Increase In Medical Expenditures Research Articles

Smoothing consumption in times of illness: Household recourse mechanisms.

We study the welfare impacts of illness shocks on rural agricultural households in the semi-arid tropical and humid eastern regions of India. These regions are characterized by rainfed agriculture, missing markets for credit and insurance, and limited access to publicly funded healthcare infrastructure. We find that illness shocks increase households' medical expenditures and reduce wage income. However, aggregate non-medical, food, and non-food consumption expenditures are insensitive to illness shocks. Disaggregating illness by the age and the gender of the household members, we observe that illness in male children leads to the largest increase in medical expenditure, and illness in prime-aged adults leads to the largest decline in per-capita wage earnings. We also find illness shocks leading to changes in household dietary diversity, higher travel expenditures, and a compensating reduction in spending on education and entertainment. Analysis of risk-coping strategies reveals that households rely on transfers from kinship networks and loans from informal sources like local moneylenders to smooth consumption. While large landowners rely on gifts from kinship networks, landless and smallholders increase borrowings from informal sources.

Medical expenditure trajectory and HbA1c progression prior to and after clinical diagnosis of type 2 diabetes in a commercially insured population in the USA

IntroductionMedical expenditures of individuals with type 2 diabetes escalate before clinical diagnosis. How increases in medical expenditures are related to glucose levels remains unclear. We examined changes in HbA1c and...

Trends in stroke, cardiovascular disease, and medical expenditure under a community-based long-term stroke prevention program.

Evidence on the effects of preventive measures for noncommunicable disease is urgently needed for low-income and middle-income countries suffering from stroke epidemics along with population aging. We sought to examine the impact of a community-based stroke prevention program on incidences of stroke and ischemic heart disease, mortality from cardiovascular disease, and medical expenditure. Trends in the incidences of stroke and ischemic heart disease were documented in a Japanese rural community, Kyowa, from 1981 through 2015. Trends in mortality from cardiovascular disease and in medical expenditures were compared between Kyowa and its surrounding municipalities from 1981 through 2004. In Kyowa, the age-and-sex-adjusted incidences of stroke and of ischemic heart disease decreased by half (from 4.1 to 1.9 and from 1.5 to 0.7 per year/1000 persons, respectively) over the past 35 years. A similar decreasing trend was observed for the age-and-sex-adjusted mortality from cardiovascular disease, and this decreasing trend occurred earlier than that in the surrounding municipalities. The medical expenditures for cardiovascular disease became lower in Kyowa than in the surrounding municipalities over time. Our study's findings suggest that a community-based stroke prevention program augmented the decline in the incidences of stroke and ischemic heart disease, mortality from cardiovascular disease, and attenuated the increase in medical expenditures for cardiovascular disease.

민간 의료 보험 가입의 효과와 자기선택 편의

As interest in health increases, private health insurance subscriptions are increasing. Many studies have been conducted to control the endogenous problem of private health insurance and usage of medical service. The change in medical expenditure after buying private medical insurance was analyzed using an instrumental variable. This study used panel data from 2011 to 2018 of the Korea Health Panel Survey. In order to control self-selection bias, which are likely to explain the increase in medical expenditure by subscribing to health-sensitive people, regression analysis was performed using an instrumental variable called the number of families. We find that joining private health insurance increases healthcare usage and ignored self-selection generates substantial downward bias in the estimates. First, the additional private health insurance increases the changes in medical expenditure by 4.8 million won per year. In addition, for specific types and types of insurance, it was analyzed that the subscription of mixed private medical insurance of cancer insurance increases the change in medical expenditure. Finally, changes in medical expenditure due to private medical insurance coverage of patients with diabetes and hyperlipidemia, which are mild chronic diseases, appeared differently. Diabetes patients subscribed to a mixed type of cancer insurance, and hyperlipidemia patients subscribed to a fixed-benefit type of general disease insurance, resulting in increased medical expenditure. The results of this study can find practical implications for the insurance company to develop insurance products.

