Biomedical subjects
Publications and source records attributed to D D Wirtschafter.
The authors describe their use of outcomes research in improving the care of infants in a ten-hospital network of neonatal intensive care units. Improvements in the processes of care for infants born with very low birth weights, and those suffering from chronic lung disease and nosocomial infections, are among the issues discussed.
Data Envelopment Analysis (DEA) identifies price and technical inefficiencies among decision-making units. With controls for differences in case-mix and standardized outcomes, DEA's "best practice" frontier can be interpreted as a "cost-effectiveness" frontier. This study illustrates the key concepts, identifies the decisions required to use the technique for medical care decision making, and presents an application to a system of nine hospitals that offer obstetric services.
Third-party insurers typically pay at least 50% more for cesarean sections than for vaginal deliveries, suggesting that a reduced national cesarean-section rate could save payers more than $1 billion annually. This paper discusses the payment implications of a cost-effectiveness study, based on the experience within one health maintenance organization, in which cesarean-section rates were unrelated either to direct costs or to perinatal outcomes. Given these results, insurers should consider paying a flat fee for obstetric services unless differing risk levels or risk-adjusted outcomes justify different amounts.
This study employs two risk-adjustment strategies to model the cost-effectiveness of obstetric services for eight hospitals in an urban health maintenance organization. Costs are adjusted by an index based on the expected length of a mother's stay, derived from a two stage regression analysis. Logistic regression of the probability of a cesarean-section on a set of clinical indicators constitutes the first stage. The second stage, an ordinary least squares regression, accounts for 30% of the variation in the logarithm of hours of stay but generates unbiased estimates for various subsets of cases. Adjusted costs per delivery range from roughly 22% below to 31% above the mean. Perinatal mortality rates--adjusted for differences in birthweight, sex, plurality, and race--serve as the outcome indicators. Risk-adjusted costs and risk-adjusted mortality rates are positively correlated with one another (r = .69, P = .06); in particular, the lowest cost hospital generated excellent outcomes. Adjusted cesarean-section rates, however, are not correlated with either adjusted costs (r = -.03, P = .95) or adjusted perinatal mortality rates (r = -.13, P = .75). These results suggest that cost management should focus on staff levels and mix more than on practice patterns and that care management should focus on practice patterns in relation to their influences on outcomes.
Primary care physicians were trained on three rheumatology topics to assess the effectiveness of an educational strategy for continuing medical education. Algorithm training was shown to be at least as effective as that based on standard prose monographs. Both training groups improved their knowledge of patient management skills but there were no statistically significant differences between groups in the amount learned. When algorithms were used to design text materials, the designed texts required less study time than did the annotated clinical algorithms alone. That difference was significant for the shoulder pain materials (P less than 0.05) but not for the osteoporosis materials. The ratio of knowledge gained to study time was significantly higher for the algorithm group on the low back pain topic (P less than 0.05) but not for the other topics. Taped interview problems tests were studied as a method for assessing patient management skills related to problem-specific indicator conditions and were found to produce interrater reliability greater than 0.80 on five of the six tests.
Clinical algorithms have been used successfully in a variety of health care settings to assist health care professionals in the diagnosis and management of medical problems. In addition to their clinical applications, algorithms also serve as an instructional resource by themselves and when used in conjunction with other educational methodologies. A recommended algorithm development process is described for cancer educators who wish to take advantage of the unique contribution clinical algorithms can offer for their educational programs. Algorithm design conventions are reviewed and specific writing suggestions are offered for the guidance of educators who want to design their own clinical algorithms. Objections to clinical algorithms can often be attributed to a misunderstanding of their proper role, which is to facilitate, not dictate, the decision process and guide the application of management logic. Clinical algorithms are a valuable instructional resource that can be used in a wide range of educational settings from self-instruction units to the design of lecture presentations.
Aortic thrombosis in the very-low-birthweight premature infant has remained both a diagnostic and a therapeutic dilemma. Nine small infants were evaluated for symptoms of extremity and/or visceral ischemia. All were found to have aortoiliac thrombosis most likely related to indwelling umbilical artery catheters. Diagnostic and therapeutic options were evaluated. An angiogram obtained through the catheter was found to be the most effective diagnostic technique. Local infusion of intra-arterial streptokinase (50 U/kg/h) directly into the clot for 36 hours resulted in resolution of ischemic symptoms. No complications were encountered with the use of this protocol.
