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PubMed1996

Hospital charges for stroke patients.

BACKGROUND AND PURPOSE: Stroke is a common disease with a yearly cost in the United States of approximately $30 billion. The increasing prevalence of managed care and cost-containment measures may affect the delivery of stroke care now and in the future. This study was performed to determine (1) hospital charges and test utilization for stroke patients and (2) the effectiveness of educational efforts in modifying test utilization and related hospital charges. METHODS: Patients with a diagnosis of stroke who were discharged from either the neurology service or another service of the Department of Medicine (DOM) were identified. Data on test utilization and hospital charges were collected and analyzed. Following this analysis, educational sessions were held in an effort to reduce the use of specific diagnostic tests. The effectiveness of these methods was studied in a second group of stroke patients. RESULTS: In the baseline period there were 303 stroke patients, of which 262 (86%) were discharged from the neurology service and 41 (14%) were discharged from other services of the DOM. Patients on the neurology service had a lower mean length of stay than patients on the other services of the DOM (9.2 days versus 10.5 days) and lower mean total charges per case ($13,149 versus $15,727), although the respective differences were not statistically significant. Patient on the neurology service were more likely to have both brain CT and MRI performed (82 of 262 patients, 31.3%) than patients on the other services of the DOM (4 of 41, 9.8%, P = .005). In addition, patients on the neurology service were more likely to undergo a transthoracic echocardiogram than patients on the other services of the DOM (71.8% versus 53.7%, P = .025). After educational sessions, the percentage of stroke patients on the neurology service having both CT and MRI fell from 31.3% to 17.7% (P = .005), and the number of stroke patients having a transthoracic echocardiogram fell from 71.8% to 60.3% (P = .025). However, the overall charges for stroke patients on the neurology services did not decrease. CONCLUSIONS: Education can be successful in reducing the utilization of and associated charges for specific diagnostic tests for some stroke patients. A multidisciplinary approach to case management, using tools such as care maps, may be necessary to realize significant cost savings in certain groups of stroke patients.

Aged↗
PubMedDate not supplied

WIC program participation--a marketing approach.

Recent evaluation studies have described the benefits accruing to low-income women and children who participate in the Special Supplemental Food Program for Women, Infants, and Children (WIC). However, participation is not uniform among all groups of eligible persons. This study examines the geographic variation in WIC participation rates of eligible pregnant women in Rhode Island to determine whether the program is effective in reaching the neediest segments of the population. Eight groups of small geographic areas in Rhode Island (census tracts) were formed on the basis of need for maternal and child health services, as determined from a statistical method employing factor and cluster analysis of existing health and sociodemographic data. Among these eight groups, participation rates in WIC during 1983-84 ranged from 46 percent to more than 100 percent of estimated eligible pregnant women. The rates were positively correlated with measures of need, strongly (r = 0.92) with an index of maternal risk, and less strongly (r = 0.79) with an index of birth outcomes. The results of this study have enabled the Rhode Island WIC Program to direct its outreach efforts more specifically to geographic areas where the need for the program's assistance is greatest. The procedures described in this report comprise a technique that can be generally applied to measure program effectiveness in marketing and outreach where relevant data are available by small geographic areas. The data requirements are (a) population-based estimates of program need and (b) program utilization measures. If these data can be aggregated to a common set of small geographic areas, the use of marketing analysis techniques becomes possible, and program benefits in the area of outreach and recruitment can be realized.

Female↗
PubMedDate not supplied

Comparison between manual and automatic coding of medical record statistical cards at a university hospital.