What is the major driver of China’s hospital medical expenditure growth? A decomposing analysis

ObjectivesThis study aimed to quantify increases in the medical expenditures of public hospitals associated with changes in service use and prices, which could inform policy efforts to curb the future...

Direct medical costs of obesity in the United States and the most populous states.

BACKGROUND: After a dramatic increase in prevalence over several decades, obesity has become a major public health crisis in the United States. Research to date has consistently demonstrated a correlation between obesity and higher medical costs for a variety of U.S. subpopulations and specific categories of care. However, by examining associations rather than causal effects, previous studies likely underestimated the effect of obesity on medical expenditures. OBJECTIVE: To estimate the causal effect of obesity on direct medical care costs at the national and state levels. METHODS: This study is a pooled cross-sectional analysis of retrospective data from the 2001-2016 Medical Expenditure Panel Surveys. Adults aged 20-65 years with a biological child living in the household were included in the study sample. Primary outcomes were individual-level medical expenditures due to obesity, overall, as well as separately by type of payer and category of medical care. Results were reported at the national level and separately for the 20 most populous states. The expenditure estimates were obtained from 2-part models of instrumental variables in which the respondent's body mass index (BMI) was instrumented using the BMI of their biological child. RESULTS: Adults with obesity in the United States compared with those with normal weight experienced higher annual medical care costs by $2,505 or 100%, with costs increasing significantly with class of obesity, from 68.4% for class 1 to 233.6% for class 3. The effects of obesity raised costs in every category of care: inpatient, outpatient, and prescription drugs. Increases in medical expenditures due to obesity were higher for adults covered by public health insurance programs ($2,868) than for those having private health insurance ($2,058). In 2016, the aggregate medical cost due to obesity among adults in the United States was $260.6 billion. The increase in individual-level expenditures due to obesity varied considerably by state (e.g., 24.0% in Florida, 66.4% in New York, and 104.9% in Texas). CONCLUSIONS: The 2-part models of instrumental variables, which estimate the causal effects of obesity on direct medical costs, showed that the effect of obesity is greater than suggested by previous studies, which estimated only correlations. Much of the aggregate national cost of obesity-$260.6 billion-represents external costs, providing a rationale for interventions to prevent and reduce obesity. DISCLOSURES: Novo Nordisk financed the development of the study design, analysis, and interpretation of data, as well as writing support of the manuscript. Cawley, Biener, and Meyerhoefer received financial support from Novo Nordisk to conduct the research study on which this manuscript is based. Smolarz and Ramasamy are employees of Novo Nordisk. Ding and Zvenyach have no conflicts to declare. Our research has been presented as a poster at the 2020 Academy Health Annual Research Meeting (Virtual), July 28-August 6, 2020.

Changes in chronic medication adherence, costs, and health care use after a cancer diagnosis among low-income patients and the role of patient-centered medical homes.

Approximately 40% of patients with cancer also have another chronic medical condition. Patient-centered medical homes (PCMHs) have improved outcomes among patients with multiple chronic comorbidities. The authors first evaluated the impact of a cancer diagnosis on chronic medication adherence among patients with Medicaid coverage and, second, whether PCMHs influenced outcomes among patients with cancer. Using linked 2004 to 2010 North Carolina cancer registry and claims data, the authors included Medicaid enrollees who were diagnosed with breast, colorectal, or lung cancer who had hyperlipidemia, hypertension, and/or diabetes mellitus. Using difference-in-difference methods, the authors examined adherence to chronic disease medications as measured by the change in the percentage of days covered over time among patients with and without cancer. The authors then further evaluated whether PCMH enrollment modified the observed differences between those patients with and without cancer using a differences-in-differences-in-differences approach. The authors examined changes in health care expenditures and use as secondary outcomes. Patients newly diagnosed with cancer who had hyperlipidemia experienced a 7-percentage point to 11-percentage point decrease in the percentage of days covered compared with patients without cancer. Patients with cancer also experienced significant increases in medical expenditures and hospitalizations compared with noncancer controls. Changes in medication adherence over time between patients with and without cancer were not determined to be statistically significantly different by PCMH status. Some PCMH patients with cancer experienced smaller increases in expenditures (diabetes) and emergency department use (hyperlipidemia) but larger increases in their inpatient hospitalization rates (hypertension) compared with non-PCMH patients with cancer relative to patients without cancer. PCMHs were not found to be associated with improvements in chronic disease medication adherence, but were associated with lower costs and emergency department visits among some low-income patients with cancer.

