The cost of treatment of psychiatric emergencies: a comparison of hospital and community services

This study aimed to compare the costs of treatment by community-based and hospital-based psychiatric services. The design entailed random allocation of patients presenting with psychiatric emergencies over a subsequent 3-month period to one of two services, followed by retrospective quantification of service use and its cost for each group. One hundred patients with emergency presentations to the psychiatric service via the Accident and Emergency Department, liaison psychiatrist and approved social worker were included in the study. Their use of a range of terms of service was recorded and disaggregated costings of these items of service was calculated. The use of non-psychiatric services was similar for both groups, but the use of psychiatric services differed, with the hospital group making greater use of in-patient beds and the community group employing more frequent home-based interventions. The total cost of treatment for the community group (pound 56,000) was much lower than for the hospital group (pound 130,000), although the median patient cost was 50% higher in the community group (pound 938 v. pound 610), and a greater proportion of the community service expenditure (10% v. 2%) was due to failed contacts. Taken together with clinical outcome, which showed no advantages for the hospital-based service over the community-based service, our findings suggest that this form of community psychiatric service is a cost-efficient alternative to hospital-based care for this group of patients.     

Do community hospitals reduce the use of district general hospital inpatient beds?

Community hospitals have been supported by the general public and by professionals as one means of increasing choice between local, low technology, care and high technology care at the district general hospital. However, there is no information on the impact of community hospitals on district general hospital use subsequent to NHS and community care reforms. Examination of routinely gathered activity data in the Bath Health District revealed that availability of community hospital beds was associated with reduced use of central inpatient services in the city of Bath. The reduction was most apparent for medical and geriatric beds. Decrease in the use of surgical beds was small. However, total inpatient bed use (including central and community hospital beds) was higher in the population with access to community hospital beds. We conclude that community hospitals offer one option for accessible health care and, as such merit systematic evaluation of costs and benefits. This study presents some evidence that savings could be achieved through improved efficiency.     

Effects of Medicare's prospective payment system on service use by depressed elderly inpatients

OBJECTIVE: To determine the effects of Medicare's prospective payment system (PPS) on hospital care, changes in length of stay and intensity of clinical services received by 2,746 depressed elderly patients in 297 acute care general medical hospitals were studied. METHODS: A pre-post design was used, and differences in sickness at admission were controlled for. Data on length of stay and use of specific clinical services were obtained from the medical record using a medical record abstraction form. Care provided on units exempt from PPS was compared with care provided in nonexempt units. RESULTS: After implementation of PPS, the average length of stay fell by up to three days within the different types of acute care settings studied, but this decline was partially offset by proportionately more admissions to psychiatric units, which had longer lengths of stay. Intensity of clinical services increased after PPS implementation, especially in nonexempt psychiatric units. CONCLUSION: Despite financial incentives for hospitals to reduce clinical services under PPS, its implementation was not associated with a marked decline in length of stay, when averaged across all treatment settings, and was associated with an increase in the intensity of many clinical services used by depressed elderly patients in general hospitals.     

Psychiatric consultation to a general hospital medical evaluation service

Psychiatric consultation to a general hospital medical evaluation service was reviewed and compared with consultation patterns for general hospital inpatients and psychiatric emergency service patients. Results of a questionnaire survey indicated nearly 1 in 5 patients admitted to this acute medical service (24-hour maximum stay) required psychiatric consultation. A study of those patients seen by psychiatric consultants is reported. The prevalence of depressive illness as well as the psychiatric hospitalization referral rate was substantially greater than in general hospital inpatient or psychiatric emergency service evaluations. The implications of this relatively new area of consultation-liaison for hospital staffing and medical education are discussed.     

