Interpreting cost analyses of clinical interventions.

OBJECTIVE: In the present era of cost containment, physicians need reliable data about specific interventions. The objectives of this study were to assist practitioners in interpretation of economic analyses and estimation of their own costs of implementing recommended interventions. DATA SOURCES: MEDLINE search from 1966 through 1995 using the text words cost or expense and medical subject heading (MeSH) terms costs and cost analysis, cost control, cost of illness, cost savings, or cost-benefit analysis. STUDY SELECTION: The 4 eligibility criteria were clinical trial with random assignment; health care quality improvement intervention tested; effects measured on the process or outcome of care; and cost calculation mentioned in the report. DATA EXTRACTION: After independent abstraction and after consensus development, financial data were entered into a costing protocol to determine which costs related to the intervention were provided. DATA SYNTHESIS: Of 181 articles, 97 (53.6%) included actual numbers on the costs of the intervention. Of 97 articles analyzed, the most frequently reported cost figures were in the category of operating expenses (direct cost, 61.9%; labor, 42.3%; and supplies, 32.0%). General overhead was not presented in 91 (93.8%) of the 97 studies. Only 14 (14.4%) of the 97 studies mentioned start-up costs. The text word $ in the abstract and the most useful MeSH index term of cost-benefit analysis appeared with nearly equal frequency in the articles that included actual cost data (37.1 % vs 35.1%). Two thirds of articles indexed with the MeSH term cost control did not include cost figures. CONCLUSIONS: Statements regarding cost without substantiating data are made habitually in reports of clinical trials. In clinical trial reports presenting data on expenditures, start-up costs and general overhead are frequently disregarded. Practitioners can detect missing information by placing cost data in a standardized protocol. The costing protocol of this study can help bridge care delivery and economic analyses.

Managing care, incentives, and information: an exploratory look inside the "black box" of hospital efficiency.

OBJECTIVE: We sought to estimate the impact of individual dimensions of hospitals' managed care strategies on the cost per hospital discharge. STUDY SETTING/DATA SOURCES: Thirty-seven member hospitals of seven health systems in the Pacific, Rocky Mountain, and Southwest regions of the United States were studied. STUDY DESIGN: Separate cross-sectional regression analyses of 21,135 inpatient discharges were performed in 1991 and 23,262 discharges in 1992. The multivariate model was estimated with hospital cost per discharge as the dependent variable. Model robustness was checked by comparing regression results at the individual discharge level with those at the level of the hospital/clinical condition pair. DATA COLLECTION/EXTRACTION METHODS: Information on hospitals' managed care strategies was provided by mail and phone survey of key informants in 1991 and 1992. Other hospital characteristics were collected from AHA Annual Survey data, and discharge data from hospital abstracting systems. PRINCIPAL FINDINGS: The pooled discharge analysis indicated three dimensions of hospital managed care strategy that consistently related to lower costs per hospital discharge: the proportion of hospital revenues derived from per case or capitation payment, the hospital's mechanisms for sharing information on resource consumption with clinicians, and the use of formalized, systematic care coordination mechanisms. CONCLUSIONS: Three strategies appear to hold promise for enhancing the efficiency of inpatient resource use: (1) "fixed price" hospital payment incentives, (2) hospital approaches to sharing resource use information with clinicians, and (3) the application of formal care management mechanisms for specific clinical conditions.

Are reporting errors under PPS random or systematic?

This study examines how hospitals respond to the reimbursement and monitoring methods used under the Medicare Prospective Payment System. Under the reimbursement system, hospitals can follow several strategies to increase profit. The strategies examined here are: 1) providing inaccurate reports of diagnoses, and 2) unnecessarily admitting patients. Empirical evidence supports the contention that hospitals follow these strategies and that the extent to which they do differs across diagnoses. The results have implications for the form of monitoring done under the Prospective Payment System.

Acute portal hypertension after gastric administration of ethanol in the pig.

A single gastric administration of 15 ml/kg of 40% ethanol to anesthetized pigs resulted in an increased portal venous blood pressure which increased with increasing blood alcohol levels. For the first 2 h there was no significant alteration in liver blood flow, but 3 h after the administration of ethanol, when portal blood pressure reached its highest values, liver blood flow had decreased. This was probably caused by increased hepatic vascular resistance as shown in electron thin-section phase-contrast microscopy which at this time showed marked hepatocyte swelling, narrowing of the sinusoids and platelet aggregates in small portal branches.

