Declining prevalence of anemia in childhood in a middle-class setting: a pediatric success story?

To study trends of anemia among middle-class children, we collected 6,162 hematocrit measurements from the medical records of 2,432 children, ages 9 months through 6 years, as seen at a private pediatric clinic during the past 18 years. A decline in prevalence of anemia was observed during that period. The overall age-adjusted rate of anemia decreased from 6.2% in 1969 to 1973, 5.8% in 1974 to 1977, 3.8% in 1978 to 1981, and 2.7% in 1982 to 1986. The decline was also observed when trends were determined for three age groups using a single hematocrit measurement per child. The 1982 to 1986 prevalences of anemia for various age groups among this middle-class pediatric population were relatively low: 2.8% among 9- to 23-month-old children, 2.4% among 24- to 47-month-old children, and 2.7% among 48- to 83-month-old children. Most of these recent cases of anemia were mild--most were only slightly less than the hematocrit values used to define anemia--and most did not show strong evidence of iron deficiency based on elevated levels of erythrocyte protoporphyrin. We conclude that iron deficiency is now mild and uncommon in these middle-class children. This improved nutritional status with regard to iron is probably related to increased intake of iron among infants and young children during the past two decades. These findings suggest that the recommended screening schedule for iron deficiency with hemoglobin or hematocrit measurements may need to be reassessed for well-defined populations of low-risk children.

Change in the Medicare case-mix index in the 1980s and the effect of the prospective payment system.

Persistent increases in the Medicare case-mix index over the 1980s have been ascribed to changes both in medical treatment ("real changes") and in the way medical information is recorded ("coding changes") in hospitals. These changes have been attributed, in the absence of appropriate data and analyses, to the incentives of the Medicare prospective payment system (PPS). Using data for 1980-1986 from 235 hospitals, we estimate the effect on the Medicare case-mix index of a series of variables that reflect medical treatments and coding practices. Each of these underlying real or coding variables was changing prior to PPS and would likely have continued to change even in the absence of PPS. Furthermore, PPS may have had a distinct effect on these variables. These underlying trends and the PPS effects must each be estimated. Thus, the analysis begins by developing separate estimates for each of these real and coding variables (1) in the absence of PPS (autonomous effects) and (2) as a result of PPS (induced effects). Then, changes in the case-mix index are regressed against all of these variables to determine the degree to which specific autonomous real or coding variables or induced real or coding variables actually influenced measured case mix. Results show that real and coding changes each accounted for about half of the change in the Medicare case-mix index between 1980 and 1986, with the influence of coding starting to wane by 1986. PPS-induced factors explain about 80 percent of the change in measured case mix over time, autonomous factors about 20 percent. Especially powerful determinants of case-mix change included PPS-induced substitution of surgical for medical care and PPS-induced improvements in the accuracy of coding that led to assignment of patients to higher-weighted DRGs. Also, stringent Medicare peer review organizations appeared to restrain rises in case-mix indexes for their hospitals. Outpatient substitution for inpatient treatment, which others attributed to PPS, was well underway before PPS was announced.

Trauma systems and the costs of trauma care.

OBJECTIVE: This study examines the cost of providing trauma services in trauma centers organized by publicly administered trauma systems, compared to hospitals not part of a formal trauma system. DATA SOURCES AND STUDY SETTING: Secondary administrative discharge abstracts for a national sample of severely injured trauma patients in 44 trauma centers and 60 matched control hospitals for the year 1987 were used. STUDY DESIGN: Retrospective univariate and multivariate analyses were conducted to examine the impact of formal trauma systems and trauma center designation on the costs of treating trauma patients. Key dependent variables included length of stay, charge per day per patient, and charge per hospital stay. Key impact variables were type of trauma system and level of trauma designation. Control variables included patient, hospital, and community characteristics. DATA COLLECTION/EXTRACTION METHODS: Data were selected for hospitals based on (1) a large national hospital discharge database, the Hospital Cost and Utilization Project, 1980-1987 (HCUP-2) and (2) a special survey of trauma systems and trauma designation undertaken by the Hospital Research and Educational Trust of the American Hospital Association. PRINCIPAL FINDINGS: The results show that publicly designated Level I trauma centers, which are the focal point of most trauma systems, have the highest charge per case, the highest average charge per day, and similar or longer average lengths of stay than other hospitals. These findings persist after controlling for patient injury and health status, and for demographic characteristics and hospital and community characteristics. CONCLUSIONS: Prior research shows that severely injured trauma patients have greater chances of survival when treated in specialized trauma centers. However, findings here should be of concern to the many states developing trauma systems since the high costs of Level I centers support limiting the number of centers designated at this level and/or reconsidering the requirements placed on these centers.

A partial test of a hospital behavioral model.

