Achieving self-sustainability of service delivery in an eye care program in Madagascar using time-driven activity based costing.

BACKGROUND: In the absence of adequate and reliable external funding, eye care programs in developing countries need a high level of financial self-sustainability for maintenance and growth. To cope with these cost pressures, an eye care program in Sava, Madagascar adopted a Time-Driven Activity Based Costing (TDABC) methodology to better manage the cost of, and to improve revenue associated with, their three principle activities: consultation visits, cataract operations, and sale of glasses. METHODS: Direct (variable) and indirect (fixed) cost estimates and revenue sources were gathered by activity (consultation, cataract operation, sale of glasses) and location (hospital or outreach) and TDABC models were established. Estimates were made of the proportion of the ophthalmologist's time (by far the scarcest and most expensive resource) dedicated to consultation, cataract operation, or sale of glasses. These proportions were used to attribute costs by activity. The hospital manager and medical director modified staff roles, program activities, and infrastructure investments to reduce costs and expand revenue sources by activity while monitoring activity specific efficiency and profit. RESULTS: The TDABC model for patient consultations showed that they were time consuming for the ophthalmologist and only resulted in net profit for the institution if the ophthalmologist converted most cataract patients into accepting surgery and refractive error patients into purchasing glasses from the hospital optical shop. The TDABC model for cataract surgery showed the programs needed to reduce the cost of imported consumable surgical products, reduce operation time, and, most importantly, reduce the number of very costly surgical camps providing essentially free surgery. In addition the model pushed the hospital to train staff in marketing skills so that a higher proportion of cataract cases come directly to the hospital willing to pay for surgery. The TDABC model provided the optical shop manager, for the first time, data on both the cost of supplies (frames and lenses) and the price of glasses sold resulting in strategies to maximize profit through preferential product presentation and customer experience. The eye program in the Sava region in northern Madagascar improved its cost recovery from 68 to 102% through patient revenue. CONCLUSIONS: TDABC models helped the Sava eye care program develop more efficient service delivery and increase revenue in excess of steadily increasing costs.

Costs of Planned Home vs. Hospital Birth in British Columbia Attended by Registered Midwives and Physicians.

BACKGROUND: Home birth is available to women in Canada who meet eligibility requirements for low risk status after assessment by regulated midwives. While UK researchers have reported lower costs associated with planned home birth, there have been no published studies of the costs of home versus hospital birth in Canada. METHODS: Costs for all women planning home birth with a regulated midwife in British Columbia, Canada were compared with those of all women who met eligibility requirements for home birth and were planning to deliver in hospital with a registered midwife, and with a sample of women of similar low risk status planning birth in the hospital with a physician. We calculated costs of physician service billings, midwifery fees, hospital in-patient costs, pharmaceuticals, home birth supplies, and transport. We compared costs among study groups using the Kruskall Wallis test for independent groups. RESULTS: In the first 28 days postpartum, we report a $2,338 average savings per birth among women planning home birth compared to hospital birth with a midwife and $2,541 compared to hospital birth planned with a physician. In longer term outcomes, similar reductions were observed, with cost savings per birth at $1,683 compared to the planned hospital birth with a midwife, and $1,100 compared to the physician group during the first eight weeks postpartum. During the first year of life, costs for infants of mothers planning home birth were reduced overall. Cost savings compared to planned hospital births with a midwife were $810 and with a physician $1,146. Costs were similarly reduced when findings were stratified by parity. CONCLUSIONS: Planned home birth in British Columbia with a registered midwife compared to planned hospital birth is less expensive for our health care system up to 8 weeks postpartum and to one year of age for the infant.

Effect of sociodemographic factors on surgical consultations and hip or knee replacements among patients with osteoarthritis in British Columbia, Canada.

