Economic impact on physicians and hospitals of proposed changes in Medicare reimbursement for coronary interventions

BACKGROUND: The federal government is implementing changes in reimbursement for angioplasty and coronary stenting. These include reductions in physician reimbursement and a redesignation of intracoronary stents to a different diagnosis-related group than other methods of intracoronary intervention. OBJECTIVE: The aim of this study was to examine the financial impact on physicians and hospitals of proposed federal reimbursement policies for percutaneous coronary revascularization procedures. METHODS: We modeled the financial effects of 3 different stenting strategies: strategy I is the most conservative, with stents reserved for addressing lab complications; strategy II stents are used for suboptimal results after attempts at conventional percutaneous transluminal coronary angioplasty (PTCA); strategy III is the most aggressive, with initial stenting of all accessible lesions. We used economic data on PTCA and stent costs from a 1996 dataset and made assumptions about PTCA and stent success rates and restenosis rates based on published data. RESULTS: Under current reimbursement policies, physician revenues and profits are approximately equal under all 3 stenting strategies. After the proposed changes, there is a slight financial incentive for physicians to pursue the more aggressive strategy III, but the major financial effect is a substantial overall decline in revenues with any of the 3 strategies. For hospitals, the present situation strongly favors the more conservative strategies, but after the proposed changes the more aggressive stenting strategies will be more profitable, thus realigning physician and hospital incentives. Health care delivery organizations that combine physician and hospital income streams achieve the greatest financial stability. CONCLUSIONS: Current reimbursement policies for angioplasty and stenting have created misaligned incentives between physicians and hospitals. Proposed changes do not present physicians with large economic incentives to pursue aggressive versus conservative stent strategies but substantially address the current disparity in hospital financial incentives.     

Wanted: Champions of psychiatric rehabilitation.

Psychiatric rehabilitation has been shown to significantly impact the course of severe mental illness. Unfortunately, its impact has been muted by organizational barriers that impede implementation of these strategies in many treatment settings. Identifying champions from the ranks of the treatment team who will be responsible for start-up and maintenance of treatment innovations is one of many strategies that helps overcome these barriers. Some psychologists have excellent credentials for assuming the role of champion. Implications for becoming leaders of program development in terms of its impact on the psychologist's role per se are discussed. If more psychologists are to become active leaders in program development in hospital settings, graduate schools need to commit greater resources toward recruiting and training students in this area. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Early office-based vs late hospital-based nasolacrimal duct probing. A clinical decision analysis

BACKGROUND: Controversy exists regarding the treatment of infants with symptomatic nasolacrimal duct obstruction. One philosophy advocates "early" nasolacrimal duct probing, generally in the office. An alternate strategy advocates medical management until the infant is approximately 12 months old to allow for spontaneous resolution, with those with persistent nasolacrimal duct obstruction usually treated by "late" probing in the hospital with the use of general anesthesia. METHODS: We used clinical decision analysis to compare these two opposing treatment strategies. A decision tree was constructed with the usual designations for probability nodes and decision points, comparing early probing at 6 months of age in the office and late probing at 12 months of age in the hospital. The initial decision point thus addressed treatment of children who still had symptomatic nasolacrimal duct obstruction at 6 months of age. One repeated probing under same-strategy conditions was performed for patients in whom initial office probing failed. Values for probability nodes were derived from the ophthalmic literature, including a 70% rate of spontaneous resolution of nasolacrimal duct obstruction between the ages of 6 and 12 months. RESULTS: Both the early office probing strategy and the late hospital probing strategy yielded success rates greater than 99%. Based on prevailing fees, the late hospital strategy cost $2,310,000 more than the early office strategy per 10,000 patients, even though fewer procedures were performed. CONCLUSION: Early office probing and late hospital probing have similar high success rates, albeit at a higher cost for the late hospital probing strategy.     

Ostracism: How much it hurts depends on how you remember it.

