A theory of fiscal policy response to an epidemic.

Governments worldwide have issued massive amounts of debt to inject fiscal stimulus during the COVID-19 pandemic. This paper analyzes fiscal responses to an epidemic, in which interactions at work increase the risk of disease and mortality. Fiscal policies, which are designed to borrow against the future and provide transfers to individuals suffering economic hardship, can facilitate consumption smoothing while reduce hours worked and hence mitigate infections. We examine the optimal fiscal policy and characterize the condition under which fiscal policy improves social welfare. We then extend the model analyzing the static and dynamic pecuniary externalities under scale economies-the decrease in labor supply during the epidemic lowers the contemporaneous average wage rate while enhances the post-epidemic workforce health and productivity. We suggest that fiscal policy may not work effectively unless the government coordinates working time, and the optimal size of public debt is affected by production technology and disease severity and transmissibility.

Factors Influencing Nurses' Work Interruption in Wuhan Isolation Wards During the COVID-19 Pandemic.

BACKGROUND Through January 2021, the novel coronavirus (COVID-19) continued to create significant pressure on medical staff who have worked to treat patients with the disease and control its spread. This study aimed to increase understanding of the situation and influencing factors of nurses' work interruption in Wuhan's isolation ward during the COVID-19 pandemic. MATERIAL AND METHODS A self-designed general situation questionnaire and work interruption questionnaire were used to survey 160 nurses from Beijing, Chongqing, and Jilin who worked during the COVID-19 pandemic in Wuhan in March 2020. The questionnaire could only be answered once by each nurse via a WeChat account. The submitted answers were verified by 2 researchers. RESULTS The results showed that the rate of interruption of work among nurses in the isolation ward was 25%, and the rate of nurses experiencing a negative experience was 96.9%. The results of univariate analysis showed that the following factors were related to the work interruption of the nurses in the isolation ward (all P<0.05): emergency public incident training; emergency public incident treatment experience; knowledge of COVID-19 pneumonia; hours worked per shift in the quarantine area; and negative physiologic experience. Logistic regression analysis showed that negative experience, hours worked per shift, and emergency public incident training were the independent factors influencing work interruption among nurses in the isolation wards. CONCLUSIONS The incidence of interruption of work among nurses in the isolation ward was 25%. Negative experiences, long working hours per shift, and lack of emergency public incident training made the nurses more prone to work interruption.

Variation in Payment per Work Relative Value Unit for Breast Reconstruction and Nonbreast Microsurgical Reconstruction: An All-Payer Claims Database Analysis.

BACKGROUND: Commercial payments for implant-based breast reconstruction have increased within the past decade, whereas reimbursements have stagnated for microsurgical techniques. The physician payment-to-work relative value unit ratio allows for standardization when comparing procedures of differing complexity. This study aimed to characterize payment per work relative value unit for common breast and nonbreast microsurgical procedures. METHODS: The Massachusetts All-Payer Claims Database was queried from 2010 to 2014 for Current Procedural Terminology (CPT) codes related to microsurgical and breast reconstruction. International Classification of Diseases codes were further used to categorize procedures by anatomical region, including head and neck, breast, trunk, and extremities. Physician payments, both commercial and governmental, were aggregated by anatomical region and CPT code. Payment distributions were described with means and medians and compared using statistical tests. RESULTS: Among 3435 commercial claims, distributions of physician payments per work relative value unit for microsurgical and common breast procedures differed only for breast free flaps billed through S codes (p < 0.001). Microsurgical breast procedures (CPT code 19364) had significantly greater median payments per work relative value unit compared to microsurgery of the head and neck, trunk, and upper extremities (p = 0.004). Payment per work relative value unit for common breast and nonbreast microsurgical procedures did not differ significantly among governmental claims (p = 0.103). CONCLUSIONS: Adjustment of physician payments by work relative value units did not show significant variability across common breast procedures, except for S codes, suggesting that payments are mostly driven by differences in work relative value units and individual contractual negotiations. Lower payments per work relative value unit for other regions compared to breast suggests an opportunity for negotiation with commercial payers.

Vascular Surgeons Are Not Adequately Valued by Traditional Productivity Metrics.

