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PubMed2003

Case-mix adjusting performance measures in a veteran population: pharmacy- and diagnosis-based approaches.

OBJECTIVE: To compare the rankings for health care utilization performance measures at the facility level in a Veterans Health Administration (VHA) health care delivery network using pharmacy- and diagnosis-based case-mix adjustment measures. DATA SOURCES/STUDY SETTING: The study included veterans who used inpatient or outpatient services in Veterans Integrated Service Network (VISN) 20 during fiscal year 1998 (October 1997 to September 1998; N = 126,076). Utilization and pharmacy data were extracted from VHA national databases and the VISN 20 data warehouse. STUDY DESIGN: We estimated concurrent regression models using pharmacy or diagnosis information in the base year (FY1998) to predict health service utilization in the same year. Utilization measures included bed days of care for inpatient care and provider visits for outpatient care. PRINCIPAL FINDINGS: Rankings of predicted utilization measures across facilities vary by case-mix adjustment measure. There is greater consistency within the diagnosis-based models than between the diagnosis- and pharmacy-based models. The eight facilities were ranked differently by the diagnosis- and pharmacy-based models. CONCLUSIONS: Choice of case-mix adjustment measure affects rankings of facilities on performance measures, raising concerns about the validity of profiling practices. Differences in rankings may reflect differences in comparability of data capture across facilities between pharmacy and diagnosis data sources, and unstable estimates due to small numbers of patients in a facility.

Aged↗
PubMed1999

Patient satisfaction with HIV service provision in NPMS hospitals: the development of a standard satisfaction questionnaire. NPMS Steering Group.

A self-completion satisfaction questionnaire evaluating the standard of care of HIV outpatient services was developed as part of the National Prospective Monitoring System on the Use, Cost and Outcome of HIV Service Provision in English Hospitals (NPMS). The questionnaire was designed in conjunction with service users and health care professionals, and piloted in three London and three non-London HIV clinics. In addition to testing alternative methods of administering the questionnaire, the pilot provided satisfaction scores on a variety of aspects of service provision for participating clinics. The questionnaire was completed by 548 respondents and was most effectively collected using a sealed box in the clinic waiting area. Mean satisfaction scores for the attitude and skills of staff members was 4.7 (95% CI 4.6-4.7) but satisfaction scores were significantly lower for the clinic environment with a mean of 4.1 (95% CI 4.1-4.2). Satisfaction scores did not differ significantly by gender, age, sexual orientation, ethnic group, employment status or severity of symptoms. London respondents were more satisfied with the clinic environment and seeing preferred members of staff than their non-London counterparts, however there were no other differences between clinics. The questionnaire functioned well in practice and provided meaningful and useful information for individual clinics as well as at aggregate level.

Acquired Immunodeficiency Syndrome↗
PubMed2003

Trends in comprehensive service availability in outpatient drug abuse treatment.

Comprehensive medical and psychosocial services are essential to quality addiction treatment, but their availability declined in the 1980s. To determine whether this downward trend in the availability of comprehensive services continued in the 1990s, we analyzed data from a national panel study of outpatient substance abuse treatment units in 1990, 1995, and 2000. Response rates were greater than 85%. Regarding the availability of comprehensive services, including physical examinations, routine medical care, mental health services, financial counseling and employment counseling, administrators reported whether any substance abuse treatment client received the service in the past year. With the exception of physical examinations, whose reported availability increased from 1990 to 1995, and financial counseling, whose reported availability decreased during the same time, the reported availability of comprehensive services changed little during the 1990s. These findings highlight the continuing need to monitor access to comprehensive services and other quality markers in addiction treatment over time.

Data Collection↗
PubMed2005

Changes in veterans' use of outpatient care from 1992 to 2000.

OBJECTIVES: During the mid-1990s, the Veterans Health Administration (VHA) reorganized and placed greater emphasis on high-quality primary care. To determine whether the reorganization was associated with changes in patterns of out-patient VHA use, we sought to evaluate changes in characteristics of veterans who use VHA outpatient services between 1992 and 2000. METHODS: We merged 2 waves of the National Survey of Veterans to determine changes in patterns of outpatient care use. We evaluated the extent to which veterans who received outpatient care received that care from the VHA. RESULTS: The odds ratio for VHA-only outpatient care relative to non-VHA-only care in 2000 relative to 1992 was 1.75 (95% confidence interval [CI]=1.51, 2.04), and the odds ratio for dual relative to non-VHA-only care was 1.22 (95% CI=1.08, 1.37). Veterans who were older, had low incomes, and had no additional health insurance coverage were most likely to increase their use of VHA outpatient care. CONCLUSIONS: Our results suggest that the VHA is increasingly serving veterans who have trouble accessing the private health care system.

Ambulatory Care↗
PubMed2000

Symptoms of striatofrontal dysfunction contribute to disability in geriatric depression.

