Background Management of severe malaria with limited resources requires comprehensive planning. Expected length of stay (LOS) and the factors influencing it are useful in the planning and optimisation of service delivery. Methods A secondary, competing-risk approach to survival analysis was performed for 1217 adult severe malaria patients from the South-East Asia Quinine Artesunate Malaria Trial. Results Twenty percent of patients died; 95.4% within 7 days compared to 70.3% of those who were discharged. Median time to discharge was 6 days. Compared to quinine, artesunate increased discharge incidence (subdistribution-Hazard ratio, 1.24; [95% confidence interval 1.09-1.40]; P = .001) and decreased incidence of death (0.60; [0.46-0.80]; P < .001). Low Glasgow coma scale (discharge, 1.08 [1.06-1.11], P < .001; death, 0.85 [0.82-0.89], P < .001), high blood urea-nitrogen (discharge, 0.99 [0.99-0.995], P < .001; death, 1.00 [1.00-1.01], P = .012), acidotic base-excess (discharge, 1.05 [1.03-1.06], P < .001; death, 0.90 [0.88-0.93], P < .001), and development of shock (discharge, 0.25 [0.13-0.47], P < .001; death, 2.14 [1.46-3.12], P < .001), or coma (discharge, 0.46 [0.32-0.65], P < .001; death, 2.30 [1.58-3.36], P < .001) decreased cumulative incidence of discharge and increased incidence of death. Conventional Kaplan-Meier survival analysis overestimated cumulative incidence compared to competing-risk model. Conclusions Clinical factors on admission and during hospitalisation influence LOS in severe malaria, presenting targets to improve health and service efficiency. Artesunate has the potential to increase LOS, which should be accounted for when planning services. In-hospital death is a competing risk for discharge; an important consideration in LOS models to reduce overestimation of risk and misrepresentation of associations.

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A Competing-Risk Approach for Modeling Length of Stay in Severe Malaria Patients in South-East Asia and the Implications for Planning of Hospital Services

This paper describes a methodology that demonstrates how specific types of patient/cost data can be used to construct a model that predicts the expected increase or decrease in costs associated with a change in patient load, expansion of an existing patient service department, closure of an existing patient service department, or installation of a specific patient service department. Data from a group of New York State hospitals are used to illustrate the development of the model's components that produce cost estimates. A computer-based model is used to demonstrate the methodology's application to a specific hospital. Additionally, a number of program runs that simulate the cost impact of patient load and/or service mix changes are presented. Finally, the methodology's potential management and regulatory applications are discussed.

A methodology for determining a hospital's expected costs for changes in patient load and service mix

I cambiamenti demografici ed epidemiologici in atto pongono seri interrogativi sulla tenuta dei principi posti a fondamento del Servizio Sanitario Nazionale (SSN) italiano e il prossimo decennio rappresenta un momentum critico per la tenuta del suo formato istituzionale. Le politiche di rimborsabilita possono rappresentare un rilevante strumento di policy per orientare i comportamenti di erogatori e pazienti. Oggi questo aspetto non sembra essere adeguatamente presidiato e il sistema di remunerazione adottato appare non piu coerente al contesto, miope e per lo piu orientato al breve periodo. Il contributo discute le prospettive di sviluppo delle politiche di rimborsabilita per il SSN in un’ottica di Value-Based Health Care (VBHC) ed enfatizza l’esistenza di gap da colmare e di punti di attenzione da non sottovalutare in fase applicativa. Propone altresi uno sviluppo teorico al modello fondante la logica VBHC. Allo stesso tempo, mostra come il sistema abbia gia in dote informazioni e, in parte, know-how adeguati per una graduale diffusione e implementazione di tecniche di misurazione e modelli di finanziamento che possano stimolare logiche di rimborsabilita centrate sul valore.

Approccio value-based e logiche di finanziamento: implicazioni per le politiche di rimborsabilità in sanità

As medical care delivery systems grow in complexity, the understanding of interaction between entities within the system becomes a key aspect in resource planning. The model presented in this paper is geared to aiding resource planning both at the community or regional level and at the medical facility level. At the regional level the problem is related to the elimination of duplication and the sharing of services. At the medical facility level the concern is the balancing of the supply and demand of services among the departments. The framework of the model is a directed graph with nodes representing the service entities and branches representing the interrelationships. At the regional level, entities are hospitals, clinics, and centralized supportive units, such as the data center or the central laboratory. At the medical center level, entities are generally departments within the facility. An iterative procedure is used to simulate the propagation effect of a change on all entities. The model at the medical center level, as implemented in a minicomputer system was applied to a real problem. The results strongly correlated with another, independent study.

Y C Wong

Papers

An input-output model for resources planning in a medical care system.