RESUMO
Workers under 50 on average will spend 10-20% of their future hours working. So, assuming they value leisure time at the wage rate, the value of their lives is 5-10 times their future lifetime earnings. This value is close to values of life estimated by compensating wage differentials or willingness to pay.
Assuntos
Salários e Benefícios , Valor da Vida , Adulto , Idoso , Emprego/economia , Feminino , Humanos , Masculino , Métodos , Pessoa de Meia-Idade , Estados UnidosRESUMO
OBJECTIVE: To simulate whether allowing small businesses to offer employer-funded medical savings accounts (MSAs) would change the amount or type of insurance coverage. STUDY SETTING: Economic policy evaluation using a national probability sample of nonelderly non-institutionalized Americans from the 1993 Current Population Survey (CPS). STUDY DESIGN: We used a behavioral simulation model to predict the effect of MSAs on the insurance choices of employees of small businesses (and their families). The model predicts spending by each family in a FFS plan, an HMO plan, an MSA, and no insurance. These predictions allow us to compute community-rated premiums for each plan, but with firm-specific load fees. Within each firm, employees then evaluate each option, and the firm decides whether to offer insurance-and what type-based on these evaluations. If firms offer insurance, we consider two scenarios: (1) all workers elect coverage; and (2) workers can decline the coverage in return for a wage increase. PRINCIPAL FINDINGS: In the long run, under simulated conditions, tax-advantaged MSAs could attract 56 percent of all employees offered a plan by small businesses. However, the fraction of small-business employees offered insurance increases only from 41 percent to 43 percent when MSAs become an option. Many employees now signing up for a FFS plan would switch to MSAs if they were universally available. CONCLUSIONS: Our simulations suggest that MSAs will provide a limited impetus to businesses that do not currently cover insurance. However, MSAs could be desirable to workers in firms that already offer HMOs or standard FFS plans. As a result, expanding MSA availability could make it a major form of insurance for covered workers in small businesses. Overall welfare would increase slightly.
Assuntos
Comércio/economia , Poupança para Cobertura de Despesas Médicas/economia , Modelos Econômicos , Adolescente , Adulto , Comércio/estatística & dados numéricos , Saúde da Família , Gastos em Saúde/estatística & dados numéricos , Humanos , Seguro Saúde/economia , Seguro Saúde/estatística & dados numéricos , Poupança para Cobertura de Despesas Médicas/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricosRESUMO
OBJECTIVE: To evaluate whether adjusting the Health Plan Employer Data and Information Set (HEDIS) low birth weight (LBW) measure for maternal risk factors is feasible and improves its validity as a quality indicator. DATA SOURCE: The Washington State Birth Event Record Data for calendar years 1989 and 1990, including birth certificate data matched with mothers' and infants' hospital discharge records, with 5,837 records of singlet on infants identified as LBW (< 2,500 g) and a 25 percent sample ( n = 31,570) of the normal-weight births ( = 2,500 g). STUDY DESIGN: We reviewed literature on factors associated with birth weight and identified factors for risk adjustment that are associated with LBW and th at are not modifiable by the health plan . We used vit al records Data to develop and test possible risk adjustment strategies. Finally, because feasibility is important for a HEDIS measure, we assessed health plan readiness to produce a risk-adjusted measure. PRINCIPAL FINDINGS: An LBW indicator that is adjusted for maternal risks represents health plan performance better than the unadjusted rate. In the most parsimonious risk adjustment model LBW risk was higher for mothers with a history of prior preterm birth , LBW, or fet al death . Risk was also high er for primiparas or mothers with high parity, mothers less than 19 years of age, and primiparas over age 35. In a model adding race to these obstetric factors, black, Asian/Pacific Islander, or other non-white, non-Hispanic race were also significantly associated with higher LBW risk. While adjusting for maternal risk improved the LBW measure's validity, the rate adjustment magnitude was small (0.17 percentage points) for the most plausible model. Th is may not be mean in gf ul clinically or for measuring differences in quality. The costs and data collection requirements of risk adjustment could be substantial for health plans lacking access to State birth records data. CONCLUSIONS Selection of risk adjusters for quality measures depends on judgments of their effect, legitimacy, and feasibility. A comprehensive examination of validity and feasibility is needed to understand to what extent outcome measures represent quality and how their value compares to their cost of collection .
