Indirect costs of teaching in Canadian hospitals.

We sought to determine whether there are indirect costs of teaching in Canadian hospitals. To examine cost differences between teaching and nonteaching hospitals we estimated two cost functions: cost per case and cost per patient-day (dependent variables). The independent variables were number of beds, occupancy rate, teaching ratio (number of residents and interns per 100 beds), province, urbanicity (the population density of the county in which the hospital was situated) and wage index. Within each hospital we categorized a random sample of patient discharges according to case mix and severity of illness using age and standard diagnosis and procedure codes. Teaching ratio and case severity were each highly correlated positively with the dependent variables. The other variables that led to higher costs in teaching hospitals were wage rates and number of beds. Our regression model could serve as the basis of a reimbursement system, adjusted for severity and teaching status, particularly in provinces moving toward introducing case-weighting mechanisms into their payment model. Even if teaching hospitals were paid more than nonteaching hospitals because of the difference in the severity of illness there should be an additional allowance to cover the indirect costs of teaching.     

Hospital discharge reports: content and design.

The information required by family doctors on initial and final discharge reports from hospitals was specified and 546 such reports from hospitals in Aylesbury, Amersham, Banbury, Oxford, and High Wycombe were reviewed for the availability and accessibility of important information. Several items could have been recorded better, including the name of the hospital, the specialty (or department) concerned, and the name of the consultant in charge of the case. Drug reactions seemed to be under-reported in the initial discharge reports and information about treatment on discharge was inadequate. The recording of the prognosis and information given to the patient was deficient and communication on follow-up needs to be improved. The use of obscure abbreviations was widespread. There is room for improvement in the ease of access to important information, especially the diagnostic assessment, and the time taken for final reports to reach the general practitioner.     

Impact of the NHS reforms on English hospital productivity: an analysis of the first three years.

OBJECTIVES: To evaluate the effect of purchaser mix, market competition, and trust status on hospital productivity within the NHS internal market. METHODS: Hospital cost and activity data were taken from routinely collected data for acute NHS hospitals in England for 1991-2 to 1993-4. Cross sectional and longitudinal regression methods were used to estimate the effect of trust status, competition, and purchaser mix on average hospital costs per inpatient, after adjusting for outpatient activity levels, casemix, teaching activity, regional salary variation, hospital size, scale of activity, and scope of cases treated. RESULTS: Real productivity gains were apparent across the study period for NHS hospitals on average. Casemix adjustment drastically improved cross sectional comparisons between hospitals. Gaining trust status and increasing host district purchaser share were associated with productivity increases after adjustment for casemix, regional salary differences, and hospital size and scope. Hospitals that became trusts during the study period were on average less productive at the beginning of the period than those that did not, and there were no significant productivity differences between trust waves at the end of the period in 1993-4. Market concentration was not associated with productivity differences. CONCLUSION: Further analysis is needed to determine whether overall and trust associated productivity gains are transient effects, one off shifts, or self perpetuating reorientations of organisational behaviour. Hospitals may have chosen to become trusts because they anticipated being able to increase productivity. Increases in the proportions of small purchasers were associated with increasing costs. Importantly, this study could not adjust for changes in the quality of care.     

Tertiary cancer services in Britain: benchmarking study of activity and facilities at 12 specialist centres.

OBJECTIVE--To collate information on current activity and facilities in British hospitals to assist the planning of future cancer services. DESIGN--12 hospitals delivering specialist cancer services provided information on the size of population served, activity levels related to non-surgical oncology for 1994-5, and facilities available. Inconsistencies in the recording of data were resolved through meetings of all participants. SETTING--Five single specialty NHS trusts and seven specialist cancer facilities within multispecialty trusts, serving a combined population of 24.3 million. MAIN OUTCOME MEASURES--Activity levels and facilities per million population served. RESULTS--The facilities available per million population served varied widely between centres. In contrast, the range in the number of new referrals per million population (seen either at the centre or in peripheral clinics) was relatively small. Considerable variations were observed in the number of attendances per patient and amount of radiotherapy and chemotherapy delivered. Overall it was estimated that 40-45% of all new cases of cancer are currently being referred to non-surgical oncologists. For the seven hospitals which could provide data on trends in activity, the average increase in chemotherapy day case episodes between 1992-3 and 1994-5 was 83%. CONCLUSIONS--The results of this study provide a benchmark both for purchasers and providers of cancer care. The increase in the use of chemotherapy points to an urgent need for a unified system for monitoring both activity and outcomes of treatment.     

