Utilization of pharmacists in physician assistant didactic curricula in the United States

INTRODUCTION

The primary objective was to describe the percentage of physician assistant (PA) programs who utilize pharmacists to lecture on pharmacology/pharmacotherapeutics content. Secondary objectives were to describe the percentage of pharmacology/pharmacotherapeutics lectures pharmacists deliver, the percentage of programs who employ a full-time pharmacist to coordinate the Pharmacology/Pharmacotherapeutics courses, and the inclusion of pharmacists in other courses in the curricula.

METHODS

This was a prospective, cross-sectional, cohort survey. All PA programs listed on the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) website with an available email address for the Director of Pre-Clinical Education/Didactic Education, Academic Coordinator, or Chair/Director were recruited for the study. A link to an online survey was distributed to each program. The survey collected data on program characteristics as well as utilization of pharmacists in the curriculum. Descriptive statistics were used for all analyses.

RESULTS

Of the 187 programs receiving the survey, 66 completed the survey (35%). Eighty-three percent of programs reported that pharmacists were utilized to deliver pharmacology/pharmacotherapeutics content. For those programs who utilize pharmacists, 80% reported pharmacists teach more than 75% of the lectures. Twenty-three (35%) programs reported having a full-time pharmacist on faculty to coordinate these courses. Almost half of respondents also commented that pharmacists were involved in other courses in the curriculum.

CONCLUSIONS

More than 80% of programs responding to the survey utilize pharmacists to deliver pharmacology/pharmacotherapeutics content. Studying the utilization of pharmacists and their impact in other health sciences curricula is warranted.

Predicting construction disputes: an aetiological approach

There is considerable interest in construction disputes among both researchers and practitioners; however, most of that interest is in the techniques used to resolve disputes. Practitioners are understandably interested in efficiency in resolution; human nature perhaps allows them to expect that disputes are inevitable. However, there seems to be little interest among researchers in considering the wider issues associated with disputes, which might allow explanation and prediction. There is little empirical evidence in the literature and anecdote abounds. This paper aims to generate debate by proposing that an aetiological approach to construction disputes is to be welcomed since it may lead to explanation or prediction of construction disputes. The work is theoretical and it is argued that the lack of an empirical base means that there has been little scientific consideration of construction disputes. Although it is commonly accepted that disputes need to be avoided, the absence of any empirical data dictates that structured prediction and avoidance are unlikely. An aetiological approach to construction disputes will help develop a mature and sophisticated research base, which may help industry performance. Prediction allows avoidance or at least informed management action if avoidance is not preferred.

A model to estimate the lifetime health outcomes of patients with type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model (UKPDS no. 68)

AIMS/HYPOTHESIS

The aim of this study was to develop a simulation model for type 2 diabetes that can be used to estimate the likely occurrence of major diabetes-related complications over a lifetime, in order to calculate health economic outcomes such as quality-adjusted life expectancy.

METHODS

Equations for forecasting the occurrence of seven diabetes-related complications and death were estimated using data on 3642 patients from the United Kingdom Prospective Diabetes Study (UKPDS). After examining the internal validity, the UKPDS Outcomes Model was used to simulate the mean difference in expected quality-adjusted life years between the UKPDS regimens of intensive and conventional blood glucose control.

RESULTS

The model's forecasts fell within the 95% confidence interval for the occurrence of observed events during the UKPDS follow-up period. When the model was used to simulate event history over patients' lifetimes, those treated with a regimen of conventional glucose control could expect 16.35 undiscounted quality-adjusted life years, and those receiving treatment with intensive glucose control could expect 16.62 quality-adjusted life years, a difference of 0.27 (95% CI: -0.48 to 1.03).

CONCLUSIONS/INTERPRETATIONS

The UKPDS Outcomes Model is able to simulate event histories that closely match observed outcomes in the UKPDS and that can be extrapolated over patients' lifetimes. Its validity in estimating outcomes in other groups of patients, however, remains to be evaluated. The model allows simulation of a range of long-term outcomes, which should assist in informing future economic evaluations of interventions in type 2 diabetes.

Cost effectiveness of photodynamic therapy with verteporfin for age related macular degeneration: the UK case

AIM

To estimate the potential cost effectiveness of photodynamic therapy (PDT) with verteporfin in the UK setting.

