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Biomedical subjects

Peter C Smith

Publications and source records attributed to Peter C Smith.

At least 19 recordsLinked to original sources
PubMed2007

The effects of expanding patient choice of provider on waiting times: evidence from a policy experiment.

Long waiting times for inpatient treatment in the UK National Health Service have been a source of popular and political concern, and therefore a target for policy initiatives. In the London Patient Choice Project, patients at risk of breaching inpatient waiting time targets were offered the choice of an alternative hospital with a guaranteed shorter wait. This paper develops a simple theoretical model of the effect of greater patient choice on waiting times. It then uses a difference in difference econometric methodology to estimate the impact of the London choice project on ophthalmology waiting times. In line with the model predictions, the project led to shorter average waiting times in the London region and a convergence in waiting times amongst London hospitals.

Choice Behavior↗
PubMed2006

Hospital case payment systems in Europe.

Since the introduction of the system of diagnosis related groups (DRGs) for USA Medicare patients in 1983, case payment mechanisms have gradually become the principal means of reimbursing hospitals in most developed countries. The use of case payments nevertheless poses severe technical and policy challenges, and there remain many unresolved issues in their implementation. This paper introduces a special issue of the journal that describes and compares experience with the use of case payments for reimbursing hospitals in nine European countries. The editorial sets the policy scene, and argues that DRG systems must be seen both as a technical reimbursement method and as a fundamental incentive mechanism within the health system.

Diagnosis-Related Groups↗
PubMed2005

User charges and priority setting in health care: balancing equity and efficiency.

User charges are the major source of finance for many health care systems. However, traditional approaches to health care priority setting, such as cost-effectiveness analysis, usually assume there are no user charges and therefore may ignore important implications for equity and efficiency. This paper therefore develops a rudimentary model of priority setting in which the fixed health care budget can be augmented by user charges. The paper uses methods analogous to models of optimal commodity taxation to develop a set of rules for the inclusion of a health technology in the subsidized health care package, and the calculation of its associated copayment rate. The results indicate that optimal levels of subsidy depend on the cost-effectiveness of the intervention, its price elasticity of demand, the epidemiology of the associated disease, and the policy maker's attitude towards equity. The model has important implications for policy making in three domains: health care priority setting, evaluation of health care technologies, and charging policy.

Delivery of Health Care↗
PubMed2005

Missing clinical information during primary care visits.

CONTEXT: The coordinating function of primary care is information-intensive and may be impeded by missing clinical information. However, missing clinical information has not been explicitly investigated in the primary care setting. OBJECTIVE: To describe primary care clinicians' reports of missing clinical information. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional survey conducted in 32 primary care clinics within State Networks of Colorado Ambulatory Practices and Partners (SNOCAP), a consortium of practice-based research networks participating in the Applied Strategies for Improving Patient Safety medical error reporting study. Two hundred fifty-three clinicians were surveyed about 1614 patient visits between May and December 2003. For every visit during 1 half-day session, each clinician completed a questionnaire about patient and visit characteristics and stated whether important clinical information had been missing. Clinician characteristics were also recorded. MAIN OUTCOME MEASURES: Reports of missing clinical information frequency, type, and presumed location; perceived likelihood of adverse effects, delays in care, and additional services; and time spent looking for missing information. Multivariate analysis was conducted to assess the relationship of missing information to patient, visit, or clinician characteristics, adjusting for potential confounders and effects of clustering. RESULTS: Clinicians reported missing clinical information in 13.6% of visits; missing information included laboratory results (6.1% of all visits), letters/dictation (5.4%), radiology results (3.8%), history and physical examination (3.7%), and medications (3.2%). Missing clinical information was frequently reported to be located outside their clinical system but within the United States (52.3%), to be at least somewhat likely to adversely affect patients (44%), and to potentially result in delayed care or additional services (59.5%). Significant time was reportedly spent unsuccessfully searching for missing clinical information (5-10 minutes, 25.6%; >10 minutes, 10.4%). After adjustment, reported missing clinical information was more likely when patients were recent immigrants (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.06-2.99), new patients (OR, 2.39; 95% CI, 1.70-3.35), or had multiple medical problems compared with no problems (1 problem: OR, 1.09; 95% CI, 0.69-1.73; 2-5 problems: OR, 1.87; 95% CI, 1.21-2.89; >5 problems: OR, 2.78; 95% CI, 1.61-4.80). Missing clinical information was less likely in rural practices (OR, 0.52; 95% CI, 0.29-0.92) and when individual clinicians reported having full electronic records (OR, 0.40; 95% CI, 0.17-0.94). CONCLUSIONS: Primary care clinicians report that missing clinical information is common, multifaceted, likely to consume time and other resources, and may adversely affect patients. Additional research on missing information is needed to focus on validating clinicians' perceptions and on conducting prospective studies of its causes and sequelae.