OBJECTIVE: To examine whether symptoms of striatofrontal dysfunction contribute to disability in geriatric depression. DESIGN: Cross-sectional evaluation of the relationship of specific cognitive impairments, psychomotor retardation, severity of depression, and medical burden to impairment of instrumental activities of daily living. SETTING: Inpatient and outpatient services of a psychiatric university hospital located in a suburban metropolitan area.Patients. One hundred and fifty elderly psychiatric inpatients and outpatients with major depression and cognitive function ranging from normal to moderate dementia. MEASURES: Psychomotor retardation was evaluated with the Hamilton retardation item and executive dysfunction was assessed with the initiation/perseveration (IP) domain of the Dementia Rating Scale. Disability, severity of depression and medical burden were assessed with the Instrumental Activities of Daily Living Index of the Multilevel Assessment Instrument, the Hamilton Depression Rating Scale and the Cumulative Illness Rating Scale-Geriatric, respectively. RESULTS: In the entire sample (N = 150) and in the non-demented subjects (N = 101), stepwise regression analyses revealed that IP and psychomotor retardation were associated with IADL impairment. Additionally, a 'striatofrontal component', which consisted of IP and psychomotor retardation was also significantly associated with IADL impairment in the whole sample, as well as in the non-demented patients. CONCLUSION: Clinical symptoms and neuropsychological findings associated with striatofrontal dysfunction contribute to disability in depressed elderly patients.

Activities of Daily Living↗
PubMed2004

An assessment of the feasibility of telephone and email consultation in a chest clinic.

One hundred and sixty-four consecutive patients attending a busy respiratory outpatient service were asked how acceptable was the concept of alternating face to face consultation with consultation by either telephone or email. The patients were then assessed as to their suitability for such non-traditional methods of consultation. Thirty patients (18.3%) were not agreeable to other forms of consultation and five could not speak English. One hundred and thirty-three (84%) had a suitable daytime telephone number for consultation purposes, but only 34 (21%) had email access, with this being commoner in the younger ages. One hundred and five patients were not thought to be suitable for alternative methods of consultation because of: the severity of their condition, the difficulty of assessing it over the telephone, or because they needed to attend the hospital for investigations. However, even in a clinic where the policy was already to return as many patients as possible to the care of their primary care physicians, and in a clinic where much work was already shared with respiratory nurse specialists, over one-third of patients were thought to be suitable for alternating face to face with telephone consultation. The diagnoses in those cases included asthma, suspected obstructive sleep apnoea, chronic obstructive pulmonary disease (COPD), unexplained cough, and some patients with respiratory malignancy being visited at home by the palliative medicine services. However, for those with asthma and for those awaiting results of investigations especially, use of telephone consultation appears to be an acceptable and convenient way of reducing the pressure upon time available for face to face consultations.

Computer Literacy↗
PubMed2005

Post-discharge home-based support for older cardiac patients: a randomised controlled trial.

BACKGROUND: Hospital and exercise-based cardiac rehabilitation programmes do not suit many older patients and home-based rehabilitation may be more effective. OBJECTIVE: To evaluate a home-based intervention for patients aged 65 years or over discharged home from hospital after emergency admission for suspected myocardial infarction. DESIGN: A single-blind randomised controlled trial comparing home-based intervention by a nurse with usual care. SUBJECTS: Patients aged 65 years or over discharged home after hospitalisation with suspected myocardial infarction (n= 324). INTERVENTION: Home-based intervention (n = 163) consisted of home visits at 1-2 and 6-8 weeks after hospital discharge by a nurse who encouraged compliance with and knowledge of their treatment regimen, offered support and guidance about resuming daily activities, and involved other community services as appropriate. MEASUREMENTS: Up to 100 days after admission, data were collected on deaths, hospital readmissions and use of outpatient services. Survivors were sent a postal questionnaire to assess activities of daily living and quality of life. RESULTS: At 100 day follow-up there was no difference in deaths, activities of daily living or overall quality of life, but those in the intervention group scored significantly better on the confidence and self-esteem subsections. The intervention group had fewer hospital readmissions (35 versus 51, relative risk 0.68, 95% CI 0.47-0.98, P < 0.05) and fewer days of hospitalisation after initial discharge (mean difference -1.7, 95% CI -2.09 to -1.31, P < 0.05). A total of 42/43 individuals in the intervention group had resumed driving at follow-up, compared with 32/43 in the usual care group (observed difference between proportions 23%, 95% CI 9-37%, P < 0.05). CONCLUSION: Amongst older patients discharged home after hospitalisation for suspected myocardial infarction, home-based nurse intervention may improve confidence and self-esteem, and reduce early hospital readmissions.

Age Factors↗
PubMed1995

Selecting a bedside glucose monitor for outpatient clinics.

