Capita Utilization Research Articles

For many patients who use large amounts of health care services, the need is intense yet temporary.

Patients who accumulate multiple emergency department visits and hospital admissions, known as super-utilizers, have become the focus of policy initiatives aimed at preventing such costly use of the health care system through less expensive community- and primary care-based interventions. We conducted cross-sectional and longitudinal analyses of 4,774 publicly insured or uninsured super-utilizers in an urban safety-net integrated delivery system for the period May1, 2011-April30, 2013. Our analysis found that consistently 3percent of adult patients met super-utilizer criteria and accounted for 30percent of adult charges. Fewer than half of super-utilizers identified as such on May1, 2011, remained in the category seven months later, and only 28percent remained at the end of a year. This finding has important implications for program design and for policy makers because previous studies may have obscured this instability at the individual level. Our study also identified clinically relevant subgroups amenable to different interventions, along with their per capita utilization and costs before and after being identified as super-utilizers. Future solutions include improving predictive modeling to identify individuals likely to experience sustained levels of avoidable utilization, better classifying subgroups for whom interventions are needed, and implementing stronger program evaluation designs.

MP4-11 RADICAL PROSTATECTOMY TRENDS IN THE UNITED STATES: 1998–2011

You have accessJournal of UrologyProstate Cancer: Epidemiology & Natural History I1 Apr 2015MP4-11 RADICAL PROSTATECTOMY TRENDS IN THE UNITED STATES: 1998–2011 Mark Tyson, Paul Andrews, Erik Castle, and Alexander Parker Mark TysonMark Tyson More articles by this author , Paul AndrewsPaul Andrews More articles by this author , Erik CastleErik Castle More articles by this author , and Alexander ParkerAlexander Parker More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.154AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Radical prostatectomy (RP) is one of many treatment options available for men with clinically localized prostate cancer. It is unknown how the per capita volume and distribution of RP in the US have changed over time. The purpose of this study is to examine national trends in RP rates using a serial, cross-sectional analytic design. METHODS The Nationwide Inpatient Sample (NIS) was used for this study. Adult men older than age 45 years who underwent RP between 1998 and 2011 were included in the study. The main outcome measure was annual RP rates (minimally invasive RP [MI-RP] and open RP). Negative binomial regression was used to study the trends in the annual rates of open RP and MI-RP. RP count was the dependent variable and calendar-year quarter of hospital discharge was the independent variable, with the size of the population at risk for prostate cancer surgery as the offset term (as determined from intercensal population estimates). RESULTS Weighted estimates revealed that 962,917 adult males older than age 45 years underwent RP in the US during the study period. The annual rate of RP remained relatively stable during the study period from 1,425 RP per million in 1998–1999 to 1,330 RP per million in 2010–2011 (p=0.90). The annual rate of open RP decreased from 1,424 per million in 1998–1999 to 435 per million in 2010–2011 (P<.001), whereas the annual rate of MI-RP increased from <1 per million in 1998–1999 to 895 per million in 2010–2011 (P<.001). Since 2006, the estimated number of hospitals providing open RP has decreased by 18% (P<.001), while the number of hospitals providing MI-RP has increased by 191% (P<.001). The median open RP case load per hospital has decreased by 7% (P<.001), while the median case load for hospitals providing MI-RP has declined by 17% (P<.001). The percentage of hospitals providing fewer than 50 MI-RPs per year increased from 12% to 26% since 2006 (P<.001). CONCLUSIONS The per capita utilization rate for RP in the US has remained stable from 1998 to 2011. The rapid expansion of MI-RP has led to a considerable reduction in open RP utilization rates and in the median annual hospital case load. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e30-e31 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mark Tyson More articles by this author Paul Andrews More articles by this author Erik Castle More articles by this author Alexander Parker More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Geographic variation in rates of common surgical procedures in France in 2008–2010, and comparison to the US and Britain

