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PubMed1995

A model for predicting transfusion requirements in head and neck surgery.

INTRODUCTION: Although allogeneic blood transfusions have allowed surgeons increased latitude in resecting advanced cancers, they can cause significant morbidity or even death in rare instances. Potential side effects may include transmission of infection and immunosuppression leading to an increased risk of cancer recurrence. Because patients have become more reluctant to receive transfusions, they frequently request preoperative autologous blood donation (PABD). In practice, however, only 50% or less of the donated blood is ultimately transfused while the remainder is discarded. PURPOSE: The purpose of this study was to develop a transfusion prediction and risk assessment (TPRA) model for predicting the need for perioperative blood transfusions in patients undergoing major head and neck oncologic surgical procedures. By knowing the probability for blood transfusion, the physician and patient can make an educated decision regarding the need for PABD. PATIENTS AND METHODS: Over a 4-year period, 436 patients underwent major head and neck surgical procedures for neoplasms of the upper aerodigestive tract, the thyroid gland, and the salivary glands. Data obtained prospectively on each patient included age and gender, the TNM stage, primary disease site, type of prior treatment, estimated intraoperative blood loss, duration of surgery, transfusion requirements, preoperative and postoperative hemoglobin and hematocrit levels, type of procedure and method of reconstruction. These variables were examined singly and in combination both for descriptive purposes and to evaluate their interrelationships. In order to develop the TPRA model, only the 12 variables available prior to the surgical procedure were examined. Variables associated with transfusion need were evaluated further in a multivariate analysis. The logistic regression model allowed a linear expression of patient characteristics to be related to a function of the probability of transfusion need. Analyses of association between categorical variables and transfusion status were based on chi-squared, Fisher's Exact, and Mann-Whitney U tests. RESULTS: Overall, 51 (11.7%) patients required blood transfusions. The median number of units transfused was 2.0 (range, 1 to 13 U). Univariate analysis demonstrated a higher probability for blood replacement in patients with oropharyngeal or hypopharyngeal primary tumor sites, a preoperative hemoglobin level below normal, prior chemotherapy, composite resection, flap reconstruction, between 50 and 59 years of age, and T3 or T4 tumor stage. Logistic regression analysis demonstrated that the need for flap reconstruction, a preoperative hemoglobin below the normal level, and T3 or T4 primary stage were the three factors most significantly associated with the need for transfusion (P < .03). Based on eight combinations of these three variables, transfusion risk predictions were obtained. The TPRA model predicted that patients with a normal hemoglobin level who did not require flap reconstruction and did not have either a T3 or T4 primary stage tumor had the lowest probability (.02) for requiring blood transfusion. Patients at highest risk (.65) were those with less than a normal hemoglobin level, who required flap reconstruction, and had T3 or T4 primary tumor stage. Based on the TPRA model, an algorithm was developed which could serve as a guideline for preoperative transfusion planning. CONCLUSION: By using the TPRA model to change guidelines for preoperative transfusion planning, costs can theoretically be reduced by 50% without significantly increasing the risk of exposing patients to allogeneic blood transfusion. If the TPRA model proves accurate in a follow-up study to test its validity, it may have clinical utility for aiding the surgeon in more cost-effective transfusion planning.

Adolescent↗
PubMed1995

New York City's 1993 child immunization day: planning, costs, and results.

OBJECTIVES: This study evaluates New York City's Child Immunization Day (1993), with emphasis on the cost and effects of a mass campaign and the use of strategies from developing nations in an inner-city context. METHODS: The methodology was designed to (1) document the planning and implementation process, (2) analyze the number and characteristics of children in the target group, and (3) estimate costs. RESULTS: Neither the social mobilization nor the political will that characterize successful campaigns in developing nations occurred in New York City's campaign. Despite substantial time and effort from both private and public agencies, turnout for the event was low. In total, 2647 families and 5237 children were assessed for health care and insurance needs, 2949 children were immunized at a cost of about $279 per immunized child, and 7236 vaccines were administered. CONCLUSIONS: The differences between inner cities and developing nations have a bearing on strategies used in planning and implementing mass campaigns. New strategies need to be forged from a blending of these contexts to create effective campaigns in industrialized inner cities.

Child Health Services↗
PubMed1995

Capitalizing strategic planning costs to recognize future value.

As healthcare organizations devote more resources to strategic planning, financial managers should consider capitalizing, rather than expensing, planning costs. Traditionally, healthcare organizations have absorbed these costs in the year a plan is developed. However, a strategic plan may be viewed as an intangible asset that provides the organization with future benefits. Therefore, its costs can be amortized over the plan's life.

Accounting↗
PubMed1996

Developing information systems for integrated systems.

As the structure of healthcare delivery systems changes, an increasing number of healthcare executives are rethinking their organizations' approaches to the delivery of care. At the same time, many executives are re-engineering their organizations' information systems to provide the infrastructure necessary to support changing requirements. Healthcare executives can take a number of steps to ensure that their organizations' information systems help reduce costs and improve quality of patient care.

Community Health Planning↗
PubMed1985

Medicaid and Blue Cross DRG payment plans: a comparison.

