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PubMed2002

Manual and manipulation techniques for rheumatic disease.

Table 1 summarizes many of the studies cited in this article. Can we specifically answer the question, "Does manipulation effectively treat musculoskeletal disorders and arthritis?" It is apparent that many individuals make decisions to see therapists who use manual techniques for pain relief and improved function even though few third-party payers cover such treatments. If this question could unequivocally be answered in the affirmative, these treatments would likely be reimbursed by the payers. The studies noted in Table 1 show mixed results for several conditions. Each study has its strengths and weaknesses, but the most powerful ones indicate that manual techniques are beneficial for back and neck pain when compared with no treatment or "placebo." Comparative studies against other techniques such as physical therapy, education, or exercise do not show a clear superiority for manual therapy, however. Thus, one would have to conclude that these techniques have usefulness, primarily as adjuncts to a comprehensive treatment program. Particularly, manual techniques are useful for painful conditions as a means to break the pain cycle and increase tolerance of exercise and other educational approaches. Although clinical trials do provide important information, they do not provide information on the mechanism by which the therapy assists in the healing process. Further work is needed to understand the mechanism by which manipulation affects pain and motion. Such research should clarify the discrepancies reported in the clinical trials and provide better designs for future studies.

Humans↗

PubMed1996

Barriers to cancer screening.

Many barriers to cancer screening have been summarized and discussed. Barriers have been documented in all patient populations, but some groups such as ethnic minorities and the elderly face unique barriers. The barriers to cancer screening, are multifactorial, but much of the responsibility for change must lie with health care providers and the health care delivery industry. This is not to free the patient of all responsibility, but some significant barriers are beyond their direct control. Take, for example, socioeconomic status, disease knowledge, and culturally related perceptions and myths about cancer detection and treatment. The health care industry must do a better job identifying and overcoming these barriers. The significant effects of provider counseling and advice must not be underestimated. Patients must first be advised, and then further actions must be taken if they reject the screening advice. Did they refuse adherence to recommendations because they do not view themselves as susceptible, because of overwhelming personal barriers, or because of a fatalistic attitude toward cancer detection and treatment? If that is the case, physicians and health care institutions must attempt to change perceptions, educate, and personalize the message so that patients accept their disease susceptibility [table: see text]. Multiple patient and provider risk factors have been identified that can be used to target patients particularly at high risk for inadequate cancer screening and providers at high risk for performing inadequate screening. Research has clearly demonstrated the effectiveness of interventions to improve tracking of patient and physician compliance with screening recommendations. Further research is needed to show the impact of managed-care penetration and payer status on screening efforts, and incentive schemes need to be tested that reward institutions and third-party payers who develop uniform standards and procedures for cancer screening. The greatest responsibility lies with medical and health care institutions and those who determine the priorities of these institutions. Patient and physician barriers to mass cancer screening can be addressed by institutional support. If the quality of care delivered by providers, group practices, managed-care organizations, and HMOs is assessed with priority given to the regularity and consistency with which basic screening procedures are performed, cancer screening will undoubtedly receive greater attention in the clinic. Medical institutions must collaborate to develop standards for cancer screening with attention to the cost-effectiveness of various screening techniques to determine how limited resources can best be spent in cancer control. Such efforts should keep in mind "that a very small change implemented over a broad population may have a greater effect in absolute numbers than a large level of change applied in a small segment of the population."

Cultural Characteristics↗

PubMed1996

Managed care, accountability, and the physician.

The 1990s is truly the era of increased accountability in the practice of medicine. Through the methods of cost and quality measurement and the introduction of a manager (i.e., the MCO), society as a whole will benefit from a medical delivery system that focuses on linking the outcomes of care delivered to the processes of the care provided. Report cards serve an important tool by which information about quality and costs can be quantified and shared with the purchasers and users of the medical delivery system. Purchasers and patients are asking for greater accountability from payers and providers. The increased accountability of physicians to health plans, IDSs, hospitals, and patients with whom they interact has major implications on the definition of success in the managed medical delivery system of today. The theme of accountability has been described by the examples of the HEDIS Quality Report Card for health plans and Quality Report Cards for hospitals, PCPs, and specialists. Physicians must provide high-quality care to each patient they see but must also develop the mindset and structures to manage an entire population of patients. The expectations of each of the entities with whom they interact must be understood, and physicians need to develop the skills and infrastructure to put total quality management and information technology to work to help them facilitate the delivery of high-quality care in a cost-effective manner. Everyone involved in the health care system--from purchasers to payers to consumers--shares the same goals as physicians: provide the highest-quality care and achieve the best possible outcomes in the most cost-effective manner.

