Quantitative assessment of macular microvasculature and radial peripapillary capillary plexus in the fellow eyes of patients with retinal vein occlusion using OCT angiography.

PURPOSE: To evaluate the macular microvasculature and radial peripapillary capillary (RPC) plexus in the fellow eyes of patients diagnosed with unilateral retinal vein occlusion (RVO), using optical coherence tomography angiography (OCTA). METHODS: Seventy-two fellow eyes of patients with unilateral RVO and 74 healthy control eyes were consecutively enrolled. All subjects underwent a complete ophthalmological assessment, including optical coherence tomography (OCT) and OCTA measurements. Foveal avascular zone (FAZ) area, macular vessel density (VD), and perfusion density (PD) of the superficial capillary plexus (SCP) were measured. The perfusion and flux index (FI) of the RPC plexus were measured using a 4.5mm×4.5mm ONH angiography scan acquisition protocol. RESULTS: The mean macular ganglion cell-inner plexiform layer (GC-IPL), and retinal nerve fibre layer (RNFL) in the inferior quadrant were significantly thinner in the fellow eyes of RVO patients compared to control eyes (P=0.010 and P=0.043, respectively). The mean macular VD in the outer ring was significantly lower in fellow eyes of RVO patients compared to control eyes (P=0.027). The mean RPC perfusion showed no significant difference between fellow eyes of RVO patients and control eyes in the four quadrants (P>0.05, all). The mean peripapillary global, inferior and nasal FI were significant lower in the fellow eyes of RVO patients compared to control eyes (P=0.033, P=0.008, P=0.009, respectively). CONCLUSION: In the fellow eyes of RVO patients, macular VD was significantly lower in the outer region, and peripapillary structural and microvascular alterations were remarkable in the inferior quadrant. The results of this study showed that the presence of RVO might be related to retinal microvasculature changes in both the macular and peripapillary regions of the unaffected fellow eyes.

Longitudinal study of health maintenance organization efficiency.

Longitudinal studies looking at health maintenance organization (HMO) efficiency in the United States have not been performed before this study--previously there have only been small inter-group studies comparing efficiencies. The objectives here were twofold: to analyse HMO efficiency longitudinally, using a data envelopment analysis (DEA) model; and to compare the various types of HMOs and their efficiency using DEA. A cohort of HMOs was followed longitudinally and a number of variables measuring efficiency were studied. Data were derived from the HMO database survey (HCIA Inc.) for 1993-1997. Thirty-six HMOs were followed over a five-year period, and baseline input and output variables were collected. These measures are proxies for efficiency using the DEA methodology. Over all, using the DEA model it was demonstrated that HMOs tended to improve efficiency over time. Independent Practice Association HMOs appeared to show the highest level of improved efficiency. HMO type, profit status, federal eligibility and age were predictive variables for efficiency. Results of this study demonstrate that HMOs are improving efficiency longitudinally, and in general, certain specific models are longitudinally more efficient than others. Moreover, attributes of efficient HMOs have been identified. For policy-makers looking at efficiency, this information can be used to determine which HMO models are more appropriate when trying to achieve cost containment and effectiveness.

Regional variation in physician practice pattern: an examination of technical and cost efficiency for treating sinusitis.

OBJECTIVE: An examination of the physician efficiency and resulting cost patterns by region. DATA SOURCES: Virginia Medicaid sinusitis related claims for 1993 were aggregated to physician level (n = 178), and Area Resources File for 1993 was used to identify regions for evaluation. STUDY DESIGN: The best practice performance in the usage of five resources (i.e., primary care physician visits, referral services, emergency room visits, prescriptions, laboratory tests) was identified using Data Envelopment Analysis (DEA). Five regions in Virginia were identified according to regional planning to evaluate the variation in efficiency across these regions. PRINCIPAL FINDINGS: Inefficient physicians consumed significantly more resources and were 48% more costly than efficient physicians. Substantial regional variation was found and mainly attributed to the differences in use of prescriptions and laboratory procedures. Urban-rural discrepancy may explain part of the variation. CONCLUSIONS: As this study reveals the existence of substantial variation in physician efficiency, actions should be taken to minimize the variation that is more affected by personal and structural factors. For example, information on efficient use of resources and corresponding patient outcomes can be disseminated to the attending physicians. Educational workshops can be conducted to allow sharing of experience between efficient and inefficient physicians. Efforts should also be directed to help inefficient physicians to adhere to practice guidelines.