Assuntos
Peso ao Nascer , Planos de Assistência de Saúde para Empregados/normas , Recém-Nascido de Baixo Peso , Bem-Estar Materno/classificação , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Cuidado Pré-Natal/normas , Indicadores de Qualidade em Assistência à Saúde , Risco Ajustado/estatística & dados numéricos , Adulto , Causalidade , Estudos de Viabilidade , Feminino , Hospitais/normas , Humanos , Recém-Nascido , Modelos Logísticos , Masculino , Bem-Estar Materno/etnologia , Análise Multivariada , Avaliação de Resultados em Cuidados de Saúde/métodos , Probabilidade , Fatores de Risco , Washington/epidemiologiaRESUMO
The authors discuss a system that describes the resources needed to treat different subgroups of the population under age 65, based on burden of disease. It is based on 173 conditions, each with up to 3 severity levels, and contains models that combine prospective diagnoses with retrospectively determined elements. We used data from four different payers and standardized the cost of most services. Analyses showed that the models are replicable, are reasonably accurate, explain costs across payers, and reduce rewards for biased selection. A prospective model with additional payments for birth episodes and for serious problems in newborns would be an effective risk adjuster for Medicaid programs.
Assuntos
Efeitos Psicossociais da Doença , Doença/classificação , Cuidado Periódico , Recursos em Saúde/economia , Modelos Econométricos , Risco Ajustado/economia , Índice de Gravidade de Doença , Adolescente , Adulto , Criança , Pré-Escolar , Doença/economia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Medicaid , Michigan , Pessoa de Meia-Idade , Estados UnidosRESUMO
BACKGROUND: Comprehensive geriatric assessment (CGA) can be effective in inpatient units, but such inpatient settings are prohibitively expensive. If similar benefits could be obtained in outpatient settings, CGA might be a more attractive option. OBJECTIVES: To assess the cost-effectiveness (CE) of an outpatient geriatric assessment with an intervention to increase adherence. SUBJECTS: Three hundred fifty-one community-dwelling, elderly subjects with at least one of four geriatric conditions. MEASURES: In addition to the measures of functioning, we collected data on the costs of the intervention itself and on the use of medical services in the 64 weeks after the intervention. RESULTS: The intervention, which prevented functional decline, cost $273 per participant. The intervention group averaged three more visits than the control group in the first 32 weeks after the intervention, but only 1.2 extra visits in the next 32 weeks. We estimate that the costs of these additional medical services would be $473 for the 5 years after the intervention, leading to a total cost per Quality Adjusted Life Year (QALY) of $10,600. CONCLUSIONS: The CE of this program compares favorably with many common medical interventions. Whether investments should be made in health care resources on treatments that lead to modest improvements in the functioning of community-dwelling elderly people remains a societal decision.
Assuntos
Assistência Ambulatorial/economia , Assistência Ambulatorial/psicologia , Avaliação Geriátrica , Serviços de Saúde para Idosos/economia , Cooperação do Paciente/psicologia , Atividades Cotidianas , Idoso , Assistência Ambulatorial/estatística & dados numéricos , Assistência Integral à Saúde/organização & administração , Análise Custo-Benefício , Pesquisa sobre Serviços de Saúde , Serviços de Saúde para Idosos/estatística & dados numéricos , Humanos , Equipe de Assistência ao Paciente/organização & administração , Cooperação do Paciente/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Anos de Vida Ajustados por Qualidade de Vida , Estados UnidosRESUMO
Has the nature of hospital competition changed from a medical arms race in which hospitals compete for patients by offering their doctors high quality services to a price war for the patients of payors? This paper uses time-series cross-sectional methods on California hospital discharge data from 1986-1994 to show the association of hospital prices with measures of market concentration changed steadily over this period, with prices now higher in less competitive areas, even for non-profit hospitals. Regression results are used to simulate the price impact of hypothetical hospital mergers.
