Showing papers in "Medical Care in 1984"

Hospital efficiency measurement and evaluation. Empirical test of a new technique.

Abstract: A new technique for identifying inefficient hospitals, Data Envelopment Analysis (DEA), is field tested by application to a group of teaching hospitals. DEA is found to provide meaningful insights into the location and nature of hospital inefficiencies as judged by the opinion of a panel of hospital experts. DEA provides insights about hospital efficiency not available from the widely used efficiency evaluation techniques of ratio analysis and econometric-regression analysis. DEA is, therefore, suggested as a means to help identify and measure hospital inefficiency as a basis for directing management efforts toward increasing efficiency and reducing health care costs.

Does practice make perfect? Part I: The relation between hospital volume and outcomes for selected diagnostic categories.

Abstract: The effect of a greater volume of patients with similar conditions being treated at a hospital on the outcomes achieved is studied using a variety of categories of patients, 15 surgical and 2 medical, and involving 550,000 patients treated in over 1,200 nonfederal United States acute care hospitals. After demonstrating that there are significant differences in the outcomes of patients, taking into account patient health status, the authors examine the impact of being treated in a hospital with a high or low volume of similar patients. Strong and consistent evidence is found that high volume is associated with better outcomes for surgical patients, which supports regionalizing patient care by procedure. Two additional variables, relative difficulty of the procedure and risk level of the patients, are analyzed to determine whether they change the relationship between volume and outcome. Some evidence is found that low-volume hospitals are associated with the poorest outcome for low-risk surgical patients. The evidence for medical patients is weak and mixed. Possible alternative explanations for the observed findings for surgical and medical patients are discussed.

Describing health states. Methodologic issues in obtaining values for health states.

Abstract: In health status index construction quantitative values for different states of health are frequently obtained by presenting written descriptions to raters whose values are elicited using one or more methods. In this study the authors examined the influence of several aspects of this measurement pro

Does practice make perfect? Part II: The relation between volume and outcomes and other hospital characteristics.

Abstract: The effect of a greater volume of patients with similar conditions being treated at a hospital on the outcomes achieved is investigated for almost 500,000 selected surgical and medical patients treated in over 1,200 nonfederal United States hospitals. In Part I the authors found strong and consistent evidence for surgical patients that high volume is associated with better outcome; evidence for medical patients was mixed. In this paper the authors include other hospital variables related both to volume and outcome--hospital size, teaching status, and expenditures--to determine whether they mask the true relationship; still, strong and consistent evidence that greater volume produces better outcome was found for both surgical and medical patients. This relation was significant for low-, medium-, and high-risk patients. Among the hospital variations added, only size was consistently and strongly related to outcome; greater size was associated with poorer outcome after accounting for volume. The potential importance of the findings for reducing deaths and days in hospital on a national level is discussed. The evidence is strongly supportive of the need for policies that would promote greater regionalization of a given service, and not greater size, to obtain better quality outcome for patients treated.

Choosing the Correct Unit of Analysis in Medical Care Experiments

Abstract: The statistical methodology of health research experiments published in Lancet, the New England Journal of Medicine, and Medical Care between 1975 and 1980 for the presence or absence of an error of experimental design and analysis was examined. The error is the result of inappropriately using patie

The Validity of Self-reported Physician Utilization Measures

Abstract: Respondents' reports of outpatient medical care use in the preceeding year are compared with actual utilization. The authors examine the predictors of the discrepancy between reported and actual utilizaton as well as the extent to which reporting error biases models of utilization behavior. The aver

Improving physician performance through peer comparison feedback.

Abstract: A project to improve physician performance in colorectal cancer screening was evaluated as part of an ambulatory quality assurance program. A minimum standard was adopted requiring a digital examination and stool test for occult blood at annual check-ups of patients aged 40 years and older. During a

Relating satisfaction with access to utilization of services.

Abstract: Underlying the continuing emphasis on access by health services researchers and policymakers is the assumption that patients having poorer access will receive less than appropriate health care, other things being equal. However, recent research results typically have not supported this assumption, and the nature and importance of relationships between access and use still remain unclear. Most published studies have sought to define general relationships that are descriptive of the behavior of all patients in a population facing access problems. The authors use interview data to show that significant relationships between satisfaction with access and use of services can be found if segments of the population, homogeneous in terms of age, sex, or other characteristics, are considered separately. This approach is based on the assumption that dissatisfaction with a particular dimension of access may be salient for some groups of patients but not others, and it is consistent with the view that patients' beliefs and perceptions are important determinants of health behavior.

Improving drug prescribing in a primary care practice.

