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PubMed2006

Lack of patients? A hypothesis for understanding discrepancies between hospital resources and productivity.

BACKGROUND: Despite a substantial increase in hospital resources, increased hospital admissions and out-patient visits, long waiting lists have been a significant problem in Norwegian health care. A detailed analysis of the development in resource allocation and productivity at St. Olavs University Hospital in central Norway was therefore undertaken. METHODS: Resource allocation and patient volume was analysed during the period 1995 to 2001. Data were analysed both for emergency and elective admissions as well as outpatient visits specified into new referrals and follow-up consultations. RESULTS: Full time employee equivalents for doctors and nurses increased by 36.6% and 25.9%, respectively, and all employees by 28.1%. However, admitted patients, outpatient consultations and surgical procedures only increased by 10%, 15% and 8.3%, respectively. Thus, the productivity for each hospital employee, defined as operations pr. surgeon, outpatient consultations pr. doctor etc. was significantly reduced. A striking finding was that although the number of outpatient consultations increased, the number of new referrals actually went down and the whole increase in activity at the outpatient clinics could be explained by a substantial increase in follow-up consultations. This trend was more evident in the surgical departments, where some departments actually showed a reduction in total outpatient consultations. CONCLUSION: In view of the slow increase in hospital activity in spite of a significant increase in resources, it can be speculated that patient volume might be a limiting factor for hospital activity. The health market (patient population) might not be big enough in relation to the investments in increased production capacity (equipment and manpower).

Efficiency, Organizational↗
PubMed2004

Resource use after subarachnoid hemorrhage: comparison between endovascular and surgical treatment.

OBJECTIVE: The aim of this study was to compare resource use after endovascular treatment and surgical clipping of ruptured intracranial aneurysms. METHODS: The study population consisted of patients with aneurysmal subarachnoid hemorrhage who were actively treated in Kuopio University Hospital. The baseline patients' characteristics were obtained from the institution's aneurysm registry. Variables indicating resource use in the intensive care unit (ICU) were obtained from the ICU patient data management system. The Therapeutic Intervention Scoring System was used to measure the intensity of treatment in the ICU. All care days in the ICU and in the hospital and all Therapeutic Intervention Scoring System points that were accumulated during the 12-month follow-up period were calculated. Outcomes were assessed according to the Glasgow Outcome Scale. RESULTS: The study population consisted of 68 patients who underwent endovascular treatment and 103 patients who had surgery. The median lengths of stay in the ICU (1.7 versus 1.8 d) and the hospital (14.0 versus 15.0 d), as well as the accumulated Therapeutic Intervention Scoring System points (56 versus 55), among patients who underwent endovascular or surgical treatment were similar (P = NS for all). The modality of treatment did not influence the number of ICU or hospital patient days or the intensity of ICU treatment, regardless of the patient's preoperative clinical status. CONCLUSION: The modality of treatment of patients with subarachnoid hemorrhage does not seem to affect resource use. Endovascular and surgical treatment are likely to require a similar amount of ICU resources in the year after initial treatment.

Adult↗
PubMed2002

The allocation of scarce medical resources across medical conditions.

This study aimed to determine if the criteria participants use to make decisions concerning scarce medical resources differ across medical conditions - from life-saving to life-enhancing surgery (heart transplant, in vitro fertilization treatment and cosmetic surgery). Participants completed three questionnaires requiring them to rank order 16 hypothetical patients in order of priority for each medical condition. Demographic information about the hypothetical patients varied on four dimensions: age, annual income, smoking behaviour and whether or not the patient had children. There were significant main effects of age, smoking behaviour and income across all three medical conditions, with young people, non-smokers and those on a low income being given the highest priority for each treatment. Whether or not a patient had children influenced allocation decisions only on the IVF and heart transplant cases with very large effect sizes. This study supports previous research in the kidney dialysis and organ transplant areas of the allocation of resources. Most importantly, the results show that such effects are not restricted to life-saving resources but also to life-enhancing resources--IVF and cosmetic surgery.

