Economic evaluation of hysteroscopic endometrial ablation versus vaginal hysterectomy for menorrhagia.

OBJECTIVES: To estimate society's expenses and benefits of hysteroscopic endometrial ablation and vaginal hysterectomy for the treatment of women with menorrhagia. METHODS: Between June 1992 and July 1993, 40 women with menorrhagia underwent vaginal hysterectomy by five surgeons in one hospital. These patients were compared retrospectively with the first 40 patients having had endometrial ablation for menorrhagia during the same period by the senior author (GAV). The age, parity, weight of patients, and uterine size were similar in both groups. Measurable variables that would incur costs included surgical time, procedure time (anesthetist and resource use in operating room), length of hospital stay, convalescence (value of patient time), and indirect costs associated with subsequent surgical procedures. Measurable benefits included reduction in blood loss and complications, and effectiveness of procedure. RESULTS: The total cost per episode of care was estimated to be $5373 and $2279 (1995 Canadian dollars) for vaginal hysterectomy and hysteroscopic endometrial ablation, respectively, a mean savings of $3094. The benefits derived from both procedures were comparable. Vaginal hysterectomy eliminated bleeding in 100% of patients and had a complication rate of 41%. Endometrial ablation eliminated or improved bleeding in 90% of patients (amenorrhea 46%, hypomenorrhea 35%, eumenorrhea 9%, no significant change 10%), was associated with no complications, and resulted in 82% patient satisfaction. CONCLUSION: Endometrial ablation is 82% effective and 58% less expensive than vaginal hysterectomy for the treatment of women with menorrhagia.

Resource utilization groups (RUGs): defining chronic care, rehabilitation and nursing home case mix in Canada.

The two major purposes of this study were: (1) to evaluate Resource Utilization Groups (RUGs III) as a unified method for classifying all residential, chronic care and rehabilitation patients at the St. Joseph's Health Centre, London, and (2) to compare the potential funding implications of RUGs and other patient/resident classification systems. RUGs were used to classify a total of 336 patients/residents in residential, extended care, chronic care and rehabilitation beds at the Health Centre. Patients were also concurrently classified according to the Alberta Long Term Care Classification System and the Medicus Long Term Care System. Results show that RUGs provide relatively more credit for higher acuity patients than do the Alberta or Medicus systems. If used as a basis for funding, chronic care and rehabilitation hospitals would be entitled to more funding (relative to residential/nursing homes) under RUGs than under the other two patient classification mechanisms.

Funding in-hospital same-day surgery in Canada.

The significant advantage of replacing global (i.e., cost-based) ambulatory funding with the same dollar value of case mix (i.e., input-based) ambulatory funding is that the fundamental basis for funding has been altered. First of all, it is widely believed that case mix-based funding establishes even more compelling incentives for hospitals to control resource utilization and costs without reducing service volumes than global systems. Case mix also represents a more precise policy instrument for ministries of health because incentives (e.g., different funding rates for various types of day surgery) can easily be incorporated to direct the composition of services rather than merely limit total hospital day surgery expenditures, as is currently done. Using the hybrid global/case mix day surgery funding system described above, funding policies can be designed to control both total cost and case mix composition while at the same time introducing incentives toward increasing ambulatory services. Although historical funding inequities remain unrectified, further inequities as ambulatory surgery volumes or case mixes change can be avoided.

Evolutions in hospital funding in Canada.

Although global funding continues to be the principal method used for hospital reimbursement in Canada, a number of provincial ministries of health have recently introduced supplementary funding approaches. These initiatives aim to replace the mentality of "what you spend is what you get" with a funding system that is based on what hospitals produce. This article compares such initiatives in British Columbia, Alberta, and Ontario. Aspects examined include the hospital "product", cost determination, incentives, the definition of equity, the figure of merit for funding, population-based funding, and quality.

Principles for funding on a case mix basis: construction of case weights (RIWs).

The construct of Resource Intensity Weights (RIWs) contains implicit financial incentives if they are used for hospital funding purposes. This paper compares the RIW (funding) credit to the expected average per diem cost for each of the new subcategories (typicals, deaths, transfers, signouts and outliers) of Case Mix Groups (CMGs). RIW construction, and inherent incentives for a hospital to reduce costs or length of stay (LOS), differ significantly for each subcategory. At some point or points in a patient's LOS, when RIW credit equals case cost, RIWs are incentive neutral. However, it can also be demonstrated that RIW credit is not generally congruent with average costs on each day of a patient's stay. Financial incentives (both positive and negative) arise when RIW credit and costs differ. Only by being fully aware of these differences can hospitals determine how to respond to the introduction of case mix funding to maintain financial viability. Funding agencies, too, need to appreciate the sometimes subtle policy implications that come with the adoption of RIWs for funding purposes.

Weighting case mix groups: the fatal flaw in resource intensity weights.

