Effects of individual and neighborhood socioeconomic status on the risk of all-cause mortality in chronic obstructive pulmonary disease: A nationwide population-based cohort study, 2002-2013.

BACKGROUND: Numerous previous studies have shown that individual socioeconomic status (SES) is associated with mortality in patients with chronic obstructive pulmonary disease (COPD), but few empirical studies have evaluated the effects of individual SES and neighborhood deprivation on mortality in COPD patients. METHODS: We performed a prospective cohort study to examine the effect of socioeconomic disparity on all-cause mortality in newly diagnosed COPD patients in a setting with universal health care coverage. We used representative population-based nationwide cohort data from the Korean National Health Insurance claims database (2002-2013). We included patients who were at least 40 years old and newly diagnosed with COPD (N = 9275). To analyze the data, we utilized a frailty model and Cox's proportional hazard regression. RESULTS: A total of 1849 (19.9%) of the 9275 eligible participants died during the study period. Compared to high-income patients from advantaged neighborhoods, the adjusted hazard ratio (HR) for middle-income COPD patients who lived in advantaged and disadvantaged neighborhoods was 1.22 (95% CI, 1.03-1.43) and 1.36 (95% CI, 1.15-1.60), respectively. For low-income patients, the adjusted HR for patients who lived in disadvantaged neighborhoods was higher than for patients who lived in advantaged neighborhoods (HR, 1.43; 95% CI, 1.17-1.74 vs. HR, 1.36; 95% CI, 1.11-1.66). There was no difference in the adjusted HRs for high-income patients who lived in advantaged and disadvantaged neighborhoods (HR, 1.01; 95% CI, 0.84-1.22). CONCLUSIONS: Socioeconomic disparity contributes to all-cause mortality in COPD patients and neighborhood deprivation exacerbates the effect of individual SES on all-cause mortality in COPD patients.

Inequality in the long run.

This Review presents basic facts regarding the long-run evolution of income and wealth inequality in Europe and the United States. Income and wealth inequality was very high a century ago, particularly in Europe, but dropped dramatically in the first half of the 20th century. Income inequality has surged back in the United States since the 1970s so that the United States is much more unequal than Europe today. We discuss possible interpretations and lessons for the future.

Personal and practice predictors associated with the income of Ontario chiropractors.

OBJECTIVE: Practice-based information may allow policy makers and associations the opportunity to interpret utilization rates and anticipate the impact of future growth of professions. The objective of this study was to assess the association between income and specific personal, practice, and treatment characteristics in a sample of Ontario chiropractors. METHODS: Descriptive and regression analyses were used to assess end-of-year practice summary data obtained from a professional billing software program voluntarily submitted by 731 individual chiropractors. RESULTS: The model explained 65% of the variance in income. Significant explanatory factors regarding income were those related to treatment characteristics, with the largest contribution made by the total number of new patients seen in the year, which uniquely contributed 17% of the total variance. Personal and practice-related characteristics made significant but relatively small contributions; however, the location of the practice and years since graduation appear to impact income, especially in the formative years of practice development. CONCLUSION: The variance in annual practitioner income was predicted by a combination of personal, practice, and treatment characteristics but not surprisingly primarily by the total number of new patients seen in the year. A negative association between average treatment costs and number of patients seen suggests cost sensitivity. The results provide important benchmarks that can be used to guide expectations of new graduates and to assess future trends. Further work is needed to determine if the findings can be generalized.

[Health care financing: is it enough and appropriate?]. / Es la financiación sanitaria suficiente y adecuada?

INTRODUCTION: The object of this short paper is to present the results of Spanish public health care expenditures projections until 2013 according to the expected impact of the main demographic and technological health cost drivers. MATERIAL AND METHODS: Future annual health expenditures are estimated using a simple method based on the decomposition of the past main growth factors in two scenarios. The main cost drivers considered were the following: demography, which includes the increasing number of people and the impact of population ageing; the increase in the price of health care inputs above the general price level; and the impact of changes in medical practice related with expanding medical technology. RESULTS AND DISCUSSION: In 2013, public health care expenditure may be around 5.7% and 6% of gross domestic product (GDP); that is, at least, between 0.24 and 0.53 additional GDP points will be spent on public health care. The main factor responsible for the future expenditure increase will continue to be the increase in the average health service intensity, followed by demographic factors. In the base-case scenario, public expenditure increase until 2013 will be compatible with a real 2.5% annual increase in consumption of non-health goods and services. In order to finance the future costs, the Spanish population will have to devote to public health expenditure less than 7% of income increase until 2013. CONCLUSION AND PERSPECTIVES: Despite being important, the expected Spanish GDP growth until 2013 may be enough to finance the increase in public health expenditure as a result of the impact of demographic changes. Expanding medical technology is expected to continue being the main driver of future costs.

