[CT scanners in the Brazilian Unified National Health System: installed capacity and utilization]. / Capacidade de produção e grau de utilização de tomógrafo computadorizado no Sistema Único de Saúde.

This study analyzes the supply and use of computed tomography scanners (CT) in the Brazilian Unified National Health System (SUS) according to State and administrative levels in the year 2009. Secondary data were used to estimate the installed CT capacity in public healthcare facilities and in private services outsourced by the SUS and calculated the rate of utilization. Average national CT utilization was less than 10%. The public sector showed lower CT use than the private sector outsourced by the SUS. The number of CT tests in the SUS was less than half the number produced in developed countries. The results thus suggest the need for further studies on management practices with high-technology equipment in order to improve allocation of current and future public resources in supplying CT tests.

[Pediatric intensive care in Latin America]. / Los cuidados intensivos pediátricos en Latinoamérica.

OBJECTIVE: To describe the practice of pediatric intensive care in Latin America and compare it with two European countries. DESIGN: Analysis of data presented by member countries of the Sociedad Latinoamericana de Cuidado Intensivo Pediátrico (SLACIP), Spain and Portugal, in the context of a Symposium of Spanish and Portuguese - speaking pediatric intensivists during the Fifth World Congress on Pediatric Intensive Care. SETTING: Pediatric intensive care units (PICUs). PARTICIPANTS: Pediatric intensivists in representation of each member country of the SLACIP, Spain and Portugal. INTERVENTIONS: None. VARIABLES OF INTEREST: Each country presented its data on child health, medical facilities for children, pediatric intensive care units, pediatric intensivists, certification procedures, equipment, morbidity, mortality, and issues requiring intervention in each participating country. RESULTS: Data from 11 countries was analyzed. Nine countries were from Latin America (Argentina, Colombia, Cuba, Chile, Ecuador, Honduras, México, Dominican Republic and Uruguay), and two from Europe (Spain and Portugal). Data from Bolivia and Guatemala were partially considered. Populational, institutional, and operative differences were identified. Mean PICU mortality was 13.29% in Latin America and 5% in the European countries (P=0.005). There was an inverse relationship between mortality and availability of pediatric intensive care units, pediatric intensivists, number of beds, and number of pediatric specialty centers. Financial and logistic limitations, as well as deficiencies in support disciplines, severity of diseases, malnutrition, late admissions, and inadequate initial treatments could be important contributors to mortality at least in some of these countries. CONCLUSION: There are important differences in population, morbidity and mortality in critically ill children among the participating countries. Mortality shows an inverse correlation to the availability of pediatric intensive care units, intensive care beds, pediatric intensivists, and pediatric subspecialty centers.

A prior authorization program of a radiology benefits management company and how it has affected utilization of advanced diagnostic imaging.

Radiology benefits management companies have evolved in recent years to meet the need to control the rapid growth in advanced diagnostic imaging. The Obama administration and other key policymakers have proposed using them as a cost-control mechanism, but little is known about how they operate or what results they have produced. The main tool they use is prior authorization. The authors describe the inner workings of the call center of one radiology benefits management company and how its prior authorization program seems to have slowed the growth in the utilization of MRI, CT, and PET in the large markets of one commercial payer.

The potential impact of comparative effectiveness research on U.S. health care expenditures.

Comparative effectiveness research (CER) has the potential to slow health care spending growth by focusing resources on health interventions that provide the most value. In this article, we discuss issues surrounding CER and its implementation and apply these methods to a salient clinical example: treatment of prostate cancer. Physicians have several options for treating patients recently diagnosed with localized disease, including removal of the prostate (radical prostatectomy), treatment with radioactive seeds (brachytherapy), radiation therapy (IMRT), or--if none of these are pursued--active surveillance. Using a commercial health insurance claims database and after adjustment for comorbid conditions, we estimate that the additional cost of treatment with radical prostatectomy is $7,300, while other alternatives are more expensive--$19,000 for brachytherapy and $46,900 for IMRT. However a review of the clinical literature uncovers no evidence that justifies the use of these more expensive approaches. These results imply that if patient management strategies were shifted to those supported by CER-based criteria, an estimated $1.7 to $3.0 billion (2009 present value) could be saved each year.

Medicine as ecoculture.

