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Many parasites of seasonally available hosts must persist through times of the year when hosts are unavailable. In tropical environments, host availability is often linked to rainfall, and adaptations of parasites to dry periods remain understudied. The bird-parasitic fly Philornis downsi has invaded the Galapagos Islands and is causing high mortality of Darwin’s finches and other bird species, and the mechanisms by which it was able to invade the islands are of great interest to conservationists. In the dry lowlands, this fly persists over a seven-month cool season when availability of hosts is very limited. We tested the hypothesis that adult flies could survive from one bird-breeding season until the next by using a pterin-based age-grading method to estimate the age of P. downsi captured during and between bird-breeding seasons. This study showed that significantly older flies were present towards the end of the cool season, with ~ 5% of captured females exhibiting estimated ages greater than seven months. However, younger flies also occurred during the cool season suggesting that some fly reproduction occurs when host availability is low. We discuss the possible ecological mechanisms that could allow for such a mixed strategy.

Since health professionals provide frontline care to COVID-19 patients, information on vaccine acceptance among healthcare workers is needed. We developed and implemented an anonymous internet-based cross-sectional survey with direct solicitation among employees of a safety net health system. Items queried demographic and health-related characteristics, experience with and knowledge of COVID-19, and determinants of decisions to vaccinate. COVID-19 vaccine acceptance groups (acceptors, hesitant, refusers) were defined, an adapted version of the WHO vaccine hesitancy scale was included. The survey demonstrated good reliability (Cronbach’s alpha = 0.92 for vaccine hesitancy scale, 0.93 for determinants). General linear and logistic regression methods examined factors which were univariately associated with vaccine hesitancy and vaccine acceptance, respectively. Multivariable models were constructed with stepwise model-building procedures. Race/ethnicity, marital status, job classification, immunocompromised status, flu vaccination and childhood vaccination opinions independently predicted hesitancy scale scores. Gender, education, job classification and BMI independently predicted acceptance, hesitancy, and refusal groups. Among hesitant employees, uncertainty was reflected in reports of motivating factors influencing their indecision. Despite a strong employee-support environment and job protection, respondents reported physical and mental health effects. The appreciation of varied reasons for refusing vaccination should lead to culturally sensitive interventions to increase vaccination rates amongst healthcare workers.

OBJECTIVES In 2012, the Ohio Department of Medicaid introduced requirements for enhanced care management to be delivered by Medicaid managed care organizations (MCOs). This study evaluated the impact of care management on reducing infant mortality in the largest Medicaid MCO in Ohio. STUDY DESIGN Observational study using infant and maternal individual-level enrollment and claims data (2009-2015), which used a quasi-experimental research design built on a sibling-comparison approach that controls for within-family confounders. METHODS Using individual-level data from the largest MCO in Ohio, we estimated linear probability models to examine the effect of infant engagement in care management on infant mortality. We used a within-family fixed-effects research design to determine if care management reduced infant mortality and estimated models separately for healthy infants and nonhealthy infants. RESULTS Infant engagement in care management was associated with a reduction of 7.4 percentage points (95% CI, -10.7 to -4.1; P

Properties of social networks and shared patient networks of physicians are associated with important outcomes, including costs, quality, information exchange, and organizational effectiveness.To determine whether practice consolidation affects size, strength, and stability of US practice-based physician shared patient networks.We used a dynamic difference-in-differences (event study) design to determine how 2 types of vertical consolidation (hospital and health system practice acquisition) and 2 types of horizontal consolidation (medical group membership and practice-practice mergers) affect individual shared patient network characteristics, controlling for physician fixed effects and geographic market (metropolitan statistical area).Practice-based US physicians whose practices consolidated 2009-2014 are identified via health system, hospital, and medical group affiliation information and appearance/disappearance of listed practice affiliations in the SKA Physician Database.Outcomes measured were network size (number of individual physicians with whom a physician shares patients within 30 d), strength (average number of shared patients within those relationships), and stability (percent of shared patient relationships that persist in the current and prior year), all generated from Medicare Shared Patient Patterns (30-d) data.Shared patient network stability increases significantly after acquisition of practices by horizontal practice-practice mergers [βt=1=0.041 (P0.001), βt=2=0.047 (P0.001), βt=3=0.041 (P0.001), βt=4=0.031 (P0.05), where t is the number of years after the consolidation event]. These effects were robust to sensitivity analyses. Shared patient network size and strength are not observably associated with practice consolidation events.Practice consolidation can increase the stability of physician networks, which may have positive implications for organizational effectiveness.

