[Costs of care and nursing in a teaching hospital]

O trabalho aborda a questão dos custos assistenciais nos hospitais de ensino. E demonstra alguns caminhos a serem tomados pela administração de enfermagem a fim de que se possa desenvolver nos enfermeiros uma consciência maior da importância do desempenho das atividades de enfermagem correlacionando a qualidade do trabalho com os custos.

Financial analysis of an inner city trauma center: charges vs collections

The changes in the economy and in tax rules have caused hospitals to assess the financial viability of different areas within their institutions. While emergency departments generally have become recognized as a cost-effective portal of entry for patients, trauma centers, particularly those located in the inner city, usually are seen as areas of large investment and small financial return. This study looks at a large, inner-city trauma service and the charges, collections, and demographics of the trauma population it serves. For patients admitted to the trauma service, total collections were 77% of charges. There was no difference in collections between those patients with blunt injuries and those with penetrating injuries; violent vs nonviolent injuries; patients transferred in vs primary receivals; or patients transferred out after stabilization vs those retained at the trauma center.

Feasibility of prime vendor purchasing for a state university hospital

The economic feasibility of implementing a prime vendor purchasing system for pharmaceuticals was evaluated in a midwestern university hospital. Inventory costs, personnel costs, and check processing costs under the current purchasing system were compared with costs estimated for a proposed prime vendor purchasing system. For each step in the purchasing process that would be changed under the proposed system, work measurement techniques were used to determine personnel costs. The total savings from reductions in inventory holding costs, personnel costs, and check processing costs under the proposed prime vendor system was +98,396.37, or 2.4% of the value of pharmaceuticals purchased. Since the pharmacy department could not negotiate a contract in which the prime vendor's service fee was 2.4% or less, implementing a prime vendor purchasing system would not have been cost effective. Therefore, the hospital retained its existing purchasing system. Through detailed analysis of the major costs involved in pharmaceutical purchasing, the hospital was able to determine that it was not cost effective for it to use prime vendor purchasing.

The financial impact of a comprehensive adolescent pregnancy program on a university hospital

This study investigated the financial impact which an adolescent pregnancy program had on one of its sponsoring agencies, the University Hospital, Salt Lake City, UT. Financial data from hospital billings and collections on the 75 teens who delivered during a 12-month period were reviewed. A comparison of the money for salaries supplied to the special program by the hospital with the amount of estimated "new" money generated for the hospital by the program yielded an income to expenditure ratio greater than two. Eighteen teens who were in the lowest self-pay category were matched to self-pay teens delivering at the same hospital who received traditional prenatal care. The hospital collection rate for teens in the special program was not significantly greater than that of the comparison group. The investment in an adolescent pregnancy program was beneficial mainly from the viewpoint of recruitment of patients who were brought into the hospital system as a result of the adolescent pregnancy program.

The determinants of biological prescription in French hospitals

We present in this paper the first stage of a broader work, the aim of which is to better understand the volume, modalities, determinants and cost-benefit ratio of the medical prescription in hospitals. Through a sample of 1800 patients observed in 1978 and 1979, in 18 medical or surgical services of 6 French hospitals of different size, statute and location, we have pursued a double objective: first, to establish the basic elements of an 'observatory' of the biological prescription in order to quantify this prescription; secondly, to shed some light on the factors which might explain the differences observed between hospitals, services and diseases. Linear and non-linear econometric models have been used to perform the analysis of the 252,000 data that had been collected. This research has given rise to an evaluation of the informative content of the diagnostic tests ordered by the physicians. This analysis is discussed further in the present volume.

Economic analysis of a new drug: potential savings in hospital operating costs from the use of a once-daily regimen of a parenteral cephalosporin

The introduction of a new drug requires clear demonstration of its clinical efficacy and documentation of its adverse effects, but economic consequences of the new drug generally receive less attention. A new cephalosporin antibiotic, cefonicid, can be administered parenterally once daily, rather than three or four times daily, which is required for conventional cephalosporins. Methods of industrial engineering and cost accounting were used to determine the potential savings in hospital operating costs that would be available by reducing the frequency of intravenous administration of cephalosporin antibiotics. The variable cost of administering parenteral cephalosporin antibiotics averaged $2.24 per dose, $0.95 of which was attributable to labor costs and $1.28 to the costs of materials. Given present patterns of cephalosporin use, at four study hospitals the average potential savings per day for patients receiving intravenous cephalosporins ranged from $3.72 to $7.23, with a weighted mean of $5.42. Estimated national savings in hospital operating costs that would occur with use of an intravenous cephalosporin administered once daily range from $85.1 million to $115.4 million yearly.

The failure of physician education as a cost containment strategy. Report of a prospective controlled trial at a university hospital

To test the hypothesis that physician education is an effective strategy to reduce total hospital costs, we evaluated three educational interventions at a large university hospital. This prospective controlled study spanned two academic years and involved 1,663 patients and 226 house staff. In the first year, weekly lectures on cost containment (medicine and surgery) and audit with feedback (medicine only) both failed to produce a significant change in total hospital charges. The "dose" of the intervention was increased on medicine in the second year by combining the lecture and audit strategies. Again, total charges did not change significantly. While decreased use occurred for certain selected services, the impact was not great enough to affect total hospital charges significantly. We conclude that, in the absence of other cost containing incentives, physician education alone is not an effective hospital cost containment strategy.

