Percent Of Health Care Expenditures Research Articles

The eye health system and social influence on health decision making − An example from couching in Nasarawa State, Nigeria

Introduction: The health systems assessment approach is applied to eye health to assess its readiness to meet the goals of the global action plan for eye care. The overall blindness prevalence in Nigeria is 0.78% (1.17 million people are blind of which 84% is avoidable). Cataract accounts for 43% of blindness. With a surgical rate of 300/million/year, couching is still being undertaken with 42.7% of eyes that had cataract treatment having been couched. Aims: This study assesses the eye health system of Nasarawa State, Nigeria and to find out why couching is still being practiced. Settings and Design: A mixed qualitative and quantitative method was used. Subjects and Methods: Questionnaires and interview guidelines were adapted from the International Agency for Prevention of Blindness/Eye Health Systems Assessment manuals. Health systems building blocks of governance, finance, human resources and service delivery along with traditional system were assessed, and their strengths and weaknesses were identified. Results: Eighteen interviews were conducted. There is no eye care coordinator to supervise eye care functions in the state. Eye care is not separately financed from the general healthcare. Seventy percent of healthcare expenditure is from out-of-pocket payments. There are enough but inequitably distributed eye care workers to meet the recommendations of vision 2020 for the population. The cataract surgical rate is less than 200/million/year and less than 100 surgeries/surgeon/year. Couching is encouraged through strong community influence despite the poor visual outcome. Conclusion: The Nasarawa State eye health system has the resources to meet the eye care demands of the population; however, it lacks co-ordination, and ineffective service delivery makes the surgical output low, thereby encouraging couching.

Sleep Disordered Breathing and Heart Failure and the Role of Pacing and Cardiac Resynchronization Therapy

At least 20% of hospital admissions among persons older than 65 are due to heart failure (HF).1 In 1993, there were 875,000 hospitalizations in the United States with the first listed discharge diagnosis as HF, and about 2.5 million had it listed as an associated condition.2 Approximately 60 percent of health care expenditures for HF were for hospital care. There were three million office visits annually for HF at a cost of 3 billion dollars per year. Despite the advances of pharmacological therapies, revascularization procedures, device therapies and meticulous cardiac surgical techniques in the last decade, the short and long term mortality of this condition remains high. In the population based sample from the Framingham Heart Study, the one year mortality among men and women was 28 percent and 24 percent and five year mortality was 59 percent in men and 45 percent in women respectively.3 Unfortunately, much of our understanding and management of heart failure have been focused on while the patient is awake. Relatively little attention is paid to the pathophysiological sequelae of heart failure that occur nocturnally. "Nocturnal" management of heart failure may have an important impact. The purpose of this article is to review the pathogenesis and management of heart failure through management of sleep related breathing disorder.

Family Therapy Meets Internal Medicine: Innovations in Medical Family Therapy

This article describes a growing area of the field of marriage and family that is termed family therapy or family health In short, this area involves collaborative approaches to health care in which health care providers and marriage and family therapists or other family-oriented mental health professionals work together to provide an integrated, biopsychosocial approach to care that actively considers and engages the patient's family or support system in the treatment process.Review of LiteratureMedical family or collaborative family health care has been billed as the next frontier of marriage and family (Bloch, 1992). Medical family involves collaboration among family therapists and health care providers who, in more integrated collaborative models, may be practicing in the same facility. This interest in coordinated care has developed in the context of a call for more cost-effective and innovative approaches to health care (McDaniel, Hepworth & Doherty, 1992; Patterson, Peek, Heinrich, Bischoff, & Scherger, 2002). Four factors have contributed to the interest in collaborative approaches:* First, an enormous number of mental health problems are presented in medical settings, particularly in primary care. Up to 40 percent of primary care patients have a diagnosable mental disorder, and one-half to two-thirds of those meeting criteria for a mental disorder go unrecognized (deGruy, 1997).* Second, a small percentage (10%) of patients, termed utilizers, accounts for 40 to 60 percent of health care expenditures. Half of these high utilizers have psychiatric diagnoses, such as depression or somatization disorder, and frequently have a history of abuse or neglect (Seaburn, Lorenz, Gunn, Gawinski, & Mauksch, 1996). These high utilizers often are not amenable to a traditional biomedical approach and demand expensive diagnostic procedures that often are unable to detect any observable biomedical cause for their complaints.* Third, shorter hospital stays and increasing use of outpatient surgery have led to family members taking on greater burdens of health care in the home (McDaniel et al., 1992). Thus, family members are providing significant amounts of informal health care but are infrequently actively involved in the treatment process by medical providers.* Fourth, advances in health care and prescription medications have meant more focus on chronic illness and lifestyle issues, which often can be greatly influenced by family dynamics and relationships (Campbell, 2003; Rolland, 1994).Active family involvement can play a significant role in improving treatment adherence over the course of chronic illnesses. In each of these four areas, one can see how the addition of a mental health professional, such as a marriage and family therapist working alongside medical providers, would serve to enhance the overall health care services for patients and their family members.Given these four factors, family therapists have much to offer health care providers in addressing some of the more difficult and frustrating aspects of their work (Bischof, 1996). For example, issues of noncompliance with medical treatment and difficulties altering destructive health behaviors such as cigarette smoking or overeating may be understood more clearly as the family system and patient or family beliefs are investigated by the family therapist. Research in the area of compliance or adherence with medical treatment recommendations reveals that only one-third of patients correctly follow physicians' directives, and approximately half of patients are not taking medications as prescribed (Ekstrand & Chesney, 2002). It has been suggested that noncompliance may be related to the power differential between the physician and patient and that patients may not feel their problems have been adequately listened to or understood or do not fully understand the rationale for the recommended plan of treatment. …

Economic Grand Rounds: Trends in Managed Care, 2000 Edition

Economic Grand Rounds: Trends in Managed Care, 2000 Edition

Sex differences in the use of health care services.

