Episodes Of Medical Care Research Articles

Healthcare services gap analysis: a supply capture and demand forecast modelling, Dubai 2018–2030

BackgroundHealth systems aim to provide a range of services to meet the growing demand of Dubai's heathcare system aims to provide a range of services to meet the growing demand of its population health needs and to ensure that standards of easy access, quality, equity and responsiveness are maintained. Dubai Health Authority (DHA) uses health services planning tools to assess the health needs of its population and sets priorities and effective regulatory strategies to achieve equilibrium of supply and demand of healthcare services and ensure adequate healthcare services are available, in terms of both quality and quantity. This study aims to measure the gap between demand and supply in health care services in Dubai at the baseline and to forecast the gap size and type (according to medical specialty, key medical planning units and geographical area) till 2030. The specific consequential aim includes identification of appropriate strategic directions for regulation, licensing, policies, insurance.MethodologyThe supply of healthcare services, professionals and medical equipment is captured through a census of all healthcare facilities licensed for practice in the Emirate of Dubai. The demand is estimated using a need based approach, where demand for episodes of medical care are estimated by age and gender and aligned to the internationally defined diagnosis related groups (IR-DGRs). The estimated episodes are then forecasted into the future, until 2030, using three scenarios of population growth (high, medium and low) for the emirate of Dubai. The captured supply and forecasted demand has been categorized into eight key health-planning units (KPUs) to allow for understanding of the population healthcare service needs by main service categories. Using a software for health services planning, a gap analysis between supply and demand is conducted till year 2030.ResultsThe results revealed a current and expected undersupply and oversupply for some healthcare services by medical specialty and geographical area of the Emirate. By 2030, the largest gaps exists in acute beds, which would require 1,590 additional beds, for acute-same day beds, an additional 1575 beds, for outpatient consultation rooms, an additional 2,160 consultation rooms, for emergency department, an additional 107 emergency bays, and for long-term care and rehabilitation beds, an additional 675 beds. The top specialty needs for these categories include cardiology, orthopedics, rheumatology, psychiatry, pediatric medicine & surgery, gastroenterology, hematology & oncology, renal medicine, primary care, respiratory medicine, endocrinology, rehabilitation and long-term care.ConclusionsThere is an existing and growing requirement to support the healthcare services capacity needs for the top service lines and geographical areas with the largest gaps. Future licensing is required to ensure that new facilities are geographically distributed in a balanced way, and requests for licensing that create or augment oversupply should be avoided.

Does It Still Show a Deficit? Arguing Post-COVID-19 Health Financing System in Bogor, Indonesia

Before the COVID-19 pandemic, the Bogor City Government regulated to cover the health financing claim during the Indonesian National Health Insurance (NHI) integration period due to the lower amount of health care claim per episode in regional hospitals compared to ones that NHI paid. This study aimed to address post-COVID-19 health financing at two hospitals in Bogor City, West Java Province, Indonesia. Descriptive analysis using the aggregate statistical summaries was taken to explore the medical care episodes of the data series at two hospitals for the last two years. Of the 890 checked medical records data, the deficit occurred in 197 (22.1%) medical care episodes, while five (0.6%) exceeded the hospitals' tariffs. The remaining 688 (77.3%) medical care episodes had suits with the Indonesian Case Based Groups. Almost a quarter of medical care episodes in aggregate experienced a deficit in the two years before the pandemic. This study is the first to provide new insight into the discussion on medical care financing in a developing country's post-pandemic era in a newly-implemented NHI system.

New-Onset Diabetes After Statin Exposure in Elderly Women: The Australian Longitudinal Study on Women's Health.

