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PubMed1990

Economic aspects of patterns of mental health care: cost variation by setting.

The paper examines the evidence regarding the extent to which differences exist in health and mental health status of psychiatric patients treated in the specialty mental health, general medical, and informal care sectors. Differences in types of patients treated in the three sectors are important to identify since there are dramatic differences in the average costs of treatment. We use data from the Baltimore Epidemiological Catchment Area Survey to estimate a statistical model of treatment setting choice. Our results suggest that there is little support for attributing major differences in treatment costs across sectors to differences in the health and mental health status of patients.

Costs and Cost Analysis↗
PubMed1997

Low utilization of formal medical services by injured persons in a developing nation: health service data underestimate the importance of trauma.

BACKGROUND: Assessment of the societal importance of trauma relies, in large part, on hospital and other health service data. Such data are of limited value in developing nations if a significant proportion of injured persons do not receive formal medical care. METHODS: We undertook an epidemiologic study of trauma in Ghana. Via household visits, we surveyed 21,105 persons living in 432 urban and rural sites. RESULTS: During the preceding year, there had been 13 fatal injuries (62 per 100,000) and 1,597 nonfatal injuries resulting in > or = 1 days of lost activity (7 per 100). Of the fatally injured, only 31% received formal medical care (hospital or clinic). Of the nonfatal injuries, 58% received formal care, but with major differences between urban and rural sites. Only 51% of rural injured received formal medical care, compared with 68% of urban injured (p < 0.001). Even among those with more severe injuries (disability time > or = 1 month), 26% of rural injured never had formal care. Overall hospital use was especially low, with only 27% of all injured persons using hospital services. Among those with more severe injuries, 60% of urban, but only 38% of rural injured received hospital care (p < 0.001). CONCLUSIONS: These data indicate low utilization of formal medical services by injured persons in this developing nation. Even many of those with severe injuries do not receive medical care, especially in rural areas. Assumptions that rely on health service data, especially hospital data, underestimate the importance of trauma. Appropriate commitment of health care resources might thus be affected. Population based data are needed to fully assess the extent and societal impact of injuries in developing nations.

Data Interpretation, Statistical↗
PubMed1988

Health hazards related to ergonomic work conditions.

Health hazards related to unsuitable ergonomic work conditions among female employees in Sweden are reviewed. The statistics on reported occupational strain injuries form an important source of information on prevention. The report rate is higher among men than among women, but in some high risk occupations the figures are similar. Reported cases concerning neck, arm and shoulder disorders constitute a larger proportion among women. This finding probably reflects differences in work load characteristics, women more often performing repetitive monotonous work tasks in the manufacturing industry. Serious ergonomic problems exist for women in the service sector although the statistical evidence for increased morbidity is not yet available.

Accidents, Occupational↗
PubMed1995

Complaint intensity and health care services.

The author extends his Complaint Intensity Outcome Framework by including a customer-need component and applying the model to a sample of elderly health care consumers. The results indicate that immediate action should be taken to improve complaint mechanisms and performance related to the quality of physicians. Other attributes require less dramatic action, and some require none at all.

Aged↗
PubMed1999

Congruence between self-reported and actually provided prosthodontic services among Swedish dentists.

The purpose of this study, comprising two parts, was to investigate the congruence between answers given by general dentists in questionnaires concerning prosthodontic services and the recorded information on the services actually performed by each dentist. In Part I it is investigated whether questionnaire reports of weekly working hours devoted to prosthodontics can be used as indicators of actual prosthodontic production. Part II deals with the dentists' self-reported numbers of single crowns, fixed partial dentures (FPDs), and removable dentures. These reported services are compared with the services actually provided. Part I: A regression analysis indicates a lacking precision for the individual dentist, indicated by a relatively low explained variance (R2 = 0.20). However, a highly significant association is seen between the two production measures (P = 0.000). Part II: The congruence between stated and actually provided services is higher for single crowns and removable dentures than for FPDs. Bivariate regression models are statistically significant for all three services. In Part II, the reported weekly working hours used for prosthodontics covaries significantly with prosthodontic production, but the association is not as strong as in Part I. Although the precision in both Part I and Part II is low for the individual dentist, the questionnaire measure is found to be useful as an indicator in a population of dentists. It is concluded that the questionnaire data can be used as reasonably valid expressions of prosthodontic activity in population-oriented analyses among general dentists.