Delivery of Health Care↗

PubMed1998

Prevention of chickenpox in reproductive-age women: cost-effectiveness of routine prenatal screening with postpartum vaccination of susceptibles.

OBJECTIVE: To evaluate economic and clinical outcomes of a program of routine prenatal serotesting for varicella and postpartum vaccination of seronegative women. METHODS: An analytic cost-effectiveness model was constructed to compare the current strategy of no serotesting with 1) selective serotesting of pregnant women without a prior history of chickenpox and 2) serotesting of all pregnant women. In both serotesting strategies, seronegative women were vaccinated postpartum. The model followed a hypothetical cohort of 4 million women over 20 years. Costs and chickenpox disease outcomes during and outside of subsequent pregnancies were considered. The incremental cost-effectiveness (cost per adult chickenpox case prevented) of selective serotesting compared with the current strategy was measured. RESULTS: Compared to no testing, selective serotesting would prevent 43% (48,577 of 112,654) of adult chickenpox cases, save $21.8 million in discounted medical and work loss costs from the societal perspective, and cost $1126 per case prevented from the health payer's perspective (medical costs only). The model was sensitive to varicella seroprevalence and incidence of chickenpox among susceptible women but was relatively insensitive to the cost of serologic testing and vaccination. Compared with selective serotesting, the serotest-all strategy would prevent an additional 15,645 cases, at a societal cost of $7653 per additional case prevented. CONCLUSION: The selective serotesting strategy could prevent nearly half of chickenpox cases among this cohort and is cost-saving from the societal perspective. From the health payer's perspective, it compares favorably with other generally accepted preventive practices. It should be considered for prevention of chickenpox among women of childbearing age.

Adult↗

PubMed2000

Effect of Medicaid managed care on pregnancy complications.

OBJECTIVE: This study examined the impact of managed care on hospital obstetric outcomes in Medicaid-sponsored women. METHODS: The study sample consisted of a total of 525,517 maternal deliveries for singleton births from three payer groups, Medicaid managed care, Medicaid fee-for-service, and private managed care in 439 short-term-stay nonfederal hospitals in California and Florida. Quality of care comparisons were made using six indicators. Data were derived from linked computer files of birth certificates, hospital discharge abstracts, Medicaid eligibility records, Medicaid health care claims, and surveys of hospital characteristics. RESULTS: The overall multivariate likelihood of an adverse maternal outcome during hospitalization for a delivery was not significantly different between Medicaid managed care and Medicaid fee-for-service groups in California and Florida. However, mothers in the Medicaid managed care group compared with mothers in the private managed care group experienced a higher likelihood of eclampsia (California) (adjusted odds ratio = 1.26; 95% confidence interval 1.05, 1.57; P = .04). CONCLUSION: Overall, managed care has not adversely affected pregnancy outcomes in Medicaid-sponsored women. Yet, payer system changes may be insufficient to achieve complete parity of outcomes relative to private managed care patients.

California↗

PubMed2003

Tertiary care centers: a strategy for fiscal survival.

