The cost of medical education

As the result of another study which identified the indirect costs at a large teaching hospital in which Monash University has established a clinical school, it has been possible to estimate the cost per annum for each medical student. This is the sum of direct university costs ($4,617), Tertiary Education Assistance Scheme ($1,200) and indirect costs ($44)--in aggregate therefore $5,900 (rounded). Thus the cost of the six-year course for each student is approximately $35,500.     

The institutional review board as a mirror of scientific and ethical standards

Decisions by institutional review boards (IRBs) are presumed to reflect the norms and standards of the scientific community. Such criteria have shifted as changes have occurred in experimental interventions and protocols, codes of federal regulatory agencies, norms among investigators, and expectations of participants. The tension created by shifting norms and standards raises two questions: (a) Should IRBs evaluate the scientific (e.g., design) features of the proposed research, and (b) should consistent standards be expected even in areas that are in constant flux (e.g., AIDS research)? We discuss these questions and propose a mechanism to keep IRBs abreast of emergent issues and sensitized not only to the costs of doing research but also to the costs of not doing it.     

The cost of cancer home care to families

BACKGROUND: For the most part, previous research on costs of cancer care has focused on the formal medical care costs. Research on home care for patients with cancer has emphasized direct care costs (expenditures). Among indirect costs, only loss of income to family members has been studied. However, a major component of indirect costs, the family labor expended to care for the patient with cancer, needs to be included for a more realistic appreciation of home care costs. METHODS: The costs of family labor are estimated by imputing monetary values for the time spent caring for the patient with cancer. The assigned monetary cost either is equated with income losses of the helper in question or is based on a putative market value of the expended labor time. In addition, out-of-pocket expenditures examined in this study cover all cancer care-related expenses for which the patient was not reimbursed by third parties. Data were obtained from a convenience sample of 192 patients with cancer and their families in lower Michigan. RESULTS: When family labor is included in the cost calculations, average cancer home care costs for a 3-month period ($4563) are not much lower than the costs of nursing home care. The substantial variation in home care costs (standard deviation [SD] = $4313) appears to be unrelated to the type of cancer diagnosis, type of treatment, or time since diagnosis but seems to be driven by the functional status of the patient and the family living arrangements. CONCLUSIONS: Outpatient care for patients with cancer coupled with greater reliance on home care appear to be economically attractive because costs to families usually are underestimated.     

Hospital costs--the medical student component

A study of indirect costs which could be attributed to undergraduate teaching in a large affiliated teaching hospital has shown that they are very small. Thus direct university costs in 1975 were $1,800,000 (7-6% of all expenditure at the hospital); indirect costs were $41,000 (approximately 0-2% of the hospital expenditure). It is concluded that the 45% difference in bed costs per day between teaching and non-teaching hospitals from a previous investigation is therefore not the result of the clinical school indirect demands on hospital expenditure.     

Pharmacokinetics of rifampin under fasting conditions, with food, and with antacids

OBJECTIVES: To test a method of measuring the related cost of acute otitis media (AOM) and to provide a preliminary calculation of the indirect and directs costs associated with a single, medically treated episode of AOM. DESIGN: The Otitis Media Diary was used to measure indirect and direct costs associated with AOM in a prospective cohort study. Measured values included the parental time spent in otitis-specific child care and the number and type of medications used. A previously developed economic model was used to calculate the monetary costs associated with the value of caregiver time and the total opportunity cost of AOM. SETTING: The pediatric clinic of Madigan Army Medical Center, Tacoma, Wash. PATIENTS: A cohort of 25 children (12 with AOM and 13 controls) aged 1 to 3 years. MAIN OUTCOME MEASURES: Caregiver time and medication use. RESULTS: The total cost attributable to AOM in the 3-month period following diagnosis was $1330.58 (95% confidence interval, $1008.75-$1652.43), with the majority of that cost stemming from the indirect, rather than direct, costs of illness. After conservative estimates of unmeasured expenses, such as clinic visits and transportation, were accounted for, indirect costs, accrued primarily by parental time, accounted for nearly 90% (95% confidence interval, 87.1%-92.3%) of the total 3-month cost associated with AOM and its medical treatment. The cost items of the Otitis Media Diary were also highly correlated with each other and with other measures of clinical and functional health status. CONCLUSIONS: Otitis Media Diary measures of parental time and medication use appear to provide a more accurate means of calculating the real social costs attributable to the AOM disease process in this cost-effectiveness analysis.     

