What can we learn from international comparisons of costs by DRG?

Objectives

The objective of this study was to compare costs data by diagnosis related group (DRG) between Belgium and Switzerland. Our hypotheses were that differences between countries can probably be explained by methodological differences in cost calculations, by differences in medical practices and by differences in cost structures within the two countries.

Methods

Classifications of DRG used in the two countries differ (AP-DRGs version 1.7 in Switzerland and APR-DRGs version 15.0 in Belgium). The first step of this study was to transform Belgian summaries into Swiss AP-DRGs. Belgian and Swiss data were calculated with a clinical costing methodology (full costing). Belgian and Swiss costs were converted into US$ PPP (purchasing power parity) in order to neutralize differences in purchasing power between countries.

Results

The results of this study showed higher costs in Switzerland despite standardization of cost data according to PPP. The difference is not explained by the case-mix index because this was similar for inliers between the two countries. The length of stay (LOS) was also quite similar for inliers between the two countries. The case-mix index was, however, higher for high outliers in Belgium, as reflected in a higher LOS for these patients. Higher costs in Switzerland are thus probably explained mainly by the higher number of agency staff by service in this country or because of differences in medical practices.

Conclusions

It is possible to make international comparisons but only if there is standardization of the case-mix between countries and only if comparable accountancy methodologies are used. Harmonization of DRGs groups, nomenclature and accountancy is thus required.     

What can health care professionals in the United Kingdom learn from Malawi?

Debate on how resource-rich countries and their health care professionals should help the plight of sub-Saharan Africa appears locked in a mind-set dominated by gloomy statistics and one-way monetary aid. Having established a project to link primary care clinics based on two-way sharing of education rather than one-way aid, our United Kingdom colleagues often ask us: "But what can we learn from Malawi?" A recent fact-finding visit to Malawi helped us clarify some aspects of health care that may be of relevance to health care professionals in the developed world, including the United Kingdom. This commentary article is focused on encouraging debate and discussion as to how we might wish to re-think our relationship with colleagues in other health care environments and consider how we can work together on a theme of two-way shared learning rather than one-way aid.     

What can clinical teachers learn from Harry Potter and the Philosopher's Stone?

Many clinical teachers acquire a working knowledge of the principles of teaching and learning through observation, by adopting positive and rejecting negative examples of clinical instruction. Well selected vignettes of teaching behaviours taken from contemporary film and literature may provide rich substrate by which to engage clinical teachers in discourse about instructional technique. This paper draws on J K Rowling's novel and its companion film, Harry Potter and the Philosopher's Stone, and critically analyses the teaching styles of the staff at Hogwarts School of Wizardry and Witchcraft in the context of contemporary generic and medical education literature. Specifically, it argues that effective teachers demonstrate not only an in-depth knowledge of their discipline but possess a keen appreciation of the cognitive changes that occur in their students during the learning process. They are, furthermore, proficient in core instructional skills such as small group facilitation, feedback and questioning. Most importantly, effective teachers model appropriate attitudes in their professional setting and possess highly developed personal qualities such as creativity, flexibility and enthusiasm.     

What can developing economies learn from health system reforms of developed countries?

This paper outlines some general lessons developing nations can draw from the health system reform experiences of developed nations. Using the experiences of developed countries, developing countries should be better able to anticipate socio-economic changes and choose an optimal path for their health systems development to accompany those changes. Most developed countries have adopted rather common objectives and principles in their health systems because of market failure in health care; developing countries may start adopting those principles because they do not have market conditions in the first place. It is suggested that developing countries strengthen what is probably the most fundamental initial systemic asset they have: public finance. They should do so by attracting democratically, possibly through earmarked taxes, resources otherwise channelled through the private sector, competing with public finance for limited real resources. This effort can be promoted by giving consumers, mainly of high income groups and in urban areas, more say (through institutions performing the OMCC function) in the nature of care these groups have access to under auspices of public finance. Where feasible, private insurance as a major source of finance should be seen as a transitional phenomenon, giving way to the emergence of OMCC institutions which require similar financial and managerial market infrastructure. Private and competitive provision of care may be unrealistic in many developing areas because of both scarcity of real resources, mainly manpower, and health needs. The challenge of government is, as resources grow, to divest itself from the provision of care and stay involved in activities and facilities that are of 'public nature'--under specific circumstances--that foster private competitive provision. In general, the government should play an enabling role also by investing in health promotions and management skills for health systems.     

What can the U.S. learn from national health accounting elsewhere?