Extensive clinical research has consistently shown statins lower the risk of cardiovascular events and mortality. Some studies also suggest statins increase the risk of new-onset diabetes. Research to date has rarely included elderly women, hence little is known about the risk of diabetes after statin exposure in this population. Our objectives were to evaluate and estimate the risk of new-onset diabetes associated with statin exposure in a cohort of elderly Australian women. We performed an analysis of a population-based longitudinal cohort study with data linkage to the national death index and to national databases of non-hospital episodes of medical care and prescription medications dispensing. Participants included 8372 Australian women born between 1921 and 1926, alive at 1 January 2003, free of diabetes, and eligible for data linkage. Statin exposure was ascertained based on prescriptions dispensed between 1 July 2002 and 31 August 2013. Over 10years of follow up, 49% of the cohort had filled a prescription for statins and 5% had initiated treatment for new-onset diabetes. Multivariable Cox regression showed statin exposure was associated with a higher risk of treatment for new-onset diabetes (hazard ratio 1.33; 95% confidence interval [CI] 1.04-1.70; p=0.024). This equates to a number needed to harm (NNH) of 131 (95% CI 62-1079) for 5years of exposure to statins. Risk increased with increasing dose of statin from the hazard ratio of 1.17 (95% CI 0.84-1.65) for the lowest dose to 1.51 (95% CI 1.14-1.99) for the highest dose. The dose-response for statins on new onset of diabetes suggests elderly women should not be exposed to higher doses of statins. Elderly women currently taking statins should be carefully and regularly monitored for increased blood glucose to ensure early detection and appropriate management of this potential adverse effect, including consideration of de-prescribing.

Implementation and Randomized Controlled Trial Evaluation of Universal Postnatal Nurse Home Visiting

We evaluated whether a brief, universal, postnatal nurse home-visiting intervention can be implemented with high penetration and fidelity, prevent emergency health care services, and promote positive parenting by infant age 6 months. Durham Connects is a manualized 4- to 7-session program to assess family needs and connect parents with community resources to improve infant health and well-being. All 4777 resident births in Durham, North Carolina, between July 1, 2009, and December 31, 2010, were randomly assigned to intervention and control conditions. A random, representative subset of 549 families received blinded interviews for impact evaluation. Of all families, 80% initiated participation; adherence was 84%. Hospital records indicated that Durham Connects infants had 59% fewer infant emergency medical care episodes than did control infants. Durham Connects mothers reported fewer infant emergency care episodes and more community connections, more positive parenting behaviors, participation in higher quality out-of-home child care, and lower rates of anxiety than control mothers. Blinded observers reported higher quality home environments for Durham Connects than for control families. A brief universal home-visiting program implemented with high penetration and fidelity can lower costly emergency medical care and improve family outcomes.

Medical and Supportive Care Among People with ALS in the Months Before Death or Tracheostomy

People with amyotrophic lateral sclerosis (ALS) who choose tracheostomy demonstrate a strong and mostly consistent attachment to life from the point of diagnosis. It is unclear if these patients also use medical and health services to a greater degree than patients who decide against tracheostomy. In this research, patients with a high likelihood of dying over six months (forced vital capacity < 50% predicted) were followed monthly until death or tracheostomy with long-term mechanical ventilation (LTMV). Patient service use was measured by caregiver reports of 1) ALS-specific prosthetic devices, 2) allied health or medical services, 3) legal preparation for medical care or the end of life, and 4) medical care episodes. Caregivers also reported all patient prescription medications. At follow-up, 57 patients died and 14 elected to have tracheostomy and LTMV. Patients who opted for LTMV were younger and had higher household incomes. They were significantly more likely to use nasal ventilation, paid home care, and family or personal counseling over follow-up, and they were also more likely to remain on medications. The proactive orientation to health and desire to live despite severe disability reported for people choosing LTMV thus extends as well to more intensive use of medical and supportive care in the months before tracheostomy. A challenging task for clinicians is to acknowledge this strong desire to live while providing appropriate expectations for life after tracheostomy.