Financing HIV service provision in England: estimated impact of the cost of antiretroviral combination therapy

The objective of this study was to provide population-based estimates on the cost of HIV service provision in England and the use of dual or triple antiretroviral combination therapy. Contemporary cost estimates of treating HIV-infected individuals by clinical stage of HIV infection (indexed to 1995/96 prices) were linked to the number of diagnosed HIV-infected individuals using statutory medical services in England during 1996. Two cost measures were used: the first one was based on average hospital prices derived from a number of English HIV units. These results were compared with those estimated using standard unit costs obtained through specific costing studies performed at a national HIV referral centre. Overall annual expenditure on HIV service provision was estimated for different treatment scenarios as was expenditure by clinical stage of HIV infection. Using hospital prices, in 1996 the total annual cost estimate for HIV service provision amounted to pound sterling 131 m (range pound sterling 83 m to pound sterling 233 m), or pound sterling 150 m (95% CI pound sterling 126 m to pound sterling 173 m) using standard costs, if all patients with HIV disease were treated with AZT monotherapy. For all eligible patients to be treated with dual therapy, cost estimates amounted to pound sterling 161 m (range pound sterling 126 m to pound sterling 173 m) per year using hospital prices or pound sterling 180 m (95% CI pound sterling 156 m to pound sterling 203 m) when using standard cost estimates, while for triple therapy annual estimated expenditure amounted to pound sterling 204 m per year (range pound sterling 157 m to pound sterling 306 m) when using hospital prices or pound sterling 223 m (95% CI pound sterling 199 m to pound sterling 246 m) using standard costs. Increasingly costs will be more evenly distributed across the 3 stages of HIV infection, with a greater proportion of costs generated by HIV-infected individuals before the onset of AIDS. Using non-standardized hospital prices may systematically underestimate the real cost of service provision. Monitoring prospectively the use, cost and outcome of HIV service provision in a standardized format will provide information on the actual cost impact over the next 2-3 years of combination therapy compared with the scenario-based estimates produced in this paper.     

League tables and acute myocardial infarction

BACKGROUND: Comparison of the outcomes of care provided by hospitals is a growing trend. Outcomes need to be distinguished into those attributable to the practice of hospitals and those that arise from differences in the characteristics of patients and the underlying morbidity of the populations for whom hospitals provide care. We explored these issues for deaths in hospital or within 30 days of discharge after acute myocardial infarction in Scotland, UK. METHODS: We used records from December, 1992, to November, 1993, for 14,359 episodes of acute myocardial infarction, the death records of those who died, and 9391 death records for individuals who died after acute myocardial infarction but who had not been in hospital in the 30 days before death. Hospital discharge records were taken from the Scottish Morbidity Records. The outcomes we investigated were all-cause mortality within 30 days of discharge from hospital, and death from acute myocardial infarction at any time during the study period. We estimated separately effects attributable to patients' characteristics, hospitals, and areas of residence with multilevel modelling. FINDINGS: We found significant differences between hospitals by age, sex, and medical history. The odds ratios for death ranged from 0.62 (95% CI 0.50-0.80) to 1.28 (1.07-1.59), relative to the average performance for Scotland as a whole. Analysis including area of residence, deaths occurring out of hospital, and more detailed information about patients showed no significant differences between hospitals for patients aged 70 years. By postcode area, there was a strong association between out-of-hospital deaths and deaths in hospital or shortly after discharge. INTERPRETATION: Hospital outcomes may vary from one subgroup of patients to another and should be assessed independently of patients' areas of residence. Measures of performance that do not provide valid comparisons could diminish public confidence in hospital services.     

Projected cost-effectiveness of primary angioplasty for acute myocardial infarction

