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Biomedical subjects

H S Luft

Publications and source records attributed to H S Luft.

At least 19 recordsLinked to original sources
PubMed1995

Regionalization of cardiac surgery in the United States and Canada. Geographic access, choice, and outcomes.

OBJECTIVE: To determine how regionalization of facilities for coronary artery bypass surgery (CABS) affects geographic access to CABS and surgical outcomes. DESIGN: Computerized hospital discharge records were used to measure hospital CABS volume and in-hospital post-CABS mortality rates. Relationships between surgical volume and age- and sex-adjusted mortality rates were compared using chi 2 tests. Small-area analysis of the association between CABS rates and distances to nearest CABS hospital was performed using multivariate linear regression methods. SETTING: All nonfederal hospitals in New York, California, Ontario, Manitoba, and British Columbia. PATIENTS: All adult residents of the five jurisdictions who underwent CABS in a hospital in their jurisdiction from 1987 through 1989. RESULTS: In New York and Canada, approximately 60% of all CABS operations took place in hospitals performing 500 or more CABS operations per year, compared with only 26% in California. The highest mortality rates were found among California hospitals performing fewer than 100 CABS operations per year (adjusted 14-day in-hospital mortality was 4.7% compared with 2.4% in high-volume California hospitals, P < .001). The percentage of the population residing within 25 miles of a CABS hospital was 91% in California, 82% in New York, and less than 60% in Canada. Eliminating very low-volume (< 100 cases per year) CABS hospitals in California would increase travel distances to a CABS hospital only slightly for a small number of residents. The Canadian degree of regionalization was not associated with lower CABS rates within provinces for populations living at more remote distances from the nearest CABS hospital. CONCLUSION: Regionalization of CABS facilities in New York and Canada largely avoids the problem of low-volume outlier hospitals with high postoperative mortality rates found in California. New York has avoided the redundancy of facilities that exists in California while still providing residents a geographically convenient selection of CABS hospitals. Stricter regionalization in Canada may leave residents with a more narrow choice of facilities, but does not disproportionately affect access to surgery for populations living at remote distances from CABS facilities.

Canada↗
PubMed1992

Costs and coverage. Pressures toward health care reform.

Signs of discontent with the health care system are growing. Calls for health care reform are largely motivated by the continued increase in health care costs and the large number of people without adequate health insurance. For the past 20 years, health care spending has risen at rates higher than the gross national product. As many as 35 million people are without health insurance. As proposals for health care reform are developed, it is useful to understand the roots of the cost problem. Causes of spiraling health care costs include "market failure" in the health care market, expansion in technology, excessive administrative costs, unnecessary care and defensive medicine, increased patient complexity, excess capacity within the health care system, and low productivity. Attempts to control costs, by the federal government for the Medicare program and then by the private sector, have to date been mostly unsuccessful. New proposals for health care reform are proliferating, and important changes in the health care system are likely.

Delivery of Health Care↗
PubMed1991

A method for risk-adjusting employer contributions to competing health insurance plans.

Biased selection can threaten the viability of multiple choice health systems unless payments to particular plans are adjusted to offset risk differences among employees. We report the results of a study designed to predict medical care utilization and expenditures for groups of fee-for-service plan (FFS) and health maintenance organization (HMO) enrollees, using characteristics commonly available in the personnel files of large employers. Simulation analyses indicate that the six-equation, maximum likelihood model predicts well for groups of 1,000 or more. Additional data are required to reduce prediction errors for smaller groups. This new methodology potentially allows risk-rating of employer contributions to competing health plans, based on the expected utilization of the individuals choosing each plan.

Economic Competition↗
PubMed1990

Does quality influence choice of hospital?

In recent years, much information has been provided to the public and to physicians about hospital quality measured in terms of patient outcomes. To examine if, before these public data releases, quality influenced the attractiveness of a hospital to referring or admitting physicians and to patients, we estimated the influences of quality, charges, ownership, and distance on the choice of hospitals for patients with seven surgical procedures and five medical diagnoses in hospitals in three geographic areas in California in 1983. Greater distance and public or proprietary ownership consistently reduced the likelihood of selection while medical school affiliation increased the likelihood of selection. For five of seven surgical procedures and two of five medical diagnoses, hospitals with poorer than expected outcomes attracted significantly fewer admissions. The reverse held for two surgical procedures and one medical diagnosis. The results suggest that quality played an important role in choices among hospitals even before explicit data were widely available.