OBJECTIVE: To quantify the effect of demographic variables and socioeconomic status (SES) on surgical consultation and total joint arthroplasty (TJA) rates among patients with osteoarthritis (OA), using population-based administrative data. METHODS: A cohort study was conducted in British Columbia using population data from 1991 to 2004. From April 1996 to March 1998, we documented 34,420 new patients with OA and these patients were followed to March 2004 for their first surgical consultation and TJA. Effects of age, sex, and SES were evaluated by Cox proportional hazards models after adjusting for comorbidities and pain medication used. RESULTS: During a mean 5.5-year followup period, 7475 patients with OA had their first surgical consultations and 2814 patients received TJA within a 6-year mean followup period. Crude hazards ratio (HR) for men compared to women was 1.25 (95% CI 1.20-1.31) for surgical consultation and was 1.14 (95% CI 1.06-1.23) for TJA. The interaction between sex and SES was significant. Stratified analysis showed among men an HR of 1.42 (95% CI 1.27-1.58) and 1.52 (95% CI 1.26-1.83) for surgical consultations and TJA, respectively, for the highest SES compared with the lowest SES quintiles. Similarly significant results were observed among women. CONCLUSION: Differential access to the healthcare system exists among patients with OA. Women with OA were less likely than men to see an orthopedic surgeon as well as to obtain TJA. Patients with higher SES consulted orthopedic surgeons more frequently and received more TJA than those with the lowest SES.

Cataract surgical outcome and predictors of outcome in Lumbini Zone and Chitwan District of Nepal.

PURPOSE: To evaluate visual acuity outcome from cataract surgery based on a population-based survey among people aged 50 years and older in Lumbini Zone and Chitwan District of Nepal. METHODS: A randomly selected, population-based cross sectional epidemiological study of blindness, visual impairment and cataract surgical outcome was conducted. All subjects underwent a comprehensive ocular examination by an ophthalmic assistant, while people with visual impairment (visual acuity less than 6/18) after refraction and all cataract surgical cases underwent dilated fundus examination by an ophthalmologist. RESULTS: 5,916 people were enumerated and 5,141 (86.9%) examined. Among the 359 people who had cataract surgery, 485 eyes were included in the study. First eye surgery was before 2000 in 84 (23%), between 2000 and 2003 in 130 (36%), and after 2003 in 145 (41%). A presenting visual acuity ≥ 6/18 was achieved in 298 (61.4%) eyes (10 [17.8%] and 288 [67.1%] of aphakic and pseudophakic eyes, respectively) and best corrected vision ≥ 6/18 in 411 (84.7%) in all eyes. A presenting visual acuity less than 6/60 was found in 27 (6.3%) pseudophakic eyes. There was no significant difference in visual outcome based on age, sex, literacy, or institution. Uncorrected refractive error was the main cause (72.9%) of visual impairment in pseudophakic eyes. CONCLUSIONS: Visual acuity outcome after cataract surgery requires further improvement to meet World Health Organization standards, particularly improvement in preoperative biometry and refractive services. The same quality cataract surgery was provided in and equitably distributed throughout Lumbini Zone and Chitwan District independent of age, sex, literacy or location.

Quantifying the association of radiographic osteoarthritis in knee or hip joints with other knees or hips: the Johnston County Osteoarthritis Project.

OBJECTIVE: To quantify the association of radiographic osteoarthritis (ROA) in one knee or hip joint with other knee or hip joints. METHODS: We analyzed baseline data from the Johnston County Osteoarthritis Project (n = 3068). We fit 4 models for left/right knee/hip. The Kellgren-Lawrence (KL) radiographic grade severity scale was KL 0/1 (no/questionable ROA), 2 (mild ROA), or 3/4 (moderate/severe ROA). We estimated associations between KL grade in contralateral joints and other joint sites (e.g., worst hip in knee models), adjusting for sex, race/ethnicity (African American/white), age, and measured body mass index, using cumulative odds logistic regression models. Interactions were investigated: race/ethnicity by sex; race/ethnicity and sex by the 2 explanatory variables. RESULTS: Contralateral joint KL grade was strongly associated with KL grade, with OR ranging from 9.2 (95% CI 7.1, 11.9) to 225.0 (95% CI 83.6, 605.7). In the left knee model, the contralateral joint association was stronger among African Americans than whites, but for the other models the associations by race/ethnicity were identical. Models examining other joint sites showed weaker but mostly statistically significant associations (OR 1.4 to 1.8). CONCLUSION: We found a strong multivariable-adjusted association between KL grades in contralateral knees and hips, and a modest association with the other joint site (e.g., knees vs hips). These results suggest that diagnosis of ROA in 1 large joint may be a marker for risk of multijoint ROA, and warrant interventions to reduce the incidence or severity of ROA at these other joints.

Trends in physician-diagnosed osteoarthritis incidence in an administrative database in British Columbia, Canada, 1996-1997 through 2003-2004.

