Copyright (c) 2009 All rights reserved. http://works.bepress.com/john_romley Recent documents in John Romley en-us Mon, 09 Nov 2009 18:06:33 PST 3600 http://works.bepress.com/john_romley/8 http://works.bepress.com/john_romley/8 Tue, 07 Jul 2009 20:35:04 PDT John Romley Other health care http://works.bepress.com/john_romley/7 http://works.bepress.com/john_romley/7 Thu, 08 Jan 2009 14:09:46 PST John Romley Legal services http://works.bepress.com/john_romley/6 http://works.bepress.com/john_romley/6 Tue, 06 Jan 2009 18:49:42 PST One of the most important and vexing issues in health care concerns the cost to improve quality. Unfortunately, quality is difficult to measure and potentially confounded with productivity. Rather than relying on clinical or process measures, we infer quality at hospitals in greater Los Angeles from the revealed preference of pneumonia patients. We then decompose the joint contribution of quality and unobserved productivity to hospital costs, relying on patient heterogeneity for plausibly exogenous quality variation. We find that more productive hospitals provide higher quality, demonstrating that the cost of quality improvement is substantially understated by methods that do not take into account productivity differences. After accounting for these differences, we find that a quality improvement from the 25th percentile to the 75th percentile would increase costs at the average hospital by nearly fifty percent. The cost of improvements in traditional metrics of hospital quality such as risk-adjusted mortality is modest, suggesting that other factors such as amenities are important drivers of both hospital costs and patient choice. John A. Romley Hospitals http://works.bepress.com/john_romley/5 http://works.bepress.com/john_romley/5 Tue, 06 Jan 2009 18:47:11 PST Amenities such as good food, attentive staff, and pleasant surroundings may play an important role in hospital demand. We use a marketing survey to measure amenities at hospitals in greater Los Angeles and analyze the choice behavior of Medicare pneumonia patients in this market. We find that the mean valuation of amenities is positive and substantial. From the patient perspective, hospital quality therefore embodies amenities as well as clinical quality. We also find that a one-standard-deviation increase in amenities raises a hospital's demand by 38.4% on average, whereas demand is substantially less responsive to clinical quality as measured by pneumonia mortality. These findings imply that hospitals may have an incentive to compete in amenities, with potentially important implications for welfare. Dana Goldman Hospitals http://works.bepress.com/john_romley/4 http://works.bepress.com/john_romley/4 Tue, 06 Jan 2009 18:44:12 PST Objective: To review and characterize existing health care efficiency measures in order to facilitate a common understanding about the adequacy of these methods.Data Sources: Review of the MedLine and EconLit databases for articles published from 1990-2008, as well as search of the "gray" literature for additional measures developed by private organizations.Study Design: We performed a systematic review for existing efficiency measures. We classified the efficiency measures by perspective, outputs, inputs, methods used, and reporting of scientific soundness.Principal Findings: We identified 265 measures in the peer-reviewed literature and 8 measures in the gray literature, with little overlap between the two sets of measures. Almost all of the measures did not explicitly consider the quality of care. Thus, unless quality is assumed to be equivalent across groups, the measures may reflect the costs of care only, not efficiency. Evidence on the measures' scientific soundness was mostly lacking: evidence on reliability or validity was reported for 6 measures (2.3%) and sensitivity analyses were reported for 67 measures (25.3%).Conclusions: Efficiency measures have been subjected to few rigorous evaluations of reliability and validity, and methods of accounting for quality of care in efficiency measurement are not well-developed at this time. Use of these measures without greater understanding of these issues is likely to engender resistance from providers and could lead to unintended consequences. Peter Hussey Other health care http://works.bepress.com/john_romley/3 http://works.bepress.com/john_romley/3 Tue, 06 Jan 2009 18:38:46 PST In choosing their hospital, patients are concerned with both quality of care and amenities such as comfortable rooms. This column summarises recent research showing that patients value amenities and more productive hospitals compete for patients by supplying higher quality. We need to assess the value of amenities in relation to other hospital benefits, since improving amenities is more costly than improving care. Dana Goldman Hospitals http://works.bepress.com/john_romley/2 http://works.bepress.com/john_romley/2 Tue, 06 Jan 2009 18:35:15 PST Objective: This study had two purposes: (1) to characterize the density of liquor stores and bars that individuals face according to race, economic status, and age in the urban United States and (2) to assess alternative measures of retailer density based on the road network and population. Method: We used census data on business counts and sociodemographic characteristics to compute the densities facing individuals in 9,361 urban zip codes. Results: Blacks face higher densities of liquor stores than do whites. The density of liquor stores is greater among nonwhites in lower-income areas than among whites in lower- and higher-income areas and nonwhites in higher-income areas. Nonwhite youths face higher densities of liquor stores than white youths. The density of liquor stores and bars is lower in higher-income areas, especially for nonwhites. Conclusions: Mismatches between alcohol demand and the supply of liquor stores within urban neighborhoods constitute an environmental injustice for minorities and lower-income persons, with potential adverse consequences for drinking behavior and other social ills. Our results for bars are sensitive to the measure of outlet density as well as population density. Although neither measure is clearly superior, a measure that accounts for roadway miles may reflect proximity to alcohol retailers and thus serve as a useful refinement to the per-capita measure. If so, alcohol policy might also focus on density per roadway mile. Further research on the existence, causes, and consequences of environmental injustice in alcohol retailing is warranted. John A. Romley Other health care