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Paying for hospital emergency care under a single-payer system

ANNALS OF EMERGENCY MEDICINE 2001年第3期37卷 309-317页

作者： Duckett, SJ Jackson, T La Trobe Univ Sch Publ Hlth Bundoora Vic 3086 Australia Monash Univ Hlth Econ Unit W Heidelberg Vic Australia

Hospital emergency services are one of the key drivers of hospital activity, yet there has been surprisingly little attention paid to appropriate funding models for single-payer systems, in which funders must be concerned with issues of access and financial viability of emergency departments. This article analyzes the dynamics of hospital emergency services in terms of the key products and cost drivers. It reviews the currently available systems for categorizing emergency activity and evaluates their applicability for funding purposes with particular emphasis on the susceptibility to gaming of both triage and disposition, it identifies and evaluates 3 models for use in single-payer health systems for funding hospital emergency services (fully variable, fully fixed, and mixed variable/fixed) in terms of the key products and cost drivers in the ED. Approaches to the setting and rebasing of fixed grants are considered. Problems of potential incentive effects and double payment for admitted patients make the setting of variable payments problematic, particularly for patients subsequently admitted as inpatients. Key characteristics of an ED funding model in single-payer systems are proposed.

关键词：诊断相关患者组/经济学急诊室医院/经济学筹资政府/经济学医院费用/统计学和数值数据支付标准制定和审核单付费者系统/经济学伤病员分拣/经济学维多利亚人类

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Diagnosing acute cardiac ischemia in the emergency department: A systematic review of the accuracy and clinical effect of current technologies

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ANNALS OF EMERGENCY MEDICINE 2001年第5期37卷 453-460页

作者： Lau, J Ioannidis, JPA Balk, EM Milch, C Terrin, N Chew, PW Salem, D New England Med Ctr Div Clin Care Res Evidence Based Practice Ctr Boston MA 02111 USA

Study objective: Acute cardiac ischemia (ACI) encompasses the diagnoses of unstable angina pectoris and acute myocardial infarction (AMI). Accurate diagnosis and triage of patients with ACI in the emergency department should increase survival for these patients and reduce unnecessary hospital admissions. Methods: We conducted a systematic review of the English-language literature published between 1966 and December 1998 on the accuracy and clinical effect of diagnostic technologies for ACI. We evaluated prospective and retrospective studies of adult patients who presented to the ED with symptoms suggesting ACI. Outcomes were diagnostic performance (test sensitivity and specificity) and measures of clinical effect. Meta-analyses were performed when appropriate. A decision and cost-effectiveness analysis was conducted that investigated Various diagnostic strategies used in the diagnosis of ACI in the ED. Results: We screened 6,667 abstracts, reviewed 407 lull articles, and included 106 articles in the main analysis. Single measurements of biomarkers at presentation to the ED have low sensitivity for AMI, although they have high specificity. Serial measurements greatly increase the sensitivity for AM[ while maintaining their excellent specificity. Diagnostic technologies to evaluate ACI in selected populations, such as electrocardiography, sestamibi perfusion imaging, and stress EGG, may have very good to excellent sensitivity;however, they have not been sufficiently studied. The Goldman Chest Pain Protocol has good sensitivity (about 90%) for AMI but has not been shown to result in any differences in hospitalization rate, length of stay, or estimated costs in the single clinical effect study performed. Its applicability to patients with unstable angina pectoris has not been evaluated. The use of an Acute Cardiac Ischemia-Time-Insensitive Predictive instrument led to the appropriate triage of 97% of patients with ACI presenting to the ED and reduced unnecessary hospita

关键词：急性病心绞痛不稳定型/诊断费用效益分析决策支持技术心电描记术/经济学心电描记术/标准急诊处理/经济学急诊处理/方法急诊处理/标准循证医学运动试验/经济学运动试验/标准医院费用/统计学和数值数据住院/统计学和数值数据住院时间/统计学和数值数据心肌梗死/诊断前瞻性研究可重复性结果回顾性研究敏感性与特异性技术评估生物医学治疗结果伤病员分拣/经济学伤病员分拣/方法伤病员分拣/标准成年人人类

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Effect of transradial access on quality of life and cost of cardiac catheterization: A randomized comparison

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AMERICAN HEART JOURNAL 1999年第3期138卷 430-436页

