Social valuation of life through prevention for industrial risk: The economic rationale versus social practices

At present social and economical implications of prevention programmes for industrial health risks tend to stress the role of the economical factors within the decision process. In considering lethal risks, the assessment of the prevention programmes' effectiveness may be obtained by calculating the implicit cost of human life. Numerous authors have shown the large variability of these implicit costs, even when considering control policies related to comparable industrial nuisances. The aim of this paper is to review some factors that pertain to the variability of life valuation in relation to decision-making processes and social values. The principles underlying the regulation of environmental and occupational industrial health risks do not refer to the concept of ‘effective’ allocation of prevention resources.Besides, decision-making processes tend to generate rather large disparities as far as the choice of the pollutants to be controlled is concerned, for example: the high priority attached to lead, asbestos or ionizing radiations is rather detrimental for the whole set of other pollutants.Disparities are also to be found at the implementation level, according to the polluter's size: care is generally taken of the larger enterprises, and seldom of the smaller ones. Moreover, in some sectors such as the nuclear industry, the rationale of the risk prevention policy partially reflects an attempt to prevent public fear.     

An economic model of large Medicaid practices.

Public attention given to Medicaid "mills" prompted this more general investigation of the origins of large Medicaid practices. A dual market demand model is proposed showing how Medicaid competes with private insurers for scarce physician time. Various program parameters--fee schedules, coverage, collection costs--are analyzed along with physician preferences, specialties, and other supply-side characteristics. Maximum likelihood techniques are used to test the model. The principal finding is that in raising Medicaid fees, as many physicians opt into the program as expand their Medicaid caseloads to exceptional levels, leaving the maldistribution of patients unaffected while notably improving access. Still, the fact that Medicaid fees are lower than those of private insurers does lead to reduced access to more qualified practitioners. Where anti-Medicaid sentiment is stronger, access is also reduced and large Medicaid practices more likely to flourish.     

The clinical rationale for menses-free contraception

The impact of monthly menstruation may range from a minor inconvenience for some women to a major health concern for those who suffer from menstrual disorders and health conditions that are aggravated during their menstrual cycle. Oral contraceptives (OCs) have been used safely in continuous regimens for the treatment of menstrual disorders in some women and for others who choose to extend their 28-day menstrual cycle to accommodate major life events. There is no physiological requirement for the monthly hormone withdrawal bleed that is experienced by women taking cyclic OCs or for a menstrual period in women who do not desire to (or cannot) become pregnant. Thus, the use of continuous or extended-cycle OC regimens that eliminate the menstrual cycle represents a viable and attractive option for many women. The availability of more choices for menstrual suppression, such as continuous use of OCs, will improve the quality of life for many women who suffer from menstrual-related disorders and provide greater convenience for women with busy and active lifestyles.     

The economic effect of implementing an EMR in an outpatient clinical setting

Central Utah Multi-Specialty Clinic, a 59-physician group with practices in nine locations treating 200,000 active patients, documented the economic impact of implementing an electronic medical record. During the one-year period of the study, the clinic experienced direct reductions in spending and increases in revenue of more than $952,000 compared with the prior year, and anticipates cumulative savings of more than $8.2 million over the next five years.     

Development of clinical methods for utilization review in psychiatric day treatment

When a time-limited day treatment program was reconfigured to serve individuals with long-standing psychotic disorders, the number of treatment episodes exceeding six months rose to 70%. To justify this concentration of resources, the program needed methods to identify individuals for whom sustained treatment was appropriate. This report describes development of utilization review methods adapted to publicly funded day treatment of individuals with serious mental illness and training of clinicians in new documentation skills. Data from three years of operation suggest that symptom severity is not a reliable indicator of medical necessity in day treatment. As expected with a clinically based system, a composite measure of benefit and medical necessity indicators weighted toward functioning in living, learning, working, and socializing environments predicted physician reviewer denial of continued day treatment, but length of stay did not.     

Extended outpatient civil commitment and treatment utilization

OBJECTIVE: This study considers four hypotheses regarding the impact of extended involuntary outpatient commitment orders on services utilization. METHOD: All Victorian Psychiatric Case Register (VPCR) patients who had extended (180+ day) outpatient commitment orders in the nine year study period and a matched treatment compliant comparison group with extended periods of outpatient care (N = 1182), both with at least two years of post-episode experience, were evaluated. Pre/post episode utilization was compared via paired t tests with individuals as their own controls. Logistic and OLS regression as well as repeated measures ANOVA via the GLM SPSS program and post hoc t tests were used to evaluate between group and across time differences. RESULTS: Extended episodes of care for both groups were associated with reduced use of hospitalization and increases in outpatient services. Extended orders did not promote voluntary participation in the post-period. Outpatient services during the extended episode for those on orders were raised to the level experienced by the treatment compliant comparison group and maintained at that level via subsequent renewal of orders throughout the patients' careers. OLS regression results indicate that approximately six community care service days were required for those on orders to achieve a one-day reduction in hospital utilization following the extended episode. CONCLUSION: Outpatient commitment for those on extended orders in the Victorian context enables a level of community-based services provision, unexpected in the absence of this delivery system, which provides an alternative to hospitalization.     

