Unit Expenditures Research Articles

The Efficacy of Caudal Anesthesia in Pediatric Surgery

Background: Despite a long history of safety, spinal anesthesia (SA) is still seldom used outside of specialist pediatric institutions and is sometimes debated as a primary anesthetic approach for children. To lessen the risk of postoperative apnea, it is often used on previously preterm newborns who have not yet reached viability (60 weeks post- conception) (GA). There is, however, a wealth of evidence indicating its safety and effectiveness for appropriate operations in adolescents. Objective: The primary purpose of this investigation is to assess the efficacy of Caudal anesthesia pediatric surgery. Method: Tertiary care hospital was the setting for this prospective investigation. 200 children, ages 4 to 10, were included in the research because they were all given different types of anesthesia for infraumbilical or lower extremities surgery during the study's 1-year time frame. The research participants had a thorough preoperative assessment. During the study 50 patients of each were given different anesthesia including Endotracheal intubation, LMA, Caudal block and local anesthesia. Results: Majority was belonged to 4-6 years age group, 70% and 60% were male. Plus, majority of the patients were undergone circumcision, 35% and Herniorrhaphy, 28%. Followed by 20% undergone appendectomy and 5% undergone hypospadias repair. Besides, anesthesia induction and recovery on the operating room table, was lowest in the local anesthesia group (P = 0.015), whereas the results were comparable in the other groups. However, patients with caudal and local anesthesia spent significantly less time in the postoperative recovery unit (P < 0.001). In fact, patients who got Caudal block had less complication where only 1% had Convulsions, Bloody puncture and vomiting. Conclusion: Caudal anesthesia as a sole method for pediatric subumbilical surgery is a relatively safe method. Patients having operation under caudal anesthesia have faster discharge times from postoperative recovery units, compared with general anesthesia. This probably reduces recovery unit expenditures.

Making voluntary medical male circumcision services sustainable: Findings from Kenya's pilot models, baseline and year 1.

Voluntary medical male circumcision is a crucial HIV prevention program for men in sub-Saharan Africa. Kenya is one of the first countries to achieve high population coverage and seek to transition the program to a more sustainable structure designed to maintain coverage while making all aspects of service provision domestically owned and implemented. Using pre-defined metrics, we created and evaluated three models of circumcision service delivery (static, mobile and mixed) to identify which had potential for sustaining high circumcision coverage among 10-14-year-olds group, a historically high-demand and accessible age group, at the lowest possible cost. We implemented each model in two distinct geographic areas, one in Siaya and the other in Migori county, and assessed multiple aspects of each model’s sustainability. These included numerical achievements against targets designed to reach 80% coverage over two years; quantitative expenditure outcomes including unit expenditure plus its primary drivers; and qualitative community perception of program quality and sustainability based on Likert scale. Outcome values at baseline were compared with those for year one of model implementation using bivariate linear regression, unpaired t-tests and Wilcoxon rank tests as appropriate. Across models, numerical target achievement ranged from 45–140%, with the mixed models performing best in both counties. Unit expenditures varied from approximately $57 in both countries at baseline to $44-$124 in year 1, with the lowest values in the mixed and static models. Mean key informant perception scores generally rose significantly from baseline to year 1, with a notable drop in the area of community engagement. Consistently low scores were in the aspects of domestic financing for service provision. Sustainability-focused circumcision service delivery models can successfully achieve target volumes at lower unit expenditures than existing models, but strategies for domestic financing remain a crucial challenge to address for long-term maintenance of the program.