Geographic variation in use of elective surgeries has been widely studied in the US, where over-utilization is incentivized. We wanted to explore recent trends in the geographic variation of common surgical procedures in France – where a global budget, centralized planning process, and compulsory insurance scheme are in place – and to compare measures of variation there to those in the US and Britain. For 2008–2010, we calculated French age- and sex-adjusted per capita utilization rates and four measures of geographic variation for hip fracture admission (which is standard treatment and shows minimal geographic variation across countries) and 14 elective surgical procedures. We found substantial geographic variation in age-sex adjusted per capita admission rates for elective procedures: radical prostatectomy, spine surgery, and CABG showed the greatest variation, while hip fracture, colectomy, and cholecystectomy showed the least. Among older patients, most French admission rates were lower than those seen in the US. In general, measures of geographic variation were lower in France than those reported in the US or Britain. French policymakers could use analyses of geographic variation in service utilization to inform policy, to identify areas for intervention, or to measure the effectiveness of efforts designed to reduce variation in care.

Are community-living and institutionalized dementia patients cared for differently? Evidence on service utilization and costs of care from German insurance claims data

BackgroundDementia patients are often cared for in institutional arrangements, which are associated with substantial spending on professional long-term care services. Nevertheless, there is little evidence on the exact cost differences between community-based and institutional dementia care, especially when it comes to the distinct health care services. Adopting the perspective of the German social security system, which combines Statutory Health Insurance and Compulsory Long-Term Care Insurance (payer perspective), our study aimed to compare community-living and institutionalized dementia patients regarding their health care service utilization profiles and to contrast the respective expenditures.MethodsWe analysed 2006 claims data for 2,934 institutionalized and 5,484 community-living individuals stratified by so-called care levels, which reflect different needs for support in activities of daily living. Concordant general linear models adjusting for clinical and demographic differences were run for each stratum separately to estimate mean per capita utilization and expenditures in both settings. Subsequently, spending for the community-living and the institutionalized population as a whole was compared within an extended overall model.ResultsRegarding both settings, health and long-term care expenditures rose the higher the care level. Thus, long-term care spending was always increased in nursing homes, but health care spending was comparable. However, the underlying service utilization profiles differed, with nursing home residents receiving more frequent visits from medical specialists but fewer in-hospital services and anti-dementia drug prescriptions. Altogether, institutional care required additional yearly per capita expenses of ca. €200 on health and ca. €11,200 on long-term care.ConclusionCommunity-based dementia care is cost saving from the payer perspective due to substantially lower long-term care expenditures. Health care spending is comparable but community-living and institutionalized individuals present characteristic service utilization patterns. This apparently reflects the existence of setting-specific care strategies. However, the bare economic figures do not indicate whether these different concepts affect the quality of care provision and disregard patient preferences and caregiver-related aspects. Hence, additional research combining primary and secondary data seems to be required to foster both, sound allocation of scarce resources and the development of patient-centred dementia care in each setting.

Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991-2010.

Total knee arthroplasty (TKA) is one of the most common and costly surgical procedures performed in the United States. To examine longitudinal trends in volume, utilization, and outcomes for primary and revision TKA between 1991 and 2010 in the US Medicare population. Observational cohort of 3,271,851 patients (aged ≥65 years) who underwent primary TKA and 318 563 who underwent revision TKA identified in Medicare Part A data files. We examined changes in primary and revision TKA volume, per capita utilization, hospital length of stay (LOS), readmission rates, and adverse outcomes. Between 1991 and 2010 annual primary TKA volume increased 161.5% from 93,230 to 243,802 while per capita utilization increased 99.2% (from 31.2 procedures per 10,000 Medicare enrollees in 1991 to 62.1 procedures per 10,000 in 2010). Revision TKA volume increased 105.9% from 9650 to 19,871 while per capita utilization increased 59.4% (from 3.2 procedures per 10,000 Medicare enrollees in 1991 to 5.1 procedures per 10,000 in 2010). For primary TKA, LOS decreased from 7.9 days (95% CI, 7.8-7.9) in 1991-1994 to 3.5 days (95% CI, 3.5-3.5) in 2007-2010 (P < .001). For primary TKA, rates of adverse outcomes resulting in readmission remained stable between 1991-2010, but rates of all-cause 30-day readmission increased from 4.2% (95% CI, 4.1%-4.2%) to 5.0% (95% CI, 4.9%-5.0%) (P < .001). For revision TKA, the decrease in hospital LOS was accompanied by an increase in all-cause 30-day readmission from 6.1% (95% CI, 5.9%-6.4%) to 8.9% (95% CI, 8.7%-9.2%) (P < .001) and an increase in readmission for wound infection from 1.4% (95% CI, 1.3%-1.5%) to 3.0% (95% CI, 2.9%-3.1%) (P < .001). Increases in TKA volume have been driven by both increases in the number of Medicare enrollees and in per capita utilization. We also observed decreases in hospital LOS that were accompanied by increases in hospital readmission rates.