Cost-Effectiveness of Rotavirus Vaccination: Exploring Caregiver(s) and ``No Medical Care'' Disease Impact in Belgium

To estimate the cost-effectiveness of universal childhood rotavirus vaccination in Belgium, taking into account the impact of caregiver burden and the burden of sick children for whom no medical care is sought ("no medical care'' ). A cohort of newborns is modeled in relation to costs and health outcomes for rotavirus disease, distinguishing episodes leading to consultations, hospitalizations, and deaths from no medical care episodes. Fully funded universal vaccination is compared with no vaccination as well as with the current situation in Belgium, whereby the 2-dose Rotarix or the 3-dose RotaTeq vaccine can be bought at market prices, which are partially reimbursed. Compared with no vaccination, fully funded universal rotavirus vaccination would cost 51,030 per quality-adjusted life year (QALY) gained with Rotarix and 65,767 with RotaTeq (for society, 7572 and 30,227 per QALY, respectively). However, there is considerable uncertainty due to some analytical choices: the proportion of simulations with an acceptable incremental cost-effectiveness ratio (given a willingness to pay 50,000 for an additional QALY), increases from 2%/0.6% (Rotarix/RotaTeq) to 86%/59% when considering no medical care, and including 2 caregivers to estimate QALY loss instead of zero. Uncertainty is greater still under the societal than under the health care payer perspective. For the Belgian health care payer, at current vaccine prices, universal childhood rotavirus vaccination is unlikely to be judged cost-effective versus no vaccination but would be a more efficient and equitable choice than continuing with current practice.

Using healthcare claims data for outcomes research and pharmacoeconomic analyses.

Healthcare claims data are a practical complement to data from randomised controlled trials (RCTs) for evaluating health outcomes in non-experimental settings and for generalising results to a broader population. Claims data are a relatively inexpensive way to obtain useful information about patient demographics, as well as healthcare resources used for specific medical conditions and procedures from large numbers of patients over extended periods of time. With claims data, it is possible to identify patients who meet specific medical or sociodemographic criteria, estimate their costs, define episodes of medical care, and measure outcomes more globally than is possible with RCT data. Statistical methods exist to address some of the inherent issues with claims data due to their limited clinical detail. We also identify extensions of claims data to productivity issues, the use of centralised claims data such as in Canada, and the application of new statistical methods to outcomes research literature such as sample selection correction methods.

The Effect of Health Insurance Cost Sharing within Episodes of Medical Care

Moral Hazard Control It has long been recognized that health insurance can inflate medical care expenditures by introducing moral hazard into the medical care consumption decision (Pauly, 1968; Feldstein, 1971; Feldstein, 1977). By forcing consumers to share in the marginal cost of care, health insurance deductibles and copayments are conventionally considered an effective means of combating moral hazard (see Rejda, 1989, pp. 84-87). However, the effectiveness of consumer cost sharing may be limited to controlling the frequency of a consumer's contact with the medical care system and, possibly, the frequency of hospitalization (Manning et al., 1987; Keeler and Rolph, 1988). The consumer seemingly controls the initial contact with the medical care system. Hence, deductibles and copayments would be expected to influence the likelihood of a patient contacting a physician and, thus, affect overall expenditures. For example, Lohr, et al. (1986) find that patients subject to cost sharing under their insurance contracts are less likely to make contact with the medical care system than patients with full insurance coverage. Choices regarding hospitalization generally fall into two categories: those involving elective procedures, where the decision to be hospitalized is the consumer's, and those involving serious illness, where the decision regarding hospitalization is the physician's. One would expect, then, that the effectiveness of consumer cost sharing in controlling inpatient expenditures would depend upon the type of hospitalization involved. Presumably, some degree of discretion exists regarding outpatient treatment at the margin (e.g., performing an additional lab test, increasing a prescription dosage). The extent of consumer control over such marginal outpatient expenditures is not clear. If physicians match particular treatments to particular health states without regard for the consumer's tastes for the intensity of treatment or the consumer's ability to pay and if consumers acquiesce to the treatments prescribed, deductibles and copayments will not be effective at influencing outpatient expenditures within an episode of care. An episode of care is defined as all treatment for a particular condition or symptom arising out of an initial contact with the medical care system (see Keeler and Rolph, 1988, for example). Fee-for-service (FFS) physicians generally have marginal revenue greater than or equal to zero for each additional service performed. Health maintenance organization (HMO) physicians generally have marginal revenue less than or equal to zero for each additional service performed. As long as the value of the physician's time is greater than zero, expenditure of additional time without additional marginal revenue is costly to the physician. The HMO delivery system, in effect, imposes cost sharing on the physician. HMOs have been advocated as a means of controlling consumer moral hazard. Several studies have shown HMOs to have lower expenses than FFS care, primarily because of reduced hospitalization rates (see, for example, Luft, 1981; Manning et al., 1984). One would also expect the financial incentives associated with HMOs to affect the delivery of outpatient care. This study tests the influence of cost sharing on marginal outpatient expenditures within individual episodes of medical care. The empirical tests go beyond previous work by comparing expenditures for consumers with the same diagnosed condition in both FFS and HMO contexts.(1) The effects of physician compensation systems and consumer characteristics, including insurance coverage, upon outpatient expenditures of individuals over the age of 14 are compared across 39 diagnoses.(2) The Data and Empirical Design Data The data set used in this analysis is from the Rand Health Insurance Experiment (RHIE), conducted by the Rand Corporation from 1974 to 1982. The experiment was a controlled trial in health care financing funded by the U. …

