Copyright (c) 2009 All rights reserved. http://works.bepress.com/emmett_keeler Recent documents in Emmett Keeler en-us Sun, 31 May 2009 05:46:28 PDT 3600 http://works.bepress.com/emmett_keeler/11 http://works.bepress.com/emmett_keeler/11 Tue, 01 May 2007 17:24:57 PDT OBJECTIVE: To compare quality of care measured by explicit criteria, implicit review, and sickness-adjusted outcomes at different types of hospitals. DESIGN: Further analysis of data retrospectively abstracted from medical records to evaluate the effects of prospective payment on quality of care for hospitalized Medicare patients. SETTING: Hospitals in five states were sampled to represent the national Medicare admissions along many dimensions. PATIENTS: A total of 14,008 elderly patients with one of the following five diseases: congestive heart failure, acute myocardial infarction, pneumonia, stroke, or hip fracture. These patients were randomly sampled from those with these diseases in 297 hospitals in two time periods, 1981 to 1982 and 1985 to 1986. OUTCOME MEASURES: Explicit criteria, implicit review, and mortality within 30 days of admission adjusted for sickness at admission. RESULTS: Quality of care ratings for hospital types are similar using explicit criteria, implicit review, and outcomes adjusted for sickness at admission. Quality differences between types of hospitals were large, with the lowest group estimated to have four percentage points higher mortality than major teaching hospitals in a cohort of patients with average mortality of 16%. Quality varies from state to state, but teaching, larger, and more urban hospitals have better quality in general than nonteaching, small, and rural hospitals. Hospital quality persists over time, but small nonteaching hospitals narrowed the gap with better quality hospitals between 1981 and 1986. CONCLUSIONS: The different measures led to consistent and plausible relationships between quality and hospital characteristics. Thus, valid information about hospital quality can be obtained. We need to develop ways to use such information to improve care. E. B. Keeler http://works.bepress.com/emmett_keeler/10 http://works.bepress.com/emmett_keeler/10 Tue, 01 May 2007 17:16:38 PDT Background: Since the recognition that human immunodeficiency virus is transmissible by blood transfusion there has been increasing public and professional support for autologous blood donations before elective surgery. Autologous blood donation is, however, a more expensive process than the donation of allogeneic blood by community volunteers. Furthermore, there have been recent improvements in the safety of the volunteer blood supply. Methods: We used a decision-analysis model to assess the cost effectiveness of donating autologous blood for four surgical procedures. Cost data were collected from the observation of transfusion practice at the University of California, Los Angeles, in 1992. Estimates of the risks of transfusion-associated diseases and the costs of treating them came from the medical literature. Cost effectiveness was expressed in dollars per quality-adjusted year of life saved. We performed sensitivity analyses of the variables in our model and examined the effect of strategies suggested to reduce costs. Results: Substituting autologous for allogeneic blood resulted in little expected health benefit (0.0002 to 0.00044 quality-adjusted year of life saved) at considerable additional cost ($68 to $4,783 per unit of blood). The additional cost of autologous blood was primarily a function of the discarding of units that were donated but not transfused and of a more labor-intensive donation process. The cost-effectiveness values ranged from $235,000 to over $23 million per quality-adjusted year of life saved. Conclusions: Given the improved safety of allogeneic transfusions today, the increased protection afforded by donating autologous blood is limited and may not justify the increased cost. Jeff Etchason http://works.bepress.com/emmett_keeler/9 http://works.bepress.com/emmett_keeler/9 Tue, 01 May 2007 17:06:52 PDT Tuberculosis (TB) is a leading cause of disease and death, with ~2 billion people infected and ~2 million deaths annually. Sputum smear microscopy (SSM) has remained the cornerstone of TB diagnosis for more than a century and is a pillar of the global strategy to control the disease, although it has significant limitations. As the epidemic continues, more attention is being paid to the impact that improving existing diagnostic methods and introducing new procedures might have in resource-limited settings. We estimated the potential global impact of better diagnostic tests, to provide guidance for health-care workers, test developers, funding agencies and policymakers. Emmett Keeler http://works.bepress.com/emmett_keeler/8 http://works.bepress.com/emmett_keeler/8 Tue, 01 May 2007 16:50:32 PDT Emmett Keeler http://works.bepress.com/emmett_keeler/7 http://works.bepress.com/emmett_keeler/7 Tue, 01 May 2007 16:39:17 PDT Workers under 50 on average will spend 10-20% of their future hours working. So, assuming they value leisure time at the wage rate, the value of their lives is 5-10 times their future lifetime earnings. This value is close to values of life estimated by compensating wage differentials or willingness to pay. Emmett B. Keeler http://works.bepress.com/emmett_keeler/6 http://works.bepress.com/emmett_keeler/6 Tue, 01 May 2007 16:35:40 PDT US hospital prices are rising again after years of limited growth. We analyze trends in hospital prices during a period of significant price growth (1999-2003) to assess whether hospitals that are part of multi-hospital systems were able to increase their