Standardized Telephonic Case Management in a Hispanic Heart Failure Population

Background: Heart failure (HF) is as common in Hispanic as it is in non-Hispanic populations. However, there do not appear to be any published reports of HF disease management programs which include Hispanic populations. Objective:To test the effectiveness of a standardized telephonic disease management intervention, Pfizer Inc.’s At Home With Heart Failure?, in decreasing acute care resource use and cost in Hispanic patients with HF. Participants and methods: A factorial design was used to analyze data obtained in a randomized controlled clinical trial. Patients with HF were enrolled in the trial when admitted to hospital, randomized to the intervention or usual care control groups, and followed for 6 months. Of the 358 participants, 93 (26%) were Hispanic (35 in the intervention group, 58 in the usual care group). Data were analyzed to determine if comparable decreases in acute care resource use were evident in Hispanic and non-Hispanic intervention group patients. Intervention: Registered nurses telephoned patients after hospital discharge to provide advice, solve problems, encourage adherence, and facilitate access to needed services. Results: Acute care resource use was lowered as effectively in the Hispanic patients as in the non-Hispanic patients, despite significant between-group differences in education, income, and living situations. When a fully crossed (language by group) analysis was conducted, no significant differences were found between the Hispanic and non-Hispanic intervention groups. However, in most categories there was a trend towards lower resource use in the Hispanic intervention group. The cost of inpatient care was more than $US1000 (2000 values) less in the Hispanic than the non-Hispanic intervention group. Conclusion: The results of this study suggest that Hispanic patients with HF are receptive of, and responsive to, a case management intervention provided in a culturally competent manner, despite differences in cultural views on chronic illness and self-care as discussed in the literature.     

An Independent Practice Association-Supported Disease Management Program

Background: Disease management has been shown to improve outcomes in patients with chronic diseases such as coronary artery disease (CAD). Yet Independent Practice Associations (IPA) have expressed concern with the promise of disease management (DM) to improve patient outcomes. Managed care initiatives promote the use of case management, DM, and the use of practice guidelines. However, some physicians think that this may impinge on their autonomy. Objective: To demonstrate that integration of an independent DM company in conjunction with an IPA enhances compliance with guideline-recommended medications, reduces morbidity and improves quality of life in patients with CAD. Design: IPA physicians and an independent DM company were contracted with a health plan to provide care to patients with current or recent CAD. The DM company facilitated physician-ordered guideline implementations, provided member education, facilitated medication compliance, and collected all data, using a decision support software system. Collected data included: hospital utilization, quality of life, and reported medications and associated compliance rates. Setting: A large IPA group in the Midwest region of the US. Study Participants: Sixty-five high-risk patients with CAD who were active in the DM program as of April 2, 2002 and in the program for at least 180 days were included in the analysis. Results: The average age of the patients was 73.4 years and 54% were male. The mean duration in the DM program was 10 months (median = 7 months). For those patients (n = 54) with baseline and follow-up mental and physical quality-of-life (QOL) scores, mental QOL scores increased by 2.6% (not significant) and physical QOL scores increased by 11% (p < 0.05). In the 19 patients in the program for 12 months, a trend of reduced hospital admissions was observed. Medication compliance at baseline versus the most recent status for eligible patients was as follows: antihyperlipidemic therapy 59.7% versus 67.7%; β-adrenoceptor antagonist therapy post-myocardial infarction 60.0% versus 66.7%; and antiplatelet therapy was maintained at 98.4%. Conclusions: In spite of the small sample size and relatively short study duration, these results indicate that an integrated DM program may enhance clinical outcomes for patients and reduce hospital admissions.     

Treatment of Pneumonias in a Managed-Care Organisation

Objective: To evaluate a pneumonia disease management programme in a naturalistic setting. Design and Setting: A 300 000 member managed-care organisation introduced an antibacterial treatment guideline designed to change antibacterial prescribing by physicians. A relational database was created to measure changes in healthcare resources, use of antibacterials and health event profiles. One year of data before and after promoting the treatment guideline was compared. Intervention: The primary disease management intervention was the promotion of the guideline through mailings and face-to-face interventions by 2 disease management specialists. Participants: All patients with pneumonia diagnoses on the medical claims database were included in the analysis. Results: The study demonstrated that medical costs increased by 5 to 10% after the treatment guideline was implemented. Health event analysis demonstrated changes in antibacterial prescribing and average cost per antibacterial selected. In both years, the highest success rate was with the amoxicillin group. Although there were fewer patients, doxycycline also had success rates of at least 70%. The econometric model demonstrated that holding other variables constant, including patient age and the presence of any comorbidities, treatment with amoxicillin was associated with a statistically significant reduction in health event costs. Conclusions: The study identified the need for validating treatment guidelines with results from actual practice. The data also demonstrate the use and importance of measuring clinical and economic outcomes from disease management interventions by using databases readily available within most managed-care organisations. In addition, the econometric model was useful in comparing different drug groups with these retrospective data.     