Use of agency-employed supplemental nurses on nursing personnel costs was examined in 19 adult patient care units in a large academic medical center. Results indicated that the modest use of supplemental nurses was cost-efficient with regard to overall nursing personnel costs, but heavy reliance on supplemental nurses to meet staffing needs was not cost-efficient. In addition, there was no statistical difference in hourly personnel cost between the use of supplemental nurses and overtime worked by permanent nurses.

Background Wide variations exist in healthcare expenditures, though most prior studies have assessed aggregate utilization. We sought to examine healthcare utilization variation in New York State by assessing hospitals in peer groups of similar capabilities. Methods Using charge data in New York State from the 2008 Statewide Planning and Research Cooperative System (SPARCS) and cost-to-charge ratios at the cost-center level drawn from Institutional Cost Reports, we calculated total, routine, and ancillary costs for patients discharged with an acute myocardial infarction (AMI) diagnosis in 2008. We assessed the correlation of these cost data to Hospital Referral Region (HRR) Medicare reimbursement data from the 2007 Dartmouth Atlas of Health Care. After describing hospital level cost variability, we examined characteristics associated with higher costs within peer groups of similar cardiac care capabilities. Results We found greater costs in hospitals providing the highest level of cardiovascular services, with cardiac surgery capable hospitals and non-invasive hospitals having total costs of $21,166 and $9268 per AMI discharge, and ancillary costs of $12,006 and $4167 per AMI discharge, respectively. Substantial variability in utilization existed in all levels of hospitals and across individual departmental cost centers. The two factors most frequently associated with higher total and ancillary costs across peer groups were patient case mix index and major or minor teaching status. Conclusions Significant variation in cost per AMI discharge exists even within peer groups of hospitals with similar cardiac care capabilities. Implications These findings support measurement and analysis at the hospital level to further understand the reasons for variation in utilization.

The authors assessed an expansion of Vermont's Dr. Dynasaur program that would cover all residents age 25 and younger. The current Dr. Dynasaur program combines Vermont's Medicaid program and Child Health Insurance Program for children ages 0 through 18 to provide a seamless insurance program for those with family incomes below 317 percent of the federal poverty level. The authors used RAND's COMPARE-VT microsimulation model with Vermont-specific demographic, economic, and actuarial data to estimate the effects on health insurance coverage, costs, and premiums. They also identified the new revenues required to fund the program expansion and explored three alternative financing strategies to raise those funds: (1) an increase in the Vermont income tax, (2) a Vermont payroll tax, and (3) a Vermont business enterprise tax. The authors found that enrollment would increase by more than 260 percent under the 100-percent enrollment scenario and by nearly 200 percent under the 70-percent enrollment scenario by 2019. Not surprisingly, the children and young adults who move off employer-sponsored insurance (ESI) and into Dr. Dynasaur 2.0 have considerably lower expected health care costs than those who remain on ESI, increasing the per-person premiums by nearly $1,000 for those remaining enrolled in ESI. Annual health care expenditures per person for children and young adults in 2019 are estimated at $4,325 with Medicare prices. The combination of increased reimbursement rates, large increases in enrollment, and relatively low Dr. Dynasaur premiums (no more than $720 per year) will require significant new tax revenues to meet program obligations.

Use of supplemental RNs (SRNs) is common practice among US hospitals to fill gaps in nurse staffing. The objective of this study was to examine the relationship between use of SRNs and patient outcomes. Multilevel modeling was performed to analyze hospital administrative data from 19 hospital units in a large tertiary medical center for the years 2003 to 2006. Patient outcomes included in-hospital mortality, medication errors, falls, pressure ulcers, and patient satisfaction with nurses. Use of SRNs ranged from 0% to 30.4% of total RN hours per unit quarter. Among 188 of the 304 unit quarters in which SRNs were used, the average SRN use was 9.8% in non-ICUs and 6.4% in ICUs. All observed effects of SRN use on patient outcomes were nonsignificant. Use of SRNs was substantial and varied widely by unit. No evidence was found that links SRN use to either adverse or positive patient outcomes.

In the past three decades, the shortage of nurses willing to work in hospitals has been a persistent challenge in the United States. Hiring supplemental registered nurses-nurses on short-term contracts obtained through an external staffing agency-has been common to fill gaps in nurse staffing. But there has been insufficient evidence about supplemental nurse workforce trends to inform workforce policy. To address this concern, we compared qualifications and characteristics of supplemental nurses with those of permanent nurses during 1984-2008. The two groups shared similar education levels in terms of possessing a baccalaureate or higher degree. Supplemental nurses were somewhat less experienced than permanent nurses, averaging fifteen years of experience in 2008 compared to eighteen years for permanent nurses. The supplemental nurse workforce was more diverse racially and ethnically and more likely to be male than the permanent nurse workforce. These data show that employing supplemental nurses could help meet the challenges of an aging nursing workforce, the projected future shortage of nurses, and an increasingly diverse US population.