The coding error rate of systems for medical record statistical cards (MRSCs) throughout health services is about 30%. A program using automatic coding has been developed at the Institute of Clinical Surgery II, Padua University Hospital, with a view to reducing this percentage. Out of an overall sample of 4776 MRSCs from all departments of the hospital, 54 were automatically coded at our institute. Categories of discrepancy between the discharge diagnosis codes of the 4722 manually coded MRSCs and the other 54 MRSCs were classified as follows: types I-III, diagnosis assigned to an erroneous under-class, class or heading (ICD-9) respectively; type IV, incorrect diagnosis formulation precluding code assignment; type V, two or more discrepancies on MRSC; and type VI, secondary diagnosis not coded. Discrepancy rates were as follows: 22.3% and 0.0% for type I; 21.3% and 0.0% for type II; 17.6% and 0.0% for type III; 1.9% and 0.0% for type IV; 5.8% and 0.0% for type V; 31% and 1.9% for type VI. Code discrepancy rates for surgical procedures, which were also compared, ranged from 7.0 to 12.5% for manual coding, while no discrepancy was observed in automatically-coded MRSCs. The results clearly demonstrate the utility of the system reported on, and it is suggested that it should be used in a modified form in other hospital departments.

Abstracting and Indexing↗
PubMed1990

What is too much variation? The null hypothesis in small-area analysis.

A small-area analysis (SAA) in health services research often calculates surgery rates for several small areas, compares the largest rate to the smallest, notes that the difference is large, and attempts to explain this discrepancy as a function of service availability, physician practice styles, or other factors. SAAs are often difficult to interpret because there is little theoretical basis for determining how much variation would be expected under the null hypothesis that all of the small areas have similar underlying surgery rates and that the observed variation is due to chance. We developed a computer program to simulate the distribution of several commonly used descriptive statistics under the null hypothesis, and used it to examine the variability in rates among the counties of the state of Washington. The expected variability when the null hypothesis is true is surprisingly large, and becomes worse for procedures with low incidence, for smaller populations, when there is variability among the populations of the counties, and when readmissions are possible. The characteristics of four descriptive statistics were studied and compared. None was uniformly good, but the chi-square statistic had better performance than the others. When we reanalyzed five journal articles that presented sufficient data, the results were usually statistically significant. Since SAA research today is tending to deal with low-incidence events, smaller populations, and measures where readmissions are possible, more research is needed on the distribution of small-area statistics under the null hypothesis. New standards are proposed for the presentation of SAA results.

Age Factors↗
PubMed1978

Emergency department social work: a program description and analysis.

This article reports on the development of a social work component in the Emergency Department of a teaching-research hospital. It examines the rationale for developing the service and the objectives of the program. It also presents a statistical analysis of the first 2 full years of service. Finally, some of the major problems experienced in establishing such a program are discussed and possible solutions recommended.

Continuity of Patient Care↗
PubMed1990

Violating assumptions of statistical procedures: JHCM reporting guidelines.

JHCM authors have a responsibility to provide enough information for the reader to evaluate reported study conclusions and implications adequately, and to do so without overshadowing attention to statistical detail. Guidelines are presented for discussing the assumptions and requirements underlying the statistical procedures used, including what to report when there are violations.

Authorship↗
PubMed1981

[Medical statistics in compulsory accident insurance].

The medical statistics in the compulsory accident insurance are conceived as a secondary statistic. It includes both injuries and medical services. Since the Swiss National Accident Insurance Fund started in 1918, there were regular reports about medical statistics. The current statistics of the agency are organized as a sampling statistic. Only disability benefits are covered in toto. The statistical organization permits the identification of single cases in terms of specific characteristics and to analyze them further. The new accident insurance law makes accident insurance obligatory for all persons who are not self-employed. The regulation, included in this law, to record statistics uniformly will hopefully help toward the improvement of medical statistics within the compulsory accident insurance scheme.

Accidents↗
PubMed2006

'Give me a break' - respite care for older carers of mentally ill persons.

BACKGROUND: The concept of respite care has been widely accepted and used throughout most developed countries, although primarily in connection with frail elderly, people with dementia, people with developmental disability or children. This paper aims at exploring older family carers' needs for, access to and use of respite services when caring for people with a mental illness (excluding dementia) in the community. METHOD: Data were collected through: semi-structured interviews with 26 mental health professionals, 21 family carers aged over 55 years and 25 respite service providers; demographic questionnaires; field notes; and local area, state and national documents relating to respite care services. Demographic data were analysed using descriptive statistics. All 72 interviews, field notes and other documents were analysed using content analysis. RESULTS: Current respite services are not adequate to meet the needs of mentally ill patients and older carers. The unique aspects of respite care for older carers of persons with mental illness are poorly understood. CONCLUSION: Bringing these issues to light creates the potential to address the unmet needs of older carers, improve provision of respite services, enhance quality of life of those who can benefit from respite services, and assist mental health professionals to work better with carers.