Physicians' Utilization and Charges for Outpatient Diagnostic Imaging in a Medicare Population

For 10 common clinical presentations, we assessed differences in physicians' utilization of and charges for diagnostic imaging, depending on whether they performed imaging examinations in their offices (self-referral) or referred their patients to radiologists (radiologist-referral). Using previously developed methodologies, we generated episodes of medical care from an insurance claims database. Within each episode, we determined whether diagnostic imaging had been performed, and if so, whether by a self-referring physician or a radiologist. For each of the 10 clinical presentations, we compared the mean imaging frequency, mean imaging charges per episode of care, and mean imaging charges for diagnostic imaging attributable to self- and radiologist-referral. Depending on the clinical presentation, self-referral resulted in 1.7 to 7.7 times more frequent performance of imaging examinations than radiologist-referral (P < .01, all presentations). Within all physician specialties, self-referral uniformly led to significantly greater utilization of diagnostic imaging than radiologist-referral. Mean imaging charges per episode of medical care (calculated as the product of the frequency of utilization and mean imaging charges) were 1.6 to 6.2 times greater for self-referral than for radiologist-referral (P < .01, all presentations). When imaging examinations were performed--including those performed in both physicians' offices and hospital outpatient departments--mean imaging charges were significantly greater for radiologists than for self-referring physicians in seven of the clinical presentations (P < .01). This result is related to the high technical charges of hospital outpatient departments; in office practice, radiologists' mean charges for imaging examinations were significantly less than those of self-referring physicians for seven clinical presentations (P < .01). Nonradiologist physicians who operate diagnostic imaging equipment in their offices perform imaging examinations more frequently, resulting in higher imaging charges per episode of medical care. These results extend our previous research on this subject by their focus on a broader range of clinical presentations; a mostly elderly, retired population; and the inclusion of higher-technology imaging examinations.

Episodes of medical care: nursing students' use of medical services.

Episodes of medical care: nursing students' use of medical services. J A Solon, R D Rigg, S H Jones, J J Feeney, J W Lingner, and C G ShepsCopyRight https://doi.org/10.2105/AJPH.59.6.936 Published Online: August 29, 2011

Delineating episodes of medical care.

Delineating episodes of medical care. J A Solon, J J Feeney, S H Jones, R D Rigg, and C G ShepsCopyRight https://doi.org/10.2105/AJPH.57.3.401 Published Online: August 29, 2011