OBJECTIVE: Prevalence of osteoarthritis (OA) is expected to increase due to population aging. However, there is little information on the trends in the incidence of OA over time. The purpose of this study was to describe changes in physician-diagnosed OA incidence rates between 1996-1997 and 2003-2004 in British Columbia (BC), Canada. METHODS: We used data on all visits to health professionals and hospital admissions covered by the Medical Services Plan of BC (population approximately 4 million) for the fiscal years 1991-1992 through 2003-2004. Rates were standardized to the BC population in 2000. We used 2 definitions of OA: 1) at least 1 visit or hospitalization with a diagnostic code for OA, and 2) at least 2 visits or 1 hospitalization with a code for OA. Incidence rates were calculated with a 5-year run-in period to exclude prevalent cases. RESULTS: Between 1996-1997 and 2003-2004, crude incidence rates of OA based on definition 1 increased from 10.5 to 12.2 per 1,000 in men and from 13.9 to 17.4 per 1,000 in women. The age-standardized rates did not change in men and increased from 14.7 to 16.7 per 1,000 in women. Incidence rates based on definition 2 were almost 50% lower, but the trends were similar. CONCLUSION: We observed an increase in the incidence of OA in both men and women due to population aging and an additional increase in women beyond the effect of aging. These trends have important implications for public health and provision of health services to this very large group of patients.

Effects of timing and duration of gestational exposure to serotonin reuptake inhibitor antidepressants: population-based study.

BACKGROUND: Late-gestational serotonin reuptake inhibitor (SRI) exposure has been linked to adverse neonatal outcomes; however, the impact of timing and duration of exposure is unknown. AIMS: To determine whether late-gestational exposure to an SRI is associated with increased risk of adverse neonatal outcome relative to early exposure. METHOD: Population-based maternal and neonatal health records were linked to prenatal maternal prescription records for an SRI medication (n=3500). RESULTS: After controlling for maternal illness and duration of exposure, using propensity score matching, neonatal outcomes did not differ between late and early exposure (P>0.05). After controlling for maternal illness, longer prenatal exposure increased the risks of lower birth weight, respiratory distress and reduced gestational age (P<0.05). CONCLUSIONS: Using population health data, length of gestational SRI exposure, rather than timing, increased the risk for neonatal respiratory distress, lower birth weight and reduced gestational age, even when controlling for maternal illness and medication dose. These findings highlight the importance of distinguishing the specific impact of medication exposure from exposure to maternal illness itself.

Major congenital malformations following prenatal exposure to serotonin reuptake inhibitors and benzodiazepines using population-based health data.

BACKGROUND: To determine a population-based incidence of congenital anomalies following prenatal exposure to serotonin reuptake inhibitor (SRI) antidepressants used alone and in combination with a benzodiazepines (BZ). METHODS: Population health data, maternal health, and prenatal prescription records were linked to neonatal records, representing all live births (British Columbia, Canada, N=119,547) during a 39-month period (1998-2001). The incidence and risk differences (RD) for major congenital anomalies (CA) and congenital heart disease (CHD), including ventricular and atrial septal defects (VSD, ASD), from infants of mothers treated with an SRI alone, a benzodiazepine (BZ) alone, or SRI+BZ in combinationcompared to outcomesno exposure. RESULTS: Risk for a CA or CHD did increase following combined SRI+BZ exposure compared with no exposure. However, using a weighted regression model, controlling for maternal illness characteristics, combination therapy risk remained significantly associated only with CHD. The risk for an ASD was higher following SRI monotherapy compared with no exposure, after adjustment for maternal covariates. Dose/day was not associated with increased risk. CONCLUSIONS: Infants exposed to prenatal SRIs in combination with BZs had a higher a incidence of CHD compared to no exposure, even after controlling for maternal illness characteristics. SRI monotherapy was not associated with an increased risk for major CA, but was associated with an increased incidence of ASD. Risk was not associated with first trimester medication dose/day.

Nurse anaesthetic care during cataract surgery: a comparative quality assurance study.