Disparities in end-of-life care, expenditures, and place of death by health insurance among cancer patients in China: a population-based, retrospective study

BackgroundDisparities in the utilization, expenditures, and quality of care by insurance types have been well documented. Such comparisons have yet to be investigated in end-of-life (EOL) settings in China, where public insurance covers over 95% of the Chinese population. This study examined the associations between health insurance and EOL care in the last six months of life: outpatient visits, emergency department (ED) visits, inpatient services, intensive care unit (ICU) admissions, expenditures, and place of death among the cancer patients.MethodsA total of 398 patients diagnosed with cancer who survived more than 6 months after diagnosis and died from July 2015 to June 2017 in urban Yichang, China, were included. Descriptive analysis and multivariate regression models were used to investigate the bivariate and independent associations, respectively, between health insurance with EOL healthcare utilization, expenditures and place of death.ResultsUrban Employee Basic Medical Insurance (UEBMI) beneficiaries visited EDs more frequently than Urban Resident-based Basic Medical Insurance (URBMI) and New Rural Cooperative Medical Scheme (NRCMS) beneficiaries (marginal effects [95% Confidence Interval]: 2.15 [1.81–2.48] and 1.92 [1.59–2.26], respectively). NRCMS and UEBMI beneficiaries had more hospitalizations than URBMI beneficiaries (1.01 [0.38–1.64] and 0.71 [0.20–1.22], respectively). Compared to URBMI beneficiaries, NRCMS beneficiaries and UEBMI beneficiaries had ¥15,722 and ¥43,241 higher expenditures. Similarly, UEBMI beneficiaries were most likely to die in hospitals, followed by NRCMS (UEBMI vs. NRCMS: 0.23 [0.11–0.36]) and URBMI (UEBMI vs. URBMI: 0.67 [0.57–0.78]) beneficiaries.ConclusionsThe disproportionately lower utilization of EOL care among NRCMS and URBMI beneficiaries, compared to UEBMI beneficiaries, raised concerns regarding quality of EOL care and financial burdens of NRCMS and URBMI beneficiaries. Purposive hospice care intervention might be warranted to address EOL care for these beneficiaries in China.

PCN251 DISPARITIES IN END-OF-LIFE CARE BY HEALTH INSURANCE AMONG CANCER PATIENTS IN CHINA: A POPULATION-BASED, RETROSPECTIVE STUDY

Disparities in the utilization, expenditures, and quality of care by insurance type have been well documented. Such comparisons have yet investigated in the end-of-life (EOL) settings in China where public insurance covers over 95% of the Chinese population. This study examined the associations between health insurance and EOL care in the last six months of life: outpatient services, emergency department (ED) visit, inpatient services, intensive care unit (ICU) admissions, expenditures, and place of death. A population-based retrospective study of 398 patients diagnosed with cancer, survived more than 6 months after diagnosis, and died from July 2015 to June 2017 in urban Yichang, China. Descriptive analysis and multivariate regressions were used to investigate the bivariate and independent associations, respectively, of health insurance with EOL healthcare utilization, expenditures and place of death. Urban Employee Basic Medical Insurance (UEBMI) beneficiaries visited EDs more frequently than Urban Resident-based Basic Medical Insurance (URBMI) and New Rural Cooperative Medical Scheme (NRCMS) beneficiaries (marginal effects [95% Confidence Interval]: 2.51 [1.49-2.81] and 1.92 [1.24-2.60], respectively). NRCMS and UEBMI beneficiaries had more hospitalizations than URBMI beneficiaries (1.04 [0.25-1.94] and 0.73 [0.11-1.36], respectively). Compared to URBMI beneficiaries, NRCMS beneficiaries and UEBMI beneficiaries had ¥16,001 and ¥44,002 higher expenditures. Similarly, UEBMI beneficiaries were the most likely to die at hospitals, followed by NRCMS (UEBMI vs. NRCMS: 0.27 [0.07-0.47]) and URBMI (UEBMI vs. URBMI: 0.72 [0.58-0.86]) beneficiaries. The disproportionately higher utilizations of EOL care among NRCMS and URBMI beneficiaries, compared to UEBMI beneficiaries, raised concerns regarding quality of EOL care and financial burdens of NRCMS and URBMI beneficiaries. Targeted hospice care intervention might be warranted to address EOL care for these beneficiaries in China.

Caudal Anesthesia for Pediatric Subumbilical Surgery, Less Load on the Postoperative Recovery Unit.

