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Variations in the use of cardiac procedures in the Veterans Health Administration

AMERICAN HEART JOURNAL 1999年第4期137卷 706-713页

作者： Mirvis, DM Graney, MJ Univ Tennessee Dept Prevent Med Memphis TN 38105 USA Univ Tennessee Dept Med Memphis TN 38105 USA Dept Vet Affairs Med Ctr Memphis TN USA

Background Considerable variability exists in the use of cardiac procedures for patients with heart disease. One cause for this variability is the availability of local facilities to perform these procedures. This study was initiated to identify health system features that are related to rates of catheterization, percutaneous coronary angioplasty, and coronary artery bypass graft surgery in the Veterans Affairs health care system in which structured referral systems are intended to compensate for variation in local resource availability Methods Medical records of 30,901 patients admitted to a Veterans Affairs medical center with coronary artery disease were analyzed. Odds ratios (OR) and 95% confidence intervals (CI) for undergoing each procedure, based on clinical variables (age, sex, race, coronary artery disease type, and a computed comorbidity score), and local Veterans Affairs facility features (geographic region, primary service area size, and hospital complexity) were estimated by logistic regression. Results Regression models demonstrated significant associations between the odds of undergoing each procedure and medical center geographic and complexity features, after adjustment for clinical variables. Associations included the presence of a cardiac catheterization laboratory For undergoing catheterization (OR 1.86, CI 1.76 to 1.95) and the presence of a cardiac surgical program for angioplasty (OR 1.46, CI 1.36 to 1.57) and bypass grafting (OR 1.43, CI 1.34 to 1.53). Including health system variables in addition to clinical variables in the regression models improved the discriminating ability of the models by 44.2% to 51.4%. Conclusions Geographic location and the complexity of the local Veterans Affairs hospital are important determinants of the use of cardiac procedures in the Veterans Affairs health care system, even though referral networks are intended to correct for local differences in hospital complexity.

关键词：血管成形术经腔经皮冠状动脉/利用置信区间冠状动脉分流术/利用卫生服务易得程度/统计学和数值数据心脏导管插入术/利用医院退伍军人/统计学和数值数据医院退伍军人/利用 Logistic模型病案心肌缺血/外科学比值比医师诊疗模式/统计学和数值数据美国美国退伍军人事务部利用情况审核/统计学和数值数据老年人女(雌)性人类男(雄)性中年人

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Realizing the potential of clinical judgment: A real-time strategy for predicting outcomes and cost for medical inpatients

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AMERICAN JOURNAL OF MEDICINE 2000年第3期109卷 189-195页

作者： Charlson, ME Hollenberg, JP Hou, J Cooper, M Pochapin, M Pecker, M Cornell Univ Weill Med Coll Div Gen Internal Med Dept Med New York NY 10021 USA New York Presbyterian Hosp New York NY USA

PURPOSE: We sought to determine whether illness severity and anticipated level of function, as evaluated at the time of admission, were associated with outcomes and costs of care for patients admitted to the medical service. METHODS: hll 1,759 patients admitted to the medical service at a large urban academic medical center between July 1, 1997, and September 30, 1997 (excluding those admitted directly to the intensive care units or for protocol chemotherapy), were evaluated and categorized by the admitting intern by illness severity (not ill, mildly ill, moderately ill, severely ill, or moribund) and anticipated level of function at discharge (excellent, good, fair, or poor) as part of their routine sign-out process. Interns' ratings were always available within 24 to 28 hours of admission. In-hospital mortality, length of stay, cost of hospitalization, and anticipated billing revenue were evaluated. RESULTS: Patients who were more severely ill had significantly greater in-hospital mortality. For example, mortality was 1.1% (11 of 972) among those who were not ill or mildly ill, 3.6% (26 of 724) among those who were moderately ill, and 15% (9 of 60) among those who were severely ill. Illness severity (P = 0.003) and anticipated functional status (P < 0.01) were significant predictors of in-hospital mortality. Illness severity and function were also significant predictors of greater length of stay and greater costs of hospitalization (all P < 0.0001). The 389 patients who were moderately ill with fair or poor anticipated function were associated with the largest cumulative losses (about $330,ODD during the 3-month period), whereas the 798 mildly ill patients with good or excellent function were associated with the largest cumulative profits ($550,000). CONCLUSION: Physicians' estimates of patients' illness severity and anticipated function at the time of discharge, as made by interns using a system designed to help them sign out to their colleagues, predict outcomes

关键词：医学科学研究中心/经济学医学科学研究中心/统计学和数值数据临床工作能力医院费用医院死亡率医院市区/经济学医院市区/统计学和数值数据判断住院时间/统计学和数值数据纽约市比值比 ROC曲线疾病严重程度指数治疗结果利用情况审核/统计学和数值数据成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Postacute care following stroke or hip fracture - Single services and combinations used by medicare beneficiaries (1987-1992)

