When you've seen how one doctor works, you've not seen how all doctors work.
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Efficiency↗
Biomedical subjects
J Lipscomb
Publications and source records attributed to J Lipscomb.
Determining VA physician requirements through empirically based models.
OBJECTIVE: As part of a project to estimate physician requirements for the Department of Veterans Affairs, the Institute of Medicine (IOM) developed and tested empirically based models of physician staffing, by specialty, that could be applied to each VA facility. DATA SOURCE/STUDY SETTING: These analyses used selected data on all patient encounters and all facilities in VA's management information systems for FY 1989. STUDY DESIGN: Production functions (PFs), with patient workload dependent on physicians, other providers, and nonpersonnel factors, were estimated for each of 14 patient care areas in a VA medical center. Inverse production functions (IPFs), with physician staffing levels dependent on workload and other factors, were estimated for each of 11 specialty groupings. These models provide complementary approaches to deriving VA physician requirements for patient care and medical education. DATA COLLECTION/EXTRACTION METHODS: All data were assembled by VA and put in analyzable SAS data sets containing FY 1989 workload and staffing variables used in the PFs and IPFs. All statistical analyses reported here were conducted by the IOM. PRINCIPAL FINDINGS: Existing VA data can be used to develop statistically strong, clinically plausible, empirically based models for calculating physician requirements, by specialty. These models can (1) compare current physician staffing in a given setting with systemwide norms and (2) yield estimates of future staffing requirements conditional on future workload. CONCLUSIONS: Empirically based models can play an important role in determining VA physician staffing requirements. VA should test, evaluate, and revise these models on an ongoing basis.
Efficiency, Organizational↗
Comparative 2D-electrophoretic mapping of human and rodent hepatic stress proteins as potential biomarkers.
Toxicologic studies in rodents demonstrate that two-dimensional polyacrylamide gel electrophoresis of proteins (2DE) is very useful in the detection and evaluation of chemical toxicity by providing information regarding cellular status at the molecular level. Identification of a set of specific biomarkers of exposure or effect, with a proclivity for both a particular rodent and human target tissue, is required for development of an electrophoretically based testing system. In this regard, stress proteins, such as the heat shock and glucose-regulated proteins (Hsp and Grp), are appropriate candidates. The present investigation was undertaken to identify these stress proteins on conventional two-dimensional electrophoretic gel patterns of human and rat liver homogenates. The following stress proteins were identified, their x, y coordinate positions mapped, and abundances determined, and these data statistically analyzed and compared: Hsp25, Hsp32, Hsp60, Hsc70, Hsp70, Hsp90, Grp75, Grp78, Grp94, protein disulfide isomerase (PDI), and ER-60. With the exception of Hsp25 and Hsp32, the stress proteins examined were constitutively expressed at detectable levels in both unstressed human and rat liver; in virtually identical patterns. Based on our results, the human hepatic 2DE stress protein pattern seems well-suited to toxicologic screening particularly in in vitro applications and via extrapolations from rodent exposures.
Animals↗
Preventing occupational illness and injury: nurse practitioners as primary care providers.
Nurse practitioners with master's degrees were surveyed to assess the type and volume of occupational health services provided by primary care as compared with occupational health practitioners and the knowledge base in occupational health in these two groups. Thirty-six percent of 224 nonoccupational health nurse practitioners reported caseloads with 10% or more occupationally related chief complaints; 21% reported treating work-related injury or illness at least once per week. By contrast, a large percentage of nonoccupational health practitioners failed the knowledge-based exam. Large-scale prevention of occupational illness and injury warrants that primary care providers receive training in occupational health.
Accidents, Occupational↗
Costing medical care: using Medicare administrative data.
This paper describes how the PORTS are using data from the Medicare administrative records systems to study the medical care costs of specific conditions. The general strengths and weaknesses of the Medicare databases for studying cost related issues are discussed, and the relevant data elements are examined in detail. Changes in the nature of the data collected over time are noted. Information is provided on how the PORTS are using these data to estimate the cost to Medicare of treating Medicare beneficiaries with specific conditions and the social (opportunity) cost of treating these patients. Furthermore, information is provided on how data from the Medicare administrative records system can be used to determine the cost of services for patients who have been identified through other large databases (i.e., state hospital discharge tapes) or who have been enrolled in prospective cohort studies.
Costs and Cost Analysis↗
Environmental health: assuming a leadership role.