BACKGROUND: Managed care organizations use a variety of payment strategies to contract for high-end tertiary services with academic healthcare centers. We assessed the financial outcome of these strategies and attempted to identify those that maintain a balance between cost and reimbursement. METHODS: Patients admitted with an Injury Severity Score > or =16, hospital charges > or =$100,000, and a managed care organization as the payer were evaluated. RESULTS: A fixed reimbursement contract decreased reimbursement by 28% and negatively impacted the margin by 215%. The addition of a stop-loss provision to a fixed reimbursement contract is the best strategy to share the risk between payer and provider. If the fixed reimbursement strategy continued, the negative impact to the margin would have been $36,984 per patient. CONCLUSIONS: Fixed reimbursement strategies shift all the risk to the academic healthcare center. If volume, severity of illness, or cost is not controlled, they negatively affect the financial outcomes. The addition of a stop loss at $100,000 of charges paid at 40% of the entire claim most equitably distributes risk between the academic healthcare center and the managed care organization. It also excludes the negative impact of increasing severity of illness and volume and should induce cost control.

Academic Medical Centers↗

PubMed1999

Market factors and the availability of community pharmacies.

The purpose of this study was to examine the relationships between the availability of community pharmacies and 4 types of market factors. A composite data set was created that linked, at the county level, data on: (1) type and number of pharmacies; (2) population characteristics; (3) payer variables; (4) health care system factors; and (5) competitive factors. In this exploratory study, secondary data were used to assess the association between the availability of community pharmacies and the influence of market factors. To assess the market influences on availability of community pharmacies, 2 regressions were performed. In 1 model, the number of community pharmacies per 10,000 population was the dependent variable, whereas the dependent variable in the other regression was the proportion of independently owned community pharmacies. The independent variables in each regression were the market factors--population characteristics, payer variables, health care system factors, and competitive variables. Squared terms were included for 8 of 15 market factors to account for nonlinearities in the relationships. Multiple market factors were correlated with both the number of community pharmacies and the proportion of independently owned pharmacies in an area. Several of the relationships were not linear and changed direction within the range of data. Counties with either a low or a high percentage of elderly people had fewer pharmacies and a lower proportion of independently owned pharmacies compared with counties with a moderate percentage of elderly people. Counties that were scarcely or highly rural had fewer community pharmacies but a higher proportion of independently owned pharmacies than counties that were moderately rural. Areas with a greater percentage of the population earning less than the poverty level had more pharmacies, especially independently owned ones. Fewer community pharmacies were found in areas with higher health maintenance organization penetration rates. The number of hospital admissions was positively associated with the number of pharmacies but negatively associated with the proportion of independently owned pharmacies. The availability of community pharmacies varies across the country. In light of the trend toward fewer independently owned pharmacies, potential problems in accessing pharmacy services could develop in certain areas, including those that are highly rural and those with a high percentage of people earning less than the poverty level. Future research and policy issues are identified.

Data Collection↗

PubMed2001

Cerivastatin versus branded pravastatin in the treatment of primary hypercholesterolemia in primary care practice in Canada: a one-year, open-label, randomized, comparative study of efficacy, safety, and cost-effectiveness.