Deficit Reduction Act: Effects on Utilization of Noninvasive Musculoskeletal Imaging

To ascertain the effects of the payment reductions in the Deficit Reduction Act (DRA), which affected only in-office imaging, on the utilization of noninvasive musculoskeletal imaging. This study of nonidentifiable aggregate data did not require institutional review board approval. Medicare Part B Physician/Supplier Procedure Summary Files for 2004, 2006, and 2008 were used. By using descriptive statistics and weighted linear regression, all 111 relevant procedure codes were evaluated to measure the effect of the DRA's payment reductions on change in utilization growth rate between the pre-DRA (2004-2006) and post-DRA (2006-2008) periods. Overall, between the pre-DRA and post-DRA periods, the type of imaging studied demonstrated a 2% deceleration (reduction in per capita utilization growth rate) in the office and a 0.7% deceleration in the outpatient hospital setting. However, nonradiologist and radiologist utilization were both still growing, particularly for nonradiographic imaging. In the office, for both nonradiologists and radiologists, larger DRA payment reductions were associated with greater deceleration; deceleration was approximately 0.2% greater for each additional 1% of reimbursement reduction. There was no payment-reduction-size-related acceleration in the outpatient setting. The growth rate of in-office noninvasive musculoskeletal imaging performed by nonradiologists and the growth rate of this type of imaging being referred to radiologists decreased in the period following the implementation of the DRA. Nonetheless, after the DRA, in-office nonradiographic noninvasive musculoskeletal imaging performed by nonradiologists was still growing much more rapidly than that performed by radiologists.

Ex Vivo Generated Red Cells as Transfusion Products

Ex Vivo Generated Red Cells as Transfusion Products

Medical innovation and age-specific trends in health care utilization: Findings and implications

Health care utilization is expected to rise in the coming decades. Not only will the aggregate need for health care grow by changing demographics, so too will per capita utilization. It has been suggested that trends in health care utilization may be age-specific. In this paper, age-specific trends in health care utilization are presented for different health care sectors in the Netherlands, for the period 1981–2009. For the hospital sector we also explore the link between these trends and the state of medical technology. Using aggregated data from a Dutch health survey and a nationwide hospital register, regression analysis was used to examine age-specific trends in the probability of utilizing health care. To determine the influence of medical technology, the growth in age-specific probabilities of hospital care was regressed on the number of medical patents while adjusting for confounders related to demographics, health status, supply and institutional factors. The findings suggest that for most health care sectors, the trend in the probability of health care utilization is highest for ages 65 and up. Larger advances in medical technology are found to be significantly associated with a higher growth of hospitalization probability, particularly for the higher ages. Age-specific trends will raise questions on the sustainability of intergenerational solidarity in health care, as solidarity will not only be strained by the ageing population, but also might find itself under additional pressure as the gap in health care utilization between elderly and non-elderly grows over time. For hospital care utilization, this process might well be accelerated by advances in medical technology.

The Oversight and Practice of Oocyte Donation in the United States, United Kingdom and Canada

In vitro fertilization using donated oocytes is an important medical technique that provides the only option for some infertile patients to have children. The technique remains ethically contentious, however, and, as a result of this controversy, different oversight approaches have been developed in countries around the world. This paper examines the oversight and practice of oocyte donation in Canada, the United Kingdom and the United States to examine how policy choices have influenced the development and use of this medical technology. Examining per capita utilization of oocyte donation in these three countries provides evidence that supply-side policies-specifically policies affecting the compensation of potential oocyte donors-have substantially influenced the use of this technology. These results should provide useful insight for policymakers developing or revising oocyte donation policies.