Six states--Michigan, New Jersey, Ohio, Pennsylvania, Utah, and Washington--have enacted DRG-based Medicaid prospective payment plans. These systems closely parallel Medicare's due to the time and expense involved in developing and implementing an alternative case-mix payment method. A comparison of peer groups, capital costs, blend factors, outlier payments, medical education costs, etc., reveals similarities and differences in the plans that these states have adopted. Ten Blue Cross/Blue Shield plans have adopted prospective payment systems, mostly without setting DRG rates. These systems differ from Medicare and Medicaid DRG systems and from each other in a variety of ways. More state Medicaid programs probably will adopt prospective payment systems similar to Medicare's and Blue Cross/Blue Shield plans will continue to modify their hospital contracts. Hospitals' efforts to contain costs will be impeded if the major insurers within a state base their prospective payment systems on different product lines or units of output.

Blue Cross Blue Shield Insurance Plans↗
PubMed1998

Features of employment-based health plans.

This Issue Brief focuses on changes to the health care financing and delivery system as implemented by employers. It discusses health plan costs, cost sharing, plan funding, health care delivery systems, services covered under various health plan types, coverage limitations, and retiree health coverage. National health expenditures are estimated at $1.035 trillion, representing 13.6 percent of Gross Domestic Product in 1996, up from $699.5 billion and 12.2 percent in 1990. Rising health care spending is also evident at the employer level: In 1996, employer spending on private health insurance totaled $262.7 billion, up from $61.0 billion in 1980. Business health spending as a percentage of total compensation increased from 3.7 percent in 1980 to a high of 6.6 percent in 1993, and declined to 5.9 percent in 1996. Employment-based health plans are the most common source of health insurance coverage among the nonelderly population in the United States, providing coverage to nearly two-thirds of those under age 65. Despite the growth of many cost-sharing provisions, individuals are paying a smaller percentage of total health care costs. In 1960, 69 percent of private health care expenditures were paid out of pocket. Between 1993 and 1996, only 37 percent of private health expenditures were paid out of pocket. One of the most significant developments of the 1980s, which has continued throughout the 1990s, is the growth of managed care plans. As recently as 1994, traditional indemnity plans were the most commonly offered type of employment-based health plan. As fewer employers offered traditional indemnity plans, participation in these plans declined and participation in managed care plans increased. In 1997, 15 percent of employees participating in a health plan were enrolled in an indemnity plan, compared with 52 percent in 1992. Since 1993, employment-based health benefit cost inflation has been virtually nonexistent. Employers have kept cost increases low by using managed care and making other changes. Workers have been shifted to, have been induced to choose, or have voluntarily selected managed care health plans. Preferred provider organization (PPO) and point-of-service (POS) plans have experienced relatively strong gains in enrollment. Employers have also increased the use of utilization review for active workers, and cut back on health benefits for retirees. These changes are in stark contrast to the pre-1993 period, which saw even faster change, with rising health care costs and increasing deductibles and coinsurance for workers in non-HMOs.

Cost Sharing↗
PubMed1999

Population management takes disease management to the next level.

The increased development and implementation of disease management programs reflect attempts by a growing number of health plans to reduce costs while providing patients with high-quality care. Unfortunately, few of these programs are generating optimal cost savings. Instituting initiatives for a select group of plan members afflicted with a disease will not produce the positive results that a comprehensive population management program can. Through the integration, coordination, and management of all of a population's healthcare needs, diabetes population management programs are producing significantly greater cost savings than are other disease management programs, including those for diabetes.

Chronic Disease↗
PubMedDate not supplied

The impact of public-sector expenditures for contraceptive services in California.

A methodology previously used to calculate the number of unintended pregnancies averted nationally through publicly funded contraceptive services has been adapted for a state-level analysis in California. An estimated 136,800 unintended pregnancies--which would result in approximately 36,000 births, 85,100 abortions and 15,700 miscarriages--are averted each year because publicly funded contraceptive care is available from clinics and private physicians in California. Federal and state expenditures of $46 million for contraceptive services in California in FY 1989 resulted in an estimated savings of $232-$509 million in public costs for abortions, for prenatal and maternity care and for medical care, welfare and supplementary nutritional programs during the first two years after a birth. These savings represent an average of $7.70 saved for each dollar spent to provide contraceptive services. This savings/cost ratio is 75 percent higher than that previously estimated for the United States as a whole.

Abortion, Induced↗
PubMed1983

Hospice care: perspectives on a Blue Cross Plan's community pilot program.

A community approach to the provision of hospice care utilizing existing community institutions in the metropolitan Washington, DC, area was started as a pilot project among three entities: the Washington Home, a licensed, skilled nursing facility, which served as the hospice inpatient unit; Georgetown University Hospital and its home care program, which were to serve as the sole referral sources; and Group Hospitalization, Inc., the local Blue Cross Plan. Insufficient referrals resulted in expansion of referral sources to include other hospice home care providers and acute care hospitals in the general community. As other community hospices developed, the Blue Cross Plan expanded the pilot program and fostered the communitywide coordination of hospice services.

Blue Cross Blue Shield Insurance Plans↗