METHODS

Using data from a variety of sources a Markov model was built to produce estimates of the cost effectiveness (incremental cost per quality adjusted life year (QALY) and incremental cost per vision year gained) of PDT for two cohorts of patients (one with starting visual acuity (VA) of 20/40 and one at 20/100) with predominantly classic choroidal neovascular disease over a 2 year and 5 year time horizon. A government perspective and a treatment cost only perspective were considered. Probabilistic and one way sensitivity analyses were undertaken.

RESULTS

From the government perspective, over the 2 year period, the expected incremental cost effectiveness ratios range from 286 000 (starting VA 20/100) to 76 000 UK pounds (starting VA 20/40) per QALY gained and from 14 000 (20/100) to 34 000 UK pounds (20/40) per vision year gained. A 5 year perspective yields incremental ratios less than 5000 UK pounds for vision years gained and from 9000 (20/40) to 30 000 UK pounds (20/100) for QALYs gained. Without societal or NHS cost offsets included, the 2 year incremental cost per vision year gained ranges from 20 000 (20/100) to 40 000 UK pounds (20/40), and the 2 year incremental cost per QALY gained ranges from 412 000 (20/100) to 90 000 UK pounds (20/40). The 5 year time frame shows expected costs of 7000 (20/40) to 10 000 UK pounds (20/100) per vision year gained and from 38 000 (20/40) to 69 000 UK pounds (20/100) per QALY gained.

CONCLUSION

This evaluation suggests that early treatment (that is, treating eyes at less severe stages of disease) with PDT leads to increased efficiency. When considering only the cost of therapy, treating people at lower levels of visual acuity would probably not be considered cost effective. However, a broad perspective that incorporates other NHS treatment costs and social care costs suggests that over a long period of time, PDT may yield reasonable value for money.

Estimating the relationship between disease progression and cost of care in dementia

BACKGROUND

Previous studies have shown a positive relationship between disease severity and cost.

AIMS

To explore the factors affecting time to institutionalisation and estimate the relationship between the costs of care and disease progression.

METHOD

Retrospective analysis of a longitudinal data-set for a cohort of 100 patients diagnosed with Alzheimer's disease or vascular dementia.

RESULTS

Changes in both Mini-Mental State Examination (MMSE) and Barthel scores have independent and significant marginal effects on costs. Each one-point decline in the MMSE score is associated with a pound sterling 56 increase in the four-monthly costs, whereas each one-point fall in the Barthel index is associated with a pound sterling 586 increase in costs.

CONCLUSIONS

It may be inappropriate for economic models of disease progression in dementia to be based solely on measures of cognitive change. MMSE and the Barthel index are independent significant predictors of time to institutionalisation and cost of care, but changes in the Barthel index are particularly important in predicting costs outside institutional care.

The excess cost of acute exacerbations of chronic bronchitis in patients aged 45 and older in England and Wales

INTRODUCTION

Chronic Bronchitis is a serious and costly health problem. Prevalence is estimated at 45 per 10,000 persons in the United Kingdom. Approximately 120,000 Pounds would be saved for every 100 hospital admissions avoided. A reduction in acute exacerbations of chronic bronchitis (AECB), treatment failures, and subsequent hospital admission could have a significant impact on the burden of AECB borne by secondary care facilities in the UK National Health Service (NHS).

OBJECTIVE

The aim of this study is to provide an economic assessment of the direct cost to the health care system associated with the management of chronic bronchitis and its acute exacerbations.

DESIGN

A prevalence-based, excess-cost-of-illness analysis is undertaken from the perspective of the UK NHS. Disease prevalence data, primary health care resource utilization, hospital inpatient and outpatient resource utilization, and costs of health care were taken from a variety of data sources, including a large UK national survey of general practice (GP) consultations, the General Practice Research Database, a survey from a single NHS hospital trust, and the national health-care resource and cost statistics.

RESULTS

From 1994 to 1995, approximately 233,000 cases of chronic bronchitis were detected in the persons aged 45 and older in the United Kingdom. Prevalence peaked at 204 per 10,000 in the group of subjects aged 75 to 84 years. During that same period, the total excess cost of primary care associated with AECB was calculated at 35.7 million Pounds. The largest component of primary care costs was the excess cost of all prescription medicines, which totaled 27.8 million Pounds. The excess cost attributed to antibacterial and respiratory prescription medications alone was estimated at 9 million Pounds. Excess costs attributed to GP consultations and hospital emergency room visits were 6.5 million Pounds and 1.3 million Pounds, respectively. The excess costs arising from inpatient hospital episodes included 8.3 million Pounds for hospital admissions, 660,000 Pounds for outpatient costs, and 225,000 Pounds for day care.