Aged↗
PubMed2005

Effects of antipsychotic medication on psychiatric service utilization and cost.

BACKGROUND: Based on randomized clinical trials, consensus has been emerging that the first line of treatment for individuals with psychotic disorders should be the newer atypical or second generation antipsychotic medications rather than the older neuroleptics. Given that acquisition costs of atypical antipsychotics are generally higher than typical antipsychotics, uncertainty exists whether the newer atypicals are cost effective alternatives when used in ordinary practice settings. AIMS OF THE STUDY: The introduction of newer atypical antipsychotic agents has prompted evaluation of their overall effectiveness in reducing health care costs given their higher acquisition costs. This paper focuses on the effects of differing classes of atypical versus typical antipsychotic medications on psychiatric service utilization and cost for persons with serious mental illness treated in usual practice settings. METHODS: Descriptive statistics are used to compare patient characteristics, service rates and costs across psychotropic medication groups. Prediction equations employing ordinary least squares regression models are used to explain variation in cost due to pharmacy group membership controlling for demographics, clinical diagnoses and symptoms. Subjects were 338 Medicaid clients with serious mental illness from Florida, Pennsylvania and Oregon treated in ordinary clinical settings. Resource utilization and costs were operationalized using administrative databases to measure consumption of treatment services and pharmaceuticals for a six month period. RESULTS: Inpatient service use was significantly higher for individuals on atypical only and combination atypical/typical medications compared to those on typical medications only, whereas outpatient use was highest for those on typicals. Furthermore, six-month costs for both pharmacy and psychiatric services were significantly greater for persons in the atypical only (USD 6528) and combination typical/atypical groups (USD 6589) compared to those on typicals only (USD 3463). There were still significantly higher costs associated with atypical only and the combination typical/atypical users after multivariate controls were used. DISCUSSION: This study showed that Medicaid clients in community settings using atypical only and typical/atypical combination medications had the highest costs both in pharmacy and service use when compared to those on typical only medications. However, this study design does not allow us to ascribe a causal relationship between medication group and service costs. Given that olanzapine was the most recent medication in the compendium of available drugs at the time of this study, it is possible that those in the olanzapine only group were failing on other drugs. Caution must be used in drawing policy implications regarding cost effectiveness of newer medications since individuals who are getting the newer atypical or combination medications in community mental health center settings may be unstable on the older medications. IMPLICATIONS FOR FUTURE RESEARCH: A longer follow-up period is needed to determine if the cohort remaining on current atypical medications stabilize over time while those taking the newest drug on the market become the most costly population.

Adult↗
PubMed1998

Relating personnel costs in special care units and in traditional care units to resident characteristics.

