Are dual eligibles admitted to poorer quality skilled nursing facilities?

BACKGROUND

Dual eligibles, persons who qualify for both Medicare and Medicaid coverage, often receive poorer quality care relative to other Medicare beneficiaries.

OBJECTIVES

To determine whether dual eligibles are discharged to lower quality post-acute skilled nursing facilities (SNFs) compared with Medicare-only beneficiaries.

RESEARCH DESIGN

Following the random utility maximization model, we specified a discharge function using a conditional logit model and tested how this discharge rule varied by dual-eligibility status.

SUBJECTS

A total of 692,875 Medicare fee-for-service patients (22% duals) who were discharged for Medicare paid SNF care between July 2004 and June 2005.

MEASURES

Medicare enrollment and the Medicaid Analytic Extract files were used to determine dual eligibility. The proportion of Medicaid patients and nursing staff characteristics provided measures of SNF quality.

RESULTS

Duals are more likely to be discharged to SNFs with a higher share of Medicaid patients and fewer nurses. These results are robust to estimation with an alternative subsample of patients based on primary diagnoses, propensity of being dual eligible, and likelihood of remaining in the nursing home.

CONCLUSIONS

Disparities exist in access to quality SNF care for duals. Strategies to improve discharge planning processes are required to redirect patients to higher quality providers, regardless of Medicaid eligibility.

Mind the gaps: what's missing from current economic evaluations of universal HPV vaccination?

BACKGROUND

Since the original licensing of human papilloma virus (HPV) vaccination for women, evidence is accumulating of its effectiveness in preventing HPV-related conditions in men, and universal vaccination (vaccinating men and women) is now recommended in some countries. Several models of the cost-effectiveness of universal HPV vaccination have been published, but results have been mixed. This article assesses the extent to which economic studies have captured the range of values associated with universal HPV vaccination, and how this influences estimates of its cost-effectiveness.

METHODS

Eight published economic evaluations of universal HPV vaccination were reviewed to identify which of the values associated with universal HPV vaccination were included in each analysis.

RESULTS

Studies of the cost-effectiveness of universal HPV vaccination capture only a fraction of the values generated. Most studies focused on impacts on health and health system cost, and only captured these partially. A range of values is excluded from most studies, including impacts on productivity, patient time and costs, carers and family costs, and broader social values such as the right to access treatment. Further, those studies that attempted to capture these values only did so partially.

DISCUSSION

Decisions to invest in universal HPV vaccination need to be based on a complete assessment of the value that it generates. This is not provided by existing economic evaluations. Further work is required to understand this value. First, research is required to understand how HPV-related health outcomes impact on society including, for instance, their impact on productivity. Second, consideration should be given to alternative approaches to capture this broader set of values in a manner useful to decisions-makers, such as multi-criteria decision analysis.

The economic cost of nonepileptic attack disorder in Ireland

The present study endeavored to calculate a conservative estimate of both incidence- and prevalence-based costs of nonepileptic attack disorder (NEAD) in Ireland by applying previously identified prevalence figures to Irish population figures. Variables related to the economic cost of NEAD were identified based on a retrospective chart review of patients diagnosed with NEAD at Beaumont Hospital, Dublin. The annual cost per patient of undiagnosed NEAD was calculated as €20,995.30. The combined cost of diagnosis and psychological treatment of NEAD was estimated at €8728. Although it is difficult to determine precise economic costings, early diagnosis and intervention would result in a significant economic saving to the exchequer, a reduction in hospital waiting-list times, and a better prognosis for patients.

The role of GP's compensation schemes in diabetes care: evidence from panel data

We investigate the impact of the implementation of Diabetes Management Programs with financial incentives in the Italian Region Emilia-Romagna between 2003 and 2005. We focus on avoidable hospitalisations for diabetic patients for whom GPs receive additional payments exceeding capitation. We estimate a panel count data model to test the hypothesis that those patients under the responsibility of GPs receiving a higher share of their income through ad-hoc payments, are less likely to experience avoidable hospitalisations. Our findings indicate that financial transfers may help improve the quality of care, even when they are not based on the ex-post verification of performance. The estimated effect indicates that, at sample averages, an increase of 100 Euros of the financial incentives paid to GPs (around 17% of the yearly payment received by GPs for diabetes programmes) is expected to reduce the number of diabetic ACSCs by 1%, around 100 cases when projected on the entire region.