Variability in Costs across Hospital Wards. A Study of Chinese Hospitals

Introduction

Analysts estimating the costs or cost-effectiveness of health interventions requiring hospitalization often cut corners because they lack data and the costs of undertaking full step-down costing studies are high. They sometimes use the costs taken from a single hospital, sometimes use simple rules of thumb for allocating total hospital costs between general inpatient care and the outpatient department, and sometimes use the average cost of an inpatient bed-day instead of a ward-specific cost.

Purpose

In this paper we explore for the first time the extent and the causes of variation in ward-specific costs across hospitals, using data from China. We then use the resulting model to show how ward-specific costs for hospitals outside the data set could be estimated using information on the determinants identified in the paper.

Methodology

Ward-specific costs estimated using step-down costing methods from 41 hospitals in 12 provinces of China were used. We used seemingly unrelated regressions to identify the determinants of variability in the ratio of the costs of specific wards to that of the outpatient department, and explain how this can be used to generate ward-specific unit costs.

Findings

Ward-specific unit costs varied considerably across hospitals, ranging from 1 to 24 times the unit cost in the outpatient department — average unit costs are not a good proxy for costs at specialty wards in general. The most important sources of variability were the number of staff and the level of capacity utilization.

Practice Implications

More careful hospital costing studies are clearly needed. In the meantime, we have shown that in China it is possible to estimate ward-specific unit costs taking into account key determinants of variability in costs across wards. This might well be a better alternative than using simple rules of thumb or using estimates from a single study.     

Problems in determining the incidence of cervical cancer.

Since cancer registries have different recording practices, the incidence rates that they report must be compared with caution. Indexes of reliability of recording indicated that in 1971 the reported incidence of cervical cancer in Ontario was too high. In 1971 Ontario used a method of passive reporting of cancer cases: the Ontario Cancer Registry linked hospital reports, death certificates and reports from the Ontario Cancer Treatment and Research Foundation''s treatment centres to produce a single record for each case. Pathological confirmation was requested for cases thus recorded by the registry. In 26% of cases a diagnosis other than cervical cancer was indicated. With these cases omitted, the incidence rate became 15.1/100 000, as opposed to the 20.5/100 000 reported by the registry.     

Unit Cost of Medical Services at Different Hospitals in India

Institutional care is a growing component of health care costs in low- and middle-income countries, but local health planners in these countries have inadequate knowledge of the costs of different medical services. In India, greater utilisation of hospital services is driven both by rising incomes and by government insurance programmes that cover the cost of inpatient services; however, there is still a paucity of unit cost information from Indian hospitals. In this study, we estimated operating costs and cost per outpatient visit, cost per inpatient stay, cost per emergency room visit, and cost per surgery for five hospitals of different types across India: a 57-bed charitable hospital, a 200-bed private hospital, a 400-bed government district hospital, a 655-bed private teaching hospital, and a 778-bed government tertiary care hospital for the financial year 2010–11. The major cost component varied among human resources, capital costs, and material costs, by hospital type. The outpatient visit cost ranged from Rs. 94 (district hospital) to Rs. 2,213 (private hospital) (USD 1 = INR 52). The inpatient stay cost was Rs. 345 in the private teaching hospital, Rs. 394 in the district hospital, Rs. 614 in the tertiary care hospital, Rs. 1,959 in the charitable hospital, and Rs. 6,996 in the private hospital. Our study results can help hospital administrators understand their cost structures and run their facilities more efficiently, and we identify areas where improvements in efficiency might significantly lower unit costs. The study also demonstrates that detailed costing of Indian hospital operations is both feasible and essential, given the significant variation in the country’s hospital types. Because of the size and diversity of the country and variations across hospitals, a large-scale study should be undertaken to refine hospital costing for different types of hospitals so that the results can be used for policy purposes, such as revising payment rates under government-sponsored insurance schemes.     

Coronary thrombolysis--clinical guidelines and public policy: results of an Ontario practitioner survey.

