Comparing uninsured and privately insured hospital patients: admission severity, health outcomes and resource use.

This paper compares uninsured hospital patients with privately insured patients in terms of severity of illness on admission, emergency department use, leaving the hospital against medical advice, length of stay, and in-hospital mortality and morbidity rates. This cross-sectional study includes 29,237 admissions to 100 US hospitals in 1993 and 1994. We found that uninsured patients are sicker, indicating that hospitals should expect uninsured patients to have increased service needs. Our results indicate that the uninsured exhibit higher likelihood of leaving against medical advice, shorter lengths of stay and poorer health outcomes suggest that the uninsured may not be receiving necessary care. Further studies are needed.

Linking health outcomes and resource efficiency for hospitalized patients: do physicians with low mortality and morbidity rates also have low resource expenditures?

This study addresses the question of whether physicians with better health outcomes for their patients spend more or less to accomplish these results. Several studies have examined this outcome-cost relationship at the hospital level, but the results are conflicting. The study sample (using an administrative database [1995 MQPro Comparative Database, MediQual Systems, Inc., Westborough, MA, USA]) comprised 175,249 adult medical service admissions to 100 hospitals in 25 states spanning 26 diagnosis-related groups (DRGs) during 1993 and 1994. Logistic regression models were used to estimate the expected probability of in-hospital mortality or morbidity; age, sex, severity of illness on admission, year of admission, insurance status and hospital were controlled for. The regression residuals were employed as quality indicators. Residual charges and length of stay (LOS) were estimated for each patient using an ordinary least squares regression model and were employed as resource efficiency indicators. A positive, statistically significant association at the physician level was found between mean morbidity residuals and each of the three mean resource efficiency residuals (LOS, 1.42 beta coefficient; ancillary charges, 1.78; and total charges, 1.27, all significant at the P < 0.001 level). The same positive and significant association was found between mortality residuals and each resource efficiency residual (LOS, 0.77 beta coefficient; ancillary charges, 0.80; and total charges, 0.68, all significant at the P < 0.01 level) when patients staying only one or two days were excluded. The results support our hypothesis that, on average, physicians with lower adjusted mortality or morbidity rates also have lower adjusted resource expenditures.

Toward a systems quality paradigm: relating health outcomes, resource expenditures, and appropriateness of cholecystectomy patients.

This study addresses the question for cholecystectomy patients of whether there is an association among manifesting better health outcomes and the quantity of hospital resources consumed when the appropriateness of this surgery is also considered. 10,043 cholecystectomies performed by 218 surgeons in 43 Pennsylvanian hospitals are analysed using data from an administrative data set. Performance measures are adjusted for admission severity of illness and other patient variables. The results demonstrate a statistically significant positive association between adjusted hospital total charges and adjusted morbidity controlling for whether specified clinical criteria are met that validate the need for a cholecystectomy. This study illustrates a systems quality paradigm wherein performance is examined in terms of health outcomes, appropriateness and resource expenditures, as well as the relationships among these three dimensions.

Occurrence of validating clinical findings in the hospital record for appendectomy, cholecystectomy and intervertebral disc excision patients: comparisons among hospitals and among surgeons.

This study examines the variation among 36 Pennsylvania hospitals, and the individual surgeons practicing in them, in the proportion of appendectomy, cholecystectomy and intervertebral disc excision patients with clinical findings in the hospital record that validate the need for surgery. Using admissions from January 1990 through June 1991, we performed logistic regressions on the probability of validating clinical findings controlling for patient age, sex, admission severity of illness, and Medicaid and Health Maintenance Organization membership. Our results show that hospitals, and surgeons, vary significantly in their validation rates for cholecystectomy and disc surgery and, to a lesser extent, appendectomy. We also found that increased procedure-specific volume at both the hospital and surgeon levels is not related to the odds of validating clinical findings. We define a future research agenda to investigate the reasons for the observed differences among hospitals and among surgeons.

Surgeon volume and hospital resource utilization.

This study examines whether surgeons who perform a particular procedure more often incur lower hospital charges and shorter lengths of stay than surgeons with less volume. The 43 Pennsylvania hospitals included in the 1991 MedisGroups Comparative Hospital Database form the study hospitals. The analysis looks at four frequently occurring surgical procedures: cholecystectomy, prostatectomy, hysterectomy, and intervertebral disc excision. Regression models are estimated separately for total charges, ancillary charges, and length of stay for each surgical procedure. The explanatory variable of interest is surgeon volume for the specific procedure. Control variables include patient age, sex, admission severity of illness, insurance plan, and hospital. For cholecystectomy, prostatectomy, and intervertebral disc surgery, we find a significant negative association between surgeon volume and both hospital charges and length of stay. We find no such volume effect for hysterectomy. The paper discusses management and policy implications of these findings.

