Why rural residents migrate for family physician care.

Several studies have examined why rural residents bypass local hospitals, but few have explored why they migrate for physician care. In this study, data from a random mail survey of households in rural Iowa counties were used to determine how consumers' attitudes about their local health system, health beliefs, health insurance coverage and other personal characteristics influenced their selection of local vs. nonlocal family physicians (family physician refers to the family practice, internal medicine or other medical specialist providing an individual's primary care). Migration for family physician care was positively associated with a perceived shortage of local family physicians and use of nonlocal specialty physician care. Migration was negatively associated with a highly positive rating of the overall local health care system, living in town, Lutheran religious affiliation and private health insurance coverage. By understanding why rural residents prefer to bypass local physicians, rural health system managers, physicians and policy-makers should be better prepared to design innovative health organizations and programs that meet the needs of rural consumers.

Cost-effectiveness of a limited-donor blood program for neonatal red cell transfusions.

BACKGROUND: Very-low-birthweight infants have typically been given fresh red cells (RBCs), a practice in which aliquots of RBCs for several infants were issued each day from a single unit. Recently, to limit donor exposures, large volumes of RBCs are reserved for the long-term transfusion support of individual infants. STUDY DESIGN AND METHODS: Medical records were examined retrospectively to assess the costs of a limited-donor program for providing RBC transfusions to very-low-birthweight infants. Costs of multiple- and limited-donor programs were compared by using two samples of 30 consecutive infants treated at The University of Iowa Hospitals and Clinics in 1993 and 1997. Effectiveness was evaluated with respect to the number of donor exposures per infant. RESULTS: The cost, in 1997 dollars, of preparing each small-volume transfusion in the multiple-donor program was $27.86 per transfusion, while that in the limited-donor program was $34.83. This difference was largely attributable to use of white cell reduction in association with the limited-donor program in 1997. Eliminating the costs associated with white cell reduction rendered the costs of the limited- and multiple-donor transfusions comparable. The limited-donor program had donor exposures of 2.0 per infant, while the multiple-donor program had 3.6 exposures per infant (p<0.002). CONCLUSION: The limited-donor blood program reduces donor exposure without adversely affecting costs.

Fiscal policy dilemmas and health spending in South Africa.

There is broad agreement that government has an important role to play in the development of human capital, especially in health and education. Multilateral organizations, such as the World Bank, commonly call for public sector investment in human resources but the use of health spending to combat unemployment remains controversial. This article examines public sector expenditures in health and focuses on three arguments: 1) public goods; 2) investment in human capital; and 3) Keynesian spending in periods of high unemployment.

Client satisfaction with substance abuse treatment.

A survey of 15 publicly-funded treatment agencies in Iowa was conducted to identify correlates of satisfaction with substance abuse treatment for voluntary clients. We used stratified least-squares regression analysis to identify program characteristics that were associated with greater satisfaction levels. In order to investigate satisfaction among voluntary clients, we stratified the data using three measures of client choice. These were self-reports of the extent to which the respondent felt pressured by the threat of jail, legal action, or family demands. Women tended to be more satisfied than men. Satisfaction scores for clients who indicated they were in treatment by choice were correlated with judgements about program characteristics. Phone availability, time with counselor, counselor skill, and sensitivity were associated with greater levels of satisfaction in all three models. Parking, privacy and cleanliness were significant in two out of three models.

Management and economic perspectives on efficiency.

Efficiency has different connotations and denotations in management, organizational behavior, and economics. This article explores different economic and organizational orientations that have given rise to alternative definitions with the hope that better understanding of these perspectives will improve terminology and theory building.

Geographic variation in primary care visits in Iowa.