Effect of a prospective payment method for health facilities on direct medical expenditures in a low-resource setting: a paired pre-post study.

Almost all sub-Saharan countries have adopted cost-reduction policies to facilitate access to health care. However, several studies underline the reimbursement delays experienced by health facilities, which lead to deficient implementation of these policies. In April 2016, for its free care policy, Burkina Faso shifted from fee-for-service (FFS) paid retrospectively to FFS paid prospectively. This study tested the hypothesis that this new method of payment would be associated with an increase in direct medical expenditures (expenses covered by the policies) associated with deliveries. This paired pre-post study used data from two cross-sectional national surveys. Observations were paired according to the health facility and the type of delivery. We used a combined approach (state and household perspectives) to capture all direct medical expenses (delivery fees, drugs and supplies costs, paraclinical exam costs and hospitalization fees). A Wilcoxon signed-rank test was used to test the hypothesis that the 2016 distribution of direct medical expenditures was greater than that for 2014. A total of 279 pairs of normal deliveries, 66 dystocia deliveries and 48 caesareans were analysed. The direct medical expenditure medians were USD 4.97 [interquartile range (IQR): 4.30–6.02], 22.10 [IQR: 15.59–29.32] and 103.58 [IQR: 85.13–113.88] in 2014 vs USD 5.55 [IQR: 4.55–6.88], 23.90 [IQR: 17.55–48.81] and 141.54 [IQR: 104.10–172.02] in 2016 for normal, dystocia and caesarean deliveries, respectively. Except for dystocia (P = 0.128) and medical centres (P = 0.240), the 2016 direct medical expenditures were higher than the 2014 expenses, regardless of the type of delivery and level of care. The 2016 expenditures were higher than the 2014 expenditures, regardless of the components considered. In the context of cost-reduction policies in sub-Saharan countries, greater attention must be paid to the provider payment method and cost-control measures because these elements may generate an increase in medical expenditures, which threatens the sustainability of these policies.

Effects of Cancer on the Socio-Economic Dimensions of Patients: Evidence from Nakuru Level 5 Oncology Clinic

This study aimed to show how cancer has affected the economic and psychosocial aspects of patients’ livelihoods in Nakuru County. The study adopted descriptive survey design and draw on a quantitative inquiry. The sample size, determined by Fishers method, were 245 patients and 10 medical officers (medical superintendent, oncologists and nurses) drawn from the Nakuru County Teaching and referral Hospital. The research instruments employed were the questionnaire and interview schedules. Before the actual data collection, piloting of questionnaires and the interview schedule was done in Moi Teaching and Referral Hospital in Uasin Gishu County. Data analysis followed both parametric and non-parametric approaches. Data was presented using graphs, tables and scatter diagrams. The findings of the study suggest a strong association of cancer with loss of income (????16, 0.01 = 40.101) and a significant increase in medical expenditure (????12, 0.01 = 66.789). Similarly, it was shown that cancer patients were impacted both socially and economically by cancer type (????12, 0.033 = 22.46) and duration of treatment. The results from the study will contribute immensely to the development of new strategies to improve patients’ economic status in the management of cancer within Nakuru county and Kenya in general.