Aged↗
PubMed1990

Services and charges by PPO physicians for PPO and indemnity patients. An episode of care comparison.

Physicians who participate in preferred provider organizations (PPOs) usually agree to various types of utilization review and sometimes discount their charges or agree to accept lower fees. This study was performed to determine whether they provided more or fewer services to their PPO patients than to their indemnity patients and whether the discounting resulted in lower expenditures for each episode of illness. In 1984, Metropolitan Life offered PPO coverage to Dade County (Florida) school board employees and dependents but only a standard indemnity plan to Dade County government employees and dependents. Episodes of care were examined for patients with chest pain, hypertension, joint pain, gastrointestinal or liver disorders, and lower back pain cared for by physicians who treated patients in both the PPO and indemnity employee groups. For PPO patients, charges per physician service were the same or lower, but total physician charges during an episode were higher. For services such as laboratory tests, diagnostic x-rays, and room and board, PPO and indemnity patients' charges were not significantly different.

Fees, Medical↗
PubMed1988

Competition, regulation, and hospital costs, 1982 to 1986.

We used data on 5490 nonfederal, short-term general hospitals to evaluate the relative effectiveness of regulatory and market-oriented cost-control policies on hospital cost inflation between 1982 and 1986. All-payer rate-regulation programs reduced inflation rates by 16.3% in Massachusetts, 15.4% in Maryland, and 6.3% in New York, compared with the control hospitals in 43 states with neither all-payer rate regulation nor an aggressive market-oriented strategy. New Jersey hospitals experienced a rate of cost inflation similar to the control hospitals. Given the effectiveness of its regulatory program in the 1970s, however, New Jersey began and ended the period from 1982 to 1986 with the lowest costs, controlling for wages and patient mix. California's market-oriented cost-control policy reduced inflation rates by 10.1%. Hospitals with large percentages of patients insured by Medicare's prospective payment system experienced cost inflation rates 16.1% lower than hospitals with small percentages of Medicare patients. Investor-owned hospitals experienced rates of cost increase 11.6% higher than private nonprofit hospitals and 15.0% higher than public hospitals.

Cost Control↗
PubMed1988

Hospital competition and surgical length of stay.

The hypothesis that competitive pressures encourage hospitals to accommodate patient and physician preferences for longer lengths of stay was tested. Seven hundred forty-seven nonfederal short-term hospitals were divided in terms of the number of neighboring hospitals within a 24-km radius, and this measure of hospital concentration and competition was measured against length of stay for ten surgical procedures, using 1982 data on 498454 patient discharges. Patient, physician, and hospital characteristics associated with length of stay were controlled for. Competition-related percentage increases in length of stay were identified for all procedures, including total hip replacement (14.8%), transurethral prostatectomy (13.9%), intestinal operations (14.0%), stomach operations (14.7%), hysterectomy (6.9%), cholecystectomy (9.1%), hernia repair (10.5%), appendectomy (8.4%), cardiac catheterization (22.9%), and coronary artery bypass graft surgery (21.2%). It was concluded that there is a strong association between the number of hospital competitors in the local market and the average length of stay in US hospitals.

Catchment Area, Health↗
PubMed1988

Hospital volume and patient outcomes. The case of hip fracture patients.

Patients achieve better outcomes at hospitals that treat larger numbers of patients with certain diagnoses or who are undergoing particular procedures. However, the causal direction underlying this relationship is less well understood. Do patients treated at institutions with higher volumes of patients achieve better outcomes because the hospital staff and physicians have gained expertise by practice (the "practice makes perfect" hypothesis)? Do hospitals with a community reputation for excellent results attract higher volumes of patients because primary care physicians refer patients to specialists who practice there (the "selective referral" hypothesis)? Or, are both explanations important? This article addresses this question through a detailed analysis of patients with a particular diagnosis: hip fracture. In addition, two measures of patient outcomes are compared: long hospital stays as a proxy for in-hospital complications and in-hospital death.

Aged↗
PubMed1988

HMOs and the quality of care.

