Reuse of permanent cardiac pacemakers.

Cardiac pacemakers are part of a growing group of expensive implantable electronic devices; hospitals in which 100 pacemakers are implanted per year must budget over $300 000 for these devices. This cost represents a considerable burden to health care resources. Since the "life-span" of modern pacemakers often exceeds that of the patients who receive them, the recovery and reuse of these devices seems logical. Pacemakers can be resterilized and tested with current hospital procedures. Reuse should be acceptable under Canadian law, but the manner in which the pacemakers are recovered and the patients selected should follow careful guidelines. Every patient should provide written informed consent before receiving a recovered pacemaker. Properly executed, reuse of pacemakers should provide a high level of health care while maintaining or reducing the cost of these devices.     

Effect of a self-care education program on medical visits

A prospective, randomized, controlled trial of self-care educational interventions was conducted in a health maintenance organization to determine their effect on ambulatory care utilization. Statistically significant decreases in total medical visits and minor illness visits were found in each of three experimental groups as compared with a control group. These decreases averaged 17% and 35%, respectively. These results were most clearly linked to a system of written communications emphasizing personal decision making about the use of medical care. The addition of a nurse counseling session to the written materials may increase cost savings and appears to be attractive to "high utilizers." A telephone information service was offered but not used. It is estimated that the decreases in utilization could result in a savings of approximately $ 2.50 to $ 3.50 for each dollar spent ona nurse counseling session to the written materials may increase cost savings and appears to be attractive to "high utilizers." A telephone information service was offered but not used. It is estimated that the decreases in utilization could result in a savings of approximately $ 2.50 to $ 3.50 for each dollar spent on the educational interventions. Self-care education systems may have important effects on medical care costs, physician satisfaction, and patient confidence.     

有限性财政支持和负责任的选择:福利国家后的卫生保健

福利国家在医疗保健的金融资助上片面追求公平、公正、平等。坚持医疗保健享有权的公平、公正、平等虽然符合世俗道德,但不符合情理和伦理学要求,并且会误导政府制定出财政上无法持续、医疗经费支付不合理的保健政策,把医疗保健作为福利来对待从而加重国家和个人的经济负担,而不能全面保障国民的保健需求。从国家政策和个人的选择、医疗保健项目与自我使用的权利和可利用的资源、享有权与道德风险、享有权与政治风险、国家福利制度与制药企业间、医疗技术的进步与医疗成本、医学进步与老年人口增长七个方面全方位探讨医疗保健与人的状况的有限性的关系。建议:发展中国家应该审慎研究发达国家的医疗保健政策,但绝不能照搬;他们需要建立和制定符合自己国情的医疗保障体系和政策,使国民享有全面的医疗保障;为了保障医疗财政支持的可持续性及全面保障国民的保健需求,应建立健康储蓄账户,并以强制性购买灾难性健康保险作为补充,对于一些贫穷的地方或地区,由国家支付经费为其建立健康储蓄账户,形成以家庭为单位的医疗经费支付单位,这样可以避免医疗保健享有权的五大危害:过度消费、政治风险、资源不足的风险、风险转移、哲学风险。     

Prioritizing Oregon's hospital resources. An example based on variations in discretionary medical utilization.