Substantial evidence demonstrates that ostracism has powerful negative effects on psychological well-being. However, little is known about how to ameliorate the negative effects of this ubiquitous social experience. A key preliminary strategy for developing effective methods to reduce the negative impact of ostracism is to examine factors that influence the persistence of these effects. Therefore, the authors examined whether the persistence of these negative effects is dependent on the vantage perspective from which an experience of exclusion is recalled. Using a virtual ball-toss game, being ostracized elicited an immediate aversive effect; furthermore, these effects persisted when individuals recalled the experience from an observer perspective compared with a field perspective. This study shows, for the first time, that the persistence of the debilitating effects of ostracism is influenced by how individuals recall that experience. These results have implications for the development of ameliorative strategies to manage the impact of social exclusion. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Screening to prevent renal failure in insulin dependent diabetic patients: an economic evaluation

OBJECTIVE: To examine the conditions necessary to make screening for microalbuminuria in patients with insulin dependent diabetes mellitus cost effective. DESIGN: This economic evaluation compared two strategies designed to prevent the development of end stage renal disease in patients with insulin dependent diabetes with disease for five years. Strategy A, screening for microalbuminuria as currently recommended, was compared with strategy B, a protocol in which patients were screened for hypertension and macroproteinuria. INTERVENTION: Patients identified in both strategies were treated with an angiotensin converting enzyme inhibitor. SETTING: Computer simulation. MAIN OUTCOME MEASURES: Strategy costs and quality adjusted life years (QALYs). RESULTS: The model predicted that strategy A would produce an additional 0.00967 QALYs at a present value cost of $261.53 (1990 US$) per patient (or an incremental cost/QALY of $27,041.69) over strategy B. The incremental cost/QALY for strategy A over B was sensitive to several variables. If the positive predictive value of screening for microalbuminuria (impact of false label and unnecessary treatment) is < 0.72, the effect of treatment to delay progression from microalbuminuria to macroproteinuria is < 1.6 years, the cumulative incidence of diabetic nephropathy falls to < 20%, or > 64% of patients demonstrate hypertension at the onset of microalbuminuria, then the incremental costs/QALY will exceed $75,000. CONCLUSION: Whether microalbuminuria surveillance in this population is cost effective requires more information. Being aware of the costs, recommendation pitfalls, and gaps in our knowledge should help focus our efforts to provide cost effective care to this population.     

Modeling Interfirm Dependency: Game Theoretic Simulation to Examine the Holdup Problem in Project Networks

Subcontractor selection strategies used by contractors can significantly affect short-term project and long-term organizational success. Existing research on subcontractor selection strategy implicitly assumes that the evaluation of subcontractors depends on current conditions. We extend this perspective by integrating an agent-based simulation model with game theory to examine whether precontract partner selection strategies that do not consider subcontractor selection as a repeated game may lead to a version of the holdup problem. The holdup problem we investigate focuses on relationship-specific investments in learning after the introduction of an innovation or organizational change across a project network. A minimum total cost strategy may decelerate the rate of adaptation to an innovation or organizational change, thereby proving that the holdup problem can exist in project networks. The findings contribute to subcontractor selection strategy literature by simulating the impact of the holdup problem in project networks, distinguishing task interdependence as a moderating variable, and identifying that the minimum total cost strategy can be a suboptimal strategy for project networks adapting to systemic changes.     

Management service organizations: effective strategy to assume and manage full risk agreements?

A management services organization (MSO) has emerged as one structure to manage professional and hospital risk agreements. Health plans and direct payers are transferring traditional functions to medical groups and health systems under these agreements. How does a hospital and affiliated medical group develop a strategy to assume, manage, and mutually benefit from these agreements? When do market forces dictate whether an MSO is the most appropriate organizational model to utilize? The development of an MSO can offer an effective organizational strategy to capture capitated contracts and assume responsibility for population-based medical services. This article explores the features of such an organization, areas for potential collaboration between the medical group and hospital, as well as the impact on patient care.     

