Social costs of the most common inflammatory rheumatic diseases in Mexico from the patient's perspective

OBJECTIVE: To estimate the social costs of rheumatoid arthritis (RA), ankylosing spondylitis (AS), and gout from the patient's perspective. METHODS: We carried out a cross-sectional analysis of the cost and resource utilization of 690 RA, AS, and gout patients from 10 medical centers and private facilities in five cities of Mexico. The information was obtained from the baseline of a dynamic cohort. We estimated out-of-pocket expenses, institutional direct costs, and direct medical costs. RESULTS: The mean (SD) annual out-of-pocket expense (USD) was $610.0 ($302.2) for RA, $578.6 ($220.5) for AS, and $245.3 ($124.0) for gout. Figures correspond to 15%, 9.6%, and 2.5% of the family income. They also represented 26.1%, 25.3%, and 24.4% of the total annual cost per RA, AS, and gout patients, respectively. The expected direct institutional patient/year costs were 1,724.2 for RA, $1,710.8 for AS, and $760.7 for gout. The total patient annual costs were $2,334.3 for RA, $2,289.4 for AS, and $1,006.1 for gout. Most out-of-pocket expenses were used to purchase drugs, pay for laboratory tests, imaging studies, and alternative therapies. CONCLUSIONS: From the patient's perspective, the cost of RA, AS, and gout represents 25% of direct medical costs. The cost of RA is higher than that for AS and gout.     

Overcoming a perfect storm: an academic cardiology section's story of survival.

Increasingly, academic institutions are grappling with financial pressures that threaten the academic mission. The author presents an actual case history in which a section of cardiology in an academic health center was confronted with huge projected deficits that had to be eliminated within the fiscal year. The section used eight principles to shift from deficit to profitability (i.e., having revenue exceed costs). These principles included confronting the brutal facts, managing costs and revenue cycles, setting expectations for faculty, and quality improvement. The section accomplished deficit reduction through reducing faculty salaries (nearly $2 million) and nonfaculty salaries ($1.3 million) and reducing operational costs while maintaining revenues by increasing individual faculty productivity and reducing accounts receivable. In the face of these reductions, clinical revenues were maintained, but research revenue and productivity fell (but research is being fostered now that clinical services are profitable again). These principles can be used to stabilize the financial position of clinical practices in academic settings that are facing financial challenges.     

Home visits: why do rates vary so much?

Data including information on patient age, gender, who initiated the visit and call classification was collected during office hours from 12 G.P. rural teaching practices with a combined GMS patient population of 24,720, over a 2 month period. There were a total of 603 home visits, giving an annual visiting rate of 143/1000. Visiting rates varied between practices from 45 to 305/1000 per year. When high visiting practices (>210/1000/year) were compared to low visiting rate practices (>90/1000/year), patients tended to be older (79.7 v. 74.5 years) and calls were 12 times more likely to be doctor initiated (16.6% v. 1.4%) or classified as routine( 50.7% v. 44.9%). The variation between practices was related in part to patient age but appears largely due to differences in doctor home visiting behaviour. There are no recent figures on home visiting in Ireland.     

Six-year trends in productivity and utilization of 73 clinical laboratories: a College of American Pathologists Laboratory Management Index Program study

