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The relatively new concept of physician hospital organizations is gaining strength in the managed-care world. PHOs exist to make and maintain contractual arrangements--especially between employer groups and healthcare providers--and provide information services, physician referrals, utilization-management services and more.
Chronic low back pain is a major social, economic, and healthcare issue in the United States. Various techniques are utilized in managing discogenic pain, with or without disc herniation. Percutaneous techniques are rapidly replacing traditional open surgery in operations requiring discectomy, decompression, and fusion. The percutaneous access to the disc was first used in the 1950s to biopsy the disc with needles. Percutaneous access to the disc using endoscopic techniques was developed in the 1970s. Technical advances in the use of intradiscal therapies led to the development of intradiscal electrothermal annuloplasty (IDET), DISC Nucleoplasty, and DeKompressor, along with laser-assisted, endoscopic, and Nucleotome disc decompressions. The indications for percutaneous lumbar disc decompression include low back and lower extremity pain caused by a symptomatic disc. Internal disc disruptions and disc herniations are common causes of low back and/or lower extremity pain which may become chronic, if not diagnosed and treated. Annular tears lead to migration of the nuclear material and deranged internal architecture. In the chronically damaged intervertebral disc, leakage of nuclear material from annular tears can initiate, promote, and continue the inflammatory process and delay or stop recovery of vital remaining intradiscal tissue. The most often stated goal of central nuclear decompression is to lower the pressure in the nucleus and to allow room for the herniated fragment to implode inward. Provocative discography prior to percutaneous lumbar disc decompression is recommended. Percutaneous disc decompression may result in a small number of complications but occasionally, these could be serious.
The race is on to determine which organization will become the accreditation agency of choice for the managed care industry. At stake is enormous clout at the state and national levels--and a lot of money. Squaring off against the traditional accreditation leader, the Joint Commission on Accreditation of Healthcare Organizations, are: the National Committee for Quality Assurance, the American Association of Preferred Provider Organizations, and the Utilization Review Accreditation Commission.
BACKGROUND: Current healthcare trends may render financial risk of cardiac operation a key component of clinical decision making. It has been suggested, based on large cohorts of patients stratified by clinical risk, that the cost of operation can be predicted from models of clinical risk since length of stay (LOS) is highly correlated to clinical risk, and LOS is correlated to hospital costs and charges. Direct correlation of actual surgical costs with surgical risk are lacking. METHODS: Variable direct costs, LOS, and The Society of Thoracic Surgeons predicted mortality risk [STS risk (%)] were collected and analyzed in 628 consecutive patients undergoing coronary artery bypass grafting (CABG) at our institution in 1997. RESULTS: Cost of CABG had a near-normal distribution, and cost in 21 outlier patients (cost > two standard deviations above the mean) was an average 5.3 times normal (median cost). For individual patients, cost was well correlated to LOS (R2 = 0.48) but not with STS risk (R2 = 0.12). LOS was also poorly predicted by STS risk (R2 = 0.09). However, despite its poor prediction of cost, STS risk was an unbiased estimator over the entire population. A result manifested, when patients were grouped into similar risk (<1%, 1-2%, 2+ -3%, 3+ -5%, 5+ -10%, and >10%) cohorts, by high correlation between cost and STS risk (R2 = 0.99), cost and LOS risk (R2 = 0.99), and LOS and STS risk (R2 = 0.97). CONCLUSIONS: Our data demonstrated that, in large CABG cohorts, surgical risk models can accurately predict cost of CABG. However, despite a trend for increasing cost with increasing STS risk, surgical risk models based on preoperative data are poor predictors of cost in individual patients. Use of these models should be limited to analysis of cost trends in cardiac operation, but not for predicting financial risk in individual patients during clinical decision making.
Epistaxis has a reported prevalence of 10-12 per cent in the general population and is thus one of the commonest emergencies in Otolaryngology. We suggest that the patient uses a surgical mask to prevent blood spray during epistaxis management. Utilizing the described technique we have found that protective clothing worn by the healthcare professional is consistently 'blood-free' at the end of the procedure. This is in contrast to findings when no facemask is applied.
