Methods to estimate and analyze medical care resource use. An example from liver transplantation.

This paper describes a method to construct a standardized health care resource use database. Billing and clinical data were analyzed for 916 patients who received liver transplantations at three medical centers over a 4-year period. Data were checked for completeness by assessing whether each patient's bill included charges covering specified dates and for specific services, and for accuracy by comparing a sample of bills to medical records. Detailed services were matched to a standardized service list from one of the centers, and a single price list was applied. For certain services, clinical data were used to estimate service use or, if a match was not possible, adjusted charges for the services were used. Twenty-three patients were eliminated from the database because of incomplete resource use data. There was very good correspondence between bills and medical records, except for blood products. Direct matches to the standardized service list accounted for 69.3% of services overall; 9.4% of services could not be matched to the standardized service list and were thus adjusted for center and/or time period. Clinical data were used to estimate resource use for blood products, operating room time, and medications; these estimations accounted for 21.3% of services overall. A database can be constructed that allows comparison of standardized resource use and avoids biases due to accounting, geographic, or temporal factors. Clinical data are essential for the creation of such a database. The methods described are particularly useful in studies of the cost-effectiveness of medical technologies.

The relationship between hospital volume and outcomes of hepatic resection for hepatocellular carcinoma.

BACKGROUND: Volume-outcome relations have been established for several complex therapies. However, few studies have examined volume-outcome relations for high-risk procedures in general surgery, such as hepatectomy for hepatocellular carcinoma (HCC). OBJECTIVE: To evaluate the relation between hospital volume and outcome for patients undergoing hepatectomy for HCC. DESIGN: Retrospective cohort study. SETTING: All acute-care hospitals in California. PATIENTS: Hospital discharge data were analyzed for each patient in California who underwent major hepatic resection for HCC from January 1, 1990, through December 31, 1994. Hospitals were grouped according to number of hepatectomies performed at each center during the 5-year study. MAIN OUTCOME MEASURES: Outcome measures included operative mortality and length of hospital stay. Regression analyses were used to adjust for differences in patient mix. RESULTS: Five hundred seven patients underwent hepatectomy for HCC during the study. Hepatic resections were performed in 138 hospitals, with an overall in-hospital mortality rate of 14.8%. Three quarters of patients were treated at hospitals that average 3 or fewer hepatic resections for HCC per year. These low-volume providers represent 97.1% of all hospitals treating patients with HCC statewide. Significant reductions in risk-adjusted operative mortality rates (22.7%-9.4%; P = .002, multiple logistic regression) and risk-adjusted length of stay (14.3-11.3 days; P = .03, multiple linear regression) were observed as hospital volume increased. CONCLUSIONS: Low operative mortality and length of stay were associated with high-volume centers. These data support regionalization of high-risk procedures in general surgery, such as hepatectomy for HCC.

Epidemiology and prevention of periodontal disease in individuals with diabetes.

OBJECTIVE: This article reviews the epidemiological evidence of the relationship between diabetes and periodontal disease, possible physiological mechanisms for the association, and effects of interventions on the occurrence and severity of periodontal disease among individuals with diabetes. RESEARCH DESIGN AND METHODS: A comprehensive qualitative review of published literature in the area was performed. RESULTS: Much of the research in this area was found to contain methodological problems, such as failing to specify the type of diabetes, small sample sizes, and inadequate control of covariates such as age or duration of diabetes. CONCLUSIONS: Trends indicate that periodontal disease is more prevalent and more severe among individuals with diabetes. This trend may be modified by factors such as oral hygiene, duration of diabetes, age, and degree of metabolic control of diabetes. Generally, poor oral hygiene, a long history of diabetes, greater age, and poor metabolic control are associated with more severe periodontal disease. The association of diabetes and periodontal disease may be due to numerous physiological phenomena found in diabetes, such as impaired resistance, vascular changes, altered oral microflora, and abnormal collagen metabolism. With some modifications, the same prevention and treatment procedures for periodontal disease recommended for the general population are appropriate for those with diabetes. People with diabetes who appear to be particularly susceptible to periodontal disease include those who do not maintain good oral hygiene or good metabolic control of their diabetes, those with diabetes of long duration or with other complications of diabetes, and teenagers and pregnant women.