In this study, 107 primary total joint replacement (TJR) patients were assessed preoperatively using the SF-36 (Mental Component Score [MCS] and Physical Component Score [PCS]), Beck Depression Inventory (BDI), Spielberger Trait Anxiety Inventory, Interpersonal Support Evaluation List, and the Coping Strategies Questionnaire. Patients with preoperative MCS or = 50. Low MCS patients used more catastrophizing coping techniques (P

We investigated the extent to which children continuously enrolled in two mature county-organized Medicaid managed care plans for 6, 12, and 24 months received recommended well-child visits and immunizations. We also investigated whether any improvements in compliance were evident during the period 1989-92. Compliance was low for well-child visits and immunizations at the recommended ages regardless of eligibility group. Although slight improvements in immunizations were made over time, little progress was made in compliance with well-child visits. Continued vigilance is required to achieve the government's goal of 90 percent immunization compliance among 2-year-olds.

March 2001 (Revised from May 2000). During the 1980s and 1990s there were great increases of health insurance coverage for poor children through the Children’s Health Insurance Program (CHIP) and extended Medicaid eligibility. Problems remain for the small number of children with serious medical conditions whose care is a high proportion of total health care expenditures on children. We report on the adequacy of health insurance coverage for a sample of children with serious and rare illnesses treated at the single tertiary care pediatric hospital in Indiana. One-third of privately insured children in our data had inadequate insurance. Compared to families with inadequate health insurance families with adequate insurance were 50 percent less likely to delay care for themselves and 67 percent less likely to delay care for a child. Our research identifies policy relevant deficiencies in private health coverage for seriously ill children ineligible for either Medicaid or CHIP.

Managed care may improve access to health care to previously underserved populations when providers need plan enrollees. However, capitation and utilization management often give providers the incentive to withhold care. Managed care organizations have yet to demonstrate that racial disparities in treatment are not exacerbated. Using Medicaid eligibility, claims, and managed care encounter data, we examine racial disparities in service use among Medicaid beneficiaries after mandatory enrollment in managed care. We use count data models adjusted for nonrandom selection within difference-in-differences econometric approaches. The results show that mandatory enrollment has disproportionately reduced the relative use of physician and inpatient services among African-American beneficiaries.

OBJECTIVE We examined the differential effect of Medicaid managed care (MMC) among Aid to Families With Dependent Children (AFDC) and Supplemental Security Income (SSI) enrollees over time by comparing the experiences of adult nonelderly enrollees in the Health Plan of San Mateo in California versus Ventura County's fee-for-service (FFS) enrollees. RESEARCH DESIGN Four years of administrative claims data were used to construct a longitudinal data set and estimate panel data models to decompose the effect of managed care over time. RESULTS AFDC MMC enrollees exhibited generally fewer ambulatory visits, lower expenditures, and higher monthly probabilities of a preventable hospitalization relative to comparably enrolled FFS patients. SSI MMC enrollees had more emergency department visits and higher monthly probabilities of hospitalization. However, SSI MMC enrollees had more ambulatory visits and more medications during the first year of enrollment relative to SSI FFS enrollees, although levels were similar in subsequent years. SSI MMC enrollees did not exhibit a significantly higher level of expenditures in the first year of enrollment, although in subsequent years, expenditure levels were significantly lower. CONCLUSIONS The results for emergency department visits and preventable hospitalizations presented a decidedly downbeat picture of access to care for AFDC and SSI enrollees in MMC. However, some aspects of utilization under managed care exhibited results consistent with long-term- oriented treatment for enrollees with a greater likelihood of remaining in the system for a longer period of time (SSI enrollees). By contrast, enrollees more likely to be enrolled for shorter periods (AFDC enrollees) tended to exhibit care patterns under MMC consistent with lower levels of care relative to FFS.

1 Parke-Davis Pharmaceutical Research, Ann Arbor, MI, 2 Stadtlander Drug Company Inc., and University of Pittsburgh, Pittsburgh, PA, 3 Ohio State University, Columbus, OH, 4 University of Wisconsin Hospitals & Clinics, Southfield, MI, 5 University of Arizona College of Pharmacy, Tucson, AZ, 6 Indiana University, Bloomington, IN, 7 Merck Research Laboratories, Blue Bell, PA, 8 University of South Carolina College of Pharmacy, Columbia, SC

We use experimental panel data to estimate impacts of managed care on medical care use counts free of endogenous treatment effect bias. Our count regressions also allow for excess zeros and correct for possible attrition bias.