Studies of prosody perception by cochlear implant patients

Prosodic information is conveyed to normally-hearing listeners by variations in acoustic fundamental frequency, amplitude envelope, and duration of speech segments. This study measured cochlear implant patients' sensitivity to these parameters in electrically coded speech. The psychophysical discrimination of electric parameters used to code prosodic information, were examined, together with prosody perception using speech processing strategies which modified the contributions of these parameters. Patients were implanted with the Cochlear Limited prosthesis and used the MPEAK speech processing strategy. In the psychophysical studies, difference limens were measured for steady-state and time-varying stimuli, of different pulse rates and pulse durations, over a series of different stimulus durations. These limens were obtained using an adaptive procedure which converged on the 50 per cent correct point. In the prosody perception studies, performance was measured for the MPEAK strategy and for strategies which modified the contributions of pulse rate and pulse duration. Data were collected for five tests of prosodic contrasts. Difference limens for steady-state pulse rates were larger at higher rates (17 per cent at 400 pulses/s) than at lower rates (6 per cent at 100 pulses/s). For some patients, limens for the time-varying pulse rates were larger than those for the steady-state pulse rates while for the other patients, the limens were similar. Difference limens for pulse duration were 0.3 dB, corresponding to 4 per cent of the dynamic range, for steady-state stimuli and doubled in size for the time-varying stimuli. Prosody perception performance was generally poorer for the modified strategies than for the MPEAK strategy, suggesting that the removal of information coded by pulse rate and pulse duration reduced the perception of prosodic contrasts.     

Choosing the Right Parameter for Single-Duct Constant Air Volume System Supply Air Temperature Reset

To improve system efficiency under part-load conditions, the supply air temperature set point for a single-duct constant air volume air handling unit (AHU) system is often reset based on either return air temperature or outside air temperature. Both reset strategies make engineering sense as long as the reset schedules are reasonable. Quite often the decision to use one over the other is made with the assumption that they will both achieve some energy savings. However, the impact of these two strategies on AHU energy consumption could be very different. An in-depth analysis and comparison of these two commonly used supply air temperature reset strategies for a single-duct constant air volume system is presented in this paper. It is shown that the reset strategy based on outside air temperature is inherently better than that based on return air temperature, with lower energy consumption and improved building comfort level.     

Strategies for revising judgment: How (and how well) people use others’ opinions.

A basic issue in social influence is how best to change one’s judgment in response to learning the opinions of others. This article examines the strategies that people use to revise their quantitative estimates on the basis of the estimates of another person. The authors note that people tend to use 2 basic strategies when revising estimates: choosing between the 2 estimates and averaging them. The authors developed the probability, accuracy, redundancy (PAR) model to examine the relative effectiveness of these two strategies across judgment environments. A surprising result was that averaging was the more effective strategy across a wide range of commonly encountered environments. The authors observed that despite this finding, people tend to favor the choosing strategy. Most participants in these studies would have achieved greater accuracy had they always averaged. The identification of intuitive strategies, along with a formal analysis of when they are accurate, provides a basis for examining how effectively people use the judgments of others. Although a portfolio of strategies that includes averaging and choosing can be highly effective, the authors argue that people are not generally well adapted to the environment in terms of strategy selection. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cost comparison of immediate angioplasty versus thrombolysis followed by conservative therapy for acute myocardial infarction: a randomized prospective trial. Mayo Coronary Care Unit and Catheterization Laboratory Groups

OBJECTIVE: Immediate angioplasty and thrombolysis followed by conservative therapy are treatment strategies for acute myocardial infarction. The objective of this study was to compare the costs of these two strategies during a 12-month period. METHODS: Of 103 patients with acute myocardial infarction who sought medical assistance within 12 hours after onset of symptoms, 4 were excluded from analysis for various reasons, 51 received tissue plasminogen activator, and 48 underwent immediate angioplasty as the initial revascularization strategy. The main outcome determinants were direct monetary costs and indirect measures of costs, including duration of hospital stay and return to work. RESULTS: No significant difference in monetary costs between the two initial treatment strategies could be demonstrated. A trend was noted toward a briefer hospital stay and fewer late in-hospital procedures for patients treated initially with immediate angioplasty. Other measures of indirect costs were not statistically different. CONCLUSION: The hypothesis that thrombolysis followed by conservative therapy would be more cost-effective than immediate angioplasty in the treatment of patients with acute myocardial infarction could not be substantiated. The two strategies seem to have similar cost-effectiveness.     