CONCLUSIONS

These results suggest that improving the management of AECB with the objective of reducing the number of AECB treatment failures and the associated hospital admissions could significantly reduce expenditures by the UK NHS.

Current cost of medical negligence in NHS hospitals: analysis of claims database

OBJECTIVES

To identify trends in the incidence and cost of clinical negligence claims. To determine the current annual cost to the NHS as a whole in terms of cash paid out to patients and their solicitors and the defence costs incurred.

DESIGN

Analysis of records on database.

SETTING

A well defined group of hospitals within one health authority which collected information on a consistent basis over many years.

MAIN OUTCOME MEASURES

Data on individual claims. Trends in incidence of claims and costs identified independently from organisational reforms and changes in accounting practices.

RESULTS

The rate of litigation increased from 0.46 to 0.81 closed claims per 1000 finished consultant episodes between 1990 and 1998. Overall expenditure on clinical negligence by the NHS in England in 1998 was estimated at 84 pound sterling million (95% confidence interval 48 pound sterling million to 130 pound sterling million).

CONCLUSIONS

After adjustment for hospital activity, the rate of closed claims increased during the 1990s by about 7% per annum, a substantial rate of growth but not the uncontrolled explosion sometimes alluded to in the wider media. More coordination and openness are needed in data collection.

Cost effectiveness of an intensive blood glucose control policy in patients with type 2 diabetes: economic analysis alongside randomised controlled trial (UKPDS 41). United Kingdom Prospective Diabetes Study Group

OBJECTIVE

To estimate the cost effectiveness of conventional versus intensive blood glucose control in patients with type 2 diabetes.

DESIGN

Incremental cost effectiveness analysis alongside randomised controlled trial.

SETTING

23 UK hospital clinic based study centres.

PARTICIPANTS

3867 patients with newly diagnosed type 2 diabetes (mean age 53 years).

INTERVENTIONS

Conventional (primarily diet) glucose control policy versus intensive control policy with a sulphonylurea or insulin.

MAIN OUTCOME MEASURES

Incremental cost per event-free year gained within the trial period.

RESULTS

Intensive glucose control increased trial treatment costs by pound 695 (95% confidence interval pound 555 to pound 836) per patient but reduced the cost of complications by pound 957 (pound 233 to pound 1681) compared with conventional management. If standard practice visit patterns were assumed rather than trial conditions, the incremental cost of intensive management was pound 478 (-pound 275 to pound 1232) per patient. The within trial event-free time gained in the intensive group was 0.60 (0.12 to 1.10) years and the lifetime gain 1.14 (0.69 to 1.61) years. The incremental cost per event-free year gained was pound 1166 (costs and effects discounted at 6% a year) and pound 563 (costs discounted at 6% a year and effects not discounted).

CONCLUSIONS

Intensive blood glucose control in patients with type 2 diabetes significantly increased treatment costs but substantially reduced the cost of complications and increased the time free of complications.

Estimating long-term cost savings from treatment of Alzheimer's disease. A modelling approach

OBJECTIVE

This paper puts forward a proposal for a modelling approach to the estimation of long term cost savings from the treatment of Alzheimer's disease (AD).

DESIGN

In the proposed modelling approach, disease progression is defined in terms of intervals in the Mini-Mental State Exam (MMSE) scale. Clinical trial data are then used to determine the time at which a particular patient moved into a more severe stage of the disease. By comparing these durations across treatment groups, survival analysis is used to measure the impact of treatment in delaying the onset of a more costly stage of the disease.

SETTING

Patients with varying severity of AD.

PATIENTS AND PARTICIPANTS

The model uses clinical trial data on 1333 patients recruited internationally in 2 studies from 67 centres.

INTERVENTIONS

The aim of these clinical studies was to evaluate the safety and efficacy of 2 non-overlapping dose ranges of rivastigmine relative to placebo over a 26-week treatment period in patients with probable AD.

