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Annual circulation of influenza viruses causes substantial disease and death worldwide, disproportionately affecting young children and older adults (2,2). Globally, influenza causes [approximately equal to] 9.4 million hospitalizations each year [...]

Background Patients with multimorbidities have the greatest healthcare needs and generate the highest expenditure in the health system. There is an increasing focus on identifying specific disease combinations for addressing poor outcomes. Existing research has identified a small number of prevalent 'clusters' in the general population, but the limited number examined might oversimplify the problem and these may not be the ones associated with important outcomes. Combinations with the highest (potentially preventable) secondary care costs may reveal priority targets for intervention or prevention. We aimed to examine the potential of defining multimorbidity clusters for impacting secondary care costs. Methods and findings We used national, Hospital Episode Statistics, data from all hospital admissions in England from 2017/2018 (cohort of over 8 million patients) and defined multimorbidity based on ICD-10 codes for 28 chronic conditions (we backfilled conditions from 2009/2010 to address potential undercoding). We identified the combinations of multimorbidity which contributed to the highest total current and previous 5-year costs of secondary care and costs of potentially preventable emergency hospital admissions in aggregate and per patient. We examined the distribution of costs across unique disease combinations to test the potential of the cluster approach for targeting interventions at high costs. We then estimated the overlap between the unique combinations to test potential of the cluster approach for targeting prevention of accumulated disease. We examined variability in the ranks and distributions across age (over/under 65) and deprivation (area level, deciles) subgroups and sensitivity to considering a smaller number of diseases. There were 8,440,133 unique patients in our sample, over 4 million (53.1%) were female, and over 3 million (37.7%) were aged over 65 years. No clear 'high cost' combinations of multimorbidity emerged as possible targets for intervention. Over 2 million (31.6%) patients had 63,124 unique combinations of multimorbidity, each contributing a small fraction (maximum 3.2%) to current-year or 5-year secondary care costs. Highest total cost combinations tended to have fewer conditions (dyads/triads, most including hypertension) affecting a relatively large population. This contrasted with the combinations that generated the highest cost for individual patients, which were complex sets of many (6+) conditions affecting fewer persons. However, all combinations containing chronic kidney disease and hypertension, or diabetes and hypertension, made up a significant proportion of total secondary care costs, and all combinations containing chronic heart failure, chronic kidney disease, and hypertension had the highest proportion of preventable emergency admission costs, which might offer priority targets for prevention of disease accumulation. The results varied little between age and deprivation subgroups and sensitivity analyses. Key limitations include availability of data only from hospitals and reliance on hospital coding of health conditions. Conclusions Our findings indicate that there are no clear multimorbidity combinations for a cluster-targeted intervention approach to reduce secondary care costs. The role of risk-stratification and focus on individual high-cost patients with interventions is particularly questionable for this aim. However, if aetiology is favourable for preventing further disease, the cluster approach might be useful for targeting disease prevention efforts with potential for cost-savings in secondary care., Author(s): Jonathan Stokes 1,*, Bruce Guthrie 2, Stewart W. Mercer 2, Nigel Rice 3, Matt Sutton 1 Background There are several outcomes that are important to health systems. However, especially [...]

