Antimicrobial resistance and antibiotic consumption in Mexican hospitals / Resistencia antimicrobiana y consumo de antibióticos en hospitales mexicanos

Abstract: Objective: To establish the current situation of antimicrobial resistance and antibiotic consumption in Mexican hospitals. Materials and methods: Antimicrobial susceptibility data from blood and urine isolates were collected. Defined daily dose (DDD) of antibiotic consumption/100 occupied beds (OBD) was calculated. Results: Study period: 2016 and 2017. Of 4 382 blood isolates, E. coli and K. pneumoniae were most frequently reported, with antimicrobial resistance >30% for most drugs tested, only for carbapenems and amikacin resistance were <20%. A. baumannii had antimicrobial resistance >20% to all drugs. Resistance to oxacillin in S. aureus was 20%. From 12 151 urine isolates, 90% corresponded to E. coli; resistance to ciprofloxacin, cephalosporins and trimethoprim/sulfamethoxazole was >50%, with good susceptibility to nitrofurantoin, amikacin and carbapenems. Global median antimicrobial consumption was 57.2 DDD/100 OB. Conclusions: This report shows a high antimicrobial resistance level in Gram-negative bacilli and provides an insight into the seriousness of the problem of antibiotic consumption.

Resumen: Objetivo: Establecer la situación actual de la resistencia antimicrobiana y el consumo de antibióticos en hospitales mexicanos. Material y métodos:F Se colectaron datos de susceptibilidad antimicrobiana de aislamientos de sangre y orina. Se calculó la dosis diaria definida (DDD) del consumo de antibióticos/100 estancias. Resultados: Periodo de estudio de 2016 a 2017. De 4 382 aislamientos en sangre, E. coli y K. pneumoniae fueron las más frecuentes, con resistencia >30% a la mayoría de las drogas evaluadas; sólo para carbapenémicos y amikacina la resistencia fue <20%. A. baumannii tuvo resistencia >20% a todos los fármacos. La resistencia a oxacilina en S. aureus fue de 20%. De 12 151 aislamientos en urocultivos, 90% correspondió a E. coli; la resistencia a ciprofloxacina, cefalosporinas y trimetoprima/sulfametoxazol fue >50%, con buena susceptibilidad a nitrofurantoína, amikacina y carbapenémicos. La mediana del consumo global de antibióticos en DDD/100 estancias fue de 57.2. Conclusiones: Este reporte muestra el nivel elevado de resistencia en bacilos Gram-negativos y brinda una perspectiva de la gravedad del problema del consumo de antibióticos.

Antimicrobial resistance and antibiotic consumption in Mexican hospitals.

OBJECTIVE: To establish the current situation of antimicrobial resistance and antibiotic consumption in Mexican hospitals. MATERIALS AND METHODS: Antimicrobial susceptibility data from blood and urine isolates were collected. Defined daily dose (DDD) of antibiotic consumption/100 occupied beds (OBD) was calculated. RESULTS: Study period: 2016 and 2017. Of 4 382 blood isolates, E. coli and K. pneumoniae were most frequently reported, with antimicrobial resistance >30% for most drugs tested, only for carbapenems and amikacin resistance were <20%. A. baumannii had antimicrobial resistance >20% to all drugs. Resistance to oxacillin in S. aureus was 20%. From 12 151 urine isolates, 90% corresponded to E. coli; resistance to ciprofloxacin, cephalosporins and trimethoprim/sulfamethoxazole was >50%, with good susceptibility to nitrofurantoin, amikacin and carbapenems. Global median antimicrobial consumption was 57.2 DDD/100 OB. CONCLUSIONS: s. This report shows a high antimicrobial resistance level in Gram-negative bacilli and provides an insight into the seriousness of the problem of antibiotic consumption.