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Environmental Health↗
Comparison of analytic models for estimating the effect of clinical factors on the cost of coronary artery bypass graft surgery.
The cost of treating disease depends on patient characteristics, but standard tools for analyzing the clinical predictors of cost have deficiencies. To explore whether survival analysis techniques might overcome some of these deficiencies in the analysis of cost data, we compared ordinary least square (OLS) linear regression (with and without transformation of the data) and binary logistic regression with two survival models: the Cox proportional hazards model and a parametric model assuming a Weibull distribution. Each model was applied to data from 155 patients undergoing coronary artery bypass grafting. We examined the effects of age, sex, ejection fraction, unstable angina, and number of diseased vessels on univariable and multivariable predictions of costs. The significant univariable predictors of cost were consistent in all models: ejection fraction was significant in all five models, and age and number of diseased vessels were each significant in all but the OLS model, while sex and angina type were significant in none of the models. The significant multivariable predictors of cost, however, differed according to model: ejection fraction was a significant multivariable predictor of cost in all five models, age was significant in three models, and number of diseased vessels was significant in one model. All five models were also used to predict the costs for an average patient undergoing surgery. The Cox model provided the most accurate predictions of mean cost, median cost, and the proportion of patients with high cost. This study shows: (1) lower ejection fraction and older age are independent clinical predictors of increased cost of CABG, and (2) the Cox proportional hazards model shows considerable promise for the analysis of the impact of clinical factors upon cost.
Aged↗
Spontaneous abortions and birth defects related to tap and bottled water use, San Jose, California, 1980-1985.
We recently studied pregnancies occurring during 1980-1985 in four study areas in Santa Clara County, California. Two of the areas were exposed to solvent-contaminated drinking water during 1980 and 1981, and two were unexposed. There was an overall excess of spontaneous abortions among women who reported any tapwater consumption during the first trimester of pregnancy compared with those who reported no tapwater consumption [odds ratio (OR) = 4.0; 95% confidence interval (CI) = 1.8-9.1)], regardless of exposure to the contaminated water. The odds ratio for spontaneous abortion for women reporting any vs no tapwater was 6.9 (95% CI = 2.7-17.7) after adjustment for numerous potential confounders using multiple logistic regression analyses. The elevated odds ratio of spontaneous abortion was seen among tapwater drinkers who used no filters or softener-type filters but not among women who reported use of active filters. Spontaneous abortion rates were reduced in women who reported any vs no bottled water consumption (OR = 0.26; 95% CI = 0.16-0.43). Among women who reported no tapwater consumption, no birth defects occurred among 263 live births; in comparison, among women who reported tapwater consumption, 4% of 908 live births had defects (P = 0.0001). We observed no relation between birth defects and bottled water use.
Abortion, Spontaneous↗
Financial counseling for families of children with chronic disabilities.
A program to teach financial management skills to parents of children with chronic illnesses and disabilities was developed. To test the effectiveness of this program, a randomized, controlled prospective study was conducted of 115 families of children with spina bifida, 58 of whom received financial counseling while 57 served as controls. Significantly more frequent changes in behavior were found in the intervention group than in the control group at the end of the one-year study for 18 of the 68 variables, including such items as establishing records, using a budget, obtaining low-cost life insurance and taking appropriate tax deductions. Three-quarters of the families in the intervention group believe that the counseling program had had or would have a beneficial effect on the quality of their lives. Financial counseling may benefit families with chronically ill or disabled children.
Budgets↗
Symptom prevalence and odor-worry interaction near hazardous waste sites.
Retrospective symptom prevalence data, collected from over 2000 adult respondents living near three different hazardous waste sites, were analyzed with respect to both self-reported "environmental worry" and frequency of perceiving environmental (particularly petrochemical) odors. Significant positive relationships were observed between the prevalence of several symptoms (headache, nausea, eye and throat irritation) and both frequency of odor perception and degree of worry. Headaches, for example, showed a prevalence odds ratio of 5.0 comparing respondents who reported noticing environmental odors frequently versus those noticing no such odors and 10.8 comparing those who described themselves as "very worried" versus "not worried" about environmental conditions in their neighborhood. Elimination of respondents who ascribed their environmental worry to illness in themselves or in family members did not materially affect the strength of the observed associations. In addition to their independent effects, odor perception and environmental worry exhibited positive interaction as determinants of symptom prevalence, as evidenced by a prevalence odds ratio of 38.1 comparing headaches among the high worry/frequent-odor group and the no-worry/no-odor group. In comparison neighborhoods with no nearby waste sites, environmental worry has been found to be associated with symptom occurrence as well. Potential explanations for these observations are presented, including the possibility that odors serve as a sensory cue for the manifestation of stress-related illness (or heightened awareness of underlying symptoms) among individuals concerned about the quality of their neighborhood environment.