Objectives. Each year approximately 100,000 Medicare patients undergo knee replacement surgery. Patients, referring physicians, and surgeons must consider a variety of factors when deciding if knee replacement is indicated. One factor in this decision process is the likelihood of revision knee replacement after the initial surgery. This study determined the chance that a revision knee replacement will occur and which factors were associated with revision. Methods. Data on all primary and revision knee replacements that were performed on Medicare patients during the years 1985 through 1990 were obtained. The probability that a revision knee replacement occurred was modeled from data for all patients for whom 2 full years of follow-up data were available. Two strategies for linking revisions to a particular primary knee replacement for each patient were developed. Predictive models were developed for each linking strategy. ICD-9-CM codes were used to determine hospitalizations for primary knee replacement and revision knee replacement. Results. More than 200,000 hospitalizations for primary knee replacements were performed, with fewer than 3% of them requiring revision within 2 years. The following factors increase the chance of revision within 2 years of primary knee replacement: (1) male gender, (2) younger age, (3) longer length of hospital stay for the primary knee replacement, (4) more diagnoses at the primary knee replacement hospitalization, (5) unspecified arthritis type, (6) surgical complications during the primary knee replacement hospitalization, and (7) primary knee replacement performed at an urban hospital. Conclusions. Revision knee replacement is uncommon. Demographic, clinical, and process factors were related to the probability of revision knee replacement.

A cross-sectional, community-based survey of a random sample of 1750 of 242,311 Medicare recipients was performed. The patients were at least sixty-five years old and had had a primary or revision knee replacement (either unilaterally or bilaterally) between 1985 and 1989. Three samples were surveyed separately: a national sample (to reflect the United States as a whole) and samples from Indiana and the western part of Pennsylvania (sites chosen for convenience to assess the validity of the findings for the national sample on a regional level). Each sample was stratified by race, age, residence (urban or rural), and the year of the procedure. Valid and reliable questionnaires were used to elicit the participants' assessments of pain, physical function, and satisfaction two to seven years after the knee replacement. Of the 1486 patients who were eligible for inclusion in the survey, 1193 (80.3 per cent) responded. The mean age of the respondents was 72.6 years. Eight hundred and forty-nine respondents (71.2 per cent) were white, and 849 (71.2 per cent) were women. The participants reported that they had little or no pain in the knee at the time of the survey, regardless of the age at the time of the knee replacement, the body-mass index, or the length of time since the knee replacement. After adjustment for potential confounding variables, predictors of better physical function after the replacement were an absence of problems with the contralateral knee, primary knee replacement (rather than revision) (Indiana sample only), and a lower body-mass index (Indiana and western Pennsylvania samples). Four hundred and fifteen (85.2 per cent) of the 487 patients in the national sample were satisfied with the result of the knee replacement. In what we believe to be the first community-based study of the outcome of knee replacement, patients reported having significant (p = 0.0001) and persistent relief of pain, improved physical function, and satisfaction with the result two to seven years postoperatively. The findings of the present study suggest that age and obesity do not have a negative impact on patient-relevant outcomes (pain and physical function). Dissemination of these findings has the potential to increase appropriate referrals for knee replacement and thereby reduce the pain and functional disability due to osteoarthrosis of the knee.

Objective. To evaluate the nature, risks, and benefits of osteoarthritis (OA) management by primary care physicians and rheumatologists. Methods. Subjects were 419 patients followed for symptoms of knee OA by either a specialist in family medicine (FM) or general internal medicine (GIM) or by a rheumatologist (RH). Management practices were characterized by in-home documentation by a visiting nurse of drugs taken to relieve OA pain or to prevent gastrointestinal side effects of nonsteroidal anti-inflammatory drugs (NSAIDs) and by patient report (self-administered survey) of nonpharmacologic treatments. Changes in outcomes (knee pain and physical function) over 6 months were measured with the Western Ontario and McMaster Universities Osteoarthritis Index. Results. Patients of RHs were 2-3 years older (P = 0.035) and tended to exhibit greater radiographic severity of OA (P = 0.064) and poorer physical function (P = 0.076) at baseline than the other 2 groups. In all 3 groups, knee pain and physical function improved slightly over 6 months; however, between-group differences were not significant. Compared to drug management of knee pain by FMs or RHs, that by the GIMs was distinguished by greater utilization of acetaminophen and nonacetylated salicylates (P = 0.008), lower prescribed doses of NSAIDs (P = 0.007), and, therefore, lower risk of iatrogenic gastroenteropathy (P < 0.001). In contrast, patients of RHs were more likely than those of FMs and GIMs to report that they had been instructed in use of isometric quadriceps and range-of-motion exercises (P ≦ 0.001), application of heat (P = 0.051) and cold (P < 0.001) packs, and in the principles of joint protection (P = 0.016). Neither physician specialty nor specific management practices accounted for variations in patient outcomes. Conclusion. This observational study identified specialty-related variability in key aspects of the management of knee OA in the community (i.e., frequency and dosing of NSAIDs, use of nonpharmacologic modalities) that bear strong implications for long-term safety and cost. However, changes in knee pain and function over 6 months were unrelated to variations in management practices.