Assuntos
Competição Econômica/tendências , Setor de Assistência à Saúde/tendências , Instituições Associadas de Saúde/economia , Preços Hospitalares/tendências , Hospitais com Fins Lucrativos/economia , Hospitais Filantrópicos/economia , California , Área Programática de Saúde/economia , Área Programática de Saúde/estatística & dados numéricos , Grupos Diagnósticos Relacionados , Setor de Assistência à Saúde/estatística & dados numéricos , Pesquisa sobre Serviços de Saúde/métodos , Preços Hospitalares/estatística & dados numéricos , Hospitalização/economia , Hospitais Públicos/economia , Medicaid , Medicare , Propriedade/economia , Análise de Regressão , Estados UnidosRESUMO
Flat capitation (uniform prospective payments) makes enrolling healthy enrollees profitable to health plans. Plans with relatively generous benefits may attract the sick and fail through a premium spiral. We simulate a model of idealized managed competition to explore the effect on market performance of alternatives to flat capitation such as severity-adjusted capitation and reduced supply-side cost-sharing. In our model flat capitation causes severe market problems. Severity adjustment and to a lesser extent reduced supply-side cost-sharing improve market performance, but outcomes are efficient only in cases in which people bear the marginal costs of their choices.
Assuntos
Capitação/estatística & dados numéricos , Comportamento do Consumidor/estatística & dados numéricos , Competição em Planos de Saúde/economia , Modelos Econométricos , Sistema de Pagamento Prospectivo/estatística & dados numéricos , Comportamento do Consumidor/economia , Setor de Assistência à Saúde , Necessidades e Demandas de Serviços de Saúde/economia , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Humanos , Seleção Tendenciosa de Seguro , Competição em Planos de Saúde/estatística & dados numéricos , Reembolso de Incentivo , Gestão de Riscos/economia , Gestão de Riscos/estatística & dados numéricosRESUMO
OBJECTIVES: (1) To describe the issues in developing a clinical predictor of cesarean delivery that could be used to adjust reported cesarean rates for case mix, and (2) to compare its performance to other, simpler predictors using clinical and statistical criteria. DATA SOURCES: Singleton births greater than 2,500 grams in Washington State in 1989 and 1990 for whom mothers and infant hospital discharge records could be matched to birth certificate data. DESIGN: Statistical analysis of retrospective merged hospital and birth certificate data, which were used to develop variables and models to predict the probability that any particular delivery would be a cesarean. PRINCIPAL FINDINGS: Merged data led to better predictor variables than those based on one source. A simple four-category hierarchical classification into births with prior cesarean, breech but no prior cesarean, first birth, and other explains 30 percent of the variance in individual cesarean rates. The full clinical model fit the data well and explained 37 percent of the variance. Multiparas without serious complications comprised 35 percent of the mothers and averaged less than 2 percent cesareans. A hospital's predicted cesarean rate depends strongly on the proportion of its births that are first births. CONCLUSION: Government and private agencies have reported cesarean rates as measures of hospital performance. Depending on data and resources available, both simple and complex measures of case mix can be used to adjust reported rates. These adjustments should not include all variables related to the rates. Proper adjustments may not alter hospital rankings greatly, but they will improve the validity and acceptability of the reports.
