, especially with respect to the capacity to work.

Adult↗
PubMedDate not supplied

Use of acupuncture in the treatment of sinus and nasal symptoms: results of a practitioner survey.

BACKGROUND: The use of complementary medicine is increasingly popular in the United States. The use of acupuncture and its efficacy in treating chronic sinus and nasal symptoms is not well studied. METHODS: Regional licensed acupuncturists (1516) were mailed our acupuncture and chronic sinus and nasal symptoms survey. RESULTS: Three hundred thirty-one surveys (22%) were returned. Ninety-nine percent of those who returned surveys reported treating patients with chronic sinus and nasal symptoms. On a five-point scale the mean perceived efficacy for the overall treatment of chronic sinus and nasal symptoms was 4.2. The mean cost of an acupuncture treatment course for chronic sinus and nasal symptoms was calculated to be dollar 730.00. CONCLUSION: Complementary medicine practitioners frequently use acupuncture in the treatment of patients with chronic sinus and nasal symptoms. Although practitioners report good efficacy using acupuncture to treat such patients, quantitative data are certainly needed to substantiate these self-reports.

Acupuncture Points↗
PubMed1998

Postprostatectomy urinary incontinence: a comparison of the cost of conservative versus surgical management.

OBJECTIVES: Post-radical prostatectomy stress incontinence occurs in up to 20% of patients. Postprostatectomy incontinence is initially treated with undergarments, pads, or drip collectors. Patients with persistent leakage are often treated with a transurethral bulking agent (Contigen) or placement of an artificial genitourinary sphincter (AGUS). We have compared the direct costs of each treatment at our institution over 10 years. METHODS: The Mayo Clinic estimating office provided the Medicare and non-Medicare charges for patients receiving both collagen injection (outpatient) and AGUS placement (2-day hospitalization) during August 1995. The Mayo Store provided the current price of all undergarments, pads, and drip collectors carried. Two local grocery stores provided the cost of Depends undergarments. RESULTS: The following items were the least expensive carried at the Mayo Clinic Store: Entrust undergarments, Active Style pads, and Conveen drip collectors at $0.99, $0.52, $1.05 each, respectively. The average cost of Depends undergarments was $0.52 each. The cost of wearing 5 of the least expensive undergarments or pads per day for 10 years is $9497. The average estimated Medicare and non-Medicare cost for outpatient (general anesthesia) collagen injection is $4300 and $5625, respectively. The average Medicare and non-Medicare cost for AGUS placement is $15,400 and $20,300, respectively. Factoring in our current 22.4% reoperation rate, the average per patient Medicare and non-Medicare cost for AGUS placement is $18,850 and $24,847, respectively. CONCLUSIONS: The cost of the AGUS placement compares favorably with the cost of transurethral collagen injection (under general anesthesia) in patients requiring several (more than three) collagen injection treatments or requiring the continued use of undergarments after collagen injection. Whereas the cost of transurethral collagen injection, when effective, compares favorably with conservative treatment, AGUS placement is significantly more expensive than conservative management for almost all patients except the exceedingly rare patient wearing more than 9 undergarments or pads per day. When the psychosocial benefit of urinary continence is considered, however, transurethral injection of collagen or AGUS placement often becomes the preferred treatment.

Ambulatory Surgical Procedures↗
PubMed2003

A study of influenza and influenza-related complications among children in a large US health insurance plan database.

BACKGROUND: Influenza places a substantial burden on the affected individual and society. While there are data available on the overall occurrence of influenza in children, less information is available on the differential impact of influenza on healthcare for previously healthy children and those at high risk of developing influenza-related complications. OBJECTIVE: To compare the frequency of influenza-related complications in healthy and 'at-risk' children, and quantify the associated use of medical resources and costs. DESIGN: Data were obtained from a large US-based health insurance plan database. MAIN OUTCOME MEASURES AND RESULTS: A total of 23 188 health insurance claims with an influenza diagnosis were identified over the 3-year period 1995-1997 (3 247 834 patient-years). Influenza-related complications were observed in approximately a quarter of the total diagnosed cases, with younger children (0-4 years of age) at substantially greater risk. 'At-risk' children were more likely to develop influenza-related complications than otherwise healthy children. The greatest difference in incidence rate in the 0-4 year age group was for asthma (incidence rate ratio 8.7, 95% CI 5.2-14.4), and in the 5-14 year age group for asthma (incidence rate ratio 8.5, 95% CI 5.2-13.7) and acute sinusitis (incidence rate ratio 2.7, 95% CI 1.2-5.4). The average direct medical costs of influenza in children under 15 years with complications were more than 3.5 times higher than those without. CONCLUSIONS: Measures to prevent and treat influenza-related complications are certainly warranted for at-risk children, although the elevated incidence rates for several common complications even among healthy children should prompt consideration of these measures for all children.

