The impact of nonreferral outpatient co-payment on medical care utilization and expenditures in Taiwan

BackgroundTaiwan's National Health Insurance's (NHI) generous coverage and patients' freedom to access different tiers of medical facilities have resulted in accelerating outpatient care utilization and costs. To deter nonessential visits and encourage initial contact in primary care (physician clinics), a differential co-payment was introduced on 15th July 2005. Under this, patients pay more for outpatient consultations at “higher tiers” of medical facilities (local community hospitals, regional hospitals, medical centers), particularly if accessed without referral.ObjectivesThis study explored the impact of this policy on outpatient medical activities and expenditures, different co-payment groups, and tiers of medical facilities.MethodsA segmented time-series analysis on regional weekly outpatient medical claims (January 2004 to July 2006) was conducted. Outcome variables (number of visits, number of outpatients, total cost of outpatient care) and variables for cost structure were stratified by tiers of medical facilities and co-payment groups. Analysis used the auto-regressive integrated moving-average model in STATA 9.0.ResultsThe overall number of outpatient visits significantly decreased after policy implementation due to a reduction in the number of patients using outpatient facilities, but total costs of care remained unchanged. The policy had its greatest impact on the number of visits to regional and local community hospitals but had no influence on those to the medical centers. Medical utilization in physician clinics decreased due to an audit of reimbursement declarations. Overall, the policy failed to encourage referrals from primary care to higher tiers because there was no obvious shifting of medical utilization and costs reversely.ConclusionsDifferential co-payment policy decreased total medication utilization but not costs to NHI. The results suggest that the increased level of co-payment charge and the strategy of a single cost-sharing policy are not sufficient to promote referrals within the system. To achieve an effective co-payment policy, further research is needed to explore how patients' out-of-pocket payment affects medical utilization and which forces (not susceptible to co-payment) act in tertiary facilities.     

Decision support considerations in the development and implementation of an electronic medical record

The requirement for decision support capability has been a major force in the evolution of the electronic medical record (EMR). The EMR should deliver contextual information so that financial and clinical decision makers can efficiently, and with patient-centered understanding, deliver appropriate care. An organization's pursuit of the EMR is based in its need to overcome problems managing information and its analysis and to create a picture of the patient in terms of outcomes. This discussion is designed for use as a guide to how pharmacy management can support or lead an enterprise's EMR and decision support evolution.     

Safety and effectiveness of thromboprophylaxis use in hospitalized elderly medical patients at a Saudi tertiary care center

IntroductionAppropriate prescribing of thromboprophylaxis according to guidelines’ recommendations can heighten over- or underutilization risk. The study intended to evaluate the safety and effectiveness of appropriate/inappropriate thromboprophylaxis use among hospitalized elderly medical patients.MethodsA retrospective observational cohort study was conducted, including patients who were ≥60 years old, hospitalized for an acute medical illness that required hospitalization in a medical ward for >48 h, and received thromboprophylaxis. Against the American College of Chest Physicians guidelines, the thromboprophylaxis use appropriateness was assessed.ResultsA total of 370 patients met the inclusion criteria, in 71.9% of whom thromboprophylaxis use was appropriate. The mean age of the included patients was 75 years (±9.1), and 72.4% of them were at high risk of venous thromboembolism (VTE), and almost all these patients received appropriate thromboprophylaxis. The occurrence of bleeding was significantly higher in the appropriate use group during hospitalization than the inappropriate use group (11.7% vs. 2.9%, p = 0.009); the majority of these bleeding events were classified as major. There were no differences in VTE events during hospitalization or 90 days all-cause mortality between the two groups.ConclusionThe study demonstrates high prescribers’ compliance with recommendations in high-risk patients. In patients at low risk for VTE, the overutilization of thromboprophylaxis did not increase their bleeding risk. This study suggests that the benefits of thromboprophylaxis in elderly patients, regardless of their VTE risk, may outweigh the risk of bleeding.     

Safety, efficacy, and lipid profile of doxazosin at a VA medical center

The Veterans Administration Lakeside Medical Center (VALMC) is a 500-bed hospital located in downtown Chicago providing a broad scope of inpatient and outpatient medical services for more than 12,000 veterans. The VALMC Pharmacy and Therapeutics Committee requested a study to evaluate doxazosin mesylate (Cardura) to determine if this agent would be an acceptable alternative to other formulary agents. It appears that doxazosin provides several therapeutic advantages, including once-daily dosing, when compared with other more costly antihypertensive agents.