A comparison of Western European and US University hospitals. A case report from Leuven, West Berlin, Leiden, London, and San Francisco

To assess how closely US university hospitals resemble those in other Western countries, I compared four major European university hospitals--Leuven, Belgium; Klinikum Steglitz , West Berlin; Leiden, the Netherlands; and St Thomas', London--with a US institution--University of California, San Francisco ( UCSF ). University of California had 1.6 to 2.4 more total employees, 1.1 to 1.7 more registered nurses, 2.1 to 8.5 more staff physicians, and 1.5 to 3.0 more house officers per adjusted occupied bed. University of California's costs per bed were 2.2 to 3.5 times higher, its inclusive per diem charges at least four times higher, and its malpractice premium at least 50 times greater. Medical patients at UCSF and West Berlin were more severely ill, as judged by organ system failure, need for organ system support, and levels of consciousness. Compared with UCSF , the European hospitals had more explicit rationing of care according to age and illness severity. Overall, European university hospitals are larger, less expensive, less technology intensive, staffed by fewer employees and physicians, occupied by less severely ill patients, and more apt to serve as regional referral centers. As US university hospitals move into a price-competitive era, they may come to resemble their European counterparts.

Effect of a publicly funded tuberculosis service on the diagnosis of tuberculosis at a teaching hospital

The speed and accuracy of diagnosis of tuberculosis on general medical teaching services were retrospectively compared to that on a designated publicly funded tuberculosis service and to recent discouraging reports in the literature. The diagnosis was confirmed in all patients on the designated service and in 78.8% of patients not on the designated service within one week. No patient was discharged undiagnosed. Acid-fast smears done by the hospital laboratory showed a sensitivity of 82.5% and a specificity of 98.4%. Radiologic reports indicated the presence of tuberculosis or cavities in 85% of chest x-ray films in patients with pulmonary disease. These results may indicate that a publicly funded tuberculosis service, by providing emphasis on tuberculosis, allows more rapid and accurate diagnosis of tuberculosis in all patients. The impact of such training on future health care delivery should be recognized when decisions regarding allocation of public funds are made.

Acute leukemia in adults: cost effectiveness of treatment

Costs of treating 174 adult patients with acute leukemia were compiled and analyzed over the five-year period 1974 to 1979. The average overall cost per patient was $18,760, and increased over the period of study. Increased total hospital costs were incurred by patients who achieved a favorable response to induction chemotherapy and by those with a diagnosis of acute lymphocytic leukemia (ALL). To assess the impact of successful treatment on hospital expenditures, total months of survival were compared with total hospital costs to determine cost per month of life. Using this analysis, improved survival, favorable response to chemotherapy, and a diagnosis of ALL were associated with significant decreases in cost per month of life. The long-term survivors (alive greater than or equal to 2 years from diagnosis) best demonstrated this effect, with a mean hospital cost per month of survival from diagnosis of $563, which was significantly less than $6,937 for those who achieved a partial remission, $10,703 for those with treatment failure, and $8,240 for those who were untreated. These costs linked to outcome are comparable to those reported in other disorders that require prolonged and intensive hospital care. With the progressive improvement in response rate and in percentage of long-term survivors that is being observed in adults with acute leukemia, these costs should continue to decrease.

Trend analysis of surgery revenues at Osaka University Hospital

To identify medical and administrative revenue trends at a surgical center, for use in strategic planning, an off-line data processing system utilizing coding sheets was developed. Data on 66,402 surgical procedures performed at the Osaka University Hospital Surgical Center between 1966 and 1981 were processed to study trends in revenues. Trend analysis shows that (a) revenues at the surgical center have been increasing year by year; (b) technical charges, such as operation and anesthesia fees, have increased with each revision of the medical remuneration system of Japanese government health insurance; and (c) the length of time patients stay in the operating room has gradually increased.

Data quality. An illustration of its potential impact upon a diagnosis-related group's case mix index and reimbursement

The Health Care Finance Administration has developed a Medicare reimbursement methodology that will include an adjustment factor for hospital case mix. The patient classification scheme proposed for use in determining a hospital's case mix is the AUTOGRP Diagnosis-Related Groups (DRG) methodology developed at Yale University. The reliability of a case mix measure calculated using the DRG methodology is dependent on complete and accurate diagnostic and surgical data. The source of this data for the HCFA data base (MEDPAR) is the Medicare billing form, which is based on the patient medical record. Data from the MEDPAR file, the original medical record discharge order, and a reabstracted record are compared and analyzed for their effect upon DRG classification and the resultant Medicare reimbursement ceiling for one large teaching hospital. The study results show widely divergent diagnostic and surgical data that results in a significant variation in DRG classification and reimbursement ceilings.

Measuring severity of illness: comparisons across institutions

Conventional methods for classifying patients with respect to utilization of health care resources are based almost exclusively on diagnostic criteria. We review a new severity of illness index which is generic to most medical and surgical conditions in a hospital, and which has been found to produce subgroups of patients more homogeneous with respect to hospital resource use (as assessed by total charges, length of stay, routine charges, and laboratory charges) than diagnostic-related groups, staging, and generalized patient management paths. We use the severity of illness groups to compare total charges and length of stay across hospitals. We find that charges and length of stay in an academic teaching hospital are similar to those in community hospitals with and without teaching programs when controlling for severity of illness. (Am J Public Health 1983; 73:25-31.)

Michigan's Medical Service Plan: factors responsible for its success

Eight years after the implementation of its medical service plan, the University of Michigan Medical School carried out a study to determine the extent to which the plan met its original objectives. An analysis of the plan's revenue and expenses, a review of the impact on medical school programs of education, research, and patient care, and an assessment of the environment influencing chairman and faculty recruitment and retention all support the conclusion that Michigan's medical service plan has been successful. In an effort to determine why the plan has succeeded, 35 individuals were surveyed to identify the factors thought to be responsible. A total of 32 potential factors were named; six were considered to be "key/critical," and another 11 were identified as "important/contributory." It is hoped that a sharing of Michigan's experience and understandings will be of help to the approximately 110 medical service plans that exist within the nation's 126 medical schools.