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JOURNAL OF AGING AND HEALTH 1999年第1期11卷 27-48页

作者： Berg, K Intrator, O Brown Univ Ctr Gerontol & Hlth Care Res Providence RI 02912 USA Hebrew Univ Jerusalem Jerusalem Israel

Objective: To describe the use of postacute services alone or in combination following a hospitalization for a hip fracture or stroke by Medicare beneficiaries who were relatively well and living in the community prior to the index event. Methods: Health-service use histories were constructed using Medicare claims. Patients in the study represented all subjects from a 1% sample of Medicare beneficiaries who were age 70 years or older at the time of the index hospitalization. Results: From 1987 to 1992, the proportion of patients receiving any postacute care and those receiving combinations of care increased. For example, there was a doubling of the proportion of patients with either condition using sequences of rehabilitation with home health or SNF and home health. Within I year of the hospitalization, 42.6% of patients with stroke and 35.0% post-hip fracture had been rehospitalized. Discussion: Resource use and assessment of patient outcomes should be examined across the continuum of postacute care and in the months beyond to examine the relative effectiveness of different combinations of care.

关键词：脑血管障碍/康复髋骨折/康复家庭医疗保健服务/统计学和数值数据家庭医疗保健服务/利用 Medicare 医护疗养所/统计学和数值数据医护疗养所/利用病人再入院康复中心/统计学和数值数据康复中心/利用治疗结果美国利用情况审核/统计学和数值数据老年人老年人 80以上女(雌)性人类男(雄)性

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The effect of health care coverage on medical cost, utilization, and well-being of the aged

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Journal of Health and Social Policy 1992年第1期4卷 1-11页

作者： Slivinske, L.R. Fitch, V.L. Department of Sociology Youngstown State University Youngstown OH 44555 United States

The relationship of medical insurance, utilization and health status indicators was examined for 463 elderly individuals. The uninsured were less well and tended to utilize the health care system more often than those with more types of coverage. Need was found to be the best predictor of utilization. A profile describing those with above average levels of well-being also was developed. Methodological issues and health care policy recommendations are discussed.

关键词：方差分析数据收集判别分析卫生保健费用老年人保健服务/利用健康状况指标保险健康/统计学和数值数据未参加医疗保险者/统计学和数值数据俄亥俄利用情况审核/统计学和数值数据老年人女(雌)性人类男(雄)性中年人

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Changing patterns of physician services utilization in Ontario, Canada, and their relation to physician, practice, and market-area characteristics

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MEDICAL CARE RESEARCH AND REVIEW 1996年第2期53卷 179-206页

作者： Hurley, J Brown, J MCMASTER UNIV HAMILTON ON L8S 4L8 CANADA

In both the United States and Canada, the environment in which physicians practice is becoming increasingly constrained. The understanding of how physicians respond to economic incentives is still relatively crude. In this article, the authors use physician-specific data for physicians in four specialties in the province of Ontario, Canada, to examine utilization trends during the 1983-1990 period and relate these utilization changes to physician, practice, and market-area characteristics. The analysis of trends in utilization reveals marked variation across specialties in the degree of change, its distribution among physicians within each specialty, and the way in which utilization growth was achieved. The physician, practice, and market-area characteristics explained a substantial amount of variation in the levels of utilization across physicians and over time;they were less able to explain year-to-year changes in utilization.

关键词：诊疗工作管理医学回归分析专业医学/统计学和数值数据利用情况审核/统计学和数值数据

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Pastoral research in a hospital setting: a case study.

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Journal of pastoral care 1991年第3期46卷 283-290页

作者： Hover, M. Travis 3rd., J.L. Koenig, H.G. Bearon, L.B. Duke University Medical Center Durham 27710. NC United States

Provides a summary of research procedures and outcome data of a utilization review of the pastoral services of a large university medical center. Notes particularly the value of such a project both in terms of concret... 详细信息

关键词：卫生服务研究医院病床数 500张以上医院大学/利用部门间关系北卡罗来纳牧师心理治疗/组织和管理牧师心理治疗/统计学和数值数据病人满意度/统计学和数值数据规划技术问卷调查利用情况审核/方法利用情况审核/统计学和数值数据

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Case Mix Measurement in English Hospitals: An Evaluation of Five Methods for Predicting Resource Use

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Journal of Health Services Research & Policy 1996年第1期1卷 10-19页

作者： Söderlund, Neil Gray, Alastair Milne, Ruairidh Raftery, James Department of Public Health and Primary Care University of Oxford United Kingdom Centre for Sociolegal Studies Wolfson College University of Oxford United Kingdom National Case Mix Office Winchester United Kingdom