Assessing the Effects of Prescription Adjustment and Medication Non-adherence Associated with Medication Efficacy Classifications from Leftover Drugs through the SETSUYAKU-BAG Campaign

The increase in medical expenditure has been worsening and poses a serious social problem. Commonly, leftover drugs are retained by patients. We estimated the possible reduction in prescription rates by appropriately reusing leftover drugs, and investigated the medication efficacy classifications that render leftover drugs due to the medication non-adherence. A retrospective cross-sectional survey of prescription data was performed at community pharmacies engaged in the appropriate reuse of leftover drugs through the SETSUYAKU-BAG campaign. We evaluated the drug costs and number of drugs originally prescribed, the reduction in expenditure and numbers after the use of leftover drugs, and then calculated the prescription reduction ratio (PRR) based on the number of drugs. Factors contributing to non-adherence were analyzed by the PRR. After reviewing the prescription information of 1792 patients, the reduction rate in drug expenditure was found to be 20.1%. Purgatives, Chinese medicines, and agents for peptic ulcer had higher PRRs and belonged to the top ten medications according to the prescription efficacy classifications. Non-adherence associated with the medication efficacy classifications was assessed by analyzing 5466 formulations. Thirty percent of formulations were found to be non-adherent. According to the medication efficacy classifications, six medications including agents for hyperlipidemias, peptic ulcer, psychotropics agents, and others, were less adherent than antihypertensives. These results suggest that adjusting prescriptions by appropriately reusing leftover drugs in community pharmacies could reduce medical costs. Further considerations are necessary for improving medication adherence in Japan. Healthcare providers should monitor medication adherence more carefully, with the results identified in this study.

Policy of prevention: Medical utilization under a wellness plan.

Wellness programs constitute central components of disease prevention efforts under the Affordable Care Act and are likely to remain a component of employer provided health insurance. This paper evaluates the impact of such programs on medical utilization 4 to 7years after enrollment in the plan. Using a unique suited data provided by a large private employer, I analyze medical expenditure and utilization for individuals enrolled in a wellness plan. The analysis compares expenditures and visits between wellness members and nonmembers who are matched through propensity score methods. The results show that although the wellness program increases utilization of preventive and outpatient care, by as much as 1.57 visits per year, there is no comparable decline in emergency or inpatient care, resulting in an overall increase in medical expenditure of around $507 per person per year. The increase in medical expenditure persists even 6 to 7years of continued enrollment in wellness. I find some evidence of improved health, as diagnoses of diabetes decline 0.8 percentage points among wellness members. The results suggest that employer savings stemming from improved health and more judicious use of medical services are not likely to materialize in this wellness program.

Does High Systolic Blood Pressure Truly Increase Medical Expenditure?—An Empirical Analysis of the New 2017 ACC/AHA Hypertension Guideline

Background: High blood pressure (BP) or hypertension is considered one of the top global disease burden risk factors. In November 2017, the ACC/AHA and other organizations announced a new hypertension guideline of 130/80 mmHg. Data and Methods: We evaluate the effects of BP on increases in medical expenditures using transformation tobit models and a dataset containing 175,123 medical checkups and 6,312,125 receipts from 88,211 individuals in three health insurance societies. The sample period was April 2013 to March 2016. We first created a database of combined checkup results and medical expenditures. The power transformation tobit model was then used to remove the effects of other variables, and we investigated the relation between medical expenditures and BP, especially systolic BP (SBP). Results: We observed negative effects of SBP on medical expenditures. The results raise uncertainty about the reliability of the new guideline, at least for SBP. Although the simple correlation coefficient of medical expenditures and SBP was positive, the sign of the SBP estimate became negative when a variable representing obesity was included. In terms of other medical checkup items, while LDL is considered the “bad” cholesterol, it reduced medical expenditures. Conclusion: Our results did not support the new 2017 ACC/AHA guideline for SBP. A wide and careful range of reviews not only for heart diseases but also for other disease types will be absolutely necessary. New studies to verify the guideline should also be conducted. Limitations: The dataset was observatory, the sample period only 3 years, and we could not complete a time-series analysis of individuals.

The impact of pharmaceutical interventions on the rational use of proton pump inhibitors in a Chinese hospital.

