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PubMed2004

Day surgery for thyroglossal duct cyst excision: a safe alternative.

The goal of this study was to assess which factors affect length of stay in patients operated on for a thyroglossal duct cyst (TDC) and whether day surgery is a safe alternative to a postoperative admission. All charts of patients with TDC excisions at one children's hospital from 1995 to 2001 were reviewed retrospectively. Chi-square tests and multiple logistic regression were used as statistical tests, with p<0.05 considered significant. One hundred children with a mean age of 6 years were operated on for TDC; 46% had day-surgery, with a median length of stay (LOS) of 4 h, and the other 54% were admitted overnight after TDC excision, with a median LOS of 24 h. Factors that significantly prolonged LOS were drain placement, start of surgery after 1 p.m., and surgery being performed by the ENT surgical service rather than the pediatric general surgery service. There was only one hospital readmission for a patient with day surgery at 36 h postoperation for wound hematoma that resolved with nonoperative treatment. Day surgery is safe for routine TDC excisions. There must be a shift in surgeons' behavior if the trend towards an increase in outpatient services for TDC excisions is to continue.

Ambulatory Surgical Procedures↗
PubMed2006

Horizontal equity in health care utilization evidence from three high-income Asian economies.

This paper compares the extent to which the principle of "equal treatment for equal need"(ETEN) is maintained in the health care delivery systems of Hong Kong, South Korea and Taiwan. Deviations in the degree to which health care is distributed according to need are measured by an index of horizontal inequity. Income-related inequality in utilization is split into four major sources: (i) direct effect of income; (ii) need indicators (self-assessed health status, activity limitation, and age and gender interaction terms); (iii) non-need variables (education, work status, private health insurance coverage, employer-provided medical benefits, Medicaid status (low-income medical assistance), geographic region and urban/rural residency and (iv) a residual term. Service types studied include western doctor, licensed traditional medicine practitioner (LTMP), dental and emergency room (ER) visits, as well as inpatient admissions. Violations of the ETEN principle are observed for physician and dental services in Hong Kong . There is pro-rich inequity in western doctor visits. Unusually, this inequity exists for general practitioner but not specialist care. In contrast, South Korea appears to have almost comprehensively maintained ETEN although the better-off have preferential access to higher levels of outpatient care. Taiwan shows intermediate results in that the rich are marginally more likely to use outpatient services, but quantities of western doctor and dental visits are evenly distributed while there is modest pro-rich bias in the number of LTMP episodes. ER visits and inpatient admissions in Taiwan are either proportional or slightly pro-poor. Future work should focus on the evaluation of policy interventions aimed at reducing the observed unequal distributions.

Asia↗
PubMedDate not supplied

Insurance coverage and health care use among near-elderly women.

OBJECTIVES: Data on near-elderly (ages 55-64) women's access to and use of health care have been limited. In this study, we sought to examine the status of near-elderly women's health insurance coverage in the United States and how it may influence their use of health care services. METHODS: A nationwide random sample of women aged 55-64 was drawn from the 2002 wave of the Health and Retirement Study. Descriptive statistics were calculated and multivariable regression analyses were performed to quantify the impact of insurance coverage on near-elderly women's use of outpatient services, inpatient services, and prescription medication over a 2-year period. RESULTS: In 2002, 9.4% of near-elderly women in the United States were uninsured and 15.4% had public coverage. Those who had coverage for a particular service were significantly more likely to use that service compared to women without coverage, with odds ratios ranging from 2.0-6.7 for services such as a physician visit, hospital stay, dental visit, and use of prescription medication. Among those who had at least one physician visit, near-elderly women who had some of the cost covered by insurance reported significantly more visits than women without coverage. Likewise, for near-elderly women regularly taking prescription medications, having more extensive coverage significantly increased their likelihood of medication adherence. The frequency of hospitalization was also higher for women who had complete coverage for the cost. CONCLUSIONS: The nature of a near-elderly woman's insurance coverage significantly affects her use of health care services. More attention is needed to improve the health care of near-elderly women with inadequate insurance coverage.

Attitude to Health↗
PubMed2006

Cost of schizophrenia: direct costs and use of resources in the State of São Paulo.

