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PubMed2006

Performance-based budgeting in the public sector: an illustration from the VA health care system.

This paper estimates frontier cost functions for US Department of Veterans Affairs (VA) hospitals in FY2000 that are consistent with economic theory and explicitly account for cost differences across patients' risk, level of access to care, quality of care, and hospital-specific characteristics. Results indicate that on average VA hospitals in FY2000 operate at efficiency levels of 94%, as compared to previous studies on US private sector hospitals that average closer to 90% efficient. Using these cost frontiers, management systems potentially could be implemented to enhance the equitable allocation of the VA medical care global budget and systematically distribute funds across hospitals and networks. The paper also provides recommendations to improve the efficiency of delivering health care services applicable to public sector organizations.

Benchmarking↗
PubMed1979

Charging for hospital pharmaceutical services: flat free based on the medication record.

A 200-bed hospital's change in pricing drug products from a cost-plus-fee system to a flat fee per dose based on the medication administration record (MAR) is described. With the flat-fee system, drug charges are not recorded when the drug is dispensed by the pharmacy; data for charging doses are obtained directly from the MAR forms generated by the nursing staff. Charges are 55 cents per oral or suppository dose and $3.00 per injection dose. Drugs administered intravenously, topical drugs, injections costing more than $10.00 per dose, and miscellaneous nondrug items are still charged on a cost-plus-fee basis. Man-hours are saved in the pharmacy department because of the elimination of the pricing function and maintenance of price lists. The need for nursing staff to charge for any doses administered from emergency or Schedule II floor-stock supplies is eliminated. The workload for business office personnel is reduced because the number of individual charges is less than with the cost-plus charging system. The system is accepted by patients and third-party payers and has made a complete unit dose drug distribution system possible at lower cost.

Fees, Pharmaceutical↗
PubMed2005

Introduction of picture archiving and communication system at The Townsville Hospital.

The performance of a medical imaging department (MID) can be judged by the timing and availability of an image and its report to the treating physician, as this can impact on the patient's treatment, as well as the length and cost of a patient's hospitalization. The use of digital imaging has dramatically improved report turnaround time. In October 2001, The Townsville Hospital (TTH) was opened as a 460 bed greenfield site and as part of the installation a picture archiving and communication system, including web distribution of images and reports to wards and clinics, was included. This retrospective analysis of the MID at TTH is the first data on departmental productivity and individual workload and how these have changed since the hospital's opening 2 years ago, with some ideas for further improvement.

Efficiency, Organizational↗
PubMed1995

ASHP national survey of hospital-based pharmaceutical services--1994.

The results of a national survey of pharmaceutical services in federal and nonfederal community hospitals conducted by ASHP during summer 1994 are reported and compared with the findings of earlier ASHP surveys. A simple random sample of community hospitals (federal and nonfederal) was selected from hospitals registered by the American Hospital Association. A questionnaire was mailed to each director of pharmacy. The adjusted gross sample size was 896. The net response rate was 44% (393 usable replies). The mean number of hours that respondents' pharmacies were open per week for inpatient services was 107.5. An increasing number of pharmacy directors were managing other departments within the institution. Of respondents, 18% indicated that a patient-focused-care model was in place. Complete unit dose drug distribution was offered by 92% of respondents, and 67% provided complete, comprehensive i.v. admixture services. A total of 29% provided decentralized inpatient pharmaceutical services. Automation of some type to support drug distribution was used by 55%. Provision of ambulatory care pharmaceutical services was indicated by 82% of nonfederal hospitals and by 98% of federal hospitals. Home infusion therapy services were offered by 27% of respondents. Some 89% had a computerized pharmacy system. The most commonly offered clinical pharmacy services for inpatients were drug-use evaluations and programs to monitor drug therapy, adverse drug reactions, and drug-food interactions. About half of respondents indicated that they did not provide pharmaceutical care. One third indicated that pharmacists had the authority to write drug orders or prescriptions. Pharmacokinetic consultations were provided by 65% and nutritional-support consultations by 35%. Of nonfederal respondents, 86% participated in quality assurance for inpatient dispensing and 28% did so for ambulatory care dispensing. A well-controlled formulary system was in place at 60% of the hospitals. About 74% of inpatient pharmacy expenditures went for drugs and fluids, 20% for staff activities, and 6% for other noncapital expenditures. Almost half of respondents indicated that staff reductions had occurred. About 9% of nonfederal hospitals had an ASHP-accredited residency program. The 1994 ASHP survey revealed a continuation of growth in some areas of hospital pharmacy (clinical services, computerization, formulary management techniques, and residency programs) and identified static areas (ambulatory care services, scope of drug distribution services, and quality assurance programs) that should be addressed by pharmacy leaders.