Outcome Measures of Efficacy Associated with a Web-Enabled Asthma Self-Management Programme

Objective: To assess the efficacy of a World Wide Web—enabled asthma self-management intervention on quality-of-life indicators among self-selected participants with asthma. Design: A quasi-experimental design was used in which quality-of-life outcome indicators were derived from the Mini Asthma Quality of Life Questionnaire (MiniAQLQ); this self-administered instrument includes a global score and 4 domain scores (emotional status, environmental triggers, symptoms and activity restrictions). Baseline and re-measure scores were statistically tested for change over a 6-month period of engaged participation. Intervention: The web-enabled interactive MyAsthma? intervention which builds on patient-centred self-management skills based on education, appropriate medication usage and symptom control. Participants: A national sample of 437 patients with self-reported symptoms of mild intermittent to severe asthma who registered as participants in MyAsthma?. Engaged use of the Internet for building asthma self-management skills was examined as a construct of participation in the intervention. Main outcome measures and results: Based on participants’ self-reported responses, high volume users of the web-enabled intervention reported improved quality-of-life scores that were both statistically and clinically significant. Participants with a documented number of site visits greater than the group median (17 or more visits over the 6-month period of observation) were 1.6 times more likely to report an improvement in their global MiniAQLQ score compared with participants with less than the median number of visits [adjusted odds ratio (OR) = 1.60, 95% confidence interval (CI) 1.03, 2.48]. A similar effect associated with website visit frequency was observed with respect to participants’ emotional subscales scores (adjusted OR = 1.76, 95% CI 1.09, 2.85) and activity subscale scores (adjusted OR = 1.64, 95% CI 1.06, 2.55). Conclusions: Based on pre-/post-test measures derived from a standardised and validated instrument, the web-enabled MyAsthma? self-management programme was associated with a positive change in patient reported scores of quality of life. Although these results are preliminary and not derived from rigorously controlled clinical trials, the strength of this evidence is noteworthy nonetheless. We acknowledge that self-selection bias in observational studies is a threat to both internal and external validity. Research based on randomised clinical trials is needed to further document the effects of web-enabled disease management interventions targeting patients with asthma.     

Technology-Based Disease Management

Background: Although information technology applications are part of all disease management programs, most programs involve extensive nurse interventions. Objective: To present clinical and financial outcomes data from One Health Plan’s technology-based program(s), which provide asthma, diabetes mellitus, and cardiovascular care to over 90 000 participants. Methods: The programs are designed to support the health plan’s patient population with asthma, diabetes, congestive heart failure, and coronary artery disease. Data from the health plan’s medical and pharmaceutical claims were used to identify the total patient population. The program(s) use extensively mail, Internet, and Interactive Voice Response (IVR) services with only limited nurse interventions to engage the patients and intervene in their care.Patient engagement consisted of an introductory mailing supported by follow-up mailing. The objective was for the targeted patient to respond by completing a survey on paper, over the Internet, or via IVR. The CareResults ^SM program, uses participant-reported information to risk stratify the population and to track patients progress as part of the measurements of the program’s results. The risk stratification algorithm scores the participant’s clinical status and ability to self-manage their care. Both dimensions impact the participant’s risk score, which in turn determines the follow-up activities. CareResults ^SM mails a personalized feedback booklet as part of a care kit to educate the participant on the current treatment protocols. The goal is to help the participant recognize good healthcare and teach them to work with their physicians to achieve this. Results: The programs demonstrate that improved outcomes can be rapidly achieved for a large number of participants without costly nurse interventions. One Health Plan offered the program to over 250 000 members in the year 2000 and had over 93 000 elect to participate. Improved clinical outcomes were demonstrated for asthma, diabetes, and the cardiovascular diseases. Highlights include a 55.2% increase in candidates with diabetes receiving glycosylated hemoglobin A_1c test, and a 27% self-reported increase in the use of low-dose aspirin for participants with a cardiovascular condition. Financially, current analysis comparing 1999 costs to 2000 costs indicates that the program’s per member per year net savings ranged from $US300 to $US1000 depending on the specific disease state. In all cases, the programs demonstrated a significant positive gross saving. Conclusion: One Health Plan’s experience demonstrates that the technology-based CareResults ^SM program produces positive financial and clinical results without significant nurse interventions.     