作者： Cooper, CJ El-Shiekh, RA Cohen, DJ Blaesing, L Burket, MW Basu, A Moore, JA Med Coll Ohio Div Cardiol Toledo OH 43699 USA Harvard Univ Sch Med Beth Israel Deaconess Med Ctr Boston MA USA

Background Transradial access is a recently developed alternative For diagnostic cardiac catheterization. Its effects on quality of life after the procedure, patient preference, and cost are unknown. Methods and Results We performed a randomized single-center trial in which 99 patients underwent transfemoral and 101 underwent transradial diagnostic cardiac catheterization. Quality of life was measured with the SF-36 and visual analog scales at baseline, 1 day, and 1 week. Patients were examined at 1 day and at 1 week after for complications. Costs were measured prospectively. One patient in the femoral group and 2 in the radial group crossed over to the alternative access site. There were no major access site complications. One patient in the transfemoral group had a minor stroke. Transradial catheterization significantly reduced median length of stay (3.6 vs 10.4 hours, P <.0001). Over the first day alter the procedure, measures of bodily pain, back pain, and wa king ability favored the transradial group (P <.05 for all comparisons). Over the week after the procedure, changes in role limitations caused by physical health, bodily pain, and back pain favored the transradial group (P <.05 for all comparisons). There was a strong patient preference for transradial catheterization as well (P <.0001). Transradial catheterization led to significant reductions in bed, pharmacy, and total hospital costs ($2010 vs $2299, P <.0001). dConclusions Among patients undergoing diagnostic cardiac catheterization, transradial access leads to improved quality of life after the procedure, is strongly preferred by patients, and reduces hospital costs.

关键词：冠心病/放射摄影术股动脉心脏导管插入术/经济学心脏导管插入术/方法心脏导管插入术/标准医院费用/统计学和数值数据病人满意度前瞻性研究生活质量桡动脉女(雌)性人类男(雄)性中年人

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Does enrollment in a randomized clinical trial lead to a higher cost of routine care?

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AMERICAN HEART JOURNAL 2002年第1期143卷 140-144页

作者： Weiss, JP Parsons, LS Every, NR Weaver, WD Hlatky, MA Stanford Univ Sch Med Dept Hlth Res Stanford CA 94305 USA Stanford Univ Sch Med Dept Policy & Med Stanford CA 94305 USA Univ Washington Sch Med Ctr Cardiovasc Outcomes Res Seattle WA 98195 USA Henry Ford Hosp & Med Ctr Detroit MI 48202 USA

Background Reimbursement for the routine care of patients enrolled in clinical trials is controversial. Our objective was to determine the added medical costs, if any, associated with enrollment in a randomized clinical trial. Methods We analyzed data from the Myocardial Infarction Triage and Intervention (MITI) Trial (1988-1991) and the registry of all patients admitted to 19 Seattle area coronary care units (1988-1993). The major trial entry criteria were age 35 to 71 years, symptom duration 15 minutes to, 6 hours, and acute myocardial infarction on electrocardiogram. The trial group consisted of 264 of 324 randomized patients who received thrombolytics and had available cost data. From 11,932 registry patients, we identified a control group who met trial entry criteria but who were not enrolled because of logistic barriers or presentation outside the trial enrollment period, 335 of whom received thrombolytics and had available cost data. The groups were compared for total cost for initial hospitalization, with and without multivariable adjustment for baseline characteristics. Results Total hospital cost was not different between trial patients (median $11,516) and control subjects (median $14,200) (trial/control mean cost ratio 0.91 [95% CI 0.82-1.02]). Participation in the trial had an insignificant effect on costs in the multivariable model (cost ratio 1.04, 95% CI 0.95-1.16). Significant predictors of cost included hospital of admission, length of stay, and coronary revascularization procedures. Conclusion Participation in the MITI randomized trial had no effect on the cost of routine care.