OBJECTIVE--To provide an alternative to Oregon's treatment-specific approach to rationing, we propose a prioritization based on the local hospital resources invested in discretionary medical admissions. DESIGN--We used 1988 Oregon hospital discharge data to determine age- and sex-adjusted per-capita rates of inpatient days for discretionary medical admissions (for high-variation medical conditions) in each of 33 hospital service areas. Potential ceiling rates were defined based on prevailing utilization rates for discretionary medical admissions in each hospital service area. Savings were calculated under the assumption that resources allocated for inpatient treatment of these conditions in areas that exceed the ceiling rates were reduced accordingly. SETTING--Nonfederal, acute-care hospitals used by Oregon residents. STUDY POPULATION--Oregon residents. MAIN OUTCOME MEASURES--Savings were defined in terms of patient days, hospital beds, hospital charges, and average costs. RESULTS--Among the 16 largest hospital service areas, patient-day rates for discretionary medical admissions ranged from 188 to 335 patient days per thousand. Potential savings from applying different ceiling rates ranged from $0.4 million to $94.7 million per year. If the rate in the state capital (Salem) were used as the ceiling (218 days per thousand), then 238 beds could be closed in 20 hospital service areas, for an estimated cost savings of $47.3 million. CONCLUSIONS--Hospital resources invested in discretionary admissions in high-rate areas represent an important potential source of funds for reallocation to meet other defined health care needs. Setting limits based on units of health care supply (eg, beds, capital equipment, and physicians) should be considered as an option for resource reallocation within health care.     

Effect of improved glycemic control on health care costs and utilization

CONTEXT: Because of the additional costs associated with improving diabetes management, there is interest in whether improved glycemic control leads to reductions in health care costs, and, if so, when such cost savings occur. OBJECTIVE: To determine whether sustained improvements in hemoglobin A(1c) (HbA(1c)) levels among diabetic patients are followed by reductions in health care utilization and costs. DESIGN AND SETTING: Historical cohort study conducted in 1992-1997 in a staff-model health maintenance organization (HMO) in western Washington State. PARTICIPANTS: All diabetic patients aged 18 years or older who were continuously enrolled between January 1992 and March 1996 and had HbA(1c) measured at least once per year in 1992-1994 (n = 4744). Patients whose HbA(1c) decreased 1% or more between 1992 and 1993 and sustained the decline through 1994 were considered to be improved (n = 732). All others were classified as unimproved (n = 4012). MAIN OUTCOME MEASURES: Total health care costs, percentage hospitalized, and number of primary care and specialty visits among the improved vs unimproved cohorts in 1992-1997. RESULTS: Diabetic patients whose HbA(1c) measurements improved were similar demographically to those whose levels did not improve but had higher baseline HbA(1c) measurements (10.0% vs 7.7%; P<.001). Mean total health care costs were $685 to $950 less each year in the improved cohort for 1994 (P =.09), 1995 (P =.003), 1996 (P =.002), and 1997 (P =.01). Cost savings in the improved cohort were statistically significant only among those with the highest baseline HbA(1c) levels (>/=10%) for these years but appeared to be unaffected by presence of complications at baseline. Beginning in the year following improvement (1994), utilization was consistently lower in the improved cohort, reaching statistical significance for primary care visits in 1994 (P =.001), 1995 (P<.001), 1996 (P =.005), and 1997 (P =.004) and for specialty visits in 1997 (P =.02). Differences in hospitalization rates were not statistically significant in any year. CONCLUSION: Our data suggest that a sustained reduction in HbA(1c) level among adult diabetic patients is associated with significant cost savings within 1 to 2 years of improvement.     

