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PubMed1992

Interregional variations in measures of health from the Health and Lifestyle Survey and their relation with indicators of health care need in England.

STUDY OBJECTIVE: The aim was to assess the extent to which a range of routinely available need indicators which have been suggested for use in NHS spatial resource allocation formulas were associated geographically in England with the different dimensions of population health status collected in the 1985/86 Health and Lifestyle Survey (HLS). DESIGN: Regional health authorities were ranked according to each of the HLS health variables which varied significantly between authorities. The HLS health variables were regressed on a selection from the range of routinely available morbidity and socioeconomic indicators available from the 1981 census. The potential need indicators were also regressed on the health variables. SETTING: The analyses were undertaken at individual level and at regional health authority level in England. SUBJECTS: The study comprised the English component of the HLS random sample representative of the population in private households in Great Britain. MAIN RESULTS: The different HLS health variables did not yield consistent regional health authority rankings. Among the variables, forced expiratory volume in one second (FEV1) and self assessed health appeared to be associated with most of the other health and need variables except longstanding illness. Longstanding illness was not strongly associated with any of the other HLS health variables but appeared to show some association with three deprivation indices constructed from the 1981 Census. CONCLUSIONS: There may be a case for including a measure of chronic ill health in the new NHS system of capitated finance in addition to the all cause standardised mortality ratio which is used currently as a measure of need for health care.

Chronic Disease↗
PubMed1996

Demographic and epidemiological aspects of plastic surgery: profile of a supradistrict specialty.

The workload of plastic surgery is often poorly understood by the public and those responsible for financing health care. The authors have used linked statistical data to analyse demographic and epidemiological profiles of workload in plastic surgery in Oxfordshire. The analyses were constructed for residents of the district and for patients treated from other districts. The former provides a profile of workload generated for plastic surgery from a geographically-defined population. The latter complements this by adding information about 'imported' workload. Admission rates for plastic surgery were higher for children and elderly people than for other age groups; higher for males than females; and they increased during the 11 years of the study. Most of the increase represented an increase in people treated by the service, rather than an increase in readmissions, although there was a modest increase in the latter too. Lengths of stay per admission and total time spent in hospital per person declined considerably. The bulk of the workload in plastic surgery is concerned with the treatment of trauma (including burns), cancer and congenital malformations. The main clinical conditions treated by the specialty are documented distinguishing, for each condition, the extent to which the patients came from outside the authority in which the provider unit is cited.

Adolescent↗
PubMed2001

Interrelationships among mortality rates, drug costs, total cost of care, and length of stay in United States hospitals: summary and recommendations for clinical pharmacy services and staffing.

We evaluated interrelationships and associations among mortality rates, drug costs, total cost of care, and length of stay in United States hospitals. Relationships between these variables and the presence of clinical pharmacy services and pharmacy staffing also were explored. A database was constructed from the 1992 American Hospital Association's Abridged Guide to the Health Care Field, the 1992 National Clinical Pharmacy Services database, and 1992 Health Care Finance Administration mortality data. A severity of illness-adjusted multiple regression analysis was employed to determine relationships and associations. Study populations ranged from 934-1029 hospitals (all hospitals for which variables could be matched). The only pharmacy variable associated with positive outcomes with all four health care outcome measures was the number of clinical pharmacists/occupied bed. That figure tended to have the greatest association (slope) with reductions in mortality rate, drug costs, and length of stay. As clinical pharmacist staffing levels increased from the tenth percentile (0.34/100 occupied beds) to the ninetieth percentile (3.23/100 occupied beds), hospital deaths declined from 113/1000 to 64/1000 admissions (43% decline). This resulted in a reduction of 395 deaths/hospital/year when clinical pharmacist staffing went from the tenth to the ninetieth percentile. This translated into a reduction of 1.09 deaths/day/hospital having clinical pharmacy staffing between these staffing levels, or 320 dollars of pharmacist salary cost/death averted. Three hospital pharmacy variables were associated with reduced length of stay in 1024 hospitals: drug protocol management (slope -1.30, p=0.008), pharmacist participation on medical rounds (slope -1.71, p<0.001), and number of clinical pharmacists/occupied bed (slope -26.59, p<0.001). As drug costs/occupied bed/year increased, severity of illness-adjusted mortality rates decreased (slope -38609852, R(2) 8.2%, p<0.0001). As the total cost of care/occupied bed/year increased, those same mortality rates decreased (slope -5846720642, R(2) 14.9%, p<0.0001). Seventeen clinical pharmacy services were associated with improvements in the four variables.

Cost Savings↗
PubMed1984

A basic strategy for financing long term care.

As pressure mounts to contain Medicaid long term care spending, short-range "quick fixes" must be avoided. Three such false solutions in particular have shortcomings that may actually exacerbate long term care's financial dilemma because they are based on inadequate definitions of the problem. Two of these proposals--legislation to broaden family responsibility toward institutionalized elders on Medicaid and expanded state power to put liens on such elders' real property--err by trying to mandate "caring" and are predicated on a misunderstanding of the "spend-down" problem. The other proposal--to provide tax incentives to family members who care for elders--requires a large administrative apparatus, assumes an elasticity of supply that may not exist, and could disrupt the "gift relationship" on which family exchanges are often based. What is needed is a strategy with short term, intermediate, and long term objectives that move toward an insurance approach. The short term plan should lay the groundwork for intermediate strategy and control costs by changing rate-setting methods and putting limits on facility construction. The intermediate plan should change the problem's definition from one of merely controlling Medicaid long term care expenditures to one of efficiently managing state resources for the elderly through the development of state financing and local delivery systems that target older persons in greatest need. An effective means of doing this is through the creation of social/HMOs, which have five key features: integration of service responsibility and authority; flexibility in organizational design; balanced clientele; pooled prepaid funding; and financial risk for the provider organization. Finally, the long term strategy should transfer much of the long term care financial burden from individuals and state Medicaid agencies to insurance mechanisms. Many individuals would thus avoid impoverishment caused by health care spending and Medicaid would greatly reduce its caseload. Insurance coverage is an appropriate funding mechanism, moreover, in that relatively few persons will ever incur high costs.

