Monitoring costs in the ICU: a search for a pertinent methodology.

Attempts to determine costs in the intensive care unit (ICU) were not successful until now, as they failed to detect differences of costs between patients. The methodology and/or the instruments used might be at the origin of this failure. Based on the results of the European ICUs studies and on the descriptions of the activities of care in the ICU, we gathered and analysed the relevant literature concerning the monitoring of costs in the ICU. The aim was to formulate a methodology, from an economic perspective, in which future research may be framed. A bottom-up microcosting methodology will enable to distinguish costs between patients. The resulting information will at the same time support the decision-making of top management and be ready to include in the financial system of the hospital. Nursing staff explains about 30% of the total costs. This relation remains constant irrespective of the annual nurse/patient ratio. In contrast with other scoring instruments, the nursing activities score (NAS) covers all nursing activities. (1) NAS is to be chosen for quantifying nursing activities; (2) an instrument for measuring the physician's activities is not yet available; (3) because the nursing activities have a large impact on total costs, the standardisation of the processes of care (following the system approach) will contribute to manage costs, making also reproducible the issue of quality of care; (4) the quantification of the nursing activities may be the required (proxy) input for the automated bottom-up monitoring of costs in the ICU.

Dimensionality of the Pay Satisfaction Questionnaire: a validation study in Belgium.

This study examined the underlying dimensions of the Pay Satisfaction Questionnaire to test whether the robust 4-factor structure (Pay Level, Benefits, Raises, and Structure or Administration) often established in the United States can be generalized to other countries and cultures as well. Data of 4 samples (for-profit employees, nonprofit nurses, cultural centre employees, and nonprofit teachers) were analysed with confirmatory factor analyses. The results for the first 3 samples yielded support for the original 4-factor structure of the Pay Satisfaction Questionnaire. In the teachers' sample, the irrelevant Benefits items were excluded from the analysis, resulting in a 3-factor structure of pay satisfaction.

Definitions and methods of cost assessment: an intensivist's guide. ESICM section on health research and outcome working group on cost effectiveness.

OBJECTIVE: To define the different types of costs incurred in the care of critically ill patients and to describe some of the most commonly used methods for measuring and allocating these costs. DESIGN: Literature review. Definitions for opportunity, direct and indirect, fixed, variable, marginal, and total costs are described and interpreted in the context of the critical care setting. Two main methods of costing are described: the 'top-down' and 'bottom-up' methods together with a number of cost proxies, such as the use of weighted hospital days, diagnosis-related groups, severity and activity scores, and effective costs per survivor. CONCLUSIONS: The assessment and allocation of costs to critically ill patients is complex and as a result of the different definitions and methods used, meaningful comparisons between studies are plagued with difficulty. When undertaking a study looking to measure costs, it is important to state: (a) the aim of the cost assessment study; (b) the perspective (point of view); (c) the type of costs that need to be measured; and (d) the time span of assessment. By being explicit about the rationale of the study and the methods used, it is hoped that the results of economic evaluations will be better understood, and hence implemented within the critical care setting.

The physician-patient relationship as a game of strategic information transmission.

We show that the intuition underlying the supplier-induced demand (SID) hypothesis is reflected in the cheap-talk literature from game theory, and in the credence-good literature from the economics of information. Applying these theories, we conclude that a neoclassical version of the SID hypothesis is only relevant for treatment decisions involving an expensive treatment that is equally effective in curing several states, but efficient in curing only some of these states (in that a cheaper treatment is efficient otherwise). For a simple game involving such a treatment decision, we show that a Nash equilibrium exists where the patient is able to constrain the physician in inducing demand, without the market for the potentially induced treatment failing. This equilibrium allows us to derive comparative statistics and welfare results.

Differences in managerial behaviour between head nurses and medical directors in intensive care units in Europe.

We attempt to determine whether differences appear between the managerial behaviour of European intensive care head nurses on the one side and medical directors on the other. In order to come up with a managerial job and competency analysis of ICU managers, observations and interviews were performed. Additionally, focus groups consisting of ICU experts were organized. The results are discussed according to managerial behaviour taxonomies and existing competency models. There seems to be some differentiation between the two managerial positions studied. Head nurses are more involved in planning/coordinating and motivating/reinforcing activities, whereas medical directors are more involved in socializing/politicking, decision making/problem solving, interaction with others and disciplining.

A model of physician behaviour with demand inducement.

We present a model of the physician-patient relationship extending on the model by Farley [Farley, P.J., 1986. Theories of the price and quantity of physician services. Journal of Health Economics 5, 315-333] of supplier-induced demand (SID). First, we make a case for the way this model specifies professional ethics, physician competition, and SID itself. Second, we derive predictions from this model, and confront them with the neoclassical model. Finally, we stress the importance of considering how SID affects patient welfare in providing an example where physicians' ability to induce makes patients better off. To evaluate patient welfare, we derive approximations of the patients' welfare loss due to physician market power in both the neoclassical model and the inducement model.