The use of diagnostic tests, especially imaging studies, varies markedly across the United States-with higher costs but no better patient outcomes associated with the highest-use regions. A proposed new model of the health care system draws on an analogy with the ecosystem to explain the geographic variations in physician test ordering. This framework emphasizes the adaptability and interdependence of the components of the system. Patients and physicians are influenced by the health care organizations in their community, including the practice site in which the physician works, local hospitals, malpractice lawyers, and imaging centers. These are in turn influenced by institutions in society at large, including the media, health care plans, and the government. Further adaptations to the explanatory model account for the psychologic and sociologic aspects of physician behavior. Understanding the medical ecoculture is essential for effective health care reform because widely touted changes, such as the introduction of an electronic medical record or comparative effectiveness studies, do not address the adaptability and interdependence that characterize the medical ecoculture.

Controlling the escalating use of advanced imaging: the role of radiology benefit management programs.

Since the late 1990s, the use of advanced diagnostic imaging modalities has increased by double-digit rates, outpacing the rate of increase of medical spending overall. In an attempt to assure the appropriate use of advanced imaging procedures, private insurers are increasingly contracting with radiology benefit management programs (RBMs) to reduce overall use and expenditures for radiology services. This article describes the services offered by RBMs and then presents trends in utilization of advanced imaging procedures from three health plans that adopted RBM prior authorization protocols. The implementation of prior authorization protocols by each plan was associated with declines in use of advanced imaging procedures, especially during the first year of the program. Although more rigorous empirical analysis is required in order to draw definitive conclusions, these trends suggest that RBM prior authorization initiatives may be a viable approach for addressing concerns about appropriate use of advanced imaging.

Does advanced medical technology encourage hospitalist use and their direct employment by hospitals?

In the United States, inpatient medical care increasingly encompasses the use of expensive medical technology and, at the same time, is coordinated and supervised more and more by a rapidly growing number of inpatient-dedicated physicians (hospitalists). In the production of inpatient care services, Hospitalist services can be viewed as complementary to sophisticated and expensive medical equipment in the provision of inpatient medical care. We investigate the causal relationship between a hospital's access to three types of sophisticated diagnostic and therapeutic medical equipment - intensity-modulated radiation therapy, gamma knife, and multi-slice computed tomography - and its likelihood of using hospitalists. To rule out omitted variables bias and reverse causality, we use technology-specific Certificate of Need regulation to predict technology use. We find a strong positive association, yet no causal link between access to medical technology and hospitalist use. We also study the choice of employment modality among hospitals that use hospitalists, and find that access to expensive medical technology reduces the hospital's propensity to employ hospitalists directly.

Catching the proton wave.

Proton therapy is hailed as a huge leap in treating certain cancers. But hospitals that want proton centers need deep pockets, lots of land and the right staff.

Use of technological equipment in critical care units: nurses' perceptions in Greece.

AIMS AND OBJECTIVES: The aim of this study was to determine the perceptions of nurses who work in critical care units about positive and negative effects related to the use of technological equipment and identify relationships between these perceptions and demographic characteristics of participants. BACKGROUND: Previous researchers have investigated the perceptions of nursing personnel about the effects of technology on clinical practice. However, most of them focus on specific negative effects. Positive and negative effects have never been studied as a whole. DESIGN: Critical care nurses were surveyed to elicit their perceptions regarding the use of technological equipment. The instrument comprised a 14-item questionnaire and a series of demographic characteristics. A five-point Likert scale was used for each of these 14 questions. METHODS: The questionnaire was administered to 122 nurses working at the four critical care units of a major academic hospital in Patras, Greece, from 1/10/2003 to 31/12/2003. The completion of the questionnaires was achieved by means of a personal interview. RESULTS: A total of 118 questionnaires were completed. The majority of nurses recognized the positive effects of equipment regarding patient care and clinical practice. At the same time, they agreed that use of equipment possibly leads to increased risk due to human errors or mechanical faults, increased stress and restricted autonomy of nursing personnel. CONCLUSIONS: The use of machines does not add to nursing prestige and this may be related to decreased autonomy. Human errors, mechanical faults and increased stress do not seem to come as a result of time constriction but rather of inadequate education. Undergraduate and continuing education should respond efficiently to the needs of contemporary critical care. RELEVANCE TO CLINICAL PRACTICE: Recognition of positive and negative effects of machines through the investigation of perceptions of nurses is the first step before looking for ways of maximizing advantages and facing disadvantages of equipment use.

Physicians perceived usefulness of high-cost diagnostic imaging studies: results of a referral study in a German medical quality network.