Economic impacts of Medicaid in North Carolina

OBJECTIVE: The purpose of this study is to provide estimates of the economic impacts of Medicaid program expenditures in North Carolina in state fiscal year (SFY) 2003. STUDY DESIGN: The study uses input-output analysis to estimate the economic impacts of Medicaid expenditures. DATA SOURCES/STUDY SETTING: The study uses North Carolina Medicaid program expenditure data for SFY 2003 as submitted by the North Carolina Division of Medical Assistance to the federal Centers for Medicare and Medicaid Services (CMS). Industry structure data from 2002 that are part of the IMPLAN input-output modeling software database are also used in the analysis. PRINCIPAL FINDINGS: In SFY 2003 $6.307 billion in Medicaid program expenditures occurred within the state of North Carolina-$3.941 billion federal dollars, $2.014 billion state dollars, and $351 million in local government funds. Each dollar of state and local government expenditures brought $1.67 in federal Medicaid cost-share to the state. The economic impacts within North Carolina of the 2003 Medicaid expenditures included the following: 182,000 jobs supported (including both full-time and some part-time jobs); $6.1 billion in labor income (wages, salaries, sole proprietorship/partnership profits); and $1.9 billion in capital income (rents, interest payments, corporate dividend payments). If the Medicaid program were shut down and the funds returned to taxpayers who saved/spent the funds according to typical consumer expenditure patterns, employment in North Carolina would fall by an estimated 67,400 jobs, and labor income would fall by $2.83 billion, due to the labor-intensive nature of Medicaid expenditures. LIMITATIONS: Medicaid expenditure and economic impact results do not capture the economic value of the improved health and well-being of Medicaid recipients. Furthermore, the results do not capture the savings to society from increased preventive care and reduced uncompensated care resulting from Medicaid. ConclusionS: State and local government expenditures do not fully capture the economic consequences of Medicaid in North Carolina. This study finds that Medicaid makes a large contribution to state and local economic activity by creating jobs, income, and profit in North Carolina. Any changes to the Medicaid program should be made with caution. RELEVANCE: The rising costs of health care and the appropriate role of government health insurance programs are the object of current policy debates. Informed discussion of these issues requires good information on the economic and health consequences of alternative policy choices. This is the first systematic study of the broader economic impacts of Medicaid expenditures in North Carolina.     

When does mass screening for open neural tube defects in low-risk pregnancies result in cost savings?

Using a decision analysis model, we estimated the savings that might be derived from a mass prenatal screening program aimed at detecting open neural tube defects (NTDs) in low-risk pregnancies. Our baseline analysis showed that screening v. no screening could be expected to save approximately $8 per pregnancy given a cost of $7.50 for the maternal serum alpha-feto-protein (MSAFP) test and a cost of $42,507 for hospital and rehabilitation services for the first 10 years of life for a child with spina bifida. When a more liberal estimate of the costs of caring for such a child was used, the savings with the screening program were more substantial. We performed extensive sensitivity analyses, which showed that the savings were somewhat sensitive to the cost of the MSAFP test and highly sensitive to the specificity (but not the sensitivity) of the test. A screening program for NTDs in low-risk pregnancies may result in substantial savings in direct health care costs if the screening protocol is followed rigorously and efficiently.     

Canadian health expenditures: Where do we really stand internationally?

There are different ways to measure how much Canada spends on health care and the quality of these measurements may vary. This paper examines Organization for Economic Cooperation and Development data for 3 common standards of measure: health expenditures as a proportion of gross domestic product (GDP), nominal spending per capita (US dollars) and spending per capita in purchasing power parities (PPP) equivalents. In 1994, the most recent year for which there were firm data. Canada spent 9.9% of its GDP on health care (rank 3 of 29), and $1999 PPPs per capita (rank 3). However, actual spending was only US$1824 per capita (rank 14). In the same year Japan spent 7% of GDP on health care (rank 22), $1478 in PPPs per capita (rank 16), but actually spent US$2614 per capita (rank 3). Although each measure is suitable for some policy purposes, Canadian spending remains modest by international standards.     

Cost-effectiveness of induction of labour versus serial antenatal monitoring in the Canadian Multicentre Postterm Pregnancy Trial.

