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PubMed2004

Economics of antibiotic use policies.

Today more than ever, hospitals must effectively manage the use of antibiotics to control costs and preserve their usefulness. To achieve this goal, antibiotic management must evolve from overly simplistic antibiotic cost containment to more complex, multidisciplinary, appropriate use programs that are founded on clinical outcomes-based pharmacoeconomic analyses. This article addresses common cost-containment activities as they relate to antibiotics and examines their consequences. Examples of successful antimicrobial stewardship and the role of pharmacoeconomic analyses also are provided. Cost-effectiveness studies of cefepime are presented to illustrate the utility of these analyses and provide information that can form the basis for decisions regarding placement of cefepime on hospital formularies.

Anti-Bacterial Agents↗
PubMed2005

Relationships among self-care agency, self-efficacy, self-care, and glycemic control.

Costly complications of diabetes often arise from poor glycemic control. Appropriate diabetes self-care management may improve control. This study examined whether self-care management affects glycemic control and mediates relationships between self-efficacy and self-care agency with glycemic control. In a cross-sectional correlational design, data from a prior study of 141 insulin-requiring adults with type 1 or type 2 diabetes were examined using descriptive statistics, Pearson's correlation, and multiple hierarchical regression. Findings indicated that greater self-care agency and self-efficacy lead to greater self-care management, in turn leading to better glycemic control. Self-care management did not mediate between self-efficacy or self-care agency and glycemic control. Thus, beliefs or capabilities for self-care are insufficient to improve glycemic control; doing so requires self-care management.

Adult↗
PubMed2001

Physicians, thou shalt ration: the necessary role of bedside rationing in controlling healthcare costs.

Physicians are often asked to be "gatekeepers," determining their patients' access to medical therapies and technologies. At the same time, most physicians have been taught that they should act as patient advocates, pursuing patients' best interests regardless of cost. This paper reviews moral arguments ethicists have made for and against "bedside rationing." It argues that healthcare rationing is appropriate in order to help control healthcare costs, and that rationing decisions made at the bedside by physicians must be part of the rationing system. A system that attempts to control costs by mandating an elaborate set of rules would be burdensome, and many physicians would find ways

Decision Making↗
PubMedDate not supplied

A low-cost environmental control system for quadriplegics.

This paper describes a low-cost environmental control system for quadriplegics. With a single custom designed input switch, a disabled patient can turn up to three electrical devices on or off. The design could easily be extended to handle additional devices. The system can be constructed in one day for approximately $40.00 in parts cost, plus the cost of labor.

Environment, Controlled↗
PubMed1990

Organ transplantation costs, insurance coverage, and reimbursement.

With few exceptions, most organ transplantation procedures are expensive, although there is considerable variability in costs across transplantation programs. Because of their high cost, many public and private insurers are in the process of carefully evaluating their transplantation coverage and reimbursement policies. Some public insurers have decided to discontinue paying for some procedures on grounds that the resources expended on transplantation could be used to benefit a larger number of people without catastrophic disease. Thus, transplantation is being pitted against health promotion and disease prevention initiatives. Some insurers have also been reluctant to pay for selected transplants, arguing that they are "experimental" or "investigational." Pancreas, lung, and heart-lung transplants are often classified as such. While these decisions have a reasonable basis, concerns related purely to cost, not benefit, have made insurers hesitant to extend coverage to procedures they view as inefficacious. Transplantation programs performing pancreas, heart-lung, and lung transplantation, therefore, do so at some risk. They may not be reimbursed for the procedures they perform, or, more likely, the level of payment received is likely to be substantially below actual hospital costs. To control costs, insurers have also begun to designate transplantation centers. In doing so they limit coverage and reimbursement to programs they regard as "centers of excellence." To become a designated center, a transplantation program must meet preestablished volume and outcome requirements, which insurers believe will assure quality and minimize costs. Thus, designated centers are expected to provide cost-effective transplantation services. If insurers choose to regionalize transplantation programs, controlling both their number and distribution, it is quite possible that patient access to transplantation, as well as their choice of provider, will be severely constrained. In conclusion, concerns related to transplantation costs undoubtedly will have enormous implications for the delivery of transplantation services throughout the foreseeable future. Most significantly, the number of "qualified" centers, using insurer criteria, may be restricted to a small subset of currently active programs. This could have a dramatic affect on the start-up of new programs and the continuation of others.