Need-based resource allocation: different need indicators, different results?

BackgroundA key policy objective in most publicly financed health care systems is to allocate resources according to need. Many jurisdictions implement this policy objective through need-based allocation models. To date, no gold standard exists for selecting need indicators. In the absence of a gold standard, sensitivity of the choice of need indicators is of concern. The primary objective of this study was to assess the consistency and plausibility of estimates of per capita relative need for health services across Canadian provinces based on different need indicators.MethodsUsing the 2000/2001 Canadian Community Health Survey, we estimated relative per capita need for general practitioner, specialist, and hospital services by province using two approaches that incorporated a different set of need indicators: (1) demographics (age and sex), and (2) demographics, socioeconomic status, and health status. For both approaches, we first fitted regression models to estimate standard utilization of each of three types of health services by indicators of need. We defined the standard as average levels of utilization by needs indicators in the national sample. Subsequently, we estimated expected per capita utilization of each type of health services in each province. We compared these estimates of per capita relative need with premature mortality in each province to check their face validity.ResultsBoth approaches suggested that expected relative per capita need for three services vary across provinces. Different approaches, however, yielded different and inconsistent results. Moreover, provincial per capita relative need for the three health services did not always indicate the same direction of need suggested by premature mortality in each province. In particular, the two approaches suggested Newfoundland had less need than the Canadian average for all three services, but it had the highest premature mortality in Canada.ConclusionSubstantial differences in need for health care may exist across Canadian provinces, but the direction and magnitude of differences depend on the need indicators used. Allocations from models using survey data lacked face validity for some provinces. These results call for the need to better understand the biases that may result from the use of survey data for resource allocation.

Intergenerational Coresidence of Older Adults in Japan: Conditions for Cultural Plasticity

This study investigated individual-level conditions and prefecture-level contextual factors that enable and/or restrict intergenerational coresidence arrangements between older parents and adult children. We implemented multinomial logistic regression within a hierarchical approach to compare traditional and nontraditional styles of intergenerational coresidence arrangements. Individual data (N = 3,565) came from the Nihon University Japanese Longitudinal Study of Aging. We supplemented these with information on socioeconomic and welfare characteristics of Japanese prefectures. Whereas the traditional pattern of coresidence was primarily a value-driven arrangement, nontraditional coresidence was both a value-driven and a need-driven arrangement for older parents with limited physical abilities. Relatively strong economic conditions at the prefecture level were enabling factors for coresidence, whereas the greater per capita utilization of local welfare resources had both enabling and inhibiting effects on coresidence arrangements. The differences between the two types of coresidence are consistent with a shift of intergenerational living arrangements in Japan from a preventive arrangement to a contingent arrangement for older parents in need. We suggest that intergenerational family traditions contain a great amount of plasticity to accommodate societal modernization by adapting to the changing cultural and socioeconomic contexts of the society.

Thomas Pogge’s Global Resources Dividend: A Critique and an Alternative

AbstractPogge’s proposal for a Global Resources Dividend (GRD) has been criticized because its likely effects would be less predictable than Pogge supposes and could even be counterproductive to the main aim of relieving poverty. The GRD might also achieve little with respect to its secondary aim of promoting environmental protection. This article traces the problems to Pogge’s inadequate conception of natural resources. It proposes instead to conceive of natural resources in terms of ‘ecological space’. Using this conception, redistributive principles follow with a more definite logic from Pogge’s own supporting moral argument. The proposed alternative approach also promises a more direct contribution to Pogge’s secondary aim of resource conservation and environmental protection. I conclude that if any redistributive resource-based tax should be levied on nations, then there are at least four decisive reasons to favour levying a tax related to a nation’s per capita utilization of ecological space rather than the GRD.

Trends in inpatient treatment intensity among Medicare beneficiaries at the end of life.