Inclusiveness in the health economic evaluation space

This paper presents an overview of Gavin Mooney's contributions to broadening the evaluative space in health economics. It outlines how Mooney's ideas have encouraged many, including ourselves, to expand the conventional QALYs/health gain approach and look more broadly at what it is that is of value from health services. We reflect on Mooney's contributions to debates around cost-effectiveness analysis, Quality Adjusted Life Years (QALYs) and cost-utility analysis as well as his contribution to the development and application of contingent valuation and discrete choice experiments in health economics. We conclude by suggesting important avenues for future research to take forward Mooney's work.

Design of Economic Evaluations of Mindfulness-Based Interventions: Ten Methodological Questions of Which to Be Mindful

Mindfulness-based interventions (MBIs) are being increasingly applied in a variety of settings. A growing body of evidence to support the effectiveness of these interventions exists and there are a few published cost-effectiveness studies. With limited resources available within public sectors (health care, social care, and education), it is necessary to build in concurrent economic evaluations alongside trials in order to inform service commissioning and policy. If future research studies are well-designed, they have strong potential to investigate the economic impact of MBIs. The particular challenge to the health economist is how best to capture the ways that MBIs help people adjust to or build resilience to difficult life circumstances, and to disseminate effectively to enable policy makers to judge the value of the contribution that MBIs can make within the context of the limited resourcing of public services. In anticipation of more research worldwide evaluating MBIs in various settings, this article suggests ten health economics methodological design questions that researchers may want to consider prior to conducting MBI research. These questions draw on both published standards of good methodological practice in economic evaluation of medical interventions, and on the authors’ knowledge and experience of mindfulness-based practice. We argue that it is helpful to view MBIs as both complex interventions and as public health prevention initiatives. Our suggestions for well-designed economic evaluations of MBIs in health and other settings, mirror current thinking on the challenges and opportunities of public health economics.

Acute costs and predictors of higher treatment costs of trauma in New South Wales, Australia

BACKGROUND

Accurate economic data are fundamental for improving current funding models and ultimately in promoting the efficient delivery of services. The financial burden of a high trauma casemix to designated trauma centres in Australia has not been previously determined, and there is some evidence that the episode funding model used in Australia results in the underfunding of trauma.

AIM

To describe the costs of acute trauma admissions in trauma centres, identify predictors of higher treatment costs and cost variance in New South Wales (NSW), Australia.

MATERIALS AND METHODS

Data linkage of admitted trauma patient and financial data provided by 12 Level 1 NSW trauma centres for the 08/09 financial year was performed. Demographic, injury details and injury scores were obtained from trauma registries. Individual patient general ledger costs (actual trauma patient costs), Australian Refined Diagnostic Related Groups (AR-DRG) and state-wide average costs (which form the basis of funding) were obtained. The actual costs incurred by the hospital were then compared with the state-wide AR-DRG average costs. Multivariable multiple linear regression was used for identifying predictors of costs.

RESULTS

There were 17,522 patients, the average per patient cost was $10,603 and the median was $4628 (interquartile range: $2179-10,148). The actual costs incurred by trauma centres were on average $134 per bed day above AR-DRG costs-determined costs. Falls, road trauma and violence were the highest causes of total cost. Motor cyclists and pedestrians had higher median costs than motor vehicle occupants. As a result of greater numbers, patients with minor injury had comparable total costs with those generated by patients with severe injury. However the median cost of severely injured patients was nearly four times greater. The count of body regions injured, sex, length of stay, serious traumatic brain injury and admission to the Intensive Care Unit were significantly associated with increased costs (p<0.001).

CONCLUSION

This multicentre trauma costing study demonstrated the feasibility of trauma registry and financial data linkage. Discrepancies between the observed costs of care in these 12 trauma centres and the NSW average AR-DRG costs suggest that trauma care is currently underfunded in NSW.