BACKGROUND: Potential cost differences between statins are driven primarily by drug costs, differential lowering effects on low-density lipoprotein cholesterol (LDL-C) levels, and adverse drug interactions and reactions. OBJECTIVE: The purpose of this study was to compare the efficacy, safety, and direct treatment costs of cerivastatin and branded pravastatin in adult patients with primary hypercholesterolemia over a 1-year period. METHODS: This was a multicenter (48 sites), randomized, open-label, parallel-group, optional dose-titration study conducted in Canada. Patients aged 18 to 75 years with documented primary hypercholesterolemia (mean LDL-C > or = 160 mg/dL [> or = 4.5 mmol/L] and at least 1 fasting triglyceride measurement < or = 400 mg/dL [< or = 4.5 mmol/L]) that did not respond adequately to dietary intervention were enrolled. Patients who were on a diet at study entry were instructed to continue that diet for the duration of the study. Patients not following a diet were also entered into the study provided they had received previous dietary counseling and were unwilling or unable to comply with this dietary advice. Before randomization, treating physicians were required to record a target lipid level for each patient and then instructed to randomize patients to treatment with any dose and any titration schedule of cerivastatin or branded pravastatin according to their normal practice. Physicians were not required to titrate the study drug dose if the patient did not achieve the predefined target goal. Lipid analyses were conducted at baseline/randomization and at months 3, 6, 9, and 12. All samples drawn for lipid analyses were collected after a fast of > or = 10 hours. A cost-minimization approach was used to compare the direct treatment costs between cerivastatin and branded pravastatin. Since the analysis was from the perspective of the third-party payer (Ministries of Health), only costs attributed to the third-party payer were included. RESULTS: A total of 417 patients were randomized to once-daily treatment with cerivastatin 0.1 mg to 0.4 mg (n = 209) or branded pravastatin 10 mg to 40 mg (n = 208); 39 (9.4%) of patients discontinued prematurely, 19 (4.6%) because of an adverse event. The incidence of adverse events was similar for cerivastatin (73.6%) and branded pravastatin (74.9%). The majority of adverse events were mild or moderate and included headache, nausea, pain, and dizziness. Both cerivastatin and pravastatin were effective in lowering LDL-C to target levels (mean reduction 29.8% and 27.5%, respectively, P = 0.35). An LDL-C decrease of > or = 20% from baseline to end point was achieved in 74.2% of cerivastatin patients and 74.0% of pravastatin patients. The annualized direct hyperlipidemia treatment cost was 19% higher in the branded pravastatin group compared with the cerivastatin group. A sensitivity analysis designed to examine the impact of generic pricing on the cost-minimization analysis indicated that the cost difference between cerivastatin and generic pravastatin was not significant. CONCLUSIONS: Both cerivastatin and branded pravastatin were well tolerated and effective in lowering LDL-C by > or = 20% versus baseline. A cost savings in favor of cerivastatin was a reflection of the lower drug acquisition cost of cerivastatin compared with branded pravastatin.

Adolescent↗

PubMedDate not supplied

Pharmacoeconomic analysis of oral therapies for onychomycosis: a US model.

An evaluation of treatment practices in 13 countries, not including the United States, has shown oral terbinafine to be more cost-effective (from a government payer perspective) than griseofulvin, itraconazole, and ketoconazole in the treatment of onychomycosis of toenails and fingernails. The purpose of this study was to evaluate the clinical and economic effects of oral griseofulvin, itraconazole, ketoconazole, and terbinafine in the treatment of onychomycosis from the perspective of a third-party payer in the United States. A previously constructed decision-analytic model evaluating the costs of onychomycosis in 13 countries outside the United States was updated to determine the costs of treating onychomycosis in the United States. Clinical management patterns were assessed to identify and quantify physician visits, laboratory tests, and adverse drug reaction treatment components for patients with toenail and fingernail onychomycosis. A random-effects model meta-analysis of treatment efficacy (mycologic cure) and New York Metropolitan Medicare charge data for physician fees were used in the treatment model. A sensitivity analysis assessing alternative dosing regimens and a rank order stability analysis investigating the effects of length of treatment, success rates, relapse rates, and drug acquisition costs on overall results were also conducted. Terbinafine had the lowest cost per mycologic cure after one treatment regimen for onychomycosis in both toenail and fingernail infections ($791.00 and $454.00, respectively). The costs of treating toenail and fingernail infections were comparatively higher for therapy with itraconazole ($1535.00 and $767.00, respectively), griseofulvin ($2385.00 and $837.00, respectively), and ketoconazole ($10,025.00 and $1512.00, respectively). As a primary treatment choice, terbinafine also had the lowest overall expected cost per patient for both toenail and fingernail infections ($977.00 and $550.00, respectively). Griseofulvin had expected costs ($1543.00 and $822.00, respectively) similar to itraconazole ($1588.00 and $894.00, respectively), whereas ketoconazole was the most expensive primary treatment choice ($2359.00 and $1287.00, respectively). This study demonstrates that terbinafine is an economical and cost-effective treatment for patients with dermatophytic onychomycosis, supporting European and Canadian studies. Except for the rank order of griseofulvin and itraconazole, sensitivity analyses show that these results are fairly stable.

Administration, Oral↗

PubMed1999

A comparative economic analysis of simvastatin versus atorvastatin: results of the Surrogate Marker Cost-Efficacy (SMaC) study.

