[Do women misuse health services?].
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Denmark↗
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The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality.
OBJECTIVE: To identify issues related to the quality of health care in the United States, including its measurement, assessment, and improvement, requiring action by health care professionals or other constituencies in the public or private sectors. PARTICIPANTS: The National Roundtable on Health Care Quality, convened by the Institute of Medicine, a component of the National Academy of Sciences, comprised 20 representatives of the private and public sectors, practicing medicine and nursing, representing academia, business, consumer advocacy, and the health media, and including the heads of federal health programs. The roundtable met 6 times between February 1996 and January 1998. It explored ongoing, rapid changes in health care and the implications of these changes for the quality of health and health care in the United States. EVIDENCE: Roundtable members held discussions with a wide variety of experts, convened conferences, commissioned papers, and drew on their individual professional experience. CONSENSUS PROCESS: At the end of its deliberations, roundtable members reached consensus on the conclusions described in this article by a series of discussions at committee meetings and reviews of successive draft documents, the first of which was created by the listed authors and the Institute of Medicine project director. The drafts were revised following these discussions, and the final document was approved according to the formal report review procedures of the National Research Council of the National Academy of Sciences. CONCLUSIONS: The quality of health care can be precisely defined and measured with a degree of scientific accuracy comparable with that of most measures used in clinical medicine. Serious and widespread quality problems exist throughout American medicine. These problems, which may be classified as underuse, overuse, or misuse, occur in small and large communities alike, in all parts of the country, and with approximately equal frequency in managed care and fee-for-service systems of care. Very large numbers of Americans are harmed as a direct result. Quality of care is the problem, not managed care. Current efforts to improve will not succeed unless we undertake a major, systematic effort to overhaul how we deliver health care services, educate and train clinicians, and assess and improve quality.
Health Services Misuse↗
Appropriateness of acute medical care for the elderly: an analysis of the literature.
Over the past 30 years, an explosion in health care expenditures has occurred. Prior to 1960, health care accounted for 4.4% of the U.S. Gross National Product; today it is 11%. Before rational solutions to controlling this rise can be proposed, we must determine whether the care that we are currently paying for is appropriate to the needs of the elderly. This paper analyzes the literature regarding appropriateness of acute care provided to the elderly. We identified 17 articles that explicitly cited appropriate or inappropriate care (including under-, over- and misuse) provided in hospital and ambulatory settings and for procedures, and 19 articles that presented data on the appropriateness of medication use in the elderly. Virtually every study included in this review found at least double-digit levels of inappropriate care. Perhaps as much as one-fifth to one-quarter of acute hospital services or procedures were felt to be used for equivocal or inappropriate reasons, and two-fifths to one-half of the medications studied were overused in outpatients. The few studies that examined underuse or misuse of services also documented the existence of these phenomena. This was especially true for the ambulatory care of chronic physical and mental conditions and concerned the use of low-cost technologies (visits, preventive services, some medications). Thus, we conclude that there appears to be a substantial problem in the matching of acute services to the needs of elderly patients. This mismatch occurs both in terms of overuse and underuse, at least for areas where research has been conducted.
Acute Disease↗
[Heavy users of psychiatric care].
OBJECTIVE: This paper reviews findings and problems of heavy users research. METHODS: The German- and English language literature about "heavy users" and relevant border areas was analyzed. RESULTS: Heavy users are patients who consume a disproportionate share of medical services. The characteristics of heavy users are inhomogeneous. Social problems, denial of illness, non-compliance, comorbid personality disorders and substance misuse contribute significantly to heavy use. Future studies should define heavy use illness-related. More research is needed to clarify whether heavy use of special services is adequate to the patients situation. CONCLUSIONS: Heavy users should be identified early, in order to offer them alternative services, which better fulfil the patients specific conditions and prevent an inadequate heavy use of expensive services.
Case Management↗
Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress.
The literature on continuous quality improvement (CQI) has produced some evidence, based on nonrandomized studies, that its clinical application can improve outcomes of care while reducing costs. Its effectiveness is enhanced by a nucleus of physician involvement, individual practitioner feedback, and a supportive organizational culture. The few randomized studies, however, suggest no impact of CQI on clinical outcomes and no evidence to date of organization-wide improvement in clinical performance. Further, most studies address misuse issues and avoid examining overuse or underuse of services. The clinical application of CQI is more likely to have a pervasive impact when it takes place within a supportive regulatory and competitive environment, when it is aligned with financial incentives, and when it is under the direction of an organizational leadership that is committed to integrating all aspects of the work.
Ambulatory Care↗
Ambulance use, misuse, and unmet needs in a developing emergency medical services system.
