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PubMed2006

The emerging context for advances in comparative effectiveness assessment.

The call for an entity for independent assessment and guidance on alternative medical interventions is timely. The emergence of four developments underscores the importance and sets the stage for progress: an improving evidence base; growing recognition of the importance of variation in the effectiveness of treatments across patients; recent emphasis on transparency; and growing adoption of pay-for-performance initiatives. To advance progress on these issues, the Institute of Medicine (IOM) has convened a Roundtable on Evidence-based Medicine. The roundtable is exploring ways to improve the development of evidence, the thoroughness with which it is applied, and the mechanisms for increasing national capacity for the work.

Cost-Benefit Analysis↗
PubMed2006

Improving tomorrow's health care with today's tools: a conversation with Larry C. Glasscock. Interview by John K. Iglehart.

The chairman and CEO of WellPoint Inc. provides some factual background on one of the nation's largest health insurers, which covers 34.2 million lives. Its own employees are offered the opportunity to join a consumer-directed health plan, which gives the company some real-life data on which to base its strategies in the marketplace. Glasscock believes that future reform efforts in his company and at the national level must focus on improving quality and affordability, reducing the number of uninsured Americans, and improving the health of those insured by WellPoint and everyone else.

Blue Cross Blue Shield Insurance Plans↗
PubMedDate not supplied

Looking at the U.S. health care system in the rear-view mirror.

John Wennberg and his colleagues hold up a rear-view mirror on the U.S. health care system, reflecting pervasive inconsistencies and showing that more resources are not necessarily equivalent to better care. The work shows that although many hospitals are investing time and money to improve efficiency, quality, and overall patient care, the system is in trouble. Two basic reforms would help produce a system that encourages value, with efficient, effective, patient-centered care. These changes involve how we pay for care and investment in health information technology. We should begin by implementing these principles in Medicare, the largest U.S. purchaser of care.

Delivery of Health Care↗
PubMed1986

Effectiveness of medical necessity guidelines in reducing cost of oxygen therapy.

Concern for the rising costs of respiratory therapy in patient care caused a third party payor to implement reimbursement guidelines for inhospital delivery of oxygen (O2) therapy. While these guidelines are physiologically appropriate, their effectiveness in cost reduction has not been documented. To determine the effect of similar guidelines on the cost of O2 therapy, we prospectively studied 77 noncritically ill patients for whom physicians ordered O2. If pretreatment arterial blood gas determinations had not been ordered, ear oximetry was performed. The cost of O2 therapy to each patient, as based on total patient charges for O2, appliances, delivery, and assessment of oxygenation throughout hospitalization, was computed in three ways: Cost A, actual charges for O2 therapy initiated by physician order; Cost B, projected charges for O2 therapy using physiologic guidelines alone (PaO2 less than 60 mm Hg or SaO2 less than 90 percent); and Cost C, projected charges for O2 therapy using combined physiologic and clinical guidelines (PaO2 less than 60 mm Hg, SaO2 less than 90 percent or clinical record reasonably indicating hypoxemia). Of the 77 patients, 23 (30 percent) met the physiologic guidelines and 48 (62 percent) met the combined physiologic and clinical guidelines. The cost (total patient charges) of O2 therapy can be reduced through implementation of medical necessity guidelines, but physiologic guidelines alone appear more cost effective than combined physiologic and clinical guidelines.

Blood Gas Analysis↗
PubMed2002

Recognition and treatment of mental disorders in children: considerations for pediatric health systems.

General healthcare systems currently play an active role in the identification and treatment of children with mental disorders. As many as one-third of children identified and treated for mental health problems receive outpatient mental healthcare from primary care providers. Although some children do receive treatment, over half of those who need mental health care do not receive this service. Fortunately, current levels of unmet need for adequate care coincide with mounting scientific evidence to support the efficacious use of psychosocial, community-based, and pharmacological interventions. Scientific evidence indicates that the appropriate identification and treatment of mental disorders in childhood can reduce symptoms of child psychopathology, improve adaptive functioning, and sometimes serve as a buffer to further long-term impairment. However, mental health treatment can only be beneficial if it reaches those families in need, is amenable to clinical practice implementation, and is administered with an adequate dose. Future challenges lie in creating practice-relevant efficacious interventions to improve the identification of child mental health needs and to improve access to high quality, appropriate mental healthcare. Primary care settings will play an important role in this activity. Although many barriers exist, pediatric health systems will continue to play an important role in the identification and treatment of mental disorders in children. The quality of current pediatric mental healthcare could be enhanced by increased opportunities for physician training, a restructuring of current training efforts, an increased focus on patient engagement strategies, equitable care incentives and reimbursement, as well as an integrated view of physical and mental health.

Child↗
PubMed2004

Reference pricing of pharmaceuticals for Medicare: evidence from Germany, The Netherlands, and New Zealand.

