Caring for ventilated patients in the community: a pilot study examining costs, quality of life and preferences

This paper describes a pilot study that identifies the implications for resource use when ventilated patients are moved from hospital to the community, and pilots two generic health status survey instruments to measure quality of life experienced in the community for use in a future full evaluation. A group of 11 ventilated patients living in the community were interviewed to identify their resource use, and the SF-36 questionnaire, EuroQol questionnaire and Patient Generated Index were used to investigate implications on quality of life and whether these measures were suitable for use in this group of patients. The main results indicate that the cost of care varies considerably between hospital and community and across patients. The quality of life measures proved inadequate, and highlighted the problems of measuring quality of life for patients with deteriorating health status. All patients much preferred home care to hospital care. A full multi-disciplinary evaluation is required to determine an effective method of providing the care.     

The Economic Burden of Complications Occurring in Major Surgical Procedures: a Systematic Review

Objectives

On the basis of a systematic review, we aimed to establish the cost and drivers of cost and/or resource use of intra- and perioperative complications occurring as a result of selected major surgical procedures, as well as to understand the relationship between costs and severity of complication and, consequently, the economic burden they represent. We also assessed the clinical and economic methodologies used to derive costs and resource use across the studies with a view to providing guidance on reporting standards for these studies.

Methods

We searched EMBASE, MEDLINE and Econlit (from 2002 to 2012) for study publications including resource use/cost data relating to surgical complications.

Results

We identified 38 relevant studies on pancreatic (n = 14), urologic (n = 4), gynaecological (n = 6), thoracic (n = 13) and hepatic surgery (n = 1). All studies showed that complications lead to higher resource use and hospital costs compared with surgical procedures without complications. Costs depend on type of complication and complication severity, and are driven primarily by prolonged hospitalisation. There was considerable heterogeneity between studies with regard to patient populations, outcomes and procedures, as well as a lack of consistency and transparency of reporting of costs/resource use. Complication severity grading systems were used infrequently.

Conclusions

The overall conclusions of included studies are consistent: complications represent an important economic burden for health care providers. We conclude that more accurate and consistent data collection is required to serve as input for good-quality economic analyses, which in turn can inform hospital decisions on cost-efficient allocation of their limited resources.     

临床护理路径在子宫肌瘤合并糖尿病围手术期的应用

目的探讨临床路径在子宫肌瘤合并糖尿病围手术期的实用性。方法将40例子宫肌瘤合并糖尿病的病人随机分为实验组和对照组,每组20例,实验组采用制订的临床路径表格进行诊疗护理,对照组按常规的和一般医疗护理方法。对比两组病人在掌握子宫肌瘤及糖尿病知识和相关技能、住院时间、住院费用、和病人满意度等的差异。结果实验组患者的住院天数、住院费用、术后并发症发生率明显低于对照组(p<0.01),而患者的满意度和健康知识明显提高。结论推广应用临床路径,加强了患者对所患疾病的了解,加深对疾病发展的认识,主动参与护理,提高病人遵医行为,控制血糖,减少术后并发症,缩短住院天数,减少住院费用,提高病人满意度,促进病人早日康复,减轻患者精神负担和经济压力,节约社会医疗资源。     

A pilot study on patient-related costs and factors associated with the cost of specialist palliative care in the hospital: first steps towards a patient classification system in Germany

Background

Specialist palliative care in the hospital addresses a heterogeneous patient population with complex care needs. In Germany, palliative care patients are classified based on their primary diagnosis to determine reimbursement despite findings that other factors describe patient needs better. To facilitate adequate resource allocation in this setting, in Australia and in the UK important steps have been undertaken towards identifying drivers of palliative care resource use and classifying patients accordingly. We aimed to pioneer patient classification based on determinants of resource use relevant to specialist palliative care in Germany first, by calculating the patient-level cost of specialist palliative care from the hospital’s perspective, based on the recorded resource use and, subsequently, by analysing influencing factors.

Methods

Cross-sectional study of consecutive patients who had an episode of specialist palliative care in Munich University Hospital between 20 June and 4 August, 2016. To accurately reflect personnel intensity of specialist palliative care, aside from administrative data, we recorded actual use of all involved health professionals’ labour time at patient level. Factors influencing episode costs were assessed using generalized linear regression and LASSO variable selection.

Results

The study included 144 patients. Mean costs of specialist palliative care per palliative care unit episode were 6542€ (median: 5789€, SE: 715€) and 823€ (median: 702€, SE: 31€) per consultation episode. Based on multivariate models that considered both variables recorded at beginning and at the end of episode, we identified factors explaining episode cost including phase of illness, Karnofsky performance score, and type of discharge.