The Ontario Medical Association (OMA) guidelines for intravenous thrombolysis in acute myocardial infarction were released in March 1988 and contributed to a government decision against special per-case funding to assist hospitals using tissue-type plasminogen activator (tPA). In October 1988, 1512 cardiologists, internists and physician-administrators who were OMA members were mailed a questionnaire seeking their views on the OMA guidelines and related issues. Of the 419 questionnaires (28%) that were returned, 392 contained usable responses. Among the respondents 268 (68%) had used thrombolytic drugs in the preceding 12 months; the mean number of cases was 10.6 (standard deviation 12.9). A strong or a mild preference for tPA over streptokinase was registered by 64% of the respondents; 28% had no preference. However, the self-reported ratio of actual streptokinase:tPA use was about 3:1, and 73% indicated that the government''s funding policy had limited the availability of tPA in their hospital. The respondents were almost equally divided as to whether the policy should be changed. The guidelines were deemed helpful by 85% of the noncardiologists, as opposed to 52% of the cardiologists (p less than 0.005). OMA involvement in developing and circulating such guidelines was supported by 74% of the respondents and opposed by 18%; opposition was more likely to come from those who found the guidelines unhelpful (p less than 0.001). Support for involvement by the College of Physicians and Surgeons of Ontario was much weaker (supported by 32%, opposed by 62%). Overwhelming opposition to government involvement was evident.     

A survey of medical quality assurance programs in Ontario hospitals.

OBJECTIVE: To determine the prevalence and types of medical quality assurance practices in Ontario hospitals. DESIGN: Survey. SETTING: All teaching, community, chronic care, rehabilitation and psychiatric hospitals that were members of the Ontario Hospital Association as of May 1990. PARTICIPANTS: The person deemed by the chief executive officer of each hospital to be most responsible for medical administration. INTERVENTION: A questionnaire to obtain information on each hospital''s use of criteria audit, indicators inventory, occurrence screening and reporting, and utilization review and management (URM) activities. OUTCOME MEASURES: Prevalence of the use of the quality assurance activities, the people responsible for the activities and the relative success of the URM program in modifying physicians'' performance. RESULTS: Of the 245 member hospitals participants from 179 (73%) responded. Criteria audits were performed in 136 (76%), indicators inventory in 43 (24%), occurrence screening in 44 (25%), occurrence reporting in 61 (34%) and URM in 123 (69%). In-hospital deaths were reviewed in 157 (88%) of the hospitals. In all, 87 (55%) of the respondents from hospitals that had a URM program or were developing one indicated that their program was successful in modifying physicians'' practices, and 29 (18%) reported that it was not successful; 26 (16%) stated that the effect was still unknown, and 16 (10%) did not respond. Seventy (40%) stated that results of tissue reviews were reported at least 10 times per year and 94 (83%) that medical record reviews were reported at least as often. The differences in the prevalence of the quality assurance activities between the hospitals were not found to be significant. CONCLUSIONS: Many Ontario hospitals are conducting a wide variety of quality assurance activities. Further study is required to determine whether the differences in prevalence of these activities between hospitals would be significant in a larger, perhaps national, sample. Strategies are needed to ensure universal involvement and participation in the improvement of the quality of care and the assessment of the cost-effectiveness of health care treatments. Recommendations to achieve these objectives are suggested.     

Containing Ontario's hospital costs under universal insurance in the 1980s: what was the record?

In recent years the Ontario government has been concerned that the proportion of public expenditures devoted to health care is at an all-time high. In addition, the media have devoted considerable attention to specific incidents that may represent inadequate funding of hospital services. To shed light on the debate on health care expenditures we analysed the trend in expenditures of Ontario''s hospital sector in the 1980s in terms of the amount of inputs (e.g., labour) used to produce hospital services (e.g., a patient-day or admission) and after adjustment for general inflation. As in the 1970s the number of inputs grew relatively slowly during the 1980s. Inputs per patient-day grew at an annual rate of 0.46% and inputs per admission at an annual rate of 2.4%. Cost increases were largely accounted for by hospital wage increases; this could have been due to Ontario''s rapidly expanding economy. These findings indicate that Ontario has continued to be successful in containing the number of inputs used in the hospital sector. However, after two decades of substantial success with publicly acceptable cost control, the government faces increased scrutiny as the media and the public focus attention on several areas of perceived inadequate funding in health care services.     

Cost of primary health care services in the emergency department and the family physician's office.