Ambulances in Taiwan have always been viewed by medical personnel and the population at large purely as transport vehicles. The emergency medical services (EMS) system upgrading will require a change of concept. Following emergency medical technicians (EMT) training in Keelung, a 400000-inhabitant mid-sized port city in northern Taiwan, we began prospective data collection to evaluate the patterns of ambulance use, misuse and potential needs within the community. Over a 3-month period, 1035 calls, 572 fully documented patient transfers and 17703 emergency department (ED) visits at the city's largest hospital were collected and analysed. The daily call volume was 0.32 per 10000 population with 31.7% of all ambulances dispatched resulting in no patient being transferred. The majority of patient transports were for trauma (61.2%), with almost all of the no patient transfers also following trauma, having been called in by someone passing by or witnessing the accident. Of those transported, 27.6% did not require even basic EMT care and so were considered misuse. Conversely, the majority of critically ill patients presenting to the hospital ED did not arrive by EMS ambulance, giving a conservatively projected unmet need of 86%. Despite low call volumes, misuse and non-transport, rates appear high. This is because the majority of accidents are called-in by passers-by who have no first aid training and a cultural aversion to becoming involved. At the same time unmet needs are also high, with education required to get the public to change their practice, and further study needed to see if this will, in fact, improve outcomes.
Ambulances↗
Cost containment: Europe. The Netherlands.
In The Netherlands, 8.3% of the gross national product is allocated to health care. Medical care provided in ICUs consumes approximately 8% of hospital budgets, or approximately 2.5% of the total healthcare budget. The high cost of intensive care medicine in The Netherlands has become a matter of concern during the last decade. A national intensive care study was conducted from 1989 through 1990 to evaluate the effectiveness and organization of ICUs in the country. This study has shown that there is an association between the operational characteristics of ICUs and the hospital in which these units operate. In approximately 50% of ICUs studied, a marked mismatch existed between the provision and the use of resources. Surgical activities in the hospital were the major observed cause for this mismatch, mainly because ICUs were often used instead of the recovery room, which operated only about 8 to 10 hrs/day during working days. In addition to an absence of clearly written policies for the use of the facilities, a lack of sound ICU business organization and management was also documented and may have contributed to the observed misuse of resources and the dissatisfaction and burnout of hospital personnel. In order to improve the use of resources and to establish a controllable program of cost containment in ICUs in The Netherlands, the recommendations made to Dutch authorities were aggregated under two headings: a) the adoption of a quantifiable method for defining levels of ICU care; and b) the enforcement of the professional organization and management of ICUs.
Cost Control↗
Health care in America: lost opportunities amid plenty.
Despite frequent breakthroughs in medicine, and in the face of an expenditure on health that is almost twice that of any other country in the world, there are significant problems with health care in the United States. Fundamental failings reflect the underuse, overuse, and misuse of resources, which result in inadequate care for important medical conditions. An apparent blind faith in the benefits of science and technology may help account for these startling inadequacies, as lavish funding of the biomedical research effort diverts attention from the fundamental matter of delivering care for common diseases. With a shift in research priorities, the United States could shape a health care system that is far more responsive to the needs of its people.
Biomedical Research↗
Advice seeking and appropriate use of a pediatric emergency department.
OBJECTIVES: To determine whether seeking advice prior to an unscheduled visit to a pediatric emergency department (PED) influences appropriate use of this setting for minor illnesses. DESIGN: Cross-sectional questionnaire survey. SETTING: The medical emergency department of the Montreal (Quebec) Children's Hospital, a major referral and urban teaching hospital. PARTICIPANTS: Four hundred eighty-nine of 562 consecutive parents visiting the PED over two periods, one in February and the other in July 1989. INTERVENTIONS: None. MEASUREMENTS/MAIN RESULTS: Parents of children between 0 and 18 years of age visiting the PED were asked whether they had previously sought advice from family, friends, or a physician. Other factors possibly related to the decision to seek care were also measured. Appropriateness was rated, blind to discharge diagnosis, by two pediatricians using a structured series of questions incorporating the child's age, time of the visit, clinical state, and problem at presentation. Thirty-four percent of visits among respondents were judged appropriate. In bivariate analysis, appropriate visits occurred significantly more often when a parent spoke to both a physician and a nonphysician (47%) prior to visiting the PED than when no advice was sought (29%; P < .05). In multivariate analysis, having a regular physician and being one of two children also contributed to appropriateness. CONCLUSIONS: Appropriate use of the PED was positively influenced by seeking prior advice from both a physician and family member, having a regular physician, and having prior child care experience.
Adolescent↗
The appropriateness of hysterectomy. A comparison of care in seven health plans. Health Maintenance Organization Quality of Care Consortium.