The Development of a Tool to Assess Quality of Cost Estimates

Objective: To develop and implement a quality assessment instrument to evaluate cost estimates in economic evaluation studies. Design and setting: The assessment instrument was devised through a consensus process. The instrument was developed in the process of estimating a national set of provincial standard costs for healthcare services in Canada. Participants: All healthcare providers for a variety of services including public health, inpatient acute care, ambulatory care, physicians, pharmaceuticals, blood and ambulance services, and workers’ lost productivity. Main outcome measures: An assessment form which evaluated estimates for the full cost of resources; the appropriate inclusion of resources and resource prices; the degree of detail in the unit of measurement; basis of evidence; and the sample of providers from which cost estimates were generated. Results: When applied to existing cost estimates, a wide variation in quality was observed between service categories and provinces. Inpatient hospital, physician services, and drugs had high quality estimates; public health, nursing home, and home care had lower quality estimates. Conclusions: This quality assessment instrument can be used to target deficiencies in cost estimates and to identify administrative units which are leaders in the field, and hence which can serve as role models for further development of these data.     

Insulin Therapy in Patients with Type 2 Diabetes Mellitus

Objective: To support policy-making for patients with diabetes mellitus we compared the costs and effectiveness of initiation of insulin therapy in patients with type 2 diabetes mellitus in 2 settings in The Netherlands. Design: Retrospective cohort study. Setting: A shared-care setting and an outpatient care setting of a university hospital. Both settings are located in Amsterdam, The Netherlands. Patients: All patients with type 2 diabetes mellitus above 40 years of age who were transferred to insulin therapy in 1993 in both settings. Intervention: Initiation and monitoring of insulin therapy in patients with type 2 diabetes mellitus. Study perspective: Healthcare sector. Main outcome measures: Baseline and 12 months glycosylated hemoglobin (HbA_1c) values and fasting blood glucose levels, and direct healthcare costs of insulin therapy. Costs were expressed in 1996 Dutch guilders (NLG) [NLG1 = 0.5 US dollars ($US)]. Results: In the shared-care setting (n = 57) the per patient healthcare costs during 1 year of follow-up averaged NLG2467. In the secondary care setting (n = 45) healthcare costs averaged NLG2740. A sensitivity analysis demonstrated that healthcare costs per patient were in the same range in both settings, ranging from NLG2000 to about NLG3400 ($US1000 to $US1700). Mean HbA_1c values fell from 9.1 to 7.9% (shared-care setting; p < 0.05) and from 10.2 to 8.2% (secondary care setting; p < 0.05). The percentage of patients with poor glycemic control (HbA_1c >8.5%) decreased from 56 to 30% (shared-care setting) and from 76 to 36% (secondary care setting). The percentage of patients with good glycemic control (HbA_1c <7%) increased from 4 to 23% (shared-care setting) and from 2 to 18% (secondary care setting). Conclusions: The study shows that in the first year of insulin therapy in patients with type 2 diabetes mellitus, acceptable glycemic control (HbA_1c >8.5%) can be attained in the majority of patients in both a shared-care and a secondary care setting, at comparable low average costs per patient.     