Adolescent↗
PubMed2005

Designing equitable antiretroviral allocation strategies in resource-constrained countries.

BACKGROUND: Recently, a global commitment has been made to expand access to antiretrovirals (ARVs) in the developing world. However, in many resource-constrained countries the number of individuals infected with HIV in need of treatment will far exceed the supply of ARVs, and only a limited number of health-care facilities (HCFs) will be available for ARV distribution. Deciding how to allocate the limited supply of ARVs among HCFs will be extremely difficult. Resource allocation decisions can be made on the basis of many epidemiological, ethical, or preferential treatment priority criteria. METHODS AND FINDINGS: Here we use operations research techniques, and we show how to determine the optimal strategy for allocating ARVs among HCFs in order to satisfy the equitable criterion that each individual infected with HIV has an equal chance of receiving ARVs. We present a novel spatial mathematical model that includes heterogeneity in treatment accessibility. We show how to use our theoretical framework, in conjunction with an equity objective function, to determine an optimal equitable allocation strategy (OEAS) for ARVs in resource-constrained regions. Our equity objective function enables us to apply the egalitarian principle of equity with respect to access to health care. We use data from the detailed ARV rollout plan designed by the government of South Africa to determine an OEAS for the province of KwaZulu-Natal. We determine the OEAS for KwaZulu-Natal, and we then compare this OEAS with two other ARV allocation strategies: (i) allocating ARVs only to Durban (the largest urban city in KwaZulu-Natal province) and (ii) allocating ARVs equally to all available HCFs. In addition, we compare the OEAS to the current allocation plan of the South African government (which is based upon allocating ARVs to 17 HCFs). We show that our OEAS significantly improves equity in treatment accessibility in comparison with these three ARV allocation strategies. We also quantify how the size of the catchment region surrounding each HCF, and the number of HCFs utilized for ARV distribution, alters the OEAS and the probability of achieving equity in treatment accessibility. We calculate that in order to achieve the greatest degree of treatment equity for individuals with HIV in KwaZulu-Natal, the ARVs should be allocated to 54 HCFs and each HCF should serve a catchment region of 40 to 60 km. CONCLUSION: Our OEAS would substantially improve equality in treatment accessibility in comparison with other allocation strategies. Furthermore, our OEAS is extremely different from the currently planned strategy. We suggest that our novel methodology be used to design optimal ARV allocation strategies for resource-constrained countries.

Acquired Immunodeficiency Syndrome↗
PubMed2001

Predictors of mortality and resource utilization in cirrhotic patients admitted to the medical ICU.

BACKGROUND AND OBJECTIVE: Cirrhotic patients admitted to the medical ICU (MICU) are associated with high mortality rates and high resource utilization. This study identifies specific predictors of increased mortality and resource utilization and uses them to develop and validate prognostic models in cirrhotic patients admitted to the MICU. METHODS: Cirrhotic patients admitted to the MICU were identified from the Critical Care Section database (January 1993 to October 1998). Clinical data were extracted from chart review including hospital course variables, mortality, and length of stay (LOS). Total cost per case (TCPC) was obtained from the Transition System INC: Multivariate logistic and linear regression analyses identified the independent predictors of increased mortality and resource utilization used for model building (MB) and model validation (MV). RESULTS: A total of 582 cases were randomized to the MB and MV groups. Each group contained 240 cases after exclusion criteria were applied. The MICU mortality rate was 36.6%, and the in-hospital mortality rate was 49.0%. Acute physiology, age, and chronic health evaluation (APACHE) III score (odds ratio [OR], 4.7; 95% confidence interval [CI], 2.70 to 8.16; p < 0.001), mechanical ventilation (OR, 4.57; 95% CI, 2.35 to 8.34); p < 0.001), and the use of pressors (OR, 7.57; 95% CI, 4.35 to 13.18; p < 0.001) were independent predictors of MICU mortality. APACHE III score (OR, 4.96; 95% CI, 2.97 to 8.29; p < 0.001), the use of pressors (OR, 6.55; 95% CI, 3.66 to 11.72; p < 0.001), and acute renal failure (ARF) (OR, 4.31; 95% CI, 2.41 to 7.71; p < 0.001) were independent predictors of in-hospital mortality. Increased LOS in the MICU was associated with mechanical ventilation, ARF, bronchoscopy, bacteremia, use of pressors, transjugular intrahepatic portosystemic shunt (TIPS), and never received cardiopulmonary resuscitation (CPR) (p < 0.005). Source of admission, platelet transfusion, bacteremia, pneumonia, and never received CPR were independently associated with increased total LOS (p < 0.001). Mechanical ventilation, platelet transfusion, bronchoscopy, TIPS, sepsis, and never received CPR were independent predictors of increased TCPC (p < 0.001). CONCLUSION: Simple prognostic models for mortality and resource utilization have been developed for cirrhotic patients admitted to the MICU.