Sex differences in the use of health care services can be substantial at several stages of life. However, the extent to which differences in reproductive biology and mortality affect the use of health care services is unclear. We studied age- and sex-specific per capita use of health care resources for a one-year period during 1994 and 1995 in the Canadian province of Manitoba, where there is universal insurance for a comprehensive range of health care services. Using information obtained from administrative records of physicians' services and acute hospital care, we tabulated the use of health care resources by male and female subjects in three categories: care for conditions specific to sex, care provided to persons who died during the study year, and care provided for all other conditions. The crude annual per capita use of health care resources (in Canadian dollars) was greater for female subjects ($1,164) than for male subjects ($918). Approximately 22 percent of health care expenditures for female subjects was associated with conditions specific to sex, including pregnancy and childbirth, as compared with 3 percent of expenditures for male subjects. An estimated 14 percent of health care expenditures for male subjects was consumed by persons who died during the study period, as compared with 10 percent of expenditures for female subjects. After adjustment for the use of health care associated with sex-specific conditions and differences in mortality, the female:male ratio in health care expenditures was reduced from 1.3 to 1.0. Expenditures for health care are similar for male and female subjects after differences in reproductive biology and higher age-specific mortality rates among men have been accounted for.

Justice and the Economics of Terminal Illness

Justice and the Economics of Terminal Illness The costs of medical care have reached a level that can no longer be ignored: $1.25 billion a day in the United States. The expenditures for health care as a proportion of GNP are now almost 11 percent. [1] Insurance planners, government officials, labor leaders responsible for health care benefit plans, as well as ordinary citizens, have recently confronted the question of whether it is acceptable to limit health care based on economic considerations, especially as some of the most expensive care is at best only useful or even useless. The most obvious area to impose such limits is health care for the terminally ill. Terminal illness can be defined as illness in which, on the basis of the best available diagnostic criteria and in light of available therapies, a reasonable estimation can be made prospectively and with a high probability that a person will die within a relatively short time. [2] Enormous amounts are spent for heroic interventions on patients who die soon after receiving treatment. Indeed, between 20 and 30 percent of health care expenditures are devoted to the terminally ill. [3] Ethical questions about the legitimacy of using economic considerations for deciding about the provision of such care are sure to become crucial. Conceptual and ethical clarity is required in addressing the ethics of the economics of care for the terminally ill. Conceptual analysis alone reveals two separate issues, one of which presents no serious ethical problem, while the other poses an enormous ethical dilemma. Useless Versus Marginally Beneficial Care An initial distinction must be made between care that is of no benfit at all to a patient, and marginally beneficial that is beneficial but not very helpful relative to the social and economic costs involved. Useless Care. Some may hold that whether a given treatment is useless should be determined by a clinician or a consensus of medical professionals. It is more appropriate, however, to define it with reference to the patient's perspective: Useless care offers no net benefit for the patient, given the patient's value system and concept of benefit. Useless care is really undesired care. Not much is known about the dynamics of useless care. Its extent and its proportion relative to total care for the terminally ill or to total expendable care are unclear. Physicians who fear litigation may provide such care. If so, the law may need to be changed so that physicians will not have to practice defensive medicine. However, it is more likely that the law does not require the provision of useless care and that the real problem is that physicians have unreasonable fears about their legal jeopardy, which may be remedies by education. No rational person would want care that was perceived as useless or of zero net benefit. If patients or their agents are actively trying to refuse such care, its provision is a violation of the ethical principle of autonomy and the legal requirement that patients' bodies not be invaded against their consent. If the patient would refuse the care if only he or she knew that it served no purpose supported by his or her values, such treatment is prima facie a violation of autonomy and informed consent (even though the appearance of consent may be present in a signed form). In determining the appropriate relationship of ethics and economics in decisions about care for the terminally ill, it is important to consider some guidelines for policy formation. These guidelines might be used by health insurance planners, any future national health insurance or service, health maintenance organizations, and professional review organizations. The notion of useless care suggests the following guideline: Care judged by the competent patient (or the legal agent for the competent patient within the limits of reason) to have no benefit or care provided without a valid consent should not be covered under health insurance and should not be reimbursable. …

Commentary: Clinical laboratory information systems

Clinical laboratory testing accounts for over eight percent of health care expenditures in the U.S. The use of computer technology has led to improved analytical instrumentation as well as to data acquisition and data management systems. Clinical laboratory, information systems have demonstrated their ability to reduce clerical and technical labor costs while providing more accurate and readable reports to the physician. The majority of systems currently operating were developed by commercial systems houses, and costs can range from under $100 000 to over $1 000 000. A major challenge is the use of such systems for the collection and analysis of large databases for clinical research.