BackgroundThe prescriptions of proton pump inhibitors (PPIs) have raised concern due to both huge increase in medical expenditure and the possible long-term adverse events caused by them; therefore, an approach to taper off the irrational use of PPIs by patients is clinically warranted. The aim of this study was to evaluate the impact of pharmaceutical interventions on the rational use of PPIs.Patients and methodsA single-center, pre- to post-intervention study (pharmaceutical interventions group and control group) was performed in a Chinese hospital. Pharmaceutical interventions were performed in the post-intervention group, including educative group activities, real-time monitoring of clinical records and making recommendations to doctors on PPI prescriptions based on the criteria set at the beginning of the study. The number of patients with rational indication, the accuracy rate of administration route, the duration of therapy and the changes in total PPI costs, mean PPI costs, mean total drug costs and mean hospitalization costs were the main outcome measures.ResultsA total of 285 patients were included in the study. After 6 months of interventions, significant improvements in the number of patients with rational indication were found (96.5% in the pharmaceutical interventions group vs 71.8% in the control group, P<0.01). The accuracy rate of administration route was increased (99.3% vs 73.2%, P<0.05), while the duration of therapy was decreased (7.9±0.5 vs 14.3±0.8, P<0.01). Pharmaceutical interventions led to significant reductions in mean PPIs costs, mean total drug costs and mean hospitalization costs (P<0.001).ConclusionThis study provides important evidence on the beneficial effect of pharmaceutical interventions on enhancing the rational use of PPIs and substantial cost saving by increasing the number of patients with rational indication and reducing the risk for long-term adverse events.

Telehealth electronic monitoring to reduce postdischarge complications and surgical site infections after arterial revascularization with groin incision

It is intuitive that postdischarge surgical complications are associated with increased patient dissatisfaction, and are directly associated with an increase in medical expenditures. It is also easy to make the connection that many post-hospital discharge surgical complications, including surgical site infections (SSIs), could be influenced or exacerbated by patient comorbidities. The authors of a recent study reported that female gender, obesity, diabetes, smoking, hypertension, coronary artery disease, critical limb ischemia, chronic obstructive pulmonary disease, dyspnea, and neurologic disease were significant predictors of SSIs after vascular reconstruction was performed. The main concern for optimal patient care, especially in geographically isolated areas of West Virginia, is to have early, expeditious, and prompt diagnosis of complications and SSI. This adjunct to existing approaches could lead to improved outcomes and patient satisfaction, minimizing third-party interventions and decreasing the total cost of care. It seems reasonable to believe that monitoring using telehealth technology and managing the general health care of patients after a hospital vascular intervention will improve overall health and reduce 30-day readmissions and SSIs.

Development of Community Health Care Networks Utilizing Local Community Centers

Objectives: Japan is expected to become the first super-aging society in the world, and the collapse of the Japanese health care system is becoming a real possibility, due to the aging of the society combined with a significant increase in medical expenditure.

New cooperative medical scheme decreased financial burden but expanded the gap of income-related inequity: evidence from three provinces in rural China.

BackgroundSubsidizing healthcare costs through insurance schemes is crucial to overcome financial barriers to health care and to avoid high medical expenditures for patients in China. The health insurance could decrease financial risk by less out-of-pocket (OOP) payment, but not promise the protection equity. With the growth of New Cooperative Medical Scheme (NCMS) financing and coverage since 2008, the protection effectiveness and equity of the modified NCMS policies on financial burden should be further evaluated.MethodsA cross-sectional household survey was conducted in Zhejiang, Hubei, and Chongqing provinces by multi-stage stratified random sampling in 2011. A total of 1,525 households covered by the NCMS were analyzed. The protection effectiveness and protection equity of NCMS was analyzed by comparing the changes in health care utilization and medical expenditures, and the changes in the prevalence of catastrophic health expenditure (CHE) and its concentration indices (CIs) between pre- and post-NCMS reimbursement, respectively.ResultsThe medical financial burden was still remarkably high for the low income rural residents in China due to high OOP payment, even after NCMS reimbursement. In Hubei province, the OOP payment of the poorest quintile was almost same as their households’ annual expenditures. Even it was higher than their annual expenditures in Chongqing municipality. Effective reimbursement ratio of both outpatient and inpatient services were far lower than nominal reimbursement ratio originally designed by NCMS plans. After NCMS reimbursement, the prevalence of CHE was considerably high in all three provinces, and the absolute values of CIs were even higher than those before reimbursement, indicating the inequity exaggerated.ConclusionPolicymakers should further modify NCMS policy in rural China. The high OOP payment could be decreased by expanding the drug list and check directory for benefit package of NCMS to minimize the gap between nominal reimbursement ratio and effective reimbursement ratio. And the increase in medical expenditures should be controlled by monitoring excess demand from both medical service providers and patients, and changing fee-for-service payment for providers to a prospective payment system. Service accessibility and affordability for vulnerable rural residents should be protected by modifying regressive financing in NCMS, and by providing extra financial aid and reimbursement from government.