OBJECTIVES: This study examines the socio-economic gradient in utilization and the risk factors associated with hospitalization for four pediatric ambulatory care sensitive conditions (dental conditions, asthma, gastroenteritis, and bacterial pneumonia). Dental conditions, where much care is provided by dentists and insurance coverage varies among different population segments, present special issues. METHODS: A population registry, provider registry, physician ambulatory claims, and hospital discharge abstracts from 28 398 children born in 2003-2006 in urban centres in Manitoba, Canada were the main data sources. Physician visits and hospitalizations were compared across neighbourhood income groupings using rank correlations and logistic regressions. RESULTS: Very strong relationships between neighbourhood income and utilization were highlighted. Additional variables--family on income assistance, mother's age at first birth, breastfeeding--helped predict the probability of hospitalization. Despite the complete insurance coverage (including visits to dentists and physicians and for hospitalizations) provided, receiving income assistance was associated with higher probabilities of hospitalization. CONCLUSIONS: We found a socio-economic gradient in utilization for pediatric ambulatory care sensitive conditions, with higher rates of ambulatory visits and hospitalizations in the poorest neighbourhoods. Insurance coverage which varies between different segments of the population complicates matters. Providing funding for dental care for Manitobans on income assistance has not prevented physician visits or intensive treatment in high-cost facilities, specifically treatment under general anesthesia. When services from one type of provider (dentist) are not universally insured but those from another type (physician) are, using rates of hospitalization to indicate problems in the organization of care seems particularly difficult. KEY WORDS: Pediatric dental conditions; early childhood caries; physician visits; hospitalizations; birth cohorts; socio-economic gradient OBJECTIFS : Notre etude porte sur le gradient socioeconomique du recours a l'hospitalisation et sur les facteurs de risque associes pour quatre conditions pediatriques propices aux soins ambulatoires (problemes dentaires, asthme, gastroenterite et pneumonie bacterienne). Les problemes dentaires presentent des enjeux particuliers, car la plupart sont traites par des dentistes, et la couverture d'assurance de ces soins varie selon le segment demographique. METHODE : Nos donnees provenaient principalement d'un registre de population, d'un registre des fournisseurs, des demandes de paiement des medecins pour consultations en medecine ambulatoire et du registre des sorties des hopitaux de 28 398 enfants nes entre 2003 et 2006 dans les centres urbains du Manitoba, au Canada. Nous avons compare les visites chez le medecin et les hospitalisations pour differents groupes de revenu selon le quartier a l'aide de correlations des rangs et de regressions logistiques. RESULTATS : Des liens tres solides sont apparus entre le revenu selon le quartier et le recours a l'hospitalisation. D'autres variables--le fait pour la famille de toucher une aide au revenu, l'age de la mere a la premiere naissance, l'allaitement maternel - ont aide a predire la probabilite d'hospitalisation. Malgre la couverture d'assurance complete assortie a l'aide au revenu (y compris les visites chez le dentiste et le medecin et les hospitalisations), le fait de toucher une telle aide etait associe a des probabilites d'hospitalisation superieures. CONCLUSIONS : Nous avons constate la presence d'un gradient socioeconomique dans le recours a l'hospitalisation pour les conditions pediatriques propices aux soins ambulatoires, avec des taux de visites sur pied et d'hospitalisation plus eleves dans les quartiers les plus pauvres. La couverture d'assurance, qui varie selon le segment demographique, complique encore les choses. Le financement des soins dentaires des Manitobains prestataires de l'aide au revenu n'a pas empeche les visites chez le medecin ni les traitements intensifs dans des installations a cout eleve, plus precisement les traitements sous anesthesie generale. En l'absence d'une couverture universelle des services d'une categorie de fournisseurs (les dentistes) alors qu'une telle couverture existe pour les services d'une autre categorie de fournisseurs (les medecins), il semble particulierement difficile d'utiliser les taux d'hospitalisation pour reperer des problemes dans l'organisation des soins. MOTS CLES : problemes dentaires pediatriques; caries du jeune enfant; visites chez le medecin; hospitalisations; cohortes de naissance; gradient socioeconomique, Appropriate care in primary care physicians' offices is presumed to prevent expensive hospitalizations for untreated conditions. (1) 'Timely and effective outpatient care can help to reduce the risks of hospitalization [...]

Purpose: The purpose of this study was to quantify the effect of specific nursing home features and state Medicaid policies on the risk of hospitalization among cognitively impaired nursing home residents. Design and Methods: We used multilevel logistic regression to estimate the odds of hospitalization among long-stay (>90 days) nursing home residents against the odds of remaining in the nursing home over a 5-month period, controlling for covariates at the resident, nursing home, and county level. We stratified analyses by resident diagnosis of dementia. Results: Of 359,474 cognitively impaired residents, 49% had a diagnosis of dementia. Of those, 16% were hospitalized. The probability of hospitalization was negatively associated with the presence of a dementia special care unit (adjusted odds ratio [AOR] = 0.90, 95% confidence interval [CI] = 0.86-0.94) and with a high prevalence of dementia in the nursing home (AOR = 0.96, 95% CI = 0.88-1.03). Higher Medicaid payment rates were associated with reduced likelihood of hospitalization (AOR -- 0.95, 95% CI = 0.90-1.00), whereas any bed-hold policy substantially increased that likelihood (AOR = 1.44, 95% CI = 1.12-1.86). We observed similar results for residents without a dementia diagnosis. Implications: Directed management of chronic conditions, as indicated by facilities' investment in special care units, reduces the risk of hospitalization, but the effect of bed-hold policies illustrates how fragmentation in the financing system impedes these efforts. Key Words: Medicare, Nursing homes, Long-term care, Risk of hospitalization, Medicaid