Conclusions

This study is an important step towards patient classification in specialist palliative care in Germany as it provides a feasible patient-level costing method and identifies possible starting points for classification. Application to a larger sample will allow for meaningful classification of palliative patients.

     

Standardized Telephonic Case Management in a Hispanic Heart Failure Population

Background: Heart failure (HF) is as common in Hispanic as it is in non-Hispanic populations. However, there do not appear to be any published reports of HF disease management programs which include Hispanic populations. Objective:To test the effectiveness of a standardized telephonic disease management intervention, Pfizer Inc.’s At Home With Heart Failure?, in decreasing acute care resource use and cost in Hispanic patients with HF. Participants and methods: A factorial design was used to analyze data obtained in a randomized controlled clinical trial. Patients with HF were enrolled in the trial when admitted to hospital, randomized to the intervention or usual care control groups, and followed for 6 months. Of the 358 participants, 93 (26%) were Hispanic (35 in the intervention group, 58 in the usual care group). Data were analyzed to determine if comparable decreases in acute care resource use were evident in Hispanic and non-Hispanic intervention group patients. Intervention: Registered nurses telephoned patients after hospital discharge to provide advice, solve problems, encourage adherence, and facilitate access to needed services. Results: Acute care resource use was lowered as effectively in the Hispanic patients as in the non-Hispanic patients, despite significant between-group differences in education, income, and living situations. When a fully crossed (language by group) analysis was conducted, no significant differences were found between the Hispanic and non-Hispanic intervention groups. However, in most categories there was a trend towards lower resource use in the Hispanic intervention group. The cost of inpatient care was more than $US1000 (2000 values) less in the Hispanic than the non-Hispanic intervention group. Conclusion: The results of this study suggest that Hispanic patients with HF are receptive of, and responsive to, a case management intervention provided in a culturally competent manner, despite differences in cultural views on chronic illness and self-care as discussed in the literature.     

Negligent hiring and retention: some evidence of hospital vulnerability

Hospital human resource managers were surveyed to determine their understanding of negligent hiring employment law and the tools used in employment screening. This article describes the results, which indicate that hospital human resource managers understand the law but that there are gaps in the use of some employment screening tools. The authors make recommendations for future research.     

Managing care, incentives, and information: an exploratory look inside the "black box" of hospital efficiency.

OBJECTIVE. We sought to estimate the impact of individual dimensions of hospitals' managed care strategies on the cost per hospital discharge. STUDY SETTING/DATA SOURCES. Thirty-seven member hospitals of seven health systems in the Pacific, Rocky Mountain, and Southwest regions of the United States were studied. STUDY DESIGN. Separate cross-sectional regression analyses of 21,135 inpatient discharges were performed in 1991 and 23,262 discharges in 1992. The multivariate model was estimated with hospital cost per discharge as the dependent variable. Model robustness was checked by comparing regression results at the individual discharge level with those at the level of the hospital/clinical condition pair. DATA COLLECTION/EXTRACTION METHODS. Information on hospitals' managed care strategies was provided by mail and phone survey of key informants in 1991 and 1992. Other hospital characteristics were collected from AHA Annual Survey data, and discharge data from hospital abstracting systems. PRINCIPAL FINDINGS. The pooled discharge analysis indicated three dimensions of hospital managed care strategy that consistently related to lower costs per hospital discharge: the proportion of hospital revenues derived from per case or capitation payment, the hospital's mechanisms for sharing information on resource consumption with clinicians, and the use of formalized, systematic care coordination mechanisms. CONCLUSIONS. Three strategies appear to hold promise for enhancing the efficiency of inpatient resource use: (1) "fixed price" hospital payment incentives, (2) hospital approaches to sharing resource use information with clinicians, and (3) the application of formal care management mechanisms for specific clinical conditions.     