Effect of Common Cause Failures on Indirect Costs

Next generation bridge management systems will take into consideration multiple hazard scenarios and not only traffic loading and structural deterioration as they do now. The indirect costs used in these bridge management systems to determine optimal management strategies vary according to the hazard scenarios considered. The difference depends on whether or not the bridge failures are due to a common cause, such as a single flood or earthquake, or due to load events that may be considered statistically unrelated, such as truck loads. To illustrate the effect of common cause bridge failures on indirect costs, two examples are presented that treat the failures first as if they are due to statistically independent loading events and then as if they are due to a common cause. To examine the effect of bridge failures on indirect costs of the system, estimation is performed at the network level. The first example, on a simple network, shows the indirect cost estimate for all of the network condition states. The second example, on a complex network, shows the difference in the possible reduction of total indirect costs with a single bridge intervention as well as the change in intervention sequence. The main conclusions are that total indirect costs and optimal intervention sequences differ depending on whether or not bridge failures are due to a common cause, and that the largest changes in indirect cost estimation occur when simultaneously failed bridges affect the method of indirect cost incurrence.     

The costs of child protection in the context of welfare reform

The financing structure of any large public service system both reveals the priorities held by policymakers and drives the delivery of services. Of the $11.2 billion in public funds for child welfare services, somewhat less than half is federal. As this article explains, federal funds for child welfare overwhelmingly go to support out-of-home care (foster care and adoption services), and these costs have risen sharply in recent years. In contrast, federal funding for child protection investigations, prevention programs, and treatment services is more limited, and expenditures have not risen apace with reports of maltreatment. The article compares the high cost of foster care with the lower per capita cost of cash assistance to poor families and the per-case costs of child protection investigations and service provision. Pointing out that the great majority of families served by the child welfare system are poor, the author argues that child welfare and cash assistance should be seen and analyzed as interrelated programs serving poor families. The article examines the varied ways in which the changes in cash assistance programs introduced by the 1996 federal welfare reform law may increase the need for child welfare services and drive up the costs of child protection.     

The economic cost of obesity: the French situation

OBJECTIVE: To estimate the economic burden of obesity in France. DESIGN: A prevalence-based approach identifying the costs incurred during a given year (1992) by obese subjects. MEASUREMENTS: Direct costs (personal health care, hospital care, physician services, drugs) and indirect costs (lost output as a result of cessation or reduction of productivity caused by morbidity and mortality); economic benefits due to the reduced incidence of hip fractures. RESULTS: The direct costs of obesity (BMI > or = 27) were 11.89 billion French Francs (FF), which corresponded to about 2% of the expenses of the French care system. Hypertension represented 33% of the total amount and cancer 2.5% of the direct cost of obesity. Indirect costs represented FF 0.6 billion. These are conservative estimates as far as all obesity-related diseases and all health care and indirect costs were not included due to missing information. CONCLUSION: These results were remarkably similar to previous reports on the economic costs of obesity in other western countries (USA, Sweden, Netherlands, Australia) which concluded that the cost of obesity amounted to around 2% to 5% of the total cost of health care in industrialized societies.     

Treatment adherence process research in family therapy: A rationale and some practical guidelines.