The United States is typically seen as an outlier in health spending when compared with other advanced nations. Recent improvements in health accounting in lower- and middle-income countries suggest some common features with the high and pluralistic spending in the United States. The author discusses recent developments and findings in health accounting outside the Organization for Economic Cooperation and Development (OECD) and their relevance for the United States. He argues that we should expect more fruitful exchanges in the future.     

What can the Canadians and Americans learn from each other's health care systems?

Numerous papers have been written comparing the Canadian and US healthcare systems, and a number of health policy experts have recommended that the Americans implement their single‐payer system to save 12–20% of its healthcare expenditures. This paper is different in that it assumes that neither country will undertake a significant philosophic or structural change in their healthcare system, but there are lessons to be learned that are inherent in one that could be a major breakthrough for the other. Following the model in Canada and in Western Europe, the USA could implement universal health insurance so that the 32.0 million (2015) Americans still uninsured would have at least minimal coverage when incurring medical expenditures. Also, the USA could use smart cards to evaluate eligibility and to process health insurance claims; these changes resulting in an estimated 15% reduction in US health expenditures without adversely effecting access or quality of care. Such a strategy would result in the eventual loss of 2.5 million white‐collar jobs at hospitals, physician offices and insurance companies, a long‐term economic gain. Only a few would agree with the statement that Canada already functions with a multi‐payer reimbursement system as evidenced by (1) a federal‐provincial, tax‐supported plan, administered by each of the provinces, providing universal coverage for hospital and physician services and (2) roughly 60% of its residents receiving employer‐paid health insurance benefits, underwritten primarily by investor‐owned plans, that are less than effective to reimburse for pharmaceuticals, dental and other healthcare services. What could be learned from the USA and particularly from Western European countries is possibly implementing an approach, whereby at least upper‐income Canadians could opt out of their federal‐provincial plan and purchase private insurance coverage — being eligible for far more comprehensive “private” benefits for hospital, physician, pharmaceutical, dental and other healthcare services. Aside from generating billions of additional needed revenues from the private sector, it could (1) help eliminate long waits for non‐emergent physicians' care by appointing newly minted specialists to their medical staffs; (2) offer prompt admissions for elective cases to “private” wings of hospitals; (3) increase available funding for what is currently an undercapitalized system; (4) enhance the system's sluggish operations; and (5) encourage more competition among various providers. Although such a two‐tier approach, such as available in the USA and elsewhere, is politically dead on arrival in Canada today, private insurance being already legal and commonly available there. Interestingly, this recommended solution is utilized in most western European countries where there is a higher percentage than in Canada of public (versus private) funding of their total health expenditures. Because of various vested interests, attempts to implement any of the aforementioned proposals will undoubtedly result in considerable political rancor. There is greater likelihood, however, that the Canadians because their need to be more effective and efficient in their delivery of care, and their overall long‐term fiscal outlook will agree to the further privatization of their healthcare system before the Americans will mandate universal access, use the smart card to process insurance eligibility and claims or will impose price controls on high‐tech services and on pharmaceuticals. Copyright © 2016 John Wiley & Sons, Ltd.     

What can we learn from international comparisons of health systems and health system reform?

Most commonly, lessons derived from comparisons of international health sector reform can only be generalized in a limited way to similar countries. However, there is little guidance as to what constitutes "similarity" in this respect. We propose that a framework for assessing similarity could be derived from the performance of individual policies in different contexts, and from the cause and effect processes related to the policies. We demonstrate this process by considering research evidence in the "public-private mix", and propose variables for an initial framework that we believe determine private involvement in the public health sector. The most influential model of public leadership places the private role in a contracting framework. Research in countries that have adopted this model suggests an additional list of variables to add to the framework. The variables can be grouped under the headings "demand factors", "supply factors", and "strength of the public sector". These illustrate the nature of a framework that could emerge, and which would help countries aiming to learn from international experience.     

Reflections on empathy in medical education: What can we learn from social neurosciences?

The role of empathy in human social interaction has been examined in several research fields, including medical education (ME) and social neuroscience (SN). SN yields insights into empathy based on neurobiological processes, and such information may also be relevant to ME. In this reflection article, the authors first critically review current definitions and concepts of empathy in ME and link them to recent SN findings. In the light of recent evidence from SN, research in ME regarding the positive and negative effects of empathy for physicians and patients is discussed, as well as the question whether (future) physicians differ from the general population with regard to empathic skills. Commonly used SN paradigms and ME approaches to assess empathy are contrasted, a joint approach is advocated, and implications for further interdisciplinary studies are outlined. Finally, the authors delineate the contribution of SN to the question of whether empathy is teachable, and argue that SN findings represent a potential for new ME training approaches. In conclusion, the authors discuss how the incorporation of perspectives on empathy from different research areas would benefit ME, and suggest the translation and integration of such findings into ME research approaches.     