APACHE↗
PubMed2002

Avoiding conflicts over Africa's water resources.

Some 85% of Africa's water resources are comprised of large river basins that are shared between several countries. High rates of population growth accompanied by continued increases in the demand for water have resulted in several countries passing the point where the scarcity of water supplies effectively limits further development. Present population trends and patterns of water use suggest that more African countries will exceed the limits of their economically usable, land-based water resources before 2025. Normally, water allocation and distribution priorities within a country are aligned with national development objectives. While this may achieve national "water security" objectives, greater emphasis needs to be placed on regional efforts to ensure that the available water resources are used to derive sustainable long-term benefits for the peoples of Africa as a whole. Ideally, each country's water-resource management strategy needs to be aligned with that of its neighbors if peace and prosperity are to be maintained and conflict is to be avoided in the region.

Africa↗
PubMed2002

[Water resources deterioration and its impact on human health].

The objective of the study is to analyse the actual availability of water resources and its impact on human health deterioration. The following aspects were studied: (a) human activities and environmental deterioration; (b) statistics on the availability and demand of water resources; (c) urban and industry wastes as sources of water resources contamination; and (d) deleterious effect of contaminated water on human health. Statistical data on the impact of contaminated water on human health and the increasing demand of water resources are alarming. It is paramount that modern generations develop an environmental awareness to avoid overstressing water systems, as predicted to come about in the very near future.

Conservation of Natural Resources↗
PubMed2006

Pastoralists' responses to variation of rangeland resources in time and space.

We explore the response of pastoralists to rangeland resource variation in time and space, focusing on regions where high variation makes it unlikely that an economically viable herd can be maintained on a single management unit. In such regions, the need to move stock to find forage in at least some years has led to the evolution of nomadism and transhumance, and reciprocal grazing agreements among the holders of common-property rangeland. The role of such informal institutions in buffering resource variation is well documented in some Asian and African rangelands, but in societies with formally established private-property regimes, where we focus, such institutions have received little attention. We examine agistment networks, which play an important role in buffering resource variation in modern-day Australia. Agistment is a commercial arrangement between pastoralists who have less forage than they believe they require and pastoralists who believe they have more. Agistment facilitates the movement of livestock via a network based largely on trust. We are concerned exclusively with the link between the characteristics of biophysical variation and human aspects of agistment networks, and we developed a model to test the hypothesis that such a link could exist. Our model builds on game theory literature, which explains cooperation between strangers based on the ability of players to learn whom they can trust. Our game is played on a highly stylized landscape that allows us to control and isolate the degree of spatial variation and spatial covariation. We found that agistment networks are more effective where spatial variation in resource availability is high, and generally more effective when spatial covariation is low. Policy design that seeks to work with existing social networks in rangelands has potential, but this potential varies depending on localized characteristics of the biophysical variability.