OBJECTIVE: To estimate the direct costs of schizophrenia for the public sector. METHODS: A study was carried out in the state of São Paulo, Brazil, during 1998. Data from the medical literature and governmental research bodies were gathered for estimating the total number of schizophrenia patients covered by the Brazilian Unified Health System. A decision tree was built based on an estimated distribution of patients under different types of psychiatric care. Medical charts from public hospitals and outpatient services were used to estimate the resources used over a one-year period. Direct costs were calculated by attributing monetary values for each resource used. RESULTS: Of all patients, 81.5% were covered by the public sector and distributed as follows: 6.0% in psychiatric hospital admissions, 23.0% in outpatient care, and 71.0% without regular treatment. The total direct cost of schizophrenia was US $191,781,327 (2.2% of the total health care expenditure in the state). Of this total, 11.0% was spent on outpatient care and 79.2% went for inpatient care. CONCLUSIONS: Most schizophrenia patients in the state of São Paulo receive no regular treatment. The study findings point out to the importance of investing in research aimed at improving the resource allocation for the treatment of mental disorders in Brazil.

Brazil↗
PubMed1997

Improving ambulatory surgery reimbursement.

As outpatient services become the new focal point for managed care, ambulatory surgery reimbursement structures are coming under increasing scrutiny. Operating room managers play a key role in developing ambulatory surgery payment mechanisms that are competitive, clinically meaningful and profitable. Operating room managers must understand the market forces that are redefining outpatient surgery reimbursement as well as the reimbursement mechanisms involved. Payment methodologies in ambulatory surgery are explored.

Ambulatory Surgical Procedures↗
PubMed2004

Effect of managed care on emergency department use in an uninsured population.

STUDY OBJECTIVE: The use of managed care to decrease emergency department (ED) use has been reported with some success among Medicaid and insured populations. Our objective is to determine the effect of a managed care program (the "Program") for uninsured patients on their use of emergency, inpatient, and outpatient services. METHODS: This was a retrospective, observational study with 3 groups of patients at an urban, academic medical center: uninsured patients enrolled in the Program, uninsured patients not enrolled in the Program ("Uninsured"), and commercially insured ("Commercial") patients. All patients received services at least once annually during the 5-year study duration. Administrative databases provided data on ED visits, hospital discharges, hospital days, primary care visits, and specialty care visits during the preprogram and 4 postprogram years. RESULTS: There were 1,676 Program, 335 Uninsured, and 844 Commercial patients (2,855 total patients). Use of emergency, inpatient, and outpatient specialty clinics by all groups did not change significantly after program implementation. There was a modest increase in outpatient primary care use by Program members. CONCLUSION: Implementation of a managed care program did not significantly alter ED or inpatient hospital use patterns in an uninsured, indigent population. Providing a primary care provider and health care benefits alone was insufficient to reduce ED use in this population.

Academic Medical Centers↗
PubMed2005

Acute versus primary care: the health care decision making process for individuals with severe mental illness.

OBJECTIVES: This study's purpose was to determine factors influencing treatment choices of individuals with severe mental illness (SMI). The sample was drawn from admissions to residential crisis programs in San Francisco. Inclusion criteria were an Axis I and Axis III disorder. METHODS: This qualitative study utilized grounded theory method. Interviews and field notes were coded for recurring themes. Descriptive data were also collected. RESULTS: Participants revealed that the most important influences on treatment decisions were immediate need for care, the belief that their subacute complaints will not be taken seriously by providers, positive reinforcement for emergency service use, and enabling factors such as insurance coverage. Other remarkable findings included: numerous reports of substance induced medical crises, lack of support from family, and unawareness of client's medical conditions in psychiatric facilities. CONCLUSIONS: Health care seeking behaviors are learned and learning that will promote the use of outpatient services in SMI must include positive experiences in the delivery of care in the primary care setting. Participants were knowledgeable regarding their illnesses and able to articulate symptoms of illness well. Failure to communicate symptoms appeared to reflect the participant's perception of a lack of response to their reports.

Adult↗
PubMed1982

Medicare program; schedule of limits on hospital inpatient operating costs for cost reporting periods beginning on or after October 1, 1982--HCFA. Interim final notice with comment period.

