Value and impact of international hospital accreditation: a case study from Jordan.

We assessed the economic impact of Joint Commission International hospital accreditation on 5 structural and outcome hospital performance measures in Jordan. We conducted a 4-year retrospective study comparing 2 private accredited acute general hospitals with matched non-accredited hospitals, using difference-in-differences and adjusted covariance analyses to test the impact and value of accreditation on hospital performance measures. Of the 5 selected measures, 3 showed statistically significant effects (all improvements) associated with accreditation: reduction in return to intensive care unit (ICU) within 24 hours of ICU discharge; reduction in staff turnover; and completeness of medical records. The net impact of accreditation was a 1.2 percentage point reduction in patients who returned to the ICU, 12.8% reduction in annual staff turnover and 20.0% improvement in the completeness of medical records. Pooling both hospitals over 3 years, these improvements translated into total savings of US$ 593 000 in Jordan's health-care system.

Cost-effectiveness of clinical interventions for AIDS wasting.

Economic studies of HIV/AIDS interventions are important for providing cost-effective care. This paper presents a costeffectiveness study of a three-arm clinical trial conducted at Tufts University School of Medicine/New England Medical Center in Boston, Massachusetts that treated 50 patients with AIDS wasting from March 1998 through January 2001. This study compared the costs and impacts of a nutritional counseling intervention alone (NC arm), the nutrition intervention with oxandrolone (OX arm), and the nutrition intervention with progressive resistance training (PRTarm) for the treatment of AIDS wasting. The cost of each intervention was derived for both the three-month clinical trial and a six-month estimated community model (ECM), its projected adaptation to community-based medical care. The cost determination involved obtaining and multiplying unit economic costs and quantities expended of each resource within each study arm. The ECM average cost per client in the cost-effectiveness analysis incorporated both institutional and societal perspectives. The costeffectiveness analysis compared the cost of each intervention to its quality-adjusted life-year (QALY) gain (Zeckhauser and Shepard, 1976). From a societal perspective, for the NC arm, the cost per client totaled US dollars 983 for the actual and US dollars 596 under the ECM. For the OX arm, the cost per client totaled US dollars 3,772 for the actual study and US dollars 3,385 under the ECM. For the PRT arm, the cost per client totaled US dollars 3,189 for the actual study and US dollars 2,987 under the ECM. Under the societal perspective the cost per QALY was US dollars 55,000 (range: US dollars 51,000 to US dollars 83,000) for the NC arm, US dollars 151,000 (range: US dollars 149,000 to US dollars 171,000) for the OX arm, and US dollars 65,000 (range: US dollars 44,000 to US dollars 104,000) for the PRTarm. When using only an institutional perspective, the cost per QALY was US dollars 45,000 (range: US dollars 42,000-US dollars 64,000) for the NC arm, US dollars 147,000 (range: US dollars 147,000 to US dollars 163,000) for the OX arm, and US dollars 31,000 (US dollars 21,000 to US dollars 44,000) for the PRTarm. This paper shows that cost and cost-effectiveness analyses can be adapted to a community setting by combining information from community practice and costs with data from a randomized trial. Compared to other AIDS treatments, such as highly active antiretroviral therapies, all three interventions were affordable, but their cost-effectiveness was intermediate. Oxandrolone was the least cost effective of the interventions, even compared to nutrition alone, as it included similar or somewhat greater costs for less of an increase in quality of life. PRT was the most cost-effective treatment for AIDS wasting, particularly from an institutional perspective. Third party payers should consider coverage of PRT.

The impact of substance abuse treatment modality on birth weight and health care expenditures.

During the 1990s, substance abuse treatment programs were developed for pregnant women to help improve infant birth outcomes, reduce maternal drug dependency and promote positive lifestyle changes. This study compared the relative impact of five treatment modalities--residential, outpatient, residential/outpatient, methadone and detoxification-only--on infant birth weight and perinatal health care expenditures for a sample of 445 Medicaid-eligible pregnant women who received treatment in Massachusetts between 1992 and 1997. Costs and outcomes were measured using the Addiction Severity Index and data from birth certificates, substance abuse treatment records and Medicaid claims. Multiple regression was used to control for intake differences between the groups. Results showed a near linear relationship between birth weight and amount of treatment received. Women who received the most treatment (the residential/outpatient group) delivered infants who were 190 grams heavier than those who received the least treatment (the detoxification-only group) for an additional cost of $17,211. Outpatient programs were the most cost-effective option, increasing birth weight by 139 grams over detoxification-only for an investment of only $1,788 in additional health care and treatment costs. A second regression using five intermediate treatment outcomes--prenatal care, weight gain, relapse, tobacco use and infection--suggested that increases in birth weight were due primarily to improved nutrition and reduced drug use, behaviors which are perhaps more easily influenced in residential settings.