Introduction to health economics and decision-making: Is economics relevant for the frontline clinician?

In a climate of escalating demands for new health care services and significant constraints on new resources, the disciplines of health economics and health technology assessment (HTA) have increasingly been turned to as explicit evidence-based frameworks to help make tough health care access and reimbursement decisions. Health economics is the discipline of economics concerned with the efficient allocation of health care resources, essentially trying to maximize health benefits to society contingent upon available resources. HTA is a broader field drawing upon several disciplines, but which relies heavily upon the tools of health economics and economic evaluation. Traditionally, health economics and economic evaluation have been widely used at the political (macro) and local (meso) decision-making levels, and have progressively had an important role even at informing individual clinical decisions (micro level). The aim of this paper is to introduce readers to health economics and discuss its relevance to frontline clinicians. Particularly, the content of the paper will facilitate clinicians' understanding of the link between economics and their medical practice, and how clinical decision-making reflects on health care resource allocation.

COPD exacerbation frequency, pharmacotherapy and resource use: an observational study in UK primary care

Chronic Obstructive Pulmonary Disease (COPD) management represents a significant health resource use burden. Understanding of current resource use, treatment strategies and outcomes can improve future COPD management, for patient benefit and to aid efficient service delivery. This study aimed to describe exacerbation frequency, pharmacotherapy and health resource use in COPD management in routine UK primary care. A retrospective, observational study using routine clinical records of 511 patients with COPD, was undertaken in 10 General Practices in England. Up to 3 years' patient data were collected and analysed. 75% (234/314) patients with mild-moderate COPD (≥50% predicted FEV1) received inhaled corticosteroids (ICS). 11% of patients (54/511) received ICS monotherapy. Mean (standard deviation) annual exacerbation frequency was 1.1 (1.2) in mild-moderate, 1.7 (1.6) in severe (30-49% predicted FEV1) and 2.2 (2.0) in very severe (<30% predicted FEV1) COPD. 14% patients (69/511) had a mean exacerbation frequency of ≥3/year ('frequent-exacerbators'); 9% (27/314) of patients with mild-moderate, 19% (27/145) with severe and 29% (15/52) with very severe COPD. 14% (10/69) of frequent-exacerbators failed to receive inhaled long-acting beta agonists (LABA), 25% (17/69) inhaled long-acting muscarinic antagonists (LAMA), and 12% (`/69) ICS. Frequent-exacerbators had a median of 6.67 primary care contacts/year, 1.0 secondary care visits/year and 21% were hospitalised for COPD/year. Inhaled therapy was frequently inappropriate, with over-use of ICS in patients with mild-moderate COPD. COPD exacerbations were associated with high health resource use and occurred at all levels of disease severity. COPD management strategies should encompass risk-stratification for both exacerbation frequency and physiological impairment.

Effect of hospital-SNF referral linkages on rehospitalization

OBJECTIVE

To determine whether the rate of rehospitalization is lower among patients discharged to skilled nursing facilities (SNFs) with which a hospital has a strong linkage.

DATA SOURCES/COLLECTION

We used national Medicare enrollment, claims, and the Minimum Data Set to examine 2.8 million newly discharged patients to 15,063 SNFs from 2,477 general hospitals between 2004 and 2006.

STUDY DESIGN

We examined the relationship between the proportion of discharges from a hospital and alternative SNFs on the rehospitalization of patients treated by that hospital-SNF pair using an instrumental variable approach. We used distances to alternative SNFs from residence of the patients of the originating hospital as the instrument.

PRINCIPAL FINDINGS

Our estimates suggest that if the proportion of a hospital's discharges to an SNF was to increase by 10 percentage points, the likelihood of patients treated by that hospital-SNF pair to be rehospitalized within 30 days would decline by 1.2 percentage points, largely driven by fewer rehospitalizations within a week of hospital discharge.

CONCLUSIONS

Stronger hospital-SNF linkages, independent of hospital ownership, were found to reduce rehospitalization rates. As hospitals are held accountable for patients' outcomes postdischarge under the Affordable Care Act, hospitals may steer their patients preferentially to fewer SNFs.