Economic vulnerability to health shocks and coping strategies: evidence from Andhra Pradesh, India.

Empirical research has shown that households in developing countries are unable to sustain current levels of consumption during and after severe health crises due to substantial increase in medical expenditure and/or loss of income. Health events are also found to have an adverse impact on nutritional status and educational attainment of household members. Thus, in this study, we investigate: who are vulnerable to welfare loss from health shocks, what are the household responses to cope with the economic burden of health shocks and if policy responses like state health insurance schemes are effective in reducing the economic vulnerability. We use self-reported measures of health shocks and coping strategies from the longitudinal survey of the ongoing Young Lives project in India [Andhra Pradesh (AP)] to identify the characteristics of vulnerable groups and perform three-level random intercept logistic regression that takes into account contextual or environmental factors. What emerges is socioeconomic status of household (determined by education, wealth, occupation and caste/religious group) and its demographic characteristics like gender of the household head and proportion of elderly and disabled members matter for outcomes related to health events. Households adopt different strategies to cope with the economic costs of ill-health; borrowing is the most widely used strategy. For credit, majority of households rely on informal sources (moneylenders, friends, relatives, etc.) and have little or no access to formal sources. However, health shock to main breadwinner leads to households adopting costly strategies like reducing consumption or sending children to work. We found no evidence that the state health insurance scheme reduced the household welfare loss from health shocks and their coping strategies. The results suggest that health insurance schemes have to be complemented with access to micro-credit and social security schemes for self-employed persons/workers in informal sector to reduce the economic burden faced by households due to health shocks.

Association between periodontitis and medical expenditure in older adults: A 33-month follow-up study.

Along with rapid aging, medical expenditure for older adults has been increasing in Japan. Research has shown that periodontitis is a useful predictor for excess medical expenditure; however, limited information is available on the elderly population after adequately considering confounding factors. The aim of the present study was to evaluate the association between periodontitis and long-term medical expenditure in elderly Japanese. Baseline health and periodontal examinations were carried out in June 2008. Japanese adults (n = 245) aged 80 years were classified into quartiles based on periodontal inflamed surface area (PISA), which quantifies the degree of periodontal inflammation. Medical care use and costs were monitored by assessment of the National Health Insurance claim files from the baseline survey through the end of February 2011. Multivariable analysis of the differences in medical expenditure among PISA quartiles was carried out using linear regression with robust standard errors. The participants in the fourth (with the largest PISA) and third quartiles had significantly higher inpatient medical expenditure compared with those of the first quartile (P < 0.01 and = 0.04, respectively). Participants in the fourth quartile had significantly higher total medical expenditure (P < 0.01) compared with the first quartile. A trend was observed of higher inpatient and total medical expenditure with increasing PISA. A significant association was found between periodontitis and future increase in medical expenditure, suggesting that periodontitis might be a modifiable factor for the reduction of excess medical expenditure among elderly Japanese. Geriatr Gerontol Int 2016; 16: 856-864.

Should Health Care Systems Become Insurers?