The purpose of this study was to determine the accuracy of two bedside capillary blood glucose monitors that were being considered for purchase for an adult outpatient clinic. Participants were 101 patients 18 years or older with a diagnosis of diabetes mellitus who were attending medical service outpatient clinics. Participants were randomly assigned to two groups for bedside glucose measurement. Clinic nurses trained for the study did the bedside glucose readings and all venous blood samples were analyzed in the hospital's clinical laboratory. Results of t tests indicate a statistically significant difference between the bedside capillary and venous glucose levels for the total sample (p < or = 0.001). The difference between bedside capillary glucose and venous glucose within monitor groups for bedside capillary glucose and venous glucose was also statistically significant (p < or = 0.001) for both groups. The mean percentage difference between the venous (reference) readings and bedside capillary glucose reading was 8.3% for the Accu-Easy and 12.4% for the Glucometer Encore. This between-monitor group percentage difference was statistically significant (p < or = 0.001). Regression equations generated from patient data then used to predict venous glucose values from bedside capillary glucose values indicate variability in the accuracy of the monitors, especially in the higher ranges, which could result in undertreatment of hyperglycemia.

Bias↗
PubMed2004

Medicare program; changes to the hospital outpatient prospective payment system and calendar year 2005 payment rates. Final rule with comment period.

This final rule with comment period revises the Medicare hospital outpatient prospective payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system and to implement certain related provisions of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. In addition, the final rule with comment period describes final changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. These changes are applicable to services furnished on or after January 1, 2005. In this final rule with comment period, we are responding to public comments received on the January 6, 2004 interim final rule with comment period relating to MMA provisions that were effective January 1, 2004, and finalizing those policies. Further, we are responding to public comments received on the November 7, 2003 final rule with comment period pertaining to the ambulatory payment classification assignment of Healthcare Common Procedure Coding System (HCPCS) codes identified in Addendum B of that rule with the new interim (NI) comment indicators (formerly referred to as condition codes).

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1985

Time and financial analysis of an academic general internal medicine unit.

A detailed time and financial analysis of an academic general internal medicine unit was used to examine financial, educational, and research issues. The residents' outpatient service possessed the greatest patient visit and revenue capacity, but revenue recovery was limited by low productivity and collection rate. Outpatient revenue production could be improved but would still be less than current inpatient revenues. Full financial self-sufficiency would require improvements in several aspects of revenue production and would severely limit faculty time for teaching, personal study, and research. Indirect financial contributions to the medical center through hospitalizations and referrals dwarfed direct revenues. Several strategies for academic general internal medicine units to achieve financial and academic survival are possible, each with its own set of trade-offs. Because local circumstances differ, strategies and outcomes are likely to vary among units.

Efficiency↗
PubMed1986

Estimating hospital costs. A multiple-output analysis.

This study explores a new approach to estimating the cost of inpatient and outpatient services provided by hospitals. Data from a nationwide survey of non-federal, short-term, U.S. hospitals are used to make cost estimates based on a multiple-output cost function. The results provide information on the structure of hospital costs, and include estimates of the marginal and average incremental cost of outpatient care. Because of the innovative specification of the cost function, the study is of interest for its methodology as well as empirical results.

Costs and Cost Analysis↗
PubMed2005

Information asymmetry, insurance, and the decision to hospitalize.

We analyze the problem of second-best optimal health insurance in the context of a model in which patients and doctors must decide not only on an aggregate quantity of health services to use in treating various kinds of illness, but also have a choice between different kinds of providers (in particular, outpatient services rendered by primary-care physicians or inpatient services provided by hospital-based specialists). We consider well-informed patients' choices of provider when they have conventional insurance so they only pay part of the cost of their health services, as well as the equilibrium strategies of doctors and patients when there is patient-provider asymmetry; in the latter case we also analyze a managed-care insurance setup under which doctors are paid by capitation. We find that under certain plausible conditions, second-best optimal managed-care plans with supply-side incentives dominate second-best optimal conventional plans that rely on cost control through demand-side cost sharing.

Decision Making↗
PubMed2000

Chronic illicit drug use, health services utilization and the cost of medical care.

Few studies have examined the relationships between drug use, health services utilization and the cost of medical care for a community-based sample of drug users. The purpose of this study was to analyze recently collected data on chronic drug users (CDUs), CDUs who were also injecting drug users (IDUs) and non-drug users (NDUs) to determine whether these groups exhibited differences in health services utilization and cost. In addition to descriptive analyses, these relationships were estimated with multivariate regression models. Data were collected in 1996 and 1997 through a standardized self-reported questionnaire administered to individuals who were recruited through community outreach activities in the USA. Annual differences in health services utilization between CDUs, IDUs and NDUs were estimated for three measures: number of times admitted to a hospital, number of outpatient visits and number of emergency room episodes. Results of this study indicate that CDUs and IDUs consumed significantly more inpatient and emergency care, but less outpatient services relative to NDUs. Analyses of total health care costs showed that CDUs and IDUs each generated about $1000 in excess services utilization per individual relative to NDUs. This research is the first study to compare differences in health services utilization and cost among out-of-treatment drug users relative to a matched group of non-users in a community-based setting. The findings suggest that health care providers and managed care organizations should consider policies that promote more ambulatory care and discourage emergency room and inpatient care among drug users. Innovative and culturally acceptable approaches may be necessary to provide incentives without posing unusual financial hardship.