Relating hospital health outcomes and resource expenditures.

This study addresses the question of whether hospitals with better health outcomes for their patients spend more or less to accomplish these results. Adult medical service admissions to 43 Pennsylvania hospitals are analyzed. Health outcomes and resource expenditures are adjusted for admission severity of illness and other patient variables. The results demonstrate a positive correlation between adjusted mortality (logit regression) and adjusted total charges, ancillary charges, and length of stay (ordinary least squares regression), but only the mortality/length-of-stay relationship is statistically significant (p < .05). For patients staying at least four days, however, there is a statistically significant, positive relationship between adjusted mortality and all three adjusted measures of resource expenditures. The relationship between the adjusted morbidity and each of these three adjusted resource measures is positive and statistically significant. The positive relationship is largely unrelated to such readily observable hospital characteristics as size, staffing, teaching status, and location in urban areas.

Comparing surgical efficiency in independent practice association HMOS and traditional insurance programs.

This study examines the effect of Independent Practice Association (IPA) HMO membership on hospital total charges, ancillary charges and length of stay (LOS) for surgical patients. Intrahospital comparisons of IPA and traditional insurance patients are made after adjusting for surgical procedure, admission severity of illness, age, sex and year of admission. Our multiple regression model indicates that IPA patients undergoing 12 frequently occurring surgical procedures have lower resource use. Eight (80%) of the 10 study hospitals exhibit a negative IPA beta coefficient for total charges, ancillary charges and LOS. Five (50%) hospitals have statistically significant (p < 0.05) negative coefficients for total charges, while one (10%) hospital has a significant positive coefficient. IPA patients exhibit adjusted total charges that are 6% lower than traditional insurance, ancillary charges that are 4.3% lower, and LOS that is 10% shorter.

Comparing low-severity hospital admissions in IPA HMOs and indemnity-type programs.

This study compares the proportion of low-severity hospital patients in independent practice association (IPA) HMOs and indemnity-type programs. The length of stay of such low-severity patients is also studied. Admissions of IPA patients under age 65 to ten hospitals are compared with admissions to the same hospital of patients covered by Blue Cross and Blue Shield plans or commercial insurance programs. Admissions to the adult medical service for the eight most frequently occurring DRGs with 5 percent or more patients in the low-severity category are included. A Logit model of the probability of low-severity admission controlling for age, sex, DRG, and hospital shows no significant IPA effect. However, a multiple regression model shows that the IPAs have significantly lower average length of stay for these low-severity patients.

Inter-hospital mortality and morbidity variation in Pennsylvania.

A 1986 Pennsylvania law requires the public disclosure of hospital mortality and morbidity rates. This study of hospital admissions in 1989 and 1990 examines the variation in these health-outcome indicators for the 10 most frequently occurring DRGs in the adult medical service in a sample of 20 Pennsylvania hospitals. These mortality and morbidity rates are adjusted for admission severity, DRG, age, and sex, using a logistic regression model. The null hypothesis of no significant variation among hospitals is rejected by the statistically significant (p < 0.01) results of a likelihood ratio test on the hospital variables in logit models for both mortality and morbidity. Test results also show that 4 (20 percent) of 20 hospitals have statistically significant (p < 0.05) adjusted mortality rates, and 4 (20 percent) of 20 hospitals have significant morbidity rates. Such information may impact hospital management practices in a variety of ways.

Comparing hospital length of stay in independent practice association HMOs and traditional insurance programs.

This study compares length of hospital stay in Independent Practice Association (IPA) HMOs and traditional insurance programs. Hospital admissions from 10 IPAs are compared with admissions to the same hospital of persons covered by Blue Cross and Blue Shield Plans or commercial insurance programs. Admissions of patients under age 65 to the adult medical service for the 10 most frequently occurring DRGs are included. Regression equations are estimated using length of stay as the dependent variable and IPA membership and hospital and patient characteristics as control variables. All 10 IPAs exhibit shorter lengths of stay as indicated by negative beta coefficients, and in 6 of the 10 IPAs this coefficient is statistically significant (p less than .05). This IPA effect occurs for 7 of the 10 study DRGs, and for MedisGroups Admission Severity Groups 0, 1, and 2.