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One hundred seventy-one patients received one year of melphalan or intermittent cyclophosphamide, methotrexate, and fluorouracil after mastectomy for breast cancer with involved axillary nodes. Analysis with a median follow-up of three years indicates a favorable outcome only for patients with 1-3 positive nodes who were treated with melphalan and who experienced a leukocyte count less than 3,000/mm3 (3.0 X 10(9)/l). Tumor size, average percentage of dose received, menopausal status, and type of chemotherapy were not significant factors in recurrence of disease, after adjustment for the number of positive nodes and leukocyte count nadir during treatment based on a multifactorial analysis. These data suggest that administration of a dose of melphalan which does not produce a leukocyte count of less than 3,000/mm3 is ineffective in preventing early recurrence of disease. Since oral melphalan is known to be erratically absorbed, lack of hematologic toxicity may well be due to variable absorption of the drug on a fixed-dose region. Failure to prevent recurrence of disease in this and other trials using oral melphalan may be due to chemotherapy-related as well as disease-related factors.
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This study compares the results of in utero (fetal) and neonatal transfer of high-risk perinates to The University of Alabama Hospitals for the years 1975 through 1977. Both the percentage and total number of fetal referrals have increased. The neonatal mortality among 1061 referred cases (776 neonatal and 285 fetal) was significantly lower among those referred before delivery. Infants surviving after intrauterine transportation required continuous positive airway pressure and intermittent positive pressure ventilation less frequently than did those transported after delivery. There were significantly fewer deaths of infants transported in utero for 3 of 8 categories of mortality risk. Moreover, the length of hospital stay was significantly shorter among infants surviving after in utero transportation than among survivors of neonatal transportation.
In the face of increasing neonatal referrals from a large geographic region, community hospital resources was recruited and coordinated with regional center resources to facilitate "community-based" neonatal transport. All transport requests were first "triaged" by an attending neonatologist. Discriminant analysis was used to assess the impact of resource allocation decisions. Decisions regarding allocation of resources to an individual transport generally reflected geographic distance to be traveled, size of delivery service at referring hospital, and apparent degree of illness. Physicians participation in transports was reduced from 95% to 15% of the trips. The incorporation of community-based transport resources and nonphysician transport teams into a coordinated triage and transport process with existing center-based resources did not adversely affect neonatal survival. Capacity of the transport system was enhanced with these reallocations.
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The medical record should be viewed as an instrument to facilitate and demonstrate the achievement of explicit health care goals. Current systems do not accomplish this. Our examination of the traditional record suggests that modifications of the record should be based on the principles of information system design theory. Necessary modifications include changes which prompt the monitoring of the outcome parameters of a patient's illness, encourage the analysis of the patient's outcome, and facilitate adaptive (corrective) actions. We have termed those data elements which describe the achievement of patient-specific, problem-specific objectives as the "minimum care assurance data set." To designers of computerized medical information systems, this approach provides a rationale for selecting which data to place in computer storage from the myriad of detail in the traditional paper record.
An on-line Medicaid billing system for physicians' services was implemented and tested during a two and one-half year period in 100 offices throughout the State of +0.50,Alabama. Participating physicians represented 17% of all physicians in the state. The monthly volume of Medicaid claims entered through the system represented more than 50% of the statewide load processed by the Medicaid carrier. Users entered claims data on standard Touch Tone telephones equipped with Carddialers, and received instructions and data confirmation from the central computer facility via voice answer-back. Input time for the average claim billing for two separate services was less than one and one-half minutes and resulted in a reduction of clerical labor required for manual input by at least 50%. After a fee-for-service was inaugurated, the system workload remained at 86% of its load level before fee for service. Those physicians willing to pay for the billing service were high-volume users who had come to depend on the system and who appreciated the economics that the system had achieved for them in their office billing practices. An average claim consisting of two items of service could be billed at a cost of $0.50,, exclusive of user terminal rental ($6 per month per office) and the cost of data entry personnel (between $0.05 and $0.10 + 0.05 and $.10 per claim). Various algorithms have been offered for use in estimating an annual budget for an on-line billing system given alternative system configurations, methods of financing, annual volume of units of service, and the geographical nature of the population to be served. The tasks of preparing, processing, and storing insurance claims information have placed a costly and time-consuming burden on both providers of medical services and fiscal intermediaries. The unfortunate result is that the cost of submitting an insurance claim for professional medical services is a disproportionate fraction of the amount paid for providing the service. For general practitioners, who provide the largest number of individual services, this share may be more than one-fourth of the payment for most common services. Similarly, for the Medicaid or Medicare intermediary or for the insurance carrier, the cost of preparing and recording data from source documents is a large part of total processing costs. The objective of the On-Line Medicaid Billing System project was to demonstrate that it is possible to reduce the costs of submitting claims from the physician's office as well as to reduce the costs of data preparation in the carrier's system. This publication focuses on an economic analysis of cost effectiveness. Readers interested in system design, development, and on-line operation will find detailed descriptions in previously published reports.