Objective. We sought to determine the frequency and costs of hospitalization and to assess possible racial/ethnic disparities in a large cohort of low-income patients with diabetes who had received primary care at municipal health clinics. Methods. Administrative data from Philadelphia Health Care Centers were linked with discharge data from Pennsylvania hospitals for March 1993 through December 2001. We tested differences in hospitalization rates and mean hospital charges by age, gender, and race/ethnicity. Results. A total of 18800 patients with diabetes experienced 30528 hospital admissions, for a hospitalization rate of 0.35 per person-year. Rates rose with age and with the interaction of male gender and age. Rates for non-Hispanic Whites were higher than those for African Americans, whereas those for Hispanics, Asian Americans, and 'others' were lower. Patients who were hospitalized at least 5 times made up 10.5% of the study population and accounted for 64% of hospital admissions and hospital charges in this cohort. Conclusions. Hospitalization rates for this low-income cohort with access to primary care and pharmacy services were comparable to those of other diabetic patient populations, suggesting that reducing financial barriers to care may have benefited these patients. A subgroup of patients with multiple hospitalizations accounted for the majority of hospital admissions. (doi:10.2105/AJPH.2004.059600)

Objectives. This study assessed the economic burden of child abuse-related hospitalizations. Methods. We compared inpatient stays coded with a diagnosis of child abuse or neglect with stays of other hospitalized children using the 1999 National Inpatient Sample of the Healthcare Costs and Utilization Project. Results. Children whose hospital stays were coded with a diagnosis of abuse or neglect were significantly more likely to have died during hospitalization (4.0% vs 0.5%), have longer stays (8.2 vs 4.0 days), twice the number of diagnoses (6.3 vs 2.8), and double the total charges ($19266 vs $9513) than were other hospitalized children. Furthermore, the primary payer was typically Medicaid (66.5% vs 37.0%). Conclusion. Earlier identification of children at risk for child abuse and neglect might reduce the individual, medical, and societal costs. (Am J Public Health. 2004;94:586-590)

OBJECTIVE: This paper presents a framework for evaluation of alternative sources of estimates of the costs of hospital inpatient care in Australia, It argues that the choice of costing methods depends on the decision-context and the sensitivity of the decision to estimation errors. METHOD: Five criteria are proposed for evaluation of sources of hospital cost data, with detailed consideration of the way estimates are derived in two computerised approaches which use accounting data. Three broad approaches to cost estimation are evaluated against these criteria. RESULTS: Choosing an estimation method entails an optimisation analysis for each decision context. 'Microcosting' techniques remains the most valid approach to cost estimation, but are costly and this may, in turn, limit the sample of patients or institutions. Protocol-based cost estimates vary widely in their validity, depending on source data, but there is little justification for continued use of crude per diem cost estimates in such protocols. When precision and resolution are important objectives, clinical costing approaches provide the most valid inpatient cost estimates at a reasonable data cost. When external validity is important, or where standardisation of hospital costs is desired, use of published national cost weights may be preferred. CONCLUSION: Both primary and secondary sources of cost data must withstand challenges to internal and external validity. The 'resolution' (or precision) of cost estimates and the relative costs of collection must also be considered. IMPLICATIONS: Studies using estimates of the costs of hospital care should defend the appropriateness of the costing approach and data source for the decision context.

Introduction Stroke is one of the major causes of mortality and morbidity in older people and places a burden on scarce health care resources [1, 2]. As the incidence of [...]

The capacity of hospitals to exercise discretion in varying the intensity of their services relative to the expected sources of payment of the patient is analyzed. There have been no in-depth studies on how hospitals can reconstruct marginal costs for the payer to signify differences in reimbursement policies. A multiproduct cost function with hospital outputs is used to investigate this. Marginal costs of casemix-adjusted discharges are gathered and compared for Medicare, Medicaid, private payers and a residual category.

