Managed care. Taking the direct approach

Cost-conscious companies are turning to direct contracts with hospitals in efforts to reduce their medical bills, but they won't hesitate to sever the relationships if workers become dissatisfied with the quality or service. A national survey of some 250 Fortune 1,000 companies conducted for Modern Healthcare offers insights into what companies are looking for and what they're getting through such arrangements.     

The direct and indirect cost of diabetes in Italy: a prevalence probabilistic approach

Introduction

Diabetes mellitus is a chronic degenerative disease associated with a high risk of chronic complications and comorbidities. However, very few data are available on the associated cost. The objective of this study is to identify the available information on the epidemiology of the disease and estimate the average annual cost incurred by the National Health Service and Society for the Treatment of Diabetes in Italy.

Methods

A probabilistic prevalence cost of illness model was developed to calculate an aggregate measure of the economic burden associated with the disease, in terms of direct medical costs (drugs, hospitalizations, monitoring and adverse events) and indirect costs (absenteeism and early retirement). A systematic review of the literature was conducted to determine both the epidemiological and economic data. Furthermore, a one-way and probabilistic sensitivity analysis with 5,000 Monte Carlo simulations was performed to test the robustness of the results and define a 95 % CI.

Results

The model estimated a prevalence of 2.6 million patients under drug therapies in Italy. The total economic burden of diabetic patients in Italy amounted to €20.3 billion/year (95 % CI €18.61 to €22.29 billion), 54 % of which are associated with indirect costs (95 % CI €10.10 to €11.62 billion) and 46 % with direct costs only (95 % CI €8.11 to €11.06 billion).

Conclusions

This is the first study conducted in Italy aimed at estimating the direct and indirect cost of diabetes with a probabilistic prevalence approach. As might be expected, the lack of information means that the real burden of diabetes is partly underestimated, especially with regard to indirect costs. However, this is a useful approach for policy makers to understand the economic implications of diabetes treatment in Italy.

     

采用直接前方入路与后外侧入路行初次全髋关节置换术早期疗效比较

目的评价直接前方入路和后外侧入路行初次全髋关节置换术的早期临床疗效。方法回顾性分析2015年6月~2016年12月,采用人工全髋关节置换术治疗的患者54例,直接前方入路组27例,其中采用后外侧入路组27例。统计两组切口长度、手术时间、术中出血量、术后引流量、术后卧床时间、术后1个月髋关节Harris评分,假体位置及并发症情况。结果所有患者均获的随访,两组的切口长度、手术时间、术中出血量、术后引流量、术后卧床时间,差异有统计学意义(P﹤0.05);髋臼杯外展角、术后1个月髋关节Harris评分两组间比较,差异无统计学意义(P﹥0.05),直接前方入路组有1例股前外侧皮神经损伤,1例大粗隆骨折,后外侧组发生1例髋关节后脱位。结论直接前方入路具有手术切口小、术后卧床时间短,术后恢复快等优势,是可靠的手术入路,但建议术者选择熟悉的手术入路。     

A direct regression approach to decomposing socioeconomic inequality of health

This paper presents a new regression‐based decomposition of socioeconomic inequality of health that is more direct than other approaches. The method can be applied to both rank‐dependent and level‐dependent indicators of inequality. The response variable of our regression model is a simple reformulation of the measure of overall performance of an individual in the health and socioeconomic domains. Regression results are described in terms of marginal effects of the explanatory variables, but also in terms of their logworths or importance values. We illustrate our method, and compare it with alternatives, using Australian health and income data.     

A simple unified approach for estimating natural direct and indirect effects

An important problem within both epidemiology and many social sciences is to break down the effect of a given treatment into different causal pathways and to quantify the importance of each pathway. Formal mediation analysis based on counterfactuals is a key tool when addressing this problem. During the last decade, the theoretical framework for mediation analysis has been greatly extended to enable the use of arbitrary statistical models for outcome and mediator. However, the researcher attempting to use these techniques in practice will often find implementation a daunting task, as it tends to require special statistical programming. In this paper, the authors introduce a simple procedure based on marginal structural models that directly parameterize the natural direct and indirect effects of interest. It tends to produce more parsimonious results than current techniques, greatly simplifies testing for the presence of a direct or an indirect effect, and has the advantage that it can be conducted in standard software. However, its simplicity comes at the price of relying on correct specification of models for the distribution of mediator (and exposure) and accepting some loss of precision compared with more complex methods. Web Appendixes 1 and 2, which are posted on the Journal's Web site (http://aje.oupjournals.org/), contain implementation examples in SAS software (SAS Institute, Inc., Cary, North Carolina) and R language (R Foundation for Statistical Computing, Vienna, Austria).     