OBJECTIVES: This study sought to evaluate the cost-effectiveness of primary angioplasty for acute myocardial infarction under varying assumptions about effectiveness, existing facilities and staffing and volume of services. BACKGROUND: Primary angioplasty for acute myocardial infarction has reduced mortality in some studies, but its actual effectiveness may vary, and most U.S. hospitals do not have cardiac catheterization laboratories. Projections of cost-effectiveness in various settings are needed for decisions about adoption. METHODS: We created a decision analytic model to compare three policies: primary angioplasty, intravenous thrombolysis and no intervention. Probabilities of health outcomes were taken from randomized trials (base case efficacy assumptions) and community-based studies (effectiveness assumptions). The base case analysis assumed that a hospital with an existing laboratory with night/weekend staffing coverage admitted 200 patients with a myocardial infarction annually. In alternative scenarios, a new laboratory was built, and its capacity for elective procedures was either 1) needed or 2) redundant with existing laboratories. RESULTS: Under base case efficacy assumptions, primary angioplasty resulted in cost savings compared with thrombolysis and had a cost of $12,000/quality-adjusted life-year (QALY) saved compared with no intervention. In sensitivity analyses, when there was an existing cardiac catheterization laboratory at a hospital with > or = 200 patients with a myocardial infarction annually, primary angioplasty had a cost of < $30,000/QALY saved under a wide range of assumptions. However, the cost/QALY saved increased sharply under effectiveness assumptions when the hospital had < 150 patients with a myocardial infarction annually or when a redundant laboratory was built. CONCLUSIONS: At hospitals with an existing cardiac catheterization laboratory, primary angioplasty for acute myocardial infarction would be cost-effective relative to other medical interventions under a wide range of assumptions. The procedure's relative cost-ineffectiveness at low volumes or redundant laboratories supports regionalization of cardiac services in urban areas. However, approaches to overcoming competitive barriers and close monitoring of outcomes and costs will be needed.     

General practitioner involvement in hospital in the home. The hospital's view

INTRODUCTION: Programs involving hospitals and general practitioners (GPs) have become more commonplace, with a greater emphasis on integration of health services emerging over the last generation. Hospital in the home (HIH) refers to the delivery of acute hospital services such as intravenous therapy, anticoagulation and wound care to patients in their own homes. This study sought to determine the extent to which HIH units had involved urban GPs, issues related to GP involvement, and the likely future of such involvement. METHOD: Telephone administered structured survey to all urban HIH coordinators/directors in Melbourne, Australia. RESULTS: All 14 identified HIH coordinators were interviewed. Five units reported a direct role for GPs, six reported no role and three reported a limited role in managing intercurrent illnesses. Coordinators felt that variability of GP response and skills, GP availability and patient control were significant issues. An increase in future GP involvement was uncertain and conditional. DISCUSSION: One-third of urban hospitals surveyed have involved GPs in their programs. However, issues such as variability in skills, enthusiasm and availability threaten expansion of such involvement. This calls for a review in the way GPs are involved in hospital programs, and for better relationships with hospital nursing staff. Limiting the number of involved GPs in any hospital-GP program may offer advantages to both groups. Despite the movement of hospital work into the community, GP involvement in such work is not guaranteed.     

Colorado Medicare study: A history.

Discusses a demonstration project, conducted in Colorado during 1976–1978, designed to study what effect the availability of two new benefits under Medicare, the inclusion of the services of independent psychologists and the expansion of existing mental health coverage, will have on the use and cost of total mental health services and of other medical and hospital services. Questions that express the concerns of legislators also will be evaluated: (a) Can psychology agree on the definition of a psychologist who can deliver services on an autonomous basis, and (b) can psychology assure quality service on an independent basis? Procedures to define provider status, provide peer review, and identify reimbursable services have been instituted to address these questions and should prove to be precedent setting in future national health legislation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Day hospital/crisis respite care versus inpatient care, Part II: Service utilization and costs

OBJECTIVE: The authors compared service utilization and costs for acutely ill psychiatric patients treated in a day hospital/crisis respite program or in a hospital inpatient program. METHOD: The patients (N = 197) were randomly assigned to one of the two programs and followed for 10 months after discharge. Both programs were provided by a community mental health center (CMHC) in a poor urban community. Data were collected for developing service utilization profiles and estimates of per-unit costs of the inpatient, day hospital, and outpatient services provided by the CMHC. RESULTS: On average, the day hospital/crisis respite program cost less than inpatient hospitalization. The average saving per patient was +7,100, or roughly 20% of the total direct costs. There were no significant differences between programs in service utilization or costs during the follow-up phase. Cost savings accrued in the index episode because per-unit costs were lower for day hospital/crisis respite and the average stay was shorter. Significant differences in cost were found among patient groups with psychosis, affective disorders, and dual diagnoses; psychotic patients had the highest costs in both programs. The two programs had roughly equal direct service staff and capital costs but significantly different operating costs (day hospital/crisis respite operating costs were 51% of inpatient hospital costs). CONCLUSIONS: The programs were equally effective, but day hospital/crisis respite treatment was less expensive for some patients. Potential cost savings are higher for nonpsychotic patients. Cost differences between the programs are driven by the hospital's relatively higher overhead costs. The roughly equal expenditures for direct service staff costs in the two programs may be an important clue for understanding why these programs provided equally effective acute care.     