Ambulatory Care↗
PubMed2003

Emergency healthcare process automation using workflow technology and web services.

Emergency healthcare delivery involves a variety of interrelated activities performed from the time of a call to the ambulance service until the time of patient's exit from the emergency department of a hospital. As these activities can be viewed as parts of inter-organizational healthcare processes that involve at least two organizations (e.g. an ambulance service and a hospital), there is a need to provide the appropriate technological infrastructure for automating and managing these processes even in cases where the organizations involved use heterogeneous systems to support their internal services. Web-based workflow systems in conjunction with web services present a new way for service-oriented integration (SOI) of disparate systems and for developing distributed applications within and between organizations. Thus, process automation with the use of web services can provide an appropriate infrastructure for the integration of pre-hospital and in-hospital emergency healthcare. A prototype development of such a system is presented in this paper.

Ambulances↗
PubMed1985

Implementation and evaluation of a decentralized pharmacy service.

The implementation of a decentralized pharmacy service on a 59 bed acute patient care area was evaluated. Over a ten-month period four criteria were used to evaluate the decentralized service: (1) reported medication errors, (2) reported medication discrepancies, (3) drug costs per patient day and (4) availability and utilization of drug information. Data was collected over the ten month period for all criteria except for drug information interactions in which a self reporting data card was utilized over a six week period. Medication errors and medication discrepancies decreased by 12.5% and 80% respectively on the pilot floor as compared to the hospital (+14.8%, -18.0% respectively). Drug costs per patient day increased the least on the pilot floor (+9.1%) as compared to other areas in the hospital (range: 10.8% to 49.3%). Seventy-six percent of drug information interactions occurred on the pilot floor as compared to the central pharmacy accounting for 24% of interactions for all other hospital areas combined. It is concluded that a decentralized pharmacy service can make a significant impact on a unit dose drug distribution system by reducing medication errors, discrepancies, drug costs and by increasing the utilization of drug information resources.

Centralized Hospital Services↗
PubMedDate not supplied

[Variability in hospital care. Nasosinus surgery in Spain].

OBJECTIVES: To describe variations in the management of nasosinus disorders among the Autonomous Communities and hospitals of Spain. METHODS: We analyzed the Minimum Basic Data Set of the public health system from 1998-2000 for the diagnoses of nasosinus polyps and chronic sinusitis. We studied the distribution by regions of the rate of hospitalizations and of 4 indicators of quality of care and efficiency: mean length of stay, percentage of discharges without surgery, percentage of functional endoscopic sinus surgery and surgical complications. A cluster analysis was performed to classify hospitals according to the values of these indicators. RESULTS: We analyzed 13061 discharges from 263 hospitals. Marked differences were found in age-adjusted hospitalization rates by regions. Cluster analysis classified the centers with more than 10 annual discharges in 3 categories: a) 32 hospitals in which the 4 quality indicators were above average; b) 35 hospitals in which 3 of the indicators were below average, and c) 74 hospitals in which 2 indicators were above average and 2 indicators were below average. CONCLUSIONS: Marked interregional variations were found in hospitalization rates, as well as in the characteristics of management of nasosinus disorders in Spanish hospitals. The centers examined could be grouped into three clearly defined patterns according to indicators of quality of care and efficiency.

Adolescent↗
PubMed2001

A hospital-based multicentric study results on gestational trophoblastic disease management status in a developing country.

OBJECTIVE: To determine the clinical management of gestational trophoblastic disease in Turkey. MATERIAL AND METHODS: An inquiry form was sent to 55 health centers including university hospitals, maternity hospitals with residency programs and maternity hospitals without residency programs in 1997. The inquiry consisted of questions about the type of classification systems in use, distribution of cases according to those classifications, use of prophylactic chemotherapy and its indications, and drug preference for single-agent or combined chemotherapies. RESULTS: The overall response rate to the conducted inquiry was 47.1%. A clinical classification system was identified in 60% of the hospitals in Turkey. Generally, methotrexate was the most used single-agent chemotherapy. With regard to first-line combined chemotherapy, MAC (methotrexate, antinomycin-D, cyclophosphamide) was the preferred combination. EMA-CO (etoposide, methotrexate, actinomycin-D, cyclophosphamide, vincristine) was the most common used second-line chemotherapeutic regimen. CONCLUSION: Due to insufficient data acquisition from all the medical centers and a lack of national population-based studies, it is difficult to draw a conclusion with respect to the interpretation of the data about the management protocols of gestational trophoblastic disease.

Adult↗
PubMed2003

Enabling virtual emergency healthcare enterprises using Web services.