Animal Husbandry↗
PubMed1988

A comparison of the resource intensity of inpatients in urban and rural nonteaching hospitals.

PL 98-21 mandated a prospective payment system based on diagnosis related groups (DRGs) for all Medicare inpatients. The predetermined payment for each DRG is intended to reflect the resources used to treat patients within the DRG. Eventually, the system will allow for one payment level for each DRG in rural hospitals and a higher payment level for the same DRG in urban hospitals. This represents an equitable approach, provided there is not a predominance of high severity cases in rural hospitals and that higher costs in urban hospitals are reflective of higher priced exogenous factors beyond the control of the hospital. Equitability also requires that DRGs capture the resource intensity of treatment for a given classification of patients, equally for urban and rural patients. This work compares the pediatric population of urban hospitals without a pediatric residency program with that of rural hospitals in terms of major diagnostic category, DRG, disease severity, length of stay, and charges. It also compares the capacity of DRGs to explain the variation in resource consumption in urban and rural hospitals. A sample of 116,721 discharges from 130 urban hospitals and a sample of 54,073 discharges from 97 rural hospitals are used in this work. The results indicate that there is no difference in the patient populations of these two hospital groups. The results also indicate that DRGs explain only 50 percent of the variance in the resource variables, but this obtains equally for both populations.

Child↗
PubMed1998

The role of animal science in natural resource management: current decision making models and future needs.

Sustainable systems for land and natural resource management must be biologically, economically, and socially sustainable. Scientists and educators have historically viewed their role as developing new knowledge and technology to enhance biological and economic sustainability. Scientists have traditionally viewed sociopolitical sustainability and policy development as beyond our appropriate roles. Changing public values and perceptions on appropriate land use and natural resource protection are forcing land grant universities and their scientists and educators to re-evaluate traditional paradigms. The animal science community, in concert with the social and other biological sciences, must become more proactive in decision making processes on appropriate land use and natural resource management if we are to remain relevant. This paper describes the current situation and outlines approaches for the research and education communities to be important contributors to collaborative decision making processes on land and natural resource management.

Animal Husbandry↗
PubMed2006

Stroke caregiving: difficult times, resource use, and needs during the first 2 years.

Despite high levels of distress among stroke caregivers, research on resource use and unmet needs is limited. The major purposes of this study were to identify the most difficult times, unmet needs, and advice of caregivers during the first 2 years of caregiving; and to examine resource use and perceptions of resource importance. Qualitative and quantitative methods were used. The hospitalization period and first months at home were most difficult for 76% of caregivers. Unmet needs were related to caregiver preparation, promoting the survivor's function, and sustaining the self and family. Although 50% or more of caregivers rated most resources important, only home health care was used by 50% of caregivers. Findings can aid clinicians in educating and counseling caregivers to reduce distress.

Adaptation, Psychological↗
PubMed2005

Resource utilization and outcome in gravely ill intensive care unit patients with predicted in-hospital mortality rates of 95% or higher by APACHE III scores: the relationship with physician and family expectations.