Health care payers have become increasingly interested in economic analyses to guide the allocation of limited health care resources. The Surrogate Marker Cost-Efficacy (SMaC) study was undertaken to assess the economics of treatment with simvastatin versus treatment with atorvastatin in reducing low-density lipoprotein cholesterol (LDL-C) in patients in 10 European countries, based on the results of a 1-year, double-blind, parallel-group clinical trial. Participants were between 18 and 80 years of age (n = 177; median age, 57; 94 men and 83 women). Entry criteria were a baseline LDL-C value between 4.2 and 7.8 mmol/L (160 to 300 mg/dL) and a triglyceride value < or =4.5 mmol/L (400 mg/dL). Patients were randomly assigned to receive simvastatin 10 mg or atorvastatin 10 mg. At 16 weeks, any patients not reaching their appropriate LDL-C level received simvastatin 20 mg/d or atorvastatin 20 mg/d. Patients were then followed up for a total of 52 weeks. The overall euro cost analysis was based on the weighted average price of each product across all the independent pharmaceutical markets based on official euro conversion rates. Individual country analyses also were conducted in each local currency. Over the 52-week study, there were no significant differences in the percentage of patients achieving an appropriate LDL-C level (simvastatin 48%, atorvastatin 50%). In the overall euro cost analysis, the cumulative cost of atorvastatin (134 euros) was 33% more than for simvastatin (101 euros) during the first 16 weeks. After titration to 20 mg, the total cost of treatment during the 52-week study remained significantly lower in the simvastatin group than in the atorvastatin group (429 vs 538 euros; P<0.0001). In individual country analyses, therapy with simvastatin was significantly less expensive than therapy with atorvastatin in 8 of 10 countries (P = 0.001 to 0.003). In the remaining 2 countries, there was no significant difference in cost. Across the countries included in the evaluation, there was a significant reduction in the cost of getting patients to appropriate LDL-C levels with simvastatin compared with atorvastatin. These results should provide useful information for physicians and payers; however, additional long-term clinical trials are required to assess fully how treatment with atorvastatin affects patient outcomes, safety, and costs.

Adolescent↗

PubMed1999

The incidence of cancellation and nonattendance at a dermatology clinic.

BACKGROUND: Same-day cancellation of appointments and nonattendance by patients can disrupt management of certain aspects of medical delivery and lead to inefficient allocation of resources and lost revenue. The frequency of cancellation and nonattendance at dermatology clinics has not been well documented. OBJECTIVE: We measured same-day cancellation and nonattendance in a university dermatology clinic. METHODS: We tabulated clinic attendees, same-day cancellations, and nonattendance for a 6-month period. We examined distribution by gender, type of payer, and clinic visit type (initial or follow-up). RESULTS: Total same-day cancellation rate was 8.3%. Female patients canceled more frequently than male patients (9.2% vs 7.3%, P = .02). Cancellation rates were similar for initial and follow-up visits. The nonattendance rate was 17% with the highest rates found in state-supported categories (26%) and the lowest in commercial insurance programs (13%). Nonattendance rates did not vary significantly by gender or visit type. CONCLUSION: Same-day cancellation and clinic nonattendance is a significant factor in the efficient fiscally sound management of a busy dermatology clinic. The risk of nonattendance is assumed by physicians and seems to be correlated with payer type.

Academic Medical Centers↗

PubMed2000

Analysis of insurance payment denials using the prudent layperson standard.

STUDY OBJECTIVES: To review a sample of emergency department payment denials characterized as "not a medical emergency" and to determine medical necessity for each visit using an arbitrary "prudent layperson" standard. METHODS: This study was conducted at a university hospital and was an analysis of a convenience sample of ED payment denials classified as "not a medical emergency" by 2 managed care providers. Each corresponding visit was analyzed if the bill was still outstanding in September 1998. ED records were analyzed for chief complaint and risk factors for morbidity. Any minor disorder lasting 1 day or more and with normal vital signs recorded was considered to not meet the prudent layperson standard of an emergency. Visits for minor trauma that occurred the same day that also required radiographs or suturing were considered emergencies. RESULTS: Two hundred ED visits were retrospectively reviewed. Payer 1 denied 44 visits, of which 38 (86%) met the prudent layperson standard; payer 2 denied 156 visits, of which 113 (62%) met the standard (P >.05). CONCLUSION: A large proportion of ED visits for which payment is denied as "not a medical emergency" may meet the prudent layperson definition of an emergency.

