Hospital-specific Rates Research Articles

The quality of early-stage breast cancer care.

To assess whether recent practice has improved, the authors created detailed, evidence-based guidelines and assessed the quality of early-stage breast cancer care at four hospitals in the metropolitan New York area. Adjuvant treatments for early-stage breast cancer have been shown to improve health and longevity. However, reports from the 1980s showed marked underuse of these therapies. All 723 women with early-stage breast cancer who had a definitive surgical procedure at four participating hospitals in the Mount Sinai-NYU Health System between April 1994 and August 1996 were included. Inpatient and outpatient records were abstracted. Fifty-nine percent of women underwent breast-conserving surgery, of whom 81% received radiation therapy. Hospital-specific radiation therapy rates varied from 69% to 87%. Seventy-eight percent of women with stage 1B or greater cancer received systemic treatment, with hospital-specific rates varying from 71% to 86%. Between 18% and 33% of women who could have benefited from local or systemic adjuvant treatments did not receive them. The risk of not getting a beneficial adjuvant treatment varied more than twofold by the hospital where the breast cancer surgery was performed. The hospital where breast cancer surgery is performed is associated with the likelihood that women receive effective local and systemic adjuvant treatments. Surgeons and members of hospital quality improvement programs should encourage multidisciplinary approaches to breast cancer care.

Has DRG payment influenced the technical efficiency and productivity of diagnostic technologies in Portuguese public hospitals? An empirical analysis using parametric and non-parametric methods.

The use of Diagnosis Related Groups (DRG) as a mechanism for hospital financing is a currently debated topic in Portugal. The DRG system was scheduled to be initiated by the Health Ministry of Portugal on January 1, 1990 as an instrument for the allocation of public hospital budgets funded by the National Health Service (NHS), and as a method of payment for other third party payers (e.g., Public Employees (ADSE), private insurers, etc.). Based on experience from other countries such as the United States, it was expected that implementation of this system would result in more efficient hospital resource utilisation and a more equitable distribution of hospital budgets. However, in order to minimise the potentially adverse financial impact on hospitals, the Portuguese Health Ministry decided to gradually phase in the use of the DRG system for budget allocation by using blended hospital-specific and national DRG case-mix rates. Since implementation in 1990, the percentage of each hospital's budget based on hospital specific costs was to decrease, while the percentage based on DRG case-mix was to increase. This was scheduled to continue until 1995 when the plan called for allocating yearly budgets on a 50% national and 50% hospital-specific cost basis. While all other non-NHS third party payers are currently paying based on DRGs, the adoption of DRG case-mix as a National Health Service budget setting tool has been slower than anticipated. There is now some argument in both the political and academic communities as to the appropriateness of DRGs as a budget setting criterion as well as to their impact on hospital efficiency in Portugal. This paper uses a two-stage procedure to assess the impact of actual DRG payment on the productivity (through its components, i.e., technological change and technical efficiency change) of diagnostic technology in Portuguese hospitals during the years 1992-1994, using both parametric and non-parametric frontier models. We find evidence that the DRG payment system does appear to have had a positive impact on productivity and technical efficiency of some commonly employed diagnostic technologies in Portugal during this time span.

A population-based analysis of variation in Caesarean birth rates

Our aim was to find hospital characteristics and indicators of clinical practice patterns associated with hospital Caesarean birth rates. The data were derived from the national Finnish Birth Registry for 1987 and 1988 (n=120,277). In addition to hospital-specific Caesarean birth rates, rates in geographically defined hospital service areas were used. This was done to control for selection due to referrals. Few hospital characteristics examined were associated with Caesarean birth rates. There was a negative relationship between the hospital service area-specific rate, but not between the hospital specific rate and the size and level of the hospital. This was due to a referral system in which small, level I hospitals manage mainly low-risk deliveries. High Caesarean birth rates were characterized by frequent operations among normal birth weight, full-term deliveries and for dystoda. The relative excess of Caesareans was seen only at times convenient for surgery. Low Caesarean birth rates were characterized by less Caesareans for all major indications and at all times of the day and week. We conclude that insufficient adaptation of clinical practice patterns to fit a low-risk case mix in a hospital may lead to unnecessary operations. High Caesarean birth rates are not characterized by aggressive management of risks, but by a dispersion of operations among the normal population.

Asymptotic Corrections for Multivariate Posterior Moments with Factored Likelihood Functions

Abstract Asymptotic corrections are used to compute the means and the variance-covariance matrix of multivariate posterior distributions that are formed from a normal prior distribution and a likelihood function that factors into separate functions for each variable in the posterior distribution. The approximations are illustrated using data from the National Assessment of Educational Progress (NAEP). These corrections produce much more accurate approximations than those produced by two different normal approximations. In a second potential application, the computational methods are applied to logistic regression models for severity adjustment of hospital-specific mortality rates.

Using hospital-specific costs to improve the fairness of prospective reimbursement

Payment rates in Medicare's Prospective Payment System (PPS) are based on averages of historical hospital costs. Compared to reimbursing each hospital's own costs, pricing at the average of costs implies a massive redistribution of payments among hospitals. Because not all sources of hospital costs are accounted for in the PPS, some of this redistribution is ‘unfair’. Information in hospital-specific costs on unmeasured patient severity and input prices can be exploited to reduce payment inequities. However, fully hospital-specific rates are not optimal because costs also reflect treatment intensity and efficiency differences among hospitals.

Controlling the Rise in Cesarean Section Rates by the Dissemination of Information from Vital Records

The recent rapid increase in cesarean childbirth is a source of growing public health concern. We suggest that one method of ameliorating the rise would be to disseminate hospital-specific cesarean section rates. To make such rates comparable between hospitals, it is necessary to adjust for variations in maternal and newborn factors associated with cesarean section. We therefore applied an indirect standardization technique to three years of California vital records data. The results show sizable variations in cesarean section rates among individual hospitals and by hospital type, both before and after standardization. For such a method to be effective, complete and accurate information from birth certificates is an obvious prerequisite.

Differences among hospitals as a source of excess neonatal mortality: The District of Columbia, 1970?1978

Between 1970 and 1978 the neonatal mortality rate for black infants in the District of Columbia remained essentially constant while the national rate declined steadily. This report examines adjusted hospital-specific neonatal mortality rates in order to determine the extent to which the District's lack of improvement can be explained by excess mortality in a few hospitals. The indirect method of adjustment utilizing standardized morality ratios (SMRs) is used to control for the effect of the birth weight distribution on hospital-specific neonatal mortality rates. A generalized least squares approach is used to model the changes in the SMRs over time. No change was found in the SMRs for any hospital between 1970-72 and 1973-75, and four hospitals experienced no change in the 1973-75 to 1976-78 period (although one of these hospitals had very low SMRs initially). The remaining four hospitals experienced a 37% decline in their SMR's during the second interval (1973-75 to 1976-78). If the three hospitals that had high initial rates and showed no change in mortality rates from 1973-75 to 1976-78 had experienced the 37% decline, the District's SMR in 1976-78 would have been reduced by 20%.