OBJETIVO: Establecer la situación actual de la resistencia antimicrobiana y el consumo de antibióticos en hospitales mexicanos. MATERIAL Y MÉTODOS: Se colectaron datos de susceptibilidad antimicrobiana de aislamientos de sangre y orina. Se calculó la dosis diaria definida (DDD) del consumo de antibióticos/100 estancias. RESULTADOS: Periodo de estudio de 2016 a 2017. De 4 382 aislamientos en sangre, E. coli y K. pneumoniae fueron las más frecuentes, con resistencia >30% a la mayoría de las drogas evaluadas; sólo para carbapenémicos y amikacina la resistencia fue <20%. A. baumannii tuvo resistencia >20% a todos los fármacos. La resistencia a oxacilina en S. aureus fue de 20%. De 12 151 aislamientos en urocultivos, 90% correspondió a E. coli; la resistencia a ciprofloxacina, cefalosporinas y trimetoprima/sulfametoxazol fue >50%, con buena susceptibilidad a nitrofurantoína, amikacina y carbapenémicos. La mediana del consumo global de antibióticos en DDD/100 estancias fue de 57.2. CONCLUSIONES: Este reporte muestra el nivel elevado de resistencia en bacilos Gram-negativos y brinda una perspectiva de la gravedad del problema del consumo de antibióticos.

Utilization and Treatment Patterns of Cytoreduction Surgery and Intraperitoneal Chemotherapy in the United States.

INTRODUCTION: Cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) is an effective treatment option for selected patients with peritoneal metastases (PM), but national utilization patterns are poorly understood. The objectives of this study were to (1) describe population-based trends in national utilization of CRS/IPC; (2) define the most common indications for the procedure; and (3) characterize the types of hospitals performing the procedure. METHODS: The National Inpatient Sample (NIS) was used to identify patients from 2006 to 2015 who underwent CRS/IPC, and to calculate national estimates of procedural frequency and oncologic indication. Hospitals performing CRS/IPC were classified based on size and teaching status. RESULTS: The estimated annual number of CRS/IPC cases increased significantly from 189 to 1540 (p < 0.001). Overall, appendiceal cancer was the most common indication (25.7%), followed by ovarian cancer (23.3%), colorectal cancer (22.5%), and unspecified PM (15.0%). Remaining cases (13.5%) were performed for other indications. Most cases were performed in large teaching hospitals (65.9%), compared with smaller teaching hospitals (25.1%), large non-teaching hospitals (5.3%), or small non-teaching hospitals (3.2%). Patients were more likely to undergo CRS/IPC without a diagnosis based on level I evidence (appendiceal, ovarian, or colorectal) at large non-academic hospitals (odds ratio 2.00, 95% confidence interval 1.18-3.38, p = 0.010) compared with large academic hospitals. CONCLUSIONS: Utilization of CRS/IPC is increasing steadily in the US, is performed at many types of facilities, and often for a variety of indications that are not supported by high-level evidence. Given associated morbidity of CRS/IPC, a national registry dedicated to cases of IPC is necessary to further evaluate use and outcomes.

Cancer care in Brazil: structure and geographical distribution.

BACKGROUND: The organisation and systematisation of health actions and services are essential to ensure patient safety and the effectiveness and efficiency of cancer care. The objective of this study was to analyse the structure of cancer care envisaged in Brazilian norms, describe the types of accreditations of cancer services and their geographic distribution, and determine the planning and evaluation parameters used to qualify the health units that provide cancer care in Brazil. METHODS: This observational study identified the current organisation of cancer care and other health services that are accredited by Brazil's national health system (SUS) for cancer treatment as of February 2017. The following information was collected from the current norms and the National Registry of Health Establishments: geographic location, type of accreditation, type of care, and hospital classification according to annual data of the number of cancer surgeries. The adequacy of the number of licensed units relative to population size was assessed. The analysis considered the facilitative or restrictive nature of policies based on the available rules and resources. RESULTS: The analysis of the norms indicated that these documents serve as structuring rules and resources for developing and implementing cancer care policies in Brazil. A total of 299 high-complexity oncology services were identified in facilities located in 173 (3.1%) municipalities. In some states, there were no authorised services in radiotherapy, paediatric oncology and/or haematology-oncology. There was a significant deficit in accredited oncology services. CONCLUSIONS: The parameters that have been used to assess the need for accredited cancer services in Brazil are widely questioned because the best basis of calculation is the incidence of cancer or disease burden rather than population size. The results indicate that the availability of cancer services is insufficient and the organisation of the cancer care network needs to be improved in Brazil.