Costs and Cost Analysis↗
PubMed1996

[The US Health Care and the reform].

Securing access to medical services, controlling costs and improving quality are goals of health care system. Although they are all the same all over the country, each country has its own culture, health care system and health care problems. In the United States, employer-based and individual purchases of private health insurance coverage play a major role, although governmental programs such as Medicaid and Medicare exist for the poor and the elderly. Private health insurance had traditionally secured patients' freedom of choice of health care providers and physicians' professional freedom and had paid providers on a fee-for-service basis. Now, the U.S. has 40 million uninsured persons who do not have access to medical services, although it spends as much as its 14% of GNP on health care. In the early 1990s, this became a major political problem. President Clinton proposed the 'Health Security Act' which would enable any American to have access to comprehensive health care with managed competition to activate the health care market, but it was not enacted. Nevertheless, it is clear that managed care and managed competition will dominate and that traditional fee-for-service plan will be eroded in the health care market. Japan has a universal health care system. We do not have any uninsured or high medical costs. However, it is difficult to improve the quality of health care services within the present system. Japan can learn the system about disclosure of health care information from the managed care in the U.S.

Adolescent↗
PubMed1994

Joint position statement: essential provisions for critical care in health system reform. Society of Critical Care Medicine. American Association of Critical Care Nurses.

OBJECTIVE: Production of a statement defining the essential provisions of health system reform as determined by the Society of Critical Care Medicine (SCCM) and the American Association of Critical-Care Nurses (AACN). This document is the only nurse-physician joint statement to result from the 1994 health system reform debate. DATA SOURCES: A joint SCCM-AACN working group developed the document. Working group members referenced position papers previously developed by SCCM and AACN. DATA SYNTHESIS: Working group members refined drafts of the statement until a consensus was reached. Final versions of the paper were reviewed and endorsed by the SCCM Council and the AACN Board of Directors. CONCLUSIONS: SCCM and AACN agreed that health system reform should ultimately achieve universal coverage, access, control cost, and should improve the quality of care. SCCM and AACN endorsed improved access to and coverage for preventive care services. Recognizing that critical illness and injury cannot be prevented entirely, SCCM and AACN agreed that a reformed system must foster improved care of the critically ill and injured as described below.

Cost Control↗
PubMed1994

Patients' rights after health care reform: who decides what is medically necessary?

President Clinton's Health Security Act entitles individuals not to unlimited health care, but to a package of defined insurance benefits with specific exclusions and limitations. Like virtually all reform proposals, it would limit covered benefits to services that are medically necessary. If health reform is to control costs, not all medically necessary care can be covered. In the absence of a generally accepted definition of medical necessity, many services will not be guaranteed to all patients unless they are explicitly covered in the federal legislation or regulations. Without a federal definition of medical necessity or regulations listing covered services, health insurance plans will retain the primary authority to decide what is medically necessary for their patient subscribers.

Cost Control↗
PubMed1998

The computer based patient record: a strategic issue in process innovation.