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Pharmacy and Therapeutics committees of managed care organizations have traditionally developed formularies by limiting the numbers and kinds of pharmaceuticals they purchase, with the goal of cutting costs. These attempts to manage pharmaceutical costs do not take into account the interrelationship of the costs of various components of care; thus, drug costs may decrease, but expenditures for utilization of other resources may increase. Cost-minimization and basic cost-effectiveness studies, on which many prior- authorization and formulary programs are based, only evaluate only the cost of the drug and its effectiveness. However, with the heightened competition in the healthcare market, emphasis is increasingly being laid on patient satisfaction and outcomes. Cost-utility analysis is a potentially superior pharmacoeconomic tool because it evaluate the effect of drug therapy on quality of life; however, data from such analyses are seldom readily available to the committees that evaluate a drug's potential effects on the entire healthcare system. The purpose of this review is to stress the importance of approaching formulary management from a wider perspective and to emphasize that the results of cost-utility studies should be proactively evaluated and incorporated into decisions regarding formularies. This is especially important for symptom-intensive diseases, such as asthma, in which the quality of life can be notably impaired. Cost-utility analyses should be conducted for all newer therapies, such as salmeterol, which are highly effective and which have a positive impact on quality of life, to determine the overall effect on the managed care plan's budget.
Over five decades of independence, India has made rapid strides in various sectors. However, its performance in social sectors and particularly the healthcare sector has not been too rosy. Being the State's responsibility the healthcare has traditionally been influenced by individual State's budgetary allocation. Consequently inter-state disparity in availability and utilization of health services and health manpower are distinctly marked. This has implications for achievement of Health for All for the nation as a whole. Keeping in view the significance of studying inter-state variations in healthcare, this study focuses on the performance of healthcare sector in 15 major States in India. This is attempted through a comparative analysis of various parameters depicting availability of health services, their utilization and health outcomes. Our analysis depicts the prevalence of considerable inequity favoring high income group of States. In terms of healthcare resources, for instance, it indicates that the high income States hold a superior position in terms of: per capita government expenditure on medical and public health, total number of hospitals and dispensaries, per capita availability of beds in hospitals and dispensaries and health manpower in rural and urban areas. These parameters of availability have an impact on utilization levels and health outcomes in these States. A comparative profile of high and low income States as well as middle and low income States, both in rural and urban areas, reaffirms a greater financial burden in availing treatment at OPD and inpatient in low income States. In line with the higher financial burden and low per capita health expenditure, the health outcome indicators also depict a disconcerting situation in regard to low income States. These States are marked by lower life expectancy and higher incidence of diseases as well as high mortality rates. In this regard, demand as well as supply side constraints are observed which restrain the optimum utilization of existing health services. Among the low income States the main constraints on the demand side include illiteracy, malnutrition, and lack of infrastructure in accessing the facilities. Certain state specific supply side factors add significantly to under-utilization in low income States. In some of the States, however, corrective actions have been initiated to overcome the problem of the quality and low utilization of health facilities. In due course of time, it is likely that proper implementation of these measures may result in improved utilization level of existing health services, which may be useful to improve health status indicators. Nonetheless, overcoming the current levels of regional disparities in healthcare across three income groups of States may also require additional resources. The latter could be mobilized through assistance of donor agencies and appropriate mix of social and private insurance. Ultimately mitigating the problem of regional disparities in healthcare and protecting the poor and vulnerable from financial burden may require establishing and maintaining proper linkages between socio-economic development and healthcare planning.
