广东省省市级综合医院最优规模实证研究

目的测量广东省省市级综合性医院最优规模,对比分析国外情况,分析差异产生的原因。方法应用适存分析法,数据为1995年～2004年10年间广东省省市级综合医院的医院数量百分比和医院产出百分比。结果规模超过700张病床的医院显示出规模经济。随着医院规模越来越大,规模经济的作用更加明显。结果与国外显著不同。结论最优规模对医院与社会有不同含义。我国医院持续扩大规模的原因,可能来自于人口多带来的医疗市场规模扩大和缺乏有效的医疗费用支付机制。两种原因对卫生政策有不同涵义,建议做进一步研究。     

Technical efficiency and economies of diversification in health care

In national health services, where there is a tendency towards a lack of resources and a continuous increase in demand, it is necessary to implement decisions that promote efficiency. In this paper we focus on potential diversification economies as a strategy to increase efficiency levels. We evaluate the change in efficiency in Catalan hospitals between 1987 and 1992, and analyse the presence of possible diversification economies in each hospital. We use Data Envelopment Analysis, which does not need information on either input or output prices. The results are that the majority of hospitals could increase their efficiency and reduce their costs by diversification to the output-mix offered. Potential productivity gains are between 29% and 46%. This revised version was published online in July 2006 with corrections to the Cover Date.     

Cost-effectiveness analysis and health care resource allocation: decision rules under variable returns to scale

We argue that health programs are administered in settings that often violate the frequently stated assumption of constant returns to scale in the provision of health services. Three types of returns to scale are identified from the general economic literature: returns to scale with respect to population, effectiveness, and quality. We show that decision rules based on incremental cost-effectiveness ratios or cost-benefit tests are not optimal if returns to scale are not constant. We derive the optimal decision rules under variable returns to scale using optimization techniques, and employ several examples to illustrate the concepts and methods.     

甲磺酸左氧氟沙星血、尿浓度测定及人体内的药代动力学

采用反相高效液相色谱法测定口服甲磺酸左氧氟沙星后人血清及尿中左旋氧氟沙星药物浓度,色谱柱为ＡＬＬＴＩＭＡＣ１８５μｍ,２５０ｍｍ×４．６ｍｍ。流动相为０．００５ｍｏｌ／Ｌ磷酸溴化四丁基铵乙腈（１１１）,ｐＨ＝２．８,流速１．５ｍｌ／ｍｉｎ,荧光检测激发波长２９８ｎｍ,发射波长４５８ｎｍ,以环丙沙星为内标,室温下血、尿样品用１０％三氯乙酸沉淀蛋白后,取上清液进样测定。此方法日内、日间误差均小于６％,平均血清回收率为９４．５２％,尿回收率为９８．６８％。最低检测浓度为２ｎｇ／ｍｌ。应用此方法研究了１６名健康男性志愿者分两组分别单剂口服１００或２００ｍｇ国产甲磺酸左氧氟沙星片的药代动力学。试验结果表明,甲磺酸左氧氟沙星片在健康志愿者体内表现为明显的线性药动学,血药浓度数据符合二室模型,大部分药物以原型从尿中排泄。本项研究结果为国产甲磺酸左氧氟沙星片的临床应用提供了科学依据。     

Does the agglomeration effect occur in the hospital sector? The impact of agglomeration economies on the financial performance of hospitals—An evidence from Poland

The main aim of the article is to analyze the occurrence of agglomeration effect in the hospital sector on the basis of financial performance. The considerations are made on the example of hospitals in Poland—the country that survived the latest economic crisis relatively well, usually generating positive values of GDP, but where still there is an ongoing discussion on the final shape of healthcare financing model. The article is based on the assumption that there occur significant differences in financial performance between hospitals according to their location. The research hypothesis is as follows: Hospitals operating in big cities are featured by better financial condition than their counterparts operating in smaller towns. To verify the hypothesis, the methods of financial analysis and statistical hypothesis testing are used. As it is emphasized in the article, the assumption is true and the hypothesis can be verified positively.     