Reengineering of the workplace through Information Technology is an important strategic issue for today's hospitals. The computer-based patient record (CPR) is one technology that has the potential to profoundly modify the work routines of the care unit. This study investigates a CPR project aimed at allowing physicians and nurses to work in a completely electronic environment. The focus of our analysis was the patient nursing care process. The rationale behind the introduction of this technology was based on its alleged capability to both enhance quality of care and control costs. This is done by better managing the flow of information within the organization and by introducing mechanisms such as the timeless and spaceless organization of the work place, de-localization, and automation of work processes. The present case study analyzed the implementation of a large CPR project ($45 million U.S.) conducted in four hospitals in joint venture with two computer firms. The computerized system had to be withdrawn because of boycotts from both the medical and nursing personnel. User-resistance was not the problem. Despite its failure, this project was a good opportunity to understand better the intricate complexity of introducing technology in professional work where the usefulness of information is short lived and where it is difficult to predetermine the relevancy of information. Profound misconceptions in achieving a tighter fit (synchronization) between care processes and information processes were the main problems.

Cost Control↗
PubMedDate not supplied

Impact of DRGs on the medical profession.

OBJECTIVE: To present an overview of the history of diagnosis-related group (DRG) reimbursement and its impact on physicians and hospitals. DATA SOURCES: Recent research articles on reimbursement and medical ethics. STUDY SELECTION: Not applicable. DATA EXTRACTION: Performed by the author. DATA SYNTHESIS: The DRG system is part of a system developed at Yale University to provide hospitals with incentives to control costs. Hospital Medicare inpatients are classified into groups that are clinically coherent and homogenous with respect to resource use. The classification is also dependent on principal and secondary diagnoses and procedures, age, gender, and discharge status of the patient. Reimbursement is determined by the classification. Hospitals can create excess revenues by treating the patient more efficiently and economically, or they can absorb monetary losses by doing otherwise. It is argued that hospitals will become more frugal and that physicians will adjust their methods of practice as well. Hospitals that fail to adapt will close, reducing overall Medicare expenditures and deterring inefficiency by example. CONCLUSION: DRGs provided a way to prevent the collapse of the Medicare program but have also required stricter criteria for hospital admissions. DRGs remain in evolution and under evaluation for expansion into other health care settings.

Cost Control↗
PubMed1988

Priorities for surveillance and cost-effective control of postoperative infection.

We estimated costs of major postoperative infections (wound infection, 1.2%; bacteremia, 0.2%; pneumonia, 0.9%; and symptomatic urinary tract infection, 0.2%) in patients with common elective operations done in 22 community hospitals during 1985 to mid-1987 by review of 3936 medical records randomly drawn from 17,500 postoperative patients. Calculations based on observed rates of major infection by class of operation and hospitalization days beyond diagnosis related group assignments assumed that daily costs for infection management would be $750. Potential savings per 100 patients from infection control efforts was $13,230 to $47,970 for large-bowel operations, laminectomy, total hip prosthesis, other hip prosthesis, and hip fixation operations and $480 to $4455 for cholecystectomy, hysterectomy, and transurethral prostatectomy. Determination of infection surveillance and control priorities should include consideration of differences in prolongation of hospitalization among various operations by similar infections.

Age Factors↗
PubMed1984

Will payment based on diagnosis-related groups control hospital costs?

Previous studies have shown that the admission rates for a few surgical procedures, such as hysterectomy, vary extensively among hospital market areas, apparently because of differences in physicians' practice styles. To see whether such variations occur for most causes of admission, we classified all nonobstetrical medical and surgical hospitalizations in Maine for the years 1980 through 1982 into diagnosis-related groups (DRGs) and measured the variations in admission rates among 30 hospital market areas. Hysterectomy rates varied 3.5-fold, but 90 per cent of medical and surgical admissions fell into DRGs for which admission rates were even more variable, suggesting that professional discretion plays an important part in determining hospitalization for most DRGs. Losses in hospital revenues resulting from the DRG payment system could be offset if physicians modified their admission policies to produce more profit, well within the current limits of medical appropriateness. If this occurred, the net effect of a DRG program would be to exacerbate hospital cost inflation. We conclude that, to be successful, cost-containment programs based on fixed, per-admission hospital prices will need to ensure effective control of hospitalization rates.