OBJECTIVE: To determine the cost-effectiveness of induction of labour versus serial fetal monitoring while awaiting spontaneous labour in postterm pregnancies. DESIGN: Cost-effectiveness and cost-minimization analyses conducted as part of a Canadian multicentre randomized clinical trial. SETTING: Twenty-two Canadian hospitals, of which 19 were teaching hospitals and 3 were community hospitals. PATIENTS: Women with uncomplicated pregnancies of 41 or more weeks' gestation were randomly assigned to induction of labour or serial antenatal monitoring. Of the 3418 women enrolled, no data were received on 11. Therefore, results were based on data from 1701 women in the induction arm of the study and 1706 women in the monitoring arm. MAIN OUTCOME MEASURES: Perinatal mortality and neonatal morbidity, rates of cesarean section and health care costs. Hospital costing models were developed specifically for the study. Data on use of major resources (e.g., length of hospital stay, surgical procedures, major diagnostic tests and procedures, and medications) for all trial participants were collected and combined with data on minor tests and procedures (e.g., laboratory tests) abstracted from a detailed review of medical records of a sample of patients. RESULTS: Because the results of the clinical trial showed a nonsignificant difference in perinatal mortality and neonatal morbidity between the induction and monitoring arms, the authors conducted a cost-minimization rather than a cost-effectiveness analysis. The mean cost per patient with a postterm pregnancy managed through monitoring was $3132 (95% confidence interval [CI] $3090 to $3174) and per patient who underwent induction of labour was $2939 (95% CI $2898 to $2981), for a difference of $193. The significantly higher (p < 0.0001) mean cost per patient in the monitoring arm was due mainly to the costs of additional monitoring and the significantly higher rates of cesarean section among these patients. Estimated conservatively, the savings resulting from a universal policy of managing postterm pregnancies by induction of labour in Canada may be as high as $8 million a year. CONCLUSIONS: A policy of managing postterm pregnancy through induction of labour not only results in more favourable outcomes than a monitoring strategy but does so at a lower cost.     

Universal precautions to prevent HIV transmission to health care workers: an economic analysis.

The universal precautions recommended by the US Centers for Disease Control (CDC), Atlanta, for the prevention of HIV (human immunodeficiency virus) transmission to health care workers are widely accepted, despite little documentation of their effectiveness and efficiency. We reviewed the evidence on the risk of HIV transmission to hospital workers and the effectiveness of the universal precautions. We also evaluated the costs of implementing the recommendations in a 450-bed acute care teaching hospital in Hamilton, Ont. On the basis of aggregated results from six prospective studies the risk of HIV seroconversion among hospital workers after a needlestick injury involving a patient known to have AIDS (acquired immune deficiency syndrome) is 0.36% (upper 95% confidence limit 0.67%); the risk after skin and mucous membrane exposure to blood or other body fluids of AIDS patients is 0% (upper 95% confidence limit 0.38%). We estimated that 0.038 cases of HIV seroconversion would be prevented annually in the study hospital if the CDC recommendations were followed. The incremental cost of implementing the universal precautions was estimated to be about $315,000 per year, or over $8 million per case of HIV seroconversion prevented. If all HIV-infected workers were assumed to have AIDS within 10 years of infection the of the program would be about $565,000 per life-year saved. When less conservative, more probable assumptions were applied the best estimate of the implementation cost was $128,862,000 per case of HIV seroconversion prevented. The universal precautions implemented in the study hospital were not found to be efficacious or cost-effective. To minimize the already small risk of HIV transmission in hospitals the sources of risk of percutaneous injury should be better defined and the design of percutaneous lines, needles and surgical equipment as well as techniques improved. Preventive measures recommended on the basis of demonstrated efficacy and aimed at routes of exposure that represent true risk are needed.     