BACKGROUND AND OBJECTIVES: Definitions of medical futility, offered by healthcare professionals, bioethicists and other experts, have been rigorously debated by many investigators, but the perceptions of patients of futility have been explored only by a few. Patients were allowed to discuss their concerns about end-of-life care, so that their ideas about treatment futility or utility could be extrapolated by us. METHODS: In this cross-sectional study, in-depth, semistructured interviews were conducted with 30 elderly people who were receiving outpatient care in a large, urban Veterans Affairs medical centre in the US. Each of their healthcare providers was also interviewed. Participants were asked to consider four terms commonly used in advance directive forms (ie, life-sustaining treatment, terminal condition, state of permanent unconsciousness and decision-making capacity) and to discuss what these terms meant to them. Audiotapes of the open-ended interviews were transcribed and responses were coded and categorised by constant comparison, a commonly used qualitative method. RESULTS: The following four factors were taken into account by the participants when discussing end-of-life interventions and outcomes: (1) expected quality of life; (2) emotional and financial costs of treatment; (3) likelihood of treatment success; and (4) expected effect on longevity. CONCLUSIONS: Although the terms "utility" or "futility" were not generally used by the participants, segments of speech indicating their perceptions of these terms were identified. Treatment was not always discussed in the same way by patients and providers, but seemed to reflect the same four concerns. Therefore, it may be fruitful for providers to focus on these concerns when discussing end-of-life treatment options with their patients.
Formulating a rational health policy necessitates the ability to compare between different healthcare interventions and disease scenarios. Continuous positive airway pressure (CPAP) therapy with a conservative lifestyle strategy in sleep apnoea/hypopnoea syndrome (SAHS) was evaluated using health utility and quality-adjusted life years (QALYs) as outcome measures. A total 71 SAHS (apnoea/hypopnoea index > or = 15 h(-1)) patients completed a randomised, parallel group study over 3 months using utilities derived by the standard gamble approach (Usg) and European quality of life questionnaire (Euroqol) (Ueq). The severely impaired health status at baseline improved by 23% (Usg 0.32 to 0.55) adding 8 QALYs in the CPAP group, compared to a 4% improvement with 4.7 QALYs added in the lifestyle group (Usg 0.31 to 0.35). The Ueq showed a marginal change with CPAP (0.73 to 0.77) but did not demonstrate any improvement with lifestyle intervention. The health status impairment in sleep apnoea/hypopnoea syndrome patients is markedly improved by continuous positive airway pressure compared to a modest improvement with conservative lifestyle strategies using the standard gamble utility, which may be incorporated in effectiveness and economic analyses. The European quality of life questionnaire did not reflect a similar degree of impact and is probably not useful in this population.
BACKGROUND: The purpose of this study was to determine the extent to which poison center triage guidelines influence healthcare facility referral rates for acute, unintentional acetaminophen-only poisoning and acute, unintentional adult formulation iron poisoning. METHODS: Managers of US poison centers were interviewed by telephone to determine their center's triage threshold value (mg/kg) for acute iron and acute acetaminophen poisoning in 1997. Triage threshold values and healthcare facility referral rates were fit to a univariate logistic regression model for acetaminophen and iron using maximum likelihood estimation. RESULTS: Triage threshold values ranged from 120-201 mg/kg (acetaminophen) and 16-61 mg/kg (iron). Referral rates ranged from 3.1% to 24% (acetaminophen) and 3.7% to 46.7% (iron). There was a statistically significant inverse relationship between the triage value and the referral rate for acetaminophen (p < 0.001) and iron (p = 0.0013). The model explained 31.7% of the referral variation for acetaminophen but only 4.1% of the variation for iron. CONCLUSION: There is great variability in poison center triage values and referral rates for iron and acetaminophen poisoning. Guidelines can account for a meaningful proportion of referral variation. Their influence appears to be substance dependent. These data suggest that efforts to determine and utilize the highest, safe, triage threshold value could substantially decrease healthcare costs for poisonings as long as patient medical outcomes are not compromised.
Advancements in pharmacogenomics and chemoprevention promise to reduce cancer incidence and mortality, but utilization will undoubtedly be accompanied with ethical and legal issues that largely remain unexplored or discussed. As pharmacogenomic information is assessed more comprehensively and inexpensively, it will influence decisions regarding when and to whom chemoprevention therapy will be initiated. Pharmacogenomics will change the manner in which the liability system will perceive and analyse risks. Management of the risks related to chemopreventive treatment will differ from traditional disease management. Knowledge about cancer susceptibility will need to consider environmental factors as they relate to healthcare disparities.