The effect of parasympatholytics on the therapeutic effectiveness of the oxime HI-6 against organophosphorus compounds (Soman, substance VX, Fosdrin) in mice

BACKGROUND: Causal antidotal therapy of acute intoxications with organophosphorus compounds involving administration of the parasympatholytic and cholineesterase reactivator (oxime) has not been resolved so far satisfactorily despite knowledge of the basic mechanism of action of these noxious substances. METHODS AND RESULTS: In experiments on mice the therapeutic effect of parasympatholytics atropine, benactyzine and biperidene (Akineton) combined with oxime HI-6 on the toxicity of highly toxic organophosphates soman and substance VX and the organophosphorus insecticide phosdrine was compared as regards their influence on the LD50 of these noxious substances during 24-hour survival of experimental animals. Two levels of antidotes were tested. These findings confirm that the LD50 value of untreated intoxication with all three organophosphorus compounds is most increased by oxime HI-6 combined with benactyzine regardless of the antidote dosage. CONCLUSIONS: Oxime HI-6 is the most effective against highly toxic organophosphates and organophosphorus insecticides when combined with the centrally acting parasympatholytic benactyzine.     

Comparative costs to the Medicare program of seven prepaid group practices and controls

This research was conducted in order to compare costs to the Medicare program for providing health care service to old people enrolled in two forms of health delivery organization: open market and prepaid group practice (pgp). Two data sources were employed: cost data provided by the Social Security Administration for seven prepaid group practices in five SMSAs and northern California and interviews conducted with administrators of the prepaid groups to determine: organizational sponsorship, incentive structure, pattern of selectivity of patients, and resource availability. Major findings are: (1) Enrollees in prepaid groups incur higher physician costs. This includes services provided by practitioners in and outside the plans. (2) Overall, prepaid groups demonstrate savings to the Medicare program in provider-initiated services- in hospital care and extended care facility services, but not in home health care. (3) Reduced spending in the hospital component does not imply reduction in the extended care facility or home service. (4) Outpatient costs in the hospital are generally higher in the open market modes, probably because this mode of care is viewed as an alternative to physician visits. (5) The greatest cost savings to the Medicare program are demonstrated by groups which are relatively small, yet hospital-based.     

Recombinant erythropoietin and blood transfusions in cancer chemotherapy-induced anemia

BACKGROUND: We examined the relationship between religious attendance, religious affiliation, and use of acute hospital services by older medical patients. METHODS: Religious affiliation (n = 542) and church attendance (n = 455) were examined in a consecutive sample of medical patients aged 60 or older admitted to Duke University Medical Center. Information on use of acute hospital services during the year before admission and length of the current hospital stay was collected. Frequency of church attendance and religious affiliation were examined as predictors of hospital service use, controlling for age, sex, race, education, social support, depressive symptoms, physical functioning, and severity of medical illness as covariates using logistic regression. RESULTS: Patients who attended church weekly or more often were significantly less likely in the previous year to have been admitted to the hospital, had fewer hospital admissions, and spent fewer days in the hospital than those attending less often; these associations retained their significance after controlling for covariates. Patients unaffiliated with a religious community, while not using more acute hospital services in the year before admission, had significantly longer index hospital stays than those affiliated. Unaffiliated patients spent an average of 25 days in the hospital, compared with 11 days for affiliated patients; this association strengthened when physical health and other covariates were controlled. CONCLUSIONS: Participation in and affiliation with a religious community is associated with lower use of hospital services by medically ill older adults, a population of high users of health care services. Possible reasons for this association and its implications are discussed.     

