Formulary conversion from glipizide to glyburide: a cost-minimization analysis

Economic pressure prompted us to search for and implement cost-saving strategies at Bronx Municipal Hospital. This paper describes a cost-minimization analysis of the impact of formulary substitution of glyburide for glipizide on glycemic control, safety, and costs. In 76 patients with computerized prescription records, switching from a mean daily glipizide dose of 19 mg to a mean daily glyburide dose of 10.2 mg did not affect glycemic control. A subset of 33 elderly patients experienced only three drug-related adverse events during the 2-year observation period. The conversion program yielded a 51% reduction in overall expenditures for oral hypoglycemic agents between 1991 and 1993. These findings indicate that our conversion program was successful, which has led to its becoming a model for other New York City municipal outpatient pharmacies.

The impact of prenatal exposure to cocaine on newborn costs and length of stay

OBJECTIVE

Our intention is to determine newborn costs and lengths of stay attributable to prenatal exposure to cocaine and other illicit drugs.

DATA SOURCES AND STUDY SETTING

All parturients who delivered at a large municipal hospital in New York City between November 18, 1991 and April 11, 1992.

STUDY DESIGN

A cross-sectional analysis used multivariate, loglinear regressions to analyze differences in costs and length of stay between infants exposed and unexposed prenatally to cocaine and other illicit drugs, adjusting for maternal race, age, prenatal care, tobacco, parity, type of delivery, birth weight, prematurity, and newborn infection.

DATA COLLECTION/EXTRACTION METHODS

Urine specimens, with linked obstetric sheets and discharge abstracts, provided information on exposure, prenatal behaviors, costs, length of stay, and discharge disposition.

PRINCIPAL FINDINGS

Infants exposed to cocaine or some other illicit drug stay approximately seven days longer at a cost of $7,731 more than infants unexposed. Approximately 60 percent of these costs are indirect, the result of adverse birth outcomes and newborn infection. Hospital screening as recorded on discharge abstracts substantially underestimates prevalence at delivery, but overestimates its impact on costs.

Hospital costs of firearm injuries

The purpose of this study was to provide economic, epidemiologic, and clinical data on initial hospitalizations of patients with firearm injuries.

DESIGN

Concurrent prospective study; data obtained by medical records review.

SETTING

A county university teaching hospital designated a level I trauma center.

SUBJECTS

34,893 persons first hospitalized for firearm injuries at the King/Drew Medical Center in Los Angeles from January 1978 through December 1992.

RESULTS

The aggregate hospital cost for 34,893 firearm injuries, exclusive of professional fees, was $264,506,455.00, of which 96% was borne directly or indirectly by public funds. The charge for initial hospitalizations was $240,700,855.00. Mean and median initial charges per case were $6898.00 and $1,022.00, respectively (range, $944.00 to $296,232.00). The 5% of patients with charges greater than $100,000 accounted for 42% of all charges; 45% of all patient days were attributable to the 4% patients, with hospitalizations lasting more than 30 days. Three thousand thirty-one patients were rehospitalized a total of 4,578 times; charges for rehospitalization totaled $23,805,600.00. At least 55% (75% of identifiable weapon and missile injuries) of all charges resulted from handgun injuries. Treating the majority of patients on an outpatient basis and by using selective angiography for extremity wounds, a savings of more than $775,000,000.00 resulted. The potential cost of treating gunshot wounds at a single county hospital was more than $1 billion, or more than $100 million per year.

CONCLUSIONS

The costs for hospital treatment of firearm injuries are substantial. A lack of rehabilitation facilities forces prolonged acute hospital admissions in many cases. Avoiding prolonged hospitalization may be helpful in controlling these costs, but will be difficult to achieve. Ninety-six percent of the patients in this report had their costs of care covered by the government, because they had no primary insurance coverage. Primary prevention of firearm injuries, especially those caused by handguns, may be the most effective cost-control measure.