Imaging of the recurrence of colorectal cancer

'Joy-riding' is the term used, somewhat inappropriately, for the offence of taking a vehicle without the owner's consent. In certain areas, mainly deprived inner-city estates, there has been an increase in this crime. The aim of this study was to investigate its impact on the workload of an inner-city teaching hospital's busy accident and orthopaedic departments. In this prospective study, all patients admitted to hospital as a result of road-traffic accidents (RTAs) were identified during a 9 month period. A total of 1576 patients were admitted to the trauma unit. One hundred and fifty-two admissions were as a result of RTA and 20 (13 per cent) of these patients had injuries as a result of car crime. Of this group, eight were severely injured (ISS > 16) and six of these were innocent bystanders. Three patients (one joy-rider and two innocent bystanders) died as a result of car crime. The average length of hospital stay was 12 days (1-62 days) and the hospital in-patient costs were estimated to be at least 5200 pounds per patient. Injuries related to car crime results in a significant amount of work and financial cost to the National Health Service.     

Evaluation of the endomysial antibody for celiac disease: operating properties and associated cost implications in clinical practice

OBJECTIVE: To evaluate the operating properties of endomysial antibodies (EMAs) in the diagnosis of celiac disease and to examine, using a cost minimization model, different strategies used in the diagnosis of celiac disease. METHODS: A total of 248 EMA results were reviewed and compared with small bowel biopsy results in 66 patients who had undergone both tests. Regression analysis was used to look for predictors of positive EMA results and positive biopsy results. A cost minimization model from a societal perspective was used to evaluate the cost differences among three different strategies. RESULTS: EMAs had a sensitivity of 95% and specificity of 64%. The only predictor of a positive biopsy result that reached statistical significance was a positive EMA. The strategy of EMA as a diagnostic test for celiac disease was the most expensive strategy, with a cost of $3,174 per patient assessed. The strategy of small bowel biopsy for all patients had a cost of $997, and a strategy of EMA followed by small bowel biopsy for positive patients had a cost of $866 per patient. The results were sensitive to cost of a gluten-free diet, the specificity of the EMA and the cost of a small bowel biopsy. CONCLUSION: The EMA is best used as a screening test from both a clinical and cost perspective.     

Environmental Impact of Solid Waste Treatment Methods in Korea

The environmental impact of various solid waste treatment methods being used in Korea was assessed to provide useful information for decision making in solid waste management strategy. Among the treatment methods considered, the incineration method and the anaerobic digestion method are the most environmentally friendly, while the landfill method has the highest environmental impact. Regarding the life cycle of the treatment methods, the environmental impact of the main treatment stage is the largest, contributing 46–94% of the total impact, depending on the treatment method. The environmental impact due to wastewater treatment was 6.2, 0.2, 4.1, and 9.0% for landfilling, incineration, composting, and anaerobic digestion, respectively. Among the environmental impact categories considered, global warming, eutrophication, and acidification are the key contributors to environmental impact, with a range of 53 to 91% of the total environmental impact depending on the selected treatment method. Of these key contributors, global warming has the largest contribution. Other contributors to environmental impact, such as photochemical oxidant creation, abiotic resource depletion, and ozone depletion, contribute little to the total environmental impact. These results make it possible to construct an environmental data set and examine the environmental impact of the life cycle of various waste treatment methods to support decision making in solid waste management strategy.     

An economic analysis of different strategies of immunization against hepatitis A virus in developed countries

