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PubMed2003

Alternative strategies for stroke care: cost-effectiveness and cost-utility analyses from a prospective randomized controlled trial.

BACKGROUND AND PURPOSE: Although stroke units reduce mortality and institutionalization, their comparative cost-effectiveness is unknown. METHODS: Healthcare, social services, and informal care costs were compared for 447 acute stroke patients randomly assigned to stroke unit, stroke team, or domiciliary stroke care. Prospective and retrospective methods were used to identify resource use over 12 months after stroke onset. Cost-effectiveness and cost-utility analyses were undertaken. RESULTS: Mean healthcare and social care costs over 12 months were 11 450 pounds sterling for stroke unit, 9527 pounds sterling for stroke team, and 6840 pounds sterling for domiciliary care. More than half the costs were for the initial episode of care. Institutionalization was a large proportion of follow-up costs. Inclusion of informal care increased costs considerably. When informal care was excluded, the incremental cost-effectiveness ratio per percentage point in deaths or institutionalizations avoided in the first year was 496 pounds sterling for the stroke unit over domiciliary care; incremental cost per quality-adjusted life year quality-adjusted life year gained was 64 097 pounds sterling between these 2 groups. The stroke team was dominated by domiciliary care. CONCLUSIONS: Cost perspectives, especially those related to long-term and informal care, are important when stroke services are evaluated. Improved health outcomes in the stroke unit come at a higher cost.

Cost-Benefit Analysis↗
PubMed2006

Patient narratives: a micro-interactional analysis.

The use of narrative as a therapeutic tool is well established in many forms of counseling and psychotherapy. Similarly, it forms a significant element of many holistic consultation approaches. The value of patient narratives are recognized by many practitioners working in primary care too, but opportunities for its utilization can be limited by the practicalities of working within conventional healthcare structures. This article presents a micro-interactional analysis of the ways in which patients routinely frame and self-manage their narratives in the context of primary care encounters, and explores some of the behavioral motifs utilized by practitioners in the management of narrative-based interactions.

Communication↗
PubMed2004

Let regionalization continue to evolve.

This commentary provides a practical perspective on the benefits of regionalization within the context of the lead paper by Lewis and Kouri. Discussion of the best structure of health systems needs to take into account the reality that constitutional and funding responsibility--and therefore accountability--for our healthcare system lies with provincial governments. Accountability at the provincial government level is simply a part of regionalization and should be expected by health system managers. Regionalization of healthcare is in its infancy. Systems necessary to support regionalization, which can only be established under a regionalized structure (e.g., information technology, procurement, human resources and service planning), are evolving. Given the size and complexity of the healthcare system, as we gain more experience with regionalization the systems we need to support it will attain their potential, as will the managers of the system. Regionalization was the most appropriate option for healthcare in the 1990s given the objectives of provincial governments to achieve efficiencies, better utilize resources and improve patient care. We must allow regionalization to evolve in order to see long-term improvements in the healthcare system.

Canada↗
PubMed2006

Incremental cost-effectiveness of exercise echocardiography vs. SPECT imaging for the evaluation of stable chest pain.

AIMS: Technological advances in cardiac imaging have led to dramatic increases in test utilization and consumption of a growing proportion of cardiovascular healthcare costs. The opportunity costs of strategies favouring exercise echocardiography or SPECT imaging have been incompletely evaluated. METHODS AND RESULTS: We examined prognosis and cost-effectiveness of exercise echocardiography (n = 4884) vs. SPECT (n = 4637) imaging in stable, intermediate risk, chest pain patients. Ischaemia extent was defined as the number of vascular territories with echocardiographic wall motion or SPECT perfusion abnormalities. Cox proportional hazard models were employed to assess time to cardiac death or myocardial infarction (MI). Total cardiovascular costs were summed (discounted and inflation-corrected) throughout follow-up. A cost-effectiveness ratio < Dollars 50,000 per life year saved (LYS) was considered favourable for economic efficiency. The risk-adjusted 3-year death or MI rates classified by extent of ischaemia were similar, ranging from 2.3 to 8.0% for echocardiography and from 3.5 to 11.0% for SPECT (model chi2 = 216; P < 0.0001; interaction P = 0.24). Cost-effectiveness ratios for echocardiography were < Dollars 20,000/LYS when the annual risk of death or MI was < 2%. However, when yearly cardiac event rate were > 2%, cost-effectiveness ratios for echocardiography vs. SPECT were in the range of Dollars 66,686-Dollars 419,522/LYS. For patients with established coronary disease (i.e. > or = 2% annual event risk), SPECT ischaemia was associated with earlier and greater utilization of coronary revascularization (P < 0.0001) resulting in an incremental cost-effectiveness ratio of Dollars 32,381/LYS. CONCLUSION: Health care policies aimed at allocating limited resources can be effectively guided by applying clinical and economic outcomes evidence. A strategy aimed at cost-effective testing would support using echocardiography in low-risk patients with suspected coronary disease, whereas those higher risk patients benefit from referral to SPECT imaging.