Relationship between modifiable health risks and short-term health care charges

CONTEXT: If physical inactivity, obesity, and smoking status prove to contribute significantly to increased health care charges within a short period of time, health plans and payers may wish to invest in strategies to modify these risk factors. However, few data are available to guide such resource allocation decisions. OBJECTIVE: To examine the relationship of modifiable health risks to subsequent health care charges after controlling for age, race, sex, and chronic conditions. DESIGN, SETTING, AND PARTICIPANTS: Cohort study of a stratified random sample of 5689 adults (75.5% of total sample of 7535) aged 40 years or older who were enrolled in a Minnesota health plan and completed a 60-item questionnaire. MAIN OUTCOME MEASURE: Resource use as measured by billed health care charges from July 1, 1995, to December 31, 1996, compared by health risk (physical activity, body mass index [BMI], and smoking status). RESULTS: The mean annual per patient charge in the total study population was $3570 (median, $600), and 15% of patients had no charges during the study period. After adjustment-for age, race, sex, and chronic disease status, physical activity (4.7% lower health care charges per active day per week), BMI (1.9% higher charges per BMI unit), current smoking status (18% higher charges), and history of tobacco use (25.8% higher charges) were prospectively related to health care charges over 18 months. Never-smokers with a BMI of 25 kg/m2 and who participated in physical activity 3 days per week had mean annual health care charges that were approximately 49% lower than physically inactive smokers with a BMI of 27.5 kg/m2. CONCLUSIONS: Our data suggest that adverse health risks translate into significantly higher health care charges within 18 months. Health plans or payers seeking to minimize health care charges may wish to consider strategic investments in interventions that effectively modify adverse health risks.     

The epidemiology of dog walking: an unmet need for human and canine health

OBJECTIVE: To describe the prevalence of dog walking in New South Wales, and to identify potential health gains if more dogs were walked. DESIGN: Cross-sectional analytical survey. SETTING AND PARTICIPANTS: 894 adults in NSW in 1998 (among the owners of approximately two million domestic dogs in NSW who were potential participants in dog-walking behaviours). INTERVENTIONS: None yet. MAIN OUTCOME MEASURES: Dog walking hours per week; other DogEpi concepts to illustrate the public health gains include the DAF (dog attributable fraction), and the BBR (benefits to bites ratio). RESULTS: The response rate to the survey was 74%. 46% of households in NSW had a dog and, overall, dog owners walked 18 minutes per week more than non-dog owners. However, more than half of dog owners did not walk their dogs, and were less likely than non-owners to meet recommended levels of physical activity sufficient for health benefits. If all dog owners walked their dogs, substantial disease prevention and healthcare cost savings of $175 million per year might accrue. CONCLUSIONS: There are potential benefits of dog walking for human health; currently, among dog owners, much of this benefit remains to be realised. There are also likely benefits for canine health. Dog walking should be promoted through national strategies recommending "Walkies for all by the year 2010".     

Savings from outpatient antibiotic therapy for osteomyelitis. Economic analysis of a therapeutic strategy

Clinical, economic, and epidemiologic data were used to compare the costs of conventional inpatient care of osteomyelitis with the costs of early-discharge treatment using a once-daily parenteral antibiotic at home. Estimated expenses included inpatient medical care, outpatient visits, supplies, child care, home care, transportation, and lost productivity. Early-discharge treatment was associated with lower medical direct, non-medical direct, and indirect expenses than conventional inpatient treatment. Estimated savings per patient ranged from $510 to $22,232 (demonstrating the wide differences in estimated savings when different sources of data on hospital costs are used). These savings are due to large decreases in inpatient costs, which are partially offset by increased outpatient costs. However, because outpatient costs are more often borne by patients than are inpatient costs, early-discharge treatment could be more expensive from the patient's perspective, despite its savings for the hospital and for society as a whole.     

Costs of medical care for acute myocardial infarction attributable to tobacco consumption

BACKGROUND: Tobacco consumption is the principal modifiable risk factor causally associated with acute myocardial infarction (AMI). AMI has been an increasing and important cause of death in Mexico since 1980. METHODS: To estimate the direct health care costs of AMI, we carried out a cost of illness (COI) analysis, using data derived from an expert panel consensus and from medical chart review. We used the smoking attributable fraction (SAF) estimates to derive costs of tobacco consumption. We also estimated the benefits of a "Smoke-free Workplace" tobacco control policy in terms of avoidable deaths and health care costs savings. RESULTS: We estimated an annual average costs of 6,420 US dollars and 9,216 US dollars for non-ST segment elevation AMI (NSTEMI) and ST segment elevation AMI (STEMI), respectively. The total annual health care costs estimated for incident AMI for the IMSS state-level division of Morelos reached 2.9 million US dollars, of which 1.6 million US dollars was directly attributed to tobacco consumption. CONCLUSIONS: Our results confirm the high costs associated with smoking and show the potential benefits resulting from a tobacco control policy. Our estimates are only applicable to social security in the state-level division of Morelos and more likely represent a lower boundary of the total costs of cardiovascular diseases attributed to tobacco, because we based the costs estimation on incident cases, and we did not take into consideration the costs derived from prevalent cases, indirect costs or other intangibles.     