BACKGROUND: Reimbursements for professional services performed by clinicians are under constant scrutiny. The value of a vascular surgeon's services as measured by work relative value units (wRVUs) and professional reimbursement has decreased for some of the most common procedures performed. Hospital reimbursements, however, often remain stable or increases. We sought to evaluate fistulagrams as a case study and hypothesized that while wRVUs and professional reimbursements decrease, hospital reimbursements for these services increased over the same time period. METHODS: Medicare 5% claims data were reviewed to identify all fistulagrams with or without angioplasty or stenting performed between 2015 and 2018 using current procedural terminology codes. Reimbursements were classified into 3 categories: medical center (reimbursements made to a hospital for a fistulagram performed as an outpatient procedure), professional (reimbursement for fistulagrams based on compensation for procedures: work RVUs, practice expense RVU, malpractice expense RVU), and office-based laboratory (OBL, reimbursement for fistulagrams performed in an OBL setting). Medicare's Physician Fee Schedule was used to calculate wRVU and professional reimbursement. Medicare's Hospital Outpatient Prospective Payment System-Ambulatory Payment Classification was used to calculate hospital outpatient reimbursement. RESULTS: From 2015 to 2018, we identified 1,326,993 fistulagrams. During this study period, vascular surgeons experienced a 25% increase in market share for diagnostic fistulagrams. Compared with 2015, total professional reimbursements from 2017 to 2018 for all fistulagram procedures decreased by 41% (-$10.3 million) while OBL reimbursement decreased 29% (-$42.5 million) and wRVU decreased 36%. During the same period, medical center reimbursement increased by 6.6% (+$14.1 million). CONCLUSIONS: Vascular surgeons' contribution to a hospital may not be accurately reflected through traditional RVU metrics alone. Vascular surgeons performed an increasing volume of fistulagram procedures while experiencing marked reductions in wRVU and reimbursement. Medical centers, on the other hand, experienced an overall increase in reimbursement during the same time period. This study highlights that professional reimbursements, taken in isolation and without consideration of medical center reimbursement, undervalues the services and contributions provided by vascular surgeons.

Vascular Surgery Practice Guidelines during COVID-19 Pandemic in a Setting of High Work Volume Against Limited Resources: Perspective of a Developing Country.

BACKGROUND: The situation of coronavirus disease 2019 (COVID-19) pandemic in the Indian subcontinent is worsening. In Bangladesh, rate of new infection has been on the rise despite limited testing facility. Constraint of resources in the health care sector makes the fight against COVID-19 more challenging for a developing country like Bangladesh. Vascular surgeons find themselves in a precarious situation while delivering professional services during this crisis. With the limited number of dedicated vascular surgeons in Bangladesh, it is important to safeguard these professionals without compromising emergency vascular care services in the long term. To this end, we at the National Institute of Cardiovascular Diseases and Hospital, Dhaka, have developed a working guideline for our vascular surgeons to follow during the COVID-19 pandemic. The guideline takes into account high vascular work volume against limited resources in the country. METHODS: A total of 307 emergency vascular patients were dealt with in the first 4 COVID-19 months (March through June 2020) according to the working guideline, and the results were compared with the 4 pre-COVID-19 months. Vascular trauma, dialysis access complications, and chronic limb-threatening ischemia formed the main bulk of the patient population. Vascular health care workers were regularly screened for COVID-19 infection. RESULTS: There was a 38% decrease in the number of patients in the COVID-19 period. Treatment outcome in COVID-19 months were comparable with that in the pre-COVID-19 months except that limb loss in the chronic limb-threatening ischemia patients was higher. COVID-19 infection among the vascular health care professionals was low. CONCLUSIONS: Vascular surgery practice guidelines customized for the high work volume and limited resources of the National Institute of Cardiovascular Diseases and Hospital, Dhaka were effective in delivering emergency care during COVID-19 pandemic, ensuring safety of the caregivers. Despite the fact that similar guidelines exist in different parts of the world, we believe that the present one is still relevant on the premises of a deepening COVID-19 crisis in a developing country like Bangladesh.

Implications of the severe acute respiratory syndrome associated with the novel coronavirus-2 on vascular surgery practices.