Suggests that treatment adherence research has recently established a permanent niche in psychotherapy outcome research as a means for testing whether interventions have been implemented as intended. Advanced-level adherence methods allow investigators to move beyond treatment integrity questions regarding model fidelity and toward treatment process questions regarding therapeutic technique and intervention dosage. Though still in the developmental stage, treatment adherence process procedures appear to be congruent with the methods, goals, and theoretical framework that characterize contemporary psychotherapy process research. Because adherence process research is virtually absent from the family therapy research literature, practical guidelines are presented for conducting observational-based adherence research on family therapy models, using the example of Multidimensional Family Therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Influence of Project Type and Procurement Method on Rework Costs in Building Construction Projects

While it is widely recognized that additional costs due to rework can have an adverse effect on project performance, limited empirical research has been done to investigate the influencing factors. The research presented in this paper aims to determine the influence of different project types and procurement methods on rework costs in construction projects. Using a questionnaire survey, rework costs were obtained from 161 Australian construction projects. The direct and indirect consequences of rework are analyzed and discussed. It is shown that, contrary to expectation, rework costs do not differ relative to project type or procurement method. In addition, it was found rework contributed to 52% of a project’s cost growth and that 26% of the variance in cost growth was attributable to changes due to direct rework. To reduce rework costs and therefore improve project performance, it is posited that construction organizations begin to consider and measure them, so that an understanding of their magnitude can be captured, root causes identified, and effective prevention strategies implemented.     

Teaching hospital costs: implications for academic missions in a competitive market

CONTEXT: As the managed care environment demands lower prices and a greater focus on primary care, the high cost of teaching hospitals may adversely affect their ability to carry out academic missions. OBJECTIVE: To develop a national estimate of total inpatient hospital costs related to graduate medical education (GME). DESIGN: Using Medicare cost report data for fiscal year 1993, we developed a series of regression models to analyze the relationship between inpatient hospital costs per case and explanatory variables, such as case mix, wage levels, local market characteristics, and teaching intensity (the ratio of interns and residents to beds). SETTING AND PARTICIPANTS: A total of 4764 nonfederal, general acute care hospitals, including 1014 teaching hospitals. MAJOR OUTCOME MEASURES: Actual direct GME hospital costs and estimated indirect GME-related hospital costs based on the statistical relationship between teaching intensity and inpatient costs per case. RESULTS: In 1993, academic medical center (AMC) costs per case were 82.9% higher than those for urban nonteaching hospitals (actual cost per case, $9901 vs $5412, respectively). Non-AMC teaching hospital costs per case were 22.5% higher than those for nonteaching hospitals (actual cost per differences in case, $6630 vs $5412, respectively). After adjustment for case mix, wage levels, and direct GME costs, AMCs were 44% more expensive and other teaching hospitals were 14% more costly than nonteaching hospitals. The majority of this difference is explained by teaching intensity. Total estimated US direct and indirect GME-related costs were between $18.1 billion and $22.8 billion in 1997. These estimates include some indirect costs, not directly educational in nature, related to clinical research activities and specialized service capacity. CONCLUSIONS: The cost of teaching hospitals relative to their nonteaching counterparts justifies concern about the potential financial impact of competitive markets on academic missions. The 1997 GME-related cost estimates provide a starting point as public funding mechanisms for academic missions are debated. The efficiency of residency programs, their consistency with national health workforce needs, financial benefits provided to teaching hospitals, and ability of AMCs to maintain higher payment rates are also important considerations in determining future levels of public financial support.     

Federal policies for research on children.

Federal policies for research on children have implications for individual investigators and for the direction and quality of the research they carry out. Preliminary analyses of patterns of support, management, and planning of research help reveal the nature of federal policies for research on children and how these policies may have affected research. Generally, policies for research on children are de facto outcomes of federal support of the sciences and domestic programs of the government that include children as clients. These latter, in turn, derive from chronic and acute historical developments such as the evolution of negotiated government contracting for research and the creation of politically sophisticated groups of professionals who deliver children's services. Examining how federal policies develop and change in response to such historical forces may contribute to understanding what is learned about children and their world through research. (14 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Rework in Civil Infrastructure Projects: Determination of Cost Predictors

Within Australia, civil engineering works continue to meet the insatiable demand for new infrastructure despite project complexity and cost and schedule overruns. A significant factor that can contribute to such overruns is rework; yet to date research into the root causes and consequential costs of rework in civil infrastructure projects has been limited. Using a questionnaire survey, rework costs and probable causes were obtained from 115 civil infrastructure projects. Stepwise multiple regression was then used to determine the significant variables that contributed to rework. The regression model revealed that the following five significant predictors accounted for 25% of the variance in total rework cost: (1) ineffective use of information technologies; (2) excessive client involvement in the project; (3) lack of clearly defined working procedures; (4) changes made at the request of the client; and (5) insufficient changes initiated by the contractor to improve quality. The findings also revealed that mean total rework costs were 10% of the contract value for the sample. Interestingly, the extent of rework experienced was significantly correlated with project cost and schedule growth (p<0.01). It is suggested that future work is required to determine the underlying factors that contribute to rework in civil infrastructure projects before effective preventive strategies can be identified.     