prices faster than non-system hospitals. We find hospitals that were members of multi-hospital systems were able to increase their prices substantially more than comparable non-systems hospitals (34% for large systems and 17% for small systems). Further, we find that the systems effect is not confined to hospitals that have other system member hospitals in their local markets. One possible explanation is that hospitals belonging to non-local multi-hospital systems have improved their bargaining position vis-a-vis health plans. Glenn Melnick http://works.bepress.com/emmett_keeler/5 http://works.bepress.com/emmett_keeler/5 Tue, 01 May 2007 16:31:19 PDT Flat capitation (uniform prospective payments) makes enrolling healthy enrollees profitable to health plans. Plans with relatively generous benefits may attract the sick and fail through a premium spiral. We simulate a model of idealized managed competition to explore the effect on market performance of alternatives to flat capitation such as severity-adjusted capitation and reduced supply-side cost-sharing. In our model flat capitation causes severe market problems. Severity adjustment and to a lesser extent reduced supply-side cost-sharing improve market performance, but outcomes are efficient only in cases in which people bear the marginal costs of their choices. Emmett B. Keeler http://works.bepress.com/emmett_keeler/4 http://works.bepress.com/emmett_keeler/4 Tue, 01 May 2007 16:24:36 PDT Has the nature of hospital competition changed from a medical arms race in which hospitals compete for patients by offering their doctors high quality services to a price war for the patients of payors? This paper uses time-series cross-sectional methods on California hospital discharge data from 1986-1994 to show the association of hospital prices with measures of market concentration changed steadily over this period, with prices now higher in less competitive areas, even for non-profit hospitals. Regression results are used to simulate the price impact of hypothetical hospital mergers. Emmett B. Keeler http://works.bepress.com/emmett_keeler/3 http://works.bepress.com/emmett_keeler/3 Tue, 01 May 2007 16:17:44 PDT Objective: To understand how medical savings account (MSA) legislation for the nonelderly would affect health care costs. Design: Economic policy evaluation based on the RAND Health Expenditures Simulation Model. Setting: National probability sample of nonelderly noninstitutionalized households. Participants: Persons in 23,157 sampled households from the 1993 Current Population Survey. Interventions: Medical savings account legislation would allow all Americans who are covered only by a catastrophic health care plan to set up a tax-exempt account that they can use to pay medical bills not covered by their health insurance. The interventions we evaluate differ in the deductibles of the catastrophic plan and in whether the employee or employer funds the MSA. Main Outcome Measures: Changes in national health expenditures and net societal benefits of health care. Results: If all insured nonelderly Americans switched to MSAs, their health care expenditures would decline by between 0% and 13%, depending on how the MSAs are designed. However, not all nonelderly Americans would choose MSAs; taking into account selection patterns, health spending would change by + 1% to -2%. Conclusions: Medical savings account legislation would have little impact on health care costs of Americans with employer-provided insurance. However, depending on the size of the catastrophic limit, waste from the excessive use of generously insured care could be reduced, and MSAs would be attractive to both sick and healthy people. Emmett B. Keeler http://works.bepress.com/emmett_keeler/2 http://works.bepress.com/emmett_keeler/2 Tue, 01 May 2007 16:09:09 PDT OBJECTIVE: To analyze whether elderly patients who are black or from poor neighborhoods receive worse hospital care than other patients, taking account of hospital effects and using validated measures of quality of care. DESIGN: We compare quality of care provided to insured, hospitalized Medicare patients who are black or live in poor neighborhoods as compared with others, using simple and multivariable comparisons of clinically detailed measures of sickness at admission, quality, and outcomes. SETTING: Two hundred ninety-seven acute care hospitals in 30 areas within five states. Patients or Other Participants. The sample includes a nationally representative sample of 9932 patients 65 years of age or older who lived at home prior to hospitalization for congestive heart failure, acute myocardial infarction, pneumonia, or stroke. INTERVENTIONS: This was an observational study. Main Outcome Measures: Processes of care, length of stay, instability at discharge, discharge destination, and mortality. RESULTS: Within rural, urban nonteaching, and urban teaching hospitals, patients who are black or from poor neighborhoods have worse processes of care and greater instability at discharge than other patients (P<.05). However, this worse quality is offset by patients who are black or from poor neighborhoods being 1.8 times more likely to receive care in urban teaching hospitals that have been shown to provide better quality of care (P<.001). Because these patients receive more of their care in better-quality hospitals, there are no overall differences in quality by race and poverty status. Death rates did not vary by race or poverty status. CONCLUSIONS: Quality of hospital care for insured Medicare patients is influenced both by the patient's race and financial characteristics and by the hospital type in which the patient receives care. Katherine L. Kahn