OBJECTIVE: To develop and test a method for comparing the appropriateness of hysterectomy use in different health plans. DESIGN: Retrospective cohort study. SETTING: Seven managed care organizations. PATIENTS: Random sample of all nonemergency, non-oncological hysterectomies performed in the seven managed care organizations over a 1-year period. Patients who were not continuously enrolled in a plan for 2 years prior to their hysterectomy were excluded. MAIN OUTCOME MEASURES: Proportion of women undergoing hysterectomy in each plan for inappropriate clinical reasons according to ratings derived from a panel of managed care physicians. RESULTS: Overall, about 16% of women underwent hysterectomy for reasons judged to be clinically inappropriate. Only one plan had significantly more hysterectomies rated inappropriate compared with the group mean (27%, unadjusted). Adjusting for age and race did not affect the rankings of the plans and had little effect on the numeric results. CONCLUSION: The rates of inappropriate use of hysterectomies are similar to those for other procedures and vary to a small degree among health plans. This information may be useful to purchasers when they consider which health plans to offer their employees.
Adult↗
Measuring underuse of necessary care among elderly Medicare beneficiaries using inpatient and outpatient claims.
CONTEXT: Continuing changes in the health care delivery system make it essential to monitor underuse of needed care, even for relatively well-insured populations. Traditional approaches to measuring underuse have relied on patient surveys and chart reviews, which are expensive, or simple single-condition claims-based indicators, which are not clinically convincing. OBJECTIVE: To develop a comprehensive, low-cost system for measuring underuse of necessary care among elderly patients using inpatient and outpatient Medicare claims. DESIGN: A 7-member, multispecialty expert physician panel was assembled and used a modified Delphi method to develop clinically detailed underuse indicators likely to be associated with avoidable poor outcomes for 15 common acute and chronic medical and surgical conditions. An automated system was developed to calculate the indicators using administrative data. SETTING AND SUBJECTS: A total of 345,253 randomly selected elderly US Medicare beneficiaries in 1994-1996. MAIN OUTCOME MEASURES: Proportion of beneficiaries receiving care, stratified by indicators of necessary care (n = 40, including 3 for preventive care), and avoidable outcomes (n = 6). RESULTS: For 16 of 40 necessary care indicators (including preventive care indicators), beneficiaries received the indicated care less than two thirds of the time. Of all indicators, African Americans scored significantly worse than whites on 16 and better on 2; residents of poverty areas scored significantly lower than nonresidents on 17 and higher on 1; residents of federally defined Health Professional Shortage Areas scored significantly lower than nonresidents on 16 and higher on none (P<.05 for all). CONCLUSIONS: This claims-based method detected substantial underuse problems likely to result in negative outcomes in elderly populations. Significantly more underuse problems were detected in populations known to receive less-than-average medical care. The method can serve as a reliable, valid tool for monitoring trends in underuse of needed care for older patients and for comparing care across health care plans and geographic areas based on claims data. JAMA. 2000;284:2325-2333.
Aged↗
Global budgets and excess demand for hospital care.
Excess demand is a pervasive feature of health care systems that use global budgets to pay for hospital care, regardless of the amount of money spent by those systems. This paper presents a theory that explains this feature of global budgets. The theory emphasizes that hospital administrators control the allocation of their budget, and that they choose quantity and resource intensity to maximize their own utility. The equilibrium quantity of care provided may be less than quantity demanded by consumers, leading to excess demand for admissions. An increase in the hospital's budget may even be associated with an increase in excess demand.
Budgets↗
Deadweight loss of bacterial resistance due to overtreatment.
Widespread use of antibiotics is considered the major driving force behind the development of antibiotic resistance. The benefits of exceeding the welfare-maximizing level of antibiotic use are below the costs of resistance created by this excess quantity of antibiotics used, thereby resulting in a welfare deadweight loss. This paper uses a simple economic model to examine the theoretical and empirical aspects of the welfare loss generated by resistance and analyzes its policy implications. The annual deadweight loss associated with outpatient prescriptions for amoxicillin in the United States is estimated at US dollars 225 million.
Amoxicillin↗
Do competition and managed care improve quality?
In recent years, the US health care industry has experienced a rapid growth of managed care, formation of networks, and an integration of hospitals. This paper provides new insights about the quality consequences of this dynamic in US hospital markets. I empirically investigate the impact of managed care and hospital competition on quality using in-hospital complications as quality measures. I use random and fixed effects, and instrumental variable fixed effect models using hospital panel data from up to 16 states in the 1992-1997 period. The paper has two important findings: First, higher managed care penetration increases the quality, when inappropriate utilization, wound infections and adverse/iatrogenic complications are used as quality indicators. For other complication categories, coefficient estimates are statistically insignificant. These findings do not support the straightforward view that increases in managed care penetration are associated with decreases in quality. Second, both higher hospital market share and market concentration are associated with lower quality of care. Hospital mergers have undesirable quality consequences. Appropriate antitrust policies towards mergers should consider not only price and cost but also quality impacts.