Aged↗
PubMed2001

Factors associated with healthcare costs in women with fibromyalgia.

OBJECTIVE: To examine how women with high and low healthcare costs differ by using the Anderson Health Behavior Model of Utilization as a theoretical framework. STUDY DESIGN: One-year longitudinal design. PATIENTS AND METHODS: A total of 537 female health maintenance organization members with fibromyalgia participating in a study examining the effects of social support and education on health status and healthcare use were divided into 2 groups using a median split on health costs. Predisposing variables (demographic variables, self-efficacy, depression, and social support), enabling characteristics (income), and need variables (health status, perceived health status, disease severity, duration of symptoms, and comorbidity) were measured. Patients completed a battery of questionnaires at baseline assessment, and healthcare costs were assessed 1 year before and 1 year after baseline assessment. Healthcare data were collected from medical records. Healthcare costs were estimated by multiplying the number of each type of healthcare contact by the most recent national average cost figures. RESULTS: Multivariate analysis of covariance controlling for costs during the year before baseline assessment was performed. Low-cost patients had fewer comorbid conditions, better health status, higher self-perceived health status, less disease severity, greater self-efficacy for functioning, lower depression scores, and higher social support scores. Chi2 analyses revealed no significant differences between groups on marital status but a significant difference in income: low-cost patients were more likely to report higher incomes. CONCLUSIONS: There were several significant differences between people with higher and lower healthcare costs. Although effect sizes were small, many variables may be responsive to intervention.

Adult↗
PubMed2001

[A study of the relation between providing healthcare information and behavior changes of people in Japan. Parental behavior changes after receiving information about the sudden infant death syndrome].

OBJECTIVE: Considering the lack of evidence concerning the relationship between providing healthcare information and behavior of people in Japan, we utilized a questionnaire to survey the parents of infants to evaluate behavior change after receiving information about the Sudden Infant Death Syndrome (SIDS). METHODS: A questionnaire about SIDS information was administered in 234 municipalities in Niigata, Gifu, Shizuoka, and Hiroshima Prefectures and in Yokohama City in November and December of 1999 to 14,879 parents who visited for the 18-month health examination of their children. The questionnaire did not ask for the participants' names. Logistic regression analysis was used to study the connection between behavior change and SIDS information sources. RESULTS: 10,900 parents returned the questionnaire to give a 73.3% response rate, 19.0% of these receiving information about SIDS risk factors from hospitals or clinics, 3.7% from public health centers, and 9.2% from their friends. More received information from the mass media such as TV programs, which provided the main source for 71.1% of the parents. The degree of behavior change was evaluated after adjustment for variables concerning a variety of information sources and other appropriate factors such as the age and sex of parents and the number of their children. We found that receiving information from hospitals or clinics significantly influences behavior changes for all kinds of risk factors. Information from public health centers, baby-care groups, and friends influenced behavior changes relevant to the risk factors for feeding methods, sleeping position, and parents' smoking. There was no relation between receiving information from the mass media and behavior change of parents. CONCLUSIONS: The mass media provide far more information than do medical facilities, public health centers, baby-care groups and personal contacts but the latter played much more effective roles in making parents change their baby care behavior. These results point to an obvious discrepancy between efficiency in providing information and the degree of behavior change elicited. We should thus take the source of information and the target population into consideration when we examine the best way to provide healthcare information for people in the future.

Adult↗
PubMed2001

Development, analysis, refinement, and utility of an interdisciplinary amyotrophic lateral sclerosis database.