IntroductionCaudal epidural anesthesia, when used as a sole method for surgical anesthesia, has favorable effects on the recovery duration and the time spent in the recovery unit. In this study we made a retrospective analysis of pediatric surgery operations under local, regional and general anesthesia. We aimed to find shorter postoperative recovery times with local and regional anesthesia.Materials and methodsData of the pediatric patients undergone subumbilical surgery during the two-year period in Pediatric Surgery clinic were collected. The patients’ age, sex, surgery type, anesthesia and airway control routes, as well as duration of anesthesia, operation and recovery were obtained.ResultsData of 937 patients were analyzed, of whom 811 (86.6%) were males. Caudal anesthesia was performed in 240 patients (25.6%) and the mean age of these patients was 3.83 ± 3.00 years. The patients with caudal and local anesthesia spent significantly less time in the postoperative recovery unit, compared with general anesthesia groups (P < 0.001).ConclusionCaudal anesthesia as a sole method for pediatric subumbilical surgery is a relatively safe method. Patients having operation under caudal anesthesia have faster discharge times from postoperative recovery units, compared with general anesthesia. This probably reduces recovery unit expenditures.

Analysis of US Claims Real World Data of Hemophilia a & B Patients: Units Dispensed & Expenditures Associated with Utilization of and Switching from Standard to Extended Half-Life Factor Products

Background:Both standard half-life (SHL) and extended half-life (EHL) factor replacement products are used to treat patients with hemophilia A (hem-A) and B (hem-B). A comparison of international unit (IU) utilization and expenditures ($USD) was made between patients on SHL and EHL factor replacement products to compare utilization and to determine the impact of switching from an SHL to an EHL product.Methods:De-identified claims data from both the Truven Health MarketScan® Research (Truven) and Optum® Clinformatics® (Optum) US claims databases included male patients with hem-A (Truven from Aug 2014-Apr 2018 and Optum from Aug 2014-Dec 2017) and hem-B (Truven from Jun 2014-Apr 2018 and Optum from Jul 2014-Dec 2017) who had data for at least 3 months of product dispensation. The SHL and EHL groups were compared. A separate “switch” analysis using the Truven database examined expenditures and IUs before and after switching from nonacog-α (SHL) to FIX-Fc (EHL). Descriptive statistics were used and medians reported for expenditures and IUs to accommodate for the skewness of data distribution.Results:Hem-A: The analysis included 896 SHL and 202 EHL patients, including those who switched from an SHL to an EHL product. Quarterly expenditures and IUs dispensed were analyzed. Both the Optum and Truven databases (see Table) demonstrated higher IU dispensation (Optum: 35%, Truven: 50% higher) and expenditures (Optum: 87%, Truven: 117%) associated with EHL products versus SHL products. In the switch analysis, 35 patients switched from nonacog-α to FIX-Fc; median IUs rose from 61,228 to 75,914 [24%] and median expenditures rose from $78,945 to $155,203 [97%].Hem-B: The analysis included 50 FIX-Fc, 13 FIX-Alb, and 132 nonacog-α patients. Both databases (see Table) demonstrated higher median expenditures for the EHL products compared with nonacog-α (Optum: 179% for FIX-Fc, 189% for FIX-Alb; Truven: 234% for FIX-Fc, 245% for FIX-Alb). The IU results varied in Optum: FIX-Fc was 23% higher than nonacog-α, but FIX-Alb was 9 % lower than nonacog-α. Similarly, in Truven, the IU results varied: IUs were mixed for the SHL product compared with the EHL products: 62% higher for FIX-Fc than nonacog-α, and approximately the same for FIX-Alb and nonacog-α. In the switch analysis, 16 patients switched from nonacog-α to FIX-Fc; median IUs rose from 62,857 (nonacog-α) to 69,816 (FIX-Fc) [11%], while expenditures rose from $75,064 (nonacog-a) to $210,482 (FIX-Fc) [180%].Conclusions:This analysis in more than 1000 patients, unadjusted for severity of disease or treatment scheme, demonstrated in hem-A that higher IU utilization and expenditures were associated with EHL use compared with SHL use, and in hem-B, that higher expenditures were seen with EHL products, while IU dispensation in some cases decreased, remained the same, or increased. In patients switching from the SHL to an EHL product, higher IU dispensation and expenditures were seen. These real-world data may challenge assumptions regarding typical factor usage and expenditures associated with EHL products in patients with hem-A and hem-B. Additional analyses with adjustment for treatment scheme and disease severity are needed. [Display omitted] DisclosuresTortella:Pfizer Inc.: Employment. Chhabra:Pfizer Inc.: Employment. Alvir:Pfizer Inc.: Employment. Rubinstein:Pfizer Inc.: Employment. Young:Pfizer Ltd.: Employment. Fogarty:Pfizer Inc.: Employment.