What should be done about the uninsured poor?

The author proposes a program for the expansion of access to medical care which realistically reflects the public belief that everyone has a right to adequate health care and the assumption that the individual taxpayer should not have to pay more than $50 per year to see this happen: scrap Medicaid and create a new initiative, administered through state health departments, to subsidize private health insurance policies; require basic private health insurance coverage for all full-time (including temporary) employees; and tax the individual between $50 and $65 to insure those not in the workplace full-time. This plan offers the promise of achieving bipartisan support by relying on private health insurance linked to employment and the removal of disincentives for seeking work among the poor.     

Experiences in the implementation of a national policy: A retrospective analysis of the Australian Chronic Dental Disease Scheme

Background

The Chronic Dental Disease Scheme (CDSS) is the first public dental policy in Australia to attract Medicare benefits for dental services.

Aims

This study examines the utilisation of a new federal method of funding dental care in Australia and provides an insight into the implications of government dental programs. The program titled; Chronic Dental Disease Scheme, provided government-subsidised dental care for people suffering from a chronic medical condition.

Method

A retrospective analysis of activity data using the relevant item numbers were extracted from the open source Medicare Benefits Schedule database (MBS) for years 2007-2009.

Results

During the study period, a total of approximately five million dental services were provided. There was a disproportionate use of services between jurisdictions. The highest proportion (66%) of services was provided in the state of New South Wales (NSW) with Victoria second (22%). The adjusted value of care provided as a proportion of comprehensive examinations ranged from $1937 in the northern territory (NT) to $2900 in NSW. The value of care per dentist ranged from nearly $80 000 down to less than $1000 and the value of care per adult of the population ranged between $53 and $1 across Australia. The highest was always in NSW and the lowest always being the NT. Fixed prosthodontics (reconstruction) accounted for the significant costs associated with the program.

Conclusion

The scheme has been utilised above its budget estimate with prosthodontics accounting for the majority of expenses. Treatment plans differed between jurisdictions. The increase in utilisation of the scheme was coincident with periods of increased in subsidy and remuneration and has been postulated to be a main driver for its utilisation rather than the improvement in chronic health.     

Telephone care as a substitute for routine clinic follow-up.

DESIGN--Randomized trial. SETTING--A primary care clinic. PATIENTS--Four hundred ninety-seven men aged 54 years or older. OBJECTIVE--We examined the hypothesis that substituting clinician-initiated telephone calls (telephone care) for some clinic visits would reduce medical care utilization without adversely affecting patient health. INTERVENTION--Clinicians were asked to double their recommended interval for face-to-face follow-up and schedule three intervening telephone contacts; for control patients, the follow-up interval recommended by their clinician was unchanged. MAIN OUTCOME MEASURES--Use of medical services and health status. RESULTS--During the 2-year follow-up period, 7% of patients withdrew or became unavailable. Telephone-care patients had fewer total clinic visits, scheduled and unscheduled, than usual-care patients (19%, P less than .001). In addition, telephone-care patients had less medication use (14%, P = .006), fewer admissions, and shorter stays in the hospital (28% fewer total hospital days, P = .005), and 41% fewer intensive care unit days (P = .03). Estimated total expenditures for telephone care were 28% less per patient for the 2 years ($1656, P = .004). For the subgroup of patients with fair or poor overall health at the beginning of the study (n = 180), savings were somewhat greater ($1976, P = .01). In this subgroup, improvement in physical function from baseline (P = .02) and a possible reduction in mortality (P = .06) were also observed. CONCLUSION--We conclude that substituting telephone care for selected clinic visits significantly reduces utilization of medical services. For more severely ill patients, the increased contact made possible by telephone care may also improve health status and reduce mortality.     