The current status of evaluation and management provided by individual healthcare professionals (HCP) at amyotrophic lateral sclerosis (ALS) centers and clinics needs to be analyzed. This paper describes one ALS center's experiences with the development, analysis, refinement, and utility of an interdisciplinary, HCP-driven ALS database. The purpose and conceptual framework of the database, the general data that needed to be collected, and the types of reports that needed to be generated were determined, and, in collaboration with a computer programmer, data entry and database management systems were developed. Data were collected on 234 patients between September 1996 and August 1998, and were analyzed by a biostatistician. Based on review of the biostatistician's report and discussion of problems encountered with the systems, the database was then refined. Benefits of the database system included: systematization of data collection and reporting, reduction of redundant data collection by individuals, decreased variability of evaluation methods and management decisions from patient to patient, and increased availability of a variety of uniform patient information to assist team members in making care decisions. Ongoing refinement will ensure that this HCP-driven ALS database continues to be informative, practical and effective for decision-making and enhancing delivery of care.

Adult↗
PubMed2006

The impact of cost sharing of prescription drug expenditures on health care utilization by the elderly: own- and cross-price elasticities.

PURPOSE: To estimate healthcare demand elasticity and evaluate the impact of deductible/co-payment policy changes for prescription drugs on the use of drugs and physician visits among seniors with rheumatoid arthritis (RA) in British Columbia (BC), Canada. METHODS: According to the BC drug insurance program, prior to 2002, seniors co-paid the dispensing fee of each prescription to an annual maximum of CAN$ 200 (plan A). Starting in 2002, this plan was split into plan A and plan A1 (Premium Assistance) such that the co-payment amount equaled a maximum of CAN$ 25 and CAN$ 10 per prescription to an annual maximum of CAN$ 275 and CAN$ 200, respectively. Because of the endogeneity of the beneficiary price in the presence of a non-linear price schedule resulting from the cost-sharing policy, we implemented the method of instrumental variables to estimate price elasticities. The instrument was based on the price an individual would face under the new cost-sharing policy if their consumption remained at the pre-policy level. RESULTS: A total of 8017 patients were included. The estimated own-price elasticity of demand for prescription drugs and the cross-price elasticity of demand for physician visits were found to be negative and positive, respectively. The implications of our findings were that when cost sharing for prescription drugs increased, the demand for prescription drugs decreased and the demand for physician visits increased. CONCLUSIONS: In a predominantly publicly funded health care system, the selective introduction of market driven cost containment concepts such as patient cost-sharing might have the unintended impact of increasing overall health utilization for seniors with RA.

Aged↗
PubMed1997

Quality-of-life measures as providers of information on value-for-money of health interventions. Comparison and recommendations for practice.

Three different approaches to measuring quality of life have been developed. Global scales (e.g. time trade-off, visual analogue), multi-attribute utility scales and multidimensional scales (which may be generic or disease-specific). Each of these approaches to measurement provides different kinds of information about quality of life and each can be used to provide information to healthcare purchasers concerning the relative value-for-money of health interventions. The value-for-money of health interventions, in terms of quality of life, can be demonstrated in 2 ways: a formula-driven approach based on cost-utility analysis, which uses scales generating the unit of a quality-adjusted life-year (i.e. global and multi-attribute utility); and a non-formula-driven approach, which uses scales generating multidimensional profiles of quality of life (i.e. multi-attribute utility and multidimensional). Analysis shows that no single approach is sufficient, and that healthcare purchasers should use a variety of types of information in their decision-making, including both cost-utility and informal approaches. Healthcare resource allocation is inevitably a value-dependent activity.

Delivery of Health Care↗
PubMedDate not supplied

Monitoring purchaser expenditure patterns.

This study outlines the development and application of a methodology that allows direct comparison of the elements that make up in-patient healthcare across the West Midlands Regional Health Authority. The methodology produces a model which monitors the mechanism of resource utilization within the Region and the factors that influence it. The model shows how the uptake of healthcare varies by treatment specialty, between each provider unit, and across all purchasing authorities in the Region. The methodology accounts in all instances for demography and where appropriate for socio-economic deprivation. The novelty of this study is the generation of provider unit specialty costs that reflect both recorded activity and expenditure in the locality. The results of the investigation are made available to the purchasers to assess the levels of the services they are buying.

Adult↗
PubMed1998

Abdominal hysterectomy practice patterns in the United States.