BACKGROUND: We sought to understand the effects of coronavirus disease-2019 (COVID-19) on vascular surgery practices as related to the Vascular Activity Condition (VASCON) scale. METHODS: All members of the Vascular and Endovascular Surgery Society were surveyed on the effects of COVID-19 in their practices, educational programs, and self-reported grading of their surgical acuity level using the VASCON scale. RESULTS: Total response rate was 28% (206/731). Most respondents (99.5%) reported an effect of COVID-19 on their practice, and most were VASCON3 or lower level. Most reported a decrease in clinic referrals, inpatient/emergency room consults, and case volume (P < .00001). Twelve percent of respondents have been deployed to provide critical care and 11% medical care for COVID-19 patients. More than one-quarter (28%) face decreased compensation or salary. The majority of respondents feel vascular education is affected; however, most feel graduates will finish with the necessary experiences. There were significant differences in answers in lower VASCON levels respondents, with this group demonstrating a statistically significant decreased operative volume, vascular surgery referrals, and increased hospital and procedure limitations. CONCLUSIONS: Nearly all vascular surgeons studied are affected by the COVID-19 pandemic with decreased clinical and operative volume, educational opportunities for trainees, and compensation issues. The VASCON level may be helpful in determining surgical readiness.

Value Improvement by Assessing IR Care via Time-Driven Activity-Based Costing.

PURPOSE: To evaluate time-driven activity-based costing (TDABC) in interventional radiology for image-guided vascular malformation treatment as an example. MATERIALS AND METHODS: Retrospective analysis was performed on consecutive vascular malformation treatment cycles [67 venous malformations (VMs) and 11 arteriovenous malformations (AVMs)] in a university hospital in 2018. All activities were integrated with a process map, and spent resources were assigned accordingly. TDABC uses 2 parameters: (i) practical capacity cost rate, calculated as 80% of theoretical capacity, and (ii) time consumption of each resource determined by interviews (23 items). Thereby, the total costs were calculated. Treatment cycles were modified according to identified resource waste and TDABC-guided negotiations with health insurance. RESULTS: Total personnel time required was higher for AVM (1,191 min) than for VM (637 min) treatment. The interventional procedure comprised the major part (46%) of personnel time required in AVM, whereas it comprised 19% in VM treatment. Materials represented the major cost type in AVM (75%) and VM (45%) treatments. TDABC-based treatment process modification led to a decrease in personnel time need of 16% and 30% and a cost reduction of 5.5% and 15.7% for AVM and VM treatments, respectively. TDABC-guided cost reduction and TDABC-informed negotiations improved profit from -56% to +40% and from +41% to +69% for AVM and VM treatments, respectively. CONCLUSIONS: TDABC facilitated the precise costing of interventional radiologic treatment cycles and optimized internal processes, cost reduction, and revenues. Hence, TDABC is a promising tool to determine the denominator of interventional radiology's value.

Association of long working hours and health-related productivity loss, and its differential impact by income level: A cross-sectional study of the Korean workers.

OBJECTIVES: We aimed to explore the association between long working hours and health-related productivity loss (HRPL), due to either sickness, absenteeism or presenteeism, stratified by household income level. METHODS: From January 2020 to February 2020, data were collected using a web-based questionnaire. A total of 4197 participants were randomly selected using the convenience sampling method. The nonparametric association between weekly working hours and HRPL was determined. Subsequently, a stratified analysis was conducted according to household income (1st, 2nd, and 3rd tertiles). Finally, the differences in HRPL of the different working hour groups (<40, 40, 40-51, and ≥52 hours) were investigated using a multivariate linear regression model. RESULTS: Long working hours were more significantly associated with HRPL, as compared to the 'standard' working hours (40 hours/week). A larger proportion of productivity loss was associated with the presenteeism of workers, rather than absenteeism. The relationship between HRPL and weekly working hours was more prominent in the lower household income group. CONCLUSIONS: The results of our study indicate that HRPL is associated with long working hours, especially in the lower household income group. Reducing the workload for the individual employee to a manageable level and restructuring sick leave policies to effectively counteract absenteeism and presenteeism may be a feasible option for better labor productivity and employee health.

After the Crimea crisis: Employee discrimination in Russia and Ukraine.

