Average Number Of Inpatient Days Research Articles

Factors affecting hospitalization and mortality in a retrospective study of elderly patients with heart failure

BackgroundHeart failure (HF) has a high prevalence in an elderly population and leads to a substantial hospitalization and mortality. The objective of this study was to investigate factors that affect hospitalization and mortality in an elderly population.MethodsA retrospective observational study was conducted of HF patients aged 76–95 years residing in Region Halland, Sweden. Between 2013 and 2019, a total of 3134 patients received a novel diagnosis of HF and were subsequently monitored for one year using data from a healthcare database. The patients were categorized into HF-phenotypes according to ejection fraction (EF) and those with HF diagnose solely based on clinical criteria with no defined EF. Cox regression analysis for hospital admissions and mortality was evaluated adjusted for pharmacotherapies, healthcare utilization and clinical characteristics.ResultsEchocardiogram was performed in 56% of the patients and 51% were treated with recommended HF pharmacotherapy with betablockers combined with renin-angiotensin-aldosterone-system inhibition. The average number of inpatient days was 10.7 while the average number of visits to primary care physician was 5.4 and 8.7 to primary care nurse respectively. A Cox regression analysis for hospital admissions and mortality revealed that an eGFR < 30 ml/min was associated with a hazard ratio (HR) of 1.88 (confidence interval [CI] 1.56–2.28), elevated NT-proBNP with an HR of 2.09 (CI 1.59–2.76), diabetes with an HR of 1.31 (CI 1.13–1.52), and chronic obstructive pulmonary disease with an HR of 1.51 (CI 1.29–1.77). Having a primary care physician visit was associated to an HR of 0.16 (CI 0.14–0.19), and the use of recommended heart failure pharmacotherapy was associated with an HR of 0.52 (CI 0.44–0.61).ConclusionsIn a Swedish elderly population with HF, factors such as advancing age, kidney dysfunction, elevated NT-proBNP levels, diabetes, and COPD were associated with an increased risk of both mortality and hospitalization. Conversely, patients who received recommended heart failure treatment and made regular visits to their primary care physician were associated with a decreased risk. This indicates that elderly patients with HF benefit from recommended HF treatment and highlights that follow-ups in primary care could be advantageous.

Managing Acute Myeloid Leukemia in Older Patients: Are We Making Progress? An Analysis of Treatment Patterns and Healthcare Resource Utilization