Emergency Service, Hospital↗

PubMed1992

Universal access: its potential impact on emergency medicine.

The nation's current economic conditions, the first time in 60 years that a recession has adversely affected the middle class, might well be the actual trigger mechanism in the passage of a US universal access plan. When enacted, it would provide emergency medicine and other basic physician and hospital benefits to the currently uninsured patients now seen in hospital EDs, in doctors' offices, and as inpatients. It will, thereby, enhance current physician-patient relationships and enable many of the working poor and their dependents to receive medical care. Conventional widsom suggests that such a social insurance plan could significantly reduce the number of routine visits to hospital EDs, assuming that additional, accessible, and high-quality alternative primary-care services are developed. In any case, a universal access plan should improve the percentage of billed charges collected by emergency physicians. The nation's 1,500 third-party payers, with their managed care strategy, will have difficulty (for the reasons outlined) in micromanaging such external pressures as ensuring high-quality patient care, more benefits (including tertiary services), and less cost to the private and public sectors. As there is more micromanaging by third-party payers to reduce expenditures, it will be increasingly difficult for emergency physicians to find specialists willing to accept previously uninsured patients, except at public or teaching environments where the delivery of services to uncompensated patients has been the pattern for several decades.(ABSTRACT TRUNCATED AT 250 WORDS)

Emergency Medicine↗

PubMed1998

Economic evaluations applied to HB vaccination: general observations.

Since HB vaccines became available, there have been many economic evaluations on HB vaccination programs. The majority of them were for countries of low endemicity. Economic evaluations for countries of very low endemicity with a good surveillance system in place and high attendance of Sexually Transmitted Disease- and Intra VenousDrug Users-clinics indicate that risk group vaccination is the most cost-effective strategy to control HB. In analyses for low endemic countries, recommendations have shifted from risk group vaccination in the eighties to universal vaccination of either infants or adolescents in the nineties. For the health care payer, the resulting cost-effectiveness ratios of universal vaccination were favourable in comparison to those of other preventive interventions. From a societal point of view, universal HB vaccination was found to be cost-saving in these countries. Few published studies were set in countries of intermediate to high endemicity. They indicate that for the health care payer universal HB vaccination of neonates or infants is cost-effective compared to other interventions, or even cost-saving. Further studies are needed to support decision making in high endemic countries, where both the need for HB vaccination and the pressure on resources are highest.

Hepatitis B↗

PubMed1998

Role of external oversight in quality activities: accreditation, credentialing, licensure, and deemed status.

There currently exist a number of organizations which provide quality oversight to the ESRD program in the United States. The state surveyors confirm that dialysis facilities comply with Medicare's conditions of coverage, but surveyor activities have traditionally followed a quality assurance rather than a continuous quality improvement (CQI) model. State surveyors focus primarily on nursing homes, so their content knowledge of ESRD quality issues may be limited. The ESRD Networks have CQI expertise on their staffs, and their quality agenda is driven by their medical review boards, whose members bring scientific and technical expertise from the provider community. The success of the Networks in achieving quality goals has been hampered by personnel and resource limitations and by inconsistent direction by the Health Care Financing Administration (HCFA). Texas has developed a dialysis facility licensure program that partners its ESRD Network and its Medicare state surveyors in quality oversight activities. This collaboration has led to improved patient outcomes and may prove to be a model for other states. Non-Medicare payers may contract with dialysis providers based on performance specifications that exceed those of Medicare's conditions of coverage. A private credentialing mechanism for dialysis facilities that satisfies the performance specifications of all payers has been proposed but, in the absence of deemed status for Medicare survey and certification activities, is unlikely to achieve widespread acceptance.