Evaluación de la calidad de vida relacionada con la salud pre y post trasplante hepático, en pacientes de un hospital de alta complejidad / Health- related quality of life evaluation pre and post liver transplant in patients of a high complexity hospital

Resumen El trasplante hepático es la alternativa terapéutica indicada en pacientes con enfermedad hepática terminal para mejorar su sobrevida y calidad de vida. El objetivo de este estudio fue evaluar la calidad de vida relacionada con la salud (CVRS) de pacientes con cirrosis hepática antes y después de trasplante hepático. Se incluyeron 33 personas adultas que estaban en lista de espera para trasplante en la institución, se aplicó una serie de cuestionarios antes y después del trasplante: para evaluar la calidad de vida se utilizaron el LDQOL-1 (específico para enfermedad y trasplante hepático) y SF36 (para población general); para evaluar los síntomas depresivos y ansiosos, se utilizaron el BDI y STAI, respectivamente. Los resultados señalan una mejoría en la CVRS, así como disminución de los síntomas ansiosos y depresivos posterior al trasplante.

Abstract Liver transplantation is the therapeutic intervention of choice in patients with terminal liver disease to improve survival rate and quality of life. The aim of this study was to assess health related quality of life (HRQOL) in liver cirrhosis patients before and after liver transplantation. Thirty-three patients in waiting list for transplant in the institution were included; some questionnaires were applied before and after transplantation: to assess HRQOL were used LDQOL-1 (specific for liver disease and transplant) and SF36 (for general population); to assess depressive and anxious symptoms, BDI and STAI were used, respectively. Results showed an improvement in HRQOL and reduction in depressive and anxious symptoms after transplantation.

A taxonomy of hospitals participating in Medicare accountable care organizations.

BACKGROUND: Medicare was an early innovator of accountable care organizations (ACOs), establishing the Medicare Shared Savings Program (MSSP) and Pioneer programs in 2012-2013. Existing research has documented that ACOs bring together an array of health providers with hospitals serving as important participants. PURPOSE: Hospitals vary markedly in their service structure and organizational capabilities, and thus, one would expect hospital ACO participants to vary in these regards. Our research identifies hospital subgroups that share certain capabilities and competencies. Such research, in conjunction with existing ACO research, provides deeper understanding of the structure and operation of these organizations. Given that Medicare was an initiator of the ACO concept, our findings provide a baseline to track the evolution of ACO hospitals over time. METHODOLOGY/APPROACH: Hierarchical clustering methods are used in separate analyses of MSSP and Pioneer ACO hospitals. Hospitals participating in ACOs with 2012-2013 start dates are identified through multiple sources. Study data come from the Centers for Medicare and Medicaid Services, American Hospital Association, and Health Information and Management Systems Society. RESULTS: Five-cluster solutions were developed separately for the MSSP and Pioneer hospital samples. Both the MSSP and Pioneer taxonomies had several clusters with high levels of health information technology capabilities. Also distinct clusters with strong physician linkages were present. We examined Pioneer ACO hospitals that subsequently left the program and found that they commonly had low levels of ambulatory care services or health information technology. CONCLUSION: Distinct subgroups of hospitals exist in both the MSSP and Pioneer programs, suggesting that individual hospitals serve different roles within an ACO. Health information technology and physician linkages appear to be particularly important features in ACO hospitals. PRACTICE IMPLICATIONS: ACOs need to consider not only geographic and service mix when selecting hospital participants but also their vertical integration features and management competencies.

Risk Adjustment for Hospital Characteristics Reduces Unexplained Hospital Variation in Pressure Injury Risk.