The introduction of an internal market in the British National Health Service (NHS) has highlighted the importance of developing appropriate, valid and timely measures of hospital activity, both for the purposes of specifying and monitoring contracts and for evaluating the success of the NHS reforms in general. This paper compares the validity of five case mix methods (Diagnosis Related Groups (DRGs);Healthcare Resource Groups (HRGs) versions 1 and 2;specialty classification;a simple age categorization) in predicting resource use. Two data sets were used to compare different case mix methods. A 3% random sample (n ≃ 300 000) of the 1992/3 Hospital Episodes Statistics was used to test their ability to predict variation in length of stay, and a second set of individually costed patient episodes from two hospitals (n ≃ 40 000) was used to test their ability to explain cost variation. Analysis of variance models were used to assess the fit of each of the case mix systems to test data and a simple significance test of differences in mean squared error between models was applied. All case mix methods performed poorly on untrimmed data. When lengths of stay greater than 29 days were excluded, version 2 of HRGs explained 31% of total variance in length of stay and 25% of cost variation. DRGs explained less variance but performed better than HRGs version 1. For a typical hospital patient population consisting of a range of specialties, the difference in explanatory power between HRGs V2 and DRGs was statistically significant at the 5% level for sample sizes of approximately 2000 or greater. For individual specialties, the minimum sample size required for the difference between the groupers to be significant ranged from around 300 to over 2000. The locally developed HRGs version 2 system appears to offer superior performance in terms of resource homogeneity to other currently available approaches. It is also more adaptable and cheaper than imported alternatives and has been f

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What happens when capitated behavioral health comes to town? The transition from the Fort Bragg demonstration to a capitated managed behavioral health contract

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JOURNAL OF BEHAVIORAL HEALTH SERVICES & RESEARCH 2000年第4期27卷 390-405页

作者： Heflinger, CA Northrup, DA Vanderbilt Ctr Mental Hlth Policy Nashville TN USA

Capitated managed care contracts for behavioral health services are becoming more prevalent across the country in both public and private sectors. This study followed the transition from a demonstration project for child mental health services to a capitated managed behavioral health care contract with a for-profit managed care company. The focus of the study was on the impact-at both the service system and the individual consumer level-pertaining to the start-up and maintenance of a capitated managed behavioral health program. A case study using multiple methods and multiple sources of information incorporated a program fidelity framework that examined micro to macro levels of program implementation. The findings of this study include the following: access to services decreased, the lengths of stay and average daily census in the more intensive levels of treatment declined, difficult-to-treat children were shifted to the public sector and ratings of service system performance and coordination fell.

关键词：青少年保健服务/统计学和数值数据按人收费费用分配/统计学和数值数据保健福利计划雇员卫生服务易得程度/标准卫生服务易得程度/统计学和数值数据管理医疗规划/经济学管理医疗规划/组织和管理管理医疗规划/标准管理医疗规划/统计学和数值数据精神卫生服务/经济学精神卫生服务/组织和管理精神卫生服务/标准精神卫生服务/统计学和数值数据北卡罗来纳卫生保健质量/标准卫生保健质量/统计学和数值数据回顾性研究利用情况审核/标准利用情况审核/统计学和数值数据青少年儿童人类

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A study using working DRGs to examine variations in length of stay.

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Health information management : journal of the Health Information Management Association of Australia 1994年第1期24卷 7-11页

作者： Cheng, S. Essery, S. Braithwaite, J. Howes, M.

The results of a working DRG utilisation review study conducted at St Vincent's Hospital, Sydney in 1992 are described. The project aimed to allocate a working DRG to Cardiology and Orthopaedic patients. Working DRGs are defined as DRGs allocated on admission based on the presenting problem or provisional diagnosis. Patients were then concurrently reviewed until discharge. Actual length of stay (LOS) of patients was compared to the LOS predicted by the working DRG. Results indicated that a utilisation review program using a working DRG can predict a LOS reasonably well for large groups of patients but not for individual patients and that St Vincent's is a comparatively efficient provider of Cardiology and Orthopaedic Services. The paper describes the study design, methods and results. Medical Record Managers played an integral role in the preparation phase, design of the study, day to day coordination and analysis of results. Medical Record Managers' participation in the study is highlighted in this paper.

关键词：心脏病学科医院/统计学和数值数据心脏病学科医院/利用数据收集诊断相关患者组/统计学和数值数据诊断相关患者组/发展趋势医院/利用住院时间/统计学和数值数据住院时间/发展趋势新南威尔士矫形外科学/统计学和数值数据病人入院研究设计软件利用情况审核/统计学和数值数据

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