Behavioural Medicine Group Intervention for High-Utilising Somatising Patients

Objective: To determine the clinical effectiveness of a standardised behavioural medicine group intervention when implemented by different group leaders in 7 geographically diverse healthcare organisations (HCOs). Design: This study used longitudinal data collected for quality assurance purposes. Patients were asked to complete questionnaires measuring presenting problems (Initial Health Status questionnaire), health and functional status [Short Form-36 Health Survey (SF-36)], and physical [Medical Symptom Check List (MSCL)] and psychological distress [Brief Symptom Inventory (BSI)]. Intervention: The Personal Health Improvement Program? (PHIP) designed to treat somatising high utilisers of general medical services. Participants: Patients enrolled in PHIP courses at 7 different HCOs. Complete data were collected from 1194 patients before the course, 787 immediately after the course and 467 at a 6-month follow-up. 39% of patients who finished the course completed questionnaires at all 3 time-points (times 1, 2 and 3, respectively). Of the 467 patients who provided data at all points, complete information was obtained for 356 patients (the study sample). Main outcome measures and results: Patients’ symptoms of anxiety, depression, hostility and somatisation, as well as overall psychological distress improved (p ≤ 0.001) after the course and at follow-up as determined by repeated measures by group analysis of variance (ANOVA). Results were similar for health status (SF-36), with significant improvements in all of the functional health measures between time 1 and time 3. The majority of participants completing the PHIP reported long term reductions in patterns of distress commonly associated with high levels of medical utilisation. Participants also reported improvements in functional status. In addition, the value of the programme was highly rated by participants. Conclusions: Despite the lack of a control group, the consistency of these findings across the sites are likely to be due to the clinical effectiveness of the course content. The PHIP is an effective and standardised programme, which can be taught to leaders in a short period of time and implemented across very different sites to different populations.     

An Inner-City Asthma Disease Management Initiative

Objectives: The purpose of this study was to evaluate the effects of a recently implemented disease management programme [Asthma Control and Education Program (ACE)] on patient outcomes (clinical and functional) and on resource utilisation in socio-economically disadvantaged (and largely Hispanic) individuals with asthma treated at Hartford Hospital. Design and Setting: Using standardised measures (i.e. the Health Status Questionnaire [HSQ] and the Center for Epidemiologic Studies Depression Scale) and conducting serial assessments the investigators determined: (i) functional status at intake and follow-up; (ii) change in the level of illness severity over time; (iii) patientss’ acquisition of self-management skills; and (iv) the type and frequency of acute care services utilised pre- and post-enrolment in ACE. Patient Population:The study participants consisted of consenting individuals, aged 18 years or older, enrolled in ACE from 1 January 1997 to 30 September 1998. Each individual had a comprehensive intake interview (data collected included clinical and financial status) followed by 3 educational sessions. Results: While only 34.7% (n = 282) of the 813 patients referred from Hartford Hospital to physicians or emergency department services elected to participate in the programme, 60% of participants completed the educational sessions. 73% of these enrollees returned for the 3-month follow-up.On the HSQ, the mean Physical Composite Summary (PCS) scores increased from 33.3 ± 10.01 at baseline to 41.6 ± 11.48 at the 3-month follow up and 45.3 ± 10.30 at the 6-month follow-up. In an analysis using only those patients (n = 50) with HSQ scores at baseline and 3- and 6-month follow-ups, there were statistically significant increases in both the PCS and the Mental Composite Summary scores (p < 0.001).For the 68 patients with severity data at baseline, 3 months and 6 months there was a statistically significant improvement over time (p < 0.001). For example, 4.4% had severe disease at 6 months versus 69.1% at baseline. A subset of 73 patients for whom pre-ACE data were available realised a 37% reduction in emergency department use and a 52% reduction in in-patient visits. Conclusions: The evaluation of disease management programmes requires outcomes data. The results of this study of an asthma disease management programme indicate there was an improvement in overall functioning, illness severity, self-management, and utilisation of inpatient and emergency department services. Although a cause and effect relationship could not be assumed, the results suggest that the disease management model is an effective one for the studied population of inner-city patients, socioeconomically disadvantaged individuals previously identified as high utilisers of healthcare services and as having significant environmental exposures problematic for patients with asthma. As currently designed, however, this programme does not address the healthcare needs of the large number of referred patients who choose not to enrol or the enrollees (40%) who do not complete the education and follow-up sessions.     