Acute hepatitis A is a major public health problem in developed countries, and because a large proportion of patients with acute hepatitis A do not have any identifiable risk factors, current practice of targeting the high-risk groups for vaccination against hepatitis A virus (HAV) is unlikely to have a significant impact on the overall incidence of acute hepatitis A. No economic analysis of strategies of mass immunization against HAV is available. Three different strategies of immunization against HAV using commercially available inactivated vaccine were compared in a Markov model analysis of a cohort of 2-year-old healthy children in a developed country. In strategy I, universal vaccination was pursued. In strategy II, children were initially screened for antibody and, if susceptible, they were vaccinated. In strategy III, no vaccination was offered. Cost per person and quality adjusted life-years (QALY) gained in each strategy were the outcome measures compared. The baseline analysis showed that strategy II is more cost-effective than strategy I, with marginal cost-effectiveness ratios of $7,267. 67 and $12,833.34, respectively, compared with a strategy of no intervention. Sensitivity analysis showed that if the cost of the two-dose vaccine could be reduced to less than $57, the strategy of universal vaccination would be the preferred immunization strategy. Different strategies of mass immunization against HAV in the developed countries are cost-effective by current standards of health care interventions and should be considered for incorporation into current childhood immunization programs.     

StgR, a new Streptomyces alboniger member of the LysR family of transcriptional regulators

Many of the current tuberculosis control programmes in the Russian Federation are based on costly strategies which are underfunded and use long, individualized treatment regimens. This article compares, using a cost-effectiveness analysis, the new WHO strategy implemented in the Ivanovo Oblast (case-finding among symptomatic patients (SCF) and shorter regimens) and the old strategy (active screening of the asymptomatic population (ACF) and longer regimens). The cost per case cured was calculated at different levels of cure rate (45-95%) using three scenarios to describe the new WHO strategy (use of WHO-recommended regimens and three options at increasing rates of admission) and a fourth scenario to describe the old strategy (all patients admitted for the whole treatment and longer regimens). The cost per case detected was determined by calculating the following: yield of the new and old strategy (number of examinations necessary to diagnose one case); cost of the diagnostic process; multiplying yield per cost according to the three scenarios describing the new WHO strategy and a fourth scenario describing the old strategy. In the Ivanovo Oblast the cost per case cured, at 85% cure rate level, ranged from US$ 1197 (new strategy, scenario 1 without food) to US$ 6293 (old strategy, scenario 4) the cost per case detected ranged from US$ 1581 (new strategy, scenario 1) to US$ 4000 (old strategy, scenario 4). Significant savings can result from shifting towards the new WHO strategy. Decision-makers and health administrators should be responsible for re-investing the financial and human resources mobilized by the adoption of cost-effective strategies within the TB control programme.     

Strategic information provision and experiential variety as tools for developing adaptive leadership skills.

The development of adaptability skills is critical for organizational success and survival, yet traditional training interventions are not sufficient to promote adaptive expertise. In this article, we summarize prior research on two training techniques that develop such expertise: experiential variety and strategic information provision in the form of instructions, performance feedback, and cognitive/behavioral guidance. Prior integrative reviews have described how these strategies can promote adaptability by fostering skills in cognitive frame-switching and flexibility. We extend these arguments in the present article by reviewing prior research that supports the use of experiential variety and strategic information provision as elements of an adaptability training strategy. We examine the use of these elements not only in formal training (which was the prime focus of prior reviews), but also in developmental work experiences and in self-development. Additionally, we include a more specific focus on developing cross-cultural adaptability skills through these training techniques. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Influence of dispositional coping strategies on physical complaints and life satisfaction in the elderly

Well-being and mental and physical health in old age are influenced in a significant way by the fact that it is possible to cope successfully with ongoing hazards, threats and problems. In recent years coping research has shown increasing interest in coping processes in the elderly. Most of the studies are focused on age-related differences in coping processes and on the issue of change or stability of coping in old age. However, the goal of our study was to examine the impact of dispositional coping strategies, conceptualized as consistent personality characteristics, on physical complaints and life satisfaction among the elderly. We recurred on the model of coping modes by Krohne, which postulates two statistically independent person-specific coping dimensions named "vigilance" and "cognitive avoidance". Based on this model it is possible to identify the "classical" coping styles of "sensitization" (high vigilance and low cognitive avoidance) and "repression" (low vigilance and high cognitive avoidance). In our study, including 766 subjects older than 60 years, we found a higher frequency of "repressors" than of "sensitizers". Results show that dispositional coping strategies are significant moderator variables of both physical complaints and life satisfaction: Older people who prefer a cognitive-avoidant coping strategy ("repressors") are more satisfied with their life and have less complaints than "sensitizers".