Leveraging existing program data for routine efficiency measurement in Zambia.

Rationale: As donor contributions for HIV/AIDS stagnate globally, national governments must seek ways to improve use of existing resources through interventions to drive efficiency at the facility level. But program managers lack routine information on unit expenditures at points of care, and higher-level planners are unable to assess resource use in the health system. Thus, managers cannot measure current levels of technical efficiency, and are unable to evaluate effectiveness of interventions to increase technical efficiency. Phased Implementation of REMS: FHI 360 developed the Routine Efficiency Monitoring System (REMS)-a relational database leveraging existing budget, expenditure and output data to produce quarterly site-level estimates of unit expenditure per service. Along with the Government of the Republic of Zambia (GRZ) and implementation partner Avencion, we configured REMS to measure technical efficiency of Ministry of Health resources used to deliver HIV/AIDS services in 326 facilities in 17 high-priority districts in Copperbelt and Central Provinces. REMS allocation algorithms were developed through facility assessments, and key informant interviews with MoH staff. Existing IFMIS and DHIS-2 data streams provide recurring flows of expenditure and output data needed to estimate service-specific unit expenditures. Trained users access REMS output through user-friendly dashboards delivered through a web-based application. REMS as a Solution: District health managers use REMS to identify "outlier" facilities to test performance improvement interventions. Provincial and national planners are using REMS to seek savings and ensure that resources are directed to geographic and programmatic areas with highest need. REMS can support reimbursement for social health insurance and provide time-series data on facility-level costs for modeling. Conclusions and Next Steps: REMS gives managers and planners substantially-improved data on how programs transform resources into services. The GRZ is seeking funding to expand REMS nationally, covering all major disease areas. Improved technical efficiency supports the goal of a sustainable HIV/AIDS response.

The Impact Availability of the Components of Internal Auditing By Adding Value in Government Units in Iraq

This study aims to identify the concept of adding value, the role of internal auditing in adding value and its location in the value chain, and identifying stakeholders, the internal audit components for their addition, its adding value activities, and the indicators needed to determine the expectations of stakeholders in the value of internal audit activities. In order to reach the objectives, the study presented a theoretical presentation and a questionnaire was prepared for the opinions of 78 employees of internal audit units, public administrations, supervision bodies and academics specialized in accounting and auditing. The study found that the internal audit components for adding value in government units are efficiency and quality. Assurance, insight, objectivity. Internal auditing has a number of value-adding activities: identifying areas of spending reduction, reducing fraud and Manipulation, increase the reputation of the unit, paying attention to stakeholders’ satisfaction and expectations, improving information communication. There is a correlation between these components and the internal audit activities value-adding as well as their positive impact in adding value. And the measures of adding value: the growth rate in the Employees training and information technology expenses, the percentage applied from the internal audit recommendations, the percentage of the decrease in irregularities discovered by the SAIs, Stakeholder satisfaction ratio, percentage of tasks implemented/ planned, Percentage of the amount of violations measured to annual expenditure, Number of times support requested by SAIs, The growth in the number of annual reports, the number of requests received for the perform of auditing tasks, the amount of reduction in proposed expenditures relative to annual unit expenditures, percentage of The amount of reduction in the proposed expenditures To the annual unit expenses. The study made several recommendations, the most important of which is the need to establish local internal auditing standards, Mechanisms for employment and rotation of staff in internal audit units, attention by training them on the use of modern technologies, subordinated to periodic tests, work to achieve independence by making them administratively linked to the provincial treasuries, Adoption of measures of adding v alue in internal audit and executive management evaluation.