Statistical trends of episiotomy around the world: Comparative systematic review of changing practices

The authors' purpose for this article is to identify, review and interpret all publications about the episiotomy rates worldwide. Based on the criteria from the PRISMA guidelines, twenty databases were scrutinized. All studies which include national statistics related to episiotomy were selected, as well as studies presenting estimated data. Sixty-one papers were selected with publication dates between 1995 and 2016. A static and dynamic analysis of all the results was carried out. The assumption for the decline in the number of episiotomies is discussed and confirmed, recalling that nowadays high rates of episiotomy remain in less industrialized countries and East Asia. Finally, our analysis aims to investigate the potential determinants which influence apparent statistical disparities.     

A comparison of hospital readmission rates between two general physicians with different outpatient review practices

Background  

There has been a relentless increase in emergency medical admissions in the UK over recent years. Many of these patients suffer with chronic conditions requiring continuing medical attention. We wished to determine whether conventional outpatient clinic follow up after discharge has any impact on the rate of readmission to hospital.     

Medicaid outpatient utilization for waterborne pathogenic illness following Hurricane Floyd

OBJECTIVES: Flooding provides an opportunity for epidemics of waterborne viral, protozoan, or bacterial diseases to develop in affected areas. Epidemic levels of disease may translate into higher than average levels of health services use, depending in part on help-seeking behaviors. The authors investigated whether the flooding that occurred as a result of Hurricane Floyd in September 1999 was associated with an increase in outpatient visits for waterborne diseases among Medicaid enrollees in eastern North Carolina. METHODS: Using a difference-in-differences estimation technique, the authors examined the change in outpatient visits by North Carolina Medicaid enrollees for selected waterborne diseases following the hurricane. The study focused on counties with high concentrations of hog farming that were mildly/moderately or severely affected by the hurricane, using unaffected counties and the year before the hurricane as controls. RESULTS: Small increases in Medicaid-covered outpatient visits were found in severely affected counties for two of the six pathogens selected for analysis, relative to unaffected counties. Larger increases in visits were found for nonspecific intestinal infections in both severely and moderately affected counties following the hurricane, relative to unaffected counties. CONCLUSIONS: The large increase in visits for ill-defined intestinal infection is noteworthy. The relative lack of increase in visits with specific pathogenic diagnoses may be attributable, at least in part, to a number of factors, including incomplete diagnostic information provided by treating clinicians, low treatment-seeking behavior, and use of non-Medicaid-funded emergency services.     

A method for the measurement of outpatient resource utilization.

A method for measuring outpatient resource utilization in terms of the amounts of time different categories of patients spend with various providers is described. Patients are categorized based on selected attributes, but other attributes could be used. The method is based on two important and measurable variables: 1) frequencies of usage of different resources (e.g., nurse practitioners, physicians, x-ray), and 2) amounts of time used, by each provider type and by ancillary services (x-ray). Using the quantitative measures described, an algorithm is developed for measuring the direct labor costs of delivering primary care to different types of primary care patients.     

Opportunities for optimizing resource utilization in ambulatory academic practices

Growing emphasis on ambulatory service delivery in academic medical centers has heightened interest in improving operational efficiencies, while providing an optimal educational experience for medical students and residents. One significant challenge in the academic environment is maximizing resource utilization (both physical plant and personnel), through scheduling and operational effectiveness. This article examines how academic ambulatory practices can apply operational and scheduling process redesign methodologies to improve throughput and productivity, while enhancing the educational experience for students/residents.     

An economic approach to clinical trial design and research priority-setting

Whilst significant advances have been made in persuading clinical researchers of the value of conducting economic evaluation alongside clinical trials, a number of problems remain. The most fundamental is the fact that economic principles are almost entirely ignored in the traditional approach to trial design. For example, in the selection of an optimal sample size no consideration is given to the marginal costs or benefits of sample information. In the traditional approach this can lead to either unbounded or arbitrary sample sizes. This paper presents a decision-analytic approach to trial design which takes explicit account of the costs of sampling, the benefits of sample information and the decision rules of cost-effectiveness analysis. It also provides a consistent framework for setting priorities in research funding and establishes a set of screens (or hurdles) to evaluate the potential cost-effectiveness of research proposals. The framework permits research priority setting based explicitly on the budget constraint faced by clinical practitioners and on the information available prior to prospective research. It demonstrates the link between the value of clinical research and the budgetary restrictions on service provision, and it provides practical tools to establish the optimal allocation of resources between areas of clinical research or between service provision and research.     

Relationship between having a home doctor and outpatient utilization

While universal insurance coverage should eliminate or substantially reduce financial and certain structural barriers to medical care, inequity in utilization of care may continue to exist. We conducted a questionnaire survey of a national random sample of 4500 Japanese age 16 or over in October, 1995. Separate analyses were conducted to predict the physician visit rates for the entire respondents (N=3395) and for those with chronic conditions (N=777). Forty-three percent of the total subjects reported an ambulatory physician visit within the past three months. About 17% of subjects with one chronic condition and 14% of those with two or more chronic conditions did not have any physician visits within recent three months. The regression model demonstrated that having a home doctor, as well as comorbidity and perceived health status, is significantly associated with outpatient visit both among all subjects (p < 0.0001) and among those with chronic conditions (p < 0.01). The Japanese health system still has unevenness in outpatient resource utilization. This mainly pertains to whether they have their own regular physician. The failure of some persons with chronic diseases to be seen requires further investigation.