https://www.amjmed.com/article/0002-9343(91)90367-7/pdf

Nosocomial infection rates in adult and pediatric intensive care units in the United States

Context. —Major teaching hospitals are perceived as being more expensive than other hospitals and, thus, unattractive to managed care. However, little empirical data exist about their relative quality and efficiency. The current study compared severity-adjusted mortality and length of stay (LOS) in teaching and nonteaching hospitals. Design. —Retrospective cohort study. Setting. —Thirty hospitals in northeast Ohio. Patients. —A total of 89 851 consecutive eligible patients discharged in 1991 through 1993 with myocardial infarction, congestive heart failure, obstructive airway disease, gastrointestinal hemorrhage, pneumonia, or stroke. Main Outcome Measures. —In-hospital mortality and LOS of patients in major teaching (n=5), minor teaching (n=6), and nonteaching (n=19) hospitals were adjusted for admission severity of illness using multivariable models based on demographic and clinical data abstracted from patients' medical records. Results. —The adjusted odds of death was 19% lower (95% confidence interval [CI], 2%-34%; P =.03) for patients in major teaching hospitals compared with nonteaching hospitals but was similar (95% CI, 7% lower to 28% higher; P =.28 for patients in minor teaching hospitals. The findings were generally consistent in analyses stratified according to diagnosis, age, race, predicted risk of death, and other covariates. In addition, risk-adjusted LOS was 9% lower (95% CI, 8%-10%; P P =.17) in minor teaching hospitals. Major teaching hospitals also cared for higher proportions of nonwhite and poorly insured patients. Conclusions. —Risk-adjusted mortality and LOS were lower for patients in major teaching hospitals than for patients in minor teaching and nonteaching hospitals. If generalizable to other regions, the results provide evidence that hospital performance, as assessed by 2 commonly used indicators, may be higher in major teaching hospitals. These findings are noteworthy at a time when the viability of many major teaching hospitals is threatened by powerful health care market forces and by potential changes in federal financing of graduate medical education.

Severity-Adjusted Mortality and Length of Stay in Teaching and Nonteaching Hospitals: Results of a Regional Study

We examined the influence of the regulation of hospital rates, state certificate-of-need programs, competition, and hospital ownership on mortality rates among inpatients receiving care under Medicare for 16 selected clinical conditions that were studied as a group. Data were obtained from the records of 214,839 patients who received care in 981 hospitals in 45 states from July 1, 1983, through June 30, 1984. We found significant associations between higher mortality rates among inpatients and the stringency of state programs to review hospital rates (P less than or equal to 0.05), the stringency of certificate-of-need legislation (P less than or equal to 0.01), and the intensity of competition in the marketplace, as measured by enrollment in health maintenance organizations (P less than or equal to 0.05). Hospitals in the states with the most stringent review procedures for hospital rates had ratios of actual to predicted death rates that were 6 to 10 percent higher than those of hospitals in states with less stringent rate-review programs (P less than or equal to 0.001). Hospitals in the states with the most stringent procedures for reviewing applications for certificates of need had ratios of actual to predicted death rates that were 5 to 6 percent higher than those of hospitals in states with less stringent certificate-of-need procedures (P less than or equal to 0.05). There was no statistically significant association between mortality rates among inpatients and either the type of hospital ownership or the number of hospitals competing in the market area. Additional analyses, which examined alternative explanations for these findings, failed to change the results. These findings raise serious concerns about the welfare of patients who are admitted to hospitals in highly regulated areas and those admitted to hospitals in relatively competitive markets. They suggest that it is important to incorporate quality-assurance procedures and systems to monitor patients' outcomes into public and private programs designed to contain costs or promote competition, or both.

The Effects of Regulation, Competition, and Ownership on Mortality Rates among Hospital Inpatients

Context.—Academic medical centers are under enormous pressure to improve quality
and cut costs while preserving education.Objective.—To determine whether a reorganized academic medical service, led by
faculty members who attended more often and became involved earlier and more
intensively in care, would lower costs without compromising quality and education.Design.—Alternate-day controlled trial.Setting.—Inpatient academic general medical service.Patients.—The 1623 patients discharged from the Moffitt-Long medical service between
July 1, 1995, and June 30, 1996.Interventions.—We divided our 4-team inpatient general medical service into 2 managed
care service (MCS) teams and 2 traditional service (TS) teams. The MCS faculty
served as attending physicians more often and were required to provide early
input into clinical decisions. Patients were assigned to teams based on alternate
days of admission.Main Outcome Measures.—Outcome measures included resource use and outcomes for MCS vs TS patients,
and for MCS patients vs patients seen the previous year, adjusted for demographic
characteristics and case mix. Satisfaction of patients, house staff, and faculty
was also assessed, as was educational emphasis.Results.—A total of 806 patients were admitted to the MCS and 817 to the TS.
Demographic characteristics and case mix were similar. Clinical outcomes,
including mortality and readmission rates, were also similar, as was patient
satisfaction. Resident and faculty satisfaction were high on both services.
The average adjusted length of stay of patients on the MCS was 4.3 days vs
4.9 days on the TS and 5 days in 1994-1995 (adjusted P=.01
for MCS vs TS; MCS vs 1994-1995, P<.001). Average
adjusted hospital costs were $7007 on the MCS vs $7777 on the TS and $8078
in 1994-1995 (adjusted P=.05 for MCS vs TS; MCS vs
1994-1995, P=.002).Conclusions.—A reorganized academic medical service, led by faculty members who attended
more often and became involved earlier and more intensively, resulted in significant
resource savings with no changes in clinical outcomes or patient, faculty,
and house staff satisfaction.