Cost Structure and Profitability of Design Services Industry

This paper is a financial analysis of several key parameters that affect the cost structure of design firms in the United States. Using results of surveys conducted over the past 15 years, we have examined the cost trends and profitability of design firms. The firms’ profitability is examined as a function of utilization and overhead rate and expense ratio. The impact of overhead caps imposed by public agencies and the reimbursement of CADD costs in public projects on the profitability of design firms are discussed. To evaluate these factors, the paper first discusses in detail the four elements of cost within the design services industry. These four elements are: direct salary costs, indirect salary-related costs, direct nonsalary costs, and general and administrative costs. These design costs are usually summarized and presented as labor, overhead, and direct nonsalary costs. A detailed analysis of the elements that comprise overhead and the key elements that affect overhead are presented. Profitability is then expressed in terms of the factors described, and the effect of overhead caps and nonreimbursement of CADD costs on the firms’ profit is quantified.     

A legislative view of Medicare and DRGs.

Discusses the prospective payment system of medical costs according to diagnosis-related groups (DRGs) rather than actual cost of treatment introduced by the federal government in response to rising costs. The impact and expansion of DRGs and alternatives for Congress are discussed. It is suggested that Congress and the administration need the encouragement of health care specialists to determine the kinds of changes needed to maintain quality medical care for the elderly. (8 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The pathophysiology of stress urinary incontinence in women and its implications for surgical treatment

OBJECTIVES: To estimate the total costs of multiple sclerosis (MS) for all Canadians in 1994. METHODS: Prevalence-based study estimating disease-related societal costs for Canadians with MS in 1994. The human capital approach was used to estimate the value of lost productivity due to illness. Two components were revealed: first, direct costs, in terms of expenditures on hospital care, other institutions, physician services, other health professionals, drugs, and other expenditures; and second, indirect costs, in terms of lost productivity due to premature mortality and disability. RESULTS: The total costs of MS for Canadians were $502.3 million in 1994, with direct and indirect cost components at $188.6 million and $313.7 million, respectively. CONCLUSIONS: This study highlights the scope and magnitude of the economic consequences of MS for Canadians. The costs calculated may be used to provide guidance in the setting of national priorities for research and prevention activities.     

The economic cost of musculoskeletal disorders in Canada

OBJECTIVE: This study estimated the total cost of musculoskeletal disorders for Canadians in 1994 and assessed the sensitivity of these cost estimates to variations in the definition of musculoskeletal disorders. METHODS: Disease-related costs, from a societal perspective, were measured using a prevalence-based analysis. First, direct treatment costs, including expenditures on hospitals and other institutions, physicians and other health professionals, drugs, research, and other items were assessed. Second, indirect costs associated with lost (or foregone) productivity due to disability and premature mortality were evaluated using the human capital approach. RESULTS: The total cost of musculoskeletal disorders in Canada was $25.6 billion (in 1994 Canadian dollars, $1.00 CDN approximately $0.75 US) or 3.4% of the gross domestic product. Direct and indirect costs were estimated at $7.5 billion and $18.1 billion, respectively. Lower and upper bound estimates of the total cost of musculoskeletal disorders, derived from the sensitivity analysis, were $19.9 billion and $30.8 billion, respectively. Wide variations were reported in the total cost of various musculoskeletal disorder subcategories, with the highest costs reported for injuries ($10.7 billion), back and spine disorders ($8.1 billion), and arthritis and rheumatism ($5.9 billion). CONCLUSIONS: The economic cost of musculoskeletal disorders was substantial and was sensitive to the definition of musculoskeletal disorders and other underlying assumptions. The hallmark of this study was the variation between subcategories in their cost, pattern of health resource use, and sequelae. The cost estimates may provide guidance in setting priorities for research and prevention activities.     