An attempt has been made to determine the true cost of providing primary health care for nontraumatic conditions in the emergency departments of two hospitals in Ontario and in the offices of family physicians. A total of 1117 patients presenting with 1 of 10 common symptom/sign complexes at the emergency departments or the offices of 15 participating family physicians were studies with regard to number of visits made, type of assessment by the physician, investigations undertaken, management, therapy and outcome of the illness. Costs were calculated from the charges that would be made against the provincial health services insurance plan and from the system of hospital financing in effect in the province. The average true cost per illness episode of this type of care was $14.63 in hospital A, $14.20 in hospital B and $15.90 in the family physician''s office.     

Proficiency testing in cytology laboratories in Ontario, Canada: a decade of experience. I. Introduction and description of the testing model

There are few formally documented proficiency testing programs for cytology laboratories, and those that have been documented are not entirely comparable in format. The first of three papers documenting a mandatory universal proficiency testing program for cytology laboratories in the Province of Ontario, Canada, presents data on the structure and function of the participating laboratories (including a comparison of the data for 1974 and 1980) and on the organization of the testing model (including selection of terminology, construction and use of the survey and assessment of responses). In 1980, of the 463 medical laboratories in Ontario, 91 of 222 hospital laboratories and 65 of 216 nonhospital laboratories were licensed in cytology. In that year, the 156 cytology laboratories processed 1.48 million cytology specimens, 92% of which were gynecologic. Hospital laboratories processed 87.5% of the nongynecologic cytology specimens and 30% of the gynecologic cytology specimens. These proportions have been virtually constant for several years. Between 1974 and 1980, there was a trend in Ontario to fewer laboratories processing less than 5,000 cytology specimens per annum. Subsequent papers in this series describe the results of the initial surveys in this program and a precision study to evaluate the consistency of reporting by individual laboratories.     

The safety of obstetric services in small communities in northern Ontario.

The safety of the obstetric care system in the small hospitals of northern Ontario was assessed by analysing the outcomes of all obstetric cases over a 2-year period. Information was retrieved by place of residence rather than hospital of delivery so that the overall perinatal system, including the referral patterns, would be assessed. There was little difference in perinatal loss rate (stillbirths and neonatal deaths up to 28 days per 1000 births) for residents of areas served by different levels of obstetric care. Areas served by units where cesarean sections are done regularly but which do not have specialists in obstetrics or pediatrics had a perinatal loss rate of 10.43, whereas areas served by units staffed with two or more specialists in both obstetrics and pediatrics and handling more than 1000 deliveries per year had a perinatal loss rate of 12.13. Although many of the smaller hospitals did not have the minimum capabilities suggested for obstetric units relatively safe care was being provided. These results do not support the need for further centralization of obstetric services in northern Ontario.     

Is London overbedded?

OBJECTIVE--To examine whether there are too many hospital beds in London. DESIGN--Analysis of data from the Hospital In-Patient Enquiry, Mental Health Enquiry, health service indicators, and Emergency Bed Service. SETTING--England, London, and inner London. RESULTS--Hospital admission rates for acute plus geriatric services for London residents were very similar to the national values in all age groups. In the special case considered in the Tomlinson report--acute services in inner London--the admission rate was 22% above the value for England. However, the admission rate of inner deprived Londoners was 9% below that of comparable areas outside London. For psychiatry, admission rates in London roughly equalled those in comparable areas. When special health authorities were excluded, in 1990-1 there were 4% more acute plus geriatric beds available per resident in London than in England. Bed provision has been reduced more rapidly in London than nationally. Extrapolating the trend of bed closures forward indicates that beds (all and acute) per resident in London are now at about the national average. Data from the Emergency Bed Service indicate that the pressure on available hospital beds in London has been increasing since 1985. CONCLUSIONS--Data regarding bed provision and utilisation for all specialties by London residents do not provide a case for reducing the total hospital bed stock in London at a rate faster than elsewhere. Bed closures should take account of London''s relatively poorer social and primary health care circumstances, longer hospital waiting lists, poorer provision of residential homes, and evidence from the Emergency Bed Service of increasing pressure on beds. Higher average costs in London, some unavoidable, are forcing hospital beds to be closed at a faster rate in London than nationally.     