BACKGROUND: Research investigating risk factors for hospital-acquired pressure injury (HAPI) has primarily focused on the characteristics of patients and nursing staff. Limited data are available on the association of hospital characteristics with HAPI. OBJECTIVE: We aimed to quantify the association of hospital characteristics with HAPI and their effect on residual hospital variation in HAPI risk. METHODS: We employed a retrospective cohort study design with split validation using hierarchical survival analysis. This study extends the analysis "Hospital-Acquired Pressure Injury (HAPI): Risk Adjusted Comparisons in an Integrated Healthcare Delivery System" by Rondinelli et al. (2018) to include hospital-level factors. We analyzed 1,661 HAPI episodes among 728,266 adult hospitalization episodes across 35 California Kaiser Permanente hospitals, an integrated healthcare delivery system between January 1, 2013, and June 30, 2015. RESULTS: After adjusting for patient-level and hospital-level variables, 2 out of 12 candidate hospital variables were statistically significant predictors of HAPI. The hazard for HAPI decreased by 4.8% for every 0.1% increase in a hospital's mean mortality ([6.3%, 2.6%], p < .001), whereas every 1% increase in a hospital's proportion of patients with a history of diabetes increased HAPI hazard by 5% ([-0.04%, 10.0%], p = .072). Addition of these hierarchical variables decreased unexplained hospital variation of HAPI risk by 35%. DISCUSSION: We found hospitals with higher patient mortality had lower HAPI risk. Higher patient mortality may decrease the pool of patients who live to HAPI occurrence. Such hospitals may also provide more resources (specialty staff) to care for frail patient populations. Future research should aim to combine hospital data sets to overcome power limitations at the hospital level and should investigate additional measures of structure and process related to HAPI care.

La Sección de Hospitalaización de Pediatría del Hospital Materno Infantil Gregorio Marañón en 2016 / Pediatric Hospitalization Section of the Hospital Materno Infantil Gregorio Marañón in 2016

Entre los objetivos principales de la hospitalización pediátrica en un hospital terciario se incluyen el cuidado integral de los pacientes pediátricos ingresados incluyendo aspectos diagnósticos, curativos, preventivos y de rehabilitación. La Academia Americana de Pediatría reconoció hace más de 20 años la importancia y el papel crucial de los programas de hospitalización pediátrica. Así, la Pediatría General en un hospital terciario juega un papel muy importante en el cuidado agudo de pacientes pediátricos con patologías prevalentes, pero también como coordinador e integrador del cuidado de pacientes crónicos y de alta complejidad. También creemos que la Pediatría General en un hospital terciario tiene la responsabilidad de desarrollar los programas de calidad, implantar una cultura de seguridad en Pediatría, promover protocolos y guías clínicas en patologías prevalentes, ser referentes en la educación de los familiares de nuestros pacientes así como desarrollar los programas de e-health y cooperación internacional (AU)

The main objectives of the Pediatric Hospitalist Programs within a Tertiary Hospital include comprehensive care to hospitalized pediatric patients in diagnostic, curative, preventive, and rehabilitation aspects. The American Academy of Pediatrics recognized about 20 years ago, the importance and the key role of Pediatrics Hospitalist programs. General Pediatrics plays an important role not only for the care in acute prevalent pathologies, but also as a coordinator and integrator in chronic and highly complex patients. We also believe that General Pediatrics at a Third level hospital, has the responsibility to develop quality programs, implement safety culture in hospitalized patients, promote protocols and clinical guidelines in prevalent pathologies, health education in our population, and developing e-health and international cooperation programs (AU)

Survival in relation to hospital type after resection or sorafenib treatment for hepatocellular carcinoma in The Netherlands.