Comparison of long-term care in an acute care institution and in a long-term care institution

BACKGROUND: Acute care hospitals in Quebec are required to reserve 10% of their beds for patients receiving long-term care while awaiting transfer to a long-term care facility. It is widely believed that this is inefficient because it is more costly to provide long-term care in an acute care hospital than in one dedicated to long-term care. The purpose of this study was to compare the quality and cost of long-term care in an acute care hospital and in a long-term care facility. METHODS: A concurrent cross-sectional study was conducted of 101 patients at the acute care hospital and 102 patients at the long-term care hospital. The 2 groups were closely matched in terms of age, sex, nursing care requirements and major diagnoses. Several indicators were used to assess the quality of care: the number of medical specialist consultations, drugs, biochemical tests and radiographic examinations; the number of adverse events (reportable incidents, nosocomial infections and pressure ulcers); and anthropometric and biochemical indicators of nutritional status. Costs were determined for nursing personnel, drugs and biochemical tests. A longitudinal study was conducted of 45 patients who had been receiving long-term care at the acute care hospital for at least 5 months and were then transferred to the long-term care facility where they remained for at least 6 months. For each patient, the number of adverse events, the number of medical specialist consultations and the changes in activities of daily living status were assessed at the 2 institutions. RESULTS: In the concurrent study, no differences in the number of adverse events were observed; however, patients at the acute care hospital received more drugs (5.9 v. 4.7 for each patient, p < 0.01) and underwent more tests (299 v. 79 laboratory units/year for each patient, p < 0.001) and radiographic examinations (64 v. 46 per 1000 patient-weeks, p < 0.05). At both institutions, 36% of the patients showed anthropometric and biochemical evidence of protein-calorie undernutrition; 28% at the acute care hospital and 27% at the long-term care hospital had low serum iron and low transferrin saturation, compatible with iron deficiency. The longitudinal study showed that there were more consultations (61 v. 37 per 1000 patient-weeks, p < 0.02) and fewer pressure ulcers (18 v. 34 per 1000 patient-weeks, p < 0.05) at the acute care hospital than at the long-term care facility; other measures did not differ. The cost per patient-year was $7580 higher at the acute care hospital, attributable to the higher cost of drugs ($42), the greater use of laboratory tests ($189) and, primarily, the higher cost of nursing ($7349). For patients requiring 3.00 nursing hours/day, the acute care hospital provided more hours than the long-term care facility (3.59 v. 3.03 hours), with a higher percentage of hours from professional nurses rather than auxiliary nurses or nursing aides (62% v. 28%). The nurse staffing pattern at the acute care hospital was characteristic of university-affiliated acute care hospitals. INTERPRETATION: The long-term care provided in the acute care hospital involved a more interventionist medical approach and greater use of professional nurses (at a significantly higher cost) but without any overall difference in the quality of care.     

Health insurance status and the use of emergency and other outpatient services by adults with sickle cell disease

STUDY OBJECTIVE: To evaluate insurance status and frequency of use of emergency services in adults with sickle cell disease. DESIGN: Retrospective analysis of visits. SETTING: Emergency department and outpatient clinics of an urban university hospital. PARTICIPANTS: One hundred seventy-two subjects, who made 771 visits to the ED during 1990. RESULTS: Of the 172 subjects, 31 were covered by commercial insurance, 32 were covered by Medicare, and 109 were covered by Medicaid or were uninsured. Insurance status and frequency of use of emergency services were independent (P > .05). On discriminant analysis, Medicaid-covered and uninsured subjects were correctly classified, but commercially insured and Medicare subjects were not. Medicaid and uninsured subjects were more likely to be younger and to live closer to the hospital (P < .00005). High-frequency users of emergency services were discriminated from low-frequency users. High-frequency users were more likely to be younger, to be users of primary-care services, and to live closer to the hospital (P = .0004). CONCLUSION: Provision of primary-care services or stable insurance in the form of commercial insurance or Medicare did not decrease use of emergency services in subjects with sickle cell disease in a group of patients selected from one urban academic ED.     