OBJECTIVES: To describe longitudinal trends in the efficiency, labor productivity, and utilization of clinical laboratories in the United States. METHODS: Financial and activity data were prospectively collected from 73 clinical laboratories continuously enrolled in the College of American Pathologists Laboratory Management Index Program from 1994 through 1999. Each laboratory reported quarterly on its costs, labor inputs, and test activity using uniform data definitions. RESULTS: During the 6-year study period, there was a significant increase in laboratory labor productivity (2.1% more tests/full-time equivalent/y; P <.001). Productivity increases were offset by increasing labor expense (1.5%/full-time equivalent/y; P <.001), consumable expense (1.7%/on-site test/y; P =.005), and blood expense, which comprised more than 10% of laboratory expenses by 1999 (4.4% increase/y; P <.001). As a result, overall expense per test showed no significant change in non-inflation-adjusted dollars. Reference laboratory expense per test did not change significantly during the study period; the proportion of tests sent to reference laboratories grew slightly (0.06% increase/y; P <.001). Test volume of the median laboratory grew by 5442 tests per year (2.3% annual increase; P <.001), while the proportion of testing from inpatients declined by 1.7% per year (P <.001). Inpatient test utilization declined on a discharge basis (annual decline of 1.2 tests/inpatient discharge; P <.001) and on a per diem basis (annual decline of 0.08 tests/inpatient day; P =.002). Inpatient laboratory expense declined on a discharge basis (annual decline of $2.40 or 1.3% per discharge; P <.001), but did not change significantly per inpatient day. Most of the reduction in the expense per discharge occurred during 1994-1996. CONCLUSIONS: Between 1994 and 1999, clinical laboratories in the United States experienced significant changes in the cost of operations, utilization, and labor productivity. Laboratory administrators who compare local institutional performance with that of peers are advised to use current or forward-trended peer data. Quarter-to-quarter improvement in many measures of laboratory financial activity may not signal a superior operation, as performance of the whole industry appears to be improving.     

Prevention of the Wernicke-Korsakoff syndrome: a cost-benefit analysis.

The Wernicke-Korsakoff syndrome is a thiamine-deficiency disorder occurring primarily among alcoholics. To determine the economic feasibility of preventing this disease by fortification of alcoholic beverages with thiamine, we compared the cost of fortification with the cost of institutionalizing alcoholics with the disorder. The estimated annual incidence of institutionalization is eight per million adult population. The cost of long-term institutionalization, discounted to present value, is $70 million per year. The cost of adequately fortifying alcoholic beverages is estimated to range from $3 million per year if allithiamines are used, to as much as $17 million per year if thiamine hydrochloride proves necessary. Thus, the cost-benefit ratio may range from 1:23 to 1:4. It is economically advantageous to prevent the Wernicke-Korsakoff syndrome by fortification of alcoholic beverages with thiamine. The stability, safety and marketability of thiamine and the allithiamines in alcoholic beverages should be studied further.     

Direct and indirect costs of asthma to an employer

BACKGROUND: Asthma is a chronic inflammatory condition of the airways that has a significant effect on the use of health care resources. OBJECTIVE: This study is the first of its kind to estimate the overall cost of asthma to a major employer in the United States and to profile the nature of the asthma expenses. METHODS: The annual per capita cost of asthma was determined for beneficiaries of a major employer by analyzing medical, pharmaceutical, and disability claims data. The incremental cost of asthma was determined by using a case-control method matching asthmatic patients to individuals with no record of asthma treatment. RESULTS: The use of health care services, as well as the rate of disability, was substantially higher among asthmatic patients than among control subjects. Annual per capita employer expenditures for asthmatic patients were approximately 2.5 times those for control subjects ($5385 vs. $2121, respectively). Among asthmatic employees with disability claims, total costs were approximately 3 times higher than those among disability claimants in the employee control sample ($14,827 vs. $5280). For asthmatic employees, wage-replacement costs for workdays lost as a result of disability and sporadic absenteeism (40%) accounted for almost as much as did medical care (43%). CONCLUSION: Failure to account fully for the broader consequences of asthma in terms of indirect and comorbid treatment costs would result in a significant underassessment of the cost of asthma to an employer.     

Controlled trial of pharmacist intervention in general practice: the effect on prescribing costs.