Having a serious illness like breast cancer is a calamity for individuals and families. Along with the pain, discomfort, and dislocation comes the issue of how to pay the medical expenses for the care and treatment of the disease. If the seriously ill person has inadequate or no insurance, these problems are aggravated.Stories abound about seriously ill people losing private health insurance following diagnosis with a catastrophic disease, remaining in jobs just to maintain health insurance, or facing financial hardship because of gaps in coverage. Yet surprisingly little research has focused on the problems that people with serious illness face with health coverage and, in particular, how concerns about access to health insurance coverage shape their lives.Further, despite profoundly moving anecdotes of cancer victims and other seriously ill people about their problems with health insurance and despite recent federal and state efforts to reform the private health insurance market in ways discussed below, neither the federal government, states, nor the private sector has crafted comprehensive strategies to enhance health coverage for the seriously ill.

Gene therapy research has the potential to revolutionize the way in which many human diseases are treated. Despite its enormous potential, roundtable panelists concluded that the field needs time to mature scientifically without pressure to develop a marketable therapeutic product. In addition, health care decision makers, physicians, and the lay public need to be educated on the future medical, economic, and ethical ramifications of gene therapy.

Background: Given the rising costs of medical care in the US, efforts at improving quality of care seek also to control expenditures with high-value healthcare - better quality and lower cost. Prior studies have used variations in Medicare reimbursements at the regional level, rather than individual hospital costs, to account for the unique patient case-mix of individual hospitals. To date, higher expenditures have been unrelated to clinical outcomes. We sought to explore variation using costs, rather than payment, and to study the links between inpatient hospital Medicare expenditures, hospital costs, and Medicare's quality indicators. Methods: In New York State, we analyzed hospital discharges in 2008 for acute myocardial infarction (AMI) in the New York State Planning and Resource Cooperative System (SPARCS) database. Using SPARCS reported hospital charges and the Medicare cost-to-charge ratio we calculated, at the individual hospital level, the total costs and departmental-level ancillary costs (costs of specific hospital services) for patients discharged with a primary diagnosis of AMI. We compared total inpatient cost to Dartmouth Atlas of Health Care Medicare inpatient reimbursements, analyzed variation in ancillary costs by hospital cardiac program peer groups (based on highest-level capability), and related total costs to Medicare AMI quality scores. Results: The study analyzed data that represented 56,000 AMI cases in 150 hospitals. When comparing total costs to Medicare inpatient reimbursements, there was high correlation with an R-squared of 0.84. The mean ancillary costs per AMI discharge were $12,006 [standard deviation (SD) $4,301, coefficient of variation (COV) 0.358] for cardiac surgery-capable, $6,452 [SD $1,732, COV 0.268] for percutaneous coronary intervention-capable, $5,104 [SD $2,548, COV 0.499] for diagnostic catheterization-capable, and $4,167 [SD $2,756, COV 0.661] for non-invasive hospitals. There was no overall correlation between AMI total costs and Medicare composite AMI quality scores, yet 19.7% (28 out of 142 hospitals with AMI quality score reporting in 2008) of hospitals had above average quality scores, with lower than average total costs. Conclusions: In AMI hospitalizations, regional Medicare reimbursements have a strong correlation with total hospital costs. Hospitals vary greatly in their costs of caring for AMI patients. Though there is no overall association between the level of costs and performance on standardized quality scores, high-value healthcare in AMI does exist with numerous high-quality, low-cost hospitals. Examining the expenditures of these hospitals may be useful in identifying patterns of quality and cost-effective patient care. These findings support that high-spending is not necessary for high-quality, and that high-value healthcare can be realized.

Background Canada, which has universal single-payer health insurance, is often criticized for waiting times for surgery that are longer than those in the United States. We compared waiting times for orthopedic consultations and knee-replacement surgery and patients' acceptance of them in the United States and in the province of Ontario, Canada. Methods A stratified random sample of 1486 Medicare recipients (629 from the U.S. national sample, 428 from Indiana, and 429 from western Pennsylvania) and 516 people from Ontario who had been hospitalized for knee replacement between 1985 and 1989 were surveyed by mail in 1992. Patients were asked how long they had waited to see an orthopedic surgeon and to have surgery, the acceptability of these waiting times, and their overall satisfaction with surgery. Results About 80 percent of the questionnaires were returned, but not all the respondents answered all the questions. The rate of response to specific questions was about 60 to 65 percent in both countries. The ...