BACKGROUND: We studied whether a new model of nurse-provision of conscious sedation for cataract surgery maintained patient satisfaction and safety. METHODS: We prospectively and non-randomly studied 106 patients who had outpatient cataract surgery on a day when an anaesthetist was present at the UBC, Vancouver Hospital Eye Care Centre, and 105 patients with no anaesthetist, but instead a surgical suite nurse trained to give conscious sedation was present. Questionnaires determined patient perception of well-being, pain, and anxiety before surgery, before discharge, at 48 hours and at 6 weeks postoperative. Hospital records and a surgeon questionnaire were used to determine complications. Ophthalmology records were used to determine visual acuity (preoperative and at 6 weeks). RESULTS: No anaesthetic complications were reported in either group and there were no significant differences in surgical complications. Patient responses to assessments of discomfort, well-being, and anxiety, preoperatively and postoperatively, were very similar on the nurse days and anaesthetist days. INTERPRETATION: Conscious sedation of cataract surgery patients can be safely and effectively provided by a trained nurse for selected patients. This nursing role is likely replicable in similar operating room settings.

Descriptive epidemiology of osteoarthritis in British Columbia, Canada.

OBJECTIVE: Osteoarthritis (OA) is a highly prevalent and often disabling disease. Data on the incidence of OA in the general population are limited. Our objectives were (1) to estimate OA prevalence and incidence rates by age and sex in a geographically defined population of 4 million people [British Columbia (BC), Canada] using an administrative database; and (2) to determine the effects of different administrative definitions of OA and observation (run-in) time on such estimates. METHODS: We used data on all visits to health professionals and hospital admissions covered by the Medical Services Plan (MSP) of BC for the fiscal years 1991-92 through 2000-01. OA was defined based on International Classification of Diseases, 9th Revision, diagnostic codes required for administrative purposes. RESULTS: The overall prevalence of OA in 2001 was 10.8%: 8.9% in men and 12.6% in women. Prevalence was higher in women in all age groups. By age 70-74 years, about one-third of men and 40% of women had OA. Incidence rates in 2000-01 were 11.7 per 1000 person-years in the total population, 10.0 in men and 13.4 in women. Rates increased linearly with age between 50 and 80 years. Both prevalence and incidence depended strongly on the definition of OA and the run-in period. CONCLUSION: Prevalence of physician-diagnosed OA in BC was slightly lower than self-reported prevalence of arthritis in population surveys. Routinely collected administrative data could be a valuable source of information for OA surveillance, but more research is needed on the validity of OA diagnosis in administrative databases.

Neonatal outcomes after prenatal exposure to selective serotonin reuptake inhibitor antidepressants and maternal depression using population-based linked health data.

CONTEXT: Prenatal exposure to selective serotonin reuptake inhibitor (SSRI) antidepressants and maternal depression both alter neonatal health, and distinguishing the effects of each influence remains challenging. OBJECTIVE: To determine whether exposure to SSRIs and depression differs from exposure to maternal depression alone. DESIGN: Using population health data, records of neonatal birth outcomes were linked to records of maternal health and prenatal maternal prescriptions for SSRIs. SETTING: Population of British Columbia, Canada. PARTICIPANTS: Mothers and their infants, representing all live births during a 39-month period (N = 119,547) (1998-2001). MAIN OUTCOME MEASURES: Outcomes from infants of depressed mothers treated with SSRIs (SE-D) were compared with outcomes from infants of depressed mothers not treated with medication (DE) and nonexposed controls. To control for maternal mental illness severity, propensity score matching was used to identify a comparison group of DE mothers who were similar to the SE-D mothers in characteristics in the year preceding and during pregnancy. RESULTS: Fourteen percent of mothers were diagnosed as having depression during their pregnancy, and the incidence of prenatal SSRI exposure increased from 2.3% to 5.0% during a 39-month period. Birth weight and gestational age for SE-D infants were significantly less than for DE infants, as was the proportion of infants born at less than 37 weeks (95% confidence interval [CI], -1 to -64, -0.25 to -0.45, and -0.009 to -0.04, respectively), although differences in the incidence of birth weight less than the 10th percentile for gestational age were not significant. An increased proportion of SE-D infants had neonatal respiratory distress (13.9% vs 7.8%), jaundice (9.4% vs 7.5%), and feeding problems (3.9% vs 2.4%) compared with DE infants (95% CI of difference, 0.042-0.079, 0.003-0.334, and 0.005-0.025, respectively). When outcomes were compared between SE-D and propensity score-matched DE neonates, SE-D was associated with increased incidence of birth weight below the 10th percentile and rates of respiratory distress. CONCLUSION: With linked population health data and propensity score matching, prenatal SE-D exposure was associated with an increased risk of low birth weight and respiratory distress, even when maternal illness severity was accounted for.