▪BACKGROUND: Despite advances in the understanding of disease pathogenesis, improved treatment strategies, and evidence of better survival with treatment, a large proportion of older patients (pts) with acute myeloid leukemia (AML) remains untreated and has poor outcomes. The aim of this study is to describe current treatment patterns in pts with AML aged <60, 60-64, and ≥65 years (yrs), and assess healthcare resource utilization (HRU) in pts with AML aged <65 and ≥65 yrs in a real-world claims database.METHODS: AML pts were retrospectively identified in the MarketScan® Research Database (Truven Health) including both Commercial and Medicare Supplemental claims databases between 01/2011 to 07/2016. Pts with ≥2 AML diagnoses, ≥1 bone marrow procedure (the first AML diagnosis following the procedure was defined as the index date), and ≥12 months of continuous eligibility (baseline period) prior to the index date were included. Exclusion criteria were ≥1 diagnosis for AML relapse or remission on or before the bone marrow procedure, ≥2 diagnoses for another blood cancer, and ≥1 allogeneic hematopoietic stem cell transplantation before the bone marrow diagnosis procedure. Furthermore, pts aged ≥65 yrs at the index date were excluded if they had ≥1 claim for intensive chemotherapy at any time. The observation period spanned from index date up to the first of health plan disenrollment or the end of data availability. To accommodate different age cut-offs in accordance with National Comprehensive Cancer Network treatment guidelines, top treatments (excluding hormonal therapy agents) received post-AML diagnosis were reported in pts aged <60, 60-64, and ≥65 yrs. Listings that lacked codes for specific chemotherapy agents, but offered adequate International Classification of Diseases codes were included and reported as “unknown antineoplastic agents”. HRU, including days of hospital stay, days with outpatient services, days with emergency room visits, days with hospice care, and days with durable medical equipment use, was evaluated in pts <65 and ≥65 yrs old. To account for varying length of follow-up among pts, HRU was reported per patient per month.RESULTS: After applying the selection criteria, 2,954 AML pts were identified: 1,492 pts ≥65 yrs old (mean [SD] age: 76.8 [7.0]; 36.6% were ≥80 yrs old; mean [SD] follow-up: 212 [255] days) and 1,462 pts <65 yrs old (mean [SD] age: 51.8 [11.5]; mean [SD] follow-up: 350 [350] days), including 468 (32.0%) aged 60-64 yrs and 994 aged <60 yrs. Pts <60 yrs old received the most therapeutic interventions (i.e., ≥1 antineoplastic agent, ≥1 blood transfusion, or ≥1 hematopoietic stem cell transplant), followed by pts 60-64 and pts ≥65 yrs old (Fig. 1). Type of antineoplastic agents (excluding hormonal therapy agents) received varied by age group with “other antineoplastic agent” (other than HMAs and excluding hormonal therapy agents) and “unknown antineoplastic agent” more commonly used in younger pts. Hypomethylating agents (HMAs) were more commonly used in older pts (Fig. 1). In pts aged <60, 60-64, and ≥65 yrs treated with ≥1 HMA, azacitidine was given in 56.2%, 59.8%, and 55.7% of pts and decitabine was given in 50.5%, 47.1%, and 51.2%, respectively. In pts <60 yrs who received “other antineoplastic agents”, tretinoin (31.2%), cytarabine (30.6%), and arsenic trioxide (22.4%) were most commonly used. Pts 60-64 yrs old received cytarabine (30.7%), hydroxyurea (20.5%), and tretinoin (17.3%) as most common agents. Pts ≥65 yrs old received most commonly hydroxyurea (53.4%) and cytarabine (14.3%). Post-AML diagnosis, pts ≥65 yrs old had half the monthly all-cause average number of inpatient days compared to pts <65 yrs old (mean [SD]: 3.74 [5.28] vs. 7.74 [7.14]). Differences in the number of days with outpatient services (mean [SD]: 5.64 [4.62] vs. 5.27 [4.25]) or emergency room visits (mean [SD]: 0.22 [0.52] vs. 0.10 [0.30]; Fig. 2) were smaller.CONCLUSION: This study revealed that >40% of older AML pts (≥65 yrs) did not receive any antineoplastic therapy. This group also had fewer inpatient days compared to younger AML pts (<65 yrs old). These results show that despite medical advances, a large proportion of older AML pts remains either untreated or undertreated, revealing important unmet needs and suggesting that AML treatment has to face a much-needed expansion to improve disease management in this population. [Display omitted] DisclosuresLafeuille:Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Ltd: Research Funding; Janssen Scientific Affairs, LLC: Research Funding. Sundaram:Johnson & Johnson, LLC: Equity Ownership; Janssen: Employment. Hoehn:Janssen: Employment; Johnson & Johnson, LLC: Equity Ownership. Emond:Janssen Scientific Affairs, LLC: Research Funding. Romdhani:Janssen Scientific Affairs, LLC: Research Funding. Lefebvre:Janssen Scientific Affairs, LLC: Research Funding.

Efficacy of Miramistin-Metronidazole Combination in the Treatment of Purulent-Inflammatory Processes of Soft Tissues

Importance of the topic. The patients with purulent-inflammatory processes of soft tissues are the most common category of surgical patients, since the effectiveness of their treatment decreases due to the development of microorganism resistance to antibiotics and antiseptics. The aim of research was to study the clinical efficacy of topical application of miramistin-metronidazole combination immobilized on sodium salt of carboxymethyl cellulose in the treatment of purulent-inflammatory processes of soft tissues.Materials and methods. The study included 60 patients with purulent-inflammatory diseases of soft tissues. They were divided into 2 groups, 30 people in each group. All patients were exposed to partial surgical treatment of the purulent focus. In the first group, the treatment consisted of local application of dioxomethyltetrahydropyrimidine ointment with the antibiotic chloramphenicol, and in the second group with miramistin-metronidazole combination immobilized on the sodium salt of carboxymethylcellulose. The course of the wound process was assessed by the dynamics of the local wound temperature, the percentage of reduction of the wound size and volume and the rate of its healing; the terms of edema and purulent discharge elimination, the onset of the appearance of mature granulations and epithelialization of wounds, the cessation of the microflora growth in wounds, the average number of inpatient days were also registered. Results. Measurements of the local wound temperature demonstrated that the inflammatory process in patients of the first group lasted for 10 days, and in patients of the second group for 5-6 days. Prior to discharge from the hospital, the wound area was 16.1% and the volume of wounds was 14% less in patients of the second group compared with similar findings in patients of the first group. The edema of the tissues surrounding the wound eliminated within 1.5 days, and the exudation from the wound stopped 2 days earlier in patients of the second group. Granulation in the wound appeared 2 days, and marginal epithelialization 1 day earlier in patients of the second group. With bacterial culturing of the wound discharge, the growth ceased 1 day earlier in patients of the second group compared to patients in the first group. Such dynamics of the course of the wound process led to a 3 bed-day decrease in the hospital stay of patients of the second group.Conclusion. Local treatment of purulent-inflammatory diseases of soft tissues with miramistin-metronidazole combination allowed optimizing the course of the wound process, reducing duration of inpatient stay.