Highway freight and passenger transportation are vital contributors to national economic health and productivity. Although there has been considerable research into the design and operation of the highway system and the vehicles that use it, there has been relatively little concentrated research concerning the truck and bus driver – the human element responsible for moving the freight and passengers safely. The Federal Highway Administration's Office of Motor Carriers has developed a comprehensive multi-year plan to address the issues of driver proficiency, medical qualifications, and fitness for duty. The core of this plan will be a series of high-quality and scientifically sound research projects. The results of these projects will form the basis for regulatory changes that will be more technically defensible, better reflect the realities of the operating environments, and, to the extent possible, be based on performance standards.

There is great concern that modern rich nations will not be able to afford the future health care costs of ageing societies. Cohort change-based estimates of population ageing alone suggest some increases in future costs, even without differentially higher growth in underlying, residual ‘technology related’ costs. Accounting for these costs pushes the future costs much higher. However, these estimates of cost ignore both the increased willingness and ability of the current and future elderly to pay these costs and the likely future benefits of these expenses in terms of increased health status, improved quality of life and increased longevity from new and better medical treatments, pharmaceuticals and the like. Drawing on recent examples of the net benefits of pharmaceuticals from the United States and other nations, we argue that these benefits also need to be taken into account. We also suggest that once a socially determined level of health care benefits are provided by the public sector, the elderly should be able to privately pay for additional treatments which might also have high health benefits. The primary public policy issues are two. First, avoid the unnecessary and inefficient costs of excessive technological medicine (where waste is rampant; costs are below benefits and, therefore, the marginal value of treatment is low). Second, directly address the question of the distribution of the costs of new medical advances and existing cost-effective treatments for the elderly by determining how much of these costs should be borne by public programmes (financed by workers or from general revenues) vs. how much the low income elderly themselves can and should pay for. In this light, plans to subsidize the cost of treatments based on ability to pay are important policy considerations for future cohorts of older persons.

Economic analyses have become increasingly important in healthcare in general and with respect to pharmaceuticals in particular. If economic analyses are to play an important and useful role in the allocation of scarce healthcare resources, then such analyses must be performed properly and with care. This article outlines some of the basic principles of pharmacoeconomic analysis. Every analysis should have an explicitly stated perspective, which, unless otherwise justified, should be a societal perspective. Cost minimisation, cost-effectiveness, cost-utility and cost-benefit analyses are a family of techniques used in economic analyses. Cost minimisation analysis is appropriate when alternative therapies have identical outcomes, but differ in costs. Cost-effectiveness analysis is appropriate when alternative therapies differ in clinical effectiveness but can be examined from the same dimension of health outcome. Cost-utility analysis can be used when alternative therapies may be examined using multiple dimensions of health outcome, such as morbidity and mortality. Cost-benefit analysis requires the benefits of therapy to be described in monetary units and is not usually the technique of choice. The technique used in an analysis should be described and explicitly defended according to the problem being examined. For each technique, the method of determining costs is the same; direct, indirect, and intangible costs can be considered. The specific costs to be used depend on the analytical perspective; a societal perspective implies the use of both direct and indirect economic costs. A modelling framework such as a decision tree, influence diagram, Markov chain, or network simulation must be used to structure the analysis explicitly. Regardless of the choice of framework, all modelling assumptions should be described. The mechanism of data collection for model inputs must be detailed and defended. Models must undergo careful verification and validation procedures. Following baseline analysis of the model, further analyses should examine the role of uncertainty in model assumptions and data.

As authors of the Australian pharmaceutical guidelines, we applaud both Michael Drummond and Bernard Bloom for their thoughtful commentaries. Here we briefly discuss how and why the Australian guidelines came about, elucidate some of the issues we thought about as we were writing them, respond to some of the key issues raised by Drummond and Bloom, and discuss implications for the United States. This is a particularly interesting time to launch a discussion of pharmaceutical policy. The Food and Drug Administration (FDA) process is undergoing constant scrutiny, and the United States is once again experiencing heightened political activity over health system reform. Also, the Canadian province of Ontario is debating whether to implement pharmaceutical guidelines similar to those in Australia. If any type of national health strategy were to emerge here, pharmaceutical guidelines such as those legislated in Australia would be easier to implement here as well.