Abstract: A model for improving physician prescribing that utilizes computerized feedback was studied in a family medicine residency practice. Resident and faculty physicians were stratified by level of experience and randomized into two groups. For 9 months the experimental group received monthly printouts i

Measuring the job satisfaction of physicians in organized settings.

Abstract: The accurate measurement of physician job satisfaction in organized practice settings is important for both policy and administrative purposes. Previous efforts to measure physician job satisfaction have been unsatisfactory because of either conceptual or methodologic weaknesses. New measures of phy

The costs of urinary incontinence in nursing homes.

Abstract: A simple model was used to calculate the contribution of urinary incontinence (UI) to the costs of nursing home care. First-order costs are defined as the costs of managing UI: supplies, laundry, and labor. Second-order costs are defined as the costs of managing the complications of UI. Data were gathered from nursing homes, medical supply companies, and a large laundry company. First-order costs of four common methods of managing UI range between $ 3.00 and $ 11.00 per incontinent patient per day. Based on these estimates, UI accounts for between $ 0.5 and $ 1.5 billion (3-8%) of the costs of nursing home care. Management of UI with indwelling catheters results in the lowest first-order costs, but the second-order costs (as well as the potential increased morbidity and mortality risks) probably outweigh any cost savings. More active evaluation and treatment of UI in nursing homes could result in considerable cost savings and improved well-being for both patients and caregivers.

The effect of a Medicaid drug copayment program on the utilization and cost of prescription services.

Abstract: The effect of a copayment for pharmaceutical services in a Medicaid program is presented. Data were collected from Medicaid claim files in South Carolina (experimental program) and Tennessee (control program) for a 4-year period, 1976-1979. Utilization rates and expenditures for 1 year prior to copayment and 3 years after copayment were computed from a stratified sample of 18 counties. Both the level of prescriptions per eligible recipient and the slope of the utilization function after copayment were found to have declined with the implementation of copayment in South Carolina. The level of the expenditure series after copayment also declined, but the series retained a positive trend. Subsequent analysis of prescription quantity concluded that the increasing expenditure function was attributed to the inflation in cost of ingredients rather than an increase in average prescription size. The study concluded that a small (50¢) copayment for prescription service is a successful mechanism to control the cost and assist in financing a Medicaid prescription drug program.

Utilization and costs of Medicare services by beneficiaries in their last year of life.

Abstract: This study examines Medicare utilization in the last year of life by over 10,000 beneficiaries who died in the state of Colorado in 1978. Overall, Medicare use averaged over $6,000 in 1978, compared with use by a random sample of survivors of less than $1,000. Eighty-nine percent of the charges during the last year of life were for services received in a hospital. Average charges vary by entitlement status, with the aged using, on the average, $5,955, the disabled $7,771, and end-stage renal disease (ESRD) beneficiaries an average of $44,400 in their last year. These charges are more than six times greater than yearly charges for aged and disabled survivors and more than three times greater than the yearly charges for ESRD survivors. The distributions of data for the groups who died is highly skewed, but not as skewed as that for the survivors. The top 1% of the survivors consumed 21% of the total charges, compared with less than 9% total charges consumed by the top 1% of those who died. When the data are examined by date of service divided into quarterly periods in the last year, more than 60% of the expenditures are in the last quarter just before death, with more hospital days and more intensive hospital ancillary service use during this period.

Development of scales to measure satisfaction and preferences regarding long-term and terminal care.

Abstract: This report describes efforts to develop and test scales for measuring attitudes toward the medical care of chronically and terminally ill patients and their families. The following satisfaction scales were developed: General Satisfaction, Availability of Care, Continuity of Care, Physician Availability, Physician Competence, Personal Qualities of Physician, Communication with Physician, Involvement of Patient and Family in Treatment Decisions, Freedom from Pain, and Pain Control. Preference scales were developed to measure preference for home care and preference for physician decisions. These scales were tested in two independent study samples: Home Care Study subjects--patients and their caretakers enrolled in a trial to evaluate a new method of home care for chronically and terminally ill homebound patients; and Terminal Care Study subjects--surviving relatives of a random sample of cancer patients who died. The internal consistency, discriminant validity, and convergent validity of each scale were assessed by means of item-total correlations, Cronbach 's alpha, and comparison with other questionnaire items. The results supported the use of several scales in their original form. Recommendations are made for appropriate modifications in the remaining scales.

Developing multiattribute health indexes.