BACKGROUND: There are over 16 000 nursing homes in the United States (US), among which approximately 70% of residents are cognitively impaired. Reflecting this, approximately 20% of US nursing homes maintain Special Dementia Care Units (SCUs). SCUs supposedly provide more staff time and more specialized staff assignments to residents than do traditional care units. AIMS OF THE STUDY: This paper addresses the issues of staff time and assignment: do the costs of personal care inputs differ according to whether they are provided by SCUs or in traditional care settings? Related to this, are differences associated with the different settings, or are they accounted for by resident characteristics within the settings? METHODS: Given the bias generally associated with collection of staff time data, the author developed (supported by the Health Care Financing Administration and the National Institute on Aging) and used in this study a barcode-based system ('InfoAide'). Using InfoAide, each provider automatically recorded task- and resident-specific time expenditure data which were subsequently monetized, using prevailing local wage rates. Individual resident personal characteristics and status data were provided by another simultaneous study of SCU impacts among the same residents. Regression analysis (MANCOVA for significantly correlated dependent variables) was used to examine the relationships between cost and SCU/traditional status, and individual resident characteristics, separately for each category of provider. RESULTS: Controlling for resident characteristics, the cost of aide care is significantly (positively) related (p <=0.01) to SCU status. Cognitive impairment, ADL impairment and being restrained are also related to higher aide care cost (p <=0.05, p <=0.01, and p <=0.05, respectively). The same is generally true of Speech Therapy, Social Service and care by licensed practical nurses, although the differences between SCU and traditional care units are essentially trivial - and there are no SCU/traditional care differences for registered nurses. DISCUSSION: SCU/traditional unit status, even when combined with the central resident covariates, explains very little variance in service costs, other than among nursing aides; in separate MR analyses in which monetized service time was the dependent variable, the cumulative adjusted R2 among aides was 0.37; for each of the other categories of service provider, the adjusted R2 was less than 0.10. There were differences (particularly in cognitive and ADL impairment) between SCU and non-SCU residents; these differences were related to differences in basic services which were, in turn, provided primarily by aides. The increased level of care provided in SCUs is attributable primarily to nursing aides. However, there is relatively little (albeit statistically significant) variation in more 'elective'services according to individual characteristics or to SCU versus traditional unit placement. This discussion is limited by the absence of analyses of possible interactions among variables, and by the cross-sectional nature of the data presented here. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: This absence of a substantial relationship between SCU/traditional status suggests that dichotomization between SCU and traditional care is misplaced, and that more attention should perhaps be given to the targeting and tailoring of services related to individual gradations of impairment and need. IMPLICATIONS FOR HEALTH POLICY FORMULATIONS: A very considerable literature has developed recently pertaining to Special versus Traditional care for persons with dementing illness. These data suggest that this is not a fruitful distinction, and that more effort should be devoted to defining and quantifying the elements and quality of care provided to nursing home residents. IMPLICATIONS FOR FURTHER RESEARCH: Further research is needed into the components of optimal quality care for demented nursing home residents, and into the interaction among these components as they relate to resident outcomes.

Journal Article↗
PubMed2006

New payment model for rural health services in Mongolia.

This article describes experiences in Mongolia in designing and implementing a new method of payment for rural health services. The new method involves using a formula that allocates 65% of available funding on the basis of risk-adjusted capitation, 20% on the basis of asset costs, 10% on the basis of variations in distance-related costs, and 5% on the basis of satisfactory attainment of quality of care targets. Rural populations have inferior health services in most countries, whether rich or poor. Their situation has deteriorated in most transition economies, including Mongolia since 1990. One factor has been the use of inappropriate methods of payment of care providers. Changes in payment methods have therefore been made in most transition economies with mixed success. One factor has been a tendency to over-simplify, for example, to introduce capitation without risk adjustment or to make per case payments that ignored casemix. In 2002, the Mongolian government decided that its crude funding formula for rural health services should be replaced. It had two main components. The first was payment of an annual grant by the local government from its general revenue on the basis of estimated service population, number of inpatient beds, and number of clinical staff. The second was an output-based payment per inpatient day from the National Health Insurance Fund. The model was administratively complicated, and widely believed to be unfair. The two funding agencies were giving conflicting types of financial incentives. Most important, the funding methods gave few incentives or rewards for service improvement. In some respects, the incentives were perverse (such as the encouragement of hospital admission by the National Health Insurance Fund). A new funding model was developed through statistical analysis of data from routine service reports and opinions questionnaires. As noted above, there are components relating to per capita needs for care, capital assets, distance, and quality of care. The risk-adjusted capitation component determines needs classes by use of age, gender, and family income. The model was accepted by all concerned parties, and steps are now being taken to implement it under transitional arrangements. Many of the data used to parameterize the model are inaccurate and will need to be updated in the near future. However, the model is inherently valid, and procedures have been set in place that will ensure accuracy is improved on a continuing basis. An important reason why the government strongly supported implementation was its commitment to implement output-based budgeting across all government sectors. The new model provided a convenient way of applying output-based budgeting to one major component of the health sector.

Adolescent↗
PubMed2004

Health and support service utilization patterns of American Indians and Alaska Natives diagnosed with HIV/AIDS.