关键词：病例对照研究冠心病重症监护病房/经济学纤维蛋白溶解药/经济学纤维蛋白溶解药/治疗应用卫生服务研究医院费用/统计学和数值数据 Medicare/经济学 Medicare/立法和法学心肌梗死/药物疗法心肌梗死/经济学登记组织型纤溶酶原激活物/经济学组织型纤溶酶原激活物/治疗应用华盛顿成年人老年人女(雌)性人类男(雄)性中年人

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Effects of hospitalists on cost, outcomes, and patient satisfaction in a rural health system

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AMERICAN JOURNAL OF MEDICINE 2000年第8期108卷 621-626页

作者： Davis, KM Koch, KE Harvey, JK Wilson, R Englert, J Gerard, PD N Mississippi Hlth Serv Tupelo MS 38801 USA Mississippi State Univ Expt Stat Unit Starkville MS USA

PURPOSE: Previous studies have examined the effects of hospitalists in urban academic hospitals. We compared the outcomes of patients treated by hospitalists with those of patients treated by internists at a 647-bed rural community hospital. SUBJECTS AND METHODS: The 443 patients in the hospitalists' 10 most common diagnosis-related groups (DRGs) were compared with 1,681 patients in the same DRGs who were cared for by internists in fiscal year 1998. Length of stay, cost of care, patient illness severity, patient satisfaction, 30-day readmission rate, inpatient mortality, discharge status, and resource utilization were compared. RESULTS: The hospitalists' patients had a shorter mean (+/- SD) length of stay (4.1 +/- 3.0 days versus 5.5 +/- 4.9 days, P <0.001) and their cost of care was less than that of the internists' patients ($4,098 +/- $2,455 versus $4,658 +/- $4,084, P <0.001). Analyses that adjusted for patient age, race, sex, insurance status, severity of illness, and specific medical comorbidities confirmed these differences. The differences between hospitalists and internists were most apparent among very ill patients. Mortality rates were similar (4.5% for hospitalists versus 4.9% for internists, P = 0.80), as were the readmission rates (4.5% for hospitalists versus 5.6% for internists, P = 0.41). Patient satisfaction was similar for both groups. The internists used more resources in 8 of 11 categories. CONCLUSIONS:The hospitalists provided cost-effective care, particularly for the sickest patients, with good outcomes and patient satisfaction. (C) 2000 by Excerpta Medica, Inc.

关键词：卫生资源/利用医院费用/统计学和数值数据卫生设施管理人员/经济学卫生设施管理人员/统计学和数值数据医院社区/经济学医院社区/统计学和数值数据内科学/经济学内科学/统计学和数值数据住院时间密西西比结果评价(卫生保健) 病人满意度/统计学和数值数据乡村卫生服务/经济学乡村卫生服务/统计学和数值数据疾病严重程度指数人类

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Variability in cost of coronary bypass surgery in New York State: Potential for cost savings

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AMERICAN HEART JOURNAL 2002年第1期143卷 130-139页

作者： Cowper, PA DeLong, ER Peterson, ED Hannan, EL Ray, KT Racz, M Mark, DB Duke Clin Res Inst Outcomes Res & Assessment Grp Durham NC 27715 USA SUNY Albany Dept Hlth Policy Management & Behav Albany NY 12222 USA New York State Dept Hlth Albany NY USA Marist Coll Poughkeepsie NY USA

Objective Previous analyses of variability in bypass resource use have not focused on hospital-level variation or adequately explored the influence of patient risk. We combined a clinical database with claims data to fully characterize patient level and hospital level variability in bypass surgery cost and length of stay in New York State and explored the extent to which lower cost is associated with worse quality of care. Methods By use of 1992 clinical and claims data, we identified by multivariable regression which patient characteristics influence bypass cost and length of stay. Hospital was then incorporated as a random variable in mixed linear models to determine its impact on resource use. The relationship between risk-adjusted in-hospital mortality and cost was then explored. Results In the 21 hospitals for which cost data were available, mean leveled cost (exclusive of professional fees and noncomparable costs) was $15,713, with a mean length of stay of 14 days (n = 12,087). One fifth of the variation in resource use was explained by baseline patient risk. After adjustment for patient risk, hospital explained an additional 42% of variation in cost and an additional 8% of variation in length of stay. Among hospitals, risk-adjusted cost varied almost 3-fold and risk-adjusted length of stay varied 50%. There was no association between cost and in-hospital mortality. Conclusions As of 1992, there was considerable interhospital variability in bypass surgery cost after patient baseline risk was accounted for. This suggests that reductions in bypass cost could be achieved by normalizing clinical practice.