BACKGROUND AND OBJECTIVE: Despite an increase in recent years, hepatocellular carcinoma remains uncommon in the Netherlands. The aim of the current study is to explore potential effects of hospital type and volume on outcomes after resection or sorafenib in patients with hepatocellular carcinoma. METHODS: Initial treatment and survival of patients with hepatocellular carcinoma diagnosed in the period 2005-2011 were based on data of the Netherlands Cancer Registration. Potential risk factors (including hospital type and volume) for 30-days postoperative and long-term mortality in patients who underwent resection and in patients treated with sorafenib were evaluated by uni- and multivariate analyses. RESULTS: In the period 2005-2011, 2402 patients were diagnosed with hepatocellular carcinoma: 12% received resection and 9% sorafenib. Postoperative mortality was higher in non-university hospitals (13% versus 4%; P=0.01). Resection in non-university hospitals was associated with higher postoperative mortality (odds ratio 3.38, 95% confidence interval 1.37-10.68) and long-term mortality (hazard ratio 1.21, 95% confidence interval 1.04-1.40). Sorafenib treatment in non-university hospitals was also associated with higher long-term mortality (hazard ratio 1.39, 95% confidence interval 1.06-1.82). Hospital volume was not independent predictor for outcome. CONCLUSION: In low incidence countries, outcome after resection or sorafenib for hepatocellular carcinoma may differ between various hospital types.

The association between attendance of midwives and workload of midwives with the mode of birth: secondary analyses in the German healthcare system.

BACKGROUND: The continuous rise in caesarean rates across most European countries raises multiple concerns. One factor in this development might be the type of care women receive during childbirth. 'Supportive care during labour' by midwives could be an important factor for reducing fear, tension and pain and decreasing caesarean rates. The presence and availability of midwives to support a woman in line with her needs are central aspects for 'supportive care during labour'.To date, there is no existing research on the influence of effective 'supportive care' by German midwives on the mode of birth. This study examines the association between the attendance and workload of midwives with the mode of birth outcomes in a population of low-risk women in a German multicentre sample. METHODS: The data are based on a prospective controlled multicentre trial (n = 1,238) in which the intervention 'midwife-led care' was introduced. Four German hospitals participated between 2007 and 2009.Secondary analyses included a convenience sample of 999 low-risk women from the primary analyses who met the selection criterion 'low-risk status'. Participation was voluntary. The association between the mode of birth and the key variables 'attendance of midwives' and 'workload of midwives' was assessed using backward logistic regression models. RESULTS: The overall rate of spontaneous delivery was 80.7% (n = 763). The 'attendance of midwives' and the 'workload of midwives' did not exhibit a significant association with the mode of birth. However, women who were not satisfied with the presence of midwives (OR: 2.45, 95% CI 1.54-3.95) or who did not receive supportive procedures by midwives (OR: 3.01, 95% CI 1.50-6.05) were significantly more likely to experience operative delivery or a caesarean. Further explanatory variables include the type of hospital, participation in childbirth preparation class, length of stay from admission to birth, oxytocin usage and parity. CONCLUSION: Satisfaction with the presence of and supportive procedures by midwives are associated with the mode of birth. The presence and behaviour of midwives should suit the woman's expectations and fulfil her needs. For reasons of causality, we would recommend experimental or quasi-experimental research that would exceed the explorative character of this study.

Questionnaire results of hyperbaric oxygen therapy for acute carbon monoxide poisoning in Japan.

Carbon monoxide (CO) poisoning results in not only severe psychoneurological disorders, but can also cause secondary delayed psychoneurological disorders. Therefore, timely and appropriate treatment in the acute stage is crucial to prevent such direct neurological damage and secondary disorders. However, various conflicting results have been reported in studies of CO poisoning treatment, and the efficacy of hyperbaric oxygen therapy (HBO2T) for CO poisoning has not been established. This retrospective multi-institutional study was performed by the questionnaire in 1667 cases of acute CO poisoning in Japan. The effectiveness of HBO2T for CO poisoning was evaluated based on prognoses in cases and various classes of hospital based on the grade of their positive stance regarding HBO2T. The results showed that the prognosis in the group treated with HBOT was significantly better than that in the group treated with normobaric oxygen therapy (NBO2T) (P < 0.01), thus confirming the effectiveness of HBO2T for CO poisoning. Furthermore, while hospitals were separated into three groups according to their indication criteria for HBO2T, the ineffective ratio of NBO2T was dependent on the indication criteria, even though the effective ratio of HBO2T was the same in all three groups. In conclusion, a retrospective multi-institutional study showed that HBO2T is an effective form of therapy for CO poisoning.