Accreditation↗

PubMed1999

The third molar controversy: framing the controversy as a public health policy issue.

PURPOSE: This article summarizes the current research available concerning the removal of impacted third molars, and provides a background from which practitioners, public health policy advocates, and third-party payers can more objectively assess the the issues of appropriateness of care and overutilization of third molar surgery. MATERIALS AND METHODS: A literature review was undertaken, with emphasis on noninterventional outcome studies and studies using statistical modeling techniques. RESULTS: The health care resources being devoted to the removal of third molars are in the billions of dollars. There is an attempt at limiting these expenditures by third-party payers. These attempts have focused on the prophylactic removal of asymptomatic third molars. Some sources label the procedure as unnecessary surgery. Analysis of the literature does not answer this question with any degree of confidence. CONCLUSION: There appears to be a need for large population-based studies to provide practitioners with data to help them decide when intervention is indicated and when it is not. There is little agreement on how many third molars are being removed for so-called prophylactic reasons. The studies that are available on the nonintervention course are few and have significant flaws. The studies that argue against prophylactic removal are largely based on statistical models. The application of these models as a basis for clinical decision making is questionable. The effects of provider supply and reimbursement must be considered as an integral part of the controversy.

Consensus Statements as Topic↗

PubMed2003

Factors that predict prolonged length of stay after aortic surgery.

OBJECTIVES: In this era of managed health care, third-party payers insist that surgeons minimize hospital stay even after major operations such as aortic surgery. We attempted to identify risk factors that predict prolonged hospital length of stay (LOS) so that realistic expectations can be established for these patients who frequently are at high-risk. METHODS: In 1994 a clinical pathway for aortic surgery was implemented at our hospital. Between January 1, 1994, and December 31, 2000, data including identifiable risk factors and LOS were reviewed for 240 patients who underwent elective infrarenal aortic surgery to treat aneurysmal (n = 179) or occlusive (n = 61) disease. Risk factors were analyzed to determine their effect on LOS. Data for patients who underwent endovascular, emergency, or concomitant cardiac surgery were excluded from analysis. RESULTS: In-hospital mortality was 0.4% (1 of 240 patients), and morbidity was 18% (44 of 240 patients). Mean LOS was 8.2 +/- 5.7 days for all patients, 6.9 +/- 2.9 days for those without complications, and 13.8 +/- 6.7 days for patients with complications (P <.0001). Factors that predicted prolonged LOS (Kaplan-Meier method) included age older than 75 years (P =.0004), chronic obstructive pulmonary disease (COPD; P =.0351), intraoperative blood loss more than 500 mL (P =.0006), duration of surgery more than 5 hours (P <.0001), wound infection (P =.0311), and postoperative complications overall (P <.0001). Remaining factors associated with prolonged LOS (Cox regression analysis) included age older than 75 years (P =.0050), COPD (P =.0445), and complications overall (P =.0094). CONCLUSION: The only identifiable preoperative risk factors that correlated with increasing LOS after elective infrarenal aortic surgery (multivariate analysis) were increasing age and COPD. Third-party payers should allow longer hospitalization for patients older than 75 years and for patients with significant pulmonary disease.

Age Factors↗

PubMed1991

Utilization management: a literature review for Canadian health care administrators.

Utilization management (UM), the attempt to measure, understand and reduce inappropriate hospital use, has been in development for over 20 years. It is an outgrowth of two related phenomena: (1) the increasing responsibility of large institutional third party payers for health care costs and the increasing demand of those payers for accountability; and (2) in Canada, particularly, the debate surrounding the adequacy of hospital funding and the perceived inadequacy of cost control using global budgeting. Given the interest in UM, hospital administrators, provincial and federal associations representing hospitals, hospital employees and physicians would find a review of UM programs useful in terms of what is known about their effectiveness, and the specific initiatives in Canada. The authors underscore the critical need for formal evaluation of UM programs; to date there has been little systematic research into issues related to its implementation and impact. This issue is particularly pertinent because UM programs have not been widely implemented in Canada.

Canada↗