BACKGROUND: It has been suggested that the employment of pharmacists in general practice might moderate the growth in prescribing costs. However, empirical evidence for this proposition has been lacking. We report the results of a controlled trial of pharmacist intervention in United Kingdom general practice. AIM: To determine whether intervention practices made savings relative to controls. METHOD: An evaluation of an initiative set up by Doncaster Health Authority. Eight practices agreed to take part and received intensive input from five pharmacists for one year (September 1996 to August 1997) at a cost of 163,000 Pounds. Changes in prescribing patterns were investigated by comparing these practices with eight individually matched controls for both the year of the intervention and the previous year. Prescribing data (PACTLINE) were used to assess these changes. The measures used to take account of differences in the populations of the practices included the ASTRO-PU for overall prescribing and the STAR-PU for prescribing in specific therapeutic areas. Differences between intervention and control practices were subjected to Wilcoxon matched-pairs, signed-ranks tests. RESULTS: The median (minimum to maximum) rise in prescribing costs per ASTRO-PU was 0.85 Pound (-1.95 Pounds to 2.05 Pounds) in the intervention practices compared with 2.55 Pounds (1.74 Pounds to 4.65 Pounds) in controls (P = 0.025). Had the cost growth of the intervention group been as high as that of the controls, their total prescribing expenditure would have been around 347,000 Pounds higher. CONCLUSION: This study suggests that the use of pharmacists did control prescribing expenditure sufficiently to offset their employment costs.     

The evolving cost of HIV in South Africa: changes in health care cost with duration on antiretroviral therapy for public sector patients

A retrospective costing study of 212 patients enrolled in a nongovernmental organization-supported public sector antiretroviral treatment (ART) program near Cape Town, South Africa was performed from a health care system perspective. gamma-Regression was used to analyze total costs in 3 periods: Pre-ART (median length=30 days), first 48 weeks on ART (Year One), and 49 to 112 weeks on ART (Year Two). Average cost per patient Pre-ART was $404. Average cost per patient-year of observation was $2502 in Year One and $1372 in Year Two. The proportion of costs attributable to hospital care fell from 70% Pre-ART to 24% by Year Two; the proportion attributable to ART rose from 31% in Year One to 55% in Year Two. In multivariate analysis, Pre-ART and Year One costs were significantly lower for asymptomatic patients compared with those with AIDS. Costs were significantly higher for those who died Pre-ART or in Year One. In Year Two, only week 48 CD4 cell count and being male were significantly associated with lower costs. This analysis suggests that the total cost of treatment for patients on ART falls by almost half after 1 year, largely attributable to a reduction in hospital costs.     

1993 survey of salaries & responsibilities for hospital biomedical/clinical engineering & technology personnel

The Journal of Clinical Engineering has conducted its eighth annual survey of the salaries paid to biomedical/clinical engineering and technology personnel in U.S. hospitals. This paper reports the salary and work responsibility data obtained from 1,497 professionals in relationship to: Certification; Region of the U.S.; Teaching versus Nonteaching Facilities; Years of Experience; Education; Union Membership; and Gender. Data are included on Wage Increases and Job Responsibilities. Data are as of 12/31/92 and are compared to 12/31/91. Last year, new job categories were introduced for the overall department or group Director or Manager and the BMET Specialist. The average BMET I has 3.1 years of experience and earns $24,418 +/- $4,615 (Std. Dev.). The average BMET II has 6.8 years of experience and earns $29,853 +/- $5,782. The average BMET III has 13.3 years of experience and earns $37,205 +/- $6,269. The average BMET Specialist has 13.9 years of experience and earns $42,808 +/- $9,420. The average BMET Supervisor has 13.4 years of experience and earns $39,206 +/- $7,709. The average Clinical Engineer has 9.1 years of experience and earns $40,121 +/- $8,242. CE Supervisors have an average 12.1 years of experience and an average salary of $47,353 +/- $15,501. The overall group or department Director or Manager has 15.7 years of experience and earns $51,237 +/- $16,381 on average. Wages are the highest on the East and West Coasts. Again this year, the lowest wages were in the Southeast. BMET wages advanced up to 4.6%, year to year. The highest quartile of Director/Managers now earns between $56,000 and $212,000 per year. Certified individuals variously earn up to $7,995 more than noncertified.     