Economic costs for adult asthmatics according to severity and control status in Korean tertiary hospitals.

OBJECTIVE: The prevalence of asthma is increasing, and asthma causes considerable socioeconomic burden worldwide. Few studies have been conducted to evaluate the risk factors associated with economic cost of asthma in Korea. This study evaluated asthma cost according to severity, control, and patient factors in Korean tertiary hospitals. METHODS: Direct and indirect costs were assessed in physician-diagnosed adult asthmatics recruited from eight tertiary hospitals in Korea. Official direct medical costs were derived from the analysis of 1-year expenditures related to hospital care utilization and asthma medication. Nonofficial medical costs, nonmedical direct costs, and indirect costs were investigated using a questionnaire designed specifically for the study. RESULTS: A total of 314 patients with persistent asthma were recruited. Both direct and indirect costs were significantly higher for patients with severe persistent asthma than for those with mild and moderate persistent asthma ($2214 vs. $871 and $978, p < .001; $2927 vs. $490 and $443, p < .001, respectively). Costs of asthma increased significantly in poorly controlled compared with somewhat controlled and well-controlled asthma ($7009.8 vs. $2725.3 vs. $1517.3, respectively; p < .001). After stratification for severity, a significant cost increase in the poorly controlled asthma group was observed only for indirect costs and not for direct costs. A multivariate analysis showed that female gender was a risk factor for increased indirect costs. CONCLUSION: The burden of asthma was higher both for patients with severe persistent asthma and for patients with poorly controlled asthma. More effective strategies are needed to improve control status, particularly targeting patients with severe asthma.

Pharmaceutical penetration of new drug and pharmaceutical market structure in Taiwan: hospital-level prescription of thiazolidinediones for diabetes.

This study used Taiwan's National Health Insurance claim database (years 2000-2005) to examine how thiazolidinediones (TZD), a new class of drugs for diabetes, penetrated into Taiwan's hospitals, and its association with the concentration of all diabetes drugs at the hospital level. We collected 72 monthly summaries of diabetes prescriptions from all hospitals in Taiwan. Hospital-level pharmaceutical concentration was measured by penetration of TZD, defined as monthly market share of TZD in each hospital. Concentration of diabetes drugs was measured by Herfindahl-Hirschman indices. We found a negative association (coefficient = -0.3610) between TZD penetration and concentration of diabetes drug but a positive association between penetration of TZD and the volume of prescribed diabetes drugs (coefficient = 0.4088). In conclusion, hospital characteristics and volume of services determined the concentration of pharmaceuticals at the institution level, reflecting the heterogeneous competition between pharmaceutical companies within each hospital. Institution-level pharmaceutical concentration influences the adoption and penetration of new drugs.

Accreditation of hospitals in Lebanon: a challenging experience.

The quality of hospital care in Lebanon has witnessed a paradigm shift since May 2000, from a traditional focus on physical structure and equipment to a broader multidimensional approach, emphasizing managerial processes, performance and output indicators. In the absence of an effective consumer voice, the impetus for change has come from the Ministry of Public Health, which has supported the development of an accreditation programme for hospitals. This paper describes and analyses the experience of Lebanon in introducing this programme. It looks at the application of normative measures on private institutions that have been used to operating in a loosely controlled environment with little accountability.

The evolution of an integrated State Trauma System in Victoria, Australia.

