Cost inefficiency and hospital health outcomes

This study explores the association between cost inefficiency and health outcomes in a national sample of acute-care hospitals in the US over the period 1999-2001, with health outcomes being measured by both mortality and complications rates. The empirical analysis examines health outcomes as a function of cost inefficiency and other determinants of outcomes, using stochastic frontier analysis to obtain hospital cost inefficiency scores. The results showed no systematic pattern of association between cost inefficiency and hospital health outcomes; the basic results were unchanged regardless of whether cost inefficiency was measured with or without using instrumental variables. The analysis also indicated, however, that the association between cost inefficiency and health outcomes may vary substantially across geographical regions. The study highlights the importance of distinguishing between 'good' costs that reflect the efficient use of resources and 'bad' costs that stem from waste and other forms of inefficiency. In particular, the study's results suggest that hospital programs focused on reducing cost inefficiency are unlikely to be associated with worsened hospital-level mortality or complications rates, while, on the other hand, across-the-board reductions in cost could well have adverse consequences on health outcomes by reducing efficient as well as inefficient costs.     

A survey of nosocomial infections and their influence on hospital mortality rates

Nosocomial infections play an important role in contributing to hospital mortality. In order to obtain a large sample a survey was conducted between 1978 and 1989 of more than 66000 patients in German acute care hospitals. The data were used to assess the influence of nosocomial infections on mortality rates. Hospital infections were more frequent in female patients, but mortality with or without nosocomial infection was higher in male patients. Nosocomial infections increased hospital mortality threefold when raw numbers were used. Controlling for age and sex, the existence of at least one nosocomial infection (diagnosed at the second or a later day of hospital stay) increased hospital mortality by a factor of two. The influence of nosocomial infections was shown to be small for some diseases, such as malignancy, but was greater for others such as metabolic and immunological diseases or trauma. In the case of trauma, nosocomial infections increased hospital mortality rates by a factor of three even after controlling for age.     

Cost efficiency of US hospitals: a stochastic frontier approach

This study examined the impact of managed care and other environmental factors on hospital inefficiency in 1631 US hospitals during the period 1990-1996. A panel, stochastic frontier regression model was used to estimate inefficiency parameters and inefficiency scores. The results suggest that mean estimated inefficiency decreased by about 28% during the study period. Inefficiency was negatively associated with health maintenance organization (HMO) penetration and industry concentration. It was positively related with Medicare share and for-profit ownership status.     

A two‐stage estimation of hospital quality using mortality outcome measures: an application using hospital administrative data

This paper proposes a method of deriving a quality indicator for hospitals using mortality outcome measures. The method aggregates any number of mortality outcomes into a single indicator via a two‐stage procedure. In the first stage, mortality outcomes are risk‐adjusted using a system of seemingly unrelated regression equations. These risk‐adjusted mortality rates are then aggregated into a single quality indicator in the second stage via weighted least squares. This method addresses the dimensionality problem in measuring hospital quality, which is multifaceted in nature. In addition, our method also facilitates further analyses of determinants of hospital quality by allowing the resulting quality estimates be associated with hospital characteristics. The method is applied to a sample of heart‐disease episodes extracted from hospital administrative data from the state of Victoria, Australia. Using the quality estimates, we show that teaching hospitals and large regional hospitals provide higher quality of care than other hospitals and this superior performance is related to hospital case‐load volume. Copyright © 2009 John Wiley & Sons, Ltd.     

Demand, selection and patient outcomes in German acute care hospitals

This paper examines the effects of variation in unexpected demand on patient outcomes in acute care German hospitals. Naturally, an unexpected surge in demand may negatively affect the quality of care and thus patient outcomes, such as in-hospital mortality. We estimate models explaining patient outcomes depending on demand, unobservable patient selection and seasonal factors, as well as patient-specific risk factors and unobservable hospital and department fixed-effects. The main message of this analysis is that hospitals are well prepared to deal with this unexpected volatility in demand, as by and large it does not negatively affect patient outcomes. Hospitals seem to deal with high unexpected workload by steering the patients' length of stay relating to their severity of illness. Elective patients are discharged earlier, while discharges of high-risk emergency patients are postponed.     