This paper examines the issue of employee discrimination after a political crisis: the annexation of Crimea. The annexation, which resulted in a political crisis in Russian-Ukrainian relations, is a setting which allows us to test if a bilateral political issue caused employee discrimination. We use a quasi-experimental approach to examine how the political crisis influenced participation in major sports leagues in Russia and Ukraine. The results show that the employment conditions significantly worsened since the Crimea crisis started.

Initial Impact of COVID-19 on Radiology Practices: An ACR/RBMA Survey.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic affected radiology practices in many ways. The aim of this survey was to estimate declines in imaging volumes and financial impact across different practice settings during April 2020. METHODS: The survey, comprising 48 questions, was conducted among members of the ACR and the Radiology Business Management Association during May 2020. Survey questions focused on practice demographics, volumes, financials, personnel and staff adjustments, and anticipation of recovery. RESULTS: During April 2020, nearly all radiology practices reported substantial (56.4%-63.7%) declines in imaging volumes, with outpatient imaging volumes most severely affected. Mean gross charges declined by 50.1% to 54.8% and collections declined by 46.4% to 53.9%. Percentage reductions did not correlate with practice size. The majority of respondents believed that volumes would recover but not entirely (62%-88%) and anticipated a short-term recovery, with a surge likely in the short term due to postponement of elective imaging (52%-64%). About 16% of respondents reported that radiologists in their practices tested positive for COVID-19. More than half (52.3%) reported that availability of personal protective equipment had become an issue or was inadequate. A majority (62.3%) reported that their practices had existing remote reading or teleradiology capabilities in place before the pandemic, and 22.3% developed such capabilities in response to the pandemic. CONCLUSIONS: Radiology practices across different settings experienced substantial declines in imaging volumes and collections during the initial wave of the COVID-19 pandemic in April 2020. Most are actively engaged in both short- and long-term operational adjustments.

Characteristics of COVID-19 Community Practice Declines in Noninvasive Diagnostic Imaging Professional Work.

PURPOSE: The operational and financial impact of the widespread coronavirus disease 2019 (COVID-19) curtailment of imaging services on radiology practices is unknown. We aimed to characterize recent COVID-19-related community practice noninvasive diagnostic imaging professional work declines. METHODS: Using imaging metadata from nine community radiology practices across the United States between January 2019 and May 2020, we mapped work relative value unit (wRVU)-weighted stand-alone noninvasive diagnostic imaging service codes to both modality and body region. Weekly 2020 versus 2019 wRVU changes were analyzed by modality, body region, and site of service. Practice share χ2 testing was performed. RESULTS: Aggregate weekly wRVUs ranged from a high of 120,450 (February 2020) to a low of 55,188 (April 2020). During that -52% wRVU nadir, outpatient declines were greatest (-66%). All practices followed similar aggregate trends in the distribution of wRVUs between each 2020 versus 2019 week (P = .96-.98). As a percentage of total all-practice wRVUs, declines in CT (20,046 of 63,992; 31%) and radiography and fluoroscopy (19,196; 30%) were greatest. By body region, declines in abdomen and pelvis (16,203; 25%) and breast (12,032; 19%) imaging were greatest. Mammography (-17%) and abdominal and pelvic CT (-14%) accounted for the largest shares of total all-practice wRVU reductions. Across modality-region groups, declines were far greatest for mammography (-92%). CONCLUSIONS: Substantial COVID-19-related diagnostic imaging work declines were similar across community practices and disproportionately impacted mammography. Decline patterns could facilitate pandemic second wave planning. Overall implications for practice workflows, practice finances, patient access, and payment policy are manifold.

Healthcare workers experience in dealing with Coronavirus (COVID-19) pandemic.

OBJECTIVES: To analyze healthcare workers experiences in dealing with the Coronavirus (COVID-19) pandemic. Methods: An anonymous open web-based survey study was conducted among healthcare workers from the March 2020 to April 2020. A total of 24 relevant questions were asked based on participants' characteristics, obligations, and preparedness in healthcare workers in the event of COVID-19 pandemic. Results: Approximately 1036 healthcare workers participated in this study with high response rate. Out of all the participants, 70% were women, 52% belonged to the 26-34 year age range, 50% were nurses, 33.7% were clinicians, 74.3% agreed to work overtime, 93.1% understand why they should stay past their shift end, 97.7% thought that preventing illness among healthcare workers and providing safety to family members, nearly 94% thought that personal protective equipment (PPE) for employees will enhance their willingness to report to work. Approximately 89.3% express a desire for incentives and financial support for family members. Conclusion: We recommend that providing PPE, reducing psychological stress, financial support and safety to family members of healthcare workers will increase the willingness to report to work.