Although an increasing fraction of Medicare beneficiaries die outside the hospital, the proportion of total Medicare expenditures attributable to care in the last year of life has not dropped. We sought to determine whether disproportionate increases in hospital treatment intensity over time among decedents are responsible for the persistent growth in end-of-life expenditures. The 1985-1999 Medicare Medical Provider Analysis and Review (MedPAR) and Denominator files. We sampled inpatient claims for 20 percent of all elderly fee-for-service Medicare decedents and 5 percent of all survivors between 1985 and 1999 and calculated age-, race-, and gender-adjusted per-capita inpatient expenditures and rates of intensive care unit (ICU) and intensive procedure use. We used the decedent-to-survivor expenditure ratio to determine whether growth rates among decedents outpaced growth relative to survivors, using the growth rate among survivors to control for secular trends in treatment intensity. Data Collection. The data were collected by the Centers for Medicare and Medicaid Services. Real inpatient expenditures for the Medicare fee-for-service population increased by 60 percent, from $58 billion in 1985 to $90 billion in 1999, one-quarter of which were accrued by decedents. Between 1985 and 1999 the proportion of beneficiaries with one or more intensive care unit (ICU) admission increased from 30.5 percent to 35.0 percent among decedents and from 5.0 percent to 7.1 percent among survivors; those undergoing one or more intensive procedure increased from 20.9 percent to 31.0 percent among decedents and from 5.8 percent to 8.5 percent among survivors. The majority of intensive procedures in the United States were performed in the more numerous survivors, although in 1999 50 percent of feeding tube placements, 60 percent of intubations/tracheostomies, and 75 percent of cardiopulmonary resuscitations were in decedents. The proportion of beneficiaries dying in a hospital decreased from 44.4 percent to 39.3 percent, but the likelihood of being admitted to an ICU or undergoing an intensive procedure during the terminal hospitalization increased from 38.0 percent to 39.8 percent and from 17.8 percent to 30.3 percent, respectively. One in five Medicare beneficiaries who died in the hospital in 1999 received mechanical ventilation during their terminal admission. Inpatient treatment intensity for all fee-for-service beneficiaries increased between 1985 and 1999 regardless of survivorship status. Absolute changes in per-capita hospital expenditures, ICU admissions, and intensive inpatient procedure use were much higher among decedents. Relative changes were similar except for ICU admissions, which grew faster among survivors. The secular decline in in-hospital deaths has not resulted in decreased per capita utilization of expensive inpatient services in the last year of life. This could imply that net hospital expenditures for the dying might have been even higher over this time period if the shift toward hospice had not occurred.

The importance of productivity in estimating need for dentists

Although the number of dentists is an important determinant of supply, other factors also contribute. Technological advancements and well-trained and managed auxiliary personnel affect supply by allowing dentists to produce more dental services per unit of time. This article examines trends in dental output, productivity, number of dentists and dental care utilization from 1960 through 1998. The authors estimated growth rates for the entire period and selected subperiods using regression analysis. Growth rates for dentist productivity and per capita utilization are important to estimate the number of active dentists needed in the year 2020. Based on ADA practice survey data, the annual growth rate in dentists' productivity was 1.41 percent from 1960 through 1998. However, productivity grew at different rates during this period. It increased 3.95 percent per year from 1960 to 1974. There was a decline in productivity of 0.13 percent annually from 1974 to 1991. From 1991 to 1998, productivity grew 1.05 percent annually. Accurate estimates of changes in dentist productivity are important in evaluating the adequacy of the number of dentists to meet the demand for dental services. PRACTICE IMPLICATIONS. Since productivity generally increases over time, failure to account for changes in productivity can lead to an overestimation of the number of dentists required for any given level of demand for dental services.

Consumer satisfaction and supplier induced demand

This study examines the relationship between supply of primary physicians and consumer satisfaction with access to, and quality of, primary physician services in Norway. The purpose is to throw light on a long-standing controversy in the literature on supplier inducement (SID): the interpretation of the positive association between physician density and per capita utilization of health services. We find that an increase in the number of physicians leads to improved consumer satisfaction, and that the relationship between satisfaction and physician density exhibits diminishing returns to scale. Our results suggest that policy-makers can compute the socially optimal density of physicians without knowledge about whether SID exists, if one accepts the (controversial) assumption that consumer satisfaction is a valid proxy for patient utility.

Bar Coding Vaccines - More Than a 'check-out' Issue

This article has no abstract.