单病种限价的社会效益分析

为了控制世界范围内医疗费用的日益增长,寻求一种合理的医疗费用控制办法,目前世界各国都在进行支付方式的改革。在我国,一些医疗机构开始试行单病种限价这种医疗费用支付方式,该支付方式是在规范管理的基础上,通过医疗付费方式的改革,将医疗质量管理与节约医疗资源、控制医疗成本、降低收费价格有效地结合为一体,进而获取更大的社会效益和经济效益,促进医院可持续发展。     

The effects of case mix on hospital costs and revenues in managed care environments

Due to competition and managed care, hospitals have argued that the rate of increase in hospital cost is greater than the rate of increase in hospital revenue. It is important to pay hospitals based on the expected resource use of patients that hospitals treat. However, managed care organizations pay hospitals based on negotiated prices that do not consider the expected resource use of patients. The purpose of this paper is to provide a better understanding of those factors affecting hospital cost and revenue in California using the hospital financial and utilization data for selected years from 1986 to 1998. By developing case mix indexes (CMIs) using all hospital discharges in California, this study found that the coefficients for CMIs in total and inpatient hospital revenue models were greater than those in hospital cost models. Over time, however, the differences in coefficients for CMIs in hospital revenue and cost models become smaller and smaller. Thus, this study shows that the difference between hospital revenues and hospital costs, looking at hospital case mix, has decreased, although hospital revenues are still greater than hospital costs.     

Ethics and resource allocation: an economist's view

This paper debates some of the issues involved in attempting to apply economic analysis to the health care sector when medical ethics plays such an important part in determining the allocation of resources in that sector. Two distinct ethical positions are highlighted as being fundamental to the understanding of resource allocation in this sector -- deontological and utilitarian theories of ethics. It is argued that medical ethics are often narrowly conceived in that there is a tendency for the individual, rather than society at large, to form the focal point of the production of the service "health care'. Thus medical ethics have been dominated by individualistic ethical coded which do not fully consider questions relating to resource allocation at a social level. It is further argued that the structure of the health care sector augments these "individualistic' ethics. It is also suggested that different actors in the health care sector address questions of resource allocation with respect to different time periods, and that this serves to further enhance the influence of "individualistic' ethical codes in this sector.     

The hospital admissions study in England: are there alternatives to emergency hospital admission?

STUDY OBJECTIVE--To assess the potential for substituting alternative forms of care for admission to an acute hospital in particular groups of patients. DESIGN--A screening tool, the intensity-severity-discharge review system with adult criteria (ISD-A), developed for hospital utilisation review in the USA, was used in a cohort of hospital admissions to identify a group of patients who could potentially have been treated outside the acute hospital. These patients were further assessed by a panel of general practitioners (GPs) to determine the most appropriate alternative form of care. A cost analysis was performed on the results obtained. SETTING--General medicine and geriatric specialties in one acute hospital in the south western region. PATIENTS--Patients comprised a sample of 701 admitted to general medical and geriatric specialties. MAIN RESULTS--The screening tool identified 19.7% of admissions for whom there was potential for treatment outside the acute hospital. Assessment by the GP panel reduced this potential to between 9.8% and 15.0% of emergency admissions. The alternatives most frequently identified as "most appropriate" were the community hospital/GP bed and the urgent outpatient assessment (within either 24 or 48 hours). Potential resource savings based on the average cost were relatively small. This potential seemed to be greater for the alternative of the urgent outpatient assessment. CONCLUSIONS--Potential exists for treating a proportion of patients in lower intensity alternatives to the acute hospital. If this potential were exploited few resource savings would occur.     

Hospital resource use by patients with schizophrenia: reduction after conversion from oral treatment to risperidone long-acting injection

The chronic relapsing nature of schizophrenia is associated with significant resource use. The William Osler Health System, Brampton Civic Hospital site, in Brampton, Ontario, provides comprehensive in-patient and outpatient mental health services to the community it serves, including patients with schizophrenia. The clinical benefits observed in patients with schizophrenia treated through the injection clinic led the hospital to evaluate the costs, resource use and potential savings associated with injectable compared with oral therapy. The substantial savings accruing to the hospital and the healthcare system provide a strong economic rationale for injectable therapy as an alternative level of care for patients with schizophrenia.     

Establishing priorities for hospital education

INTRODUCTION: Integrating the emerging evidence base for medicine, measuring quality of care, reducing medical errors, and understanding the managed care environment all present new challenges to the processes and outcomes of hospital education. Establishing priorities for hospital-based education is critical as cost containment measures influence education budgets. This article examines the learning modalities preferred by health care educators in their own educational experiences and the implications of preferences for newly emerging roles in hospital education. METHODS: To determine if a typology based on learning modalities has utility for helping health care educators establish priorities, a pilot study was conducted using three groups of health care educators. Subjects in the pilot study completed a questionnaire that asked them to list three examples of their most important recent learning experiences. RESULTS: Sixty-six subjects reported 181 learning experiences. These 181 learning experiences were divided into four learning modalities displayed in a 2 x 2 matrix based on "motivation" and "management" of learning as follows: 97 in problem solving, 52 in training, 16 in schooling, and 16 in hobbying. DISCUSSION: From this study, it appears that problem solving is the prime learning modality of adults in health care, and departments of hospital education would be well advised to focus on practical learning and problem solving when developing their educational activities. This finding supports the use of selected modalities of education in meeting the new challenges of hospital education.     