Assuntos
Cesárea/estatística & dados numéricos , Grupos Diagnósticos Relacionados/classificação , Declaração de Nascimento , Feminino , Humanos , Recém-Nascido , Alta do Paciente/estatística & dados numéricos , Gravidez , Probabilidade , Análise de Regressão , Estudos Retrospectivos , Medição de Risco , WashingtonAssuntos
Planos de Seguro Blue Cross Blue Shield/economia , Cesárea/estatística & dados numéricos , Tabela de Remuneração de Serviços/normas , Obstetrícia/economia , Organizações de Prestadores Preferenciais/economia , Planos de Seguro Blue Cross Blue Shield/normas , California , Cesárea/economia , Parto Obstétrico/economia , Parto Obstétrico/métodos , Feminino , Reforma dos Serviços de Saúde , Pesquisa sobre Serviços de Saúde , Humanos , Organizações de Prestadores Preferenciais/normas , Gravidez , Métodos de Controle de PagamentosRESUMO
PURPOSE: This study examined the validity of medical-record-based nursing assessment and monitoring of signs and symptoms (nursing surveillance) in predicting patients who were admitted to ICUs and those admitted to non-ICUs. The association of this assessment and monitoring with differences in an intermediate patient outcome, instability at discharge, was also explored. Patients admitted to either setting with a diagnosis of acute myocardial infarction, cerebrovascular accident, congestive heart failure, or pneumonia, were included in the study. METHOD: A secondary analysis was carried out using a subset of data originally collected for a quality-of-care study. Data from the medical records of 11,246 patients (52% female, 48% male) with a mean age of 76.4 years were used in the present study. RESULTS: ICU patients (n = 3969) were found to have a longer length of stay and to be sicker on admission than non-ICU patients (n = 7277). Overall, patients in the ICU received significantly higher nursing assessment and monitoring of signs and symptoms scores than non-ICU patients. Nursing assessment and monitoring of signs and symptoms scores were lower for patients discharged with greater instability for three of the four diseases (cerebrovascular accidents, congestive heart failure, and pneumonia).
Assuntos
Unidades de Terapia Intensiva , Avaliação em Enfermagem , Admissão do Paciente , Idoso , Transtornos Cerebrovasculares/enfermagem , Feminino , Insuficiência Cardíaca/enfermagem , Fraturas do Quadril/enfermagem , Humanos , Tempo de Internação , Masculino , Prontuários Médicos , Infarto do Miocárdio/enfermagem , Pesquisa em Avaliação de Enfermagem , Pneumonia/enfermagem , Qualidade da Assistência à Saúde , Estudos de AmostragemRESUMO
OBJECTIVE: To understand how medical savings account (MSA) legislation for the nonelderly would affect health care costs. DESIGN: Economic policy evaluation based on the RAND Health Expenditures Simulation Model. SETTING: National probability sample of nonelderly noninstitutionalized households. PARTICIPANTS: Persons in 23 157 sampled households from the 1993 Current Population Survey. INTERVENTIONS: Medical savings account legislation would allow all Americans who are covered only by a catastrophic health care plan to set up a tax-exempt account that they can use to pay medical bills not covered by their health insurance. The interventions we evaluate differ in the deductibles of the catastrophic plan and in whether the employee or employer funds the MSA. MAIN OUTCOME MEASURES: Changes in national health expenditures and net societal benefits of health care. RESULTS: If all insured nonelderly Americans switched to MSAs, their health care expenditures would decline by between 0% and 13%, depending on how the MSAs are designed. However, not all nonelderly Americans would choose MSAs; taking into account selection patterns, health spending would change by + 1% to -2%. CONCLUSIONS: Medical savings account legislation would have little impact on health care costs of Americans with employer-provided insurance. However, depending on the size of the catastrophic limit, waste from the excessive use of generously insured care could be reduced, and MSAs would be attractive to both sick and healthy people.