BACKGROUND: Medical and technological progress has led to increased numbers of diagnostic tests, some of them inducing high financial costs. In Germany, high-cost diagnostic imaging is performed by a medical specialist after referral by a general practitioner (GP) or specialist in primary care. The aim of this study was to evaluate the physicians' perceived usefulness of high-cost diagnostic imaging in patients with different clinical conditions. METHODS: Thirty-four GPs, one neurologist and one orthopaedic specialist in ambulatory care from a Medical Quality Network documented 234 referrals concerning 97 MRIs, 96 CTs-scan and 41 intracardiac catheters in a three month period. After having received the test results, they indicated if these were useful for diagnosis and treatment of the patient. RESULTS: The physicians' perceived usefulness of tests was lowest in suspected cerebral disease (40% of test results were seen as useful), cervical spine problems (64%) and unexplained abdominal complaints (67%). The perceived usefulness was highest in musculoskeletal symptoms (94%) and second best in cardiological diseases (82%). CONCLUSION: The perceived usefulness of high-cost diagnostic imaging was lower in unexplained complaints than in specific diseases. Interventions to improve the effectiveness and efficiency of test ordering should focus on clinical decision making in conditions where GPs perceived low usefulness.

Use of high-cost operative procedures by Medicare beneficiaries enrolled in for-profit and not-for-profit health plans.

BACKGROUND: It is widely believed that for-profit health plans are more likely than not-for-profit health plans to respond to financial incentives by restricting access to care, especially access to high-cost procedures. Until recently, data to address this question have been limited. METHODS: We tested the hypothesis that the rates of use of 12 common high-cost procedures would be lower in for-profit health plans than in not-for-profit plans. Using standardized Medicare HEDIS data on 3,726,065 Medicare beneficiaries 65 years of age or older who were enrolled in 254 health plans during 1997, we compared for-profit and not-for-profit plans with respect to rates of cardiac catheterization, coronary-artery bypass grafting, percutaneous transluminal coronary angioplasty, carotid endarterectomy, reduction of femur fracture, total hip replacement, total knee replacement, partial colectomy, open cholecystectomy, closed cholecystectomy, hysterectomy, and prostatectomy. We adjusted the comparisons for sociodemographic case mix and for characteristics of the health plans other than their tax status, including the plans' location. RESULTS: The rates of carotid endarterectomy, cardiac catheterization, coronary-artery bypass grafting, and percutaneous transluminal coronary angioplasty were higher in for-profit health plans than they were in not-for-profit health plans; the rates of use of other common costly operative procedures were similar in the two types of plan. After adjustment for enrollee case mix and other characteristics of the plans, the for-profit plans had significantly higher rates than the not-for-profit plans for 2 of the 12 procedures we studied and had lower rates for none. The geographic locations of the health plans did not explain these findings. CONCLUSIONS: Contrary to our expectations about the likely effects of financial incentives, the rates of use of high-cost operative procedures were not lower among beneficiaries enrolled in for-profit health plans than among those enrolled in not-for-profit health plans.

Why is high-tech healthcare at home purchasing underdeveloped and what could be done to improve it?

Executive Letter (95)5 initiated a change of health policy preventing general practitioners (GPs) from prescribing packages of "high-tech healthcare at home" (HTHC). From 1 April 1995, district health authorities were required to establish contracts to purchase such care. Several reasons were behind this policy change including the belief that contracting would improve service quality by encouraging competition between potential suppliers, securing better value for money, and establishing service specifications and monitoring mechanisms. Our survey of 98 health authorities, however, highlighted that contracting for home total parenteral nutrition, intravenous antibiotics for patients with cystic fibrosis, intravenous chemotherapy and continuous ambulatory peritoneal dialysis is largely undeveloped. The majority of districts contracted with historic providers and authorities freely admitted that they did not know whether they were obtaining value for money or a service of adequate quality. Only three districts had developed a strategy for purchasing HTHC as required by the Executive Letter, and only 17 had plans to re-examine their approach. Contracting for HTHC presents practical problems, including the complexity of the process and the significant time demands for efficient and effective contracting. Phase two of this research sought to produce a "guide to good practice" for health authorities wishing to re-examine and improve their purchasing. We conducted case study analyses in districts that had made effective progress and those that had encountered difficulties, drawing upon lessons learned. We reported our findings to the NHS Executive and supplemented this with a "toolbox" that included sample documents covering areas such as tendering, monitoring mechanisms, service specifications and different purchasing approaches.