Leveraging existing program data for routine efficiency measurement in Zambia

Background: As donor contributions for HIV/AIDS stagnate globally, national governments must seek ways to improve use of existing resources through interventions to drive efficiency at the facility level. But program managers lack routinely available information on unit expenditures at points of care, and higher-level planners are unable to assess how resources are used throughout the health system. Thus, managers cannot measure current levels of technical efficiency, and are unable to evaluate effectiveness of interventions to increase technical efficiency. Methods: FHI 360 developed the Routine Efficiency Monitoring System (REMS), a relational database that leverages existing budget, expenditure and output data to produce quarterly site-level estimates of unit expenditure per service. Along with the Government of the Republic of Zambia (GRZ) and implementation partner Avencion, we configured REMS to measure technical efficiency of Ministry of Health resources used to deliver HIV/AIDS services in 326 facilities in 17 high-priority districts in Copperbelt and Central Provinces. REMS allocation algorithms were developed through facility assessments and key informant interviews with MoH staff. Existing IFMIS and DHIS-2 data streams provide recurring flows of expenditure and output data needed to estimate service-specific unit expenditures. Trained users access REMS output through user-friendly dashboards delivered through a web-based application. Results: District health management teams are using REMS to identify “outlier” facilities to test performance improvement interventions. Provincial and national planners are using REMS to seek savings and ensure that resources are directed to geographic and programmatic areas with highest need. REMS can support reimbursement for social health insurance and provide time-series data on facility-level costs for modeling purposes. Conclusions: REMS gives managers and planners substantially-improved data on how programs transform resources into services. The GRZ is seeking funding to expand REMS nationally, covering all major disease areas. Improved technical efficiency supports the goal of a sustainable HIV/AIDS response.

PEPFAR’S Past And Future Efforts To Cut Costs, Improve Efficiency, And Increase The Impact Of Global HIV Programs

Amid the global economic crisis, the President's Emergency Plan for AIDS Relief (PEPFAR) and other organizations have been pressed to do more with constrained resources to meet unmet needs in the worldwide HIV/AIDS pandemic. PEPFAR has approached this challenge through the development of an Impact and Efficiency Acceleration Plan, which includes improving the collection and use of economic and financial data, increasing the efficiency of HIV/AIDS program implementation, and collaborating with governments and multilateral organizations to maximize the impact of the resources provided by the United States. For example, by linking financial data with program outputs, PEPFAR was able to help its implementing partners in Mozambique reduce mean unit expenditures for people receiving antiretroviral treatment by 45 percent, from $265 to $145 per person, between 2009 and 2011. This article describes the plan's elements, provides examples of progress and challenges to its implementation, and assesses the prospects for further improvements in efficiency and impact.

Energy conservation in a furnace-mill sheet-rolling system

Energy-saving control of the furnace-mill sheet-rolling system has been developed, with redistribution of the energy between individual components of the system. Optimal control is selected on the basis of the total unit expenditures in heating and rolling the metal. Various energy-saving adjustments of the rolling cells are considered; the corresponding target functions and additional conditions are formulated.