A direct approach to control short term population dynamics in time series studies

BACKGROUND: Short term population dynamics is an important issue in several epidemiological studies. Usually, calendar time or dummy variables are used to control indirectly for this confounding. This study tested a direct method. METHODS: The study compared as proxy variables of population dynamics the summer 2003 data of cooking gas consumptions, solid urban waste production, and television access for the municipality of Bologna (Italy). RESULTS: Solid urban waste production and television access data showed similar trends. Considerably different were the >65 year olds estimates with respect to total population based on television access. CONCLUSIONS: Television access data are probably the best indicator in the estimates of population dynamics in large or densely populated areas, especially because of the possibility of stratifications with respect to age.     

Cut out the middleman. Coalition seeks big savings by taking the direct approach

A large Minnesota business coalition is planning to contract directly for healthcare services with groups of providers. The effort, headed by Fred Hamacher and Steve Wetzell, aims to save money by eliminating the middleman--a move viewed with alarm by managed-care plans in the Minneapolis/St. Paul market.     

Newspaper advertising versus direct mail marketing in a family practice: a hands-on approach

This study compares newspaper advertising and direct mail marketing to attract private patients. Newsletter advertising was distributed to 92,251 homes throughout 1991 at a cost of $20,827.13. Newspaper advertising was conducted from August 28 to October 9, 1991 at a cost of $2,261.94. The newsletter attracted 101 new patients at a cost of $206.21 per patient and a mean response rate of 0.11%. No new patients were attracted through newspaper advertising.     

A direct approach for correcting aids incidence: Variance formula and comparison with other methods

We present a direct approach for correcting the acquired immunodeficiency syndrome (AIDS) incidence data for reporting delays, based on a non-parametric method for the analysis of right truncated data. We show that the proposed method when applied for grouped data is equivalent to three other published methods. We give a simple formula for the variance of the estimated AIDS incidence. Both estimator and variance are assessed in a simulation study. It is important for the estimation of AIDS incidence in the last quarter of the period under consideration to use month rather than quarter or half-year as the time unit for the analyses. The method is illustrated using data from the United States Centers for Disease Control.     

The coombs direct antiglobulin test in Kenyans

The direct antiglobulin test (DAT) was performed on 243 subjects in Kenya. A high incidence of positive DAT was found in children with malaria of whom 70% had RBCs coated with IgG, C3 and C4 either separately or together. Only 12% of paediatric patients with conditions other than malaria had a positive DAT. Most positive DATs in association with malaria occurred in children between 18 months and five years of age. There was a lower incidence of positive DAT in Kikuyu children from an area of low malarial transmission than in children from other tribal groups who reside in areas of high malaria endemicity. A high rate of positive DAT was also found in patients with visceral leishmaniasis. Interestingly there was an association of IgG and C4 but without C3 on red cells of five patients with visceral leishmaniasis and two schoolchildren from an area endemic for visceral leishmaniasis. This combination was not found on other patients.     

The generic team approach

The Generic Team Approach is an innovation in residential teamwork which focuses on increasing the involvement of team members in designing and implementing treatment plans. One central team discipline is developed in an attempt to eliminate departmental influence and to balance professional status among team members. In this article, the authors describe the approach and analyze their experience implementing it at the Youth Development Center, a model program for troubled youth.     

The interaction of direct and indirect risk selection

This paper analyzes the interaction of direct and indirect risk selection in health insurance markets. It is shown that direct risk selection – using measures unrelated to the benefit package like selective advertising or ‘losing’ applications of high risk individuals – nevertheless has an influence on the distortions of the benefit package caused by indirect risk selection. Direct risk selection (DRS) may either increase or decrease these distortions, depending on the type of equilibrium (pooling or separating), the type of DRS (positive or negative) and the type of cost for DRS (individual-specific or not). Regulators who succeed in reducing DRS by, e.g., banning excessive advertising or implementing fines for ‘losing’ applications, may therefore (unintendedly) mitigate or exacerbate the distortions of the benefit package caused by indirect risk selection. It is shown that the interaction of direct and indirect risk selection also alters the formula for optimal risk adjustment.