This policy brief talks about what managed care for Medicaid is, how it influences kids, and how it relates to the State Child Health Insurance Program (CHIP). It focuses on what we have learned over the last 20 years through research about cost, use, and quality. It also discusses some of the expectations we had for children covered by Medicaid managed care. Finally, it talks abaout the future of Medicaid managed care and the implications for CHIP.

In this paper we analyze the cross-sectional relationship between hospital quality scores calculated by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and risk-adjusted indicators of outcomes and quality-mortality, rates of surgical/medical misadventures, adverse drug reactions, and length of stay-calculated from Nationwide Inpatient Sample discharge records. The results suggest that greater adherence to JCAHO accreditation standards is not associated with reduced mortality or lower probability of avoidable hospital or physician-caused adverse outcomes. Other hospital characteristics, such as teaching/non-teaching and urban/rural status, also exhibit little or no correlation with risk-adjusted survival and adverse-event probabilities.

This policy brief talks about what managed care for Medicaid is, how it influences kids, and how it relates to the State Child Health Insurance Program (CHIP). It focuses on what we have learned over the last 20 years through research about cost, use, and quality. It also discusses some of the expectations we had for children covered by Medicaid managed care. Finally, it talks about the future of Medicaid managed care and the implications for CHIP.

Explanations for regional variation in the use of many medical and surgical treatments is controversial.To identify factors that might be amenable to intervention, we investigated the determinants of regional variation in the use of knee replacement surgery.We examined the effect of the following factors: characteristics and opinions of surgeons; family physicians and rheumatologists; patients' severity of disease before knee replacement; access to knee-replacement surgery; surgeons' use of other surgical treatment; and county population characteristics.County utilization rates of knee replacement in Ontario, Canada.Counties that had higher rates of knee replacement had older patients (P = 0.0001), higher percentage of medical school affiliated hospital beds (P = 0.04), with more male (P = 0.02) non-North American trained referring physicians (P = 0.002) and orthopedic surgeons who had higher propensities to operate and better perceptions of outcome (P = 0.0001).After controlling for population characteristics and access to care (including the number of hospital beds, and the density of orthopaedic and referring physicians), orthopaedic surgeons' opinions or enthusiasm for the procedure was the dominant modifiable determinant of area variation. Thus, research needs to focus on the opinions of surgeons which may be important in reducing regional variation for knee replacement.

A prospective, observational cohort investigation was performed to help understand the impact of knee replacement on patients with knee osteoarthritis in community practice. Of those, 291 patients (330 knees) were eligible and willing to participate. Forty-eight orthopaedic surgeons referred 563 patients from 25 institutions within the state of Indiana. Demographics, patient completed health status, satisfaction, independent radiographic measures, surgeon reported intraoperative factors, hospital discharge factors, and independent physical examinations were recorded. A minimum 2-year followup was obtained in 92% of the patients. At followup, 88% were satisfied, 3% were neutral, and 9% were dissatisfied with the results of their knee surgery. The physical composite score improved from 27.4 +/- 0.4 (range, 13.3-50.3) to 37.7 +/- 0.7 (range, 12.9-61.3) at two years. Maximal improvement in physical composite score was seen in patients who had their surgery performed in institutions that performed greater than 50 knee replacements per year in patients with Medicare insurance; who had a better mental health status at baseline; who had surgery performed on Monday, Friday, or Saturday; who were older; who were treated with a posterior cruciate sparing device; and who had worse preoperative function. A lower likelihood of complications were found with surgeons who performed greater than 20 knee replacements per year; midweek surgeries; in patients with more severe preoperative knee dysfunction; patients with fewer comorbidities; patients with less preoperative stiffness; patients being treated by younger surgeons; and in patients undergoing unilateral knee replacement. Among voluntarily participating physicians, knee replacement can be a highly effective medical technology with high levels of patient satisfaction and low rates of complications.

BACKGROUND Most patients with osteoarthritis (OA) are treated by primary care physicians (in this article, primary care physicians are family physicians and general internists). OBJECTIVE To describe and compare the self-reported practice patterns of family physicians and general internists for the evaluation and management of severe OA of the knee, including factors that might influence referral for total knee replacement. DESIGN, SETTING, AND PARTICIPANTS A survey was developed and mailed to randomly selected community family physicians and general internists practicing in Indiana. MAIN OUTCOME MEASURE Self-reported physician practice patterns regarding OA of the knee. RESULTS Physical examination was the most common method of evaluating OA of the knee. Family physicians were more likely to examine for crepitation, joint stability, and quadriceps muscle strength than were general internists (P