The incidence of major trauma and associated fatalities in the State of Victoria, Australia, have declined over 20 years following the successful implementation of strategies to modify environmental and behavioural factors that contribute to motor vehicle injuries. However, several system deficiencies in the management of major trauma patients had remained unresolved. To investigate these shortfalls the State Government of Victoria established a task force in 1997 to review trauma and emergency services. The task force adopted the principle of "the right patient to the right hospital in the shortest time" and in 2000 began to deploy an integrated State Trauma System. Implementation of such a system required the designation of specific hospitals of various levels to care for trauma patients; the concentration of trauma expertise at these centres; integration and coordination between the service providers; development of agreed triage and transfer protocols and improved education, training and research programs. A statewide major trauma database was established to enable system monitoring and facilitate further enhancements. The Victorian experience with the development of an integrated trauma system should aid in the development of similar systems nationally and internationally and is described in this paper.

Cognitive-behavioural therapy for patients with multiple somatoform symptoms--a randomised controlled trial in tertiary care.

OBJECTIVE: (a) To evaluate the effect of a cognitive-behavioural inpatient treatment and (b) to analyse the differential efficacy of an additional ("soma") group management training of somatisation. METHODS: The final sample consisted of 191 patients with somatisation syndrome (patients with at least eight DSM-IV somatoform symptoms). Patients were randomly assigned to (I) "standard treatment + soma" or (II) "standard treatment + relaxation training." A waiting control group consisted of 34 patients. All patients were diagnosed with a structured clinical interview for DSM-IV and received an interview on medical consulting behaviour and questionnaires concerning somatoform symptoms, general psychopathology, subjective health status, and life satisfaction. RESULTS: Results show high impairment of the sample prior to treatment. At the 1-year follow-up, all outcome criteria were significantly reduced. The differential effect of the additional soma treatment was significant only for a reduction of visits to the doctor. Greatest longitudinal effect sizes were found for the reduction of somatoform symptoms. CONCLUSION: Considering the subjects' high initial impairment, the outcome results are encouraging. The specific effect on health care use highlights the socioeconomic relevance.

Hospital tiers in health insurance: balancing consumer choice with financial incentives.

Variations in efficiency and market power are generating wide variations in the prices charged by hospitals to health insurance plans. Insurers are developing new network structures that expose the consumer to some of the cost differences, to encourage but not mandate differential use of the more economical facilities. The three leading designs include hospital "tiers" within a single broad network, multiple-network products, and the replacement of copayments by coinsurance in HMO as well as PPO products. This paper describes the new network designs and evaluates the challenges they face in influencing consumers' behavior, incorporating information on clinical quality, and supporting medical education and uncompensated care.

Tiered hospital networks.

As a result of rising health care costs, health plans are experimenting with insurance products that shift greater financial responsibility for medical care to consumers and create incentives for consumers to consider cost differences when choosing among providers. Based on an October 2002 roundtable discussion, this paper discusses insurance product trends, particularly tiered hospital networks. Issues addressed include these product features' potential to reduce system costs, the effect on the hospital-health plan relationship, consumers' ability to consider cost and quality in decision making, and financial barriers to care for the chronically ill.

Hospital tiering: how will it play in Peoria?

Cost-sharing strategies such as hospital tiering will require consumers to make cost-benefit decisions where they have little experience. This responsibility may be further challenged by prevailing consumer perspectives: that health insurance is an open-ended service benefit; that medical treatment decisions should not be influenced by costs; and that consumers are not responsible for the current cost crisis. Although there are steps providers can take to prepare consumers for their new role in cost sharing, health care leaders need to begin moving from a consumer-driven to a citizen-driven approach.

The erosion of health insurance: the unintended consequences of tiered products by health plans.

When properly structured, consumer-driven health care may provide gains to both patients and the delivery system. However, the current approach by health plans could result in real harm to patients and to an already fragile health care delivery system. While health plans are presenting tiered products as a necessary mechanism to control rising hospital expenditures, this paper explores the real drivers of the rising cost of health care, including utilization, increased demand for advanced medication, and new technology. Left unchecked, such benefit designs could have dangerous public policy implications and consequences, including the further erosion of the basic tenets of health insurance.