MAIN OUTCOME MEASURES AND RESULTS

The results indicate that the average cost savings with high-dose rivastigmine at the end of the trial period are quite low (approximately 29 Pounds per patient; 1997 values), but by extrapolating to a projected lifetime of 3 years, they rise to approximately 1100 Pounds per patient. The largest long term cost savings from treatment are obtained from treating those in the mild category (i.e. MMSE > 20). However, if the time horizon over which savings are estimated is short (i.e. if life expectancy is below 2 years), more costs are saved by prioritising patients with moderate AD (i.e. MMSE between 20 and 11).

CONCLUSIONS

The model is a possible approach for estimating cost savings with treatment of AD, given the lack of long term data on resource use and drug efficacy. Caution should be used when extrapolating the results beyond the original study parameters.

Confidence intervals or surfaces? Uncertainty on the cost-effectiveness plane

Although cost-effectiveness analysis is not new, it is only recently that economic analysis has been conducted alongside clinical trials. Whereas in the past economic analysts most often used sensitivity analysis to examine the implications of uncertainty for their results, the existence of patient-level data on costs and effects opens up the possibility of statistical analysis of uncertainty. Unfortunately, ratio statistics can cause problems for standard statistical methods of confidence interval estimation. The recent health economics literature contains a number of suggestions for estimating confidence limits for ratios. In this paper, we begin by reviewing the different methods of confidence interval estimation with a view to providing guidance concerning the most appropriate method. We go on to argue that the focus on confidence interval estimation for cost-effectiveness ratios in the recent literature has been concerned more with problems of estimation than with problems of decision-making. We argue that decision-makers are most likely to be interested in one-sided tests of hypothesis and that confidence surfaces are better suited to such tests than confidence intervals. This approach is consistent with decision-making on the cost-effectiveness plane and with the cost-effectiveness acceptability curve approach to presenting uncertainty due to sampling variation in stochastic cost-effectiveness analyses.

Confidence intervals or surfaces? Uncertainty on the cost-effectiveness plane

Although cost-effectiveness analysis is not new, it is only recently that economic analysis has been conducted alongside clinical trials. Whereas in the past economic analysts most often used sensitivity analysis to examine the implications of uncertainty for their results, the existence of patient-level data on costs and effects opens up the possibility of statistical analysis of uncertainty. Unfortunately, ratio statistics can cause problems for standard statistical methods of confidence interval estimation. The recent health economics literature contains a number of suggestions for estimating confidence limits for ratios. In this paper, we begin by reviewing the different methods of confidence interval estimation with a view to providing guidance concerning the most appropriate method. We go on to argue that the focus on confidence interval estimation for cost-effectiveness ratios in the recent literature has been concerned more with problems of estimation than with problems of decision-making. We argue that decision-makers are most likely to be interested in one-sided tests of hypothesis and that confidence surfaces are better suited to such tests than confidence intervals. This approach is consistent with decision-making on the cost-effectiveness plane and with the cost-effectiveness acceptability curve approach to presenting uncertainty due to sampling variation in stochastic cost-effectiveness analyses.

An economic evaluation of vaccination against hepatitis A for frequent travellers

This paper compares the cost of using inactive Hepatitis A vaccine relative to immunoglobulin as a means of protecting frequent travellers against Hepatitis A. The number of trips to 'at risk' areas is modelled as a Poisson process and results are reported in terms of the discounted gross cost per protected trip over a 10-year period. We find that the expected cost of immunization is lower with immunoglobulin for travellers visiting 'at risk' areas less than five times in 10 years, and lower with Hepatitis A vaccine for those visiting 'at risk' areas more than five times in 10 years.

An economic analysis of varicella vaccination for health care workers

A simulation model was constructed to assess the relative costs and cost-effectiveness of different screening and vaccination strategies for dealing with hospital incidents of varicella exposure, compared with current policies, using data from published sources and a hospital survey. The mean number of incidents per hospital year was 3.9, and the mean annual cost of managing these incidents was pounds 5170. Vaccination of all staff would reduce annual incidents to 2.2 at a net cost of pounds 48,900 per incident averted. Screening all staff for previous varicella, testing those who are uncertain or report no previous varicella, and vaccinating those who test negative for VZV antibodies, reduces annual incidents to 2.3 and gives net savings of pounds 440 per incident averted. Sensitivity analyses do not greatly alter the ranking of the options. Some form of VZV vaccination strategy for health care workers may well prove a cost-effective use of health care resources.