Acute Disease↗
PubMed2005

Trauma/critical care surgeon: a specialist gasping for air.

BACKGROUND: In the last 10 years, trauma/critical care has become less attractive because of the decreasing surgical caseload, the nocturnal work hours, and the economics of the practice. Nevertheless, during the same period, the number of verified trauma centers has significantly increased. This study assesses the economic drive behind this dichotomy. METHODS: Over a 1-year period, we collected financial data on 1,907 trauma patients for both Level I trauma centers and trauma/critical care surgeons. Financial data, including payor source, cost, reimbursement, margin, and reimbursement-to-charge and reimbursement-to-direct cost ratios, were calculated. RESULTS: For commercial- and government-insured patients, the reimbursement-to-direct cost ratio was 2-and 35-fold greater, respectively, for the trauma centers than for the trauma/critical care surgeons. For uninsured patients, the addition of local government funds allowed the trauma center to cover direct cost with no margin. In contrast, even with the addition of supplemental salary dollars from the institution, for every dollar in direct cost generated by the trauma/critical care surgeons in caring for uninsured patients, they recovered 55 cents, or a loss of 45 cents per direct cost dollar spent. CONCLUSION: The economic dichotomy that exists between trauma centers and trauma/critical surgeons is significant. It drives institutional growth and, at the same time, discourages surgeons from entering the subspecialty. As physician reimbursement decreases and the number of uninsured patients increases, this economic dichotomy will amplify. Over the next decade, without a significant adjustment, the subspecialty is in danger of extinction.

Career Choice↗
PubMed1992

Must diabetes be a fatal disease in Africa? Study of costs of treatment.

OBJECTIVE: To estimate the costs of diagnosis and treatment of diabetes in Tanzania. DESIGN: Costs estimated from the reported and recorded experience of patients with newly presenting diabetes in 1989-90 and of diabetic patients first seen in 1981-2. SETTING: Muhimbili Medical Centre, Dar es Salaam. SUBJECTS: 464 patients (315 men and 149 women). 262 patients diagnosed during 1 September 1989-31 August 1990 (group 1) and 202 during 1 June 1981-31 August 1982 (group 2). RESULTS: The average annual direct cost of diabetes care in 1989-90 was $287 for a patient requiring insulin and $103 for a patient not requiring insulin. Purchase of insulin accounted for 68.2% ($156) of the average annual outpatient costs for patients requiring insulin. For patients not requiring insulin the cost of oral hypoglycaemic drugs and treatment of chronic complications and infections accounted for 42.5% ($29.3) and 48.8% ($33.7) of costs respectively. Cost of outpatient care of diabetic patients for the whole of Tanzania was estimated at $2.7m, *75,128 (32.2%) of which was for insulin. Doctors' and nurses' costs accounted for 0.2% of total costs of outpatient care. The annual direct inpatient care costs were estimated at $1.25m. Around 0.2% of the Tanzanian population aged 15 years and over used the equivalent of 8% of the total government health expenditure, which was $47,4088,382. CONCLUSION: Diabetes places a severe strain on the limited resources of developing countries. If African patients with diabetes have to pay for their treatment most will be unable to do so and will die.

Adolescent↗
PubMed2001

Rational testing of the HIV-exposed infant.

OBJECTIVES: The objectives of this study were 1) to evaluate testing regimens of human immunodeficiency virus (HIV)-exposed infants and 2) to determine optimal methods of follow-up by enzyme-linked immunosorbent assay (ELISA) testing. METHODS: We reviewed the results from 742 HIV-exposed infants in the state of North Carolina; 2474 samples were tested for HIV by DNA polymerase chain reaction (PCR) at the University of North Carolina Retrovirology Core Laboratory. We then reviewed the utility and costs of ELISA testing of all HIV-exposed infants who were seen at the Duke University Pediatric Infectious Disease Clinic between January 1, 1993, and May 5, 1998. We used likelihood ratios to model probability of HIV infection given 3 negative DNA (PCR) tests and to provide recommendations on the use of ELISA follow-up. RESULTS: The overall sensitivity of the DNA PCR was 87.1%, and its specificity was 99.9%. We evaluated 224 HIV-exposed infants who were seen at Duke University and who had at least 3 negative diagnostic tests using either DNA PCR tests or HIV blood cultures. All 178 infants who subsequently underwent ELISA testing ultimately demonstrated seroreversion. The Duke University Pediatric Infectious Disease Clinic transferred the care of 65 patients to primary care physicians before ELISA testing and retained the care of the remaining 159 patients. Children who remained in Duke's care were more likely to have documentation of seroreversion (158 of 159 vs 20 of 65). We reviewed costs of travel, physician appointment, and HIV antibody testing in a tertiary care setting. Given 3 negative PCR tests, the expected cost per case of HIV detected by a positive ELISA assay is $23.8 million. CONCLUSIONS: Documentation of seroreversion in this cohort was nearly complete in the multidisciplinary subspecialty clinic but not when such responsibility was left to the primary care physician. Given the low probability of disease in patients who have had 3 negative PCR tests, documentation of a negative ELISA may not be an appropriate use of medical resources.

