Regional grey matter shrinks in hypertensive individuals despite successful lowering of blood pressure.

The aim of the study was to determine whether the reduction in brain grey matter volume associated with hypertension persisted or was remediated among hypertensive patients newly treated over the course of a year. A total of 41 hypertensive patients were assessed over the course of a 1-year successful anti-hypertensive treatment. Brain areas identified previously in cross-sectional studies differing in volume between hypertensive and normotensive individuals were examined with a semi-automated measurement technique (automated labelling pathway). Volumes of grey matter regions were computed at baseline after a year of treatment and compared with archival data from normotensive individuals. Reductions in regional grey matter volume over the follow-up period were observed despite successful treatment of blood pressure (BP). The comparison group of older, but normotensive, individuals showed no significant changes over a year in the regions tested in the treated hypertensive group. These novel results suggest that essential hypertension is associated with regional grey matter shrinkage, and successful reduction of BP may not completely counter that trend.

The role of respiratory care practitioners in a changing healthcare system: emerging areas of clinical practice.

OBJECTIVE: To evaluate shifts in respiratory care practice in the context of changing healthcare system and market dynamics. STUDY DESIGN: Telephone survey, structured interview, and case studies. METHODS: We conducted a telephone survey of 471 respiratory care practitioners (RCPs), drawn from the membership database of the American Association for Respiratory Care. We also interviewed 10 employers of RCPs and conducted 2 in-depth case studies to supplement our survey results. We used several statistical techniques to analyze our data, including calculation of population-weighted descriptive statistics and multivariate regression models. RESULTS: Changes in the healthcare system have prompted RCPs to broaden their practice settings, skills, and responsibilities. Respiratory care practitioners are taking part in managed care-related activities, such as cost control and disease management. We found that the need for certain skills and responsibilities varies by practice setting. In our interviews, employers considered RCPs cost effective providers for certain services. CONCLUSIONS: The practice of respiratory care is evolving to meet the changing needs of the healthcare system. A key challenge is to ensure appropriate growth and development of the respiratory care profession, as well as the delivery of appropriate services under new care management settings and processes.

Outcomes and effectiveness research in the private sector.

Private-sector health care organizations increasingly tout the use of outcomes and effectiveness research in activities ranging from pharmaceutical research to insurance coverage determinations. The rapid development of this research raises important questions about the role of the Agency for Health Care Policy and Research (AHCPR) as the producer, funder, and champion of outcomes and effectiveness research. To address this issue, we reviewed the activities of pharmaceutical companies, insurers, managed care organizations, health information technology companies, and other private-sector actors in outcomes and effectiveness research. We found that it is being used in a focused way to promote business goals and other organizational objectives, particularly in the pharmaceutical, insurance, and managed care industries. We also found significant gaps in its application to important public health issues and virtually no overlap with prior federal activities in this area.

Health information systems and the role of state government.

State government entities have created a range of innovative electronic information systems to support their diverse and evolving roles in the health care system. Primary goals of these initiatives include improvement of traditional public health programs, meaningful oversight of providers, simplification of administrative procedures, and support of state purchasing decisions. We establish a taxonomy of state efforts, describing primary capabilities to (1) provide meaningful data to state decisionmakers; (2) disseminate information to purchasers and consumers; (3) coordinate and improve government services; (4) establish mechanisms for electronic transactions; and (5) support telemedicine services. Reductions in the costs of technology and use of the Internet have dramatically increased state capabilities in recent years. Both the successes and failures of existing programs offer important lessons for states that are initiating new electronic communication initiatives.

The anatomy of online information for physicians.

Online medical networked information (OMNI) is one of the newest and fastest growing types of information sources for physicians. The authors present an organizational framework for understanding the range of available OMNI sources and discuss the practical applications, strengths and limitations of online resources. Physicians can now gain access on line to a wealth of information relating to many aspects of clinical medicine and can consult interactively with colleagues on clinical and research questions. The limitations of networked online resources include lack of access, difficulty in navigating online systems and the potential for fraudulent use. Net-worked online systems are growing in popularity and may become integral to medical practice as barriers to efficient use are overcome.