Substance abuse providers' assessment of the Massachusetts Behavioral Health Program: year 6.

Substance abuse providers surveyed after Year 6 of the Massachusetts Behavioral Health Plan reported better treatment outcomes and access than in previous years. The Massachusetts Behavioral Health Partnership's clinical practices helped to improve quality of care. Its review process was highly rated. Coordination of substance abuse and mental health services was favorable, but was unfavorable with primary care. Staffing and organizational changes are described. Comparisons of outpatient and detoxification providers' responses with previous mental health and substance abuse surveys are made.

Effects of a statewide carve out on spending and access to substance abuse treatment in Massachusetts, 1992 to 1996.

OBJECTIVE: We studied the first four years of the statewide carve out for Medicaid enrollees in Massachusetts to assess its effect on access and spending. DATA SOURCES/STUDY DESIGN: Using administrative data, we compared the state's fiscal years 1992 (the last year before the carve out) through 1996 (the final year of the state's first carve-out vendor, MHMA). We evaluated the effect on spending by converting expenditures to constant (1996) prices using the medical services component of the Consumer Price Index for Boston and standardizing directly for the changing proportion of Medicaid enrollees who were disabled. We measured access through the penetration rate (proportion of enrollees using at least one substance abuse treatment service in a year . PRINCIPAL FINDINGS: Overall this carve out reduced real adjusted spending per enrollee by 40 percent from 1992 to 1996. At the same time, access improved from 38 to 43 unduplicated users per 1,000 enrollees per year f rom 1992 to 1996, adjusted for changes in Medicaid eligibility. these savings were achieved by a shift in the type of 24-h our services (hospital, detox, and residential treatment ). In 1992, 87 percent of these services were provided in hospital compared to only 1 percent in 1996. the reductions were achieved within the first two years of the carve out and sustained, but not enhanced, in subsequent years. CONCLUSIONS: By arranging Medicaid reimbursement for lower levels of care and limiting use of the most expensive settings, managed care achieved substantial cost reductions over the first four years in Massachusetts.

The costs of crime and the benefits of substance abuse treatment for pregnant women.

Although many pregnant, drug-dependent women report extensive criminal justice involvement, few studies have examined reductions in crime as an outcome of substance abuse treatment programs for pregnant women. This is unfortunate, because maternal criminal involvement can have serious health and cost implications for the unborn child, the mother and society. Using the Addiction Severity Index, differences in pre- and posttreatment criminal involvement were measured for a sample of 439 pregnant women who entered publicly funded treatment programs in Massachusetts between 1992 and 1997. Accepted cost of illness methods were supplemented with information from the Bureau of Justice Statistics to estimate the costs and benefits of five treatment modalities: detoxification only (used as a minimal treatment comparison group), methadone only, residential only, outpatient only, and residential/outpatient combined. Projected to a year, the net benefits (avoided costs of crime net of treatment costs) ranged from US$32,772 for residential only to US$3,072 for detoxification. Although all five modalities paid for themselves by reducing criminal activities, multivariate regressions controlling for baseline differences between the groups showed that reductions in crime and related costs were significantly greater for women in the two residential programs. The study provides economic justification for the continuation and possible expansion of residential substance abuse treatment programs for criminally involved pregnant women.

Cost-effectiveness model for prevention of early childhood caries.

This study presents and illustrates a model that determines the cost-effectiveness of three successively more complete levels of preventive intervention (minimal, intermediate, and comprehensive) in treating dental caries in disadvantaged children up to 6 years of age. Using existing data on the costs of early childhood caries (ECC), the authors estimated the probable cost-effectiveness of each of the three preventive intervention levels by comparing treatment costs to prevention costs as applied to a typical low-income California child for five years. They found that, in general, prevention becomes cost-saving if at least 59 percent of carious lesions receive restorative treatment. Assuming an average restoration cost of $112 per surface, the model predicts cost savings of $66 to $73 in preventing a one-surface, carious lesion. Thus, all three levels of preventive intervention should be relatively cost-effective. Comprehensive intervention would provide the greatest oral health benefit; however, because more children would receive reparative care, overall program costs would rise even as per-child treatment costs decline.

Cost-effectiveness of substance abuse services. Implications for public policy.