OBJECTIVE: This study investigates the determinants of primary care office visit rates. DATA SOURCES: Blue Cross and Blue Shield of Iowa subscriber information was sorted by residence into geographic health service areas. Cost-sharing information was also obtained from Blue Cross. Physician supply data were obtained from The University of Iowa, Office of Community-Based Programs. Hospital data were reported by the Iowa Hospital Association. STUDY DESIGN: Cases were classified into ambulatory care groups (ACGs). Use rates were computed for each group in each service area. Ordinary least squares regression models were developed to model geographic variation in each ACG-specific primary care visit rate. PRINCIPAL FINDINGS: Regression models were not significant for five out of eleven ACGs studied. Out-of-pocket expense significantly affected utilization in three out of six. The number of primary care practices per capita had a significant effect on utilization in two ACGs. The supply of hospital outpatient services was significant in one ACG. CONCLUSIONS: Study findings reveal that some ACGs are price-sensitive and some are not. Policies aimed at changing levels of primary care use should taken into account whether varying cost-sharing will influence consumer behavior in the desired direction.

A cost analysis comparing erythropoietin and red cell transfusions in the treatment of anemia of prematurity.

BACKGROUND: Anemia of prematurity is invariably observed in very low birth weight infants and may become symptomatic enough to be treated with packed red cell transfusions. Recently, treatment of this condition with recombinant human erythropoietin has been advocated. STUDY DESIGN AND METHODS: To compare the costs of training symptomatic anemia in hospitalized premature infants with transfusions alone or with erythropoietin plus red cell transfusions as needed, cost estimates were derived from local hospital and published cost data. Decision analysis and sensitivity analysis were applied to a "base case." The base case was derived from results of a multicenter erythropoietin trial in the United States in which premature infants received 500 U of erythropoietin per kg of body weight each week. Because erythropoietin treatment began on average at 3 weeks of life, when infants were clinically stable, they had already received 3.5 red cell transfusions. During the 6-week treatment period, erythropoietin-treated infants received significantly fewer additional transfusions: a mean of 1.6 versus 1.1. RESULTS: The base-case cost in 1993 dollars for treating anemia in hospitalized premature infants with erythropoietin and transfusions was $1,326. This was nearly twice the cost of conventional treatment with transfusions alone ($721). If the 6-week treatment period alone is considered, erythropoietin is 3.6 times more costly: $840 versus $235. CONCLUSION: The largest available US study using erythropoietin to treat anemia in premature infants has demonstrated a small, but significant, reduction in transfusion needs. However, this study's cost data alone do not justify the widespread use of erythropoietin in premature infants. When this issue is probed in great depth, sensitivity analyses demonstrate that major reductions in erythropoietin's cost and/or improvements in its effectiveness quite possibly will make its use economically more attractive.

Recombinant human erythropoietin vs transfusions in the treatment of anemia of prematurity. A cost-benefit analysis.

OBJECTIVE: To evaluate the costs relative to the benefits of using recombinant human erythropoietin (rHuEPO) therapy as an alternative to red blood cell (RBC) transfusions in infants with anemia of prematurity. DESIGN: A cost-benefit analysis of rHuEPO therapy was performed based on its use in very-low-birth-weight premature infants. SETTING AND PATIENTS: Data were drawn from published studies or were provided by the University of Iowa Hospitals and Clinics, Iowa City. MAIN OUTCOME MEASURES: Costs and benefits were analyzed as a comparison of incurred costs to averted costs. Incurred and averted costs of rHuEPO therapy and RBC transfusions included direct product costs and estimates of costs of adverse events. The analysis was viewed in terms of net savings. Sensitivity analysis was performed. RESULTS: The base case analysis yielded a net loss of $299.48 per infant. A 54% reduction in the direct product costs of rHuEPO therapy yielded a break-even point. No other variations in the sensitivity analysis resulted in a net savings. CONCLUSION: Using assumptions based on the current state of clinical research, it appears that routine use of rHuEPO with supplemental RBC transfusions would not generate any cost savings as an alternative to RBC transfusions alone. As further evidence is compiled on the efficacy of rHuEPO therapy in very-low-birth-weight premature infants, the true costs may be better established.

The contribution of hospitals to a local economy: a case study in Iowa and Illinois.