A framework for cost-sharing policy analysis.

To assess the effect of cost sharing, a framework for describing and evaluating cost-sharing programmes was constructed, followed by a comprehensive search of the international literature on the subject. The results indicated that cost sharing carries many potential advantages, one of which includes increased consumer attention to healthcare costs. However, proper design of cost-sharing programmes is necessary to mitigate regressivity and other common problems associated with many current programmes. These findings should help policy makers to understand and anticipate the effects of cost sharing, and to create innovative benefit design solutions that are targeted to promote health system goals.

State involvement in medical technology assessment.

State governments are reevaluating their role in the assessment of medical technologies. This paper outlines a range of state technology assessment activities, highlighting programs in Minnesota, Oregon, and Washington, and discusses the issues associated with state government involvement. Clinically oriented activities on the state level can inform efforts to contain costs, educate consumers and providers, and facilitate local consensus on the appropriate uses of new and existing technologies. Although current programs are still in their infancy and their viability remains uncertain, the importance of technology assessment is growing as technology continues to fuel increasing costs. The future of state-level technology assessment may lie in collaborative ventures with other states, the federal government, or private industry.

How much does defensive medicine cost?

Many key health reform bills in the 103rd Congress include proposals to overhaul the medical malpractice system. One of the factors motivating such legislation is the practice of defensive medicine, or care that does not benefit the patient and is provided solely to avoid malpractice claims. Estimating the costs of defensive medicine is difficult because of the many conflicting and overlapping motivations facing physicians. Although our estimates delineate a wide range of potential savings, systemwide savings from aggressive malpractice reform could approach $41 billion over five years.

Health care expenditures for people with diabetes mellitus, 1992.

The purpose of this report is to estimate diabetes prevalence and annual health care costs for people with diabetes in 1992, compare average annual costs for diabetics and nondiabetics, and estimate the portion of total U.S. health care expenditures incurred by people with the disease. Data from the 1987 National Medical Expenditure Survey were used to estimate diabetes prevalence and health care expenditures for diabetics in 1992. Diabetics were identified based on self-reports of a physician diagnosis of diabetes, a history of taking diabetic medications, or an encounter with the health care system specifically related to diabetes. Identified diabetics were classified as confirmed if they had a history of taking diabetic medications, had a diabetes-specific encounter with the health care system, or purchased diabetic equipment. Estimates of diabetes prevalence and health care expenditures were calculated separately for identified and confirmed diabetics using the National Medical Expenditure Survey database. Total health care expenditures included costs associated with inpatient hospital care, outpatient hospital care, office visits to a physician or other provider, emergency room visits, home health care, prescription drugs, dental care, and durable medical equipment purchases. We estimate that percapita annual health care expenditures in 1992 were more than three times greater for diabetics ($9,493) than for nondiabetics ($2,604). Percapita expenditures for confirmed diabetics ($11,157) were more than four times greater than for nondiabetics. In 1992, diabetics constituted 4.5% of the U.S. population but accounted for 14.6% of total U.S. health care expenditures ($105 billion). Confirmed diabetics constituted 3.1% of the U.S. population but accounted for 11.9% of total U.S. health care expenditures ($85 billion). This study found that health care expenditures for people with diabetes constituted about one in seven health care dollars spent in 1992. Health care reform and insurers should take note of these findings and structure benefit packages to promote care likely to reduce the costs of caring for diabetics.

Eliminating waste and inefficiency can do little to contain costs.

This study estimates potential savings from eliminating waste and inefficiency in the acute care sector (hospital, physician, and pharmaceutical). Our analysis indicates that in the unlikely event that all potential savings are achieved between 1994 and 2000, the rise in costs would be reduced by about 1.5 percentage points annually. This would slow the real rise in costs from a projected rate of 6.5 percent to 5 percent annually. Covering the uninsured would partially offset these savings and bring the rise in costs to more than 5.5 percent annually. If our estimate of potential efficiency savings is in error by plus or minus 50 percent, the projected rise in costs would be altered by about one percentage point. We conclude that savings from eliminating inefficiency are likely to fall far short of the Clinton administration's cost containment goals.