Cassava mosaic geminiviruses: actual knowledge and perspectives

Cassava mosaic disease (CMD) caused by cassava mosaic geminiviruses (CMGs) is one of the most devastating crop diseases and a major constraint for cassava cultivation. CMD has been reported only from the African continent and Indian subcontinent despite the large-scale cultivation of cassava in Latin America and several South-East Asian countries. Seven CMG species have been reported from Africa and two from the Indian subcontinent and, in addition, several strains have been recognized. Recombination and pseudo-recombination between CMGs give rise not only to different strains, but also to members of novel virus species with increased virulence and a new source of biodiversity, causing severe disease epidemics. CMGs are known to trigger gene silencing in plants and, in order to counteract this natural host defence, geminiviruses have evolved suppressor proteins. Temperature and other environmental factors can affect silencing and suppression, and thus modulate the symptoms. In the case of mixed infections of two or more CMGs, there is a possibility for a synergistic interaction as a result of the presence of differential and combinatorial suppressor proteins. In this article, we provide the status of recent research findings with regard to the CMD complex, present the molecular biology knowledge of CMGs with reference to other geminiviruses, and highlight the mechanisms by which CMGs have exploited nature to their advantage.     

Variations and Determinants of Hospital Costs for Acute Stroke in China

Background

The burden of stroke is high and increasing in China. We modelled variations in, and predictors of, the costs of hospital care for patients with acute stroke in China.

Methods and Findings

Baseline characteristics and hospital costs for 5,255 patients were collected using the prospective register-based ChinaQUEST study, conducted in 48 Level 3 and 14 Level 2 hospitals in China during 2006–2007. Ordinary least squares estimation was used to determine factors associated with hospital costs. Overall mean cost of hospitalisation was 11,216 Chinese Yuan Renminbi (CNY) (≈US$1,602) per patient, which equates to more than half the average annual wage in China. Variations in cost were largely attributable to stroke severity and length of hospital stay (LOS). Model forecasts showed that reducing LOS from the mean of 20 days for Level 3 and 18 days for Level 2 hospitals to a duration of 1 week, which is common among Western countries, afforded cost reductions of 49% and 19%, respectively. Other lesser determinants varied by hospital level: in Level 3 hospitals, health insurance and the occurrence of in-hospital complications were each associated with 10% and 18% increases in cost, respectively, whilst treatment in a teaching hospital was associated with approximately 39% decrease in cost on average. For Level 2 hospitals, stroke due to intracerebral haemorrhage was associated with a 19% greater cost than for ischaemic stroke.

Conclusions

Changes to hospital policies to standardise resource use and reduce the variation in LOS could attenuate costs and improve efficiencies for acute stroke management in China. The success of these strategies will be enhanced by broader policy initiatives currently underway to reform hospital reimbursement systems.     

Contribution of a general practitioner hospital: a further study.

OBJECTIVE--To audit the workload of a general practitioner hospital and to compare the results with an earlier study. DESIGN--Prospective recording of discharges from the general practitioner hospital plus outpatient and casualty attendances and of all outpatient referrals and discharges from other hospitals of patients from Brecon Medical Group Practice during one year (1 June 1986-31 May 1987). SETTING--A large rural general group practice which staffs a general practitioner hospital in Brecon, mid-Wales. PATIENTS--20,000 Patients living in the Brecon area. RESULTS--1540 Patients were discharged from the general practitioner hospital during the study period. The hospital accounted for 78% (1242 out of 1594) of all hospital admissions of patients of the practice. There were 5835 new attendances at the casualty department and 1896 new outpatient attendances at consultant clinics at the hospital. Of all new outpatient attendances by patients of the practice, 71% (1358 out of 1896) were at clinics held at the general practitioner hospital. Since the previous study in 1971 discharges from the hospital have increased 37% (from 1125 to 1540) and new attendances at consultant clinics 30% (from 1450 to 1896). The average cost per inpatient day is lower at this hospital than at the local district general hospital (pounds 71.07 v pounds 88.06 respectively). CONCLUSIONS--The general practitioner hospital deals with a considerably larger proportion of admissions and outpatient attendances of patients in the practice than in 1971 and eases the burden on the local district general hospital at a reasonable cost. IMPLICATIONS--General practitioner hospitals should have a future role in the NHS.     