OBJECTIVE: To describe nationwide practice trends for two principal techniques of abdominal hysterectomy in the United States, numbers and rates of total (TAH) and supracervical (SCH) hysterectomy were reviewed with charges for each operation. METHODS: Practice patterns for all inpatient TAH and SCH discharges in the US from 1991 to 1994 were studied using HCUP-3 NIS, a nationwide hospital discharge database. Hysterectomies performed for malignant disease, vaginally or with laparoscopic assistance were not sampled. For each year studied, the number and rate of TAH and SCH, average length of stay (LOS), and mean institutional charge were evaluated. RESULTS: From 1991 to 1994, the US TAH rate (cases/10000 females) decreased significantly from 25.7 to 20.5 (P = 0.02). During the same interval the SCH rate increased significantly from 0.16 to 0.41 (P = 0.04). Nevertheless, TAH accounted for > 99% of all abdominal hysterectomies for each of the 4 years evaluated. The mean institutional charges for the two operations generally depicted SCH to be more costly than TAH. CONCLUSION: The national rates of TAH and SCH rates changed significantly in the United States from 1991 to 1994, with TAH declining and SCH increasing. This mix of cases continues to reflect a strong preference for TAH. Although hospital charges for both procedures increased during this study, these data show that SCH is more expensive than TAH. The much lower utilization of SCH renders nominal its impact on national healthcare expenditures, however. Further studies are needed to assess specific causative factors for these changes in US hysterectomy technique.

Female↗
PubMed1999

Pre-transplant identification of risk factors that adversely affect length of stay and charges for renal transplantation.

BACKGROUND: In the current era of renal transplantation, increasing attention is being focused on resource utilization. The purpose of this study was to identify demographic, medical and immunologic risk factors that are associated with changes in length of stay (LOS) and charges for renal transplantation. METHOD: The study was a retrospective analysis of 311 consecutive renal transplants performed at a single institution. Univariate and multivariate analyses were used to examine relationships between risk factors, LOS, charges and post-operative complications. RESULTS: The following pre-transplant variables were found to be independently significant in predicting increased LOS and/or charges: African-American race, obesity for women, chronic obstructive pulmonary disease (COPD), presence of cardiac disease or previous stroke, pre-transplant dialysis time > or = 1 yr, a 10% increase in panel reactive antibody (PRA), cadaver donor and retransplantation. The analyses were performed with and without adjustment for key outcome variables such as delayed graft function (DGF) and use of induction antibody therapy. Increased LOS or charges for specific risk factors could be attributed to increased complication rates, including delayed graft function seen with various co-morbidities, or increased immunologic risk and more frequent use of induction antibody therapy. CONCLUSION: Analysis of linked financial and clinical databases can reveal demographic, medical and immunologic risk factors that correlate with LOS, charges and complications for renal transplantation. Efforts to establish quantitative relationships for various risk factors relative to resource utilization will become important in managed care and/or capitated healthcare delivery systems.

Adult↗
PubMedDate not supplied

Computerized training in breast self-examination: a test in a community health center.

Fifty-eight women recruited from a community health center completed either a brief interactive multimedia training program on breast self-examination using a breast model and computer guided feedback on accuracy of lump detection or read a National Cancer Institute pamphlet on breast self-examination and breast lumps. Women using the computer program as compared to the pamphlet group reported a higher sense of self-efficacy for being able to perform a breast self-examination immediately after their educational session and 1 month later. However, the increase in self-efficacy for the computer group diminished over 4 weeks, underscoring the importance of an environment that reminds and reinforces learning for women about the performance of regular breast self-examination. The increase in sense of self-efficacy to perform breast self-examination with roughly 20 minutes of computer-based training and the partial maintenance of that self-efficacy 30 days later suggests the utility of incorporating short, focused interventions in busy primary healthcare settings.

Adult↗
PubMed1999

Collaborative care: a professional practice model.

Healthcare economics has caused dramatic changes in resource assessment, utilization, and reorganization in hospitals. To address the mismatch between demand and resources and to ensure quality at the bedside, staff members at a 354-bed acute care facility designed and implemented the Collaborative Care Model (CCM). The authors describe this theory-based, collaborative, multidisciplinary professional practice model.

Consultants↗
PubMed2004

Assuring rural hospital patient safety: what should be the priorities?