PCN332 Healthcare Resource Utilization and Survival in Patients with Advanced Breast Cancer in Finland

In Finland, approximately 850 women annually die of advanced breast cancer (aBC). The subtype of aBC guide treatment decisions and is an essential prognostic factor. This study evaluated the subtype-related healthcare resource utilization (HCRU) and survival among patients with aBC in Finland. The study was a retrospective cohort study utilizing real world secondary (specialist) care data during 2004−2016 from the Finnish Auria Biobank covering approximately 20% of the population in Finland. Adult female patients diagnosed with aBC between 2004−2013 were identified with ICD-10 code C50 (breast cancer) and through text mining algorithms, and the data were extracted until the end of 2016. Auria Biobank data were complemented with the patients’ electronic healthcare records of Turku University Central Hospital. Overall survival (OS) was estimated using the Kaplan-Meier method. The results are presented by subtype: HR+/HER2-, HER2+, and triple negative breast cancer (TNBC). A total of 444 patients with aBC were identified, with the mean age at diagnosis of 66.0 years (range 20.6−102.5). Overall, HR+/HER2-, HER2+, and TNBC were identified for 65%, 19%, and 6% of the patients, respectively. The average number of inpatient days per patient-year was 10.6 for HR+/HER2-, 9.1 for HER2+, and 27.3 for TNBC, respectively. The average number of outpatient visits per patient-year was 34.0 for HR+/HER2-, 48.6 for HER2+, and 55.6 for TNBC, respectively. Median OS was 22.6 months (95% CI: 19.4-25.6) for HR+/HER2-, 23.1 months (95% CI: 12.7-37.7) for HER2+, and 5.5 months (95% CI: 3.6-15.2) for TNBC. TNBC patients had the highest resource use per patient-year and the shortest OS. The inpatient days per patient-year and the median OS did not differ markedly between HR+/HER2- and HER2+ patients. The generalizability of the results might be limited because the study describes only the patient population in Southwest Finland.

Preventive Loop Colostomy in Colorectal Cancer Surgery

Introduction. The problem of colonic anastomosis failure remains unsettled in colorectal surgery, since the use of various techniques of anastomotic protection does not preclude the development of complications.The aim of the study was to highlight surgical treatment outcomes of colorectal cancer using preventive stomas.Material and methods. The study included clinical outcomes of 248 patients with colorectal cancer. Group 1 included 85 patients who had a preventive colostomy after rectum resection and restoration of intestinal continuity. Group 2 (control) included 163 patients who had rectum resection without unloading stomas. The following parameters were evaluated in the study: gender, age, presence or absence of the preventive intestinal stoma, duration of stay in the surgical department, anastomotic failure.Results. In patients of group 1, colorectal anastomosis failure was manifested in 1 case (1.2%), in patients of group 2 - in 14 cases (8.6%). The average number of inpatient day in group 1 was 18, the average number of inpatient days in group 2 was 21.Conclusion. The application of a preventive intestinal stoma can reduce the incidence of failure, duration of hospital stay and improve long-term treatment outcomes

Subgroups of High-Cost Medicare Advantage Patients: an Observational Study.

There is a growing focus on improving the quality and value of health care delivery for high-cost patients. Compared to fee-for-service Medicare, less is known about the clinical composition of high-cost Medicare Advantage populations. To describe a high-cost Medicare Advantage population and identify clinically and operationally significant subgroups of patients. We used a density-based clustering algorithm to group high-cost patients (top 10% of spending) according to 161 distinct demographic, clinical, and claims-based variables. We then examined rates of utilization, spending, and mortality among subgroups. Sixty-one thousand five hundred forty-six Medicare Advantage beneficiaries. Spending, utilization, and mortality. High-cost patients (n = 6154) accounted for 55% of total spending. High-cost patients were more likely to be younger, male, and have higher rates of comorbid illnesses. We identified ten subgroups of high-cost patients: acute exacerbations of chronic disease (mixed); end-stage renal disease (ESRD); recurrent gastrointestinal bleed (GIB); orthopedic trauma (trauma); vascular disease (vascular); surgical infections and other complications (complications); cirrhosis with hepatitis C (liver); ESRD with increased medical and behavioral comorbidity (ESRD+); cancer with high-cost imaging and radiation therapy (oncology); and neurologic disorders (neurologic). The average number of inpatient days ranged from 3.25 (oncology) to 26.09 (trauma). Preventable spending (as a percentage of total spending) ranged from 0.8% (oncology) to 9.5% (complications) and the percentage of spending attributable to prescription medications ranged from 7.9% (trauma and oncology) to 77.0% (liver). The percentage of patients who were persistently high-cost ranged from 11.8% (trauma) to 100.0% (ESRD+). One-year mortality ranged from 0.0% (liver) to 25.8% (ESRD+). We identified clinically distinct subgroups of patients within a heterogeneous high-cost Medicare Advantage population using cluster analysis. These subgroups, defined by condition-specific profiles and illness trajectories, had markedly different patterns of utilization, spending, and mortality, holding important implications for clinical strategy.