Comparing high- and low-performing hospitals using risk-adjusted excess mortality and cost inefficiency

This study examines characteristics associated with high- and low-performing hospitals, where performance is defined in terms of both mortality outcomes and efficiency. In particular, we use data for Florida hospitals in 1999-2001 to classify hospitals into performance groups based on both risk-adjusted excess mortality and cost efficiency. The results indicate that hospitals in the high-performing group were more likely to be for-profit, had higher occupancy rates, had proportionately more Medicare and proportionately fewer Medicaid and self-pay patients, used fewer patient-care personnel per admission, and had higher operating margins than all other hospitals. Hospitals in the low-performing group, on the other hand, were less likely to be for-profit, had more beds, used more patient-care personnel per admission, had lower pay per patient-care personnel, had higher average costs, and had lower operating margins than all other hospitals. Interestingly, managed care presence, measured by proportion of HMO-PPO admissions, was not a significant factor in differentiating hospital performance groups.     

Marginal costs in general acute care hospitals: A comparison among California,New York and Canada

In the present paper we offer a detailed comparison of hospital costs between California and New York and two Canadian provinces (Ontario and British Columbia) in 1981 and 1985. We find that production technologies differ significantly between the two countries and between California and New York. Marginal costs and their distributions also differ across jurisdictions and across different size hospitals. Marginal cost levels were the lowest in Canadian hospitals for almost all outputs in both years and their distribution was also the tightest. Some very mild scale effects were also present in the acute care production. Hospitals in California experienced for the most part increasing marginal costs for acute care, whereas Canadian hospitals showed the reverse pattern. In New York we find a weak negative scale effect in acute care production. Density estimates conditional on hospital output reinforce these results.     

A Position Paper on How Cost and Quality Reforms Are Changing Healthcare in America

Healthcare spending in the United States is the highest in the world, yet quality indicators such as life expectancy and infant mortality lag other countries. U.S. reforms are under way to lower costs and raise quality of care, notably the Patient Protection and Affordable Care Act (PPACA). Value‐based purchasing (VBP) and programs for reducing the incidence of hospital‐acquired conditions (HACs) and hospital readmissions represent initial changes. With these programs, overarching themes are to coordinate care during and beyond hospitalization and to ensure that physicians and hospitals are aligned in their treatment strategies. Hospital malnutrition represents a large, hidden, and costly component of medical care; hospital administrators and caregivers alike must harness the benefits of nutrition as a vital component of healthcare. Medical, nursing, and allied health training programs must find places in their curricula to increase awareness of nutrition and promote knowledge of best‐practice nutrition interventions. Hospitals use dietitians and nutrition support teams as critical members of the patient care team, but more work needs to be done to disseminate and enforce best nutrition practices. Such training, nutrition interventions, and practice changes can help prevent and treat malnutrition and thus help avert HACs, reduce hospital readmissions, lower infection and complication rates, and shorten hospital stays. Nutrition care is an effective way to reduce costs and improve patient outcomes. This article calls hospital executives and bedside clinicians to action: recognize the value of nutrition care before, during, and after hospitalization, as well as develop training programs and policies that promote nutrition care.     

Hospital ownership, reimbursement systems and mortality rates

This paper analyses the effect of ownership and system of reimbursement on mortality rates. From the statistical results we could conclude that the incentive created by fee-for-service reimbursement yields a four-point reduction in the mortality rate. However, this ranking of hospital quality is completely dependent on the characteristics and illness severity of patients. To take this difficulty into account, we use an innovative duration model applied to panel data: a duration model with both patient and hospital unobserved heterogeneity. No distributional assumptions are made regarding the latter. By this way, we control the fact that patients admitted to the private sector can be different in terms of disease severity from patients admitted to the public sector.The capacity to perform innovative procedures has more effect on the mortality than the system of reimbursement and/or ownership. As such, private sector hospitals that perform more innovative procedures provide a better quality of care, measured by the probability of dying. Nevertheless, heterogeneity within hospitals is greater in for-profit hospitals than in other types of hospital. This suggests that, by choosing a for-profit hospital, patients have on average a lower instantaneous probability of dying but are less sure about the quality of the hospital.     