关键词：心排血量冠状动脉分流术/经济学冠状动脉分流术/死亡率成本及成本分析卫生资源/经济学卫生资源/利用医院费用/统计学和数值数据医院死亡率住院时间/经济学住院时间/统计学和数值数据线性模型纽约/流行病学回归分析危险性评估疾病严重程度指数老年人女(雌)性人类男(雄)性

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The costs of hospital services: a case study of Evangelical Lutheran Church hospitals in Tanzania

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HEALTH POLICY AND PLANNING 1998年第4期13卷 397-407页

作者： Flessa, S Univ Erlangen Nurnberg Sch Management D-90020 Nurnberg Germany

The health care systems of many developing countries are facing a severe crisis. Problems of financing services leads to high patient fees which make institutions of Western health care unaffordable for the majority of the rural poor. The conflict between sustainability and affordability of the official health care system challenges both local decision-makers and health management consultants. Decisions must be made soon so that the existing health care systems can survive. However, these decisions must be based on sound data, especially on the costs of health care services. The existing accounting systems of most hospitals in developing countries do not provide decision-makers with these data. Costs are generally underestimated. The leadership of the 16 hospitals of the Evangelical Lutheran Church in Tanzania is currently analyzing how the existing health care services should be restructured. Therefore, reliable estimates of the costs of hospitals services are required. A survey on 'Costing of health services of the Evang. Luth. Church in Tanzania' was prepared, which summarizes the results of seven months of field investigations in Lutheran hospitals. The major findings are that the costs of providing adequate services are much higher than expected. The most important factors determining these costs are the administrative efficiency of the hospital and the scope of services offered. The paper closes with some recommendations on how to improve the services in order to make them both affordable for the rural poor and financially sustainable for the Church. It is concluded that even the best improvement of technical efficiency will not safeguard the survival of the hospital-based health care services of the Lutheran Church in Tanzania. These findings call for a reallocation of health care resources to lower levels of the health care pyramid.

关键词：基督教费用分配发展中国家/经济学效率组织设备和供应医院/经济学卫生政策卫生服务研究/方法医院费用/统计学和数值数据医院宗教/经济学医院宗教/组织和管理组织状况研究坦桑尼亚

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Prehospital delay time in acute myocardial infarction: An exploratory study on relation to hospital outcomes and cost

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AMERICAN HEART JOURNAL 2000年第5期139卷 788-796页

作者： Caldwell, MA Froelicher, ES Drew, BJ Univ Calif San Francisco San Francisco CA 94143 USA

Background short prehospital delay is associated with improved outcomes in myocardial infarction, but the impact on cost has not been tested. Shortening delay time could reduce health care expenditures. Methods and Results Two hundred ninety-eight patients were examined with the use of a historic prospective design at 2 hospital sites. A secondary analysis was performed that used patients with confirmed myocardial infarction from the National Register of Myocardial Infarction and direct and indirect costs from the accounting system at the hospitals. Chi-square, Mann Whitney U, and Fisher exact tests were used for comparisons. Delay and 4 sets of variables were regressed on cost with the significant predictors used to construct a final model. The mean age was 71 +/- 14 years old;62% were men. There were no major differences in demographics, cardiac history, risk factors, and admission characteristics between short and long delayers. Resource utilization and clinical outcomes were similar between the 2 groups;there was no difference in cost. Additional diagnostic procedures (odds ratio 2.92;95% confidence interval 1.65-5.15) and complications (odds ratio 3.43;95% confidence interval 2.03-5.82) were significant predictors of cost. Delay was not a predictor of high cost. Conclusions short prehospital delay was not associated with improved clinical outcomes, nor did it predict cost. Explanations include (1) the low utilization of early reperfusion therapy in the short delay group, (2) the study lacked sufficient power to detect a difference in cost between short and long delayers, and (3) the severity of illness could not be adequately measured. This issue warrants further study because of the potential impacts on health care expenditures.

关键词：费用节省急救医疗服务/经济学医院费用/统计学和数值数据住院时间/经济学心肌梗死/经济学心肌梗死/死亡率心肌梗死/治疗心肌再灌注/经济学前瞻性研究登记时间和运动研究治疗结果美国老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Relation between length of hospital stay and costs of care for patients with community-acquired pneumonia

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AMERICAN JOURNAL OF MEDICINE 2000年第5期109卷 378-385页

作者： Fine, MJ Pratt, HM Obrosky, DS Lave, JR McIntosh, LJ Singer, DE Coley, CM Kapoor, WN Univ Pittsburgh Grad Sch Publ Hlth Div Gen Internal Med Dept Med Pittsburgh PA USA Univ Pittsburgh Grad Sch Publ Hlth Ctr Res Hlth Care Pittsburgh PA USA Univ Pittsburgh Grad Sch Publ Hlth Dept Hlth Serv Adm Pittsburgh PA USA Massachusetts Gen Hosp Div Gen Med Dept Med Boston MA 02114 USA Harvard Univ Sch Med Boston MA USA