Crowns↗
PubMedDate not supplied

Lithuania mental health country profile.

As a part of international mental health policy, programmes and services project, the 'country profile' instrument was used for assessment of mental health policy and services in the Republic of Lithuania. Analysis of contextual factors revealed high levels of social pathology (including violence, suicide and other self-destructive behaviour) with stigmatizing approaches by the general population to mentally disturbed persons and other vulnerable groups. Analysis of existing data about resources invested in the mental health care system raises questions for policymakers about the effectiveness of this traditional way of investment. The largest proportion of physical and human capital is concentrated in psychiatric institutions, with large numbers of beds, psychiatrists and increasing funding for medications, while other components of care--such as housing, psychosocial and vocational rehabilitation, community-based child mental health services--are not being developed. Statistical accounts keep the tradition of presenting processes as outcomes, while modern assessment of outcomes of services, programmes and policies are lacking. The findings from this country profile may be very useful in the development of modern mental health policies in the countries of Eastern and Central Europe, which have been deprived for decades from the opportunity to introduce evidence-based mental health policies and services.

Culture↗
PubMed1999

Proposed changes to designations of medically underserved populations and health professional shortage areas: effects on rural areas.

This paper reports an analysis of the proposed rule to combine medically underserved population (MUP) and health professional shortage area (HPSA) designations, as published by the Bureau of Primary Health Care (BPHC) in the Federal Register on Sept. 1, 1998 (Department of Health and Human Services, 1998). The effects of the proposed rule overall and on rural communities were examined, particularly with respect to current whole county HPSA designations and eligibility for federal assistance programs. National, county-level estimates of primary care provider counts and other measures included in the proposed rule were used. Different primary care provider sources were compared; results were highly dependent on the data source and the inclusions of counts of nurse practitioners and physician assistants. The projections of losses from the proposed rule were higher than those of the BPHC, probably due to the use of different sources for provider counts. Overall, the authors projected that more than 50 percent of current whole-county HPSAs would lose designation using the proposed rule. The proportion of rural counties that lost designation was not significantly greater than the proportion of urban counties, but because there are many more rural counties, more de-designations were projected to occur in rural areas. The researchers also predicted that 58 percent of rural whole-county HPSAs with National Health Service Corps providers would lose their designation, but most rural whole-county HPSAs with Community and Migrant Health Centers or Rural Health Clinics retained their MUP designation using the proposed rule. The proposed rule likely has a larger effect on current designations than originally projected by the BPHC.

Data Interpretation, Statistical↗
PubMed2004

Critical care medicine as a distinct product line with substantial financial profitability: the role of business planning.

OBJECTIVE: As academic health centers face increasing financial pressures, they have adopted a more businesslike approach to planning, particularly for discrete "product" or clinical service lines. Since critical care typically has been viewed as a service provided by a hospital, and not a product line, business plans have not historically been developed to expand and promote critical care. The major focus when examining the finances of critical care has been cost reduction, not business development. We hypothesized that a critical care business plan can be developed and analyzed like other more typical product lines and that such a critical care product line can be profitable for an institution. DESIGN: In-depth analysis of critical care including business planning for critical care services. SETTING: Regional academic health center in southern New Jersey. SUBJECTS: None. INTERVENTIONS: As part of an overall business planning process directed by the Board of Trustees, the critical care product line was identified by isolating revenue, expenses, and profitability associated with critical care patients. MEASUREMENTS AND MAIN RESULTS: We were able to identify the major sources ("value chain") of critical care patients: the emergency room, patients who are admitted for other problems but spend time in a critical care unit, and patients transferred to our intensive care units from other hospitals. The greatest opportunity to expand the product line comes from increasing the referrals from other hospitals. A methodology was developed to identify the revenue and expenses associated with critical care, based on the analysis of past experience. With this model, we were able to demonstrate a positive contribution margin of dollar 7 million per year related to patients transferred to the institution primarily for critical care services. This can be seen as the profit related to the product line segment of critical care. There was an additional positive contribution margin of dollar 5.8 million attributed to the critical care portion of the hospital stay of patients admitted primarily through other product lines or the emergency room. This can be seen as the profit related to the "hospital service" segment of critical care. This represented a total contribution margin of dollar 12.8 million, approximately 24% of the institution's entire contribution margin. This information was subsequently used to develop strategic plans to promote this product line. CONCLUSIONS: We were able to define the critical care product line, and we were able to demonstrate profitability through an analysis of revenue and expenses related to critical care services. Our experience suggests that the concept of critical care as a product line, in addition to a hospital service, may lead to a useful analysis of this new discipline. This plan provided a rational foundation for development of the operating and capital budgets for the health system.