This notice sets forth a schedule of limits on the hospital inpatient operating costs that may be reimbursed under Medicare for cost reporting periods beginning on or after October 1, 1982. These limits are needed to implement changes in the Medicare law that were made by section 101(a) of Pub. L. 97-248, the Tax Equity and Fiscal Responsibility Act of 1982. The new limits differ from the current per diem limits on inpatient general routine operating costs in several major respects. First, they are not restricted to costs of inpatient general routine care, but cover total inpatient operating costs, including the costs of general routine service, special care, and ancillary services. The new limits will be applied on a cost per discharge rather than cost per diem basis. Finally, they are adjusted to reflect differences in the mix of Medicare cases treated by each hospital. The limits are similar to the current limits in that they do not apply to outpatient service cost, capital-related costs, malpractice insurance costs, or costs a hospital allocates to the interns and residents (in approved programs) or nursing school cost centers on its Medicare cost report. They also do not apply to children's hospitals, long-term care hospitals, or rural hospitals with fewer than 50 beds. The notice explains our methodology for deriving and applying the new limits.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2005

Utilization of health care services among the near-elderly: a comparison of managed care and fee-for-service enrollees.

This article compares and contrasts the use of health care services among near-elderly adults (55-64 yr) across HMOs, PPOs, and fee-for-service (FFS) plans. Statistical tests are used to examine possible selection bias by type of plan [corrected] Multistage regression methods are implemented whenever the test results indicate the presence of selection bias. The findings show that compared with FFS plans, HMOs and PPOs are associated with a greater use of outpatient services and preventive services among adults in this age range. The rate of hospital admissions and the length of hospital stay are found to be similar across these types of plans.

Fee-for-Service Plans↗
PubMedDate not supplied

Do daughters with eating disorders agree with their parents' perception of family functioning?

OBJECTIVE: The current study compared the perceptions of family functioning between daughters with eating disorders (EDs) and their parents. This investigation was an expansion of the Fornari et al (Compr Psychiatry 1999;40:434-441) study, which investigated the relationship between the perceived family functioning and depressive symptoms in individuals with ED patients receiving outpatient services. METHOD: One hundred twenty-six female subjects, ranging in age from 13 to 34 years (mean 18.3 years) completed the Beck Depression Inventory (BDI) (Arch Gen Psychiatry 1961;4:561-571) and the Family Assessment Device (FAD) (J Marital Fam Ther 1983;9:171-180) on admission to an outpatient ED program. The patient's parent(s) (118 mothers and 96 fathers) also completed the FAD. Eating disorder subgroup diagnosis and major depressive disorder diagnosis were established according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition , criteria, using the Schedule for Affective Disorders and Schizophrenia-Lifetime (Arch Gen Psychiatry 1987;35:837-844). Repeated measures analysis of covariance was performed comparing family members on each of the 7 subscales of the FAD with BDI entered as the covariate. RESULTS: Statistically significant differences were found between patient and parental perceptions of overall family functioning. Mothers rated family functioning as significantly healthier and less chaotic than their daughters did. There were fewer significant differences between maternal and paternal perceptions of family functioning, and no significant differences between fathers' and daughters' perceptions of the family. Eating disorder diagnosis did not contribute to these differences in perception of family functioning. In addition, high self-reported depressive symptoms of the daughters were related to the perception of high family dysfunction for all 3 informants; depressive symptoms did not, however, alter the differences in perception between family members. DISCUSSION: Differences in viewpoints between parents and daughters regarding the family environment may contribute to the continuation of a dysfunctional family pattern and maintenance of the ED and/or impact negatively on the course of treatment. Possible implications for treatment are discussed, particularly because of the differences of the mothers' views. The results of this study strongly support the importance of including the patient's family in the initial evaluation, regardless of the patient's age.

Adolescent↗
PubMed1998

Using hospital data systems to find target populations: new tools for clinical nurse specialists.

A newly appointed diabetes clinical nurse specialist/nurse practitioner at Yale-New Haven Hospital was charged with redesigning the diabetes nursing role. For help, she turned to a special information management service within the Nursing and Operational Finance departments. This article describes the project that used an integrated financial and clinical information system to locate and characterize adult patients with diabetes mellitus. Patients with principal and secondary diagnoses of diabetes were identified by ICD-9-CM codes and tracked across inpatient and outpatient services. These data were used to identify opportunities for case management and for managing the costs related to diabetes care. The data also supported proposals made by the clinical nurse specialist/nurse practitioner to management to allocate clinical resources for the care of patients with diabetes. When the clinical wisdom of advanced practice nurses is joined with nursing information management expertise and technology, opportunities for understanding and advancing nursing's work are revealed.