Adult↗
Hypotheses to explain the higher symptom rates observed around hazardous waste sites.
Five studies were carried out around hazardous waste sites in California in which the main route of exposure was to low-level parts per billion concentrations of either gaseous emissions or airborne dust particles. Although there was no evidence suggesting excesses in cancer or birth defects, the total number and the prevalence of many of subjective symptoms were higher in areas near the site than in control neighborhoods. We discuss a number of causal processes that could explain these results. We conclude that a classical toxicological response and mass psychogenic illness are not valid explanations. Recall bias may explain part of the pattern. We present data from situations where stress alone from environmental anxiety has produced a similar magnitude of excess symptoms in populations. The fact that excess symptoms in waste site neighbors is found primarily in those who complain of odors or who are worried about environmental chemicals suggests the possibility that autonomic, stress-mediated mechanisms or behavioral sensitization are active in the genesis of these symptoms. A variety of confounders were controlled for. The hypothesis that chemically "acquired immune deficiency" can cause subtle symptomatology as a prodrome to subsequent serious disease has been raised in testimony at several toxic tort trials about waste sites. Although this hypothesis seems unlikely, particularly at sites such as the ones we studied with low airborne exposures, if true it would have profound regulatory implications.
Anxiety↗
Feasibility and cost-saving potential of outpatient cardiac catheterization.
To determine the feasibility and cost-saving potential of substituting outpatient for inpatient cardiac catheterization, 986 consecutive procedures were studied at a large referral hospital. Patients were classified prospectively as to their eligibility for outpatient cardiac catheterization according to published guidelines. Resource consumption was recorded, and cost savings were then calculated by analyzing the specific supply and personnel costs that could change as a result of inpatient versus outpatient status. Of the total of 986 patients who underwent diagnostic catheterization, 240 (24%) were outpatients, 279 (28%) were inpatients but had no exclusion criteria for outpatient catheterization and 467 (47%) were inpatients who had one or more exclusions for outpatient catheterization. The most common reasons for exclusion from outpatient catheterization were congestive heart failure (22%), unstable angina (15%), noncoronary heart disease (14%), recent myocardial infarction (11%) and severe noncardiac disease (9%). Inpatients with no exclusions for the outpatient procedure tended to be sicker than outpatients because they were older (p = 0.002), had a lower ejection fraction (p = 0.009) and had more triple vessel coronary artery disease (p less than 0.0001). The cost of the catheterization procedure itself was not different between inpatients and outpatients. Laboratory testing was more frequent among inpatients, however, and "room and board" costs were significantly higher. Although the difference in hospital charges for inpatients and outpatients was $580, a rigorous analysis indicated that the potential cost savings was only 38% of this amount, or $218 per eligible patient.(ABSTRACT TRUNCATED AT 250 WORDS)
Ambulatory Care↗
Pregnancy outcomes in women potentially exposed to solvent-contaminated drinking water in San Jose, California.
During 1980-1981, solvents leaked from an underground storage tank of a semiconductor firm in southern Santa Clara County, California, contaminating local drinking water. The contaminated well was closed in December 1981. An epidemiologic study conducted in 1983 confirmed statistically significant excesses of adverse pregnancy outcomes in an exposed community compared with an unexposed community, but could not establish a causal connection between the leak and the adverse outcomes. This study expanded the first study; adverse pregnancy outcomes occurring in 1980-1985 were studied in two communities exposed to the contaminated drinking water and in two demographically comparable but unexposed communities. The period 1980-1981 was the time period in which the well was considered to have been contaminated and 1982-1985 was considered the postcontamination time period. Both exposed and unexposed communities were considered unexposed during the latter period (1982-1985). Out of 10,055 households surveyed, interviews were conducted with 1,105 women who reported one or more eligible pregnancies. Miscarriages and birth defects were validated by medical record review or physician reports. Although the authors again observed statistically significant excesses of spontaneous abortions and birth defects in the originally studied exposed area in 1980-1981, they observed deficits of these outcomes in the second exposed study area. Adjustment for potential confounders did not alter these findings. Analyses of pregnancy outcomes during 1981 in relation to exposure estimates based on hydrogeologic modeling of water and contaminant distribution within the exposed areas also indicated that the leak was not likely to have caused the observed excesses of adverse pregnancy outcomes in the originally studied area.