The effects of aging and population growth on health care costs.

Aging and population growth both contribute importantly to the rise in health care costs. However, the percentage contribution of these factors declined between 1970 and 1990, and we expect a continued decline through 2005. Data indicate that the relative costs of treating patients age sixty-five and over grew more rapidly than did the costs of treating other patients. Sensitivity analyses indicate that regardless of whether these trends persist, the percentage contribution of aging and demography is likely to decline between 1990 and 2005. Application of our model through 2030 suggests that if current trends persist, aging will cause a major acceleration in the rise in costs.

Hospital cost containment in the 1980s. Hard lessons learned and prospects for the 1990s.

BACKGROUND: A key strategy used to contain hospital costs during the 1980s was to reduce the total number of admissions and average lengths of stay. We assessed the magnitude of the savings achieved, the effect of the reductions on the rate of increase in costs, and the prospects for future savings through reductions in the number of days patients spend in the hospital (inpatient days). METHODS: Using data from the American Hospital Association and the Health Care Financing Administration, we calculated the savings in the total number of inpatient days as the deviation from the historical increase in the number of inpatient days per year. We then estimated the real increase in costs that would have been observed if the reduction in the number of inpatient days had not occurred; we defined this value as the "underlying" rate of increase in costs. Finally, we compared the rates of increase in hospital reimbursement for Medicare beneficiaries and patients not covered by Medicare (non-Medicare patients). RESULTS: The total number of inpatient days per year decreased by 28 percent, in aggregate, between 1981 and 1988. The annual reduction was greatest in 1984 and 1985 and became progressively smaller in each subsequent year; by 1988 there was virtually no further reduction in the total number of inpatient days. The brief slowing of the increase in costs in the mid-1980s can be attributed entirely to the reduction in the number of inpatient days per year. The underlying rate of increase in costs was thus unaffected by efforts to contain spending. An increased number of outpatient visits partially offset the savings that resulted from the reduction in the number of inpatient days. This increase persisted even when the savings due to the lower number of inpatient days dwindled, and it virtually eliminated any dollar savings during the latter part of the 1980s. Between 1976 and 1982, Medicare spending on services provided by acute care hospitals rose by 9.2 percent per year in real terms, whereas non-Medicare expenditures rose by only 4.6 percent. This pattern has been reversed in recent years; in 1987-1988, Medicare spending rose by only 0.6 percent per year, whereas non-Medicare spending rose by 9 percent. CONCLUSIONS: Our findings suggest that the era of easy reductions in the number of inpatient days, with the associated attenuation of rising costs, is largely over. If further reductions in inpatient days are accompanied by an increase in the amount of ambulatory care similar to that during the past few years, the net savings will probably be negligible. Once the potential savings due to reductions in the number of inappropriate inpatient days has been exhausted, real hospital costs can be expected to rise, unless other effective measures to contain costs are implemented.

No evidence of an emerging physician surplus. An analysis of change in physicians' work load and income.

Analysis of physicians' work patterns and income between 1982 and 1987 provides strong evidence that the demand for physicians' services has risen at least as quickly as physician supply. Aggregate hours spent by US physicians who provide patient care rose by 21%, and aggregate real net income rose by more than 30% during a period in which the supply of physicians grew by only 16%. The aggregate number of visits rose by only 9%, indicating that the time spent per patient encounter rose sharply, presumably as a result of technological change and the increased complexity of care. Recently released data for 1988 are consistent with these trends. Our findings are inconsistent with the prediction by the Graduate Medical Education National Advisory Committee that there would be a large physician surplus by the year 1990. Moreover, if the upward trend in demand for physicians' services continues, as seems probable, a physician surplus should not develop in the foreseeable future. Only extensive rationing of beneficial services would be expected to alter this projection.