Using Quality Improvement Methodology to Reduce Costs while Improving Efficiency and Provider Satisfaction in a Busy, Academic Musculoskeletal Radiology Division.

Within an everchanging healthcare system, continuous evaluation of standard operating procedures must be performed to ensure optimization of system level organization, communication, and efficiency. Using the Lean management approach, our institution introduced modifications to our musculoskeletal (MSK) radiology workflow in order to facilitate beneficial change that improved clinical workflow efficiency, reduced moonlighting costs, and improved radiologist satisfaction without sacrificing quality of care. The scope of our study included the MSK division of adult inpatient and outpatient populations at three hospitals in a single academic medical center. A root cause analysis was executed to determine the causative factors contributing to clinical inefficiency. Five main factors were identified, and appropriate countermeasures were introduced. Efficiency was measured via the turnaround time (TAT) for radiographic examinations, measured from exam completion to final report submission. Moonlighting expenses were monitored for the fiscal year in which the modifications were implemented. Surveys were administered to MSK radiologists before and after the countermeasures were introduced to determine subjective ratings of efficiency and satisfaction. The average TAT within our MSK division decreased from 40 h to 12 h after introducing changes to our workflow. During one fiscal year, moonlighting expenses decreased from $26,000 to $5000. Post-study survey results indicated increased efficiency of and satisfaction with our implemented modifications to the scheduling and clinical workflow. Optimization of our radiology department's workflow led to increased productivity, efficiency, and radiologist satisfaction, as well as a reduction in moonlighting costs. This project leveraged Lean management principles to combat clinical inefficiency, waste time, and high costs.

Health care reform in China from the perspective of physicians.

Health care reform is a worldwide problem. To address the problems of costs, access, quality, efficiency, and equity, China initiated healthcare reform in 2009. The progress of China's healthcare reform has been internationally recognized as the reform has expanded insurance coverage and improved access to and reduced the costs of care over the ten-year period from 2008 to 2018. To achieve sustainable goals, attention must be focused on whether and how the reform encourages physicians. This paper highlights the role of physicians, the challenges that need to be addressed, and the direction in which to advance health reform in China from the perspective of physicians. The slow-growing and aging physician population cannot meet the ever-increasing medical demand. Physicians have a heavy workload, work long hours, have unsatisfactory income, and have a fraught relationship with patients. The situation calls for rethinking the value of physicians and rebuilding trust between physicians and patients. Further healthcare reform is needed to equitably allocate physicians with adequate training, time, and resources to deliver evidence-based practices and patient-centered care.

Benchmarking the value of care: Variability in hospital costs for common operations and its association with procedure volume.

BACKGROUND: Efforts to improve health care value (quality/cost) have become a priority in the United States. Although many seek to increase quality by reducing variability in adverse outcomes, less is known about variability in costs. In conjunction with the American Association for the Surgery of Trauma Healthcare Economics Committee, the objective of this study was to examine the extent of variability in total hospital costs for two common procedures: laparoscopic appendectomy (LA) and laparoscopic cholecystectomy (LC). METHODS: Nationally weighted data for adults 18 years and older was obtained for patients undergoing each operation in the 2014 and 2016 National Inpatient Sample. Data were aggregated at the hospital-level to attain hospital-specific median index hospital costs in 2019 US dollars and corresponding annual procedure volumes. Cost variation was assessed using caterpillar plots and risk-standardized observed/expected cost ratios. Correlation analysis, variance decomposition, and regression analysis explored costs' association with volume. RESULTS: In 2016, 1,563 hospitals representing 86,170 LA and 2,276 hospitals representing 230,120 LC met the inclusion criteria. In 2014, the numbers were similar (1,602 and 2,259 hospitals). Compared with a mean of US $10,202, LA median costs ranged from US $2,850 to US $33,381. Laparoscopic cholecystectomy median costs ranged from US $4,406 to US $40,585 with a mean of US $12,567. Differences in cost strongly associated with procedure volume. Volume accounted for 9.9% (LA) and 12.4% (LC) of variation between hospitals, after controlling for the influence of other hospital (8.2% and 5.0%) and patient (6.3% and 3.7%) characteristics and in-hospital complications (0.8% and 0.4%). Counterfactual modeling suggests that were all hospitals to have performed at or below their expected median cost, one would see a national cost savings of greater than US $301.9 million per year (95% confidence interval, US $280.6-325.5 million). CONCLUSION: Marked variability of median hospital costs for common operations exists. Differences remained consistent across changing coding structures and database years and were strongly associated with volume. Taken together, the findings suggest room for improvement in emergency general surgery and a need to address large discrepancies in an often-overlooked aspect of value. LEVEL OF EVIDENCE: Epidemiological, level III.