Expansion of health care to the uninsured and underinsured has to be cost-neutral

Any attempt to address the problem of more than 30 million uninsured and 25 million seriously underinsured citizens in the United States has to be able to offer medical services to this 20% of the population in a cost-neutral way for the US economy, since present economic conditions do not permit further expansion in health care costs. A medical system compartmentalized by medical specialty should be able to save approximately 20% of present-day health care expenditures within each specialty, which then can be used to provide the necessary coverage. Some suggestions are made as to how such cost savings can be achieved. Only an effort spearheaded by physicians can achieve the outlined targets, since, otherwise, physician efforts will easily subvert such attempts. A physician initiative that could solve the crisis would reestablish physicians as leaders in determining national health care policy and should consequently improve the recently disappointing societal image of the profession.     

Costs associated with gunshot wounds in Canada in 1991.

OBJECTIVE: To estimate the costs (in 1993 dollars) associated with gunshot wounds in Canada in 1991. DESIGN: Cost analysis using separate estimates of gunshot incidence rates and costs per incident for victims who died, those who survived and were admitted to hospital and those who survived and were treated and released from emergency departments. Estimates were based on costs for medical care, mental health care, public services (i.e., police investigation), productivity losses, funeral expenses, and individual and family pain, suffering and lost quality of life. SETTING: Canada. OUTCOME MEASURES: Costs per case, costs by type of incident (e.g., assault, suicide or unintentional shooting) and costs per capita. RESULTS: The total estimated cost associated with gunshot wounds was $6.6 billion. Of this, approximately $63 million was spent on medical and mental health care and $10 million on public services. Productivity losses exceeded $1.5 billion. The remaining cost represented the value attributed to pain, suffering and lost quality of life. Suicides and attempted suicides accounted for the bulk of the costs ($4.7 billion); homicides and assaults were the next most costly ($1.1 billion). The cost per survivor admitted to hospital was approximately $300,000; this amount included just over $29,000 for medical and mental health care. CONCLUSION: Costs associated with gunshot wounds were $235 per capita in Canada in 1991, as compared with $595 in the United States in 1992. The differences in these costs may be due to differences in gun availability in the two countries. This suggests that increased gun control may reduce Canada's costs, especially those related to suicide.     

Regional variations in the use of home care services in Ontario, 1993/95

BACKGROUND: Although regional variations in the use of many health care services have been reported, little attention has been devoted to home care practices. Given the dramatic shift in care settings from hospitals to private homes, it is important to determine the extent to which home care practices vary by geographic region. METHODS: Data from the Canadian Institute for Health Information and the Ontario Home Care Administration System database were used to assess regional variations in rates of home care use following inpatient care and same-day surgery for the fiscal years 1993, 1994 and 1995. Various measures of regional variation were employed. RESULTS: Of the 2,870,695 inpatient separations and 1,803,307 same-day surgery separations during the study period, 359,972 and 64,541, respectively, were followed by home care. The rate of home care use per 100 separations was 12.5 for inpatients and 3.6 for same-day surgery patients. There was a a 3.5-fold regional variation in the rates of home care use following inpatient care and a 7-fold variation in rates of use following same-day surgery. Additional home care funding to attain calculated target rates was estimated to be $48.9 million (30% of expenditures for patients recently discharged from hospital over the study period). For a 20% increase in service provision it was estimated that an additional injection of $42.2 million is required. INTERPRETATION: The wide regional variations in rates of home care use highlight the importance of modifying home care funding to ensure that all residents of Ontario have equal access to services. To achieve this our estimates suggest that a substantial increase in home care funding is warranted.