The cost of selected tuberculosis control measures at hospitals with a history of Mycobacterium tuberculosis outbreaks

OBJECTIVE: To determine the cost of nonrespirator-related tuberculosis (TB) control measures at several hospitals, following publication of the Centers for Disease Control and Prevention (CDC)'s revised TB infection control guidelines. DESIGN: Infection control (IC) and TB coordinators obtained cost information on tuberculin skin-test (TST) programs, addition of IC and employee health service (EHS) personnel, and the retrofit or new construction of environmental controls. SETTING: Four hospitals with, and one community hospital without, prior nosocomial multidrug-resistant TB transmission. RESULTS: During the study period, the TST program costs remained constant at four of five hospitals and increased at one hospital (median 1994 TST program cost: $5,568; range, $2,393-$44,902). Additional IC or EHS personnel were hired at four of five hospitals (median cost increase, $125,500; range, $63,000-$228,000). The median cost of new construction or new equipment purchases (ie, sputum induction booths, ultraviolet lights, or portable high-efficiency particulate air filters) at study hospitals was $163,000 (range, $45,000-$524,000) and $70,000 (range, $31,000-$93,000), respectively. CONCLUSIONS: Costs associated with implementing control measures similar to those recommended in the CDC TB IC guidelines varied widely by hospital. Engineering controls involved the largest capital outlay, but increases in personnel were the largest continuing cost. These costs represent improvements made to upgrade selected aspects of hospital TB control programs, not the cost of an optimal TB control program.     

Hospital at home or acute hospital care? A cost minimisation analysis

OBJECTIVE: To compare, from the viewpoints of the NHS and social services and of patients, the costs associated with early discharge to a hospital at home scheme and those associated with continued care in an acute hospital. DESIGN: Cost minimisation analysis. SETTING: Acute hospital wards and the community in the north of Bristol (population about 224 000). SUBJECTS: 241 hospitalised but medically stable elderly patients who fulfilled the criteria for early discharge to a hospital at home scheme and who consented to participate. MAIN OUTCOME MEASURES: Costs to the NHS, social services, and patients over the 3 months after randomisation. RESULTS: The mean cost for hospital at home patients over the 3 months was 2516 pounds, whereas that for hospital patients was 3292 pounds. Under all the assumptions used in the sensitivity analysis, the cost of hospital at home care was less than that of hospital care. Only when hospital costs were assumed to be less than 50% of those used in the initial analysis was the difference equivocal. CONCLUSIONS: The hospital at home scheme is less costly than care in the acute hospital. These results may be generalisable to schemes of similar size and scope, operating in a similar context of rising acute admissions.     

Ventilatory care in a selection of Ontario hospitals: bigger is not necessarily better! Critical Care Research Network (CCR-Net)

OBJECTIVE: To determine whether there is variability in the structure and process of ventilatory care in intensive care units (ICUs) of the hospitals of Southwestern Ontario. DESIGN: Self-administered questionnaire-based survey. SETTING: ICUs of selected community and teaching hospitals of Southwestern Ontario. PARTICIPANTS: Head of respiratory therapy service of respective hospitals; in those hospitals without respiratory therapists, the ICU nurse manager. INTERVENTION: Self-administered questionnaire. OUTCOME MEASURE(S): The availability of different models of ventilators and respiratory therapist and physician coverage were assessed. In addition, the use of clinical practice guidelines, respiratory therapists, and the nursing role in ventilatory care were determined. RESULTS: In general, the structure of ventilatory care, including availability of different modes of ventilation, and coverage by respiratory therapists and physicians was more comprehensive in larger hospitals. However, the availability of some modes of ventilation varied more than expected among hospitals of comparable size. Similarly, variability in the process of ventilatory care, defined by the availability of clinical practice guidelines and the roles of respiratory therapists varied both within and among hospitals of different size. CONCLUSIONS: The structure and process of ventilatory care in this sample of Southwestern Ontario ICUs was found to be variable. Not all this variability could be accounted for by hospital size, suggesting a potential for improvement in overall ventilatory care. Further study is required before any specific recommendations can be considered.