OBJECTIVE: To assess resource utilization and outcome in gravely ill patients admitted to an intensive care unit (ICU) and the potential association with health care workers' and family members' expectations. PATIENTS AND METHODS: We retrospectively evaluated ICU patients with a predicted in-hospital mortality rate of 95% or higher (PM95) using the Acute Physiology and Chronic Health Evaluation III (APACHE III) on 2 consecutive days. All patients were admitted to a single institution between September 30, 1994, and August 9, 2001. RESULTS: The APACHE III database contained data from 38,165 ICU patients during the study interval. Of these, 248 (0.65% of ICU admissions) achieved PM95 status and were included in the study. Between PM95 and hospital discharge, resource utilization (eg, blood transfusion, hemodialysis, surgery, and computed tomography or magnetic resonance imaging) was extensive. A total of 23% of patients survived to hospital discharge, yet all but 1 were moderately or severely disabled. One year after achieving PM95, 10% (95% confidence interval, 7%-15%) of patients were alive. For 229 patients, the medical records contained physician documentation that indicated a likely fatal outcome. Thirty-six of these medical records documented unrealistic family expectations of a good outcome. The latter finding correlated with increased resource utilization without significant improvement in 1-year survival. In contrast, absence of physician documentation of a likely fatal outcome In 19 patients correlated with an improved likelihood of hospital (74%) and 1-year (47%) survival. CONCLUSION: Despite better-than-predicted survival outcomes, patient functionality and 1-year survival were poor. Unrealistic family expectations were associated with increased resource utilization without significant survival benefit, whereas absence of physician documentation of likely impending death (which correlated with improved survival) may denote the prognostication skills of experienced clinicians.

APACHE↗
PubMed1996

Age bias, but no gender bias, in the intra-household resource allocation for health care in rural Burkina Faso.

Household survey data, time allocation data, and qualitative interviews were used to examine whether households allocate their resources for health care differently between age and gender groups. Households allocated significantly fewer resources to the health care of sick children compared to that of sick adults. In contrast there were no such differences with regard to gender. The underlying household rationale is to concentrate its resources spent for health care on productive members rather than to spread them equitably among all its sick members. While children are not productive, women were shown to contribute as much to household production as men, hence their health is valued equally with that of men. Unless we understand intra-household biases in resource allocation, policies will be undermined. Further research is needed to test the hypothesis for the households' preference of production maintenance over health maximization.

Adolescent↗
PubMed1999

Methods to estimate and analyze medical care resource use. An example from liver transplantation.

This paper describes a method to construct a standardized health care resource use database. Billing and clinical data were analyzed for 916 patients who received liver transplantations at three medical centers over a 4-year period. Data were checked for completeness by assessing whether each patient's bill included charges covering specified dates and for specific services, and for accuracy by comparing a sample of bills to medical records. Detailed services were matched to a standardized service list from one of the centers, and a single price list was applied. For certain services, clinical data were used to estimate service use or, if a match was not possible, adjusted charges for the services were used. Twenty-three patients were eliminated from the database because of incomplete resource use data. There was very good correspondence between bills and medical records, except for blood products. Direct matches to the standardized service list accounted for 69.3% of services overall; 9.4% of services could not be matched to the standardized service list and were thus adjusted for center and/or time period. Clinical data were used to estimate resource use for blood products, operating room time, and medications; these estimations accounted for 21.3% of services overall. A database can be constructed that allows comparison of standardized resource use and avoids biases due to accounting, geographic, or temporal factors. Clinical data are essential for the creation of such a database. The methods described are particularly useful in studies of the cost-effectiveness of medical technologies.

Accounting↗
PubMedDate not supplied

A comparison of resource utilization in nurse practitioners and physicians.

CONTEXT: Nurse practitioners increasingly provide primary care in a variety of settings. Little is known about how resource utilization for patients assigned to nurse practitioners compares with that for patients assigned to physicians. OBJECTIVE: To compare health care resource utilization for adult patients assigned to a nurse practitioner with that for patients assigned to a resident or attending physician. DESIGN: Prospective, quasi-randomized study. SETTING: Primary care clinic at a Veterans Affairs medical center. PATIENTS: 450 new primary care patients: 150 were assigned to a nurse practitioner, 150 to a resident physician, and 150 to an attending physician. OUTCOME MEASURES: We collected data on laboratory and radiologic testing, specialty care, primary care, emergency or walk-in visits, and hospitalizations over a 1-year period. We also collected information on baseline chronic illnesses, blood pressure, and weight. RESULTS: Resource utilization for patients assigned to a nurse practitioner was higher than that for patients assigned to a resident in 14 of 17 utilization measures (3 were statistically significant) and higher in 10 of 17 measures when compared with patients assigned to an attending physician (3 were statistically significant). None of the utilization measures for patients in the nurse practitioner group was significantly lower than those for either physician group. CONCLUSIONS: In a primary care setting, nurse practitioners may utilize more health care resources than physicians.