Public sector hospital efficiency for provincial markets in Turkey.

This study uses Data Envelopment Analysis to examine public sector hospital efficiency in 80 provincial markets in Turkey. Outputs of the study includes mortality rate as quality measure as well as inpatient discharges and outpatient visits. Patient beds, four levels of health labor, and expenditures are used to capture capital, labor and material resources as inputs. Results show that 55% of the public hospitals in served markets are operated inefficiently. Analysis of inefficient provinces suggests that in those 44 inefficient provinces are collectively overbedded, employ excessive number of specialists and other health labor. They spent approximately $70,000,000 from their revolving funds in excess compared to efficient provinces.

Characteristics of health maintenance organizations and their influence on efficiency.

This study examines the efficiency of Health Maintenance Organizations (HMOs) based on a sample of 249 HMOs operating in the United States in 1995. Data Envelopment Analysis (DEA) was used to calculate the level of technical efficiency for each HMO included in the sample. Further descriptive analyses were conducted examining various structural and operational characteristics of HMOs and their impact on efficiency. Federal qualification status, Medicare programme participation, combined Medicare and Medicaid programmes participation, chain affiliation and size were found to be significant influences on HMO efficiency.

Do primary care physicians or specialists provide more efficient care?

Sinusitis is a common health complaint and expenditures for its treatment are high; thus, it is necessary to promote efficient practice behaviours in managing patient care. This study compares resource utilization between primary care physicians and specialists in the treatment of Medicaid sinusitis patients in Virginia. Physician-level data from Virginia Medicaid claim files for 1993 were analysed. The efficiency frontier, representing the best achievable performance in the use of resources for treating sinusitis, is identified using Data Envelopment Analysis. Resource utilization (primary care physician visits, specialist visits, emergency room usage, prescriptions and laboratory tests) and corresponding costs are compared between generalists and otolaryngologists. It was concluded from this study that there are no discernible differences in technical efficiency between generalists and specialists in the treatment of sinusitis. Nevertheless, otolaryngologists are found to be more costly than generalists in treating sinusitis. Variation in both caseload and patient mix might explain variation in use of resources.

Benchmarking organ procurement organizations: a national study.

OBJECTIVE: An exploratory examination of the technical efficiency of organ procurement organizations (OPOs) relative to optimal patterns of production in the population of OPOs in the United States. DATA SOURCES: A composite data set with the OPO as the unit of analysis, constructed from a 1995 national survey of OPOs (n = 64), plus secondary data from the Association of Organ Procurement Organizations and the United Network for Organ Sharing. STUDY DESIGN: The study uses data envelopment analysis (DEA) to evaluate the technical efficiency of all OPOs. PRINCIPAL FINDINGS: Overall, six of the 22 larger OPOs (27 percent) are classified as inefficient, while 23 of the 42 smaller OPOs (55 percent) are classified as inefficient. Efficient OPOs recover significantly more kidneys and extrarenal organs; have higher operating expenses; and have more referrals, donors, extrarenal transplants, and kidney transplants. The quantities of hospital development personnel and other personnel, and formalization of hospital development activities in both small and large OPOs, do not significantly differ. CONCLUSIONS: Indications that larger OPOs are able to operate more efficiently relative to their peers suggest that smaller OPOs are more likely to benefit from technical assistance. More detailed information on the activities of OPO staff would help pinpoint activities that can increase OPO efficiency and referrals, and potentially improve outcomes for large numbers of patients awaiting transplants.

Electrodermal activity in hypothyroid patients and healthy subjects.

The involvement of the central nervous system either in hypothyroidism or in hyperthyroidim has previously been shown on the basis of visual, auditory, somatosensory, and central motor evoked potential studies by some investigators. In to our previous study, we found that abnormal electrodermal activity in nonmedicated hyperthyroid patients was not associated with psychiatric symptoms. In this study, our purpose was to investigate whether hypothyroidism results in electrodermal abnormalities in the absence of measurable psychiatric symptoms. Electrodermal activity was recorded with a skin conductance unit connected to a personal computer. Basal levels of electrodermal activity and responsiveness to repeated acoustic stimulation were studied in 14 nonmedicated hypothyroid patients and 14 healthy controls. Psychiatric rating scores indicated that patients and healthy controls had normal levels of anxiety and depression. Hypothyroid patients had lower skin conductance levels, lower fluctation rates and prolonged onset latencies compared with controls. None of the hypothyroid patients had amplitude changes. In conclusion, hypothyroid patients may have abnormal electrodermal activity that is related to the change of hypothalamic-pituitary-thyroid axis function, without associated psychiatric symptoms.