Implementation of a multiprofessional, multicomponent delirium management guideline in two intensive care units, and its effect on patient outcomes and nurse workload: a pre-post design retrospective cohort study.

AIM OF THE STUDY: Delirium is a frequent intensive care unit (ICU) complication, affecting 26% to 80% of ICU patients, often with serious consequences. This study aimed to evaluate the effectiveness, costs and benefits of following a standardised multiprofessional, multicomponent delirium guideline on eight outcomes: delirium prevalence and duration, lengths of stay in ICU and hospital, in-hospital mortality, duration of mechanical ventilation, and cost and nursing hours per case. It also aimed to explore the associations of delirium with length of ICU stay, length of hospital stay and duration of mechanical ventilation. METHODS: This retrospective cohort study used a pre-post design. ICU patients in an historical control group (n = 1608) who received standard ICU care were compared with a postintervention group (n = 1684) who received standardised delirium management – delirium risk identification, preventive measures, screening and treatment – with regard to eight outcomes. The delirium management guideline was developed and implemented in 2012 by a group of experts from the study hospital. As appropriate, descriptive statistics and multivariate, multilevel models were used to compare the two groups and to explore the association between delirium occurrence and the selected outcomes. RESULTS: Twelve percent of the 1608 historical controls and 20% of the 1684 postintervention patients were diagnosed with delirium according to the ICD-10 delirium diagnosis codes. Patients being treated for heart disease, and those with septic shock, ARDS, renal insufficiency (acute or chronic), older age and higher numbers of comorbidities were significantly more likely to develop delirium during their stay. Multivariate models comparing the historical controls with the post intervention group indicated significant differences in delirium period prevalence (odds ratio 1.68, 95% confidence interval [CI] 1.38–2.06; p <0.001), length of stay in the ICU (time ratio [TR] 0.94, CI 0.89–1.00; p = 0.048), cost per case (median difference 3.83, CI 0.54–7.11; p = 0.023) and duration of mechanical ventilation (TR 0.84, CI 0.77–0.92; p <0.001). The observed differences in the other four outcomes – in-hospital mortality, delirium duration, length of stay in the hospital, and nursing hours per case – were not significant. Delirium was a significant predictor for prolonged duration of mechanical ventilation and for both ICU and hospital stay. CONCLUSION: Standardised delirium management, specifically delirium screening, supports timely detection of delirium in ICU patients. Increased awareness of delirium after the implementation of standardised multiprofessional, multicomponent management leads to increased therapeutic attention, a prolongation of ICU stay and increased costs, but with no influence on mortality.

Evaluation of Methods to Measure Production Pressure: A Literature Review.

BACKGROUND: Production pressure is a major contributor to the occurrence of medical errors. Production pressure is the demand on health care professionals to increase the quantity of work at the expense of quality. PURPOSE: The purpose was to summarize the state of the science on measuring production pressure in health care settings so that evidence-based strategies could be identified that minimize medical errors. METHODS: This was a literature review. The electronic databases PubMed, Embase, and Scopus were queried using the keywords "work pressure" or "production pressure." RESULTS: Production pressure is often measured with quantitative approaches that measure efficiency, staff workload, capacity utilization (number of hospital beds occupied), or psychometric instruments. Ethnography is a qualitative method that is also used to assess production pressure. CONCLUSIONS: There were several strategies identified to minimize the impact of production pressure on the occurrence of medical errors. These strategies can be categorized as administrator, educational, or workflow related.