The purpose of this analysis is twofold: to examine the types of health and support services provided by CARE Act funded providers to American Indians/Alaska Natives and to compare the characteristics and service utilization patterns for this group with those of individuals from other racial/ethnic groups. We present an analysis of the demographic characteristics, service utilization, and health outcomes of all HIV-infected clients who received services in five geographic areas at agencies that were funded through the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act. Standard chi-square tests were used to test for statistically significant differences (p <.05) between the demographic characteristics and service utilization patterns of matched pairs of HIV-positive American Indian/Native Alaskans with HIV-positive individuals of other racial and ethnic backgrounds. Individuals were matched on gender, age, insurance, AIDS diagnosis, and site. Other data examined include client characteristics (income, homelessness, HIV exposure category, and source of health care), health indicators (CDC-defined disease stage, CD4+ counts, substance abuse and psychiatric illness) and service utilization (medical care; mental health treatment/counseling; substance abuse treatment/counseling; case management; dental care; housing, food, emergency financial, and transportation assistance, and buddy/companion and client advocacy services). There were no statistically significant differences between the two groups for HIV exposure category, CD4 count, substance abuse problem, and being homeless and in their likelihood to receive medical care, mental health or substance abuse treatment/counseling, dental care, food, emergency financial, and transportation assistance, as well as buddy/companion and client advocacy services. They were more likely (55% vs. 46%) to receive case management services than the matched individuals from other racial/ethnic groups. They were also more likely to receive housing assistance (35% vs. 25%). The analysis provides evidence that when individuals are matched on key demographic and health characteristics, few differences remain between HIV-positive American Indians/Native Alaskans and other racial/ethnic groups. The two exceptions are case management and housing assistance. The significantly higher use of case management is not surprising, given the emphasis by American Indians/Alaska Natives on traditional Native American case management case management. In contrast, the significantly higher use of housing assistance by American Indians/Alaska Natives was unexpected. Exploring the potential need for housing assistance among all American Indians/Alaska Natives served by the Ryan White CARE Act needs to be considered.

Adult↗
PubMed1985

Provision of abortion services in the United States.

According to abortion statistics collected by the Centers for Disease Control, between 1.3 and 1.6 million legal abortions were performed in the United States in 1981. The number of abortions performed each year appears to have plateaued. This brief paper summarizes recent trends in the provision of abortion services and describes the demographic characteristics of women who undergo legal abortions in the United States. Women who obtain abortions tend to be young, white, unmarried, and early in their reproductive careers. Most abortions are performed by suction curettage in the first trimester of pregnancy. The majority of women who obtain abortions do so in their state of residence, and non-hospital facilities have emerged as the principal providers of abortion services in the United States.

Abortion, Induced↗
PubMed2001

[Multilevel analysis of regional disparities in survival after heart failure: differences between county health services affect little patients' prognosis].

The prognosis for patients suffering from heart failure in Sweden differs from county to county, indicating a need for a comparative study in order to uncover the reasons. Conventional single-level analytical methods, however, underestimate the statistical uncertainty in such studies, leading to an inappropriate ranking of regions. Consequently, public opinion and decision-making may be misled. Conventional methods are also unable to disentangle the extent to which differences in prognosis may depend on individual or regional factors. Multilevel analysis, on the other hand, provides a better estimate of statistical uncertainty, and can both identify and quantify the extent to which differences in prognosis depend on either patient-related or regional factors. Using multilevel analysis, we examined the one-year mortality of 38,343 heart failure patients for the period 1992-1995 in every county in Sweden. Regional differences in one-year mortality were found to be very small, the most relevant factors being individual ones. The limited differences distinguishable at the county level may be explained in part by physician density: the more physicians in a county, the better an individual patient's prognosis.

Aged↗
PubMed1998

[Waiting lists as results of statistic coincidences].

Queues and waiting lists in the health services are central issues in the political debate in Norway. By means of a simulation programme (Powersim), we demonstrate some elementary properties of queuing. We show that stochastic entry to the service and stochastic need for service can produce queues. We also show that a queue-free service will need an unrealistically high and abundant capacity.

Humans↗