Is it worth it? Evaluating the economic impact of worksite health promotion.

In spite of the widely held belief that worksite health promotion programs lead to decreased health care costs, there has been little empirical evidence of this effect in the past. Because a primary reason for implementing these programs is the reduction of health care costs, this chapter focuses on research dealing with the economic impact of worksite programs. Guidelines for conducting evaluations are presented, and future trends in the organization and implementation of worksite health promotion programs are discussed.

Academic medicine as a public trust.

Academic medicine is entrusted by society with the responsibility to undertake several important social missions toward improving the health of the public, including education, patient care, and research. This trust is given implicit authority by generous public funding and considerable autonomy. Medical academia can take pride in its successes, manifested by a premier scientific establishment, the development and use of sophisticated medical technologies and drugs, and the recent dramatic declines in death rates from heart disease and stroke. Academic medicine, however, has been relatively unresponsive to a number of vexing public problems, including skyrocketing expenditures for medical care, substandard indexes of population health, uneven quality of care, an unfavorable geographic and specialty mix of physicians, and widespread disability from long-term medical and psychiatric problems. Although there are many cogent reasons why academic medicine has chosen to define its task relatively narrowly (the nature of its funding successes, the intractability of the social problems, and the attractiveness of the biomedical model), the central issue is how well academic medicine is fulfilling its responsibilities to the public. To the degree that academic medicine defines its central mission narrowly, it may violate its implicit social contract and jeopardize its primary source of financial support. Alternatively, in recognition of its public responsibilities, academic medicine can choose to expand its current activities to be more responsive to the health concerns of the general population.

Between patient and doctor. Improving the quality of care for serious mental illness.

The quality of care typically rendered to seriously mentally ill patients in this country does not reflect the extraordinary expansion and refinement in recent decades of scientifically based psychiatric diagnostic and therapeutic capacities. In this paper, the authors examine reasons for the disparity between the quality of the scientific base and the quality of care, citing recent historical influences and contemporary obstacles, and then propose strategies for change.

Lower-extremity amputation in people with diabetes. Epidemiology and prevention.

The age-adjusted rate of lower-extremity amputation (LEA) in the diabetic population is approximately 15 times that of the nondiabetic population. Over 50,000 LEAs were performed on individuals with diabetes in the United States in 1985. Among individuals with diabetes, peripheral neuropathy and peripheral vascular disease (PVD) are major predisposing factors for LEA. Lack of adequate foot care and infection are additional risk factors. Several large clinical centers have experienced a 44-85% reduction in the rate of amputations among individuals with diabetes after the implementation of improved foot-care programs. Programs to reduce amputations among people with diabetes in primary-care settings should identify those at high risk; clinically evaluate individuals to determine specific risk status; ensure appropriate preventive therapy, treatment for foot problems, and follow-up; provide patient education; and, when necessary, refer patients to specialists, including health-care professionals for diagnostic and therapeutic interventions and shoe fitters for proper footwear. Programs should monitor and evaluate their activities and outcomes. Many issues related to the etiology and prevention of LEAs require further research.

The use of in-hospital physician services for acute myocardial infarction. Changes in volume and complexity over time.

Changes between 1972 and 1982 in the use of in-hospital services were studied for 164 patients admitted with acute myocardial infarction. Resource use was measured in constant 1982 dollars adjusted for differences in clinical severity of the patients. Although average length of stay decreased by almost 40% during this period, the number of physician services doubled and total physician costs increased almost threefold. The increase in physician costs was due primarily to the use of complex diagnostic technologies and to the provision of coronary artery bypass graft surgery. The results of this study suggest that as hospital costs are constrained by prospective payment, physician costs may continue to rise as new diagnostic and therapeutic services are introduced into practice and as more care is shifted to the outpatient setting.