Communication↗
PubMed2005

How robust are hospital ranks based on composite performance measures?

BACKGROUND: Composite indices of healthcare performance are an aggregation of underlying individual performance measures. They are increasingly being used to rank healthcare organizations. Although composite indicators present the "big picture" in a way that is easy to interpret, misleading conclusions may be drawn if attention is not paid to key methodological issues in their construction. OBJECTIVES: We examine variability in performance measures in the context of the construction and use of composite measures. We illustrate how variability in the underlying data and the resulting composite may undermine the robustness of performance measures in health care. We also illustrate how variation in the methodological rules applied to aggregate the individual indicators can have an important impact on composite scores. METHODS: We use data for 117 English acute hospitals to illustrate the generic methodological issues. The variance in performance measures is partitioned into "controllable" and "uncontrollable" elements. We create a composite index from the underlying performance indicators and use Monte Carlo simulations to examine the robustness of the composite. RESULTS: Random variation beyond the control of organizations gives rise to considerable uncertainty in hospital scores. Composites are also sensitive to changes made to the weighting system and to the aggregation rules. Some hospitals can jump almost half of the league table as a result of subtle changes. CONCLUSIONS: Great care is warranted in interpreting the results of composite performance measures. Suggestions for their future development are made.

Benchmarking↗
PubMed2003

Effects of raf kinase inhibitor protein expression on suppression of prostate cancer metastasis.

BACKGROUND: Raf kinase inhibitor protein (RKIP), an inhibitor of Raf-mediated activation of mitogen-activated protein/extracellular signal-regulated kinase kinase (MEK), is expressed at lower levels in human C4-2B metastatic prostate cancer cells than in the parental non-metastatic LNCaP prostate cancer cells from which they were derived. We examined whether RKIP functions as a suppressor of metastasis. METHODS: Immunohistochemistry was used to detect RKIP expression in clinical samples of primary prostate cancer and prostate cancer metastases. LNCaP and C4-2B cells were stably transfected with plasmids that constitutively expressed antisense and sense RKIP cDNA, respectively, or with empty vector. Assays of cell proliferation, soft-agar colony formation, and in vitro cell invasion were used to examine the malignant phenotypes of the transfected cells. An orthotopic murine model was used to examine the effect of expressing RKIP in C4-2B cells on the development of spontaneous metastasis. RESULTS: Clinical samples of primary prostate cancer had detectable RKIP expression, whereas clinical samples of prostate cancer metastases did not. There were no differences in the in vitro proliferation rate or colony-forming ability between the control vector-transfected and sense RKIP vector-transfected C4-2B cells or between the control vector-transfected and the antisense RKIP vector-transfected LNCaP cells. Overexpression of RKIP in C4-2B cells was associated with decreased in vitro cell invasion, decreased development of lung metastases in vivo, and decreased vascular invasion in the primary tumor but did not affect primary tumor growth in mice. CONCLUSIONS: RKIP does not influence the tumorigenic properties of human prostate cancer cells. It appears to be a novel and clinically relevant suppressor of metastasis that may function by decreasing vascular invasion.

Aged↗
PubMed2003

After-hours telephone triage affects patient safety.

