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Biomedical subjects

H G Welch

Publications and source records attributed to H G Welch.

At least 73 records · Page 4Linked to original sources
PubMed1993

Why estimates of physician supply and requirements disagree.

OBJECTIVE: To review the major forecasts of physician supply and physician requirements. DATA SOURCES: English-language medical literature on physician manpower published between 1980 and 1990, identified from journal articles selected through searches of the MEDLINE and Health Planning and Administration databases using the search formulations physician supply, health manpower--physicians, and physician manpower. STUDY SELECTION: Sources were selected if they were repeatedly cited and provided quantitative projections. DATA EXTRACTION: Each study was reviewed for its quantitative projections and to identify its methodological assumptions. DATA SYNTHESIS: All forecasts point to a steadily increasing physician supply and, with one exception, suggest that supply will exceed requirements in the year 2000. The estimates of physician supply across studies varied primarily because of differing assumptions about entrance rates into the profession and the size and clinical work load of specific categories of physicians: researchers, teachers, administrators, residents, and women. The estimates of physician requirements were more volatile because of differences in the basic approach and assumptions about future growth and market structure. CONCLUSIONS: Even though the measurement of entrance and exit rates from the profession is a generally accepted approach to forecasting supply, apparently minor disagreements on assumptions create large discrepancies between forecasts over time. There is no accepted approach to forecasting physician requirements.

Forecasting↗
PubMed1993

Geographic variation in expenditures for physicians' services in the United States.

BACKGROUND: The national volume-performance standard recently implemented by Medicare does not account for geographic variation in expenditures for physicians' services. To study this variation, we examined expenditures for physicians' services in all metropolitan areas in the United States. METHODS: We used Medicare claims data for 1989 to measure rates of service use for beneficiaries living in the 317 U.S. metropolitan statistical areas (MSAs). The variables investigated were rates of admission to the hospital, payments to physicians for inpatient care per admission and per beneficiary, payments to physicians for outpatient care per beneficiary, and overall payments to physicians per beneficiary. Expenditures were measured in terms of allowed charges as adjusted to reflect prevailing charges in each MSA. Rates of use were adjusted for age and sex, with the exception of the variable for payments to physicians for inpatient care per admission, which was adjusted for case mix. RESULTS: Expenditures for the delivery of physicians' services to Medicare beneficiaries varied markedly among MSAs, with those for the areas with the lowest and the highest rates differing at least twofold on each measure. The measures for specific areas varied in parallel: areas with high rates of admission tended to have high levels of payment to physicians for inpatient care per admission, and areas with high payments for inpatient services tended to have high payments for outpatient services. Expenditures were not related to the number of physicians per capita but were lower in MSAs with a high proportion of primary care practitioners. The variation persisted when the 25 largest MSAs were examined; for total payments to physicians per beneficiary, there was a twofold difference between the area with the lowest rate and that with the highest, San Francisco ($872) and Miami ($1,874). The states with the highest overall payments to physicians per beneficiary were Florida, Louisiana, and Michigan. CONCLUSIONS: The marked variation among metropolitan areas in payments to physicians underscores the lack of consensus among physicians about which services are required. Moreover, the practice style in a given community appears to be influenced not by the aggregate supply of physicians but rather by the mixture of primary care physicians and specialists.

Ambulatory Care↗
PubMed1993

Discounting in cost-effectiveness analysis of healthcare programmes.

Discounting is a technique commonly used in cost-effectiveness analysis to 'make fair' comparisons of programmes whose costs and outcomes occur at different times. It is not a correction for inflation. While there is general agreement among health economists regarding the need to discount, there is less consensus on the procedure for discounting costs or benefits. We describe the method of constant-rate discounting, which uses the same rate to discount costs and benefits, and examine its impact on the cost effectiveness of selected health interventions. This methodology has significant limitations, however. Constant-rate discounting may not accurately represent the values of a society. Furthermore, discounting does not reflect the longitudinal time preferences of individuals (or groups). The philosophical rationale for constant-rate discounting is the concept of longitudinal equity, i.e. that society should make allocation decisions in such a way that present and future cohorts are treated equally, regardless of when they come into existence. In general, discounting affects the cost effectiveness of preventive interventions more than acute interventions, and it affects programmes with immediate cost more that those with ongoing cost. The reader of such analyses should be aware of these effects, and should use caution in comparing the cost effectiveness of interventions with vastly different timing of cost and benefit.

