Comparisons of health care systems in the United States, Germany and Canada.

THE PURPOSE OF THIS RESEARCH PAPER IS TO COMPARE HEALTH CARE SYSTEMS IN THREE HIGHLY ADVANCED INDUSTRIALIZED COUNTRIES: The United States of America, Canada and Germany. The first part of the research paper will focus on the description of health care systems in the above-mentioned countries while the second part will analyze, evaluate and compare the three systems regarding equity and efficiency. Finally, an overview of recent changes and proposed future reforms in these countries will be provided as well. We start by providing a general description and comparison of the structure of health care systems in Canada, Germany and the United States.

Stroke: Effect of implementing an evaluation and treatment protocol compliant with NINDS recommendations.

PURPOSE: To evaluate--relative to routine clinical practice--the potential cost-effectiveness of implementing a strategy compliant with National Institute of Neurological Disorders and Stroke (NINDS) recommendations for care of patients presenting with signs and symptoms of acute ischemic stroke. MATERIALS AND METHODS: A discrete-event simulation model of the process of stroke care from symptom onset through administration of tissue plasminogen activator (tPA) was constructed. A literature review was performed to determine process times, performance of computed tomography (CT), health outcomes, and cost estimates. The following were compared: (a) a "base-case" strategy determined on the basis of findings in the literature and (b) a NINDS-compliant strategy (ie, evaluation by emergency physician in less than 10 minutes, interpretation of CT scans within 45 minutes, and administration of tPA within 1 hour after presentation). Strategies were compared with regard to cost and effectiveness. Sensitivity analyses were performed for all relevant cost, timing, and resource parameters. Outcomes of concern were quality-adjusted life years and number of patients treated within a 3-hour therapeutic window. RESULTS: The NINDS-compliant strategy resulted in an average quality-adjusted life years value of 3.64, versus 3.63 for the base case, at an approximate cost of 434 US dollars per patient. The NINDS-compliant strategy increased the proportion of treatable patients from 1.4% to 3.7% and remained cost-effective for expenditures of up to 450 US dollars per patient. Assuming base-case parameters are used, increasing the number of CT scanners from two to eight raised the proportion of treatable patients to 1.5%. Increasing the number of available neurologists from four to eight raised the proportion to 1.44%. Reducing the time from stroke onset to emergency department arrival by 30 minutes raised the proportion to up to 7.7%. CONCLUSION: Applying NINDS recommendations is potentially cost-effective, although reducing the time from stroke onset to emergency department arrival may be even more so.

Health care resource utilization associated with a diabetes center and a general medicine clinic.

OBJECTIVE: Studies have proposed that the features of diabetes clinics may decrease hospital utilization and costs by reducing complications and providing more efficient outpatient care. We compared the health care utilization associated with a diabetes center (DC) and a general medicine clinic (GMC). DESIGN: Retrospective cohort study. SETTING: An urban academic medical center. PATIENTS/PARTICIPANTS: Type 2 diabetes patients (N = 601) under care in a DC and GMC before March 1996. MEASUREMENTS AND MAIN RESULTS: We compared baseline patient characteristics and outpatient care for the period of March 1996 to August 1997. Using administrative data from March 1996 to October 2000, we compared the probability of a hospitalization, length of stay, costs of hospitalizations, the probability of an emergency room visit, and costs of emergency room visits. Diabetes center patients had a longer mean duration of diabetes (12 years vs 6 years, P <.01), more baseline microvascular disease (65% vs 44%, P <.01), and higher baseline glucose levels (hemoglobin A1c 8.6% vs 7.9%, P <.01) than GMC patients. Diabetes center patients received more intensive outpatient care directed toward glucose monitoring and control. In all crude and adjusted analyses of hospitalizations and emergency room visits, we found no statistically significant differences for inpatient utilization or cost outcomes comparing clinic populations. CONCLUSIONS: Diabetes center attendance did not have a definitive positive or negative impact on inpatient resource utilization over a 4-year period. However, DC patients had more severe diabetes but no greater hospital utilization compared with GMC patients. Clear demonstration of the clinical and financial benefits of features of diabetes centers will require long-term controlled trials of interventions that promote comprehensive diabetes care, including cardiovascular prevention.