Cost Control↗
PubMedDate not supplied

The case of the downsizing decision.

New CEO Charles Rampart's decision to make deep across-the-board cuts at Universal Products Company, Ltd. presents division manager Andrew Jordan with a thorny problem. Plagued by slow growth, a declining stock price, and an increasingly skeptical investment community, UPC needs to control costs and control them fast. But Jordan's division is the most profitable in the company, and the 11% cut proposed by Rampart could destroy already shaky morale and seriously threaten the division's ability to compete. "There comes a time in every manager's career when he has to fight a bad decision made by his boss," argues Sam Godwyn, Jordan's vice president for marketing and sales. "To cut across the board is to take a blunt axe to the company when a surgeon's scalpel is called for." He suggests it is better to line up support for an alternative plan that links cuts to a long-term strategy and that differentiates between successful and unsuccessful divisions. "It would be a terrible mistake for us to focus only on the narrow needs of the division when the future of the whole company is at stake," counters Mary Wyatt, Jordan's vice president for finance. Yes, the downsizing will hurt the division in the short term, but the real issue is getting behind the new CEO. Supporting the downsizing decision is a necessary investment in this future credibility and effectiveness--whatever the short-term costs. Four commentators debate Jordan's dilemma and how he should resolve it.

Economic Competition↗
PubMed1990

Practice guidelines and standards: an overview.

Organized medicine, insurance companies, regulators, and the peer review organizations are all interested in practice guidelines. Recently, the U.S. Congress established the Agency for Health Care Policy and Research, which is charged with overseeing the development of practice guidelines. If properly developed, disseminated, and used, practice guidelines should reduce the incidence of inappropriate care and help control costs. Although guidelines have been used by physicians for years, guidelines now being developed should be more comprehensive, specific, exhaustive, and--on the basis of the best scientific evidence of effectiveness and expert opinion--more effectively discriminate between useful and useless care. Practice guidelines can improve the quality of care when used voluntarily by physicians in practice, when used as standards for quality monitoring and assurance programs, and when used as the basis for reimbursement for services. All interested parties should share responsibilities for the research, development, and production of appropriateness criteria, their translation into guidelines and standards, and the dissemination and maintenance of the guidelines, including evaluation, revision, and updating.

Clinical Protocols↗
PubMed1992

Health care reform: to be or not to be? Part 2: Where are we heading?

The call for a new national health care system reflects the inability of the current system to provide access for all, control costs, and maintain quality. In Part 1 of this two-part series (September American Pharmacy, p. 28), the authors discussed the forces driving our current system.

Cost Control↗
PubMed1999

Promises and perils of managed care for older patients with cardiac disease.

Managed care for elderly patients with cardiovascular disease will likely become more widespread because it has the propensity to provide comprehensive care while controlling costs. The issues of comorbidity and the changes of aging per se become increasingly important with increasing age and emphasize the need to use the basic principles of clinical decision making in the management of elderly patients, rather than focusing exclusively on a specific acute problem. Currently, there is great turmoil in the managed care market for the elderly with multiple models being tried with highly variable degrees of success from both the financial and patient satisfaction perspective. Physician leadership can be a critical element in resolving many of the dilemmas.

Aged↗
PubMed1999

The use of critical pathways in caring for schizophrenic patients in a mental hospital.

To provide quality health care and at the same time, to control cost, literature suggests that using critical pathways as a tool can enhance resource management, increase collaborative practice, and benefit patient care. This study describes the processes of developing a critical pathway in caring for schizophrenic patients in a mental hospital in Hong Kong. The perceived benefits and difficulties in using the critical pathway are discussed from a nursing perspective. Nurses believed that the use of critical pathways could improve the coordination and effectiveness of care. Also, nurses' autonomy and professional status improved. However, inadequate knowledge and resistance from other disciplines were barriers to the implementation. Recommendations are given to overcome the barriers.

Cost Control↗