Abstract: This article reviews the procedures for developing a multiattribute health index for use in population health studies and program evaluations. The development of such indexes involves two steps: 1) the creation of a multiattribute health state classification system; and 2) the mapping of the system into a single metric scale. The system must be relevant for its intended use and as concise as possible. Because a limit exists in the number of attributes that can be included in the system while maintaining reliable measurement, there may be a trade-off between specificity of detail and breadth of coverage. When mapping the system into a scale of cardinal values, five issues arise: 1) the selection of a scaling technique; 2) the use of mathematic models to quantify health; 3) the selection of anchor points; 4) the selection of raters; and 5) the identification of factors that influence raters' judgments. The article reviews the procedures that are used, discusses the issues that arise, and proposes some solutions for the development of multiattribute health indexes.

Cognitive predictors of compliance in chronic disease patients.

Abstract: Variables derived from the health locus of control construct and the Health Belief Model were used to predict compliance with medical regimen in chronically ill patients (adult-onset diabetics, hypertensives, and pulmonary disease patients) Stepwise multiple regression analyses were conducted with predictor variables: age, socioeconomic status, Internal Health Locus of Control (HLC), powerful others HLC, chance HLC, perceived severity of illness, outlook on illness, experienced symptoms, satisfaction with treatment, family support, and support of others Dependent variables included three measures of compliance with medication regimen and two measures of compliance with self-management regimen Patient satisfaction was a significant predictor of medication compliance, and lack of symptoms was most strongly associated with self-management compliance Limitations of cognitive variables in predicting compliance in many chronic disease patients are discussed

Use of a surrogate for the Sickness Impact Profile.

Abstract: The use of a surrogate Sickness Impact Profile (SIP) score was investigated in a sample of 66 chronically or terminally ill homebound patients and their caretakers. Statistically significant differences in category scores (P < 0.05) were found in only two categories. Profile analysis revealed no sys

DRGs in psychiatry. An empirical evaluation.

Abstract: On October 1, 1983, Medicare began paying general hospitals by a prospective payment system based on DRGs. Psychiatric settings are exempted automatically or by request. By January 1985, however, a decision is required on how to integrate psychiatric settings into this system. This article provides an empirical analysis of the current DHHS DRGs categories for mental disorders. Current mental disorder DRGs and alternate DRGs examined here explain less than 3-12% of the variation in psychiatric length of stay. This is in contrast to 30-50% explained variation for other disorders. Alternatives and policy implications are discussed.

Length-of-stay variations within ICDA-8 diagnosis-related groups.

Abstract: The number of bed days per inpatient episode, the length of stay (LOS), is a major indicator of hospital performance and a basic measure of patients' resource consumption. Hospital reimbursement on the basis of treated cases requires a system for accurately identifying case categories. Diagnosis Related Groups (DRGs) have been proposed for this purpose. An initial study to analyze variations in length of stay and resource consumption within DRGs is presented. Regression analysis of variation in ALOS for 7 DRGs, in terms of 8-10 independent variables not included in the classification scheme itself, was done. Results indicate that 30-65% of the large intra-DRG LOS variations are explainable by indicators of case complexity and severity despite the homogeneity claimed for the DRGs. For certain DRGs, such variations are also related to admission factors. Results indicate the need for more precise patient taxonomies than the ICDA-8-based DRGs.

Hospice home care cost savings to third-party insurers.

Abstract: A population-based, retrospective analysis of Medicare Part A and Blue Cross hospital insurance claims data was used to determine whether hospice home care cost savings to third-party insurers are substantial and result from the substitution of less expensive home care visits for more costly hospital inpatient days. The study was carried out by comparing the third-party payments of Cuyahoga County residents who died of cancer and were served by a hospice home care program (n = 152) with the insurance payments of cancer patients who never received hospice home care (n = 1,397). The data strongly supported the research hypothesis. The relative use of hospital days decreased more than 50% and the use of home care visits increased 10-fold when dying patients shifted from conventional care to hospice home care. This change in use represented a relative savings of about 40%, ranging from $1,089 per patient during the last 2 weeks of life to $2,676 per patient during the last 12 weeks of life. These results were not accounted for by group differences in age, type of cancer, or personal preference for home care.

Interspecialty variation in office-based care.

Abstract: Analysis of national survey data on physician-patient encounters raises questions about physician education and manpower policy. Data compiled by the University of Southern California Medical Activities and Manpower Projects and the United States Bureau of Health Professionals reveal differences among internists, cardiologists, family practitioners, and pediatricians in procedures used for diagnosing and treating several frequently encountered conditions. Differences are observed in expenditure of time and use of a broad range of diagnostic and therapeutic techniques. These differences remain significant even after several important characteristics of individual physicians, patients, and the practice environment have been controlled. Findings from this study underscore the necessity of reviewing the content of medical education and policies that encourage a broad range of specialists to provide primary care. The findings also emphasize the need to address the physician's knowledge base in promoting changes in practice patterns.