Assuntos
Custo Compartilhado de Seguro/legislação & jurisprudência , Financiamento Pessoal/legislação & jurisprudência , Custo Compartilhado de Seguro/estatística & dados numéricos , Dedutíveis e Cosseguros/legislação & jurisprudência , Cuidado Periódico , Estudos de Avaliação como Assunto , Financiamento Pessoal/estatística & dados numéricos , Custos de Cuidados de Saúde , Gastos em Saúde/estatística & dados numéricos , Sistemas Pré-Pagos de Saúde/economia , Pesquisa sobre Serviços de Saúde/métodos , Imposto de Renda/legislação & jurisprudência , Pessoas sem Cobertura de Seguro de Saúde , Modelos Econométricos , Estados UnidosAssuntos
Necessidades e Demandas de Serviços de Saúde/economia , Modelos Econométricos , Comportamento do Consumidor , Custos de Cuidados de Saúde , Educação em Saúde , Mau Uso de Serviços de Saúde/economia , Mau Uso de Serviços de Saúde/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Seguro Saúde , Qualidade da Assistência à Saúde , Estados UnidosRESUMO
OBJECTIVE: To analyze whether elderly patients who are black or from poor neighborhoods receive worse hospital care than other patients, taking account of hospital effects and using validated measures of quality of care. DESIGN: We compare quality of care provided to insured, hospitalized Medicare patients who are black or live in poor neighborhoods as compared with others, using simple and multivariable comparisons of clinically detailed measures of sickness at admission, quality, and outcomes. SETTING: Two hundred ninety-seven acute care hospitals in 30 areas within five states. PATIENTS OR OTHER PARTICIPANTS: The sample includes a nationally representative sample of 9932 patients 65 years of age or older who lived at home prior to hospitalization for congestive heart failure, acute myocardial infarction, pneumonia, or stroke. INTERVENTIONS: This was an observational study. MAIN OUTCOME MEASURES: Processes of care, length of stay, instability at discharge, discharge destination, and mortality. RESULTS: Within rural, urban nonteaching, and urban teaching hospitals, patients who are black or from poor neighborhoods have worse processes of care and greater instability at discharge than other patients (P < .05). However, this worse quality is offset by patients who are black or from poor neighborhoods being 1.8 times more likely to receive care in urban teaching hospitals that have been shown to provide better quality of care (P < .001). Because these patients receive more of their care in better-quality hospitals, there are no overall differences in quality by race and poverty status. Death rates did not vary by race or poverty status. CONCLUSIONS: Quality of hospital care for insured Medicare patients in influenced both by the patient's race and financial characteristics and by the hospital type in which the patient receives care.
Assuntos
Negro ou Afro-Americano/estatística & dados numéricos , Hospitais Urbanos/normas , Medicare/estatística & dados numéricos , Seleção de Pacientes , Pobreza/estatística & dados numéricos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Governo Federal , Feminino , Hospitais Rurais/normas , Hospitais Rurais/estatística & dados numéricos , Hospitais de Ensino/normas , Hospitais de Ensino/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Humanos , Masculino , Mortalidade , Análise Multivariada , Avaliação de Processos e Resultados em Cuidados de Saúde , Estados UnidosAssuntos
Técnicas de Apoio para a Decisão , Pesquisa sobre Serviços de Saúde/métodos , Obstetrícia , Serviços de Saúde da Mulher , Análise Custo-Benefício , Árvores de Decisões , Feminino , Humanos , Obstetrícia/economia , Obstetrícia/normas , Sensibilidade e Especificidade , Resultado do Tratamento , Serviços de Saúde da Mulher/economia , Serviços de Saúde da Mulher/normasRESUMO
The dramatic rise in cesarean-section (C-section) rates, and their high costs and wide variation, has raised interest in understanding the factors affecting decisions to use this procedure. The economic incentives of physicians, hospitals, payers, and mothers are examined. In the economic framework, physicians must balance their short-term interests against their reputation, which is derived from efficiently providing what mothers want. Providers who encounter higher opportunity costs while attending to mothers in prolonged labor can reduce these costs by operating or by restructuring their practices. The mainly indirect evidence on financial incentives indicates that insured mothers have low marginal financial costs when they undergo C-section. Mothers with private, fee-for-service insurance have higher C-section rates than mothers who are covered by staff-model HMOs, who are uninsured, or who are publicly insured. In conclusion, research and payment reforms to reduce distortions to good practice are proposed.
Assuntos
Cesárea/economia , Comportamento de Escolha , Parto Obstétrico/economia , Motivação , Padrões de Prática Médica/economia , Cesárea/estatística & dados numéricos , Honorários Médicos , Feminino , Reforma dos Serviços de Saúde/economia , Sistemas Pré-Pagos de Saúde/economia , Preços Hospitalares , Humanos , Seguro Saúde/economia , Imperícia/economia , Obstetrícia/economia , Gravidez , Estados UnidosRESUMO
Few capitation arrangements vary premiums by a child's health characteristics, yielding an incentive to discriminate against children with predictably high expenditures from chronic diseases. In this article, we explore risk adjusters for the 35 percent of the variance in annual out-patient expenditure we find to be potentially predictable. Demographic factors such as age and gender only explain 5 percent of such variance; health status measures explain 25 percent, prior use and health status measures together explain 65 to 70 percent. The profit from risk selection falls less than proportionately with improved ability to adjust for risk. Partial capitation rates may be necessary to mitigate skimming and dumping.