Trying to do better than average: a commentary on 'statistical inference for cost-effectiveness ratios'

In a recent paper, Laska, Meisner and Siegel address issues concerning hypothesis testing in cost-effectiveness analysis. They relate the relative magnitude of two average cost-effectiveness ratios to the incremental cost-effectiveness ratio and go on to propose a statistical procedure for testing the equality of two average ratios. In this paper, we show why the use of average cost-effectiveness ratios is misleading and argue that the appropriate focus for cost-effectiveness analysis is the estimation of confidence intervals around incremental cost-effectiveness ratios.

An economic evaluation of universal vaccination against hepatitis B virus

This report presents the results of an economic evaluation utilizing U.K. data, into a vaccination programme against Hepatitis B using a genetically engineered, yeast-derived vaccine, Engerix B. Cost-effectiveness ratios were calculated for four different programmes: an infant vaccination programme; a child vaccination programme; an adolescent vaccination programme; and a combined child and adolescent programme. For each programme, the number of annual cohorts vaccinated was varied from 1 to 25. The outcome was defined as incremental life years gained, and the results are reported as costs per incremental life-year gained. Benefits were calculated in both undiscounted and discounted forms. All costs were discounted. The discount rate used was 6%. All major epidemiological and cost assumptions were subjected to a sensitivity analysis. Baseline results with benefits discounted range from pounds188015 to pounds301365 per life year gained, depending on the duration of programme and vaccination strategy. With benefits undiscounted, the comparable range is from pounds5234 to pounds13034.

The cost of insulin-dependent diabetes mellitus (IDDM) in England and Wales

This study estimates the direct health and social care costs of insulin-dependent diabetes mellitus (IDDM) in England and Wales in 1992 to be 96 million pounds, or 1021 pounds per person in a population with IDDM estimated at 94,000 individuals. These costs include insulin maintenance, hospitalization, GP and out-patient consultations, renal replacement therapy, and payments to informal carers. Expenditure is concentrated on younger age groups, with one-third of the total expended on those aged 0-24. Around one-half of the total costs can be directly attributed to IDDM, with the remainder associated with a range of complications of the disease. The single largest area of service expenditure is renal replacement therapy. The cost estimates are most sensitive to incidence rates of IDDM, numbers on dialysis and average duration of dialysis. A further 113 million pounds may be lost each year due to premature deaths resulting in lost productive contributions to the economy. The direct and indirect costs of IDDM are therefore significant. The cost of illness framework presented here should facilitate the economic evaluation of new and existing treatment regimens, which may improve value for money by reducing costs and/or increasing the quality or quantity of life for people with IDDM.

The analysis of censored treatment cost data in economic evaluation

This article investigates the way in which the presence of censored cost data in clinical trials should dictate the inferential tests adopted when comparing treatment and nontreatment groups for the purpose of economic evaluation. The authors argue that the techniques of survival analysis are appropriate where censoring is present, and that bias will be imparted if cruder methods are used to analyze cost data, even if that data is drawn from a relevant population. The first section of the article discusses the problem of censoring and survival analysis, while the second examines three methods of dealing with censored cost data and possible biases resulting from them. The third section presents results from actual trial data using the three methods described in the preceding section. Conclusions are presented in section four, where it is argued that these methodological issues are likely to become more important as economists are called upon to evaluate the treatment of chronic conditions using data from clinical trials with finite end points.

Estimating the cost of compensating victims of medical negligence

The current system in Britain for compensating victims of medical injury depends on an assessment of negligence. Despite the sporadic pressure on the government to adopt a "no fault" approach, such as exists in Sweden, the negligence system will probably remain for the immediate future. The cost of this system was estimated to be 52.3m pounds for England 1990-1. The problem for the future, however, is one of forecasting accuracy at provider level: too high a guess and current patient care will suffer; too low a guess and future patient care will suffer. The introduction of a mutual insurance scheme may not resolve these difficulties, as someone will have to set the rates. Moreover, the figures indicate that if a no fault scheme was introduced the cost might be four times that of the current system, depending on the type of scheme adopted.

Contracts and supply assurance in the UK health care market

We present a formal model of the relationship between a health care purchaser and a provider drawing on the recent experience of explicit contracting in the UK health sector. Specifically we model the contractual relationships emerging between District Health Authorities, who are presently the dominant health care purchasers, and the providers of hospital care. The comparative static analysis implies that the transaction cost of using non-local hospitals, the expected patient demand, the extent of excess capacity in local hospitals, and the proportion of that excess capacity expected to be lost to competitive purchasers, are all important determinants of the choice of contract.