Efficacy of Continuation/Maintenance Electroconvulsive Therapy in the Treatment of Patients With Mood Disorders: A Retrospective Analysis.

The aim of the study was to contribute evidence for the efficacy of continuation and maintenance electroconvulsive therapy (c/mECT) going beyond the existing literature by examining longer-term outcomes from a single center. We conducted a retrospective observational cohort study for a 14-year period, in which a group of 27 individuals with mood disorders, as defined by International Classification of Diseases-10, were examined and received acute ECT, followed by c/mECT. Mirror-image comparison of individual data sets, 5 years before and after c/mECT, was conducted for the number and mean duration of hospitalizations, as well as inpatient days per year. Statistical analysis was performed using general equation estimation modeling. In 27 patients (63% female, mean ± SD age = 54.3 ± 11.7 years) experiencing either from bipolar (41%) or unipolar (59%) mood disorder, with most patients presenting with a depressive episode at hospital admission (93%), c/mECT was initiated after a successful course of acute ECT in addition to treatment as usual. In a 5-year period before and after starting c/mECT, we observed a significant decline in the mean number of hospitalizations per year (0.64 vs 0.32, P = 0.031), the average number of inpatient days per year (23.7 vs 6.1 days, P < 0.001), and the mean duration of hospital stays (41.6 vs 22.1 days, P = 0.031). The findings provide further support for the efficacy of c/mECT as an augmentation therapy to psychopharmacological treatment in patients experiencing mood disorders, who have responded to acute ECT. Further studies, however, using a controlled study design and larger sample sizes are needed.

Healthcare resource use in schizophrenia, EuroSC findings

ABSTRACTBackground: It is unclear if the burden associated with schizophrenia is affected by the type and severity of patient’s symptoms.Objective: This study aims to quantify healthcare resource use associated with different profiles of schizophrenia symptoms.Study design: Post-hoc analysis of data from a naturalistic follow-up study.Setting: Secondary psychiatric services in France, Germany and the UK.Patients: EuroSC cohort:, representative sample of 1,208 schizophrenia patientsMain outcome measure: We classified patients into eight health states, according to the Lenert classification (HS1–HS8), and estimated 6-month healthcare resource use (outpatient and day clinic visits, and hospitalisations) across the health states.Results: Approximately half of the patients were classed as having mild symptoms (HS1), with around 20% experiencing moderate, predominantly negative symptoms (HS2). The remaining health states were represented by <10% of patients each. Very few patients experienced extremely severe symptoms (HS8). No health state was associated with excess utilisation across all resource types. In terms of outpatient visits, patients were estimated to see a psychiatrist most often (3.01–4.15 visits over 6 months). Hospital admission was needed in 11%(HS1) – 35%(HS8) of patients and inpatient stays were generally prolonged for all health states (39–57 days). The average number of inpatient days was highest for patients in HS8 (18.17 days), followed by patients with severe negative symptoms (HS4; 13.37 days). In other health states characterised by severe symptoms (HS5–HS7), the average number of inpatient days was approximately half of those seen for HS4 (6.09–7.66).Conclusion: While none of the symptom profiles was associated with excess resource usage, hospitalization days were highest for HS with severe, predominantly negative or extremely severe symptoms. Patients with predominantly negative, moderate or severe symptoms appeared to have a high number of psychologist visits – an interesting finding that may reflect a specific therapeutic approach to the treatment of these patients.

Cost Analysis and Policy Implications of a Pediatric Palliative Care Program

ContextIn 2010, California launched Partners for Children (PFC), a pediatric palliative care pilot program offering hospice-like services for children eligible for full-scope Medicaid delivered concurrently with curative care, regardless of the child's life expectancy. ObjectivesWe assessed the change from before PFC enrollment to the enrolled period in 1) health care costs per enrollee per month (PEPM), 2) costs by service type and diagnosis category, and 3) health care utilization (days of inpatient care and length of hospital stay). MethodsA pre-post analysis compared enrollees' health care costs and utilization up to 24 months before enrollment with their costs during participation in the pilot, from January 2010 through December 2012. Analyses were conducted using paid Medicaid claims and program enrollment data. ResultsThe average PEPM health care costs of program enrollees decreased by $3331 from before their participation in PFC to the enrolled period, driven by a reduction in inpatient costs of $4897 PEPM. PFC enrollees experienced a nearly 50% reduction in the average number of inpatient days per month, from 4.2 to 2.3. Average length of stay per hospitalization dropped from an average of 16.7 days before enrollment to 6.5 days while in the program. ConclusionThrough the provision of home-based therapeutic services, 24/7 access to medical advice, and enhanced, personally tailored care coordination, PFC demonstrated an effective way to reduce costs for children with life-limiting conditions by moving from costly inpatient care to more coordinated and less expensive outpatient care. PFC's home-based care strategy is a cost-effective model for pediatric palliative care elsewhere.