Cost-Benefit Analysis↗
PubMed1993

Marrow transplantation, cost effectiveness analysis and setting limits.

Marrow transplantation is currently second only to kidney in major organ transplants performed in the United States. Like other forms of transplantation, marrow transplantation is expensive. Unlike other forms of transplantation, however, marrow transplantation is not particularly constrained by a limited supply of donor organs. High costs combined with the potential for substantial growth make difficult resource choices inevitable.

Bone Marrow Transplantation↗
PubMed1993

Could distance be a proxy for severity-of-illness? A comparison of hospital costs in distant and local patients.

OBJECTIVE: We test the hypothesis that hospital costs, after adjusting for DRG mix, are higher in distant patients than in local patients. DATA SOURCES AND STUDY SETTING: Data were obtained from the Washington State Commission Hospital Abstract Reporting System (CHARS) and included all patients discharged from 15 metropolitan hospitals in the state of Washington during fiscal year 1987 (N = 181,072). STUDY DESIGN: Distant patients were initially defined as those patients residing outside a 15-mile radius of the hospital from which they were discharged; all other patients were considered local. Distance was determined using the patient's residence zip code. Hospital charge, calculated for all patients regardless of payer, served as a proxy for cost and was adjusted using the DRG weight. PRINCIPAL FINDINGS: Average charge (adjusted for DRG weight) was higher for distant patients in all but two hospitals. Overall adjusted charge for distant patients was 15 percent higher (p < .001). This finding persisted when different distances were used to dichotomize distant and local patients. When the 20 most common DRGs were examined individually, little charge difference was found in surgical DRGs that require tertiary center services (tertiary DRGs) and in those DRGs with both moderate and predictable resource use (routine DRGs); the charge difference seemed most prominent in those DRGs with a wide array of possible resource use (heterogeneous DRGs). CONCLUSIONS: Results suggest that patients traveling long distances use more resources and incur higher hospital charges than local patients. This is not accounted for in prospective payment. We postulate that distance might serve in part as a proxy for severity-of-illness.

Catchment Area, Health↗
PubMed1993

Rationing surgery: rules or constraints?

BACKGROUND: As U.S. health care expenditures climb, the need to set limits on surgery is becoming more generally accepted. If limits are necessary, how should they be established and by whom? This article considers two fundamental approaches, rules and constraints. RESULTS: With rules, payers or policymakers ration care by prioritizing and then restricting specific procedures. Although they have the advantage of explicitness, rules based on treatment prioritization are limited by patient heterogeneity and the lack of outcomes data necessary to rank many procedures. Rules are unambiguous and free the surgeon from the obligation to set limits, but they do not accommodate clinical judgment or patient preferences. With constraints, limits are set on surgical resources (e.g., the number and distribution of surgeons), but individual surgeons determine which procedures are provided to which patients. Although constraints are more feasible than rules, it is difficult to establish an "adequate" supply of surgical resources and to ensure that limits set by the individual surgeon are based on treatment efficacy. While preserving clinical autonomy, constraints require the surgeon to assume the responsibility of rationing care. CONCLUSIONS: Surgeons should consider carefully the approach to rationing that best serves their professional interests, their patients, and society.

Ethical Theory↗
PubMed1992

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.

Bed Occupancy↗
PubMed1992

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.

Analysis of Variance↗
PubMed1992

Prudent strategies for elective red blood cell transfusion.

OBJECTIVE: To review the literature on the appropriateness of red blood cell transfusion and current physician practice, with emphasis on the physiologic and symptomatic implications of elective transfusion in the treatment of anemia. DATA SOURCES: Studies on the therapeutic use of red blood cell transfusion were identified through a search of MEDLINE (1966 to the present) and through a manual review of bibliographies of identified articles. In addition, evidence was solicited from selected experts in the field and recent consensus panels that have developed transfusion guidelines. DATA SYNTHESIS: No controlled trials of blood transfusion were identified, but data were available on four issues relevant to transfusion practice: current physician practice and evidence for excessive use of red blood cell transfusion; physiologic adaptation to anemia; human tolerance of low hemoglobin levels; and strategies for reducing homologous transfusion requirements. CONCLUSIONS: Despite the recent decline in red blood cell use because of concerns about infection, current transfusion practice remains variable because physicians have disparate views about its appropriateness. The remarkable human tolerance of anemia suggests that clinicians can accept hemoglobin levels above 70 g/L (7 g/dL) in most patients with self-limited anemia. In patients with impaired cardiovascular status or with anemias that will not resolve spontaneously, however, the data are insufficient to determine minimum acceptable hemoglobin levels, and therapy must be guided by the clinical situation. Several therapeutic strategies and pharmacologic interventions are available in the perioperative and non-operative settings to further reduce red blood cell use.