Rising Use of Physician Services by the Elderly: The Contribution of Morbidity

ABSTRACTUse of medical services by the elderly population is increasing. While rising numbers of elderly persons account for much of the overall increase, per capita increases in use of medical services within this group have been substantial. This phenomenon is commonly attributed to greater need due to the “aging” of the elderly population (i.e. an increased proportion of those 85 years of age and over) and to changing patterns of morbidity or to changing patterns of servicing the old and sick. Research to date suggests that the impact of the aging of the elderly population has been small. However, because the relationship between morbidity and rising utilization has not yet been studied, there is considerable debate about the extent to which increased “need” for care contributes to patterns of rising utilization. This research studied the impact of changes in numbers, demographics, and morbidity patterns of the elderly on per capita and aggregate consumption of ambulatory physician services at two points in time. Linked survey and physician claims data for representative samples of the elderly in 1971 and 1983 were used to study patterns of utilization of total ambulatory, consultative and non-consultative care by age and health status. The research found that per capita utilization of both consult and non-consult visits rose across all categories, with older individuals and those in poor health experiencing greater increases in utilization than younger and healthier individuals. At the aggregate level, a large percentage of the increase in utilization of medical services was related to increased numbers of elderly. Changes in ‘need’ attributable to aging of the elderly population and increased morbidity had only minor effects. At least 35 per cent of the increase in non-consult visits and 50 per cent of the increase in consult visits were not specifically related to changes in need of the elderly population and remain as unexplained changes in patterns of servicing individuals. While some of this increase was directed to individuals in poor health, the majority of increased servicing (32% of the increase in non-consultative visits and 58% of the increase in consultation visits) was directed to individuals in good health. Policy implications are discussed.

Alternative Volume Performance Standards for Medicare Physicians' Services

The Omnibus Budget Reconciliation Act of 1989 (OBRA89) established volume performance standards (VPSs) as a key element in Medicare physician reform. This policy requires making choices along three dimensions: the risk pool, the scope and nature of the standard, and the application of the standard. VPSs have most effectively controlled expenditures and changed physician behavior when they use states as the risk pool, are composed entirely of Medicare Part B services, and establish per capita utilization targets. The institution of separate standards for voluntarily formed physician groups would pose substantial administrative challenges and has the potential to effect adverse outcomes. Instead, Congress should continue to encourage prepaid plans for the purpose of lowering health care use. Under current law, VPSs will be used to adjust future price increases. Congress may not wish to emulate the example of countries that have imposed expenditure ceilings to control costs unless the current method of using VPSs proves unsuccessful.

Controlling Medical Care Costs in Canada

Canadian experience has taken on increasing importance in the United States as Americans continue to wrestle with physician cost increases well in excess of those to the north. Fee levels in the United States have risen much more rapidly than those in Canada since at least 1960, while per capita utilization has increased somewhat faster in Canada. On balance, the relative importance of fee levels in the comparative cost experience has outstripped that of per capita utilization.^1,2 But the "Canadian experience" has also shown itself to embody 10 unique provincial experiences. The difference in costs for physicians in Canada and the United States from 1971 through 1985 would have been far more, or far less, dramatic if the Canadian experience had mirrored that in Quebec, or that in British Columbia, respectively.¹In his article in this issue of<i>JAMA</i>, Hughes³updates and extends these previous comparative analyses.

Sources of small area variations in the use of medical care

This paper develops an economic model of physician care utilization which incorporates the uncertainty and practice style hypotheses proposed by Wennberg and others as explanations of the substantial intermarket variations in per capita utilization rates of many medical and surgical procedures. Practice style, which is distinguished from inducement, is modeled as a set of physician beliefs about the production function of health. In the model, per capita utilization is decomposed into a first occurences demand and an intensity demand. It is argued that the influence of practice style affects primarily the intensity with which physicians treat their patients. Alternative tests are proposed and carried out on a comprehensive aggregated measure of physician care utilization for market areas in Michigan. Although practice style is undoubtedly important for some individual procedures, the empirical results indicate that it is unimportant in determining either an aggregated index of market area utilization or the average intensity with which patients are treated by physicians.