Incentives under the Affordable Care Act are making more health care systems assume the risk of paying for patient care, making boundaries between care delivery organizations and insurers less clear-cut. Bundled payments, value-based purchasing, and accountable care organizations transfer financial risk from payers to health care systems. The goal of health care systems that adopt risk contracts is to contain costs due to the increase in financial pressures as Medicaid expands and reimbursements for Medicare and fee-for-service care shrink. Accountable care organization contracts have shown promise in slowing the increase in medical expenditures for public and private payers. Some health care systems hold ownership in an associated health plan, with increasing numbers of systems developing new ways of engaging with health plans. Physicians and hospitals must distinguish between different types of arrangements. A full ownership partnership encompasses joint governance between the insurance plan and health care system; all participants in the plan receive care from the associated health system. In partial ownership, the health care system owns a stake in the insurer, but governance and care relationships are not totally overlapping. In a partnership, the formal relationship with the insurance plan preferentially refers patients to the health care system, and the system enters into risk contracts for the patients. Finally, in contractual arrangements, health systems enter into risk-bearing contracts with insurance plans for specific patient populations. For health systems that assume risk, the arrangement drives integration, such that most of a patient’s health care needs and associated payments are addressed by a single network, allowing care to be better coordinated. Care provided outside the network is paid for by the insurer. Cost savings are generated by decreasing volume-based incentives in fee-for-service payment systems that can create overuse. Linking health care systems and payers can also overcome a lack of price transparency. One challenge is whether health care system–insurer partnerships will conflict with existing state and federal regulations designed to maintain a competitive marketplace. These include antitrust regulations, bans on the corporate practice of medicine, and prohibitions on fee-splitting. Another concern is that the health care system and insurers do not necessarily have the same goals and human resources. Merging these models will require significant investments of energy and capital that may distract from core activities. In addition, most health systems are ill-equipped to handle the complex operations of the insurance business. Systems must maintain adequate capital reserves to be a financially viable health plan. Therefore, health systems must be more judicious about assuming risk and managing population health and costs. Successful partnerships between health care systems and insurers will require certain components. (1) The integrated arrangement must rest on a foundation of high-functioning primary health care. (2) It must incorporate system-wide processes for quality improvement. (3) It must engage patients with outreach initiatives for disease self-management and preventive care. (4) Systems must be able to manage costs of care. With care delivery transformation as the ultimate goal, the leaders of health systems must nurture and build on momentum in a sustainable way.

The preoperative and intraoperative risk factors for early postoperative mechanical ventilation after scoliosis surgery: A retrospective study.

Background:Patients undergoing corrective surgery for scoliosis of spine are commonly ventilated in our institute after the operation. Postoperative mechanical ventilation (PMV) and subsequent prolongation of intensive care unit stay are associated with increase in medical expenditure and complications such as ventilator-associated pneumonia. Identification of factors which may contribute to PMV and their modification may help in allocation of resources effectively. The present study was performed to identify preoperative and intraoperative factors associated with early PMV after scoliosis surgery.Methods:One hundred and two consecutive patients who underwent operation for scoliosis correction between January 2006 to July 2011 were reviewed retrospectively. Patients requiring PMV included patients who were not extubated in the operating room and were continued on mechanical ventilation. Preoperative and intraoperative factors which were analysed included age, gender, weight, cardiorespiratory function, presence of kyphosis, number and level of vertebrae involved, surgical approach, whether thoracoplasty was done, duration of surgery, blood loss, fluids and blood transfused, hypothermia and use of antifibrinolytics.Results:The average age of the patients was 14.31±3.78 years with female preponderance (57.8%). Univariate analysis found that longer fusions of vertebrae (more than 8), blood loss, amount of crystalloids infused, blood transfused and hypothermia were significantly associated with PMV (P<0.05). Independent risk factors for PMV were longer fusion (Odds Ratio (OR), 1.290; 95% confidence interval (CI), 1.038-1.604) and hypothermia (OR, 0.096; 95% CI, 0.036-0.254; P<0.05).Conclusion:The authors identified that longer fusions and hypothermia were independent risk factors for early PMV. Implementation of measures to prevent hypothermia may result in decrease in PMV.