Academic Medical Centers↗
PubMed2006

[Models and practical games in training the medical service officers to control the medical care quality].

The 3-component structure of the model of medical service quality (MSQ) control is proposed. The model reflects the functional dependence of qualitative parameters of military treatment-and-prophylactic institutions' (TPI) activities: Qn = f(Rn, Mn), where the independent variables are the following: Rn is the provision of n-TPI with resources, Mn is the level of administrative activities and Qn function is MSQ. It allows transferring to information-and-analytical modeling of TPI as the triad of indices that reflect the resource quality (cadre, financial, material and technical), management and medical-and-statistical indices of medical service quality. For each of the model's component the information-and-analytical indices and criteria of their assessment are proposed. The scenario of practical games is based on abovementioned peculiarities of the model and consists of logically interconnected and successively solved situational problems. The methods and problems described can be used during medical service officers' training, for studying TPI physicians, in educational process of some departments of military medical higher schools. The specific feature of proposed models and methods is their applicability both in educational process and in practical work.

Delivery of Health Care↗
PubMed1998

Managed care: US research evidence and its lessons for the NHS.

OBJECTIVES: To review the high quality US evidence on performance of managed health care organisations and the available US evidence on specific managed care techniques; namely, financial incentives, utilisation management and review, physician profiling and disease management. METHODS: Literature searches were conducted using numerous databases including Medline, Embase, the Social Sciences Citation Index and the National Health Service (NHS) Centre for Reviews and Dissemination library. For inclusion of evaluations of overall performance, studies had to use a comparison group (typically fee-for-service patients), make appropriate statistical adjustments for differences between groups, and be published in a peer-reviewed journal from 1980 forward. For assessments of techniques, less-demanding inclusion criteria reflected the paucity of generalisable literature; however, more current results were required (1990 forward). RESULTS: We identified 70 articles for systematic review, covering 18 dimensions of performance (e.g. utilisation, quality of care, consumer satisfaction, equity). The strength of the evidence varied by dimension. It was strongest for utilisation and quality. In general, managed care seems to reduce hospitalisation and use of high-cost discretionary services, to increase preventive screening, and to be neutral in terms of patient outcomes. As for specific techniques, we identified 19 articles for review, but limitations of these studies prevented our drawing any definite conclusions about techniques' effectiveness. This is an important, if somewhat negative, conclusion. CONCLUSIONS: Applying US evidence is complicated by an irrelevant comparator and a higher baseline of utilisation. Managed care brought Americans the familiar NHS practices of population-based health care and resource management through gatekeeping; hence, changes due to UK adoption of managed care techniques may be modest. US evidence should be used to generate hypotheses, not to predict UK behaviour.

Disease Management↗
PubMed1992

Adapting the SERVQUAL scale to hospital services: an empirical investigation.

Defining and measuring the quality of service has been a major challenge for health care marketers. A comprehensive service quality measurement scale (SERVQUAL) is empirically evaluated for its potential usefulness in a hospital service environment. Active participation by hospital management helped to address practical and user-related aspects of the assessment. The completed expectations and perceptions scales met various criteria for reliability and validity. Suggestions are provided for the managerial use of the scale, and a number of future research issues are identified.

Data Collection↗
PubMedDate not supplied

Effect of work-hour reforms on operative case volume of surgical residents.