Reorganizing an Academic Medical Service: Impact on Cost, Quality, Patient Satisfaction, and Education

The authors describe the development, reliability testing, and validation of a 17-item instrument that measures the level of functioning of chronically mentally ill persons living in the community The Multnomah Community Ability Scale is designed to be completed by case managers The instrument provides a measure of the consumer's severity of disability which can, in turn, be used to: (a) describe an agency's "case mix" of clients; (b) measure consumer progress; (c) assign clients to different levels of service; and (d) assist payors in determining reimbursement The Multnomah Community Ability Scale is aimed specifically at persons with chronic mental illness, is sensitive to differences among individuals within this special population, and is quick and easy to complete The scale's reliability and validity have been examined in detail Inter-rater and test-retest reliability are good Criterion variables such as length of psychiatric hospitalization and clinicians' global ratings correlated highly with scale scores Finally, the instrument predicts subsequent state and local hospital admissions

A community ability scale for chronically mentally ill consumers: Part I. Reliability and validity.

We evaluated the ability of the diagnosis-related-group (DRG) classification system to account adequately for severity of illness and, by implication, for the costs of medical care. Hospital inpatients on medicine, surgery, obstetrics/gynecology, and pediatrics services in six hospitals were evaluated to provide a spectrum of patient and hospital characteristics. This evaluation was based on data from a generic index of severity of illness obtained by trained personnel from a review of hospital charts after patient discharge. Within each DRG, substantial differences were found in the distribution of severity of illness in different hospitals. Some hospitals treated larger proportions of severely ill patients and had a wide range of severity within each DRG, but these differences did not always agree with the teaching classification or the Health Care Financing Administration's case-mix index. These findings suggest that patient classification by means of unadjusted DRGs does not adequately reflect severity of illness, and they indicate that prospective payment programs based on DRGs alone may unfairly and adversely discriminate against certain hospitals.

Interhospital differences in severity of illness. Problems for prospective payment based on diagnosis-related groups (DRGs).

This study compares the financial impact of a Diagnosis Related Group (DRG) prospective payment system with that of a Severity of Illness-adjusted DRG prospective payment system. The data base of about 106,000 discharges is from 15 hospitals, all of which had a Health Care Financing Administration (HCFA) DRG case mix index greater than 1. In order to pool the data over the 15 hospitals, all charges were converted to costs, normalized to Fiscal Year 1983, and adjusted for medical education and wage levels. The findings showed that, for the study population as a whole, DRGs explained 28 per cent of the variability in resource use per case while Severity of Illness-adjusted DRGs explained 61 per cent of the variability in resource use per case. When we simulated prospective payment systems based on DRGs and on Severity-adjusted DRGs, we found that the financial impact of the two systems differed by very little in some hospitals and by as much as 35 per cent of total operating costs in other hospitals. Thus, even with a data set that is relatively homogeneous (with respect to the HCFA DRG case mix index definition of hospitals), we found substantial inequities in payment when DRGs were not adjusted for Severity of Illness. These findings suggest that, with a more representative set of hospitals, the difference between unadjusted and Severity-adjusted DRG-based prospective payment could be greater than 35 per cent of a hospital's total operating costs.

https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.75.10.1195

Severity of illness within DRGs: impact on prospective payment.

This study was undertaken to determine if a measure of severity of illness for psychiatric patients, the Psychiatric Severity of Illness Index, could produce psychiatric case mix groups that are more homogeneous with respect to resource use than the diagnosis-related groups (DRGs). Psychiatric Severity of Illness data were collected on 1,672 cases in ten hospitals of various types. Of these cases, 1,418 had enough information in the medical record to be scored using the Psychiatric Severity Index, 1,173 of which were in MDC 19 (mental diseases and disorders). We found that four Psychiatric Severity of Illness groups explained between 34% and 50% of the variation in length of stay of the combined hospital data in MDC 19, whereas nine DRGs explained between 6% and 14%. DRGs subdivided by Psychiatric Severity of Illness groups explained between 40% and 54% of the variation in length of stay. The implications of these results for cross-hospital comparisons are discussed.

Psychiatric severity of illness. A case mix study.

The authors assess the ability of the Severity of Illness Index to explain variability of resource use within each DRG. The data came from 15 hospitals, all of which had a HCFA DRG case mix index greater than 1. The data set comprised approximately 106,000 discharges, for which discharge abstract da

Angela F. Chambers

Papers

Interhospital differences in severity of illness. Problems for prospective payment based on diagnosis-related groups (DRGs).

Severity of illness within DRGs: impact on prospective payment.

Psychiatric severity of illness. A case mix study.

Severity of illness within DRGs. Homogeneity study.