Cost-effectiveness analysis, a technique for allocating resources, examines the relationship between the cost of providing treatment and resulting improvement in health measured in a single, numerical scale. In applying this concept to substance abuse services, the authors expressed effectiveness in terms of additional "abstinent years." To control for differences in clients across modalities, the authors used multivariate cost-effectiveness analysis, estimating results for a typical client at each of three alternative severity levels.

Continuing care for cocaine dependence: comprehensive 2-year outcomes.

This report presents 2-year outcome data from an outpatient continuing care study in which cocaine-dependent patients (N = 132) were randomly assigned to either standard group counseling (STND) or individualized relapse prevention (RP). Data on cocaine outcomes during the 6-month treatment phase of the study were presented in an earlier report (J. R. McKay, A. I. Alterman, J. S. Cacciola, M. R. Rutherford, & C. P. O'Brien, 1997). In the present report, a continuing care condition main effect was obtained on only 1 of 8 outcome variables examined. However, patients who endorsed a goal of absolute abstinence on entering continuing care had better cocaine use outcomes in RP than in STND, whereas the opposite was the case for those with less stringent abstinence goals. In addition, patients with current cocaine or alcohol dependence on entering continuing care who received RP had better cocaine use outcomes in Months 1-6 and better alcohol use outcomes in Months 13-24 than those in STND.

Assessment of the Massachusetts Medicaid managed Behavioral Health Program: year three.

This evaluation of the third year of the Massachusetts Medicaid managed Mental Health/Substance Abuse Program showed that overall utilization increased slightly and expenditures were nearly the same in FY1994 compared to FY1993; however, they were lower for disabled members. Providers believed that access to care, utilization, and quality of care were the same or better than a year earlier and that the clinical review process was improved. Client severity was higher. Aftercare planning improved but gaps in services persisted. Integration of care improved. Administrative and management problems continued. Lessons for similar, more recent initiatives are discussed.

Multivariate cost-effectiveness analysis: an application to optimizing ambulatory care for hypertension.

Cost-effectiveness analysis (CEA) is being used increasingly to allocate health resources efficiently. This paper develops an extension of CEA based on multivariate regression analysis and applies it to hypertension treatment. After assembling clinic and patient characteristics, outcomes, and costs for 2,439 randomly chosen patients in the 32 special hypertension clinics of the Department of Veterans Affairs (VA), we identified 19 significant predictors of cost and diastolic blood pressure (DBP) using multiple regression analysis. We classified these independent variables as "unambiguous" if a given change was associated with both lower cost and better DBP, or as "trade-off" variables if any change improving DBP entailed higher costs. The results suggest that fully implementing all unambiguous clinic changes would reduce costs by 33% while improving DBP. Multivariate CEA could help managed care companies and government programs with cost and outcome data to reduce costs and improve outcomes.

Mental health/substance abuse treatment in managed care: the Massachusetts Medicaid experience.

Massachusetts was the first state to introduce a statewide specialty mental health managed care plan for its Medicaid program. This study assesses the impact of this program on expenditures, access, and relative quality. Over a one-year period, expenditures were reduced by 22 percent below predicted levels without managed care, without any overall reduction in access or relative quality. Reduced lengths-of-stay, lower prices, and fewer inpatient admissions were the major factors. However, for one population segment--children and adolescents--readmission rates increased slightly, and providers for this group were less satisfied than they were before managed care was adopted. Less costly types of twenty-four-hour care were substituted for inpatient hospital care. This experience supports the usefulness of a managed care program for mental health and substance abuse services, and the applicability of such a program to high-risk populations.

Setting priorities for the Children's Vaccine Initiative: a cost-effectiveness approach.

To help the Children's Vaccine Initiative (CVI) achieve its goal of new and improved children's vaccines, we developed and applied a cost-effectiveness model to set priorities for vaccine development. The model measures the health benefits in additional Quality-Adjusted Life Years (QALYs) gained by the combined birth cohorts of all developing countries over an assumed useful life of a proposed vaccine (generally 10 years). It measures costs as the net cost of developing, procuring, and administering the vaccine to the same population and time frame compared to the status quo (the current vaccine, if any). It weights each dollar of in-kind allocation of the existing health infrastructure less heavily than a dollar cash outlay to purchase new vaccine to reflect severe constraints on foreign exchange and non-personnel costs. It expresses cost-effectiveness as the net cost per QALY. The model was applied to 13 candidate vaccines selected by the CVI for initial analysis on the basis of their near-term feasibility. The five most cost-effective improvements, each of which could generate a QALY inexpensively (below $25 per QALY), were an early-administration or an early two-dose measles vaccine, slow release tetanus toxoid (for women), improved typhoid vaccine, and hepatitis B combined with diphtheria-tetanus-pertussis vaccine.