Emergency healthcare delivery involves a variety of activities performed from the time of a call to the ambulance service till the time of patient's disposal from the emergency department of a hospital. As these activities are performed in at least two organizations (i.e. ambulance service and hospital) and they are interrelated to form inter-organizational healthcare processes, collaboration and coordination become a vital issue for patients and for emergency healthcare service performance. Web-based workflow systems in conjunction with web services present a new way for service-oriented integration (SOI) of disparate systems and for developing distributed applications within and between organizations. Thus, through process automation and the use of web services ambulance service and hospital emergency departments can automate their operations by making information available where and when needed and by providing an infrastructure for the integration of pre-hospital and in-hospital emergency healthcare. A prototype implementation of this approach is presented in this paper.

Computer Systems↗
PubMedDate not supplied

[Current problems of rural public health reform].

Main directions of the rural public health improvement are outlined and substantiated: creation of a regional network of medical institutions with integration of territorial public health systems, development of hospital-replacing technologies which can be realized in the rural regions, transfer to the general practitioner model with rational distribution of functions between specialists, medics and paramedics, and introduction of automated managing systems.

Delivery of Health Care, Integrated↗
PubMed1994

Uncompensated hospital care payment and access for the uninsured: evidence from New Jersey.

OBJECTIVE: We assess the impacts of New Jersey's payment for hospital uncompensated care on access for the uninsured. DATA SOURCES: Uncompensated care charges and other data were obtained from audited reports maintained by the New Jersey State Department of Health. Other data sources include the AHA Annual Survey and the Bureau of Labor Statistics. The sample includes 80 of 88 acute care hospitals in the state for 1979 to 1987. STUDY DESIGN: This study used a pre- and postdesign to assess the impacts of the introduction of uncompensated care payment. Both descriptive and multivariate analyses were used. Key variables include hospital ownership and teaching characteristics; the labor force composition; and the level of government funding for public health insurance. PRINCIPAL FINDINGS: The overall level of uncompensated hospital care increased markedly in New Jersey during the period 1979 through 1987. However, this trend can be attributed to variables other than the new payment system, including increased demand for uncompensated care. The program did result in a more even distribution of uncompensated care across hospitals. The financial condition of hospitals providing the largest share of this care also improved, ensuring continued access. CONCLUSIONS: Funding of uncompensated care via hospital payment regulation did not increase its overall provision. However, improved access was achieved as opportunities for the uninsured to receive care were made more widely available.

Financial Management, Hospital↗
PubMed1997

Using software agents to maintain autonomous patient registries for clinical research.

A software agent is an application that can function in an autonomous and intelligent fashion. We have used mobile software agents to maintain clinicians' patient research databases (patient registries). Agents were used to acquire data from the clinician and place it into the registries, copy data from hospital databases into the registries, and report data from the registries. The agents were programmed with the intelligence to navigate through complex network security, interact with legacy systems, and protect themselves from various forms of failure at multiple levels. To maximize the separation between our system and the hospital information infrastructure we often used Java, a platform-independent language, to program and distribute our software agents. By using mobile agents, we were able to distribute the computing time required by these applications to underutilized host machines upon which the registries could be maintained.

Databases as Topic↗
PubMed2000

Cardiac manifestations of fatal enterovirus infection during the 1998 outbreak in Taiwan.

BACKGROUND: An outbreak of hand-foot-and-mouth disease caused by enterovirus infection occurred in Taiwan in 1998 and more than 70 infants and children with fulminant courses died. We compared the cardiac manifestations of fatal cases with patients who survived the enterovirus infection. METHODS: A total 187 patients with enterovirus infection were treated at Taichung Veterans General Hospital between April and June 1998. Enterovirus infection was diagnosed by history, clinical features, polymerase chain reaction study and/or viral culture. Cardiac examinations including complete physical examinations, electrocardiography and echocardiography were performed on seven cases (group I) with or without central nervous system (CNS) involvement, 30 patients with CNS involvement (group II), and 150 patients without CNS involvement (group III). RESULTS: There were no significant differences in sex distribution, days of fever, heart rate, systemic blood pressure or time from the onset of symptoms to hospital admission among the three groups. All group I patients had features of acute congestive heart failure, pulmonary edema and neurologic signs except one who presented with right-sided heart failure and neurologic signs. The echocardiographic findings of group I were a lower fractional shortening, lower ejection fraction, and more severe and higher incidence of mitral regurgitation (p < 0.01) than in groups II and III, but there were no significant differences in end-systolic wall stress, left ventricular end-diastolic internal dimension and incidence of pericardial effusion among the three groups. CONCLUSIONS: We conclude that seven infants and children (group I) died due to either severe cardiomyopathy or encephalopathy. The possible pathogenesis of enterovirus infection leading to death is reviewed and analyzed.