PMD17 Surveillance of a New Drug in the United Kingdom

Reports of adverse events often surface shortly after a new drug is introduced and in many cases provoke governmental regulatory action. Deaths pose a particular challenge, because drug takers may have excess mortality risk relative to nontakers for reasons unrelated to drug use. Aside from the implications for safety surveillance, a spurious association between drug use and mortality also can confound economic comparisons based on drug use.
OBJECTIVE: To investigate, at the request of the U.K. Medicines Control Agency, safety and health-care resource utilization related to use of a new drug.
METHODS: A postmarketing surveillance program was implemented at major medical schools in England and Scotland to monitor mortality, morbidity, and healthcare resource utilization associated with use of a new drug for treating gastrointestinal conditions. The study employs a longitudinal design that identified 18,000 drug takers through automated pharmacy listings at 700+ general practitioner offices located within a one-hour drive from the medical schools. In addition to drug taking patterns and adverse event occurrences, use of ambulatory and hospital health-care resources is recorded. Instead of employing a reference group of nontakers, national death rates will serve as "historical controls."
RESULTS: Morbidity and mortality experience among drug takers will be assessed by reviewing whether incidents occurred concomitantly with use of the medicine, by examining relationships with dose and duration of use, and other evidence to establish "biologic plausibility." These experiences will be related in turn to selected measures of health-care resource utilization.
CONCLUSION: This study provides a useful template for future research to establish the safety and health care resource utilization profiles of a new drug.     

Individual and neighbourhood determinants of health care utilization. Implications for health policy and resource allocation

OBJECTIVES: To investigate the importance of both individual and neighbourhood socioeconomic characteristics for health care utilization. METHODS: Various linkage procedures generated a longitudinal dataset with information on 2,116 Nova Scotians, their residential neighbourhoods, 8 years of health care utilization and vital status. Unilevel and multilevel regression analyses were employed to examine the effects of both individual and neighbourhood characteristics on health care use. RESULTS: Individual income and education determined physician and hospital use. Also, neighbourhood characteristics, specifically average income and percentage of single mother families, were found to determine health care use. When considering individual and neighbourhood characteristics simultaneously, individual income and education determined physician and hospital use independently, while neighbourhood income determined physician use independently. CONCLUSIONS: Both individual and neighbourhood socioeconomic characteristics determine health care use. Acknowledging this allows better targeting of health policy and planning, and enables more accurate needs-based resource allocation.     

The impact on schizophrenia-related hospital utilization and costs of switching to long-acting risperidone injections in Sweden

Aim

To estimate changes in resource usage, hospitalization rates, and costs in actual practice in Sweden for schizophrenia patients after switching to long-acting injectable risperidone (Risperdal Consta).

Methods

A retrospective chart review within-subject mirror-image study using actual practice chart review data was used to compare annual hospital bed-days and annual hospital episodes for adults with schizophrenia or schizoaffective disorder before and after switching to Risperdal Consta in the period 1 January 2003 to 30 June 2005. Secondary endpoints included mean length of hospital stay per episode, the cost of hospitalization, and the cost of antipsychotic treatment. The base case analytical approach allocated all hospital episodes overlapping the switch date entirely to pre-switch treatment. In order to investigate the impact of inpatient care ongoing at the time of the switch, the change in bed-days per year was also estimated using an alternative analytical approach inspired by economic modelling.

Results

One-hundred sixty-four patients were enrolled at nine geographically diverse sites. The switch to Risperdal Consta was associated with a significant reduction in mean annual days in hospital from 39 to 21 days per year (45%), which was linked to a significant reduction in the number of hospitalizations from 0.86 to 0.63 per year (27%). The alternative “modelling-inspired” estimate of the reduction in mean annual days in hospital was also 27%.

Conclusion

A naturalistic mirror-image study found that switching to long-acting injectable risperidone led to sizeable reductions in inpatient resource use. These results coincide with the findings of other international studies.     