Treatment Patterns and Healthcare Costs in Newly Diagnosed Patients with Chronic Myeloid Leukemia Receiving Dasatinib or Nilotinib As First-Line Therapy in the United States: A Retrospective Claims Database Analysis

Background: To date, no studies have directly compared the treatment patterns and economic outcomes of dasatinib and nilotinib as 1st-line therapy for Philadelphia chromosome positive chronic myeloid leukemia in chronic phase (Ph+ CML-CP). This study aimed to address this gap using retrospective claims data. Method: Newly diagnosed adult pts with CML who received dasatinib or nilotinib as 1st-line therapy were identified from 2 large US administrative claims databases (Q1/2010 - Q4/2014). Pts with continuous health plan coverage for ≥6 months before (baseline period) and ≥1 month after the 1st-line TKI initiation (index date) were classified as dasatinib or nilotinib pts based on the 1st-line TKI. Pts were excluded from the study if they were enrolled in a clinical trial, had a stem-cell transplant, received chemotherapy (except hydroxyurea), had a metastatic cancer/solid tumor or end stage renal disease during the baseline period. Dose adjustment (dose decrease/increase of ≥20mg for dasatinib and ≥100mg for nilotinib vs the initial dose) were measured from the index date to treatment discontinuation (i.e., treatment gap of ≥60 days) or end of follow-up. Treatment adherence was measured using proportion of days covered (PDC) during a 6- and 12-month period following index date among pts with continuous health plan coverage during these periods. Treatment discontinuation, switching to another TKI, and healthcare resource utilization (HRU) and costs (pharmacy+medical costs; per person per month: PPPM; USD 2014) were measured from index date to end of follow-up. Outcomes were compared between cohorts using multivariate regression analyses adjusting for potential confounding factors identified at baseline/index date (age, gender, CML complexity, CCI, starting dose, and health plan type). Results: A total of 604 dasatinib and 418 nilotinib pts met the sample selection criteria with average follow-up of 17 months in both cohorts. Pts in dasatinib and nilotinib cohorts did not significantly differ in age (mean=51 vs 52, respectively; p=.114), sex (46% female in both cohorts; p=.834), and comorbidities (mean CCI=1.4 vs 1.5, respectively; p=.600). In dasatinib pts, 91% started with 100mg/day, 3% with Conclusions: Based on retrospective claims data, this study shows that dasatinib was associated with an increased risk of dose decrease despite majority of pts starting on the recommended dose, an increase risk of switching to another TKI, and higher total healthcare costs compared to nilotinib pts. No difference in adherence, discontinuation, and HRU was found. The study showed the association between nilotinib versus dasatinib as first-line therapy in CML patients and outcomes, not causation. The proportion of CML patients in accelerated phase or blast crisis by cohort at the first-line TKI initiation and its impact on results is unknown but was assumed to be marginal. Disclosures Chen:Novartis Pharmaceuticals Corporation: Employment, Equity Ownership. Latremouille-Viau:Janssen-Cilag GmbH, Janssen-Ortho, Inc., Merck Frosst Canada, Novartis Pharmaceuticals Corporation, Novo Nordisk Inc., Janssen Scientific Affairs, LLC, Centocor Ortho Biotech: Consultancy, Other: Dominick Latremouille-Viau is an employee of Analysis Group Inc, which has received consultancy fees from the listed organizations; AbbVie Inc., Alcon Laboratories, AstraZeneca, Bayer Healthcare Pharmaceuticals, LLC, Celgene Corporation, Forest Laboratories, Inc., Genentech, Inc., GlaxoSmithKline: Consultancy, Other: Dominick Latremouille-Viau is an employee of Analysis Group Inc, which has received consultancy fees from the listed organizations; Pfizer Canada, Inc., Savient Pharmaceuticals, Inc., Shire Pharmaceuticals Inc., Takeda Global Research & Development Center, Inc.,Takeda Pharmaceuticals U.S.A., Inc.: Consultancy, Other: Dominick Latremouille-Viau is an employee of Analysis Group Inc, which has received consultancy fees from the listed organizations. Guerin:GlaxoSmithKline, Janssen Scientific Affairs, Janssen-Ortho, Inc., Merck & Co., Inc., Merck Frosst Canada, Novartis Pharmaceuticals Corporation, Novo Nordisk Inc., Ogilvy Renault, Ortho-Clinical Diagnostics, Inc., Otsuka America Pharmaceutical, Inc.,: Consultancy, Other: Annie Guerin is an employee of Analysis Group Inc, which has received consultancy fees from the listed organizations; Pfizer Canada, Inc., RXD AbbVie Inc., Alcon Laboratories, Bayer Healthcare Pharmaceuticals, LLC, Celgene Corporation, Cempra Inc., Centocor Ortho Biotech, Cooley LLP, Cyberonics, Inc., DLA Piper, Eli Lilly & Company, Forest Laboratories, Inc., Genentech, Inc.,: Consultancy, Other: Annie Guerin is an employee of Analysis Group Inc, which has received consultancy fees from the listed organizations. Nitulescu:Novartis Pharmaceuticals Corporation, Sunovion Pharmaceuticals Inc., AbbVie Inc., Otsuka America Pharmaceutical, Inc., Shire Pharmaceuticals Inc., Genentech, Inc., GlaxoSmithKline, Merck Frosst Canada: Consultancy, Other: Roy Nitulescu is an employee of Analysis Group Inc, which has received consultancy fees from the listed organizations. Gagnon-Sanschagrin:Novartis Pharmaceuticals Corporation, Genentech, Inc., AbbVie Inc., Takeda Pharmaceuticals U.S.A., Inc.: Consultancy, Other: Patrick Gagnon-Sanschagrin is an employee of Analysis Group Inc, which has received consultancy fees from the listed organizations.