Various studies of selected health maintenance organizations (HMOs) suggest that the quality of their medical care is comparable to that delivered in the fee-for-service (FFS) sector. Unfortunately, these studies are based on a small number of mature HMOs that were operating in an environment less focused on competition and cost containment than is the case today. It is the thesis of this paper that the current environment increases the importance of quality assessment and assurance for both HMO and FFS providers. I suggest that HMOs may meet the increased demand by patients and payers for quality medical care by focusing attention on population-based outcome measures.

Cost Control↗
PubMed1987

Competition and the cost of hospital care, 1972 to 1982.

Using 1982 data from 5732 US hospitals, we found that costs were substantially higher in hospitals operating in more competitive local environments than in hospitals in less competitive environments. After controlling for wage rates, patient case mix, state regulatory programs, and hospital teaching role, average costs per admission were found to be 26% higher in hospitals in the most competitive markets (more than ten hospitals within a 24-km radius) than in hospitals with no competitors within a 24-km radius. Average costs per patient-day were 15% higher in the most competitive markets than in hospitals with no neighbors. These findings on the cost implications of nonprice competition among hospitals suggest that the new modes of hospital payment will have a greater disruptive impact on hospital behavior in areas with many, rather than few, hospitals. In anticipating the effects of new modes of payment on hospital behavior, policymakers should consider the nature of quality competition as well as price competition within local markets.

Economic Competition↗
PubMed1987

Association of volume with outcome of coronary artery bypass graft surgery. Scheduled vs nonscheduled operations.

Empirical evidence suggests that mortality rates for coronary artery bypass graft (CABG) surgery are lower in hospitals that perform a higher volume of the procedure. In recent years, the criteria for CABG surgery have been expanded to include patients with a wide variety of co-morbidities. To address the question of whether the volume-outcome relationship continues to exist for this new group of patients, discharge abstracts for 18,986 CABG operations at 77 hospitals in California in 1983 were analyzed using multiple-regression techniques. Higher-volume hospitals had lower in-hospital mortality (adjusted for case mix); this effect was greatest in patients who might be characterized as having "non-scheduled" CABG surgery. Higher-volume hospitals also had shorter average postoperative lengths of stay and fewer patients with extremely long stays. The results of this study suggest that the greatest improvement in average outcomes for CABG surgery would result from the closure of low-volume surgery units.

California↗
PubMed1987

Effects of surgeon volume and hospital volume on quality of care in hospitals.

A growing body of evidence indicates that certain surgical procedures exhibit a "volume-outcome" relationship in which a higher volume of patients undergoing a particular procedure at a hospital is associated with better outcomes for those patients. The proportion of a hospital's patients operated on by low-volume or less experienced surgeons also may be associated with poor patient outcomes and thus contribute to the hospital "volume-outcome" relationship. This paper analyzes the influence of hospital volume and the proportion of a hospital's patients operated on by low-volume surgeons on patient outcome for 10 procedures, controlling for other selected factors that may influence outcomes. The analysis is based on 503,662 patient abstracts from 757 hospitals. Results indicate that both hospital volume and the proportion of patients operated on by low-volume surgeons are related to quality of care as measured by patient outcomes. Higher hospital volume is positively related to better patient outcomes. These findings are consistent with earlier hospital "volume-outcome" research and add an additional set of procedures using more recent data to the evidence. Unlike previous research on surgeon volume, a positive relationship was found between higher percentage of patients operated on by low-volume surgeons and poorer hospital quality.

Clinical Competence↗
PubMed1987

Selective contracting for hospital care based on volume, quality, and price: prospects, problems, and unanswered questions.

There is a burgeoning interest in selective contracting for specialized hospital services based on volume, price, and quality. The systematic exclusion or inclusion of particular institutions has been extolled by some as an arrangement to reduce costs and by others as a means to increase quality of care. However, little is known about the issues and problems associated with selective contracting based on objective criteria rather than negotiations. Identification of individual institutions with performance significantly better or poorer than expected based on statistical norms is difficult and should be viewed as no more than a first step in evaluating quality and price performance. Actual data on 37 hospitals that provide coronary artery bypass graft surgery in a metropolitan region are used to illustrate some major prospects, problems, and situations arising when certain institutions are considered for exclusion from or inclusion in third-party payment programs. Selective contracting in local areas can potentially decrease duplication of services, reduce cost to purchasers, and lower expected mortality and morbidity for some patient groups. However, these gains must be evaluated against reductions in continuity of care and access to care, potential increases in mortality and morbidity for certain segments of the population, and substantial political problems.

California↗