Amodel developed from the interview and hospital records of 7,527 Longitudinal Study on Aging respondents helps represent the usage level of Medicare-reimbursed hospital resources between 1984 and 1990. A logistic regression analysis revealed that the probability of hospitalization depended on lower body restrictions, previous hospitalization and physician consultation. OLS regression studies showed that the duration of stay, medical charges and number of episodes related to previous hospitalization, physician consultation and population density.

Patients may be more likely to receive substandard care at hospitals with fewer financial resources. Researchers examined the incidence of negligent medical injuries among 30,195 patients treated at 51 acute care hospitals in New York State during 1984. The hospitals with the lowest inpatient operating costs per patient had the highest incidence of medical injuries caused by negligence. Negligent medical injuries were more likely to occur at hospitals with fewer health care personnel to care for each patient. The effect of low inpatient operating costs was more pronounced at hospitals in financial crisis. These hospitals were more likely to treat indigent patients., Objective.--To assess the relationship among hospital financial characteristics, patient payer mix, and the incidence of negligent medical injuries. Design.--Retrospective medical record review linked to hospital financial reports. Setting.--Acute care hospitals in New York State in 1984. Population.--Stratified, random sample of 30 195 medical records from 51 acute care hospitals. Main Outcome Measures.--Hospital rates of medical injury and substandard care were developed from reviews of 30 195 medical records at 51 acute care hospitals in New York in 1984. Hospital-level variables representing financial status, hospital staffing, and the proportion of self-pay and Medicaid hospital discharges were compiled from a variety of secondary sources. Results.--The likelihood of negligent medical injury was highest in those hospitals with the lowest inpatient operating costs per hospital discharge (odds ration, 2.8; 95% confidence interval, 1.5 to 5.5). The effect of low inpatient operating costs was marked among hospitals in financial distress, many of which served indigent populations. Conclusions.--Patients admitted to hospitals that are unable to expend sufficient resources on patient care may be at higher risk of substandard care. Further study of the effect of hospital financial status on quality of care appears to be warranted. (JAMA. 1993;270:845-849)

Uninsured patients or those who are covered by Medicaid may be more likely to be hospitalized for conditions that can be treated on an out-patient basis or that can be avoided entirely than insured patients. A study examined the number of hospitalizations for 12 different avoidable hospital conditions (AHCs) among patients discharged from hospitals in Massachusetts and Maryland during 1987. Uninsured patients were more likely to be hospitalized for 10 AHCs in Massachusetts and for seven AHCs in Maryland than privately insured patients. Patients who were covered by Medicaid were more likely to be hospitalized for nine AHCs in Massachusetts and seven AHCs in Maryland than patients with private insurance. The AHCs included a ruptured appendix, asthma, cellulitis, congestive heart failure, diabetes, gangrene, severe hypertension and pneumonia.

In this paper a regional supply and demand model for hospital admissions is developed which can be used for policymaking and planning purposes. It incorporates spatial factors such as travel-time costs into a model of market equilibrium in which waiting time acts implicitly as the equilibrating device. By distinguishing travel-time costs or distances it is shown that both supply and demand within local markets strongly influence admissions in a way which cannot be observed on aggregated levels: the tension between supply and demand is cushioned by a strong redistribution of patients. The model encompasses several well-known models for patient flows and hospital utilization originating in regional economics.

Author(s): Terrie E Inder [sup.[[dagger]]] [sup.1] , Steve M Liao [sup.2] The rate of preterm birth continues to rise with more than half a million of infants born prematurely in [...]

Newborn infants who lack health insurance and those covered by Medicaid may not receive adequate hospital services. A survey of discharge data for 29,751 seriously ill newborn infants hospitalized in California in 1987 found that uninsured infants and infants covered by Medicaid were discharged sooner and had smaller hospital bills than infants covered by private insurance. Uninsured infants remained in the hospital for an average of 12.7 days, Medicaid-covered infants remained for an average of 14.2 days and infants covered by private insurance remained an average of 15.2 days. Care given to uninsured infants cost an average of $11,414, care given to Medicaid-covered infants cost an average of $13,858 and care given to privately-insured infants cost an average of $15,899. Cost per day was also less for uninsured and Medicaid-covered infants. This was true even though uninsured and Medicaid-covered infants had more serious health problems than privately-insured infants.