Adaptation, Physiological↗
PubMed1992

The cost of institutional care in Alzheimer's disease: nursing home and hospital use in a prospective cohort.

OBJECTIVE: To assess the nursing home and hospital use of patients with Alzheimer's Type Dementia. DESIGN: A prospective cohort study of 126 patients entered into an Alzheimer's disease registry after diagnosis at a university hospital clinic between 1980 and 1982. Only four patients were in nursing homes at enrollment. MEASUREMENTS AND MAIN RESULTS: Data regarding nursing home use came from the registry and the individual nursing homes themselves. Hospital-use data were obtained using Medicare claims files. Follow-up was obtained on 123 patients (98%). Eighty-five (69%) had died by July 1, 1989. Three-quarters of the cohort (92) eventually resided in nursing homes. The median nursing home length of stay was 2.75 years (mean 2.95, 95% CI = 2.5, 3.4), over 10 times the national median length of stay for all diagnoses. Based on prevailing rates in the region, nursing home charges for the cohort were estimated to be between $4.3 and $6.4 million ($35,000-$52,000 per patient). During the 5-year period 1983-1988, 69 patients filed Part A (hospital) claims to Medicare for 76 admissions and 616 inpatient days. Part A Medicare reimbursement for the cohort totaled $460,000 over 5 years ($3,700 per patient), an expenditure comparable to what a random Medicare cohort might incur. CONCLUSIONS: The combination of a high rate of nursing home entry and lengthy stays makes long-term care the largest determinant of the cost of care in Alzheimer's disease. While Alzheimer's Type Dementia undoubtedly has profound indirect costs, this study demonstrates that the direct institutional costs alone are considerable.

Aged↗
PubMed1992

Readmission after surgery in Washington State rural hospitals.

BACKGROUND: Because of concern about the quality of care in rural hospitals, we examined readmission following four surgical procedures commonly performed in Washington State rural hospitals: appendectomy, cesarean section, cholecystectomy, and transurethral prostatectomy. METHODS: In a retrospective cohort study, we identified all patients discharged after receiving one of the foregoing procedures using the statewide hospital discharge database. Readmissions to any hospital in the state within 7 or 30 days of discharge were also identified. RESULTS: During the 2-year period examined, there were no significant differences in readmission rates for surgeries performed in rural and urban hospitals, although the readmission rates for all four procedures were nominally lower in rural hospitals. Logistic regression analyses that controlled for factors that influence readmission did not change these results. CONCLUSIONS: Investigating readmission rates following common surgeries, we found no evidence of low-quality surgical care in Washington State rural hospitals. Early readmission is an imperfect marker for poor surgical outcome, however, and other proxies for quality remain to be examined.

Adolescent↗
PubMed1991

British Columbia sends patients to Seattle for coronary artery surgery. Bypassing the queue in Canada.

Concern about waiting lists for elective procedures has become a highly visible challenge to the universal health insurance program in Canada. In response to lengthening queues for patients waiting for cardiac surgery, British Columbia made contracts with four Seattle hospitals to send a total of 200 patients for coronary artery bypass surgery. This article examines the cause of the queue for cardiac surgery in British Columbia and the events that led to outside contracting. Global hospital budgets and restrictions on capital expansion have limited hospital capacity for cardiac surgery. This constrained supply, combined with periodic shortages in critical care nurses and cardiac perfusion technologists, has resulted in a rapid increase in the waiting list. Reducing wide variations in the lengths of queues for individual surgeons may afford an opportunity to reduce long waits. While the patient queue for cardiac surgery has sparked a public debate about budget limits and health care needs, its clinical impact remains uncertain.

British Columbia↗