Datapoints: Inpatient Utilization for Persons With Co-occurring Disorders

14 P with co-occurring mental and substance use disorders have been shown to be frequent users of inpatient care (1). Such studies, however, are limited to a single funding stream, type of disorder, or locale. Given recent emphasis on improving care for people with such co-occurring disorders, better estimates of inpatient utilization are important to aid design of effective, efficient public mental health and substance abuse services. This column describes use of inpatient care in Delaware, Oklahoma, and Washington by clients who received at least one mental health or substance abuse service from the state mental health, substance abuse, or Medicaid agency in calendar year 1997 (2). Administrative files of these clients were matched across those agencies and categorized into three diagnostic groups: mental disorder only, substance use disorder only, and co-occurring mental and substance use disorders. Results were expected to differ across states because of potential differences in the case mix of patients served, types and amounts of services supported, regional variation in clinical practice, population dispersion and density, organization of each state authority administering services, managed care involvement, total dollars devoted to such services, and other factors. Clients with co-occurring disorders were three to four times more likely to be hospitalized than clients with mental illness only and ten to 20 times more likely to be admitted than clients with a substance use disorder only. The average number of inpatient days per admitted client differed across states by more than 100% for each diagnostic group (Figure 1). Despite the divergence in absolute values across states, in each state the length of inpatient stays were longest for admitted clients with mental illness only, followed by those with co-occurring disorders and those with a substance use disorder only. Yet across all clients, not just those admitted, the annual average number of hospital days per group was highest for the group with co-occurring disorders (data not shown). Further study is needed to assess factors associated with higher admission rates for clients with co-occurring mental and substance use disorInpatient Utilization for Persons With Co-occurring Disorders

Datapoints: Inpatient Utilization for Persons With Co-occurring Disorders

People with co-occurring mental and substance use disorders have been shown to be frequent users of inpatient care (1). Such studies, however, are limited to a single funding stream, type of disorder, or locale. Given recent emphasis on improving care for people with such co-occurring disorders, better estimates of inpatient utilization are important to aid design of effective, efficient public mental health and substance abuse services. This column describes use of inpatient care in Delaware, Oklahoma, and Washington by clients who received at least one mental health or substance abuse service from the state mental health, substance abuse, or Medicaid agency in calendar year 1997 (2). Administrative files of these clients were matched across those agencies and categorized into three diagnostic groups: mental disorder only, substance use disorder only, and co-occurring mental and substance use disorders. Results were expected to differ across states because of potential differences in the case mix of patients served, types and amounts of services supported, regional variation in clinical practice, population dispersion and density, organization of each state authority administering services, managed care involvement, total dollars devoted to such services, and other factors. Clients with co-occurring disorders were three to four times more likely to be hospitalized than clients with mental illness only and ten to 20 times more likely to be admitted than clients with a substance use disorder only. The average number of inpatient days per admitted client differed across states by more than 100% for each diagnostic group (Figure 1). Despite the divergence in absolute values across states, in each state the length of inpatient stays were longest for admitted clients with mental illness only, followed by those with co-occurring disorders and those with a substance use disorder only. Yet across all clients, not just those admitted, the annual average number of hospital days per group was highest for the group with co-occurring disorders (data not shown). Further study is needed to assess factors associated with higher admission rates for clients with co-occurring mental and substance use disor

Early Supported Discharge for Stroke Patients Improves Clinical Outcome. Does It Also Reduce Use of Health Services and Costs?