Assuntos
Capitação , Serviços de Saúde da Criança/economia , Sistemas Pré-Pagos de Saúde/economia , Medicare/organização & administração , Assistência Ambulatorial/economia , Assistência Ambulatorial/estatística & dados numéricos , Análise de Variância , Criança , Serviços de Saúde da Criança/estatística & dados numéricos , Coleta de Dados , Gastos em Saúde/estatística & dados numéricos , Sistemas Pré-Pagos de Saúde/estatística & dados numéricos , Pesquisa sobre Serviços de Saúde , Indicadores Básicos de Saúde , Humanos , Renda/estatística & dados numéricos , Modelos Estatísticos , Métodos de Controle de Pagamentos/métodos , Risco , Estados UnidosRESUMO
OBJECTIVES: Health maintenance organizations (HMOs) continue to grow in number and in their enrollment of Medicare recipients. They are also increasingly viewed as organizational structures that might contribute to control of health care costs. Yet little is known about the quality of care that elderly HMO enrollees receive. METHODS: We compared patients from three HMOs to a fee-for-service (FFS) sample that was national in scope. Sickness at admission, the quality of process of care, and mortality were assessed for patients aged 65 years and older who had been hospitalized with a diagnosis of acute myocardial infarction. RESULTS: After adjustment for sickness at admission, there were no significant mortality differences between the HMO and FFS groups at either 30 (23.2% vs 23.5%) or 180 days (34.4% vs 34.5%) after admission. Compliance with process criteria was higher for the HMO group as a whole (P < .05). The HMOs had greater compliance with three of five scales measuring different aspects of care for patients with acute myocardial infarction. CONCLUSIONS: We conclude that older patients from our participating HMOs who were hospitalized for acute myocardial infarction received hospital care that was generally better in terms of process than that received by patients in a national FFS sample.
Assuntos
Honorários Médicos/normas , Sistemas Pré-Pagos de Saúde/normas , Infarto do Miocárdio/terapia , Qualidade da Assistência à Saúde , Fatores Etários , Idoso , Feminino , Pesquisa sobre Serviços de Saúde , Hospitalização , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Auditoria Médica , Prontuários Médicos/normas , Medicare , Infarto do Miocárdio/mortalidade , Avaliação de Processos e Resultados em Cuidados de Saúde , Índice de Gravidade de Doença , Estados UnidosRESUMO
OBJECTIVE: To compare quality of care measured by explicit criteria, implicit review, and sickness-adjusted outcomes at different types of hospitals. DESIGN: Further analysis of data retrospectively abstracted from medical records to evaluate the effects of prospective payment on quality of care for hospitalized Medicare patients. SETTING: Hospitals in five states were sampled to represent the national Medicare admissions along many dimensions. PATIENTS: A total of 14,008 elderly patients with one of the following five diseases: congestive heart failure, acute myocardial infarction, pneumonia, stroke, or hip fracture. These patients were randomly sampled from those with these diseases in 297 hospitals in two time periods, 1981 to 1982 and 1985 to 1986. OUTCOME MEASURES: Explicit criteria, implicit review, and mortality within 30 days of admission adjusted for sickness at admission. RESULTS: Quality of care ratings for hospital types are similar using explicit criteria, implicit review, and outcomes adjusted for sickness at admission. Quality differences between types of hospitals were large, with the lowest group estimated to have four percentage points higher mortality than major teaching hospitals in a cohort of patients with average mortality of 16%. Quality varies from state to state, but teaching, larger, and more urban hospitals have better quality in general than nonteaching, small, and rural hospitals. Hospital quality persists over time, but small nonteaching hospitals narrowed the gap with better quality hospitals between 1981 and 1986. CONCLUSIONS: The different measures led to consistent and plausible relationships between quality and hospital characteristics. Thus, valid information about hospital quality can be obtained. We need to develop ways to use such information to improve care.