Alzheimer's disease: the burden of the illness in England

This paper reports the findings of a study that estimated the socioeconomic costs, both direct and indirect, of Alzheimer's Disease in England by using a 'burden of illness' framework. The burden of illness was calculated for all main areas of provision: hospital and residential care, general practice, day care, home care and informal care, including the calculations of costs by age-group and by service provider. The results show that the cost of this care amounted to around 1,039m pounds in 1990/91, establishing that spending associated with Alzheimer's Disease is a major area of care expenditure. Such burden of illness data should help those involved with health care decision-making, planning and priority setting, especially for health districts and social services establishing base plans for care in the community.

Is risk management necessary?

During the last 25 years, medical negligence claims in the United Kingdom have become increasingly frequent and problematical. In 1990, the Department of Health announced that district health authorities would assume vicarious liability for negligent acts by doctors in the course of their work for the National Health Service. A study of claims closed in the region covered by one Regional Health Authority shows that over a five-year period there were 7.8 claims per 100,000 population, levels in some other Regions ranging from 4.5 to 20.5 claims per 100,000, with a progressive increase. Obstetrics/Gynaecology and Anaesthetics are prominent areas for claims. It has been suggested that by the mid 1990s some 12% of the United Kingdom's National Health Service Budget might be absorbed in indemnity payments. Negligence litigation provides signals to health care providers about where they should invest in risk reduction rather than in bearing the cost of successful claims. At the national level it can be of value to create computerized data bases' of medical mishaps. Among the various types of activity which seem more practicable and worth exploring at the local level are the positive development of a "culture of safety" in health care, the creation of risk management teams to examine and document medical misadventure, and the establishment of health care organizations which do not feel threatened by their failures but which can respond in a caring, compassionate and concerned fashion to patients' distress and deal fairly with economic losses.

Medical malpractice claims in obstetrics and gynaecology: comparisons between the United States and Britain

Obstetricians and gynaecologists have been particularly affected by the increase in the cost and number of medical malpractice claims in Britain. US obstetricians and gynaecologists have experienced a disproportionately higher rate of claim than other practitioners in that country. This article reviews the US experience of obstetrics and gynaecology malpractice claims and questions the validity of showing comparisons between the US and UK. However, even if British malpractice claims do not reach the level of American claims, the effects of claims on the National Health Service, recruitment to obstetrics and gynaecology, and clinical practice are significant.

Medical malpractice in perspective. II--The implications for Britain

The "malpractice crisis" in the United States cannot be understood in isolation. Litigation is precipitated by features of the American health care and social security systems. Relative to the United Kingdom, there are fewer barriers of access to the courts, although the role of contingency fees has probably been exaggerated. Given the great institutional differences between the UK and the USA, the crisis seems unlikely to be replicated here unless there are further moves towards privatising both the costs of providing health care and the costs of its failures. It is concluded that a marginal change in the frequency or average cost of claims could have a serious impact on National Health Service resources, the medical defence societies, recruitment to specialties, and clinical practice. Debate over possible reforms is compromised by the dearth of good empirical data. Any changes, however, must address both the deterrence of bad practice and the compensation of injured patients.

Medical malpractice in perspective. I--The American experience

Concern over the possibility of an American style medical malpractice "crisis" in the United Kingdom has recently been voiced by members of both medical and legal professions. The validity of such fears is examined by reviewing the conditions that have given rise to the current American difficulties. It is argued that the rise in malpractice insurance premiums and associated restrictions in availability should be seen against the background of underwriting problems specific to medical liability in conjunction with a general decline in reinsurance cover. The evidence in relation to the clinical and resource implications of malpractice is analysed. In particular, arguments that increased litigation has influenced the practice of "defensive" medicine and the choice of specialty are critically examined. Medical malpractice claims and insurance are only part of a professional environment which is undergoing dramatic social and economic changes, many of which seem more plausible candidates to be treated as important influences on the nature and organisation of health care in the United States.

The optimal stock of health with endogenous wages. Application to partial disability compensation

The optimal quantity of health is examined in the framework of a model which posits that health capital will influence earning capacity in addition to the supply of labor. Utilizing data from the Survey of Disabled and Nondisabled Adults, eight health capital variables are tested in models of hourly wages, labor supply and yearly earnings. The results for three of the health capital variables are then compared to their evaluation by the American Medical Association and by the New York State Workers' Compensation program.