The cost analysis of cemented versus cementless total hip replacement operations on the NHS

In a time of limited resources, the debate continues over which types of hip prosthesis are clinically superior and more cost-effective. Orthopaedic surgeons increasingly need robust economic evidence to understand the full value of the operation, and to aid decision making on the 'package' of procedures that are available and to justify their practice beyond traditional clinical preference. In this paper we explore the current economic debate about the merits of cemented and cementless total hip replacement, an issue that continues to divide the orthopaedic community.

A systematic review of cost-effectiveness of monoclonal antibodies for metastatic colorectal cancer

Metastatic colorectal cancer (mCRC) imposes a substantial health burden on patients and society. In recent years, advances in the treatment of mCRC have mainly resulted from the introduction of monoclonal antibodies (MoAbs). However, the application of these MoAbs considerably increases treatment costs. The objective of this article is to review and assess the economic evidence of MoAB treatment in mCRC. A systematic literature review was conducted and cost-effectiveness (CE) as well as cost-utility-studies were identified. For this, Medline, Embase, SciSearch, Cochrane, and nine other databases were searched from 2000 through February 2013 for full-text publications. The quality of the studies was assessed via a validated assessment tool (Quality of Health Economic Studies (QHES)). A total of 843 publications were screened. Of those, 15 studies involving the MoAbs bevacizumab, cetuximab and panitumumab met all inclusion criteria. Four studies analysed the CE of first-line treatment with bevacizumab and nine the CE of cetuximab in subsequent treatment lines. Two studies dealt with the CE of panitumumab. The analysis of sequential regimes and the direct comparison of two MoABs were analysed by only one study each. The quality of the included studies was high with the exception of one study.

CONCLUSIONS

The treatment with bevacizumab, cetuximab and panitumumab is mainly considered to be not cost-effective in patients with mCRC. However, testing for Kirsten ras oncogene (KRAS) mutation prior to the treatment with cetuximab or panitumumab is found to be clearly cost-effective compared to no testing. Future research should focus on the CE of first-line treatment with cetuximab or panitumumab and studies on upcoming agents like regorafenib and aflibercept.

Global prevalence and economic burden of urgency urinary incontinence: a systematic review

CONTEXT

The prevalence and economic burden of urgency urinary incontinence (UUI) are difficult to ascertain because of overlap with data on overactive bladder and other types of incontinence.

OBJECTIVE

To summarize the evidence on the global prevalence and economic burden of UUI.

EVIDENCE ACQUISITION

A PubMed search was performed used the following terms: (urgency urinary incontinence OR urge incontinence OR mixed incontinence OR overactive bladder) AND (burden OR cost OR economic OR prevalence). A similar search was conducted using Embase. English-language articles published from 1991 through 2013 on non-neurogenic UUI were retained.

EVIDENCE SYNTHESIS

We retained 54 articles (50 studies); 22 large-scale, population-based surveys indicated varying UUI prevalence estimates with ranges of 1.8-30.5% in European populations, 1.7-36.4% in US populations, and 1.5-15.2% in Asian populations, with prevalence dependent on age and gender. Nineteen smaller-scale studies supported these findings. Despite varying methods, 11 studies estimating the costs of UUI worldwide consistently concluded that the economic burden is substantial and will increase markedly as the population ages. In a 2005 multinational study, the annual cost-of-illness estimate for UUI in Canada, Germany, Italy, Spain, Sweden, and the United Kingdom was €7 billion. A US cost-of-illness study reported a total cost of $66 billion in 2007 US dollars. The costs of routine care and nursing home admissions for UUI were major contributors to the cost.

CONCLUSIONS

UUI affects millions of men and women worldwide. Current evidence demonstrates the substantial economic burden of UUI to patients and society. Worldwide public health and clinical management programs are needed to improve UUI awareness and highlight the need for early diagnosis and management.