Methods Aimed at Improving Asthma Care and Outcomes Management

Objectives: To compare the experience of one managed care organization (MCO) [Anthem Blue Cross and Blue Shield Midwest Region] to the experience of a reference group of 15 other MCOs participating in a study designed to test the usefulness of outcomes management information in developing and implementing interventions to improve the quality of care in asthma. Study design: Prospective study. Patients and methods: Adult patients with moderate or severe asthma enrolled in sixteen participating MCOs who completed an initial baseline survey in 1993 and follow-up surveys in 1994 and 1995. Data analyses focused on differences between Anthem and the reference group at each round of data collection as well as longitudinal analyses of changes over time. Results: Baseline data suggested some deficiencies in care at all MCO sites. Cross-sectional comparisons between Anthem and the reference group revealed statistically significant differences in outcomes measures (hospitalization and emergency room visits, canceled activities per month because of asthma, asthma attacks per month, and work days lost in the past month). Improvements in these outcomes were reported over the subsequent two years. Patients at Anthem reported a significantly greater increase in peak flow meter (PFM) possession than did those in the reference group (p = 0.01) which may have resulted from an administrative change that made PFMs a funded item. However, other interventions (e.g. educational programs) may have also contributed to the improvements. Conclusions: This study illustrates the ability of MCOs to collect and use patient-reported outcomes data to monitor and improve patient care. Such information allowed this national group of participating MCOs to identify deficiencies in quality of care provided, design tailored interventions and measure the potential impact of these interventions on patient care.     

One-Year Outcomes from a Disease Management Program for Chronic Obstructive Pulmonary Disease

Objective: to present the results of our 1-year, telephonic disease management interventions for 349 patients with mild to severe chronic obstructive pulmonary disease (COPD). Methods: parameters measuring utilization of medical services, days lost from work, and quality-of-life measurements (utilizing the St. George’s Questionnaire) were determined for the 12-month period prior to enrollment of patients and compared with those observed during the 12-month participation in the program. Results: there was a statistically significant reduction in all utilization measurements and a statistically significant improvement in quality of life. Emergency room (ER) visits decreased by 57% (p < 0.001), hospitalizations by 53% (p < 0.001), intensive care unit admissions by 66% (p = 0.001), unscheduled office visits by 67% (p < 0.001), and oral antibacterial bursts by 48% (p < 0.001). Of the 114 employed patients, days missed from work were reduced by 77% (p < 0.001). The total saving from reduction in hospitalizations and ER visits was $US672 000. This was against an approximate cost of the program of $US223 500 (average of $US635 per enrollee). Costs associated with medications and physician visits were not obtained. Conclusions: these outcomes suggest that, with ongoing patient support, the provision of physical rehabilitation, and improved communication between those engaged in the healing process, it is possible to reduce utilization and overall healthcare expenditures and improve the quality of life for a population of patients with moderate to severe COPD. This intervention was both cost effective and medically effective. Our experience suggests that further trials of COPD disease management are warranted.     

The women made it work: fuzzy transitive closure of the results chain in a dengue prevention trial in Mexico

Background

A modified theory of planned behaviour (acronym CASCADA) proposes that Conscious knowledge precedes a change in Attitude, which in turn precedes positive deviations from negative Subjective norms, intention to Change, perception of Agency to change, Discussion of possible action, and Action itself. We used this as a results chain to investigate gender-specific behaviour dynamics in chemical-free dengue prevention.

Methods

Secondary analysis of the Mexican arm of a cluster randomised controlled trial used household survey data on intermediate outcomes of dengue prevention behaviour. We used a matrix of odds ratios between outcomes, transformed to a symmetrical range (?1, 1), to compute fuzzy transitive closure of the results chain for control and intervention clusters, then for male and female respondents separately in each group. Transitive closure of a map computes the influence of each factor on each other factor, taking account of all influences in the system. Cumulative net influence was the sum of influences across the results chain.

Results

Responses of 5042 women and 1143 men in 45 intervention clusters contrasted with those of 5025 women and 1179 men in 45 control clusters. Control clusters showed a distal block (negative influence) in the results chain with a cumulative net influence of 0.88; intervention clusters showed no such block and a cumulative net influence of 1.92. Female control respondents, like the overall control picture, showed a distal block, whereas female intervention responses showed no such blocks (cumulative net influence 0.78 and 1.73 respectively). Male control respondents showed weak distal blocks. Male intervention responses showed several new negative influences and a reduction of cumulative net influence (1.38 in control and 1.11 in intervention clusters).

Conclusions

The overall influence of the intervention across the results chain fits with the trial findings, but is different for women and men. Among women, the intervention overcame blocks and increased the cumulative net influence of knowledge on action. Among men, the intervention did not reinforce prevention behaviour. This might be related to emphasis, during the intervention, on women’s participation and empowerment. The fuzzy transitive closure of the CASCADA map usefully highlights the differences between gender-specific results chains.

Trial registration

ISRCTN27581154.