This paper describes three prototypical systems of therapeutic reference pricing (RP) for pharmaceuticals--Germany, the Netherlands, and New Zealand--and examines their effects on the availability of new drugs, reimbursement levels, manufacturer prices, and out-of-pocket surcharges to patients. RP for pharmaceuticals is not simply analogous to a defined contribution approach to subsidizing insurance coverage. Although a major purpose of RP is to stimulate competition, theory suggests that the achievement of this goal is unlikely, and this is confirmed by the empirical evidence. Other effects of RP differ across countries in predictable ways, reflecting each country's system design and other cost-control policies. New Zealand's RP system has reduced reimbursement and limited the availability of new drugs, particularly more expensive drugs. Compared to these three countries, if RP were applied in the United States, it would likely have a more negative effect on prices of onpatent products because of the more competitive U.S. generic market, and on research and development (R&D) and the future supply of new drugs, because of the much larger U.S. share of global pharmaceutical sales.

Cost Control↗
PubMed2006

Quality measurement: who is measuring outcomes and what are patients being told?

Change is inevitable, but participation is optional. An array of quality measures is being used by various government entities, health care purchasers and payers, and other groups. Many of the quality-measurement initiatives have not only gained the attention of large employers, but are also beginning to pique the public's interest. Novel approaches to measuring and rewarding quality are also emerging, such as pay-for-performance schemes and the use of APR-DRGs. Health care organizations that participate in the quality-measurement process and provide input will benefit by the type of measures that are ultimately created. It is much better to be part of the development process than to have insurer- or employer-designed quality measures imposed on your institution. At the very least, health care organizations would be wise to serve as watchdogs to ensure that currently proposed quality measures truly measure high-quality care.

Humans↗
PubMed2000

Clinical preventive medicine in primary care: background and practice: 1. Rationale and current preventive practices.

Impressive evidence supports the value of clinical preventive medicine, defined as the maintenance and promotion of health and the reduction of risk factors that result in injury and disease. Primary prevention activities deter the occurrence of a disease or adverse event, e.g., smoking cessation. Secondary prevention (screening) is early detection of a disease or condition in an asymptomatic stage so treatment delays or blocks occurrence of symptoms, e.g., mammographic detection of breast cancer. Tertiary prevention attempts to not allow adverse consequences of existing clinical disease, e.g., cardiac rehabilitation to prevent the recurrence of a myocardial infarction. Preventive services have decreased morbidity and mortality from both acute and chronic conditions. However, these services are underutilized for numerous reasons. Barriers to their use include physician, patient, and health system factors. The traditional disease/treatment model should be modified to incorporate more preventive services. The subsequent 2 parts of this review will discuss suggestions for integrating primary preventive services and screening into primary care practice.

Cause of Death↗
PubMed2001

Location, race, and hospital care for AIDS patients: an analysis of 10 states.

This study is the first statewide comparison of hospital utilization and inpatient mortality rates for people with acquired immune deficiency syndrome (AIDS). Data from 120,772 hospital discharge abstracts for all AIDS-related admissions in 10 states (California, Colorado, Florida, Iowa, Kansas, Maryland, New Jersey, New York, Pennsylvania, and South Carolina) in 1996 were combined with data on the number and the racial and ethnic characteristics of all people living with AIDS (PLWAs) in each state. These data were used to derive population-based estimates of the use of hospital services per PLWA and of inpatient mortality rates in each state. Multivariate analyses examined sources of variation in inpatient length of stay and inpatient mortality. The primary finding of this study is that hospital utilization rates and inpatient mortality rates for people with AIDS vary substantially across states and among racial and ethnic groups within states even after adjusting for severity of illness. Blacks and Hispanics had longer hospital stays and were more likely to die in the hospital than whites. State-level policies, such as home and community-based waiver programs and enhanced HIV reimbursement rates, significantly affected hospital use.

Acquired Immunodeficiency Syndrome↗
PubMed1999

The effects of bonus payments on emergency service performance in Victoria.

OBJECTIVES: To review and analyse the system effects of the Emergency Service Enhancement Program (ESEP): bonus payments made to public hospitals to improve access to care for patients attending emergency departments. DESIGN: A review of the first 3 years' performance data, obtained from the Victorian Emergency Department Minimum Dataset (VEMD). SETTING: 21 public hospital emergency departments in Victoria, Australia (population 4.5 million), with about 700,000 patient attendances per year. The ESEP began in April 1995. MAIN OUTCOME MEASURES: The ESEP indicators of emergency department and inpatient bed access: occasions of "ambulance bypass" (emergency department unable to accept patients arriving by ambulance); emergency waiting times for Category 1, 2 and 3 patients (National Triage Scale) compared with agreed national performance thresholds; and "access block" (> 12 hours' waiting time in the emergency department before admission to hospital). RESULTS: The number of occasions of ambulance bypass per quarter decreased from 600 in 1994 to fewer than 100 in 1997 (P < 0.001). Despite an increased proportion of patient encounters in triage categories 1, 2 and 3 (31% v. 23%), zero waiting times for Category 1 patients were consistently adhered to, and adherence to waiting time thresholds for Category 2 and 3 patients improved significantly (P < 0.001, R2 = 0.74; and P < 0.035, R2 = 0.37, respectively), particularly for Category 2 patients. The number of patients waiting longer than 12 hours in emergency departments decreased non-significantly (P = 0.3, R2 = 0.1). CONCLUSION: Our results show that the ESEP has produced sustained improvements in all the indicators linked with bonus payments.

Diagnosis-Related Groups↗