Algorithms↗
PubMed2005

Misdiagnosed patients with bipolar disorder: comorbidities, treatment patterns, and direct treatment costs.

OBJECTIVE: The purpose of this study was to examine comorbidities, treatment patterns, and direct treatment costs of patients with bipolar disorder who are misdiagnosed with unipolar depression. METHOD: This study is a retrospective analysis of data from the MarketScan Commercial Claims and Encounters (CCE) database. Logistic regressions and analyses of variance were used to compare the misdiagnosis cohort to 3 age- and gender-matched comparison cohorts (recognized bipolar, depression, and no psychiatric disorders based on ICD-9-CM criteria) during the year 2000. RESULTS: Each cohort had 769 individuals (68.0% female; mean age of roughly 42 years). The misdiagnosis cohort had higher rates of several psychiatric comorbidities than the depression cohort (e.g., personality disorders, alcohol abuse, psychotic disorder) and the bipolar cohort (e.g., generalized anxiety disorder, panic) but a lower rate of psychotic disorders than the bipolar cohort (p < .05). Compared with the bipolar cohort, the misdiagnosis cohort was more likely to receive antidepressants, but less likely to receive anticonvulsants, antipsychotics, or lithium (all p < .001). Antidepressant rates were similar among the misdiagnosis and depression cohorts. Group differences were found in mean annual costs for anticonvulsants, antipsychotics, lithium, antidepressants, and total treatment costs: bipolar (USD $442, $310, $67, $497, $8600); misdiagnosis (USD $221, $185, $20, $704, $8761); depression (USD $70, $74, $5, $657, $7288). CONCLUSION: Misdiagnosed bipolar patients received inappropriate and costly treatment regimens involving overuse of antidepressants and underuse of potentially effective medications. Patterns of psychiatric comorbidity suggest one possible strategy for improving recognition of bipolar disorder among patients presenting with depressive symptoms. Patients who present with the observed pattern of comorbidities may benefit from additional screening for bipolar disorder. It is recommended that steps be taken to minimize misdiagnosis in clinical settings.

Adult↗
PubMed1997

Comparison of laparoscopic and open adrenalectomy.

This review compares the outcomes of patients who have undergone laparoscopic and open adrenalectomy. Records of all patients who underwent adrenalectomy between January 1993 and December 1996 at Cedars-Sinai Medical Center, Los Angeles, were reviewed. Ten patients underwent laparoscopic, and ten patients underwent open adrenalectomy. The average age in the laparoscopic group (LA) was 48 years (range, 23-64) and 47 years (range, 28-79) in the open group (OA). The LA had smaller tumor size (2.9 +/- 2.0 versus 6.1 +/- 2.8 cm; P = 0.01), longer operative times (164 +/- 47 versus 124 +/- 29 minutes; P = 0.03), shorter length of postsurgical stay (4.1 +/- 2.5 versus 5.9 +/- 1.1 days; P = 0.05), and fewer days of parenteral pain medication (1.9 +/- 1.8 versus 3.4 +/- 1.0 days; P = 0.04). Although the differences did not reach statistical significance, LA also had lower estimated blood loss (118 +/- 158 versus 210 +/- 172 cc; P = 0.23), less time to oral intake (1.8 +/- 2.2 versus 2.8 +/- 1.3 days; P = 0.24), and less direct cost ($3645 +/- 1502 versus $5752 +/- 2948; P = 0.07). Complications of LA included one patient who had a prolonged ileus and adrenal insufficiency and another patient who required readmission for adrenal insufficiency. Complications of OA included one patient who had a prolonged ileus and one patient who had a 20 per cent pneumothorax. Laparoscopic adrenalectomy is the preferred technique in nonmalignant adrenal lesions less than 6 cm in size.

Adenoma↗
PubMed1991

The Medicare Optometry Parity Amendment: predicted and actual payments to optometrists and ophthalmologists.

This paper compares various costs estimates for the expansion of optometric services under the Medicare program that were developed prior to the enactment the Medicare Parity Amendment of 1986. The new law, effective April 1, 1987 redefines the conditions of optometric participation and expanded coverage to include all Medicare covered services for which optometrists are authorized to perform under the state law. The paper describes the impact of the Medicare amendment with regard to payments to optometrists and ophthalmologists. Payments to optometrists increased from $12 million in 1986, a year before the Medicare Amendment to $81 million in 1988, the first full year after the law's implementation increasing their market share of Medicare payments from 2.6% to 11.1%. Ophthalmology incurred a significant decrease in market share from 97.9% to 88.9% during this period.