OBJECTIVE: To describe the management of after-hours calls to primary care physicians and identify potential errors that might delay evaluation and treatment. STUDY DESIGN: Survey of primary care practices and audit of after-hours phone calls. Ninety-one primary care offices (family medicine, internal medicine, obstetrics, and pediatrics) were surveyed in October and November 2001. Data collected included number of persons answering the calls, information requested, instructions to patients, who decided whether to contact the on-call physician, and subsequent handling of all calls. We evaluated all after-hours calls to an index office that were not forwarded to the on-call physician. Four family physicians independently reviewed the calls while unaware that these calls had not been forwarded to the physician on call to determine the appropriate triage. POPULATION: Primary care physicians and their telephone answering services. OUTCOME MEASURES (1) Who decided to initiate immediate contact with the physician? (2) Percentage of calls identified as emergent or nonemergent by patients. (3) Independent physician ratings of nonemergent calls. RESULTS: More than two thirds of the offices used answering services to take their calls. Ninety-three percent of the practices required the patient to decide whether the problem was emergent enough to require immediate notification of the on-call physician. Physician reviewers reported that 50% (range, 22%-77%) of the calls not forwarded to the on-call physician represented an emergency needing immediate contact with the physician. CONCLUSIONS: After-hours call systems in most primary care offices impose barriers that may delay care. All clinical patient calls should be sent to appropriately trained medical personnel for triage decisions. We urge all clinicians that use an answering service to examine their policies and procedures for possible sources of medical error.

Answering Services↗
PubMed2002

Time course of morphological alterations of fungiform papillae and taste buds following chorda tympani transection in neonatal rats.

The time course of structural changes in fungiform papillae was analyzed in rats that received unilateral chorda tympani nerve transection at 10 days of age. Morphological differences between intact and denervated sides of the tongue were first observed at 8 days postsection, with an increase in the number of fungiform papillae that did not have a pore. In addition, the first papilla with a filiform-like appearance was noted on the denervated side at 8 days postsectioning. By 11 days after surgery, the total number of papillae and the number of papillae with a pore were significantly lower on the transected side of the tongue as compared to the intact side. At 50 days postsection, there was an average of 70.5 fungiform papillae on the intact side and a mean of only 20.8 fungiform papillae the denervated side. Of those few remaining papillae on the cut side, an average of 13.5 papillae were categorized as filiform-like, while no filiform-like papillae occurred on the intact side. Significant reduction in taste bud volume was noted at 4 days posttransection and further decrements in taste bud volume were noted at 8 and 30 days postsection. Electron microscopy of the lingual branch of the trigeminal nerve from adult rats that received neonatal chorda tympani transection showed normal numbers of both myelinated and unmyelinated fibers. Thus, in addition to the well-characterized dependence of taste bud maintenance on the chorda tympani nerve, the present study shows an additional role of the chorda tympani nerve in papilla maintenance during early postnatal development.

Animals↗
PubMed2002

Reducing avoidable inequalities in health: a new criterion for setting health care capitation payments.

Traditionally, most health care systems which pretend to any sort of rationality and cost control have sought to allocate their limited funds in order to secure equal opportunity of access for equal need. The UK government is implementing a fundamental change of resource allocation philosophy towards 'contributing to the reduction of avoidable health inequalities'. The purpose of this essay is to explore some of the economic issues that arise when seeking to allocate health care resources according to the new criterion. It indicates that health inequalities might arise because of variations in the quality of health services, variations in access to those services, or variations in the way people produce health, and that the resource allocation consequences differ depending on which source is being addressed. The paper shows that an objective of reducing health inequalities is not necessarily compatible with an objective of equity of access, nor with the objective of maximising health gain. The results have profound consequences for approaches towards economic evaluation, the role of clinical guidelines and performance management, as well as for resource allocation methods.

Capitation Fee↗
PubMed2002

Outpatient encounter data for risk adjustment--a view from Europe: comments on Welch.

This article comments from a European perspective on W. Pete Welch's article, which examines the use of outpatient encounter data for risk adjustment. Although diverse, Western European health care systems all seek to provide a comprehensive package of care, financed by premiums unrelated to health status. Some form of risk adjustment is therefore required as a basis for funding insurers in all systems. Two objectives have dominated: to secure equity between patients covered by different insurers and to ensure that (where implemented) competitive insurer markets operate efficiently. The commentary concludes that, although risk adjustment research of this type is important, the most fundamental requirement is to develop a more active purchasing function on the part of insurers.