PURPOSE: There has been much concern regarding the impact of work-hour reforms on the operative case volume of surgical residents. Operative case volume by PGY year and clinical rotation were examined to determine if changes in work hours affected residents' operative case volume. METHODS: A careful but aggressive plan of work-hour reduction was devised for the residency of the authors' institution with the goal to decrease work hours while maintaining optimal patient care and resident education, including operative case volume. Changes made included hiring physician extenders (PEs), decreasing call schedules to every fourth night (with the next day free from clinical activities-Q4) or call from home (HC), and night float rotation coverage for services (NF). Case volume before (academic year 2002) and after (academic year 2003) changes were compared by PGY year, for all residents and for specific rotations-private general surgery, which had changes of PE, HC, and NF for PGY5; PE, Q4 and NF for PGY1 and 10% exemption for work hours; Churchill service (a resident-run ward teaching service), which had changes of PE and Q4 for PGY5 and PGY1 and 10% exemption for work hours; and vascular surgery, which had HC and NF for PGY5. Total case volume on these services was likewise compared. Statistical analysis was by student t test. Operative case volume was measured with data from the resident-entered information on the ACGME Surgical Operative Log (SOL). Case volume for PGY4 residents could not be compared over this time period because of lack of access to archived data by PGY year for graduated residents through the ACGME SOL. Work hours before and after rotation changes were measured with an intranet-based monitoring system. This article is a retrospective review of the affects of these work-hour changes on operative case volume. RESULTS: Total case volume for the general surgical services (both private and Churchill) was unchanged over this period (5905 in 02, 5930 in 03), and likewise for the vascular service (1101 vs 1196). Overall, there was no change in mean operative volume per year for surgical residents in this program (231 cases in 2002, 246 cases in 2003; p = 0.61). For PGY5 residents, the case volume increased; 339 cases 02, 390 in 03, and p = 0.05. Mean case volume for PGY5 residents increased on the private general surgery service (136 in 02, 160 in 03, p = 0.03), but it remained stable on the Churchill service (137 in 02, 158 in 03, p = 0.39) and vascular service (65 in 02, 73 in 03, p = 0.42). For PGY3 residents, case volume remained stable (171 in 02, 187 in 03, p = 0.62), as it did for PGY2 and PGY1 residents (PGY2: 148 in 02, 121 in 03, p = 0.12; PGY1: 265 in 02, 246 in 03, p = 0.23). However, operative case volume for PGY1 residents did decrease on the private general surgery service (mean 52 cases per month 02, 43 cases per month 03, p = 0.07), while remaining stable on the Churchill service (mean 23 cases per month 02, 25 cases per month 03, p = 0.66). Average hours worked per week decreased significantly over the time period. Before work-hour reforms, residents' average work hours were as follows: PGY1 105, PGY2 97, PGY3 78.7, PGY4 111, and PGY5 92. After the changes, average work hours were PGY1 81.5, PGY2 77.7, PGY3 78.7, PGY4 75.5, and PGY5 75.9. CONCLUSIONS: Work-hour limitation can be devised to maximize resident education, optimize patient care, and maintain resident operative volume. Although some changes (HC, PE, NF) seemed to increase the operative case volume for PGY5 residents, others had no effect (Q4, HC). There does not seem to be a clear relationship between types of changes and case volume. At the PGY1 level, Q4 and PE changes decreased operative experience on 1 rotation but not on another, although the difference in this decrease seems clinically insignificant. Individualization of changes to meet the needs of specific rotations seems more important than specific changes in coverage pattern. Perhaps the most important finding is that changes can be made to bring work hours into compliance without materially effecting operative case volume.

Adult↗
PubMed2006

The effects of state parity laws on the use of mental health care.