Cytologic diagnosis of thyrotoxicosis.

In specimens obtained by fine needle thyroid puncture it is possible to define cytologic criteria of toxic goiter. This cytologic picture is compound but the authors describe marginal vacuolization and nuclear ring patterns in follicular wall fragments as fairly specific signs of thyroid hyperfunction. Thyroid puncture is hardly a measure of choice in the routine clinical evaluation of hyperthyrosis but some case histories demonstrate that due attention to the cytologic picture of toxic goiter is profitable also when the puncture was made with quite other indications.

Pronounced deficiency in T-cells and lymphocyte chromosomal aberrations in a patient with sarcoidosis, myelofibrosis and acute leukaemia following thorotrast angiography.

A patient exposed to thorotrast angiography developed sarcoidosis 21 years after the injection and myelofibrosis 13 years later. On the latter occasion an extreme deficiency in circulating lymphocytes forming rosettes with sheep erythrocytes (T-cells) was observed and a large fraction of the cells had chromosomal aberrations. Acute leukaemia developed 1 year later. The multiple clinical symptoms may be related to radiation-induced destruction of bone marrow tissue, mutations in haemopoietic cells and depression of cell-mediated immunity.

Lymphocyte locomotion III. ultrastructural studies of the lymphocyte traffic over the postcapillary venules of rat lymph nodes.

The direction of lymphocytes with amoeboid movement configuration (AMC) was evaluated by means of electron microscopy of ultrathin sections of post-capillary high-endothelium venules (HE-venules) from rat lymph nodes. Out of 104 lymphocytes, 68 lymphocytes appeared to be on their way towards the lumen of the HE-venule and 36 lymphocytes appeared to be moving away from the venular lumen at the moment of fixation. This difference, which was statistically significant (p=0.0024), is thought to reflect the relative size of the migration stream of lymphocytes at the moment of fixation.

Human auto-immune thyroiditis.

Focal or diffuse infiltration of lymphoid cells in auto-immune thyroiditis destroys the parenchyma. In the diffuse form (Hashimoto's disease), the clinical picture is characterized by fatigue and thyroid enlargement. The diagnosis is settled by cytology. All patients must be treated with thyroid hormones to avoid myxoedema. Loss of immunological tolerance and cytotoxic immune reactions is discussed.

Lymphocyte locomotion. I. The initiation, velocity, pattern, and path of locomotion in vitro.

The locomotive behaviour of human lymphocytes in coverslip preparations of clotted autoplasma was studied at +37 degrees C. Lymphocytes isolated from peripheral blood or from the tonsils did not move prior to membrane activation by means of incubation with phytohemagglutinin (PHA). After PHA stimulation the locomotion of 19 lymphocytes was analysed by time-lapse fliming. The locomotion was random, as evidenced by a median locomotive index of 0.64 (Q1-Q3 0.04-0.75) and comparatively slow, median velocity 15 mum/min (Q1-Q3 12-18). The locomotion of 5 other lymphocytes was studied at high magnification. It is suggested that the characteristic polarity of wandering lymphocytes, indicating the direction of movement, can be utilized in the analysis of the lymphocyte traffic in tissue sections of post-capillary high-endothelium venules.

Lymphocyte locomotion. II. The lymphocyte traffic over the post-capillary venules analysed by phase contrast microscopy of thin sections of rat lymph nodes.

Thin sections of lymph nodes from 14 rats were examined by phase contrast microscopy as regards direction of lymphoctes with amoeboid movement configuration (AMC) relative to the basement membrane of post-capillary high-endothelium venules (HE-cenules). Out of 118 lymphocytes with AMC, 82 appeared to be on theyr way into the venule from the lymph node parenchyma. This observation suggests that the lymphocyte traffic over the HE-venules is bi-directional, with the main migratory stream of lymphocytes from the lymph node parenchyma into the post-capillary venules.

Chromosome abnormalities identified by banding technique in a patient with acute myeloid leukaemia complicating Hodgkin's disease.

Chromosome analyses using the Giemsa banding technique were performed on bone marrow cells in a patient with the association of Hodgkin's disease and acute myeloid leukaemia. All cells had an abnormal karyotype showing an extra chromosome No. 14, loss of one chromosome No. 17 and gain of one chromosome No. 18. These abnormalities are in many respects similar to the karyotype changes of lymphoid cells in malignant lymphomas, suggesting a pathogenetic relationship between the two disorders.