Adult↗
PubMed1999

Costs of HIV medical care in the era of highly active antiretroviral therapy.

OBJECTIVES: In the USA, Medicaid is the principal payer of the health care costs of patients with HIV infection. We wished to determine how the costs to Medicaid of patients in Maryland infected with HIV have changed in the setting of highly active antiretroviral treatment. DESIGN: Observational cohort study. METHODS: Analysis of combined economic and clinical data of patients from the Johns Hopkins HIV Service, the provider of primary and sub-specialty care for a majority of HIV-infected patients in the Baltimore metropolitan region. All patients were enrolled in Medicaid and received care longitudinally in Maryland from 1 January 1995 through 31 December 1997. Monthly Medicaid payments were calculated for all inpatient and outpatient services by fiscal year, CD4 cell count, and use of protease inhibitors. RESULTS: For inpatients with a CD4 cell count < or = 50 x 10(6) cells/l, the total health care average monthly payments remained unchanged ($2629 in 1995, $2585 in 1997). Total mean monthly payments increased for those with a CD4 cell count > 50 x 10(6) cells/l (CD4 cell count 50-200 x 10(6) cells/l, $1172 in 1995 and $1615 in 1997, P < 0.05; CD4 cell count 201-500 x 10(6) cells/l, $1078 in 1995 and $1305 in 1997, P < 0.05). However, when data were stratified according to use of a protease inhibitor-containing regimen (used during approximately 50% of follow-up time in 1996-1997) it was found that hospital inpatient payments decreased significantly in all CD4 strata for patients on a protease inhibitor-containing regimen whereas pharmacy payments increased significantly. Inpatient payments associated with treating opportunistic illness were lower in 1996-1997 for patients receiving protease inhibitor therapy compared with those not receiving protease inhibitors. On balance, total health care payments tended to be slightly lower for patients receiving a protease inhibitor regimen. CONCLUSION: Although protease inhibitor-containing antiretroviral regimens are being used by only about half of our Medicaid-insured patients, when they are used, there are significantly lower hospital inpatient and community care costs, as well as lower costs associated with the treatment of opportunistic illness. Even with the concurrent increase in their pharmacy costs, total health care costs were stable or slightly lower for these patients. We believe this is a favorable result suggesting a good clinical value being achieved without an increase in costs.

AIDS-Related Opportunistic Infections↗
PubMed1992

Ambulatory care directors help hospitals gear up for growth.

The continuing shift toward outpatient care is spurring many hospitals to rethink their administrative structures. Hospitals interested in improving the coordination of their outpatient services are appointing ambulatory care directors and involving them in strategic planning for that area.

Ambulatory Care↗
PubMed2001

Economic evaluation of alcohol treatment services.

The objective of this paper is to summarize and critically review the most recent literature on economic evaluation of alcohol treatment services, identify information gaps, and suggest a research agenda for the future. The focus of the review is research published after 1995, although some of the earlier economic studies are also included. Research findings in the literature provide evidence for the following. First, for many alcoholics, day hospital treatment or even less intensive outpatient services are cost-effective alternatives to inpatient treatment. Second, alcoholism treatment often results in declining health care costs for alcoholics who are covered by private health insurance. Third, though the use of alcoholics anonymous (AA) as an alternative to more structured alcohol treatment services may be cost-effective, substance abuse outcomes from AA are sometimes less favorable and the risk of relapse is higher. Fourth, methods have recently been developed to estimate the dollar value of alcohol treatment outcomes such as avoided absenteeism, increased productivity, improved health, and avoided crime. Based on these findings and developments, new treatment approaches and changes in service delivery systems require a fresh perspective on the costs and benefits of alternative treatment services. The findings from economic evaluation studies must be reported in clear and nontechnical terms to an audience of clinicians and politicians so that they can be used in the process of decision making.

Alcoholics Anonymous↗
PubMed1996

Regulatory effects of health examination programs on medical expenditures for the elderly in Japan.