Trends in hospital efficiency among metropolitan markets.

This study evaluates trends in efficiency among American hospital markets. A total of 6010 hospitals were identified for use in the analysis from the American Hospital Association's Annual Surveys for 1989 and 1993. Using data envelopment analysis (DEA), a longitudinal study of hospital efficiency was conducted on all 314 metropolitan markets in the United States. Results suggest that large hospital markets generally demonstrated higher inefficiency. The major inefficiencies exist in the availability of hospital services, the number of operating beds, the utilization of hospital staffing and operating expenses. Consequently, the large hospital market had a significant excess of health manpower that resulted in inefficiency that amounted to approximately $23 billion. From a policy perspective, this study has shed some light on the need to establish more specific policies to address inefficiency in the health care industry.

Hospital development and the performance of organ procurement organizations.

With more than 56,000 patients on the national waiting list for organ transplants and relatively little growth in the number of donors, organ procurement organizations now recognize the need to aggressively market their services and the range of donor procurement opportunities to hospital personnel. This study examines the types and levels of hospital development activities being conducted by organ procurement organizations, the characteristics of organ procurement organizations that are more involved in hospital development, and the relationship between hospital development and organ procurement. Results from a national survey indicate that, as of the mid-1990s, organ procurement organizations had not made major investments in hospital development despite an increased recognition of the importance of these activities. Organ procurement organizations whose directors were more committed to hospital development exhibited higher levels of hospital development activity. Efforts to formalize hospital development activities through the establishment of a hospital development department and evaluation standards were associated with more organs procured per donor.

Efficiency evaluation of skilled nursing facilities.

This study employs Data Envelopment Analysis (DEA) to determine technical efficiency using skilled nursing facilities in the United States, using a 10% national sample of 324 skilled nursing facilities stratified by ownership and size cluster groupings. Results show that nonprofit and for-profit firms operate using significantly different modes of production, thus allowing the best of the for-profits to achieve a level of technical efficiency .86 times higher than the most efficient nonprofit homes. The best larger nursing homes are .89 times more efficient than the best smaller facilities, also indicating a difference in production goals and technologies. A rationale for these differences is sought through an analysis of DEA generated slacks and a logistic regression. Controlling for size and ownership in the DEA, a higher percentage of Medicare patients leads to lower efficiency, while higher occupancy and greater percentage of Medicaid patients lead to greater efficiency. Regional characteristics do not impact efficiency. It is concluded that reimbursement policies should account for differences in organizational goals created by size and ownership differentials. The great variations in efficiency demonstrate tremendous potential for cost-savings through imitation of efficient firms.

Physician benchmarking: measuring variation in practice behavior in treatment of otitis media.

The study uses Data Envelopment Analysis (DEA) to analyze physician practice behavior and develops measures of physician practice efficiency as a basis for improving productivity and reducing costs in otitis media treatment. Other objectives include determining geographic variations in practice patterns for otitis media, and the impact of inefficient practice patterns on the cost of treatment of otitis media. Only 46 (28.8%) of the 160 physicians were classified as efficient. Average total cost of an episode by efficient providers was $357.03 and $492.06 for inefficient providers. By restricting particular inputs and outputs, and directing all physicians to treat otitis media through a balanced primary care model, physicians would be able to provide the same quality care at an average savings of 23.7% per efficient and 4.4% per inefficient provider.

Technical efficiencies of Turkish hospitals: DEA approach.

This study uses Data Envelopment Analysis to examine the technical efficiencies of 573 Turkish acute general hospitals. Inputs of number of beds, number of primary care physicians, and number of specialists, and how they are used to produce outputs of inpatient discharges, outpatient visits, and surgical operations, are examined. Results illustrate that less than ten percent of Turkish acute general hospitals operate efficiently compared to their counterparts. Inefficient, compared to efficient hospitals, on average utilize 32% more specialists, 47% more primary care physicians, and have 119% more staffed bed capacity. They also produce on average less output. Particularly, 13% less outpatient visits, 16% inpatient hospitalization, and 57% less surgical procedures. Additionally, the validity of DEA is illustrated by comparing it to the ratio analysis method; no discernible differences in the results are found.