Adult↗
PubMed1975

Review of computer applications in hospital pharmacy practice.

A comprehensive literature review of the applications of computers in hospital pharmacy practice is presented. Articles are categorized as: accounting and drug usage review; purchasing and inventory control; controlled substances; outpatient services;drug distribution; drug information; and clinical services.

Accounting↗
PubMed1986

Sociodemographic factors and the use of outpatient mental health services.

What are the effects of sociodemographic factors on the use of outpatient mental health services when different demographic groups have identical health insurance coverage? The authors answer this question using data from the Rand Health Insurance Experiment. Health insurance was randomly assigned to families representative of the nonaged, noninstitutionalized civilian population in six U.S. sites. Income has no significant total effect on use when all income groups have the same coverage. When the effects of variables correlated with socioeconomic status are removed, users with higher socioeconomic status are significantly more likely to choose a mental health specialist rather than only general medical providers for their mental health care (P less than 0.05); among those who visit mental health specialists, those with higher socioeconomic status incur significantly greater expenses (P less than 0.10). Women use significantly more mental health services than men (P less than 0.05), who in turn use significantly more mental health services than children (P less than 0.05), even after controlling for demographic factors, health status, and insurance coverage. Similarly, there are large differences (roughly sixfold) by site in outpatient mental health expenses even when all sites have identical coverage.

Adolescent↗
PubMed1989

Do referral rates vary widely between practices and does supply of services affect demand? A study in Milton Keynes and the Oxford region.

Two commonly held beliefs about referral rates were investigated in this study: first that demand for services is determined by supply and secondly that there is wide variation between general practices in their referral rates. All referrals to specialist outpatient clinics were recorded during two 11-week periods by general practitioners in eight practices in the new town of Milton Keynes and in 17 practices elsewhere in the Oxford region. During the first period, only a limited outpatient service was available in the new town; for many specialist services, people had to be referred to hospitals outside the district. Referral rates from Milton Keynes were very similar to those from the rest of the region. By the second period the range of specialist facilities available locally had expanded considerably with the opening of the new district general hospital and during this period there was a statistically significant but rather small increase in referral rates from Milton Keynes. Variation in referral rates between general practices within each geographical group was greater than that between the two groups. Overall, there was about a three-fold variation between general practices in outpatient referral rates which is considerably less than that commonly thought to exist.

Delivery of Health Care↗
PubMed2002

Medicare program; changes to the hospital outpatient prospective payment system and calendar year 2003 payment rates; and changes to payment suspension for unfiled cost reports. Final rule with comment period.

This final rule with comment period revises the Medicare hospital outpatient prospective payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system. In addition, it describes changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. These changes are applicable to services furnished on or after January 1, 2003. This rule also allows the Secretary to suspend Medicare payments "in whole or in part" if a provider fails to file a timely and acceptable cost report. In addition, this rule responds to public comments received on the November 2, 2001 interim final rule with comment period (66 FR 55850) that set forth the criteria the Secretary will use to establish new categories of medical devices eligible for transitional pass-through payment under the Medicare's hospital outpatient prospective payment system. Finally, this rule responds to public comments received on the August 9, 2002 proposed rule for revisions to the hospital outpatient prospective payment system and payment rates (67 FR 52092). CMS finds good cause to waive proposed rulemaking for the assignment of new codes to Ambulatory Payment Classifications and for the payment of influenza and pneumococcal vaccines under reasonable cost; justification for the waiver will follow in a subsequent Federal Register notice.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1988

Effect of curtailed insurance benefits on use of mental health care. The Tenneco health plan.

This article presents the impact of a health insurance benefit redesign on utilization and costs for mental health care in a large corporation. The design change primarily limited coverage to 45 days of hospitalization and 20 outpatient visits. Group health insurance data before and after the benefit changes (effective January 1, 1984) were compared and analyzed. Per capita charges for mental health care between 1983 and 1985 decreased by 41%, from $89 to $53. Responses to the benefit modifications differed for inpatient and outpatient services. Inpatient costs and length of stay decreased dramatically, especially for dependents, while utilization rates remained about the same. Statistically significant increases occurred for outpatient care utilization and costs.

Adult↗