Assuntos
Hospitais/normas , Avaliação de Processos e Resultados em Cuidados de Saúde , Algoritmos , Mortalidade Hospitalar , Hospitais/estatística & dados numéricos , Hospitais Rurais/normas , Hospitais Rurais/estatística & dados numéricos , Hospitais de Ensino/normas , Hospitais de Ensino/estatística & dados numéricos , Hospitais Urbanos/normas , Hospitais Urbanos/estatística & dados numéricos , Medicaid , Avaliação de Processos e Resultados em Cuidados de Saúde/economia , Avaliação de Processos e Resultados em Cuidados de Saúde/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Sistema de Pagamento Prospectivo , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: To analyze whether important gender differences exist in the quality of hospital care provided to patients with four major medical conditions. DESIGN: Bivariate and multivariate comparisons of clinically detailed sickness at admission, quality, utilization, and outcome measures. SETTING: Acute care hospitals located in five states. PATIENTS OR OTHER PARTICIPANTS: A total of 11,242 patients 65 years or older who were hospitalized with one of four diseases: congestive heart failure, acute myocardial infarction, pneumonia, and cerebrovascular accident. We derived our data from the nationally representative sample used to study the quality of hospital care for Medicare patients before and after the implementation of the prospective payment system. A hierarchical (nested) cluster sampling design was used to draw disease-specific samples of patients hospitalized in 1981, 1982, 1985, or 1986 in one of 297 hospitals located in 30 areas within five states. INTERVENTIONS: This was an observational study. MAIN OUTCOME MEASURES: Sickness at admission, process, use rates, length of stay, discharge status, discharge destination, and mortality. RESULTS: Sex differences in sickness at admission varied by disease. There was some evidence that women received worse process of care, but the difference was very small. We found many similarities in the process and outcomes of care for male and female patients. CONCLUSIONS: After controlling for sickness at admission, age, and other important covariates, the in-hospital experiences of elderly men and women showed greater similarities than differences. The concern that sex bias enters into clinical decision making during hospitalization is eased, although not entirely eliminated.
Assuntos
Serviços de Saúde para Idosos/normas , Hospitais/normas , Avaliação de Processos e Resultados em Cuidados de Saúde/estatística & dados numéricos , Seleção de Pacientes , Idoso , Transtornos Cerebrovasculares/terapia , Comorbidade , Feminino , Insuficiência Cardíaca/terapia , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Medicare , Análise Multivariada , Infarto do Miocárdio/terapia , Pneumonia/terapia , Sistema de Pagamento Prospectivo , Análise de Regressão , Estudos de Amostragem , Viés de Seleção , Fatores Sexuais , Estados UnidosRESUMO
Mortality prediction models hold substantial promise as tools for patient management, quality assessment, and, perhaps, health care resource allocation planning. Yet relatively little is known about the predictive validity of these models. We report here a comparison of the cross-validation performance of seven statistical models of patient mortality: (1) ordinary-least-squares (OLS) regression predicting 0/1 death status six months after admission; (2) logistic regression; (3) Cox regression; (4-6) three unit-weight models derived from the logistic regression, and (7) a recursive partitioning classification technique (CART). We calculated the following performance statistics for each model in both a learning and test sample of patients, all of whom were drawn from a nationally representative sample of 2558 Medicare patients with acute myocardial infarction: overall accuracy in predicting six-month mortality, sensitivity and specificity rates, positive and negative predictive values, and per cent improvement in accuracy rates and error rates over model-free predictions (i.e., predictions that make no use of available independent variables). We developed ROC curves based on logistic regression, the best unit-weight model, the single best predictor variable, and a series of CART models generated by varying the misclassification cost specifications. In our sample, the models reduced model-free error rates at the patient level by 8-22 per cent in the test sample. We found that the performance of the logistic regression models was marginally superior to that of other models. The areas under the ROC curves for the best models ranged from 0.61 to 0.63. Overall predictive accuracy for the best models may be adequate to support activities such as quality assessment that involve aggregating over large groups of patients, but the extent to which these models may be appropriately applied to patient-level resource allocation planning is less clear.