欠发达地区农村围产儿死亡率及其影响因素

目的 利用基层计划生育部门登记资料，分析欠发达地区农村的围产儿死亡率及其影响因素。方法 利用乡镇计生站提供的妊娠相关资料进行统计分析。结果 死胎死产、早期新生儿死亡和围产儿死亡率分别为24‰，46‰和69‰。男女婴早期新生儿死亡率分别为29‰和69‰。围产儿死亡率与产次及当地经济水平有关。结论 围产儿死亡率高于已报道的同期农村的水平，不同产次围产儿死亡率的差异及较高的出生婴儿性别比反映了经济、计划生育政策对围产健康的影响。     

公立医院人力成本管理与控制的思考

作为医疗成本的重要组成部分,人力成本直接关系到医院社会效益和经济效益的提高。本文就公立医院面对医改如何加强人力成本管理与控制、提高人力资源的使用效益谈些看法。     

Adjusted mortality rates: a tool for creating more meaningful league tables for stillbirth and infant mortality rates

A number of problems associated with league tables of performance indicators have been discussed in the literature. This paper attempts to address these problems for stillbirth and infant mortality rates in order to produce meaningful and useful information for the government, general public and health professionals. Composite stillbirth and infant mortality rates, low birth-weight and very low birth-weight rates were determined for the 100 English Health Authorities for 1996-1997. Townsend deprivation scores for these districts were also obtained. The mortality rates were adjusted by multiple regression for very low birth-weight and Townsend score separately and together. Confidence intervals were calculated for the dual-adjusted rates. Almost 60% of the variability in mortality rates were explained by Townsend score and very low birth-weight rates together. Adjusted league tables showed how the individual and combined predictors affect the individual mortality rates for each Health Authority. There was considerable overlap in the confidence intervals for the adjusted rates although there were a few Health Authorities whose mortality rates were clearly below most others. We conclude that fairer and more useful information is provided by geographically based league tables which give both crude rates and rates adjusted for single and multiple predictor variables. The inclusion of confidence intervals aids interpretation of annual random variations and knowledge of differences in the effects of the individual predictors enables better resource targeting.     

Effects of selective contracting on hospital efficiency,costs and accessibility

This paper exploits a natural experiment in the state of California, to show that pro-competitive healthcare policy may have unintended long-term liabilities unless the system as a whole is carefully designed to preserve access to care for the poor. California's Medicaid Reform Act of 1982 increased competition among hospitals in urban areas, with legislation which allowed direction of patients to more efficient providers via selective contracting. This slowed the average rate of hospital cost inflation, and saved the state billions of dollars. The substantial short-term savings have been documented in empirical research, but little attention has been paid to the longer-term effects of the reforms. We find that Medicaid contracts were awarded to more efficient hospitals. The distributional effects post-reform resulted in efficiency gains for most hospitals, but costs escalated for over half of the public hospitals in the sample, as their uncompensated care burdens rose. Public hospitals continued to fail during the period, leaving over half of California's counties without a county hospital by 1990. Because public hospitals provide the vast majority of healthcare for the poor in California, there is reason for concern about erosion of their access to care as an unintended outcome of pro-competitive reforms. © 1998 John Wiley & Sons, Ltd.     