Ambulatory Care↗
PubMed2002

Primary care family physicians and 2 hospitalist models: comparison of outcomes, processes, and costs.

OBJECTIVES: To compare the care provided by family practice primary care physicians with that provided by 2 hospitalist models: critical care hospitalists and rotating residency faculty family physician hospitalists. STUDY DESIGN: Retrospective chart review. A health maintenance organization mandated that all patients be admitted to a critical care hospitalist team. The family physician hospitalists admitted all other residency patients and patients of some community family physicians. The primary care physicians admitted all their other patients. We adjusted for disease severity by using the Pneumonia Severity Index, age, sex, and comorbidities. POPULATION: Adults admitted with pneumonia to our private urban community hospital. Exclusions included patients with nosocomial pneumonia, human immunodeficiency virus, and acquired immunodeficiency syndrome. OUTCOMES MEASURED: Primary (adjusted for age, sex, comorbidities, and disease severity): hospital charges, length of stay, in-hospital mortality, readmissions, and returns to the emergency room. Secondary: chest radiographs, intensive care use, blood and sputum cultures, compliance with American Thoracic Society guidelines, lifestyle and end-of-life counseling. RESULTS: Of 97 patients, 21 were admitted to the critical care hospitalists, 53 to the family physician hospitalists, and 23 to primary care physicians. The mean charge ($5680) by the primary care physicians was significantly lower than that of the critical care hospitalists ($10,231; P=.005) and trended toward being lower than that of the family physician hospitalists ($7699; P=.08). The patients of critical care and family physician hospitalists had longer mean lengths of stay (critical care hospitalists, 3.8 days; family physician hospitalists, 3.9 days) than did those of the primary care physicians (2.6 days; P=.04 and.01, respectively). Compared with the primary care physicians, the critical care hospitalists were more likely to obtain at least 2 chest x-rays (odds ratio, 4.1; 95% confidence interval, 1.1-15.5) and trended toward increased odds of lengthy stay in the intensive care unit (odd ratio, 2.9; 95% confidence interval, 0.6-14.6). We found no other significant differences in primary or secondary outcomes. CONCLUSIONS: Claims of better and cheaper care by hospitalists need further investigation. Meanwhile, the use of hospitalists should not be mandated, and the use of family physicians as hospitalists should be considered a good alternative to the use of subspecialists.

Aged↗
PubMedDate not supplied

Are frequent callers to family physicians high utilizers?

PURPOSE: Our objective was to describe patients who telephone frequently after hours to physicians (frequent callers) and categorize their medical problems and resource utilization. METHODS: Charts of frequent callers were reviewed and compared with those of a systematically selected group from the same family medicine residency practice (control group). Data collected included demographic and clinical information, as well as information on utilization of office, emergency department, and hospital services. In addition, 4 family physicians reviewed the patient information and identified the primary diagnosis for frequent callers. RESULTS: Frequent callers were predominately female; had 3 times as many office visits, diagnoses, and medications; and had 8 times as many hospital admissions as the control group. The most common primary diagnostic categories were psychiatric disorders (36%), pain (21%), chronic illnesses (16%), pregnancy (13%), and common problems of childhood (9%). CONCLUSIONS: Frequent callers represent a unique group of patients with high utilization of health care services. Better targeted patient education and referral to other support services may decrease the number of calls and utilization of health services. Alternatively, among high utilizers, frequent telephone calls may be a substitute for other forms of care.

Ambulatory Care↗
PubMedDate not supplied

Performance management in British health care: will it deliver?

In its latest attempt to improve performance, the British National Health Service (NHS) has turned to the business models of performance management. A range of managerial instruments has been deployed, signaling national priorities to local managers and seeking to offer the information, incentives, and capacity they need to respond appropriately. The arrangements are intellectually coherent and offer the prospect of major improvements in the quality of British health care. However, implementation is at an early stage, and some key issues have to be addressed. The various performance management instruments have not yet been properly aligned, and greater conceptual clarity in implementation is required. Performance management will not be fully effective unless adequate capacity--in information, leadership, and managerial resources--is made available.

Decision Making, Organizational↗