Abnormalities, Drug-Induced↗
Resource use and cost of initial coronary revascularization. Coronary angioplasty versus coronary bypass surgery.
Although there is intense interest in the cost-saving potential of therapeutic alternatives, most studies have analyzed hospital charges rather than actual economic costs. To analyze cost differences rigorously, we studied 115 patients undergoing initial elective angioplasty (percutaneous transluminal coronary angioplasty, PTCA) and 274 patients undergoing initial elective surgery (coronary artery bypass graft surgery, CABG). Detailed resource consumption profiles were constructed and used to estimate the cost savings from switching a patient from CABG to PTCA. Four cost-accounting methods were used in the analysis; each method made different assumptions about the costs that would vary and the costs that would be fixed according to the number of procedures performed. The variable costs in the four methods were the 1) cost of supplies, 2) cost of personnel and supplies, 3) average direct costs, and 4) average direct costs plus allocated hospital overhead. The mean hospital charges for CABG patients were $19,644 versus $9,556 for PTCA patients (p less than 0.0001). The estimated cost difference between CABG and PTCA was substantially less than the $10,088 difference in charges, however, with net savings of 19%, 46%, 53%, and 78% of charges using cost-accounting methods 1-4, respectively. Thus, although the initial hospital charges for PTCA are significantly less than for CABG, the actual economic cost savings may be significantly overestimated by the use of hospital charge data.
Accounting↗
Time preference for health in cost-effectiveness analysis.
In program evaluation, should a predicted health status gain of 1 quality-adjusted life year (QALY) occurring 10 years from now be valued the same as a 1-QALY increase realizable 5 years from now? Or 1 year from now? If not, how should these future gains (or losses) be evaluated from a present-time perspective? Such questions arise frequently in cost-effectiveness analyses of disease prevention-health promotion programs. This report argues there are actually two distinct interpretations of time preference jointly relevant in many multiperiod program evaluations. 1) In ongoing programs where both present and future population cohorts are, in effect, vying for resources, decision makers must establish a relative social weighting of cohorts by specifying (now) the dollar worth of any unit QALY gain achievable in each. This is a problem of intergenerational equity in the resource allocation process. 2) Individuals, in any cohort, may possess a time preference for the sequence of events comprising their own multiperiod health outcomes. Current models, typically discounting future health gains to present value at some constant rate (r), can well accommodate the first interpretation but not (simultaneously) the second. In response, this report introduces a two-step evaluation procedure featuring the "scenario strategy," a holistic multiattribute preference approach to evaluating multiperiod health outcomes. It allows one to isolate statistically time preference effects at the individual or group level and to incorporate them naturally into the overall evaluation of multiperiod outcomes. A survey-based example and an appendix illustrate the main points.
Attitude to Health↗
Are larger dental practices more efficient? An analysis of dental services production.
Whether cost-efficiency in dental services production increases with firm size is investigated through application of an activity analysis production function methodology to data from a national survey of dental practices. Under this approach, service delivery in a dental practice is modeled as a linear programming problem that acknowledges distinct input-output relationships for each service. These service-specific relationships are then combined to yield projections of overall dental practice productivity, subject to technical and organizational constraints. The activity analysis reported here represents arguably the most detailed evaluation yet of the relationship between dental practice size and cost-efficiency, controlling for such confounding factors as fee and service-mix differences across firms. We conclude that cost-efficiency does increase with practice size, over the range from solo to four-dentist practices. Largely because of data limitations, we were unable to test satisfactorily for scale economies in practices with five or more dentists. Within their limits, our findings are generally consistent with results from the neoclassical production function literature. From the standpoint of consumer welfare, the critical question raised (but not resolved) here is whether these apparent production efficiencies of group practice are ultimately translated by the market into lower fees, shorter queues, or other nonprice benefits.
Cost-Benefit Analysis↗
The National Health Care Trust Plan: a blueprint for market and long-term care reform.
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Aged↗
Time course alterations in tremor and muscarinic receptor binding produced by trimethyltin.
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Animals↗