CONTEXT: Since reports on patient safety were issued by the Institute of Medicine, a number of interventions have been recommended and standards designed to improve hospital patient safety, including the Leapfrog, evidence-based safety standards. These standards are based on research conducted largely in urban hospitals, and it may not be possible to generalize them to rural hospitals. PURPOSE: The absence of rural-relevant patient safety standards and interventions may diminish purchaser and public perceptions of rural hospitals, further undermining the financial stability of rural hospitals. This study sought to assess the current evidence concerning rural hospital patient safety and to identify a set of rural-relevant patient safety interventions that the majority of small rural hospitals could readily implement and that rural hospitals, purchasers, consumers, and others would find relevant and useful. These interventions should help rural hospitals prioritize patient safety efforts. METHODS: As background, we reviewed literature; interviewed representatives of provider, payer, consumer, and governmental groups in 8 states; and calculated patient safety indicator rates in rural hospitals using the Agency for Healthcare Research and Quality's Health Care Cost and Utilization Project National Inpatient Sample. Based on the research literature and patient safety recommendations from national organizations, we developed a list of potentially important patient safety areas for rural hospitals. The rural relevance of these safety interventions was evaluated by a national expert panel in terms of the frequency of the problem, ability to implement, and the internal and external value to rural providers, purchasers, and consumers. FINDINGS: The limited available research suggests that patient safety events and medical errors may be less likely to occur in rural than in urban hospitals. We identified 9 areas of patient safety and 26 priority patient safety interventions relevant to rural hospitals. CONCLUSIONS: Many of the identified areas of patient safety and interventions are relevant to all types of hospitals, not just rural hospitals. However, some areas, such as transfers, are especially relevant to rural hospitals. The challenges of implementing some interventions, such as 24/7 pharmacy coverage, are significant given workforce supply and financial problems faced by many small rural hospitals. The results of this study provide an important platform for further work to test the validity and effectiveness of these interventions.

Health Priorities↗
PubMed2006

What pay for what performance?

The paper by Pink et al. is extraordinarily timely and useful for those managing the Ontario Wait Time Strategy. Pay-for-performance (PFP) has been a central tenet of this successful, publicly financed initiative, introduced 18 months ago. Governments around the world focus on wait time reduction, and this measurement is fashionably utilized as a popular indicator of how well a healthcare system is performing. Because wait time reduction is so high on the political agenda, governments are prepared to spend public money raising the question of how that money can be best spent to achieve that goal.

Canada↗
PubMed1997

The challenge to meet the mental health and biopsychosocial needs of the poor: expanded roles for hospital social workers in a changing healthcare environment.

Despite the absence of coordinated federal health care reform, social workers in hospital settings have opportunities to identify, develop, advocate for, and facilitate access to innovative health care services, resulting in improved capacity to meet the mental health and biopsychosocial needs of the poor and, potentially, reduced hospital costs over time. There are opportunities for expanded roles for social workers in forging better linkages between hospital services and the community, developing an integrated biopsychosocial healthcare delivery system within hospitals and primary care settings, utilizing information systems as tools in an integrated system, and advocating for a client-centered approach to mental health services.

Community Mental Health Services↗
PubMed2004

Strategies to increase HMG-CoA reductase inhibitor use after acute myocardial infarction.

Coronary artery disease with its accompanying complication of acute myocardial infarction (MI) is one of the major causes of death in the modern world. A variety of both primary and secondary prevention strategies have been developed for the treatment of acute MI. One of the more important of these strategies is the prescription of HMG-CoA reductase inhibitors. HMG-CoA reductase inhibitors have the potential to positively affect the outcome of acute MI in a variety of ways including the reduction of low-density lipoprotein-cholesterol levels and stabilisation of the atherosclerotic plaque. Multiple large randomised clinical trials have documented the potential of HMG-CoA reductase inhibitors to reduce both short- and long-term mortality after acute MI. This benefit exists regardless of age, gender, clinical presentation, or even baseline lipid levels. However, despite this overwhelming amount of evidence supporting the use of HMG-CoA reductase inhibitors in the post-MI setting, multiple studies have documented the presence of a significant 'treatment gap'. Indeed, often, less than half of acute MI patients who would benefit from HMG-CoA reductase inhibitor therapy actually receive it. The reasons for the low utilisation of HMG-CoA reductase inhibitors in the acute MI patient are many, but may include poor communication, the high cost of treatment, the lack of associated symptoms and confusion regarding appropriate lipid levels to target. One approach that has been tried to address these issues is the development of institutional programmes specifically targeted to increase the use of HMG-CoA reductase inhibitors in acute MI patients. These programmes, often managed by nurses or pharmacists, have been piloted in several institutions. They have been effectively implemented in both inpatient and outpatient settings. In most cases they have been implemented without a great increase in expense. They have often increased the use of HMG-CoA reductase inhibitors to >90%. Most importantly, they have documented a significant improvement in the long-term survival of acute MI patients. Based on these preliminary studies, it is recommended that the implementation of these strategies be considered by most healthcare institutions.

Drug Utilization↗