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 clinic...
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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.
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 ...
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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.
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 conce...
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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.
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...
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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
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 r...
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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.
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 Re...
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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.
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 ...
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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.
Background: Recently, simple antibiotic use and cost indicators were developed for use in long-term care facilities. It was hypothesized that these indicators also may be applicable to the acute hospital setting. Meth...
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Background: Recently, simple antibiotic use and cost indicators were developed for use in long-term care facilities. It was hypothesized that these indicators also may be applicable to the acute hospital setting. Methods: For a 24-month period, data were collected quarterly on antibiotic use and cost indicators for 11 primary care physicians in a 40-bed rural hospital. Indicators included antimicrobial use ratio (AUR, ratio of the number of antibiotic days to the number of patient care days), cost per antibiotic day, and cost of antibiotics per patient care day. One-way analysis of variance and simple linear regression were used to analyze data. Results: Quinolones (oral plus parenteral) accounted for 26% of the total antibiotic days (N = 6020) followed by ceftriaxone (19%) and cefuroxime (11.8%;oral plus parenteral). Overall trends in antibiotic use and cost included a significant increase in quarterly AUR (R-2 = 0.78, P = .004) and cost per patient care day (R-2 = 0.82, P = .002) but no significant change in quarterly total antibiotic costs or cost per antibiotic day. Among physicians there was a significant difference in mean quarterly AUR (P < .001) and mean quarterly cost per patient care day (P < .001) but no significant difference in mean quarterly cost per antibiotic day. Variation in physician-specific cost per patient care day was best explained by variation in AUR (R-2 = 0.75, P < .001). Conclusions: Significant variation in simple antibiotic use and cost indicators was identified at a rural hospital from both the facility and physician perspective. Standardized methods for antibiotic use and cost monitoring, like the one described in this article, are required before the relationship between antibiotic use ana resistance can be fully understood.
This paper analyzes the distortion effects of the hospital pricing policies in China. To help maintain equitable access to hospital services, the Chinese government regulates prices of hospital services, and provides ...
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This paper analyzes the distortion effects of the hospital pricing policies in China. To help maintain equitable access to hospital services, the Chinese government regulates prices of hospital services, and provides subsidies to public hospitals. Comparing the regulated fees of selected hospital services with their average unit costs indicates that the average cost-recovery rate of the fees is only 50%, The fees for 90% of the services are less than their average unit costs, while the fees for the high-tech services exceed their costs, Moreover, the State Price Commission allowed a drug profit margin of 15-20% over the wholesale price. The distorted fee schedule affects the behaviour of hospitals. Empirical evidence revealed problems of violation of price regulations (charging a fee exceeding the regulated fee), over-provision of profitable high-tech services and over-prescription of drugs, The Chinese experience shows that low regulated fees cannot reduce the economic burden on patients, and that distorted medical fees can result in distorted service provision and low efficiency of medical resources, Strategies to correct for the price distortions are discussed.
Both its natural history and typical age at presentation make prostate cancer a disease for whose treatment the largest third-party payer is the U.S. taxpayer. Medicare payments for prostate cancer treatment were esti...
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Both its natural history and typical age at presentation make prostate cancer a disease for whose treatment the largest third-party payer is the U.S. taxpayer. Medicare payments for prostate cancer treatment were estimated to be $1.4 billion in 1994 (1). Therefore, the cost-effectiveness analysis by Bayoumi et al. (2) in this issue of the Journal, addressing three critical issues in advanced prostate cancer—medical versus surgical castration, the role of total androgen blockade with castration plus nonsteroidal antiandrogens, and the optimal timing of any of these—is timely and appropriate. Substantial attention has been directed at potential biases in the reporting and funding of cost-effectiveness analyses of pharmaceutical agents (3,4). Identifying such biases has been easier since de facto national standards were established by the 1996 U.S. Public Health Service's Panel on Cost-effectiveness in Health and Medicine (5). This report, commissioned by a federal agency (the Agency for Healthcare Research and Quality) at the request of the Health Care Finance Administration (Medicare), has an unusual potential bias: It assumes that the government's perspective is aligned with that of society—i.e., one that incorporates all costs and effects regardless of who incurs them. In this editorial, we highlight a variety of methods, concerns, and clinical issues within (not against) the cost-effectiveness paradigm. The costs and quality-of-life tradeoffs associated with the form of therapy intended to lower serum testosterone levels lead to completely different conclusions about the optimal form of therapy depending on one's perspective. The consensus is that medical and surgical castration is equally effective (or ineffective) at prolonging life and delaying disease-specific complications (6). From a societal and Medicare perspective, the obvious preferred strategy is orchiectomy based on lower cost. The current choice of 75% of U.S. men is to receive luteinizing hormone rel
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