     

Comparative Studies of Metal Air Pollution by Atomic Spectrometry Techniques and Biomonitoring with Moss and Lichens

Our study was dedicated to the analysis of air pollution level with metals in Dambovita County, Romania; maps of the concentration distributions for air pollutants were drawn; statistical analysis includes calculation of the background concentrations and the contamination factors. The highest values of the contamination factor CF is 63.1 ± 6.63 for mosses samples and 33.12 ± 3.96 for lichens and it indicates extreme contaminations in the surroundings of steel works and an electric plant. The comparison of the distribution maps for Cr, Cu, Fe, Ni, Pb and Zn concentrations enables the identification of the pollution sources, the limits of areas with very high levels of pollution, the comparison of the concentration gradients in some areas and the influence of woodlands on the spread of pollutants through the air.     

Prevalence and Management of Anemia Among Patients with Chronic Kidney Disease in a Health Maintenance Organization

Background: Anemia often develops among patients with chronic kidney disease (CKD) and is an important cause of cardiovascular disease among patients with end-stage renal disease (ESRD). Objective: To evaluate the epidemiology and treatment of anemia among patients with CKD by undertaking an analysis of data from one Health Maintenance Organization. Methods: The CKD cohort was comprised of 1658 patients followed between 1 January 1994 and 1 December 1997 who had serum creatinine (SCr) levels above gender-specific norms. The prevalence of anemia and epoetin-α (recombinant human erythropoietin) use was determined, and the association with anemia and kidney function was assessed with multinomial logistic regression analysis. Results: 36% of patients with CKD had anemia, with at least two hematocrit (HCT) values (separated by ≥30 days) lower than the gender-specific norm (<42% for males, <36% for females). Eleven per cent of patients had a lowest HCT value less than the gender-specific norm but ≥33%, 6% had a lowest HCT value 30 to 32.9%, and 19% had a lowest HCT value <30%. The prevalence of anemia was positively correlated with the severity of kidney dysfunction.In the multivariate analysis, the independent relative risk of an HCT value <30% versus no anemia was 84.5, 9.8 and 2.0 for patients with SCr level ≥4.0, 3.0 to 3.9 and 2.0 to 2.9 mg/dl, respectively, compared with patients with SCr level <2.0 mg/dl. Epoetin-α was prescribed for only 7.4% of patients and, more significantly, for only 23% of patients with an HCT value <30%. Even among patients with an HCT value <30% who had received care from a nephrologist, only 66% received epoetin-α. Conclusions: This study demonstrates that the prevalence of anemia among patients with CKD is high and the management of anemia is suboptimal. Suboptimal treatment of anemia during CKD may lead to increased cardiovascular morbidity and cost of care among patients with CKD and ESRD.     

Hospital Length of Stay for Schizophrenia

Objective: The purpose of this study was 3-fold: (i) to determine the distribution of US patients diagnosed with schizophrenia and requiring a hospitalisation in the calendar year 1988 or 1992, by primary payer type (Medicare; Medicaid; or private insurance); (ii) to discern the mean inpatient length of stay and charge per day in 1988 or 1992, by payer type; and (iii) to test for time trends between 1988 and 1992, for inpatient hospital length of stay and charge per day. Design and setting: A retrospective study using the Healthcare Cost and Utilisation Project (HCUP-3) Nationwide Inpatient Sample (NIS), Release 1, as the database. Patients and participants: The study population was selected from all 1988 and 1992 discharges of patients that were >10 years of age; had an International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic code of 295.00 to 295.95, indicating schizophrenia as the primary diagnosis; were hospitalised between 1 and 40 days; and had Medicare, Medicaid, or private insurance, inclusive of fee-for-service or managed care, identified as the primary source of insurance coverage. The final sample used for this analysis consisted of 22 479 discharges from 1988, and 33 969 discharges from 1992. Main outcome measures and results: After adjusting for potentially confounding factors, the mean hospital length of stay for schizophrenia decreased by over 1 day (from 10.1 to 9.0; p < 0.0001) between 1988 and 1992 among individuals covered by private insurance; whereas the mean hospital length of stay for both Medicare and Medicaid beneficiaries remained unchanged. These findings existed in the presence of a uniform inflationary increase in mean hospital charges per day by payer category. Conclusions: Further research is required to determine whether the observed downward trend in hospital length of stay was a result of private payers enhancing patient care and thereby discharging patients in a more efficient manner, or if patients were discharged prematurely because of financial incentives operating within private insurance programmes.