Chi-Square Distribution↗
PubMed2000

[Case-mix classification in post-acute and long-term care. Validation of Resource Utilization Groups III (RUG-III) in the Czech Republic].

BACKGROUND: Czech facilities for non-acute, continuing care provide care for very heterogeneous group of residents with different clinical characteristics, care needs and resource use. The rate based funding of LTC doesn't reflect patient case-mix. Therefore, a case mix system RUG based on per diem resource use is being used abroad for rational and fair LTC funding. METHODS: The validity of RUG-III has been evaluated and its use for financing of LTC and geriatric care in CR examined. In a sample of 1162 residents from 18 institutions patients were assigned to one of 44 RUG-III groups regarding their clinical characteristics. Data were analyzed using analysis of variance with individual care time per patient per day as independent and RUG-III groups as dependent variables. Weighted means for each group (case-mix indexes, CMI) were calculated. RESULTS: The RUG-III system achieved 59% variance explanation of total per diem costs of nursing and therapy/rehabilitation care and meets criteria of clinical validity. The CMIs for individual groups span from 0.39 to 2.70 i.e. differences in resource use between groups were sevenfold. Resource use within groups was relatively homogeneous. CONCLUSIONS: The RUG-III represent a suitable case-mix system for nonacute institutional care in the Czech health care. Besides its use for payment incentives, RUG-III can be used in facility management, quality assurance process and for comparative analyses on national and international level.

Aged↗
PubMed2000

[The professional and the organization in the use of primary care resources].

OBJECTIVES: To analyse the professional profile and organization influence about sanitary resources use. DESIGN: Cross-sectional descriptive study. SETTING: Primary care in the Community of Murcia. MEASUREMENTS: Data were collected in the Information and Register Unit of the Primary Care Management and through personal survey about the personal and professional features of the physicians, place of work, accessibility and availability and the resources use of themselves. A two-variable study was made selecting the significant variables for the multiple regression test and multiple analysis of variance, with the corresponding multiple classification analysis. MAIN RESULTS: 24% of the frequency can be explained through the professional profile of the physicians and the organization of work of place. Resource use depend on this variables between 7% drugs use) and 46% (tapping to specialists), taking into account that the size of the quota, the greater than 65 years old persons proportion and the size of the town are the most variability explaining variables. CONCLUSIONS: In our area, the professional profile and organization have a scarce influence in the utilization of sanitary resource.

Analysis of Variance↗
PubMed2001

Payment levels, resource use, and insurance risk of medicaid versus private insured in three states.

Concerns with access and costs in the Medicaid program often lead policy makers to consider alternatives. These include subsidizing poor persons' purchases of health insurance in private markets or integrating Medicaid beneficiaries into commercial managed care systems. As policy makers consider such alternatives, a persistent question is, apart from the disabled within Medicaid, do younger Medicaid enrollees represent a different insurance risk than people of similar age and sex within private insurance pools? We use 1994 data from Georgia, Mississippi, and California to assess relative payment levels, resource use/costs, and risk-adjusted utilization of fee-for-service (FFS) Medicaid enrollees versus privately insured people. When resources are valued at private prices, the use by Medicaid enrollees represents a higher cost. After risk adjustment, Medicaid enrollee resource use appears higher than expected for the privately insured only for outpatient facility visits in the southern states and for inpatient days by pregnant women in California Medi-Cal. Indeed, we find evidence that Medicaid enrollees are underserved relative to their health needs. Given the higher dollar value of their resource usage, apparently obtained under FFS at discounted provider rates, and the lack of evidence on significant overuse relative to need, their integration into private provider systems appears challenging.

Adolescent↗