The changing dynamics of graduate medical education. Implications for decision-making.

Cost-containment pressures and changes in traditional patient-care patterns are altering the process of graduate medical education. A thorough understanding of this process is a prerequisite to implementing changes that preserve the function of graduate medical education. This report describes the structure of the graduate medical education system and analyzes possible responses to the changes that are affecting it. The decision-making process within academic health centers is described, including an assessment of the roles of hospital directors, deans and faculty, as well as external regulatory agencies such as residency review committees, medical specialty boards and state licensing agencies. The activities of these participants are analyzed within the framework of the teaching hospital's service and education functions, and potential conflicts are described and illustrated by recent examples. Understanding the complex structure and functions of graduate medical education is a first step toward responding effectively to a changing environment.

Association of volume with outcome of coronary artery bypass graft surgery. Scheduled vs nonscheduled operations.

Empirical evidence suggests that mortality rates for coronary artery bypass graft (CABG) surgery are lower in hospitals that perform a higher volume of the procedure. In recent years, the criteria for CABG surgery have been expanded to include patients with a wide variety of co-morbidities. To address the question of whether the volume-outcome relationship continues to exist for this new group of patients, discharge abstracts for 18,986 CABG operations at 77 hospitals in California in 1983 were analyzed using multiple-regression techniques. Higher-volume hospitals had lower in-hospital mortality (adjusted for case mix); this effect was greatest in patients who might be characterized as having "non-scheduled" CABG surgery. Higher-volume hospitals also had shorter average postoperative lengths of stay and fewer patients with extremely long stays. The results of this study suggest that the greatest improvement in average outcomes for CABG surgery would result from the closure of low-volume surgery units.

Episode-of-care physician payment: a study of coronary artery bypass graft surgery.

Paying physicians for an episode of care is a possible alternative to current fee-for-service payment. We studied physician billing patterns for 512 Medicare beneficiaries who received coronary artery bypass graft (CABG) surgery in 1983. Relatively elaborate decision rules had to be created to exclude services that were not part of a routine CABG. We found that 72% of charges for an episode were associated with services provided on the day of surgery. Forty-seven percent of charges were by the primary surgeon, 15% by the assistant surgeon(s), and 9% by the anesthesiologist. Our results suggest that episode-of-care payment is a complex, and somewhat costly, alternative to other methods of prospective payment to physicians, although selective contracting by a health insurer for an episode of care for certain procedures might both reduce costs and improve quality.

Residency training in internal medicine: time for a change?

Internal medicine residencies risk becoming obsolete if they are not adjusted to changing patterns of medical practice. Declining length of hospital stay, increased intensity of hospital care, movement of critical management decisions to outpatient settings, increased proportions of admissions for specific diagnostic procedures, and increased needs for perioperative consultations all erode the foundation of traditional internal medicine training. Furthermore, demographic shifts, the move to prepaid care, and a projected oversupply of subspecialists warrant more exposure to generalism and geriatrics. To prepare internists for clinical practice, some training should shift from medical wards and intensive care units to outpatient settings and surgical consultation, additional process skills must be taught, and the epidemiologically important non-internal-medicine disciplines should be included in the curriculum. These shifts will require changes in methods to pay for residency training, accreditation procedures for residency programs, and the residency certifying process. Most importantly, the model and organization of internal medicine training need to be reconsidered.

The role of changing clinical practices in the rising costs of hospital care.