Effectiveness and costs of veterans affairs hypertension clinics.

The effectiveness and costs of care for hypertension are examined in a stratified random sample of 3,087 patients from a network of 32 Veterans Affairs Hypertension Screening and Treatment Clinics (HSTP). During 2.5 years of follow-up, 66% and 88% of patients, respectively, had mean diastolic blood pressure (DBP) levels of 90 or 95 mm Hg or less; 73% remained fully in care; and the mean cost of ambulatory care per patient-year was $647 in 1989 dollars. Higher follow-up DBP levels were found in patients who were younger, had higher DBP levels, or were receiving medication on their first visits to a clinic, were receiving more intense treatment regimens at the beginning of the follow-up period, or had been under the care of the clinic for shorter periods. Patients who were more likely to remain in care were older, received more intense treatment regimens, had prior cardiovascular complications, or had been under the care of the clinic for a longer time. Higher annual costs were associated with higher entry DBP levels, shorter durations of care, more intense regimens, and prior cardiovascular complications. Overall, patient characteristics explained 13% of the variance in mean follow-up DBP, and 31% of variance in costs. Wide variations were found among clinics in clinical outcomes and costs. After controlling for differences in patient characteristics, clinic characteristics associated with better blood pressure control were more frequent clinic visits, shorter waiting times, more time spent in patient counseling, having therapists who had a single supervisor, and better staff satisfaction.(ABSTRACT TRUNCATED AT 250 WORDS)

Economic analysis of investment priorities for measles control.

An investment strategy in measles control should strike an appropriate balance among three areas: implementation of existing vaccination programs with existing technology, operations research to improve the use of existing technology, and vaccine development. As a benchmark, the existing Schwarz vaccine costs approximately $17 per DALY (disability-adjusted life year), already making it one of the most cost-effective health interventions in developing countries. National measles vaccination campaigns, such as Brazil's, are a promising extension of this technology. Operations research is indicated to study the organization of campaigns, supplying and delivering vitamin A to hospitalized children, and other issues. The development and application of an early one-dose measles vaccine would be particularly cost-effective ($5 per DALY), as it could avoid the costs to families and health institutions of the separate visit at 9 months now required for measles vaccination. All three areas present opportunities for cost-effective investments and deserve a place in an investment strategy.

Costo-eficacia de las estrategias de vacunación en servicios ordinarios y en campañas en el Ecuador / Cost-effectiveness of routine and campaing vaccination strategies in Ecuador

En julio de 1986 se realizó una encuesta domiciliaria nacional sobre cobertura de vacunación de 3 697 niños ecuatorianos, que brindó la oportunidad de realizar un análisis de costo-eficacia de (1) los servicios de vacunación ordinarios en establecimientos fijos (2) de las campañas de inmunización en masa. Una de las principales finalidades de las campañas fue complementar los servicios de vacunación ordinarios y acelerar las actividades de inmunización. Basándose en la encuesta de la cobertura, el Programa para la Reduccion de la Enfermedad Maternoinfantil (PREMI) y varias campañas anteriores aumentaron la proporción de niños menores de cinco años completamente vacunados de 43 a 64 por ciento. En un año, la campaña del PREMI se encargó de vacunar completamente a 11 por ciento de los niños menores de un año, 21 por ciento de los de 1 a 2 años y 13 por ciento de todos los menores de 5 años. La campaña también ayudó a completar el programa de vacunación cuando los niños eran todavía muy pequeños y estaban expuestos al máximo riesgo. El costo medio por dosis de vacuna (en $US de 1985) fue aproximadamente de $0,29 en los establecimientos fijos y de $0,83 en la campaña del PREMI. El total de los costos nacionales fue de $675 000 y de 1 665 000 en los servicios de vacunación ordinarios y en las campañas, respectivamente. El costo por niño completamente vacunado fue de $44,39 en los primeros y de $8,60 en las últimas. El costo de cada defunción evitada fue de unos $1 900 en los servicios de vacunación ordinarios, de $4 200 en la campaña del PREMI y de $3 200 en el programa combinado. A causa de las menores tasas de mortalidad del Ecuador, los costos por cada defunción evitada en ese país con ambas estrategias no son tan bajos como los observados en estudios pertinentes efectuados en Africa. Las campañas, pese a ser menos eficaces en función del costo que los servicios de vacunación ordinarios, mejoraron significativamente la cobertura de vacunación de los niños menores que no habían sido vacunados en los servicios ordinarios. Al comparar los costos por niño completamente vacunado en ambos servicios con los de programas similares en otros países, los resultados fueron favorables