Infection prevention and control strategies in the era of limited resources and quality improvement: a perspective paper

This paper aims to describe, using an evidence-based approach, the importance of and the resources necessary for implementing effective infection prevention and control (IPC) programmes. The intrinsic and explicit values of such strategies are presented from a clinical, health-economic and patient safety perspective. Policy makers and hospital managers are committed to providing comprehensive, accessible, and affordable healthcare of high quality. Changes in the healthcare system over time accompanied with variations in demographics and case-mix have considerably affected the availability, quality and ultimately the safety of healthcare. The main goal of an IPC programme is to prevent and control healthcare-associated infections (HAI). Many patient-, healthcare provider-, and organizational factors are associated with an increased risk for acquiring HAIs and may impact both the quality and outcome of patient care. Evidence has been published in support of having an effective IPC programme. It has been estimated that about one-third of HAIs could be prevented if key elements of the evidence-based recommendations for IPC are adequately introduced and followed. However, several healthcare agencies from over the world have reported deficits in the essential resources and components of current IPC programmes. To meet its main goal, staffing, training, and infrastructure requirements are needed. Nevertheless, and given the economic crisis, policy makers and hospital managers may be tempted to not increase or even to reduce the budget as it consumes resources and does not generate sufficient visible revenue. IPC is a critical issue in patient safety, as HAIs are by far the most common complication affecting admitted patients. The significant clinical and health-economic burden HAIs place on the healthcare system speak to the importance of getting introduced effective IPC programmes.

A validated clinical tool for the prediction of varices in PBC: the Newcastle Varices in PBC Score

BACKGROUND & AIMS

Gastro-oesophageal varices (GOV) can occur in early stage primary biliary cirrhosis (PBC), making it difficult to identify the appropriate time to begin screening with oesophageo-gastro-duodenoscopy (OGD). Our aim was to develop and validate a clinical tool to predict the probability of finding GOV in PBC patients.

METHODS

A cross-sectional retrospective study analysing clinical data of 330 PBC patients who underwent an OGD at the Freeman Hospital, Newcastle was used to create a predictive tool, the Newcastle Varices in PBC (NVP) Score, that was externally validated in PBC patients from Cambridge (UK) and Toronto (Canada).

RESULTS

48% of the Newcastle, 31% of the Cambridge, and 22% of the Toronto cohorts of PBC patients had GOV. Twenty-five percent (95% CI 18-32%) of the Newcastle cohort had GOV diagnosed at an index variceal bleed. Of the others, 37% (95% CI 28-46%) bled after a median of 1.5 years (IQR 3.75). Transplant-free survival was significantly better in those without GOV than in those with GOV (p<0.001), but similar in patients with GOV that bled and those that did not (p=0.1). The NVP score (%Probability)=1/[1+exp^-(9.186+0.001*alkaline phosphatase in IU-0.178*albumin in g/L-0.015*platelet × 10(9)) was validated in 2 external cohorts and was highly discriminant (AUROC 0.86). Cost consequences analyses revealed the NVP score to be as accurate as, but more economical than using either OGD directly or other risk scores for screening PBC patients.

CONCLUSIONS

The NVP score is an inexpensive, non-invasive, externally validated tool that accurately predicts GOV in PBC.

Basic Principles of Health Economics Applied - How to Assess if Transcatheter Aortic Valve Implantation is Worth the Investment

This article attempts to present some highlights from the rich economic literature pertaining to interventional cardiology and transcatheter aortic valve implantation (TAVI). There are currently more questions than answers, not surprisingly given the pace of technological change in interventional cardiology. For clinicians who work in a strictly regulated environment and have limited control over their use of medical technologies, this article will hopefully shed some light on the motives for policy decisions. For clinicians who make decisions on the resources used to treat their patients, it aims to provide the means of looking for evidence that will allow for informed decisions from both clinical and economic perspectives.

Health economics and cost-effectiveness research with special reference to hemato-oncology

The cost of health care is increasing globally, especially in cancer. Health economics is an increasingly important field and medical professionals should have a working knowledge of the basis for health technology assessment such as cost-effectiveness analysis, cost utility analysis and cost benefit analysis. There are limited studies on health technology assessment regarding expensive therapies, primarily from high-income countries, but these cannot be applied to countries with different gross domestic product (GDP) and cost of health care delivery. There is a need to carry out health economics related research utilizing data from India. Whereas clinical trials establish the efficacy of new drugs in controlled environments, with strict inclusion and exclusion criteria, their transferability to the "real-world" situation is not always true. With the shifting of the global cancer burden to middle-income and lower middle-income countries, this field is going to assume greater importance in the future. Health economics research conducted in India may be of benefit to other countries with similar economies. The Armed Forces Medical Services of India, with a well-established system of assessing health outcomes, and robust system of accounting for expenses, can provide the lead for these studies.