To assess whether changes in clinical practice have contributed to rising hospital costs, we studied 2011 patients who were hospitalized at the University of California, San Francisco, in 1972, 1977, or 1982. For most of the 10 diagnoses studied, there was little change in total use of services by patients. In-hospital survival did not differ during the decade, and length of stay, numbers of special-care days, and use of laboratory services generally remained the same or declined. Only for patients with acute myocardial infarction did the use of imaging procedures increase substantially (e.g., cardiac catheterization was provided to 2 per cent of patients in 1977 and 40 per cent in 1982). Contrary to conventional wisdom, "little-ticket" procedures, such as laboratory tests, did not contribute to rising costs, and new imaging techniques were commonly substituted for older, more invasive procedures. The primary causes of rising costs were the provision of surgery to patients admitted for acute myocardial infarction, delivery, or respiratory distress syndrome of the newborn and the provision of other intensive treatments for the critically ill.

Factors associated with birthweight: an exploration of the roles of prenatal care and length of gestation.

To assess the association with birthweight of prenatal medical care, length of gestation, and other prenatal factors, birth certificate data were studied for babies born in 1978 to mothers who were residents of Alameda or Contra Costa counties, California. Using multiple regression data analytic techniques, adequate prenatal care (defined by the number of prenatal care visits compared to length of gestation and month of start of care) was found to be associated with an increase of 197 grams in average birthweight. This effect was even greater for Black infants and infants of short length of gestation. Adding length of gestation to the equation increased significantly the proportion of the variance in birthweight accounted for. For babies of short gestation (less than or equal to 280 days), the addition of length of gestation was associated with a halving of the association of prenatal care with birthweight. The results suggest that researchers need to take into account the nonlinear relationship between length of gestation and birthweight when assessing factors that affect birthweight.

The failure of physician education as a cost containment strategy. Report of a prospective controlled trial at a university hospital.

To test the hypothesis that physician education is an effective strategy to reduce total hospital costs, we evaluated three educational interventions at a large university hospital. This prospective controlled study spanned two academic years and involved 1,663 patients and 226 house staff. In the first year, weekly lectures on cost containment (medicine and surgery) and audit with feedback (medicine only) both failed to produce a significant change in total hospital charges. The "dose" of the intervention was increased on medicine in the second year by combining the lecture and audit strategies. Again, total charges did not change significantly. While decreased use occurred for certain selected services, the impact was not great enough to affect total hospital charges significantly. We conclude that, in the absence of other cost containing incentives, physician education alone is not an effective hospital cost containment strategy.

Changes in the use of medical technologies, 1972-1977: a study of 10 inpatient diagnoses.

To assess the degree to which use of hospital tests and procedures changed over a five-year period, we studied 1203 patients who were hospitalized at the University of California. San Francisco, in either 1972 or 1977 with one of 10 diagnoses: acute asthma, acute myocardial infarction, lung cancer, respiratory-distress syndrome of the newborn, cataract excision, cesarean section or vaginal delivery, kidney transplantation, stapedectomy, or total hip replacement. After careful adjustment for case severity, the total number of tests and procedures per hospital stay was found to be relatively unchanged over the five-year period for most but not all the diagnoses. However, the use of certain new diagnostic procedures (such as determination of arterial blood gases, ultrasonography, fetal monitoring, and radioisotope scanning) did increase significantly. Although generalization from these limited observations must be cautious, the data suggest that a "technology imperative" may apply more to the introduction of new technologies than to the expanding use of older, established tests and procedures. Effective cost-containment strategies must recognize the complexities of technology use among different diagnoses.

Outcome of irregularly discharged psychiatric patients.

Clinicians' attitudes about the posthospitalization outcome of patients who are irregularly discharged from the hospital (i.e., against medical advice or AWOL) have been pessimistic, but unsystematic follow-up data of such patients compared with regularly discharged patients suggest that outcomes for the two groups are similar. Because of this discrepancy, the authors used data from a controlled, systematic study of a large sample of voluntary inpatients that measured global outcome over 2 years. Their findings suggest that 1 year and 2 years after admission, most patients who were irregularly discharged had outcomes similar to those of patients with regular discharges. There was, however, a subgroup of irregularly discharged patients who had worse outcomes.