Direct Service Costs↗
PubMed1988

The economics of academic health sciences libraries: cost recovery in the era of big science.

With launching of Sputnik by the Soviet Union in the late 1950s, science and technology became a high priority in the United States. During the two decades since, health sciences libraries have experienced changes in almost all aspects of their operations. Additionally, recent developments in medical care and in medical education have had major influences on the mission of health science libraries. In the unending struggle to keep up with new technologies and services, libraries have had to support increasing demands while they receive a decreasing share of the health care dollar. This paper explores the economic challenges faced by academic health sciences libraries and suggests measures for augmenting traditional sources of funding. The development of marketing efforts, institutional memberships, and fee-based services by the Louis Calder Memorial Library, University of Miami School of Medicine, is presented as a case study.

Direct Service Costs↗
PubMed1980

Echocardiographic practice in a large metropolitan area.

A survey performed concerning echocardiography in a metropolitan area. Of 110 hospitals in the area, 62 reported having echocardiographic facilities. Echocardiographic physicians and/or technicians from 41 of these hospitals responded to questionnaires designed to determine the following: (1) educational background and credentials of technicians, (2) average salaries of technicians, (3) role of the physician and technician in the performance and reporting of echocardiograms, (4) volume, cost, and method of storage of echocardiograms, and (5) number and type of echocardiographic units in use. Our data suggest various trends, including a lack of formal training among technicians, the prevalence of cardiologists-internists as directors of echocardiographic facilities, the performance of echocardiograms by cardiology fellows in only 46% of institutions with cardiology training programs, and the widespread projected availability of cross-sectional echocardiographic capability within the next two years.

Allied Health Personnel↗
PubMed2005

Care needs of residents in community-based long-term care facilities in Taiwan.

AIM: The purpose of this study is to gain an understanding both of the characteristics of residents who receive the services of nursing assistants and the service intensity (service tasks, service time and cost) of nursing assistants as a means of developing a patient classification based upon resource consumption. BACKGROUND: Most people in Taiwan send their disabled older family members to community-based long-term care facilities instead of nursing homes because they are much cheaper, and because they are generally closer to their homes, making visits more convenient. Nursing assistants make up the largest group of personnel in long-term care facilities. To determine resource use, both the service time and the actual activities performed for a resident by nursing assistants need to be assessed and this will help to develop a patient classification system to predict resource use and patient outcomes. METHODS: A descriptive survey method was used to identify the tasks performed by nursing assistants in community-based long-term care facilities in Taiwan. Nursing assistants were recruited from 10 long-term care facilities in the Shihlin and Peitou Districts of Taipei City. Thirty-four nursing assistants and 112 residents participated in this study. RESULTS: Findings showed that each nursing assistant spent 5.05 hours per day doing direct service care, which is much higher than the 2.08 hours for nursing assistants in the United States. Among service tasks provided by nursing assistants, personal care consumed 35.1% of their time. Non-complex treatments were second (33.3%). Skilled nursing and medical services were third (31.6%). The service intensity required of nursing assistants was strongly related to the residents' activities of daily living and their needs. CONCLUSION: Complex nursing procedures are normally provided by Registered Nurses in nursing homes and consumed almost as much of the nursing assistants' time as did personal care activities in this study. RELEVANCE TO CLINICAL PRACTICE: It is suggested that a training program for nursing assistants, especially for foreigners in community-based long-term care facilities, should be mandated to assure the quality of service.

Activities of Daily Living↗
PubMed2000

The cost of health conditions in a health maintenance organization.

In this retrospective cohort analysis of all adults who were members of Kaiser Permanente, Northern California, between July 1995 and June 1996 (N = 2,076,303), the authors estimated the prevalence, average annual costs per person, and percentage of total direct medical expenditures attributable to each of 25 chronic and acute conditions. Ordinary least squares regression was used to adjust for age, gender, and comorbidities. The costs attributable to the 25 conditions accounted for 78 percent of the health maintenance organization's total direct medical expense for this age-group. Injury accounted for a higher proportion (11.5 percent) of expenditures than any other single condition. Three cardiovascular conditions--ischemic heart disease, hypertension, and congestive heart failure--together accounted for 17 percent of direct medical expense and separately accounted for 6.8 percent, 5.7 percent, and 4.0 percent, respectively. Renal failure ($22,636), colorectal cancer ($10,506), pneumonia ($9,499), and lung cancer ($8,612) were the most expensive conditions per person per year.

Acute Disease↗