Background: An early supported discharge service (ESD) appears to be a promising alternative to conventional care. The aim of this trial was to compare the use of health services and costs with traditional stroke care during a one-year follow-up. Methods: Three hundred and twenty patients were randomly allocated either to ordinary stroke unit care or stroke unit care combined with ESD which was coordinated by a mobile team. The use of all health services was recorded prospectively; its costs were measured as service costs and represent a combination of calculated average costs and tariffs. Hospital expenses were measured as costs per inpatient day and adjusted for the DRG. Results: There was a reduction in average number of inpatient days at 52 weeks in favour of the ESD group (p = 0.012), and a non-significant reduction in total mean service costs in the ESD group (EUR 18,937/EUR 21,824). ESD service seems to be most cost-effective for patients with a moderate stroke. Conclusion: Acute stroke unit care combined with an ESD programme may reduce the length of institutional stay without increasing the costs of outpatient rehabilitation compared with traditional stroke care.

Changing medical doctor productivity and its affecting factors in rural China.

Using the data collected from the health facility-based survey, part of the national health service survey conducted in 1993 and 1998, this paper tries to examine changes in labour productivity among the county-level hospitals and township health centres in rural China, and to analyse factors affecting the changes. The results presented in the paper show that the average number of outpatient visits per doctor per day and the average number of inpatient days per doctor per day declined significantly over the period from 1986 to 1997. The main factors resulting in the reduction of productivity are associated with the increase of inappropriate staff recruitment in these health facilities, the significant decline of rural population covered by health insurance, particularly rural cooperative medical schemes (CMS), and the rapid rise of health care costs. The latter two factors also have brought about a reduction in the use of these health facilities by the rural population. The paper suggests that the government should tighten up the entrance of health and non-health staff into the rural health sector and develop effective measures aimed to avoid providing pervasive financial incentives to the over-provision of services and over-use of drugs. In addition, other measures that help to increase the demand for health services, such as the establishment of rural health insurance, should be considered seriously.

The importance of genetics in the public health care system: report on the closing down of a genetics division in São Paulo, Brazil

The availability of genetics services in hospitals should be an issue of public concern. Having genetics services helps shorten the time spent in making diagnoses and reduces the average number of inpatient days; it also helps accelerate the choice of adequate treatments, prevents or minimizes sequelae, and, ultimately, reduces costs. The objective of the present study was to describe the closing down in 1996 of the genetics division at the Menino Jesus Children's Hospital, a pediatric institution located in the city of São Paulo, SP, Brazil. A retrospective analysis was carried out of the work performed by this division between 1992 and 1996, with an emphasis on the detection of chromosomal abnormalities. Of all cases assessed during the study period, 571 were entered into a database. Some kind of chromosomal abnormality was observed in 20% of the 350 karyotypes performed. The existence of genetics services in hospitals helps minimize the appearance of clinical symptoms in carriers of genetic abnormalities, improves the quality of life of these patients, and enables them to receive information regarding risk of recurrence, while preventing the waste of resources that results from tests that are costly and unnecessary. Such benefits amply justify the investment in setting up genetics services of the type described here.

COMPONENTS OF CARE RESPONSIBLE FOR THE RISING COSTS INCURRED DURING THE PRE-TRANSPLANT PERIOD IN LIVER TRANSPLANT RECIPIENTS.

92 Most information regarding the cost of care of the liver transplant recipient has focused upon the surgical procedure and the initial inpatient stay. Liver transplant programs have seen a progressive increase in the number of patients on waiting lists and an increase in length of time patients spend on lists due to the limited donor pool and increased access of patients to liver transplantation. At the University of Colorado the length of the waiting period for patients transplanted from 1/1/96-12/31/96 vs 1/1/97-6/30/97 vs 7/1/97-12/31/97 was 334 ± 187 vs 447 ± 190 vs 549 ± 234 days (excluding Status 1 listings). Purpose: In this study we examined number of hospitalizations, length of stay, and dollars expended in the year prior to transplantation for inpatient and outpatient care for patients transplanted at the University of Colorado Health Sciences Center. Two 6 month intervals were compared: Group I, transplanted between July and December of 1996 (N = 26), and Group II, transplanted between January and June of 1997 (N = 32). The two groups were gender- and age-matched, had similar severity of pretransplant illness, and equivalent survival and rates of retransplantation. Results: Results are expressed as means for Group I vs. Group II for all data. The average number of inpatient days per admitted patient was 10.5 vs 18.3d and the number of inpatient days per listed patient were 4.4 vs 8.0. Charges related to all pre-transplant inpatient care were$21,794 vs $36,987 per admitted patient, and $9,221 vs $16,182 per listed patient. The pretransplant charges of outpatient care decreased from $12,407 to $6,877 per patient. In this one year interval increases in the initial charges for liver transplantation (+$6,961) were only partially offset by reduction in charges of outpatient care (-$5,530). Conclusion: Increases in numbers of listed patients and length of time on the waiting list are associated with increases in days of hospitalization and charges of inpatient pretransplant care. Cost reduction measures focused solely on outpatient care will have only a short-term and limited impact on the total costs incurred by this expanding patient population.