Over the past several years this journal has published numerous articles on the merits and benefits of effective resource management. Independently, these articles have supported the value of effective supply and materials management, management engineering and system restructuring, and clinical resource management in being able to save healthcare dollars by designing and injecting efficiencies into the healthcare delivery system. While most of these resource management activities have utilized very similar strategies (see Table 1 "Tools For Improvement"), much of the process revision and progress has remained within the walls of their own individual disciplines. Any widescale attempts to try to fully integrate all of these activities have been hampered by the intricacies of trying to mix apples and oranges. Despite these individual departmental gains, the challenge to conserve healthcare costs continues to permeate throughout all levels of the organization, and institutions are finally beginning to recognize the added value of merging these activities into a more centralized coordinated approach to resource management. Presented is a discussion on the potential value of developing a well-focused, integrated resource management program.
BACKGROUND: The computer revolution and Information Technology (IT) have transformed modern health care systems in the areas of communication, teaching, storage and retrieval of medical information. These developments have positively impacted patient management and the training and retraining of healthcare providers. Little information is available on the level of training and utilization of IT among health care professionals in developing countries. OBJECTIVES: To assess the knowledge and utilization pattern of information technology among health care professionals and medical students in a university teaching hospital in Nigeria. METHODS: Self-structured pretested questionnaires that probe into the knowledge, attitudes and utilization of computers and IT were administered to a randomly selected group of 180 health care professionals and medical students. Descriptive statistics on their knowledge, attitude and utilization patterns were calculated. RESULTS: A total of 148 participants (82%) responded, which included 60 medical students, 41 medical doctors and 47 health records staff. Their ages ranged between 22 and 54 years. Eighty respondents (54%) reportedly had received some form of computer training while the remaining 68 (46%) had no training. Only 39 respondents (26%) owned a computer while the remaining 109 (74%) had no computer. In spite of this a total of 28 respondents (18.9%) demonstrated a good knowledge of computers while 87 (58.8%) had average knowledge. Only 33 (22.3%) showed poor knowledge. Fifty-nine respondents (39.9%) demonstrated a good attitude and good utilization habits, while in 50 respondents (33.8%) attitude and utilization habits were average and in 39 (26.4%) they were poor. While 25% of students and 27% of doctors had good computer knowledge (P=.006), only 4.3% of the records officers demonstrated a good knowledge. Forty percent of the medical students, 54% of the doctors and 27.7% of the health records officers showed good utilization habits and attitudes (P=.01) CONCLUSION: Only 26% of the respondents possess a computer, and only a small percentage of the respondents demonstrated good knowledge of computers and IT, hence the suboptimal utilization pattern. The fact that the health records officers by virtue of their profession had better training opportunities did not translate into better knowledge and utilization habits, hence the need for a more structured training, one which would form part of the curriculum. This would likely have more impact on the target population than ad hoc arrangements.
BACKGROUND: Asthma changes both the volume and patterns of healthcare of affected people. Most studies of asthma health care utilization have been done in selected insured populations or in a single site such as the emergency department. Asthma is an ambulatory sensitive care condition making it important to understand the relationship between care in all sites across the health service spectrum. Asthma is also more common in people with fewer economic resources making it important to include people across all types of insurance and no insurance categories. The ecology of medical care model may provide a useful framework to describe the use of health services in people with asthma compared to those without asthma and identify subgroups with apparent gaps in care. METHODS: This is a case-control study using the 1999 U.S. Medical Expenditure Panel Survey. Cases are school-aged children (6 to 17 years) and young adults (18 to 44 years) with self-reported asthma. Controls are from the same age groups who have no self-reported asthma. Descriptive analyses and risk ratios are placed within the ecology of medical care model and used to describe and compare the healthcare contact of cases and controls across multiple settings. RESULTS: In 1999, the presence of asthma significantly increased the likelihood of an ambulatory care visit by 20 to 30% and more than doubled the likelihood of making one or more visits to the emergency department (ED). Yet, 18.8% of children and 14.5% of adults with asthma (over a million Americans) had no ambulatory care visits for asthma. About one in 20 to 35 people with asthma (5.2% of children and 3.6% of adults) were seen in the ED or hospital but had no prior or follow-up ambulatory care visits. These Americans were more likely to be uninsured, have no usual source of care and live in metropolitan areas. CONCLUSION: The ecology model confirmed that having asthma changes the likelihood and pattern of care for Americans. More importantly, the ecology model identified a subgroup with asthma who sought only emergent or hospital services.