This study assessed the importance of the hospital sector to a regional economy by examining the estimated effects of direct and indirect hospital spending on the income and employment of a metropolitan region in Iowa and Illinois. The evaluation included the role of hospital services as a regional "export." In addition, the stabilizing impact of hospital spending during business cycles was examined. Results of the study indicated that the hospitals played a vital role in the economic stability and growth of the local community.

Health services management manpower and education: outlook for the future.

There is much concern about administrative costs in health care. But little has been written on the market for health managers. This article discusses Bureau of Labor Statistics data estimating a total of 362,500 health managers in the United States in 1990 and projections showing an increase to 517,800 in 2005. The article further discusses the composition of health care employment in terms of settings and functions, and evaluates the implications of a rapidly changing market for health administrators. The authors conclude that sufficient demand exists for AUPHA programs to produce more graduates, but that curriculum should be revised and should place greater emphasis on efficient production of health services. This will provide qualitative differentiation and give health management training a competitive advantage over business and other educational backgrounds.

Percutaneous needle biopsy of musculoskeletal lesions. 2. Cost-effectiveness.

We compared the cost-effectiveness of fluoroscopically directed percutaneous needle biopsy (PNB) of musculoskeletal lesions, CT-guided PNB, and open biopsy. We independently assessed the following characteristics: suspected lesion type (metastatic deposit, infection, or primary neoplasm, as determined by clinical findings and radiologic appearance before biopsy); lesion location (axial or appendicular); and appearance on plain films (radiolucent or lytic, sclerotic, vertebral compression fracture, and soft-tissue lesions). In suspected primary tumors, cost-effectiveness of PNB was similar to that of open biopsy: fluoroscopically directed PNB was slightly more cost-effective than open biopsy whereas CT-directed PNB was slightly less cost-effective. Either type of PNB was cost-effective for suspected metastatic deposits and infections, axial and appendicular lesions, radiolucent or lytic lesions, and soft-tissue lesions. We conclude that PNB is cost-effective for most musculoskeletal lesions.

Appropriate care and the market for physician services.

Rising health care costs have led policymakers to look at ways to assure the appropriateness of care. But attempts to control spending on physician services by either reducing price or limiting utilization may be ineffective due to backward bending supply. In seeking further limits on physician spending, policymakers will have to consider this possibility.

The role of the generalist in health administration education programs.

Health administration education programs frequently have at least one faculty member who is a nondisciplinary specialist in health services rather than a member of a mainline discipline such as economics, psychology, or sociology. Such personnel perform valuable functions in research areas requiring multidisciplinary teams and extensive knowledge about health services delivery. Policy analysis, planning, organizational analysis, and program evaluation are examples of research areas where the generalist can be of value. Generalists may have more knowledge of health services than other faculty and thus can insure that research findings are realistic. Second, the generalists' broad orientation is conducive to interdisciplinary research. Third, they often are well suited to lead research teams. And finally, generalists are often better equipped to explain how research findings are useful in the practice of health administration, thus increasing the relevance of health administration programs.

Implementing EACHs (essential access community hospitals) and RPCHs (rural primary care hospitals) on a statewide basis: a preliminary analysis.

Declining hospital utilization has created excess hospital capacity in rural areas, has depressed occupancy rates, and threatens the financial viability of rural hospitals. Access to hospital care could be reduced and rural economies damaged if rural hospitals close. The federal Essential Access Community Hospital (EACH) demonstration program is an attempt to address these issues by establishing regional hospital networks. A preliminary analysis of the impact of state-wide implementation of the EACH program in Iowa suggests that about 60% of rural hospital beds and about 28% of all hospital beds would be eliminated. The EACH program could well prove difficult to implement because of the need to select hospitals for reduced services.

Monopolistic competition and the health care sector.

The model of monopolistic competition is appropriate for describing the behavior of the health care sector in the United States. Uncertainty about quality of medical and related services promotes product differentiation especially when consumers do not bear the full costs of care. New technologies can be used to signal quality even when their clinical usefulness is unproven. Recent cost containment measures may reduce employment of ineffective technologies but may also inhibit the adaptation of genuinely useful developments.