The economic costs of routine INR monitoring in infants and children--examining point-of-care devices used within the home setting compared to traditional anticoagulation clinic monitoring

INTRODUCTION

The use of point-of-care (POC) devices within the home for routine INR monitoring has demonstrated reliability, safety and effectiveness in the management of infants and children requiring long-term warfarin therapy. However, a comprehensive cost-analysis of using this method of management, compared to attending anticoagulation clinics has not been reported. The aim of this study was to compare the estimated societal costs of attending anticoagulation clinics for routine INR monitoring to using a POC test in the home.

MATERIALS AND METHODS

This study used a comparative before-and-after design that included 60 infants and children managed via the Haematology department at a tertiary paediatric centre. Each participant was exposed to both modes of management at various times for a period of ≥3 months. A questionnaire, consisting of 25 questions was sent to families to complete and return. Data collected included: the frequency of monitoring, mode of travel to and from clinics, total time consumed, and primary carer's income level.

RESULTS

The home monitoring cohort saved a total of 1 hour 19 minutes per INR test compared to attending anticoagulation clinics and had a cost saving to society of $66.83 (AUD) per INR test compared to traditional care; incorporating health sector costs, travel expenses and lost time.

CONCLUSIONS

The traditional model of care requires a considerable investment of time per test from both child and carer. Home INR monitoring in infants and children provides greater societal economic benefits compared to traditional models.

United States-based practice patterns and resource utilization in advanced neuroendocrine tumor treatment

AIM

To assess advanced neuroendocrine tumor (NET) treatment patterns and resource utilization by tumor progression stage and tumor site in the United States.

METHODS

United States Physicians meeting eligibility criteria were provided with online data extraction forms to collect patient chart data on recent NET patients. Resource utilization and treatment pattern data were collected over a baseline period (after diagnosis and before tumor progression), as well as initial and secondary progression periods, with progression defined according to measureable radiographic evidence of tumor progression. Resource categories used in the analysis include: Treatments (e.g., surgery, chemotherapy, radiotherapy, targeted therapies), hospitalizations and physician visits, diagnostic tests (biomarkers, imaging, laboratory tests). Comparisons between categories of resource utilization and tumor progression status were examined using univariate (by tumor site) and multivariate analyses (across all tumor sites).

RESULTS

Fifty-five physicians were included in the study and completed online data extraction forms using the charts of 110 patients. The physician sample showed a relatively even distribution for those affiliated with academic versus community hospitals (46% vs 55%). Forty (36.3%) patients were reported to have pancreatic NET (pNET), while 70 (63.6%) patients had gastrointestinal tract (GI)/Lung as the primary NET site. Univariate analysis showed the proportion of patients hospitalized increased from 32.7% during baseline to 42.1% in the progression stages. While surgeries were performed at similar proportions overall at baseline and progression, pNET patients, were more likely than GI/Lung NET patients to have undergone surgery during the baseline (33.3% vs 25.0%) and any progression periods (26.7% vs 23.4%). While peptide-receptor radionuclide and targeted therapy utilization was low across NET types and tumor stages, GI/Lung types exhibited greater utilization of these technologies compared to pNET. Chemotherapy utilization was also greater among GI/Lung types. Multivariate analysis results demonstrated that patients in first progression period were over 3 times more likely to receive chemotherapy when compared to baseline (odds ratio: 3.31; 95%CI: 1.46-7.48, P = 0.0041). Further, progression was associated with a greater likelihood of having a study physician visit [relative risk (RR): 1.54; 95%CI: 1.10-2.17, P = 0.0117], and an increased frequency of other physician visits (RR: 1.84; 95%CI: 1.10-3.10, P = 0.0211).