区域性医疗中心的经济分析

回顾我国区域性医疗中心建设情况,其建设模式可归纳为网络、重点和单项业务3种模式。通过对各种模式的规模经济性、改善资源配置效率、区域医疗服务质量、服务可及性,以及降低群众医疗经济负担等方面的比较分析：区域性医疗中心建设有助于不同区域医疗技术水平的提高与协调发展;有助于卫生资源配置结构和服务可及性的改善。因此,我国应明确区域医疗中心建设的目的与建设评定标准,并根据各地实际,合理选择建设模式和合理确定医疗中心的建设规模。同时,各地还应注重医疗资源的合理配置,并重视农村及边远地区医疗中心的建设。     

Learning by Doing,Scale Effects,or Neither? Cardiac Surgeons after Residency

Objective. To examine impacts of operating surgeon scale and cumulative experience on postoperative outcomes for patients treated with coronary artery bypass grafts (CABG) by “new” surgeons. Pooled linear, fixed effects panel, and instrumented regressions were estimated. Data Sources. The administrative data included comorbidities, procedures, and outcomes for 19,978 adult CABG patients in Florida in 1998–2006, and public data on 57 cardiac surgeons who completed residencies after 1997. Study Design. Analysis was at the patient level. Controls for risk, hospital scale and scope, and operating surgeon characteristics were made. Patient choice model instruments were constructed. Experience was estimated allowing for “forgetting” effects. Principal Findings. Panel regressions with surgeon fixed effects showed neither surgeon scale nor cumulative volumes significantly impacted mortality nor consistently impacted morbidity. Estimation of “forgetting” suggests that almost all prior experience is depreciated from one quarter to the next. Instruments were strong, but exogeneity of volume was not rejected. Conclusions. In postresidency surgeons, no persuasive evidence is found for learning by doing, scale, or selection effects. More research is needed to support the cautious view that, for these “new” cardiac surgeons, patient volume could be redistributed based on realized outcomes without disruption.     

Jurisdiction Size and Local Public Health Spending

Objective. To examine if a minimum efficient scale (MES) holds with respect to the population serviced by a local health department (LHD) given the congestability, externality, and scale/scope economy effects potentially associated with public health services. Data Sources/Study Setting. A nationally representative sample of LHDs in 2005. Study Design. Multiple regression analysis is used to isolate the relation between population and spending while controlling for other factors known to influence local public health costs. Data Collection. Data were obtained from the 2005 National Profile of Local Public Health Agencies, a project supported through a cooperative agreement between the National Association of County and City Health Officials and the Centers for Disease Control and Prevention. Principal Findings. The MES of a local public health department is approximately 100,000 people. After that size, additional population has little impact on public health spending per capita. Conclusions. Seventy‐seven percent of LHDs in the sample fall below the 100,000 MES. Higher levels of government may want to provide financial inducements so that smaller LHDs consolidate or enter into agreements with larger public health organizations to provide services.     

企业边界理论与医院边界选择分析

医院规模选择问题是卫生管理学界研究的热点问题,本文应用企业边界理论对医院横向和纵向边界的选择进行分析和解释,指出,医院生产能力、官僚成本、外部企业的生产效率和交易费用均可影响边界的选择。     

Rapid Reversibility of Autoinduction of Carbamazepine Metabolism After Temporary Discontinuation

Summary: Patients in whom carbamazepine (CBZ) monotherapy is discontinued for preoperative EEG/video monitoring often display toxicity if their previous maintenance dosage is resumed, even after a few days without CBZ. To determine whether this is due to rapid reversibility of autoinduction of CBZ metabolism, single-dose studies of CBZ pharmacokinetics were performed before and after discontinuation for monitoring in 6 adults receiving CBZ monotherapy. The CBZ-free period was 5.7 ± 1.1 days (mean ± SD). The pharmacokinetic parameters of CBZ before and after discontinuation were volume of distribution (Vd) 1.28 ± 0.29 versus 1.22 ± 0.331/kg (NS), elimination half-life (t 1/2) 13.7 ± 1.67 versus 22.2 ± 2.36 h (p < 0.001), and clearance (CI) 1.54 ± 0.39 versus 0.92 ± 0.32 L/kg/day (p = 0.012). Assuming that deinduction is a first-order process, a deinduction t 1/2 of 3.84 days was obtained by log linear regression analysis. We showed that after CBZ discontinuation half of the enzymatic autoinduction is already lost after 3.84 days, indicating very rapid deinduction. Our results also provide the necessary information to predict clearance and appropriate dosage reduction for CBZ at time of reintroduction.