1992 survey of salaries & responsibilities for hospital biomedical/clinical engineering & technology personnel

The Journal of Clinical Engineering has conducted its seventh annual survey of the salaries paid to biomedical/clinical engineering and technology personnel in U.S. hospitals. This paper reports the salary and work responsibility data obtained from 1,482 professionals in relationship to: Certification; Region of the U.S.; Teaching versus Nonteaching Facilities; Years of Experience; Education; Union Membership; and Gender. Data are included on Wage Increases and Job Responsibilities. Data are as of 12/31/91 and are compared to 12/31/90. This year, new job categories were introduced for the overall department or group Director or Manager and the BMET Specialist. The average BMET I has 2.4 years of experience and earns $23,647 +/- $4,442 (Std. Dev.). The average BMET II has 6.6 years of experience and earns $30,128 +/- $5,696. The average BMET III has 12.9 years of experience and earns $35,855 +/- $5,942. The average BMET Specialist has 13.5 years of experience and earns $40,910 +/- $8,938. The average BMET Supervisor has 13.3 years of experience and earns $37,905 +/- $6,786. The average Clinical Engineer has 7.4 years of experience and earns $40,413 +/- $7,899. CE Supervisors have an average 12.2 years of experience and an average salary of $46,927 +/- $9,935. The overall group or department Director or Manager has 15 years of experience and earns $49,096 +/- $17,333 on average. Wages are the highest on the West Coast. This year, the lowest wages were in the Southeast. Because of survey changes in supervisor survey categories, year-to-year changes for supervisor wages cannot be evaluated. BMET wages, however, advanced 6% to 9%, year to year. The highest quartile of Director/Managers now earns between $53,000 and $245,000 per year. Certified individuals generally earn up to $3,257 more than noncertified, except for BMET Specialists where the certified respondents earned less than the noncertified.     

The costs associated with adverse event procedures for an international HIV clinical trial determined by activity-based costing

OBJECTIVE: To determine costs for adverse event (AE) procedures for a large HIV perinatal trial by analyzing actual resource consumption using activity-based costing (ABC) in an international research setting. METHODS: The AE system for an ongoing clinical trial in Uganda was evaluated using ABC techniques to determine costs from the perspective of the study. Resources were organized into cost categories (eg, personnel, patient care expenses, laboratory testing, equipment). Cost drivers were quantified, and unit cost per AE was calculated. A subset of time and motion studies was performed prospectively to observe clinic personnel time required for AE identification. RESULTS: In 18 months, there were 9028 AEs, with 970 (11%) reported as serious adverse events. Unit cost per AE was $101.97. Overall, AE-related costs represented 32% ($920,581 of $2,834,692) of all study expenses. Personnel ($79.30) and patient care ($11.96) contributed the greatest proportion of component costs. Reported AEs were predominantly nonserious (mild or moderate severity) and unrelated to study drug(s) delivery. CONCLUSIONS: Intensive identification and management of AEs to conduct clinical trials ethically and protect human subjects require expenditure of substantial human and financial resources. Better understanding of these resource requirements should improve planning and funding of international HIV-related clinical trials.     

Managed care for uninsured patients at an academic health center: a case study.

In 1997, the University of New Mexico Health Sciences Center ("the Center") created a managed care plan ("the Plan") for its uninsured patients who were county residents. The Plan's features include pooling the resources of existing county safety-net providers, enrolling patients with primary care providers at easily accessible neighborhood-based clinics, and investing in social support services, case management, and 24-hour telephone triage. After two years of the Plan's operation, the utilization of ambulatory care services by Plan enrollees, the number of discharges per 1,000 enrollees from the Center-affiliated University Hospital, and the number of hospital days per 1,000 enrollees had all dropped significantly (p < .001 for all). For the 13,114 enrollees in the Plan, University Hospital saved an estimated $1,904,872 per year in costs. The replacement of unpaid hospital days with paying patients is estimated to have yielded over $695,000 in additional revenues per year. The authors conclude that managing the care of uninsured patients in an academic health center can reduce ambulatory care and inpatient utilization and reduce the cost of care. To achieve these favorable outcomes requires the organization of services to meet the unique needs of the uninsured and underserved population.     

1985 survey of biomedical & clinical engineering departments in U.S. hospitals.