Unintentional injury in Ireland: a comparison of mortality and morbidity data

BACKGROUND: The aim of this study was to examine the relationship between mortality and hospital admission data for the leading causes of unintentional injury in Ireland. METHODS: Mortality data were obtained from the Central Statistics Office for the years 1980-1996. Information on hospital admissions was obtained from the Hospital In-Patient Enquiry system for the years 1993-1997. RESULTS: Motor vehicle traffic accidents were the leading cause of unintentional injury death. Falls were the most common cause of unintentional injury hospital admission. Drowning and suffocation had high ratios of deaths to admissions, 2:1 and 1:3, respectively. The ratio of deaths to admissions was 1:39 for all unintentional injuries. CONCLUSION: Neither mortality data nor admissions data alone give an adequate guide to the impact of injuries, but together the two provide a reasonable basis on which to establish policy.     

Variations in mesothelioma mortality rates among migrants to Australia and Australian-born

Background: Australia’s use and consumption of asbestos occurred at the same time as its immigration boom. Our objective was to investigate mesothelioma death rates among migrants and Australian-born between 1981 and 2012.

Methods: Australian national mesothelioma deaths from 1981 to 2002 and 2006 to 2012 together with national censuses from 1981 to 2011 were extracted and combined. Directly standardised rates and negative binomial regression were applied examining differences in mesothelioma death rates with regard to country of birth.

Results: Migrants from the UK and Ireland, Italy and Germany had significantly higher mesothelioma death rates than Australian-born; lower rates were observed among migrants from other countries.

Conclusions: Our findings suggest there may have been differences in occupational health and safety between foreign and Australian-born. Because of changes in the demographics of migrants to Australia since the 1970s and changes in occupational circumstances over time, further comparisons of occupational-related health outcomes between foreign and Australian-born could identify potential occupational inequalities that may still exist today.     

Excess Mortality, Length of Stay, and Costs Associated with Serious Fungal Infections among Elderly Cancer Patients: Findings from Linked SEER-Medicare Data

OBJECTIVE: To calculate the excess mortality, length of stay, and costs attributable to serious fungal infections in hospitalized elderly patients with selected cancers. Methods: This study involved a retrospective cohort analysis using linked data from the Surveillance, Epidemiology and End Results Program of the National Cancer Institute (SEER) and Medicare claims data. Study cohorts included patients aged 65 years and older who newly received a diagnosis of a selected cancer (acute myeloid leukemia [AML] or squamous cell carcinoma of the head and neck [SCCHN]) in a SEER registry between 1991 and 1996 and who had a subsequent diagnosis of a serious fungal infection during an inpatient hospitalization, and hospitalized controls without a fungal infection matched 1:1 by age, geographic region, receipt of recent chemotherapy, concomitant bacterial infection, timing of the index hospitalization, and cancer stage at diagnosis (for SCCHN patients only). RESULTS: Eighty AML patients and 52 SCCHN patients experienced a serious fungal infection involving hospitalization. Relative to matched controls, SCCHN patients with fungal infections had significantly higher all-cause mortality (40% vs. 14%, P = 0.002), while mortality rates did not differ between AML cohorts. Patients with fungal infections had significantly longer index hospitalizations regardless of cancer type (mean: 30 days vs. 19 days for AML patients; 20 days vs. 9 days for SCCHN patients), and correspondingly higher Medicare payments (mean +/- SD: 34,268 dollars +/- 31,811 dollars vs. 21,416 dollars +/- 22,449 dollars among AML patients, P < 0.0001; 25,942 dollars +/- 29,122 dollars vs. 10,131 dollars +/- 10,686 dollars among SCCHN patients, P < 0.0001). CONCLUSIONS: Efforts to prevent these infections and/or initiate early treatment may yield both clinical and economic benefits.     

DEA在评价哈尔滨市二级医院相对效率中的应用

目的 尝试运用数据包络分析（DEA分析）对哈尔滨市48所二级医院进行相对效率综合评价。方法 共收集48所二级医院投入产出资料，采用描述性分析、聚类分析及数据包络分析进行分析研究。结果 DEA分析结果显示：①近1／2的被评价医院处于低效率运行状态；②最无效率的医院（D24）通过各指标的改善值可达到相对有效。结论 建议在增加三级医院投入的同时，也要结合二级医院的特点增加投入，建立一个良好的投资机制、经营机制。