CONCLUSION

Resource utilization in advanced NET in the United States is significant overall and data suggests progression has an impact on resource utilization regardless of NET tumor site.

The effect of parity on expenditures for individuals with severe mental illness

OBJECTIVE

To determine whether comprehensive behavioral health parity leads to changes in expenditures for individuals with severe mental illness (SMI), who are likely to be in greatest need for services that could be outside of health plans' traditional limitations on behavioral health care.

DATA SOURCES/STUDY SETTING

We studied the effects of a comprehensive parity law enacted by Oregon in 2007. Using claims data, we compared expenditures for individuals in four Oregon commercial plans from 2005 through 2008 to a group of commercially insured individuals in Oregon who were exempt from parity.

STUDY DESIGN

We used difference-in-differences and difference-in-difference-in-differences analyses to estimate changes in spending, and quantile regression methods to assess changes in the distribution of expenditures associated with parity.

PRINCIPAL FINDINGS

Among 2,195 individuals with SMI, parity was associated with increased expenditures for behavioral health services of $333 (95 percent CI $67, $615), without corresponding increases in out-of-pocket spending. The increase in expenditures was primarily attributable to shifts in the right tail of the distribution.

CONCLUSIONS

Oregon's parity law led to higher average expenditures for individuals with SMI. Parity may allow individuals with high mental health needs to receive services that may have been limited without parity regulations.

Polity and health care expenditures: the association among 159 nations

This paper hypothesized that democratic nations, as characterized by Polity IV Project regime scores, spend more on health care than autocratic nations and that the association reported here is independent of other demographic, health system or economic characteristics of nations. WHO Global Observatory data on 159 nations with roughly 98% of the world's population were examined. Regime scores had significant, direct and independent associations with each of four measures of health care expenditure. For every unit increment in a nation's regime score toward a more democratic authority structure of governance, we estimated significant (p<0.05) increments in the percent of GDP expended on health care (+0.14%), percent of general government expenditures targeted to health care (+0.25%), total per capita expenditures on health (+34.4Int$) and per capita general government expenditures (+22.4Int$), while controlling for a population's age distribution, life expectancy, health care workforce and system effectiveness and gross national income. Moreover, these relationships were found to persist across socio-economic development levels. The finding that practices of health care expenditure and authority structures of government co-vary is instructive about the politics of health and the challenges of advancing global health objectives.

Economic constraints - the growing challenge for Western breast cancer centers

Breast cancer care in Western countries has reached a considerable level of quality and standardization, which has contributed to the decline in breast cancer mortality. Certified Breast Cancer Centers (BCC) represent an important element of this development. Related to changes in reimbursement and growing costs, BCC face economic constraints which ultimately could endanger the achievements of the past. Thus, BCC have to optimize their care strategies from an economic perspective, particularly by increasing efficiency but also by adapting their service portfolio. This could result in competitive advantages and additional revenue by increasing case numbers and extra charges to patients. Furthermore, an intensification of collaboration with the outpatient sector resulting in an integrated and managed 'trans-sectoral' care approach which could allow to shift unprofitable procedures to the outpatient sector - in the sense of a win-win situation for both sectors and without loss of care quality - seems reasonable. Structured and specialized consulting approaches can further be a lever to fulfill economic requirements in order to avoid cuts in medical care quality for the sake of a balanced budget. In this review, economic constraints of BCC with a focus on the German healthcare system and potential approaches to ameliorate these financial burdens are being discussed.

Impact of selection of cord blood units from the United States and swiss registries on the cost of banking operations

BACKGROUND

Over the last 2 decades, cord blood (CB) has become an important source of blood stem cells. Clinical experience has shown that CB is a viable source for blood stem cells in the field of unrelated hematopoietic blood stem cell transplantation.

METHODS

Studies of CB units (CBUs) stored and ordered from the US (National Marrow Donor Program (NMDP) and Swiss (Swiss Blood Stem Cells (SBSQ)) CB registries were conducted to assess whether these CBUs met the needs of transplantation patients, as evidenced by units being selected for transplantation. These data were compared to international banking and selection data (Bone Marrow Donors Worldwide (BMDW), World Marrow Donor Association (WMDA)). Further analysis was conducted on whether current CB banking practices were economically viable given the units being selected from the registries for transplant. It should be mentioned that our analysis focused on usage, deliberately omitting any information about clinical outcomes of CB transplantation.