In order to evaluate if there is any correlation between the use of general medical examination programs organized by each community under the Health Service Law for the Elderly, and the medical expenditures for the elderly, an analysis was conducted based on 97 communal data of Fukuoka prefecture, Japan in 1991. According to the results, the use of health examinations showed a statistically significant negative correlation with the medical expenditures for the elderly both for in- and outpatient services. The analysis of the medical expenditure components has clarified that this negative correlation is mainly due to the low utilization rate of services at medical facilities among the communities with a high participation rate in the examination. A part of this low utilization rate could be explained by the complementary effect of the examination program as an alternative for the elderly instead of going to a medical facility for consultation. The present result suggests that a community health service program could decrease the demand for medical services of the elderly.

Aged↗
PubMed1994

Managing orthopedics and neurosciences costs through standard treatment protocols.

High-cost, high-volume specialty programs such as orthopedics and neurosciences find themselves in a position of evaluating the costs and in some cases the appropriateness of medical practices in response to payer scrutiny and provider selection processes. Orthopedics and neurosciences programs are at a stage of development analogous to that of cardiovascular care several years ago. Many of the same trends have come into play, such as payer "carve-outs" for orthopedic services, payer selection of centers of excellence based on cost and quality, reduction of Medicare reimbursement, greater use of high-cost technology, the decline of profitability due to "older, sicker, and tougher" patients, and the recent emergence of national orthopedic specialty networks oriented to national contracts for care. In an era in which payers demand value on both sides of the cost-plus-quality equation, programs are challenged to maximize the return on a patient population rife with "no-win" situations. In the orthopedic service line these include a high proportion of Medicare patients and chronic conditions such as workers' compensation medical back cases or repetitive motion injuries, which can be elusive to diagnose and expensive to treat. Many hospitals continue to lose money on joint replacement surgeries, the largest-volume orthopedic inpatient service, primarily because of the high Medicare population and the cost of implants. Neuroservices, while still relatively well reimbursed, face a rising proportion of Medicare payments as patients live longer and develop chronic, degenerative conditions. Inpatient days are decreasing due to payer pressures to limit hospital stays and to shift inpatient care to outpatient services. Some hospitals "have lost interest in (the orthopedic) service line during the last five years because of recent trends in orthopedic-related inpatient volume and payment." But by managing costs strategically, both the neurosciences and orthopedics service lines can provide substantial revenue as well as the opportunity to achieve a "center of excellence" competitive position in a managed care environment. This Special Report outlines the process and advantages of managing costs and quality of care strategically, that is, in a manner which helps these programs meet internal cost and clinical goals while responding to market situations. The hospital, physicians, and patients all benefit as costs are reduced, quality is enhanced, and the service line's competitive position is strengthened.

Cost Control↗
PubMed1977

Substitutability among different types of care under Medicare.

The question of whether Medicare coverage of outpatient services, nursing home care, and home health care reduced the use of short-term hospitals by Medicare beneficiaries, and whether reduced hospital use saved the Medicare program money, is reexamined by use of a simultaneous-equations model estimated by the two-stage least-squares method. It is argued that all alternative modes of care must be examined simultaneously for accurate results. The findings partly support and partly contradict results of previous studies: both outpatient care and nursing home care can substitute for hospital care, but a complementary relationship between outpatient and nursing home care indicates that the additional coverage resulted in greater, not less, expenditure by Medicare.

Ambulatory Care↗
PubMed1992

Health service utilisation in the public and private sector by patients with diabetes mellitus aged less than 40 years.

This paper uses the Illawarra 0-39 years diabetes register to provide a data base of health service utilisation in the public and private sectors. Eligible patients from the register were divided into a 'stable group' comprising children and adults who had had diabetes for more than one year prior to review and a 'newly diagnosed' group who were followed for one year after diagnosis. The records of inpatient and selected outpatient services at public hospitals as well as visits to general practitioners, paediatricians and physicians were considered. Less than half of all 'newly diagnosed' patients were admitted to hospital for stabilisation and none required readmission in the 12 month review period. Less than one fifth of all 'stable' patients were admitted to hospital during the year. General practitioners were the most frequently used health resource being attended by 31/38 (82%) 'stable children', 122/133 (92%) 'stable adults' and 25/25 (100%) 'newly diagnosed patients'. Public hospital Accident and Emergency Services were the least used health facility being frequented by only 9/38 (24%), 23/133 (17%) and 7/25 (28%) respectively.

Adolescent↗