PURPOSE: Patients with pneumonia often remain hospitalized after becoming clinically stable, without demonstrated benefits on outcome. The purposes of this study were to assess the relation between length of hospital stay and daily medical care costs and to estimate the potential cost savings associated with a reduced length of stay for patients with pneumonia. SUBJECTS AND METHODS: As part of a prospective study of adults hospitalized with community-acquired pneumonia at a community hospital and two university teaching hospitals, daily medical care costs were estimated by multiplying individual charges by department-specific cost-to-charge ratios obtained from each hospital's Medicare cost reports. RESULTS: The median total cost of hospitalization for all 982 inpatients was $5,942, with a median daily cost of $836, including $491 (59%) for room and $345 (41%) for non-room costs. Average daily non-room costs were 282% greater on the first hospital day, 59% greater on the second day, and 19% greater on the third day than the average daily cost throughout the hospitalization (all P < 0.05), and were 14% to 72% lower on the last 3 days of hospitalization. Average daily room costs remained relatively constant throughout the hospital stay, with the exception of the day of discharge. A projected mean savings of $680 was associated with a 1-day reduction in length of stay. CONCLUSIONS: Despite institutional differences in total costs, patterns of daily resource use throughout hospitalization were similar at all institutions. A 1-day reduction in length of stay might yield substantial cost-savings. (C) 2000 by Excerpta Medica, Inc.

关键词：波士顿队列研究社区获得性感染/经济学费用节省/统计学和数值数据医院费用/统计学和数值数据住院时间/经济学住院时间/统计学和数值数据多元分析新斯科舍宾夕法尼亚肺炎/经济学过程评价(卫生保健) 疾病严重程度指数成年人老年人女(雌)性人类男(雄)性中年人

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Trends in clinical and economic outcomes of coronary angioplasty from 1992 to 1995: A population-based analysis

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AMERICAN HEART JOURNAL 1999年第6期137卷 1012-1018页

作者： Cohen, EA Young, W Slaughter, PM Oh, P Naylor, CD Univ Toronto Sunnybrook Hlth Sci Ctr Dept Med Div Cardiol Toronto ON M4N 3M5 Canada Inst Clin Evaluat Sci Toronto ON Canada

Background The impact of recent developments in coronary angioplasty on the brood spectrum of patients treated in routine practice is largely undefined. Analysis of population-based data can provide insight into trends in clinical outcomes and associated costs of coronary angioplasty procedures. Methods and Results With the use of a comprehensive hospital discharge database covering more than 11 million Canadians, we analyzed 12,748 first-time angioplasty procedures performed from 1992 to 1995 inclusive. Patient demographics and major adverse events were recorded. With the use of forward linkage, readmissions within 12 months were classified according to procedure performed and/or most responsible diagnosis, The proportion of patients readmitted, the number of readmissions per index procedure, and diagnosis-specific readmission costs were compared by calendar year. Over the 4-year study period, there was a 21% increase in the annual volume of index procedures. There were no statistically significant differences between 1992 and 1995 in sex distribution, mean age, comorbid conditions, length of stay, or need for coronary bypass surgery related to the index procedure. The all-cause readmission rate declined from 51.6% to 47.2% between 1992 and 1995 (P <.001), primarily because of a decline in the admission rate for repeat revascularization from 24.8% to 19.6% (P <.001). The 12-month readmission cost declined by $435 (1994 Canadian dollars) per patient. Conclusions The clinical outcomes of coronary angioplasty in a broad cohort of patients have improved in recent years. Although readmissions within year of an angioplasty procedure remain common, the number related to repeat revascularization has declined, with an associated decline in downstream costs.

关键词：队列研究费用效益分析医院费用/统计学和数值数据医院费用/发展趋势住院/经济学住院/统计学和数值数据住院/发展趋势安大略病人再入院/经济学病人再入院/统计学和数值数据病人再入院/发展趋势再治疗/经济学再治疗/统计学和数值数据再治疗/发展趋势支架/经济学支架/统计学和数值数据支架/发展趋势治疗结果人类中年人

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