Antitrust Laws↗
Crowded outpatient departments in city hospitals of developing countries: a case study from Lesotho.
'Overuse' of hospital outpatient departments in urban areas of developing countries is perceived as a problem by many health planners. The World Health Organization is promoting advanced health centres, or 'reference centres', as part of a strategy to develop urban health systems and to reduce primary contact care at hospitals. However, hospital-based information to assist city health service planning is limited in many countries. This study examined user characteristics, patient flow and prescribing quality at the national referral hospital in Maseru, Lesotho, using simple and replicable methods. The study found that most users were self-referred and came from the city. The majority of respondents were aware of their local health centre but reported they would normally use the hospital when they were ill. Examination of patient flow showed that, on average, patients spent a total of 3.7 h waiting. Quality of care was compromised by a tendency to over-prescribe, particularly antibiotics and sedatives. The study suggests that in Maseru, the perception of 'overuse' is due to congestion and that improved patient flow management will reduce the numbers of patients waiting. Quality of care could be strengthened by regular audit of prescribing practices by clinicians in the hospital.
Adult↗
Developing strategies to encourage appropriate care-seeking for children with acute respiratory infections: an example from Egypt.
Determinants of care-seeking and patterns of referral for acute respiratory infections (ARIs) in children were studied in two communities in Ismailia, Egypt. A video was used to assess mothers' recognition and interpretation of clinical signs of serious illness. Mothers were questioned about which of the locally available provider options they would choose for four different locally-defined ARI illnesses; they were also read brief descriptions of hypothetical cases, and asked how they would recommend treating children in those situations. These results were compared with reported care-seeking practices during past ARI episodes that occurred in their own children. The results indicate that mothers generally recognize rapid or difficult breathing, but do not use the recognition to take appropriate actions. The data suggest that a substantial proportion of children in the study area, who are perceived to have severe respiratory illnesses, may not be brought to the government health facilities for treatment. Implications of the findings for the training policies and strategies of the Egyptian national ARI program are considered.
Child↗
Epidemiologic assessment of overmet need in mental health care.
The traditional purpose of psychiatric epidemiologic surveys has been the assessment of mental illness and, by implication, the need for care. Previous research has focused on unmet need, defined as those who meet "caseness" but do not receive care, but has rarely examined the converse. Since survey respondents receiving care but not meeting caseness have been found to represent up to one-half of mental health service users, this is a significant service delivery issue. The data are drawn from the Mental Health Supplement to the Ontario Health Survey (the Supplement), a household survey of 9,953 respondents, which used the University of Michigan's version of the Composite International Diagnostic Interview (UM-CIDI) as its diagnostic instrument. Community residents who used formal mental health services in the past year but who did not have a concurrent UM-CIDI/DSM-III-R (Diagnostic and Statistical Manual 3, revised) diagnosis were defined as "treated without CIDI disorder". Their need for care was evaluated by comparing them to "treated depressed" and "healthy" respondents, using indicators of functional impairment, vulnerability to developing disorder, and risk of relapse. The match between need and care levels was examined by comparing their type and intensity of use with those of the treated depressed. Results present strong evidence for conceptualizing need as continuous, rather than discrete. The results for the group defined as "treated without CIDI disorder" were consistently between those for the other two groups (with the "treated depressed" always showing the highest need) on all indicators as well as on a summary need index. However, their type and intensity of service use appeared to be unrelated to their level of need. Although some of the "treated without CIDI disorder" group may require preventive or follow-up treatment, the need for service for others is not as convincingly demonstrated. Outcome studies are needed to provide comparative data to describe more fully the problems experienced by this group and indicate whether treatment is helpful. In an age of fiscal restraint, when resource reallocation (rather than generation of new resources) is the likely scenario, such close examination of the fit between need and care is critical if services are to be targeted appropriately.
Adolescent↗
The mental health of Asian and Pacific Island elders: implications for research and mental health administration.
According to the 1990 census, the highly diverse Asian and Pacific Islander (API) American population has doubled in size from 1980 to 1990, and is now the nation's fastest growing minority group. Several studies have documented this population's comparative underuse of mental health services. A review of recent studies on the mental health of Asian and Pacific Island elders identifies a number of risk factors and protectors. Elder APIs appear to have poorer mental health compared to white counterparts, but not the poorest mental health within their own ethnic group. Within-group differences emerge, with recent immigrant groups and colonized populations appearing as most at-risk for mental health problems. A critical variable on this population's mental health status appears to be socioeconomic status,and yet an analysis of other demographic variables, notably nativity and gender, remain contradictory. A research agenda is proposed and implications for mental health administrators are suggested.
Age Factors↗