Strategic hospital alliances: impact on financial performance.

Acute care hospitals have increasingly been forming local strategic hospital alliances (SHAs), which consume considerable resources in forming and may affect the competitiveness of provider markets. This research shows that SHAs and market factors, which have been perceived to be threats to hospitals, are related to hospitals' financial performance. Among the findings are that SHA members have higher net revenues but that they are not more effective at cost control. Nor do the higher net revenues result in higher cash flow. However, increasing SHA penetration in a market is related to lower net revenues per case. In addition, the penetration of private health maintenance organizations in markets is associated with lower revenues and expenses.

Efficiency evaluation of community-based youth services in Virginia.

This study investigates the efficiency of community-based youth services in the Commonwealth of Virginia using data envelopment analysis (DEA). Efficiency was calculated based on resources available, the demand of services, and the service units produced. Results demonstrated the extent of inefficiency in community-based youth programs and how much efficiency can be improved relative to comparison with peer groups. The differences between large and small communities, urban and rural communities, and rich and poor communities were analyzed. There was no significant difference between each type for all three categories.

Church ownership and hospital efficiency.

Using a sample of California hospitals, the effect of church ownership was examined as it relates to nonprofit hospital efficiency. Efficiency scores were computed using a nonparametric method called data envelopment analysis (DEA). Controlling for hospital size, location, system membership, and type of church ownership, church-owned hospitals were found to be more frequently in the efficient category than their secular nonprofit counterparts. The outcomes have policy implications for reducing healthcare expenditures by focusing on increasing outputs or decreasing inputs, as appropriate, and bolstering the case for church-sponsored hospitals to retain the tax-exempt status due to their ability to manage their resources as efficiently as (or more efficiently than) secular hospitals.

Measuring the technical efficiency of psychiatric hospitals.

The purpose of this study was to assess the efficiency of psychiatric hospitals. Data Envelopment Analysis was used to examine the technical efficiency for sample of the 85 profit and not-for-profit psychiatric hospitals. Results suggests reduction of excessive resource use by all inefficient facilities would result, on average, in a $7.2 million dollar savings in operational expenses, a total of 1715 FTEs in labor reductions, and a reduction of 1129 beds.

Local markets and systems: hospital consolidations in metropolitan areas.

OBJECTIVE: This study examines the formation of local hospital systems (LHSs) in urban markets by the end of 1992. We argue that a primary reason why hospitals join LHSs is to achieve improved positions of market power relative to threatening rivals. DATA SOURCES/DATA COLLECTION: The study draws from a unique database of LHSs located in and around metropolitan statistical areas (MSAs). Data were obtained from the 1991 AHA Annual Hospital Survey, updated to the year 1992 using information obtained from multiple sources (telephone contacts of systems, systems lists of hospitals, published changes in ownership, etc.). Other measures were obtained from a variety of sources, principally the 1989 Area Resources File. STUDY DESIGN: The study presents cross-sectional analyses of rival threats and other factors bearing on LHS formation. Three characteristics of LHS formation are examined: LHS penetration of urban areas, LHS size, and number of LHS members located just outside the urban boundaries. LHS penetration is analyzed across urban markets, and LHS size and rural partners are examined across the LHSs. PRINCIPAL FINDINGS: Major hypothesized findings are: (1) with the exception of the number of rural partners, all dependent variables are positively associated with the number of hospitals in the markets; the rural partner measure is negatively associated with the number of hospitals; (2) the number of doctors per capita is positively associated with all but the rural penetration measure; and (3) the percentage of the population in HMOs is positively associated with local cluster penetration and negatively associated with rural system partners. Other findings: (1) average income in the markets is negatively associated with all but the rural penetration measure; (2) LHS size and rural partners are both positively associated with nonprofit system ownership; and (3) they are also both negatively associated with the degree to which their multihospital systems are geographically concentrated in a single state. CONCLUSIONS: The findings generally support the argument that LHS formation is the product of hospital providers attempting to improve positions of power in their local markets.