Influence of Morbidity and Health Care Structure on Hospitalization Among Adult Diabetic Patients

The aim of the study was to investigate the influence of outpatient care, overall hospital bed provision and the prevalence of diabetes on the hospital use by adult diabetic patients. Population based data were collected in Finland from a 3-year period. Hospital admissions, inpatient days, and mean length of stay due to diabetes were derived from the Hospital Discharge Register. Estimates of diabetes prevalence were derived from the Central Drug Register. Primary outpatient site, annual number of physician visits, and age at onset among diabetic patients were assessed by questionnaire. The unit of analysis was hospital district (n = 21) and all analyses refer to the 15–64 years age group. Linear regression models were used to explain discharge rates and inpatient days in the district. Large variations between hospital districts were observed in diabetes prevalence, discharge rates due to diabetes, and mean length of stay among diabetic patients. Prevalence of diabetes and overall supply of hospital beds in the district were not related to hospital use. Univariate analyses showed that the larger the proportion of diabetic patients primarily using a private practitioner, the lower the hospital use. In districts where early onset of diabetes was more common, the average number of inpatient days was significantly lower than in other districts. In stepwise regression analyses, early onset of diabetes was the only variable that entered the models. In the full model, 24.6 % of the variance in inpatient days and 16.1 % of the variance in discharge rates were explained. In conclusion, factors related to health care structure, provision of hospital beds or morbidity explain little of the regional variation in hospital use. The observed variations in hospital use probably depend mainly on local treatment policies and differences in clinical decision-making.

Influence of morbidity and health care structure on hospitalization among adult diabetic patients.

The aim of the study was to investigate the influence of outpatient care, overall hospital bed provision and the prevalence of diabetes on the hospital use by adult diabetic patients. Population based data were collected in Finland from a 3-year period. Hospital admissions, inpatient days, and mean length of stay due to diabetes were derived from the Hospital Discharge Register. Estimates of diabetes prevalence were derived from the Central Drug Register. Primary outpatient site, annual number of physician visits, and age at onset among diabetic patients were assessed by questionnaire. The unit of analysis was hospital district (n = 21) and all analyses refer to the 15-64 years age group. Linear regression models were used to explain discharge rates and inpatient days in the district. Large variations between hospital districts were observed in diabetes prevalence, discharge rates due to diabetes, and mean length of stay among diabetic patients. Prevalence of diabetes and overall supply of hospital beds in the district were not related to hospital use. Univariate analyses showed that the larger the proportion of diabetic patients primarily using a private practitioner, the lower the hospital use. In districts where early onset of diabetes was more common, the average number of inpatient days was significantly lower than in other districts. In stepwise regression analyses, early onset of diabetes was the only variable that entered the models. In the full model, 24.6% of the variance in inpatient days and 16.1% of the variance in discharge rates were explained. In conclusion, factors related to health care structure, provision of hospital beds or morbidity explain little of the regional variation in hospital use. The observed variations in hospital use probably depend mainly on local treatment policies and differences in clinical decision-making.

Utilization and cost experience of low-income families in four prepaid group-practice plans.

Abstract A number of low-income families through arrangements supported by the Office of Economic Opportunity received medical care through four community-based prepaid group-practice plans. These families required six months to achieve a utilization level not exceeding that of the regular-plan members. As compared to national data, costs were less because of reductions in hospital days for the poor under prepaid group-practice arrangements. The average number of inpatient days per 1000 Office of Economic Opportunity enrollees was 600 days under the group plan; the national average for low-income persons under the age of 65 was about 1000 days. Cost differences between the low-income families and the regular-plan members were minimal when similar benefits were compared. A package of services including comprehensive physician services, prescriptions, mental health and hospital services cost from $137 to $180 per person per year. Support of broader health services may add from $47 to $65 per person per year to the cost. (N Engl J Med 289: 67–72, 1973)