Initial assessment of patients infected with human immunodeficiency virus: the yield and cost of laboratory testing

Our objective was to determine the yield and cost of standardized laboratory testing of HIV-infected patients entering medical care after testing positive for HIV. An HIV staging and referral clinic in a municipal public hospital was our site for a cross-sectional study, and 308 patients were evaluated in the clinic between February 1, 1990 and October 1, 1991. Patients underwent standardized laboratory testing, including hematologic studies, serum chemistries, infectious disease serologies, and chest radiographs. The percentage of abnormal results for each test was determined. Abnormal results were stratified as mild or severe. They were also examined with regard to whether injection drug users or other patient subgroups had higher percentages of abnormalities. Changes and Medicare reimbursements for the tests were also determined. There were substantial numbers of abnormalities in all types of laboratory testing. Only 3% of patients had normal CD4 lymphocyte counts; 85% had counts of < 500/mm3, and 35% were < 200/mm3. Forty-four percent of patients had at least one abnormal hematologic study; 8% were severe. Nearly 75% had abnormal liver function tests; 20% of these were severe abnormalities. Fifteen percent of patients were PPD-positive, and > 50% were anergic. Fourteen percent had a positive nonspecific test for syphilis, and 7% had a positive confirmatory test. Fourteen percent of patients had an abnormal chest radiograph.(ABSTRACT TRUNCATED AT 250 WORDS)

[Alternatives to acute admissions to a city hospital. Is it possible to reduce the number of acute admissions?]

The purpose of the study was to evaluate the number of inappropriate admissions to a smaller city hospital and find possible alternatives. Physicians and surgeons from three units (abdominal surgery, internal medicine and orthopaedic surgery) together with general practitioners, doctors on homecall duty and health personnel from the region contributed to the study. In all 421 consecutive patients were included during a three-week period. The patients' median age was 60.5 years. It was found that at least 13.6% of all patients seemed to have been admitted for an inappropriate reason. According to the admitting doctor 3.4% of the patients were not ill at all. The investigation implies that one out of seven acute admissions could be replaced by alternatives such as immediate care in residential homes, more flexible contact to the outpatient's clinic, better access to geriatric evaluation and improved laboratory service. We conclude that acute admission to hospital can be replaced by other alternatives, thereby achieving greater efficiency and better economics.

The impact of clinical trial protocols on patient care systems in a large city hospital. Access for the socially disadvantaged

Some Americans suffer a higher cancer incidence and mortality than those in mainstream American society, and, in general, do not enjoy the same health status. Black Americans, for example, have higher cancer incidence and lower survival rates than do white Americans. To date, there is no known genetic basis to account for the disparities in cancer incidence and outcome between these races. Controlling for socioeconomic status greatly reduces, and sometimes nearly eliminates, the apparent contrast in cancer mortality and incidence between ethnic groups. Poverty clearly is associated with diminished access to health care, an increased incidence of cancer, and 10-15% lower 5-year survival rates. Diminished access often is manifested by low quality and inadequate continuity of health care, as well as insufficient access to methods of disease detection, diagnosis, treatment, and rehabilitation. Poor people tend to concentrate on day-to-day survival, often feel hopeless and powerless, and may become socially isolated. It is more difficult to conduct cancer treatment trials in a population characterized by such dramatic socioeconomic and cultural differences. Lack of insurance and lack of compliance become trial-limiting issues. This paper examines what must be done to tear down the economic and cultural barriers to prevention, early detection, and treatment of cancer.

Crowded outpatient departments in city hospitals of developing countries: a case study from Lesotho

'Overuse' of hospital outpatient departments in urban areas of developing countries is perceived as a problem by many health planners. The World Health Organization is promoting advanced health centres, or 'reference centres', as part of a strategy to develop urban health systems and to reduce primary contact care at hospitals. However, hospital-based information to assist city health service planning is limited in many countries. This study examined user characteristics, patient flow and prescribing quality at the national referral hospital in Maseru, Lesotho, using simple and replicable methods. The study found that most users were self-referred and came from the city. The majority of respondents were aware of their local health centre but reported they would normally use the hospital when they were ill. Examination of patient flow showed that, on average, patients spent a total of 3.7 h waiting. Quality of care was compromised by a tendency to over-prescribe, particularly antibiotics and sedatives. The study suggests that in Maseru, the perception of 'overuse' is due to congestion and that improved patient flow management will reduce the numbers of patients waiting. Quality of care could be strengthened by regular audit of prescribing practices by clinicians in the hospital.

Urban health care

Public hospitals are straining under the burden of having to care for many of the poorest and sickest people in America. The health care problems of the nation's most disadvantaged include infectious diseases such as AIDS and tuberculosis, as well as problems related to violence and lack of access to primary care. Urban hospitals are struggling to address the needs of the indigent, and to find alternatives for those who often rely on emergency rooms for routine care.

Health care reform: what it might mean to urban public hospitals

Health care reform proposals may affect public hospitals in a number of ways. To insure that such proposals benefit the underserved communities within which public hospitals operate, reform initiatives should be evaluated against 10 criteria that emphasize prevention and primary care, community health education, cost control, tort reform, and community values.