On the adoption of electricity as a domestic source by Mozambican households

In Mozambique, domestic energy is often composed of a mix of sources, primarily used for lighting and cooking, with biomass and kerosene as more common sources. Electrification programs, intended to connect new consumers countrywide, have not significantly contributed either to the intensification of electricity consumption or to the reduction of the use of biomass in households. The choice of energy source is dependent on price and on the capability of the household to invest in energy-consuming appliances. Based on the data from a household survey carried out in Mozambique during 2002/03, this paper analyzes the geographic differences in unit expenditures for domestic energy and finds evidence of an inverted energy ladder with prices of useful energy units. The data show that biomass sources are often more expensive per unit of useful energy than higher-grade sources, supporting arguments favoring electrification as a poverty alleviation strategy. In addition, this study estimates the likelihood of poor households transitioning from biomass to electricity consumption based on various factors. Results indicate that income is not a determining factor in the transition, but wealth and the level of the Primary Energy Consumption Share (PECS) are as important factors as the nature of the energy mix.

Service Use and Cost in 2002 Among Clients in Community Settings Who Were Discharged From a State Hospital in 1989

Service Use and Cost in 2002 Among Clients in Community Settings Who Were Discharged From a State Hospital in 1989

Economies of scale in Danish municipalities: Expenditure effects versus quality effects

A change in the cost structure in the Danish municipalities seems to have occurred bringing in a larger fixed element in the cost function and making unit costs higher in small municipalities than in large. The paper examines the hypothesis that small municipalities in their reaction to their higher unit costs for management make a trade-off between raising expenditures and the tax level, on the one hand, and reducing the quality of the production, on the other. Using accounting data for 1980, 1990 and 2000 it is shown that the expenditure structure has shifted since 1980 so that small municipalities now exhibit higher unit expenditures than larger municipalities. However, there also seems to be a quality substituting effect in the small municipalities as a reaction to the higher unit costs. From data based on a questionnaire to the chief executives in all municipalities indications of weak political and administrative leadership in the small municipalities are demonstrated. We find that population size and administrative capacity explain significant differences in municipal understanding of the consequences of the central government regulation defining the conditions for the local production of services.

The Performance of Administrative and Self‐Reported Measures for Risk Adjustment of Veterans Affairs Expenditures

To evaluate the performance of different prospective risk adjustment models of outpatient, inpatient, and total expenditures of veterans who regularly use Veterans Affairs (VA) primary care. We utilized administrative, survey and expenditure data on 14,449 VA patients enrolled in a randomized trial that gave providers regular patient health assessments. This cohort study compared five administrative data-based, two self-report risk adjusters, and base year expenditures in prospective models. VA outpatient care and nonacute inpatient care expenditures were based on unit expenditures and utilization, while VA expenditures for acute inpatient care were calculated from a Medicare-based inpatient cost function. Risk adjusters for this sample were constructed from diagnosis, medication and self-report data collected during a clinical trial. Model performance was compared using adjusted R2 and predictive ratios. In all expenditure models, administrative-based measures performed better than self-reported measures, which performed better than age and gender. The Diagnosis Cost Groups (DCG) model explained total expenditure variation (R2=7.2 percent) better than other models. Prior outpatient expenditures predicted outpatient expenditures best by far (R2=42 percent). Models with multiple measures improved overall prediction, reduced over-prediction of low expenditure quintiles, and reduced under-prediction in the highest quintile of expenditures. Prediction of VA total expenditures was poor because expenditure variation reflected utilization variation, but not patient severity. Base year expenditures were the best predictor of outpatient expenditures and nearly the best for total expenditures. Models that combined two or more risk adjusters predicted expenditures better than single-measure models, but are more difficult and expensive to apply.

Line-of-Duty Injury or Illness in an Air National Guard Unit

Line-of-duty injuries or illnesses (LODs) suffered by members of Air National Guard units may demonstrate the status of unit safety, unit readiness and deployability, a potentially significant area of unit expenditures, and areas of needed health promotion. This descriptive pilot study was conducted at the unit commander's request to investigate an apparent doubling of the expected number of LODs over a recent quarterly period. Twenty cases were investigated. The vast majority of LODs were musculoskeletal in nature. Decreased fitness level (identified as increased body mass index) among males and increased age were related to increased LODs. Recommendations are given to improve tracking, identify individuals at increased risk, provide pretraining assessment, and institute health promotion focused on musculoskeletal injuries.