The level of healthcare expenditures is higher at all levels of government than most politicians or citizens wish to tolerate. Purchasers of health-insurance benefits (private and public), management of integrated health plans and patients question whether the premiums they pay are reasonable. Regulatory agencies worry whether the products they approve are safe and efficacious. All payers are concerned as to whether medical technologies will be used as intended and cost effectively. Thus, many parties in healthcare systems worldwide are asking whether they are getting ‘value for money’ and what they may do to ensure that the services they pay for or approve are cost effective. Pharmaceuticals are obviously an important component in the treatment and prevention of chronic and acute disease. In the management of chronic and infectious disease, for example, drugs are playing an even more important role in increasing the quality of life than are other interventions. Yet drugs can be very expensive, especially new, innovative ones. More so than with other services, purchasers, especially governments and health plans, are especially cognisant of the price they pay for drugs and how the price/value relationship for new drugs compares with other drugs and treatments for a given disease. Similarly, regulatory agencies with responsibilities for determining which drugs may be marketed or included on a national formulary must be certain that new drugs meet their regulatory mandates, including those regarding the relationship between effectiveness and cost. Thus, for slightly different reasons, it is not a surprise that regulatory authorities and private and public purchasers alike are beginning to scrutinise the costs, marketing claims and effectiveness of new drugs they are being asked to approve or buy. However, how far such agencies go towards mandating such reviews may depend on the market in which the drugs are being reviewed and on the answers to several related questions: • what is the role of such studies? • are drugs being held to a higher standard than other procedures or treatments and should they be? • should the nature of required pharmacoeconomic studies be mandated? • what standard of evidence is desirable so that better decisions can be made using pharmacoeconomic studies?

We develop a synthetic difference-in-differences statistical design to apply to experimental data for adult women living in Hennepin County, Minnesota, to estimate the impact of Medicaid managed care on various modes of medical care use.Because the outcomes of interest are utilization counts with many persons using none of a particular mode of care we use count regression models that are adjusted for excessive zeros.We find no reductions in physician visits or hospital inpatient and emergency department care use, but reductions in hospital outpatient care.Simulations designed to judge the economic significance of our results suggest a program effect that is a savings of about ten percent.

This chapter examines the emergence of managed care in Medicaid from an alternative to the mainstream delivery system for many beneficiaries. It offers a definition that encompasses the broad spectrum of program manifestations, and presents a brief historical perspective on the major eras of managed care in Medicaid, The major program prototypes are described and their contribution to enrollment growth is discussed. Research evidence is examined to address both operational issues and program impacts. Finally, we conclude with an appraisal of contemporary issues of importance and speculation on the next generation of Medicaid managed care programs with an eye to how federal and state health care reform proposals will shape this future.

The documented growing morbidity, mortality, and disability from asthma indicate a failure in effective delivery of appropriate care. This article reviews how different components of organizational technology in hospitals, free-standing emergency centers, physician practices, prepaid groups, and schools may be linked to asthma care and asthma outcomes. A framework to address how practice patterns, risk factors, and outcomes relate to organizational characteristics, such as time orientation, uncertainty, available technology, standardization of work, specialization of work, coordination, and control strategies, is presented.

Health Care Financing Administration data from 1985 to 1990 revealed 339,152 total knee arthroplasties of which 62,730 (18.6%) were bilateral procedures (simultaneous 112,922; staged 6 weeks, 4354; staged 3 months, 4524; staged 6 months, 9829; and staged 1 year 31,401). Medicare beneficiaries undergoing bilateral procedures were an average of 73 years of age; demographics revealed that among the various simultaneous and staged groups 57% to 69% were females, 90% were white, 85% to 90% had a diagnosis of osteoarthritis, and 30% to 40% were performed in rural hospitals. Between 1985 and 1990, surgical and vascular complications ranged from 2.4% to 4% and 4.1% to 6.8%, respectively, for all types of bilateral staged and simultaneous total knee arthroplasties. All differences were statistically significant. After controlling statistically for demographic variables and diagnoses, a surrogate for case mix, it was found that individuals electing simultaneous bilateral arthroplasties experienced twice the number of intensive care days than those choosing staged procedures. Days in the intensive care unit were double when done simultaneously instead of staged (0.48 versus 0.21). Nosocomial infections were similar within groups (10% versus 13%); however, wound infections were nearly half when done simultaneously (0.5% versus 1%) versus in a staged fashion. Length of stay and cost were much less for the simultaneous procedure group who were sicker as measured by the number of diagnoses. Mortality at 30 days was highest for the simultaneous procedure group (.99%) versus staged 3 or 6 months (0.30%); however, by 2 years it was close to 4% for all groups. Staging the procedure 3 to 6 months seems to offer the fewest disadvantages, is only slightly more expensive, and has the lowest mortality rate.