Six Sigma pricing.

Many companies are now good at managing costs and wringing out manufacturing efficiencies. The TQM movement and the disciplines of Six Sigma have seen to that. But the discipline so often brought to the cost side of the business equation is found far less commonly on the revenue side. The authors describe how a global manufacturer of industrial equipment, which they call Acme Incorporated, recently applied Six Sigma to one major revenue related activity--the price-setting process. It seemed to Acme's executives that pricing closely resembled many manufacturing processes. So, with the help of a Six Sigma black belt from manufacturing, a manager from Acme's pricing division recruited a team to carry out the five Six Sigma steps: Define what constitutes a defect. At Acme, a defect was an item sold at an unauthorized price. Gather data and prepare it for analysis. That involved mapping out the existing pricing-agreement process. Analyze the data. The team identified the ways in which people failed to carry out or assert effective control at each stage. Recommend modifications to the existing process. The team sought to decrease the number of unapproved prices without creating an onerous approval apparatus. Create controls. This step enabled Acme to sustain and extend the improvements in its pricing procedures. As a result of the changes, Acme earned dollar 6 million in additional revenue on one product line alone in the six months following implementation--money that went straight to the bottom line. At the same time, the company removed much of the organizational friction that had long bedeviled its pricing process. Other companies can benefit from Acme's experience as they look for ways to exercise price control without alienating customers.

Delicate balance: 2003 salary survey.

Hospital boards are exercising more scrutiny than ever on executive pay, at a time when the disparity between salaries in health care and general industry has finally disappeared.

The right strategy and perseverance can make an IDS profitable.

Results of a recent study of 11 leading integrated delivery systems (IDSs) belie the common perception that IDSs are incapable of turning a profit. The study determined that the primary factors driving the poor financial performance of IDSs are organizational complexity, payment reductions mandated by the Balanced Budget Act of 1997, and a general lack of foresight regarding financial problems when embarking on an integration strategy. By implementing a wide range of initiatives to stem losses and improve financial performance, several of the case-study IDSs have accomplished dramatic financial turnarounds over the past three years, and all have achieved consistently stronger financial performance.

Effectiveness of food fortification in the United States: the case of pellagra.

OBJECTIVES: We evaluated the possible role of niacin fortification of the US food supply and other concurrent influences in eliminating the nutritional deficiency disease pellagra. METHODS: We traced chronological changes in pellagra mortality and morbidity and compared them with the development of federal regulations, state laws, and other national activities pertaining to the fortification of cereal-grain products with niacin and other B vitamins. We also compared these changes with other concurrent changes that would have affected pellagra mortality or morbidity. RESULTS: The results show the difficulty of evaluating the effectiveness of a single public health initiative such as food fortification without controlled experimental trials. Nonetheless, the results provide support for the belief that food fortification played a significant role in the elimination of pellagra in the United States. CONCLUSIONS: Food fortification that is designed to restore amounts of nutrients lost through grain milling was an effective tool in preventing pellagra, a classical nutritional deficiency disease, during the 1930s and 1940s, when food availability and variety were considerably less than are currently found in the United States.

Vertical integration strategies: revenue effects in hospital and Medicare markets.

The purpose of this study was to evaluate the revenue effects of seven vertically integrated strategies on California hospitals. The strategies investigated were managed care contracts, physician affiliations, ambulatory care, ambulatory surgery, home health services, inpatient rehabilitation, and skilled nursing care. The study population included 242 not-for-profit hospitals in continuous operation from 1983 to 1990. Many hospitals developed vertically integrated programs in the 1980s as inpatient utilization fell in response to the Medicare Prospective Payment program. Net revenue rose on average by $2,080 from 1983 to 1990, but fell by $2,421 from the Medicare program. On the whole, the more physicians affiliated with a hospital, the higher the net revenue. However, in the Medicare population, the number of managed care contracts was significant. The pre-hospital strategies generated significant revenue, while the post-hospital strategies did not. In the Medicare program, inpatient rehabilitation significantly reduced revenue.