OBJECTIVE: We used a quasiexperimental research design to measure the effect of state parity laws on the use of mental health care in the past year. METHODS: We pooled cross-sectional data from the 2001, 2002, and 2003 National Surveys on Drug Use and Health. Our sample included 83,531 adults 18 years of age or over with private health insurance stratified by the level of mental and emotional distress experienced in the worst month of the past year. We used a state and year-fixed effects approach to measure the effect of parity. Similar to a difference-in-difference analysis, the effect of parity was measured by comparing pre-/postchanges in mental health service use within states that switched active parity status to changes in service use within states that did not change parity status in the same calendar year. For each subgroup, we report predictions of the percentage point change in any mental health care use, prescription drug use, and outpatient care use resulting from parity laws. RESULTS: Depending on the time window used to define active parity status, we found that parity increased the probability of using any mental health care in the past year by as much as 1.2 percentage points (P<0.01) for the lower distress group and by as much as 1.8 percentage points (P<0.05) in the middle distress group. We found no statistically significant changes in service use for the upper distress group. Whether measured differences were attributable to changes in the use of prescription drug or outpatient care also depended on the definition of active parity status. CONCLUSIONS: Overall, the results of this study suggest that state parity laws succeeded in expanding access to mental health care for those with relatively mild mental health problems.

Adolescent↗
PubMed1995

Patient satisfaction and experience with health services and quality of care.

This article discusses the use of patient satisfaction and personal health care experiences as a measure of health care quality. It also presents a field-proven patient experience and satisfaction assessment methodology known as the Patient Experience Survey (PES) that has been employed throughout the country for the last decade. Finally, it offers recommendations and comments on the use of patient satisfaction data in quality assessment and improvement.

Data Interpretation, Statistical↗
PubMed1976

Reorganization of ambulatory health care in an urban municipal hospital. Primary care and its impact on hospitalization.

Ambulatory care services have been reorganized in a New York City hospital. A newly developed Neighborhood Family Care Center (NFCC) replaced the outpatient clinics. The NFCC and both inpatient and emergency services are totally integrated so as to overcome many of the deficiencies that previously existed in ambulatory care, such as inferior quality of care, minimal academic involvement, fragmentation of services, overspecialization, and unresponsiveness to patients' needs. A review of all patients admitted to the Adult Medical Service has shown a statistically significant decrease in admission rates for diabetic coma-acidosis, severe hypertension, congestive heart failure, cerebrovascular accidents, and severe asthma during the 18 months following the reorganization of ambulatory care. Analysis of cost effectiveness of these changes on the utilization of hospital beds indicates the potential for reduced expenditures of limited health care dollars.

Ambulatory Care↗
PubMed2004

Prenatal patients' views of prenatal care services: a medical center-based assessment of knowledge and intent to use support services.

BACKGROUND: Our objective was to ascertain the priority of prenatal support services from the perspective of high-risk patients. The relationship between patients' needs, and both knowledge of and intent to use services, was examined, while documenting factors associated with the intent to use available support services. METHODS: The authors of this study conducted a cross-sectional survey of 102 African-American women at a university-affiliated, urban-health center. Patients' priority support needs were compared to their knowledge of and intent to use support services using chi-square statistics. Logistic regression was used to determine factors independently associated with patients' intent to use 5 support services (substance abuse counseling, community referrals, health education, nutrition services, and social work services), while adjusting for potential socioeconomic confounding variables, knowledge, and need for services. RESULTS: Knowledge of existing services was independently associated with patient intent to use one or more support services (odds ratio 3.6; confidence interval 1.4-9.4). With each one-unit increase in parity, a 30% less odds (odds ratio 0.7; confidence interval 0.4-0.9) of using one or more support services occurred. CONCLUSIONS: Physicians should ensure prenatal patients' knowledge of support services at healthcare centers. Multiparity is inversely related to women's intent to use support services, independent of their knowledge of service availability.

Academic Medical Centers↗
PubMed1987

Queueing analysis: a useful planning and management technique for radiology.

Queueing analysis is a mathematical technique which is used for studying characteristics of queueing (waiting) for service. Recent development of improved software systems has made the technique easily available and versatile using a microcomputer. In this study the characteristics of examination time and interarrival time were determined for an emergency room radiology service, and two examples were analyzed that demonstrate the usefulness of queueing analysis in radiology. In the first example the effects of a 5% annual increase in patients on waiting time are shown, while the second example shows the use of the technique for cost analysis. Radiologists and medical administrators should be aware of the availability and value of queueing analysis for department planning and management.

Appointments and Schedules↗