Knowledge of their health insurance coverage by the elderly.

Abstract: Current legislative proposals to increase competition among private insurers assume that people are or can be well-informed about their insurance coverage. Evidence from the National Medical Care Expenditure Survey shows that among the population 65 years of age and older knowledge about health insurance coverage is substantial but generally lower than in the population younger than 65 years of age. Multivariate analysis is used to identify factors associated with high and low levels of knowledge. Although correct knowledge of coverage of particular services is highly associated with current experience of health problems, with use of these health services, and with the cost for private insurance, overall knowledge is lowest among some groups at high risk of serious illness, in particular, the old, nonwhites, and persons enrolled in Medicare but without Medicaid or private insurance supplements.

The costs and effects of behavioral programs in chronic obstructive pulmonary disease.

Abstract: This paper uses a General Health Policy Model to determine the cost-effectiveness of an experimental behavioral program for patients with chronic obstructive pulmonary disease (COPD). Patients were randomly assigned to either experimental or control groups, and only those in the experimental groups were given the behavioral strategies. Health status information was collected over 18 months, and the Health Policy Model translated program outcomes into well-year equivalents. At the end of the program, greater improvements in health status were observed in the experimental subjects, and a total of 4.41 well-years were produced. Costs of the program were gathered on a per-year basis using an administrative perspective. Both costs and health effects were discounted to present value using a 5% discount rate. Dividing costs by effects, the COPD program produced well-years at a unit cost of $24,256. Comparing the cost-utility figure to those of other health care programs using the General Health Policy Model, the behavioral program appears reasonably cost-effective as an adjunct therapy for patients suffering from COPD.

Self-care. Substitute, supplement, or stimulus for formal medical care services?

Abstract: This article examines the relationship between selected self-care practices during an episode of illness and the use of formal medical care. Stimulated by conflicting evidence and assertions, the general question addressed is: "Is self-care a substitute, a supplement, or a stimulus for use of formal medical care services?" Multiple Classification Analysis was used in a secondary data analysis of a 1976 nationwide study on access to medical care. The results suggest that self-care users may visit the physician less often and stay fewer days in the hospital, and thus they are expected to have lower expenditures for hospital and physician services. Therefore, the self-care activities examined appear to be substitutes for, rather than supplements or stimuli to, health services utilization. The results must be viewed with some caution due to limitations in the data. However, the results also argue for a greater research emphasis on self-care.

Patterns of expenditures among high utilizers of medical care services. The experience of Medicare beneficiaries from 1974 to 1977.

Abstract: The authors of this study examine temporal patterns of medical expenditures by Medicare beneficiaries. A random sample of 204,917 individuals who were alive and in the program from 1974 to 1977 was investigated. Individuals hospitalized in 1974 were found to have twice the rate of hospitalization in 1975, 1976, or 1977 compared with individuals who were not hospitalized in 1974. The increased rate of hospitalization remained constant throughout the 3 years. Individuals with large medical expenditures in 1974 were 20 times more likely to have large medical expenditures the following year, and this rate declined slowly in the following 2 years. The results suggest that the value of a Medicare voucher or the level of Medicare's payment to health maintenance organizations should include an adjustment factor for prior health care utilization. The results also suggest that multiyear limits on total Medicare coinsurance and deductible payments would be more equitable than single-year limits.

Physician perception of patient satisfaction. Do doctors know which patients are satisfied

Abstract: The purpose of this study was to discover whether advanced family practice residents could accurately predict their patients' level of satisfaction with medical care. Overall, there was no significant relationship between actual patient satisfaction and physician perception of patient satisfaction, although 2 of 10 physicians did predict patient satisfaction with some precision. Further results showed no significant relationships between individual physician prediction of "typical" patient responses to a patient satisfaction questionnaire and actual patient responses to the same instrument. High-technology medicine and the traditional, passive patient role may both interfere with physicians' ability to make accurate assessments of patient response to care.

Continuity-of-care measures. An analytic and empirical comparison.

Abstract: The authors compared four different continuity-of-care measures recently suggested in the literature. First, an analytic comparison is made and useful inequalities are derived. Then the continuity indexes are applied to an extensive data material from a Swedish ambulatory care center. The four indexes give fairly similar results, and the basic finding is the substantially higher index values for elderly patients. Finally, computed index values are compared with what could be expected under a scheme of random assignment of patients to doctors.