The Journal of Clinical Engineering has conducted a broad scope survey of hospital biomedical and clinical engineering departments throughout the U.S. An earlier report provided salary and job responsibility data. This second report provides, for the first time, numerical data on the administration, facilities, budgets, department workload, personnel workload, employment benefits, quality assurance, and other professional aspects of the departments. The present report represents approximately 6% of all U.S. hospitals, 10% of all U.S. hospital beds, and over $1.1 Billion dollars worth of hospital equipment service responsibilities. Readers are cautioned not to use the statistical averages presented here as standards or guidelines because of the substantial and appropriate differences between departments. Nevertheless, the survey data provide a useful overview of the hospital-based clinical and biomedical engineering field. The survey determined that 58% of hospital biomedical activities are organized as separate departments reporting to hospital administration. From 1984 to 1985, department budgets increased by +12% overall. While all budget categories increased, wages were the greatest factor (+11%). Teaching facilities have substantially higher budgets than non-teaching. Department floor space increased +3.2% from year to year. Nationwide, an average of 226 sq. ft. is used per department staff member. Department test equipment increased by +11.4% from 1984 to 1985. During the same period, the total dollar value of equipment serviced by the departments increased by +10.5% and the number of devices serviced increased by +4.8%. Nationwide, the statistically average department serviced 2,220 devices worth $7,068,000. Department employment is growing at +10.8% per year (teaching department staffs +7.6%; non teaching +15.9%). Employment of BMETs grew by +8.6%; Clinical Engineers by +11.5%. A measure called Devices Per Person was steady at 500 devices per person from year-to-year. A second measure called Beds Per Person was, on average, 95 beds per department staff member (lower in teaching, higher in non teaching). Other averages are 136 Beds/BMET; 402 Beds/CE; and 390 Beds/Supervisor. Hospital employment benefits are detailed. Only 23% of departments are now equipped to use telecommunications. Virtually all departments have major Q.C. procedures in place.     

1994 survey of salaries & responsibilities for hospital biomedical/clinical engineering & technology personnel

The Journal of Clinical Engineering has conducted its ninth annual survey of the salaries paid to biomedical/clinical engineering and technology personnel in U.S. hospitals. This paper reports the salary and work responsibility data obtained from 1,335 professionals in relationship to: Certification; Region of the U.S.; Teaching versus Nonteaching Facilities; Years of Experience; Education; Union Membership; and Gender. Data are included on Wage Increases and Job Responsibilities. Data are as of 12/31/93 and are compared to 12/31/92. The average BMET I has 3.7 years of experience and earns $25,464 +/- $4,838 (Std. Dev.). The average BMET II has 7.3 years of experience and earns $31,217 +/- $6,069. The average BMET III has 13.2 years of experience and earns $38,095 +/- $6,187. The average BMET Specialist has 14.3 years of experience and earns $43,017 +/- $9,322. The average BMET Supervisor has 14.2 years of experience and earns $41,194 +/- $7,844. The average Clinical Engineer has 8.4 years of experience and earns $42,392 +/- $7,630. CE Supervisors have an average 13.1 years of experience and an average salary of $47,403 +/- $9,561. The overall group or department Director or Manager has 15.5 years of experience and earns $52,245 +/- $13,567 on average. Wages are the highest on the East and West Coasts. The lowest wages are in the Southeast and Southwest. BMET wages advanced up to 5.1%, year to year. The highest quartile of Director/Managers now earns between $59,000 and $101,000 per year. Certified individuals variously earn up to $5,188 more than noncertified.     

Hospital financial audit of medical equipment maintenance: a case study.

Maintenance expense is becoming an area of importance in the business of health care. Methods for identification and determination of both types and amounts of expenses have also become important. This paper is a case study of one institution's total medical equipment maintenance expense, during the 1985/86 fiscal year. During this time, the total hospital medical maintenance expense was $683,614: of which $238,008 (34.8%) was salary; $85,858 (12.6%) was parts; $77,083 (11.3%) was contracts; $48,230 (7.1%) was service; $123,572 (18.1%) was X-ray tubes; $91,260 (13.3%) was maintenance insurance; $14,479 (2.1%) was for training; $1,212 (0.2%) was for operating expenses; and $3,912 (0.6%) was the 10-year amortized test-equipment expense. The maintenance-expense/acquisition-cost ratio was 4.36%. Arguments are presented on the need to obtain expense data that have some comparative value to other institutions and on developing benchmarks to be utilized in evaluating acceptable levels of expense.     