Common bile duct injury during laparoscopic cholecystectomy in Ontario: Does ICD-9 coding indicate true incidence?

BACKGROUND: Recent reports in the scientific and lay press have suggested that bile duct injuries during laparoscopic cholecystectomy are common in Ontario. The reports were based on administrative data collected by hospital medical records departments and the Canadian Institute for Health Information (CIHI). The current study involved a direct inspection of hospital records to determine if the CIHI data accurately captured the rate of clinically significant bile duct complications. METHODS: For the period 1991 to 1995, records of bile duct injuries after laparoscopic cholecystectomy were independently evaluated to clarify the clinical significance of the complications. Of 21 Ontario hospitals for which data on complications had been reported in the media, 18 provided detailed information on all patients reported to have suffered bile duct complications classified by the hospital as "major". In addition, each institution provided information on a random sample of one-sixth of the patients who had suffered complications classified as "minor". The reviewer then examined each relevant hospital chart to assess the grade and significance of the reported complications. RESULTS: All 24 bile duct injuries classified by the hospitals as "major" were confirmed as major (clinically relevant) injuries. Of the 80 bile duct complications classified by the hospitals as "minor", 76 (95%) were irrelevant to patient outcome. The discrepancy between data collected and reported frequency of injury lies in the use of nonspecific coding methods. INTERPRETATION: The rate of significant bile duct injuries cannot be inferred from nonspecific codes taken from the International Classification of Diseases, ninth revision, and presented in hospital discharge records. Therefore, such data must be interpreted with extreme caution.     

Distribution of NHS funds between fundholding and non-fundholding practices.

OBJECTIVES--To estimate the amount spent on specific hospital care by health agencies in 1993-4 and compare it with the resources allocated to patients registered with fundholding practices for the same type of care. To investigate whether fundholding practices and health agencies pay different amounts for inpatient care. DESIGN--Examination of hospital episode statistics, 1991 census data, and family health services authority and health agency records. SETTING--Health agencies and fundholding practices in the former North West Thames Regional Health Authority. MAIN OUTCOME MEASURES--Amount per capita allocated to inpatient and outpatient care for patients registered with fundholding and non-fundholding practices. Average specialty cost per finished consultant episode for health agencies and fundholding practices. RESULTS--The ratio of per capita funding for patients in non-fundholding practices to those in fundholding practices ranged from 59% to 87% for inpatient and day case care and from 36% to 106% for outpatient care. Average specialty costs per episode were similar for fundholding practices and health agencies. CONCLUSIONS--Fundholding practices seem to have been funded more generously than non-fundholding practices in North West Thames.     

Universal precautions to prevent HIV transmission to health care workers: an economic analysis.

The universal precautions recommended by the US Centers for Disease Control (CDC), Atlanta, for the prevention of HIV (human immunodeficiency virus) transmission to health care workers are widely accepted, despite little documentation of their effectiveness and efficiency. We reviewed the evidence on the risk of HIV transmission to hospital workers and the effectiveness of the universal precautions. We also evaluated the costs of implementing the recommendations in a 450-bed acute care teaching hospital in Hamilton, Ont. On the basis of aggregated results from six prospective studies the risk of HIV seroconversion among hospital workers after a needlestick injury involving a patient known to have AIDS (acquired immune deficiency syndrome) is 0.36% (upper 95% confidence limit 0.67%); the risk after skin and mucous membrane exposure to blood or other body fluids of AIDS patients is 0% (upper 95% confidence limit 0.38%). We estimated that 0.038 cases of HIV seroconversion would be prevented annually in the study hospital if the CDC recommendations were followed. The incremental cost of implementing the universal precautions was estimated to be about $315,000 per year, or over $8 million per case of HIV seroconversion prevented. If all HIV-infected workers were assumed to have AIDS within 10 years of infection the of the program would be about $565,000 per life-year saved. When less conservative, more probable assumptions were applied the best estimate of the implementation cost was $128,862,000 per case of HIV seroconversion prevented. The universal precautions implemented in the study hospital were not found to be efficacious or cost-effective. To minimize the already small risk of HIV transmission in hospitals the sources of risk of percutaneous injury should be better defined and the design of percutaneous lines, needles and surgical equipment as well as techniques improved. Preventive measures recommended on the basis of demonstrated efficacy and aimed at routes of exposure that represent true risk are needed.