Consumer Unit Types and Expenditures on Food Away from Home

This paper explores the relationship between consumer unit type and expenditures on food away from home using microdata from the 1989 Consumer Expenditure Survey. A log‐linear model is used to purge the effects of income and race/ethnicity from the consumer unit type/food‐away‐from‐home expenditure relationship. The income‐and race/ethnicity‐controlled propensities to purchase food away from home among eight consumer unit types are revealed in simple percentage form. These adjusted percentages are discussed in regard to current and future business strategy designed to address industrywide declines in expenditures on food away from home. The results offer support for some existing strategies as well as provide the basis for viable alternatives. Log‐linear purging is shown to be a valuable tool for consumer researchers.

A national profile of the use of intensive care by medicare patients with cancer

The broad picture of intensive care unit (ICU) outcomes and expenditures cannot be discerned from previous studies that were conducted at single hospitals and focused on narrow subsets of patients. This study provides a comprehensive national profile of ICU used by Medicare patients with cancer. The data source was the Medicare Provider Analysis and Review file for fiscal year 1990, representing 100% of all hospital admissions that occurred within 723 ICD-9-CM codes and organized into 11 code groups. Using screening criteria, admissions were categorized as surgical (both major and minor procedures) or nonsurgical (no procedures) and with and without involvement of the ICU. The categories were compared using the following outcome variables: total hospital charges, ICU charges, ancillary charges, average length of stay, and in-hospital mortality. This study population accounted for nearly 800,000 admissions, of which 143,458 (18.1%) involved the use of the ICU. Actual ICU charges represented 4.9% of the $9.3 billion in total hospital charges. Intensive care unit use is associated positively with service intensity, and 73% of all the admissions involving the ICU were for major procedures. Only 2% involved no procedures. Admissions involving use of the ICU generate higher charges and longer lengths of stay than non-ICU admissions, although the differences decrease with declining treatment intensity and resource use. In-hospital mortality rates, for those cases that used the ICU, were 9.8% for major procedures, 21.2% for minor procedures, and 37.6% for cases involving no procedures. Contrary to the conclusions drawn from previous research, these findings suggest that patients who receive less intense service and use fewer hospital resources are more likely to die in the hospital than those who receive more care, with or without a stay in the ICU during the hospitalization. A global view of ICU use does not support the conclusion that a disproportionate share of special care resources is expended on futile care of the terminally ill or excessive monitoring of low risk patients, although these problems undoubtedly exist. Analysis of comprehensive national data regarding the use of intensive care provides a perspective that challenges some of the conclusions based on more limited studies that were conducted in single hospitals and focused on nonsurvivors or subsets of patients narrowly defined in other ways.

Federation and educational finance: Primary schooling in Nigeria

Primary school enrolments in Nigeria increased substantially in the late 1970s, fell in the early 1980s and are still below peak levels. This behaviour can partly be explained by changes in the system of financing the various levels of government within the federal structure and consequently of changes in the levels of educational finance. The degree of scarcity of educational finance, however, differs across the country leading to wide variations in the contributions of state and local governments, communities and parents. While the hardest hit states have increased non-government revenues greatest, their unit expenditures are still below those in other parts of the country. This paper documents the system of federal finance in Nigeria, its implications for educational funding and the responses using budget and case study material. If, as appears likely, the Federal Government increases its direct contributions to primary schooling in the future it is argued that there is a need for both better data and a greater acceptance of the principle of equal resources per pupil.

Current trends in the development of pumped-storage stations in the World

In the development of pumped-storage stations it is possible to distinguish the following main progressive trends which provide a decrease of unit expenditures, increase of their efficiency in power systems, and reduction of the adverse impact on the environment: development of higher heads and increase of capacity with simultaneous design improvement; underground or semiunderground powerhouses and underground lower and upper reservoirs; incorporation of pumped-storage stations into hybrid power complexes; flexible use of local topographic, engineering-geological, and other conditions; and provision of greater maneuverability of the units and their greater operating time. This paper describes international research and development efforts aimed at fulfilling these trends.