中山大学附属口腔医院医疗资源配置研究

本文结合中山大学附属口腔医院分析一间医院一系列医疗资源给一个医生的分配。本文以牙床为主线,从三个主要方面来研究这间医院的资源分配情况:①对医疗资源未来需求的预测,分析一些外在因素和内在因素对医院门诊量的长期影响,主要有人口、当地经济水平和诊疗时间等。②医疗资源在一个周期内更合理的分配,分析医疗资源的平衡利用,一方面考虑同一资源如牙床在各科室的分配,另一方面则考虑不同资源的平衡搭配使用,如专家和护士的分工等。③基于更合理分配资源的未来需求。本文的研究对象是一所专科医院,但其研究方法可以用于综合医院更大范围的资源管理问题的分析,并希望能对医院资源的优化管理和使用提供借鉴依据。     

Physician Financial Incentives in Managed Care

Patients with health insurance do not make the most cost conscious healthcare decisions since they bear only a fraction of the total cost of medical care. Managed care advocates point to financial incentives as a way to reduce wasteful resource use. However, physicians with managed care contracts feel financial pressures designed to reduce waste may also limit medically necessary services and adversely impact the quality of patient care. In light of a growing public and professional distrust of the motives behind offering financial incentives, the economic theory of agency is used to illustrate how financial contracts designed to reduce wasteful resource use influence physician behavior.A review of the literature was conducted to determine the effects of financial incentives on resource use, cost and the quality of medical care. The method used to undertake this literature review followed the approach set forth in the Cochrane Collaboration handbook. This review revealed that much of the empirical evidence on the effect of managed care on physician behavior compared the experiences of traditional indemnity plan enrollees with health maintenance organization enrollees.Published studies are outdated and are influenced by statistical problems including both patient and physician selection bias. With respect to the newer types of managed care organizations, there is a paucity of information on the effects of financial incentives on physician behavior. Despite the lack of empirical evidence, the perception remains that managed care financial incentives are perverse in that they induce physicians to take actions that compromise quality of care. To evaluate the legitimacy of these concerns, research on how physician contractual arrangements influence the cost and quality of care in the newer types of plans is needed. In the absence of such research, political rhetoric bent by anecdotal evidence will continue to influence public policy and undermine managed care.     

The Effect of Advance Directive Completion on Hospital Care Among Chronically Homeless Persons: a Prospective Cohort Study

Advance care planning is relevant for homeless individuals because they experience high rates of morbidity and mortality. The impact of advance directive interventions on hospital care of homeless individuals has not been studied. The objective of this study was to determine if homeless individuals who complete an advance directive through a shelter-based intervention are more likely to have information from their advance directive documented and used during subsequent hospitalizations. The advance directive included preferences for life-sustaining treatments, resuscitation, and substitute decision maker(s). A total of 205 homeless men from a homeless shelter for men in Toronto, Canada, were enrolled in the study and offered an opportunity to complete an advance directive with the guidance of a trained counselor from April to June 2013. One hundred and three participants chose to complete an advance directive, and 102 participants chose to not complete an advance directive. Participants were provided copies of their advance directives. In addition, advance directives were electronically stored, and hospitals within a 1.0-mile radius of the shelter were provided access to the database. A prospective cohort study was performed using chart reviews to ascertain the documentation, availability, and use of advance directives, end-of-life care preferences, and medical treatments during hospitalizations over a 1-year follow-up period (April 2013 to June 2014) after the shelter-based advance directive intervention. Chart reviewers were blinded as to whether participants had completed an advance directive. The primary outcome was documentation or use of an advance directive during any hospitalization. The secondary outcome was documentation of end-of-life care preferences, without reference to an advance directive, during any hospitalization. After unblinding, charts were studied to determine whether advance directives were available, hospital care was consistent with patient preferences as documented in advance directives, and hospital resource utilization during admission. During the 1-year follow-up period, 38 participants who completed an advance directive and 37 participants who did not complete an advance directive had at least one hospitalization (36.9 vs. 36.2 %, p?=?0.93). Participants who completed an advance directive were significantly more likely to have documentation or use of an advance directive in hospital, compared to participants who did not complete an advance directive (9.7 vs. 2.9 %, p?=?0.047). Without reference to an advance directive, documentation of end-of-life care preferences occurred in 30.1 vs. 30.4 % of participants, respectively (p?=?0.96), most often due to documentation of code status. There were no significant differences in resource utilization between admitted patients who completed and did not complete an advance directive. In conclusion, homeless men who complete an advance directive through a shelter-based intervention are more likely to have their detailed care preferences documented or used during subsequent hospitalizations.