Aged↗
PubMed2004

A risk-adjusted approach to comparing the return on investment in health care programs.

The league table approach to rank ordering health care programs according to the incremental cost-effectiveness ratio is a common method to guide policy makers in setting priorities for resource allocation. In the presence of uncertainty, however, ranking programs is complicated by the degree of variability associated with each program. Confidence intervals for cost-effectiveness ratios may be overlapping. Moreover, confidence intervals may include negative ratios and the interpretation of negative cost-effectiveness ratios is ambiguous. We suggest to rank mutually exclusive health care programs according to their rate of return which is defined as the net monetary benefit over the costs of the program. However, how does a program with a higher expected return but higher uncertainty compare to a program with a lower expected return but lower risk? In the present paper we propose a risk-adjusted measure to compare the return on investment in health care programs. Financing a health care program is treated as an investment in a risky asset. The risky asset is combined with a risk-free asset in order to construct a combined portfolio. The weights attributed to the risk-free and risky assets are chosen in such a manner that all programs under consideration exhibit the same degree of uncertainty. We can then compare the performance of the individual programs by constructing a risk-adjusted league table of expected returns.

Cost-Benefit Analysis↗
PubMed1988

The retreat of the state and its transfer of responsibility: the intergenerational war.

In this article, the socially constructed nature of the conflict between the generations, or the "intergenerational war," is explored, with a description of the two major fronts of this battle: a health care financing axis and a caregiving axis. Basic to the health care financing axis is the assumption that certain individuals and populations represent an increasing and unreasonable social burden; the caregiving axis gives ideological support to familial and filial responsibility. The politics of mystification perpetuates the idea that these two axes are unrelated and that generational transfers are independent rather than interdependent. Both permit abdication of the state from social responsibility for human needs and massive budgetary reallocations to defense and tax cuts for the wealthy. An alternative approach derives from the principle of universal life-course entitlement to basic human needs.

Aged↗
PubMed1992

Designing the next generation of American hospitals.

Change has always been a part of the hospital's operating environment, but the changes predicted for American Hospitals during the next two decades pose considerable challenge to those who manage health care services and those who design medical facilities. The next generation of American Hospitals are responding to changes in technology, availability of human resources and demand of the public, private and government interest groups. Hospitals and architects that understand the predictable changes and anticipate the unknown, will be able to plan a facility that responds to the needs of future health care delivery.

Aged↗
PubMed1995

Measuring hospital mortality rates: are 30-day data enough? Ischemic Heart Disease Patient Outcomes Research Team.

OBJECTIVE: We compare 30-day and 180-day postadmission hospital mortality rates for all Medicare patients and those in three categories of cardiac care: coronary artery bypass graft surgery, acute myocardial infarction, and congestive heart failure. DATA SOURCES/COLLECTION: Health Care Financing Administration (HCFA) hospital mortality data for FY 1989. STUDY DESIGN: Using hospital level public use files of actual and predicted mortality at 30 and 180 days, we constructed residual mortality measures for each hospital. We ranked hospitals and used receiver operating characteristic (ROC) curves to compare 0-30, 31-180, and 0-180-day postadmission mortality. PRINCIPAL FINDINGS: For the admissions we studied, we found a broad range of hospital performance when we ranked hospitals using the 30-day data; some hospitals had much lower than predicted 30-day mortality rates, while others had much higher than predicted mortality rates. Data from the time period 31-180 days postadmission yield results that corroborate the 0-30 day postadmission data. Moreover, we found evidence that hospital performance on one condition is related to performance on the other conditions, but that the correlation is much weaker in the 31-180-day interval than in the 0-30-day period. Using ROC curves, we found that the 30-day data discriminated the top and bottom fifths of the 180-day data extremely well, especially for AMI outcomes. CONCLUSIONS: Using data on cumulative hospital mortality from 180 days postadmission does not yield a different perspective from using data from 30 days postadmission for the conditions we studied.

Cardiology Service, Hospital↗
PubMed2002

Development of prehospital emergency medical services: strategies for system assessment and planning.

Increasing economic capacity in the Pacific Rim has led to a greater demand for integrated pre-hospital care systems. The economic and technological growth of Taiwan, South Korea, Japan, Singapore and Hong Kong has lead to health system developments and growth of advanced healthcare and prehospital medical services. Changing economies and population distribution of many of the Southwestern countries and island regions in the South Pacific, as well as the geographical constraints necessitate a systematic and individually tailored planning process, while standardizing communication and quality of service with more will developed neighbors. While EMS systems in such a broad geographical region may take a variety of forms, each system contains some system components similar to those found in the United States and Southwest Pacific regions such as Australia and New Zealand. In evaluating EMS abroad, it is useful to compare the developing system type to one of five models: hospital based, municipal, private, volunteer, and complex. In so doing, the appropriate model system may be constructed to accommodate the demands of an evolving system.

Developing Countries↗
PubMed1995

Measuring quality of care under Medicare and Medicaid.

The Health Care Financing Administration's (HCFA) approach to measuring quality of care uses an accepted definition of quality, explicit domains of measurement, and a formal validation procedure that includes face validity, construct validity, reliability, clinical validation, and tests for usefulness. The indicators of quality for Medicare and Medicaid patients span the range of service types, medical conditions, and payment systems and rest on a variety of data systems. Some have already been incorporated into operational systems while others are scheduled for incorporation over the next 3 years.

Aged↗