Brain Diseases↗
PubMed1994

ASHP national survey of pharmaceutical services in federal hospitals--1993.

The results of a national mail survey of pharmaceutical services in federal hospitals conducted by ASHP from May to July 1993 are reported. Mailing lists were compiled of all Air Force, Army, Navy, Public Health Service, and Department of Veterans Affairs (VA) hospitals, as well as some federal prison hospitals. Questionnaires were mailed to each chief of pharmacy. The adjusted gross population size was 326. The net response rate was 76%. Complete unit dose drug distribution was offered by 85% of respondents, and 83% offered complete, comprehensive i.v. admixture programs. About half of the pharmacies provided decentralized services. Over 99% provided services to ambulatory care patients. A computerized pharmacy system was present in 99% of the departments. More than 95% of hospitals participated in adverse drug reaction, medication error management, and drug-use-evaluation programs. A total of 93% provided drug therapy monitoring, and 89% provided patient education. About 70% provided written documentation of pharmacist interventions in the medical records, and 57% participated in drug research. A total of 42% provided pharmacist-managed drug clinics, 41% participated in drug management of medical emergencies, 30% provided written medication histories, and 30% provided drug therapy management planning. Pharmacokinetic consultations were provided by 64% of departments. About 90% had a well-controlled formulary system and prescribing restrictions. Therapeutic interchange was practiced by 64%. Diversified pharmaceutical services included telephone or mail-in refill services (80%), mail-out pharmaceutical services (58%), and services to long-term-care facilities (49%). A total of 70% of the hospitals were affiliated with a pharmacy school. The first ASHP national survey of pharmaceutical services in federal hospitals showed that comprehensive distributive and clinical services were offered by most of the facilities.

Drug Information Services↗
PubMed1995

A server architecture for ambulatory patient record systems.

Baylor College of Medicine is developing the Collaborative Social and Medical Services System (CSMSS) to provide a computerized patient record (CPR) system for the Teen Health Clinics (THC) [1]. The THCs consist of five geographically distributed clinics providing health care and social services to teenagers in the Harris County Hospital District. The CSMSS is the first application built upon the Ambulatory Systems Architecture (ASA) [2]. The ASA is aimed at providing an architecture and application framework for the development and deployment of CPR systems in ambulatory care settings. This paper describes the ASA server architecture.

Ambulatory Care↗
PubMed2001

Intranet and radiology: a critical appraisal of radiological applications of Intranet technology.

The World-Wide Web (WWW or Web) is the service which led to the huge popularity of the Internet by making it user friendly. Already in the early years of the Web, this technology was also used to make internal information systems easier to use and hospitals and departments set up "Intranets". An Intranet consists of a Web Server which is installed within a local area network (LAN) and allows information retrieval with a Web browser. This paper highlights the different fields of Intranet applications in radiology and in the hospital and focuses on systems for organisational issues as well as for patient data distribution. While an Intranet can be a solution for many problems, not only in radiology, it is accompanied by serious threats and common misunderstandings which are discussed.

Computer Communication Networks↗
PubMed2005

Functional mitral regurgitation predicts 1-year mortality in elderly patients with systolic chronic heart failure.

BACKGROUND AND AIM: Mitral regurgitation (MR) has been demonstrated to be a powerful predictor of adverse outcome in middle-aged patients with chronic heart failure (CHF). In this study, we sought to define the prognostic impact of functional mitral regurgitation in a population of elderly patients with systolic CHF. METHODS: One hundred seventy-five outpatients aged >70 years with validated CHF and left ventricular ejection fraction <40% underwent clinical and echocardiographic evaluations at baseline. Mitral regurgitation was diagnosed by Color Doppler and quantified in 5 categorical values using a 0-4+ grading system. Outcome measures included 1-year mortality and hospitalization for worsening CHF. RESULTS: The distribution of patients according to the 5 different degrees of MR detected at baseline was: absent=11%, 1+=31%, 2+=38%, 3+=16%, 4+=4%. The relationship between MR and mortality was direct and approximately linear (r=0.39, p=0.00001). The prevalence of death in the 5 subgroups was 0%, 7%, 15%, 45%, 57%, respectively. Multivariate logistic regression analysis showed that MR was the strongest predictor of death (OR 4.47, 95% CI 1.50-13.0), independently of the presence of diabetes mellitus, older age and larger left ventricular end-diastolic volume. No association was found between MR and hospitalization for worsening CHF (r=0.08, p=0.41). CONCLUSIONS: This study establishes the direct and independent relationship between MR severity and one-year mortality among elders with systolic CHF. Conversely, MR does not provide useful information regarding the risk of subsequent hospitalization for worsening CHF.

Aged↗