The influence of hospital and community characteristics on the behavior of five dimensions of hospital output is examined in this article. These dimensions are the level of emergency stand-by capacity, total admissions, the diagnosis-mix of admissions and the hospital's 'style of practice' with regard to ancillary services and length of stay. A simultaneous equations model is estimated with data from a sample of 63 New England short-term general hospitals for 1970. The findings suggest that various types of short-term general hospitals have distinctive preferences for emergency capacity, volume, case mix and style of practice, and that style of practice may be more appropriately viewed as a rate of resource use per day. Specific findings of interest include the positive interdependence between protection against running out of emergency beds and length of stay, and between length of stay and ancillary service use. Hospitals that admit greater numbers of patients tend to treat more severely ill patients, and sicker patients tend to go to larger hospitals. Hospitals that provide more ancillary services tend to attract the more acutely ill patients. Relationships among other elements of the hospital's utility function represent trade-offs, i.e. substitution, in a constrained world. Among the exogenous factors, patient preferences and ability to pay have strong associations with the types of care provided by hospitals. Highly educated, high income communities, for example, tend to prefer risk averse, service intensive hospital output. Teaching hospitals are shown to prefer higher protection levels, service-intensive patterns of care, and higher admissions levels. Self-paying patients tend to be admitted for more discretionary types of diagnoses and to receive longer diagnosis-specific lengths of stay. A relatively greater supply of physician specialists in the market area is associated with increased use of ancillary services in the hospital. If replicated, these results have significant policy implications for reimbursing teaching hospitals; for defining accessibility of hospital care for the uninsured; for identifying the practice of 'skimming' by proprietary hospitals; and for specifying the role of community preferences in determining hospital performance, especially with respect to quality of care and level of emergency stand-by capacity.

Case-mix differences between teaching and nonteaching hospitals.

It has been suggested that teaching hospitals as a group have done well financially under Medicare's prospective payment system. If so, is this because teaching hospitals have reduced inefficiencies or because their case mix is not as severe as presumed? In this study, we used Disease Staging and diagnosis related groups (DRGs) to isolate case mix attributed to given patient populations from that attributed to hospital treatment standards. We also analyzed differences among types of teaching hospitals. We found few case-mix differences between teaching and nonteaching hospitals when the weighting system was independent of resource consumption (i.e., Disease Staging). However, when resources were used to weight case-mix measurement (i.e., DRGs), teaching hospitals were found to have a more serious case mix. We conclude that although teaching hospitals typically do not have a more severe case mix than nonteaching hospitals, they do use more resources to treat their patient mix under DRGs.

Redistribution of revenues under a prototypical prospective payment system: characteristics of winners and losers.

A variety of prospective payment programs have been implemented over the past decade in attempts to contain the rapidly escalating costs of providing hospital care. Eventually the hospital bills of most Americans are likely to be reimbursed on the basis of preset prices. In this simulation study the most important of the existing cost-containment programs, Medicare's Prospective Payment System, is extended to all hospital patients in order to estimate the revenue redistributions likely to take place as more and more comprehensive prospective rate-setting programs are enacted. After discussion of the methodology and results of the empirical section, the study considers several major policy issues facing the hospital industry and the likely responses by the industry.

DRGs and disease staging for reimbursing Medicare patients.

Beginning October 1, 1983, Medicare began reimbursing many hospitals on the basis of a set of fixed fees tied to Diagnosis-Related Groups (DRGs). Using 1979-1981 Maryland data for Medicare patients, this paper compares the DRG system with the Disease Staging patient classification system in terms of structure, explanation of resource consumption (length of stay) of hospital patients, and impact on reimbursement by type of hospital. The two systems are conceptually and empirically different in classifying patients. Further, Disease Staging and DRGs perform similarly in explaining length-of-stay variation among Maryland patients. However, the two systems generate substantially different reimbursements by type of hospital. Surprisingly, large hospitals (including urban, not-for-profit, teaching hospitals) fare better under a DRG-based reimbursement system than under Disease Staging, a severity-of-illness system that excludes procedures as a basis of classification. These results imply that reimbursement policy based on Disease Staging would create disincentives to perform surgery compared with the current DRGs.

Patterns of obstetrical care in hospitals.

This article examines the determinants of length of stay and ancillary service use for a single diagnostic category: normal delivery. Data for a systematic sample of 945 obstetrical admissions to 48 New England hospitals during 1969-70 are used to estimate a simultaneous equations model. The exogenous variables include socioeconomic and medical characteristics of the mother, medical condition of the newborn, type of labor and delivery, and hospital and physician characteristics. The important findings are threefold: First, evidence is found supportive of a simultaneous relationship between length of stay and ancillary services for normal deliveries. Second, the results show the importance of controlling for the performance of surgery, the presence of complications, the length of labor and the death of the baby in analyzing obstetrical utilization patterns. Third, holding maternal medical and socioeconomic factors constant, hospital size, teaching status, control and location, as well as physician mode of practice and relationship to the hospital, are important determinants of hospital use. It is concluded that the diagnostic-specific approach to utilization analysis is appropriate and useful. Only within such a narrowed focus can researchers disentangle the confounding effects of the attributes of the disease itself from the impact of hospital and physician characteristics on hospital use.

Determinants of hospital use: a cross-diagnostic analysis.

This article estimates the effects of personal, clinical, physician, and hospital characteristics in a simultaneous equations model of length of stay and ancillary services use for five narrowly defined medical and surgical conditions. These are tonsillectomy and adenoidectomy, gastroenteritis and colitis, inguinal hernia, coronary heart disease, and cholelithiasis. The data are derived from a sample survey of medical and financial records of patients discharged from any of 63 New England short-term general hospitals during the period July 1, 1969 through June 30, 1970. The results confirm the importance of a simultaneous equations formulation of utilization analysis and of inclusion of detailed measures of severity. Length of stay and ancillary services are significantly interrelated for all five conditions, corroborating results of a previous study of obstetric cases. Results for patient's employment status and value of time, attending physician specialty and mode of practice, and hospital size, control, and nature of teaching activities were less conclusive, but suggest differential effects across diagnoses, thus emphasizing the importance of a diagnostic-specific approach to utilization analysis.