Does the North Staffordshire slot system control demand of orthopaedic referrals from primary care?: A population-based survey in general practice

BACKGROUND: Attempts to manage general practice demand for orthopaedic outpatient consultations have been made in several areas of the NHS, with little robust evidence on whether or not they work. AIM: To evaluate the effect of the North Staffordshire 'orthopaedic slot system' on the demand for general practice referrals to orthopaedic outpatients. METHOD: A prospective study of 12 general practices in the slot system, 24 controls, and the 63 other general practices in North Staffordshire. Comparison periods were the baseline year (0); the first calendar year (1); and the first half of the second calendar year (2). A multifactor linear regression model was used. RESULTS: Mean referral rate decreased 22% in the slot group in period 1, and was maintained in period 2 (9.40, 7.29, 7.31 referrals per 10,000 population per month for periods 0, 1 and 2, respectively). The control and other groups showed a small decrease in period 1, but in period 2 higher referral rates were observed. The reduction in referrals of 20-40% in participating practices compared to other practices equates to 2-4 referrals per 10,000 patients per month. CONCLUSIONS: Our study suggests that practices willing and able to take up an offer of a slot system for managing their orthopaedic referrals will be able to significantly reduce referral rates for their patients when compared to similar practices who do not. Further research on the generalisability, effectiveness and cost-effectiveness of such systems is warranted.     

Implementing a simpler approach to mission-based planning in a medical school.

Changes in the education, research, and health care environments have had a major impact on the way in which medical schools fulfill their missions, and mission-based management approaches have been suggested to link the financial information of mission costs and revenues with measures of mission activity and productivity. The authors describe a simpler system, termed Mission-Aligned Planning (MAP), and its development and implementation, during fiscal years 2002 and 2003, at the School of Medicine at the University of Texas Health Science Center at San Antonio, Texas. The MAP system merges financial measures and activity measures to allow a broad understanding of the mission activities, to facilitate strategic planning at the school and departmental levels. During the two fiscal years mentioned above, faculty of the school of medicine reported their annual hours spent in the four missions of teaching, research, clinical care, and administration and service in a survey designed by the faculty. A financial profit or loss in each mission was determined for each department by allocation of all departmental expenses and revenues to each mission. Faculty expenses (and related expenses) were allocated to the missions based on the percentage of faculty effort in each mission. This information was correlated with objective measures of mission activities. The assessment of activity allowed a better understanding of the real costs of mission activities by linking salary costs, assumed to be related to faculty time, to the missions. This was a basis for strategic planning and for allocation of institutional resources.     

Primary care funding, contract status, and outcomes: an observational study

BACKGROUND: The introduction of the Quality and Outcomes Framework (QOF) provides a quantitative way of assessing quality of care in general practice. We explore the achievements of general practice in the first year of the QOF, with specific reference to practice funding and contract status. AIM: To determine the extent to which differences in funding and contract status affect quality in primary care. DESIGN OF STUDY: Cross-sectional observational study using practice data obtained under the Freedom of Information Act 2000. SETTING: One hundred and sixty-four practices from six primary care trusts (PCTs) in England. METHOD: Practice data for all 164 practices were collated for income and contract status. The outcome measure was QOF score for the year 2004-2005. All data were analysed statistically. RESULTS: Contract status has an impact on practice funding, with Employed Medical Services (EMS) and Personal Medical Services (PMS) practices receiving higher levels of funding than General Medical Services (GMS) practices (P<0.001). QOF scores also vary according to contract status. Higher funding levels in EMS practices are associated with lower QOF scores (P=0.04); while GMS practices exhibited the opposite trend, with higher-funded practices achieving better quality scores (P<0.001). CONCLUSION: GMS practices are the most efficient contract status, achieving high quality scores for an average of pound 62.51 per patient per year. By contrast, EMS practices are underperforming, achieving low quality scores for an average of pound 105.37 per patient per year. Funding and contract status are therefore important factors in determining achievement in the QOF.