Resource Intensity Weights (RIWs) for Case Mix Groups (CMGs) are calculated using American Diagnosis Related Group (DRG) weights and Canadian average-length-of-stay data. However, this calculation does not actually "Canadianize" DRG weights; it only serves to randomize them. This article demonstrates the lack of the all-important relationship between RIWs and CMG costs by using simplified graphical examples. Notwithstanding the deficiencies of RIWs, the concept of weighted CMGs is fundamentally sound. Accordingly, until MIS-level reporting is widely implemented and a sufficiently large and reliable domestic database has been accumulated, it may not be entirely inappropriate for Canadian health care institutions to use unadulterated American DRGs for case mix analysis and fiscal planning.

Determining productivity and unit costs in a bacteriology laboratory.

This paper describes in detail the process of identification of the "products" of a department of clinical microbiology, the determination of resource requirements, the identification of total resource costs and the calculation of unit costs in order to identify the items which can be regarded as profitable in relation to the OHIP fee scale, as well as those services whose true cost is not met by that scale. The process permits an assessment of the overall profitability of the entire division and provides data for judging the probable gains from contracting out services.

Determining productivity and unit costs in a bacteriology laboratory.

This paper describes in detail the process of identification of the "products" of a department of clinical microbiology, the determination of resource requirements, the identification of total resource costs and the calculation of unit costs in order to identify the items which can be regarded as profitable in relation to the OHIP fee scale, as well as those services whose true cost is not met by that scale. The process permits an assessment of the overall profitability of the entire division and provides data for judging the probable gains from contracting out services.

The metabolic and hormonal responses to glucose infusion in anaesthetized normal and diabetic dogs controlled by an artificial B-cell.

The metabolic response to glucose infusion in anaesthetized normal and pancreatectomized dogs has been assessed. Normoglycaemia was achieved in the diabetic dogs with an external artificial B-cell which administered insulin into the peripheral circulation. No differences were found in the levels of blood glucose, glucagon, lactate, pyruvate and plasma non-esterified fatty acids, either in the fasting state or in response to glucose infusion. However, compared to normal animals normoglycaemic diabetic dogs had significantly elevated circulating levels of insulin and alanine at all times. Fasting levels of the same hormones and metabolites were also measured in conscious dogs. Blood pyruvate levels were higher, and plasma non-esterified fatty acid levels lower, in the anaesthetized animals. There were also minor but consistent changes in blood glucose and plasma insulin while glucagon, lactate and alanine levels were unaffected by anaesthesia. In conclusion, controlled barbiturate anaesthesia has relatively minor effects on the metabolic and hormonal status of the dog. The metabolic and hormonal response to glucose infusion in pancreatectomized dogs treated with an artificial B-cell was almost entirely normalized, except for peripheral hyperinsulinaemia and hyperalaninaemia.

Blood glucose regulation using closed- and open-loop insulin delivery systems. II. Peripheral primed square wave infusions.

Glucose was infused into anaesthetized dogs before and after pancreatectomy. In the diabetics blood glucose was regulated first by closed-loop and then by open-loop insulin delivery schemes. Insulin requirements for the latter were determined by resolving the former into a sequence of 3 different infusion rates: during the baseline and recovery periods, basal insulin was delivered at 0.37 +/- 0.02 mU/kg/min, while during the 60 min glucose infusion (10 mg/kg/min) there was an 8 min infusion at 4.96 +/- 0.37 mU/kg/min and a 52 min component at 1.85 +/- 0.08 mU/kg/min. With the open-loop method under these highly standardized conditions glycaemia was similar to normal controls but IRI levels were significantly higher, 13.5 vs 8.0 microU/ml (p less than 0.05) in the baseline and recovery periods and 74 vs 25 microU/ml (p less than 0.05) during the glucose infusion. It was concluded that: constant normoglycaemia can be maintained in the basal state by a constant rate of peripheral insulin delivery but at rates resulting in peripheral hyperinsulinaemia; the glycaemic response to glucose infusion can be normalized by a two component waveform of insulin delivery; and the closed-loop method can serve as a useful guide in determining insulin requirements.

Blood glucose regulation using an open-loop insulin delivery system in pancreatectomized dogs given glucose infusions. I. Portal square waves.

This study characterizes the glycaemic and insulin responses of a group of 5 anaesthetized dogs to a portal glucose infusion of 10 mg/kg/min before and after pancreatectomy. Insulin was administered intraportally to the pancreatectomized dogs according to a simple preprogrammed waveform composed of a constant basal rate of 0.35 +/- 0.02 mU/kg/min which was increased to 2.00 mU/kg/min at the time of the 60 minute glucose challenge. When this square waveform was applied the glycaemic response was similar to that seen in the normal controls in the baseline and challenge periods. Blood glucose concentration differed significantly (p less than 0.05) only from 20 to 100 minutes after the end of the challenge when it was higher by 20 +/- 1 mg/dl. Insulin levels were not significantly different from controls. It may be concluded that normoglycaemia and normoinsulinaemia can be maintained by a simple constant rate of portal insulin delivery while the blood glucose response to a glucose infusion can be ostensibly normalized without hyperinsulinaemia simply by enhancing insulin delivery during the challenge. The feasibility of this approach implies that with further development of the preprogrammed waveforms and with a greater understanding of their characteristics portable insulin delivery systems may be realized which accomodate more physiological challenges. The portal route for insulin delivery may however be necessary if peripheral hyperinsulinism is inappropriate.