Occupational injury and illness in the United States. Estimates of costs, morbidity, and mortality

OBJECTIVE: To estimate the annual incidence, the mortality and the direct and indirect costs associated with occupational injuries and illnesses in the United States in 1992. DESIGN: Aggregation and analysis of national and large regional data sets collected by the Bureau of Labor Statistics, the National Council on Compensation Insurance, the National Center for Health Statistics, the Health Care Financing Administration, and other governmental bureaus and private firms. METHODS: To assess incidence of and mortality from occupational injuries and illnesses, we reviewed data from national surveys and applied an attributable risk proportion method. To assess costs, we used the human capital method that decomposes costs into direct categories such as medical and insurance administration expenses as well as indirect categories such as lost earnings, lost home production, and lost fringe benefits. Some cost estimates were drawn from the literature while others were generated within this study. Total costs were calculated by multiplying average costs by the number of injuries and illnesses in each diagnostic category. RESULTS: Approximately 6500 job-related deaths from injury, 13.2 million nonfatal injuries, 60,300 deaths from disease, and 862,200 illnesses are estimated to occur annually in the civilian American workforce. The total direct ($65 billion) plus indirect ($106 billion) costs were estimated to be $171 billion. Injuries cost $145 billion and illnesses $26 billion. These estimates are likely to be low, because they ignore costs associated with pain and suffering as well as those of within-home care provided by family members, and because the numbers of occupational injuries and illnesses are likely to be undercounted. CONCLUSIONS: The costs of occupational injuries and illnesses are high, in sharp contrast to the limited public attention and societal resources devoted to their prevention and amelioration. Occupational injuries and illnesses are an insufficiently appreciated contributor to the total burden of health care costs in the United States.     

Surgical outcome and cost-minimisation-analyses of laparoscopic and open hernia repair: a randomised prospective trial with one year follow up

OBJECTIVE: To compare outcome and costs between laparoscopic and open hernia repair. DESIGN: Prospective randomised study. SETTING: One university and two district hospitals in Sweden. SUBJECTS: 200 men aged 25-75 years. MAIN OUTCOME MEASURES: Operating time, hospital stay, complications, and time to recovery. A cost-minimisation-analysis was used in which the total costs were calculated for a defined period of time for each option. RESULT: The one year follow-up rate was 98%. Mean (SD) operation times in the laparoscopic and open groups were 72 (30) and 62 (25) minutes, respectively (p = 0.009). Hospital stay and complication rates did not differ between the groups. Among employees the mean (SD) periods off work in the laparoscopic and open groups were 10 (8) and 23 (21) days, respectively (p = 0.0001). The mean direct costs of the laparoscopic operation were increased by SEK 4037 (US$ 483) but the savings in indirect costs resulting from earlier return to work were SEK 11392 (US$ 1364). CONCLUSIONS: Laparoscopic hernia repair gave the employed patients faster recovery and return to work, and was the most cost-effective strategy provided that both direct and indirect costs were included.     

Impact of valid selection procedures on work-force productivity.

Used decision theoretic equations to estimate the impact of the Programmer Aptitude Test (PAT) on productivity if used to select new computer programers for 1 yr in the federal government and the national economy. A newly developed technique was used to estimate the standard deviation of the dollar value of employee job performance, which in the past has been the most difficult and expensive item of required information. For the federal government and the US economy separately, results are presented for different selection ratios and for different assumed values for the validity of previously used selection procedures. The impact of the PAT on programmer productivity was substantial for all combinations of assumptions. Results support the conclusion that hundreds of millions of dollars in increased productivity could be realized by increasing the validity of selection decisions in this occupation. Similarities between computer programers and other occupations are discussed. It is concluded that the impact of valid selection procedures on work-force productivity is considerably greater than most personnel psychologists have believed. (37 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)