RESULTS

A disproportionate number of units with high total nucleated cell (TNC) counts are selected, compared to the distribution of units by TNC available. Therefore, the decision to use a low threshold for banking purposes cannot be supported by economic analysis and may limit the economic viability of future public CB banking.

CONCLUSIONS

We suggest significantly raising the TNC level used to determine a bankable unit. A level of 125 × 10(7) TNCs, maybe even 150 × 10(7) TNCs, might be a viable banking threshold. This would improve the return on inventory investments while meeting transplantation needs based on current selection criteria.

Time to detoxify medical literature from guideline overdose

The current financial turmoil in the United States has been attributed to multiple reasons including healthcare expenditure. Health care spending has increased from 5.7 percent of the gross domestic product (GDP) in 1965 to 16 percent of the GDP in 2004. Healthcare is driven with a goal to provide best possible care available at that period of time. Guidelines are generally assumed to have the high level of certainty and security as conclusions generated by the conventional scientific method leading many clinicians to use guidelines as the final arbiters of care. To provide the standard of care, physicians follow guidelines, proposed by either groups of physicians or various medical societies or government organizations like National Comprehensive Cancer Network. This has lead to multiple tests for the patient and has not survived the test of time. This independence leads to lacunae in the standardization of guidelines, hence flooding of literature with multiple guidelines and confusion to patients and physicians and eventually overtreatment, inefficiency, and patient inconvenience. There is an urgent need to restrict articles with Guidelines and develop some strategy like have an intermediate stage of pre-guidelines and after 5-10 years of trials, a systematic launch of the Guidelines. There can be better ways than this for putting together guidelines as has been suggested by multiple authors and researchers.

Major Findings from The Changing Body: Health, Nutrition, and Human Development in the Western World since 1700

This paper discusses findings from The Changing Body: Health, Nutrition, and Human Development in the Western World since 1700 (Cambridge University Press) The book is built on the authors' work with 300 years of height and nutrition data and discusses their findings in the context of technophysio evolution, a uniquely modern form of rapid physiological development, the result of humanity's ability to control its environment and create technological innovations to adapt to it.

Health care market deviations from the ideal market

A common argument in the health policy debate is that market forces allocate resources efficiently in health care, and that government intervention distorts such allocation. Rarely do those making such claims state explicitly that the market they refer to is an ideal in economic theory which can only exist under very strict conditions. This paper explores the strict conditions necessary for that ideal market in the context of health care as a means of examining the claim that market forces do allocate resources efficiently in health care.

Cost-effectiveness analysis of early veno-venous hemofiltration for severe acute pancreatitis in China

AIM: To determine the most cost-effective hemofiltration modality for early management of severe acute pancreatitis (SAP) in China.

METHODS: We carried out a search of Pub-Medline and Chinese Biomedical Disk database. Controlled clinical trials on Chinese population were included in the analysis. The four decision branches that were analyzed were: continuous or long-term veno-venous hemofiltration (CVVH/LVVH), short-term veno-venous hemofiltration (SVVH), SVVH plus peritoneal dialysis (PD), and non-hemofiltration control group. The effectiveness of the technique was determined by survival rate, complications prevention and surgery preservation. The total cost of hospitalization was also assessed.

RESULTS: The SVVH only technique was the least costly modality, $5809 (44 449 RMB), and was selected as the baseline treatment modality. SVVH only arm achieved the lowest C/E ratio in terms of overall survival, complications prevention and surgery preservation. In incremental cost-effectiveness analysis, the CVVH/LVVH only and the control arms were inferior to other techniques. Sensitivity analysis showed SVVH only and SVVH plus PD arms overlapped in C/survival ratio.

CONCLUSION: The role of early veno-venous hemofiltration as an alternative therapy for SAP remains controversial. However, we propose that early use of short-term high-volume veno-venous hemofiltration would have a beneficial impact on the management of SAP.