Preemptive biopreparedness: can we learn anything from history?

The treat of bioterrorism is in the public eye again, and major public health agencies are urging preparedness efforts and special federal funding. In a sense, we have seen this all before. The Centers for Disease Control and Prevention grew substantially during the Cold War era in large part because Alexander Langmuir, Chief Epidemiologist of the CDC, used an earlier generation''s anxieties to revitalize the CDC, create an Epidemic Intelligence Service, and promote epidemiologic "surveillance" as part of the nation''s defense. Retrospective investigation suggests that, while Langmuir contributed to efforts promoted by the Department of Defense and the Federal Civil Defense Administration, the United States did not have real cause to fear Communist biological warfare aggression. Given clear historical parallels, it is appropriate to ask, What was gained and what was lost by Langmuir''s central role in that first instance of American biopreparedness? Among the conclusions drawn is that biopreparedness efforts fed the Cold War climate, narrowed the scope of public health activities, and failed to achieve sustained benefits for public health programs across the country.     

What can we learn from the experiences of consultants around the time of a child's death?

Aims To describe how paediatric consultants report dealing with child and neonatal deaths as part of their daily work. Background Paediatric consultants are involved with children and their families facing death through illness. This study focused on consultant's involvement around the time of death including: decision making and its associated difficulties, talking to parents and the use of coping strategies. Consultants with more than 5 years experience were asked what experience has taught them and consultants with less that 5 years experience were asked what they felt was the biggest change from being a registrar. Methods Following Multicentre Research Ethics Committee (MREC) approval a pre‐piloted self‐administered questionnaire (with one reminder) was sent to 100 of the paediatric consultants within the South West Region. Results There was a 61% response rate. Most consultants had experienced a variety of opinions when talking to parents about when to withdraw or withhold life sustaining treatment. Uncertainty (39%) and disagreement (44%) made decision making difficult. Discussion with colleagues (41%), ‘honesty and time with parents’ (28%) and planning or ‘stage managing’ talking with parents (38%) were well used strategies to deal with this. New consultants find responsibility and decision making the biggest change from being a registrar. Conclusions We can learn much from the experiences of consultants around the time of a child's death. Their approach during resuscitation and withdrawal or withholding life sustaining treatment describes many strategies that have been developed to ease the often complex decision‐making process. Although consultants have built up personal support networks and individual coping strategies many recognize that these are not all encompassing and some harbour unresolved feelings of grief. Enabling health professionals to genuinely care, ‘giving oneself totally yet preserving oneself totally’ remains a challenge.     

Quadruple-first line drug resistance in Mycobacterium tuberculosis in Vietnam: What can we learn from genes?

In Vietnam, a country with high tuberculosis (137/100.000 population) and multidrug-resistant (MDR)-TB burdens (7.8/100.000 population), little is known about the molecular signatures of drug resistance in general and more particularly of second line drug (SLD) resistance. This study is specifically focused on Mycobacterium tuberculosis isolates resistant to four first-line drugs (FLDs) that make TB much more difficult to treat. The aim is to determine the proportion of SLD resistance in these quadruple drug resistant isolates and the genetic determinants linked to drug resistance to better understand the genetic processes leading to quadruple and extremely drug resistance (XDR). 91 quadruple (rifampicin, isoniazid, ethambutol and streptomycin) FLD resistant and 55 susceptible isolates were included. Spoligotyping and 24-locus MIRU-VNTR techniques were performed and 9 genes and promoters linked to FLD and SLD resistance were sequenced. SLD susceptibility testing was carried out on a subsample of isolates. High proportion of quadruple-FLD resistant isolates was resistant to fluoroquinolones (27%) and second-line injectable drugs (30.2%) by drug susceptibility testing. The sequencing revealed high mutation diversity with prevailing mutations at positions katG315, inhA-15, rpoB531, embB306, rrs1401, rpsL43 and gyrA94. The sensitivity and specificity were high for most drug resistances (> 86%), but the sensitivity was lower for injectable drug resistances (< 69%). The mutation patterns revealed 23.1% of pre-XDR and 7.7% of XDR isolates, mostly belonging to Beijing family. The genotypic diversity and the variety of mutations reflect the existence of various evolutionary paths leading to FLD and SLD resistance. Nevertheless, particular mutation patterns linked to high-level resistance and low fitness costs seem to be favored.