OBJECTIVE: This study was designed to investigate the efficacy and feasibility of a web-based depression stigma education tool for healthcare professionals. METHODS: A web-based depression stigma program utilizing adult learning theories was developed. Forty-two consecutive subjects were enrolled from University of Maryland staff and graduate students. Primary outcomes were Bogardus Social Distance Scale with a vignette on major depression disorder (BSDS-MDD) and the Depression Stigma Scale (DSS) administered before and after the intervention. RESULTS: Internet-based education significantly decreased the level of depression stigma (BSDS-MDD 10.6+/-4.4 versus 7.2+/-4.4, p<0.001; DSS-personal 12.7+/-7.2 versus 7.8+/-5.3, p<0.001; DSS-perceived 21.7+/-5.5 versus 12.4+/-5.5, p<0.001). After the educational intervention the subjects' knowledge about depression significantly improved (pre-test DKS=18.2+/-8.2 versus post-test DKS=20.6+/-4.1, p<0.001). The program was very well accepted by participants. For 100% of participants, it was not difficult to operate the program. CONCLUSIONS: Computer-assisted education was effective in reducing the stigma of depression and increasing knowledge about depressive disorder. A web-based intervention has the potential to be used for educating graduate students and university staff about depression and for reducing depression stigmata. Healthcare professionals interacting with people with stigmatizing conditions can benefit from web-based computer education.
OBJECTIVE: No research has evaluated the impact of an increase to a copay that is reflective of today's healthcare market. This study examined the effect of an increase from a $10 to $15 copay for brand drugs on key pharmaceutical utilization measures, including participation rates, treatment continuation, and expenditures, in an adult population. STUDY DESIGN: A quasi-experimental, pre-post design with control group was used. PATIENTS AND METHODS: Two different employer plans implemented an increase from $10 to $15 for brand copays in January of 1997. The utilization and expenditures of these plans were compared with those of a control group with a constant brand copay of $10 for 6 months preceding and 6 months following the copay increase. RESULTS: When other predictor variables were controlled for, the copay increase was not associated with a statistically significant difference in overall utilization compared with the control group, although brand utilization was significantly lower in the copay group. Savings to the payer were substantial, and resulted primarily from cost-shifting, reduction in brand utilization, and an increase in the generic fill rate. The rates of continuation with chronic medications in the 6 months following the copay increase were not reduced in the copay group compared with the control group. CONCLUSION: A copay increase can provide substantial savings to a payer without being a major deterrent to overall utilization or resulting in discontinuation of chronic medications.
On January 1, 2004, Intermountain Healthcare Health Plans implemented a polypharmacy edit and reduced the quantity limits of triptans to minimize the risks associated with triptan polypharmacy. The intervention covered one oral triptan brand per month and allowed one alternate formulation, limited monthly oral triptan quantities, and recommended use of prophylactic medication. During 2003, the prescription count per quarter for triptans increased from 4,816 to 5,359. The number of utilizing members increased from 2,659 to 2,781 over the course of the year. Total ingredient cost for fourth-quarter 2003 was dollar 932,950. For first-quarter 2004, the prescription count was 4,131 (used by 2,423 members) at a total ingredient cost of dollar 583,988. Fourth-quarter 2004 utilization was 4,763 prescriptions, 2,719 members, and dollar 700,534 total ingredient cost. The total triptan spend was dollar 872,718 lower during 2004 compared with 2003. Total medical claims remained constant over the two-year period for members who had a history of at least one triptan during that time. Educating members and health care professionals about the appropriate use of triptans can improve outcomes, and reevaluation of polypharmacy edits and quantity limits based on evolving clinical data improves the appropriate use of triptans.