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Hospitals

Authors: Steiner CA, Elixhauser A, and Schnaier J.
Title: The Healthcare Cost and Utilization Project: An Overview.
Publication: Effective Clinical Practice 5(3):143-51.
Date: 2002.
Abstract: Healthcare Cost and Utilization Project (HCUP)—a family of databases including the State Inpatient Databases (SID), the Nationwide Inpatient Sample (NIS), the Kids' Inpatient Database (KID), and the outpatient databases State Ambulatory Surgery Data (SASD) and State Emergency Department Data (SEDD). Multistate, inpatient (SID, NIS, KID) and outpatient (SASD, SEDD) discharge records on insured and uninsured patients. Partnership between the Agency for Healthcare Research and Quality (AHRQ) and public and private statewide data organizations. Selected data elements from inpatient and outpatient discharge records, including patient demographic, clinical, disposition and diagnostic/procedural information; hospital identification (ID); facility charges; and other facility information. Varies by database: NIS 1988-2000; SID 1995-2000; KID 1997 and 2000; SASD 1995-2000; and SEDD in pilot phase. Future data years anticipated for all datasets and back years for SID and SASD. UNITS OF ANALYSIS: Patient (in states with encrypted patient identification), physician, market, and state. Quality assessment, use and cost of hospital services, medical treatment variations, use of ambulatory surgery services, diffusion of medical technology, impact of health policy changes, access to care (inference), study of rare illness or procedures, small area variations, and care of special populations. Largest collection of all-payer, uniform, state-based inpatient and ambulatory surgery administrative data. Lacks clinical detail (e.g., stage of disease, vital statistics) and laboratory and pharmacy data. Ability to track patients across time and setting varies by state. Access available to all users who sign and abide by the Data Use Agreement. Application kits available at www.ahrq.gov/data/hcup. HCUPnet, an online interactive query tool, allows access to data without purchase (http://hcupnet.ahrq.gov/).

Authors: Romano P, Elixhauser A, McDonald K, Miller M.
Title: HIM's Role in Monitoring Patient Safety.
Publication: J AHIMA 73(3):72-4.
Date: 2002.
Abstract: The AHRQ Patient Safety Indicators (PSIs) were developed to focus on potentially preventable instances of harm to patients, such as surgical complications and other iatrogenic events. The PSIs are based solely on hospital administrative data, such as data from the Healthcare Cost and Utilization Project (HCUP), which rely upon diagnosis and procedure information that is coded using the International Classification of Diseases—9th revision—Clinical Modification (ICD-9-CM). HIM professionals can make a major contribution to the national effort to monitor and prevent medical errors through their application and ongoing refinement of ICD-9-CM. Several steps can be taken by HIM professionals to improve ICD-9-CM coding to better identify patient safety events, including (1) introduce more specific complication codes, (2) encourage clearer coding of iatrogenic conditions using available codes, (3) address the variability in medical record documentation, and (4) collaborate with local quality improvement leaders to investigate cases that arouse concern. The administrative data that HIM professionals generate have long been used for reimbursement. More recently these data have been used for research and quality assessment and they hold promise for identifying patient safety problems. However, to fulfill this promise, the quality of the data must continue to improve. HIM professionals will be at the forefront in helping to improve the usefulness of administrative data, thereby addressing the national challenge of reducing medical errors.

Authors: Jiang HJ, Elixhauser A, et al.
Title: Care of Women in U.S. Hospitals, 2000.
Publication: HCUP Factbook No. 3.
Date: 2002.
Abstract: Based on HCUP Nationwide Inpatient Sample (NIS) data, this report provides an overview of hospital care for women and compares hospital stays for women and men. It also includes statistics on obstetric care in hospitals. Six out of the top 10 conditions for nonobstetric hospital stays pertain to the circulatory system, making up 18 percent of all stays for women and 23 percent for men. Depression is the most common reason for nonobstetric hospitalization among women ages 18-44. For two cardiac conditions—heart attack and hardening of the arteries of the heart—hospital stays for women are less likely to involve heart procedures than those for men. Hypertension is the most common co morbidity among nonobstetric patients. Among patients covered by Medicaid or uninsured, the percentage of nonobstetric hospital stays for ambulatory care sensitive (ACS) conditions is higher for women than for men. Two out of five obstetric stays are attributed to women with Medicaid or no insurance. Women with private insurance are more likely to have Cesarean sections than women uninsured or covered by Medicaid.
Availability: AHRQ Publication No. 02-0044, available from the AHRQ Publications Clearinghouse.

Authors: Elixhauser A, Machlin S, Zodet M, et al.
Title: Annual report on access to and utilization of health care for children and youth in the United States—2001.
Publication: Ambulatory Pediatrics 2(6): 419-37.
Date: 2002.
Abstract: This report provides an update on insurance coverage, use of health care services and health expenditures for children and youth in the United States as well as new information on parents' perceived quality of care for their children. In addition the report provides information on variation in hospitalization for children from a 24-state hospital discharge data source. The study uses the Medical Expenditure Panel Survey (MEPS) and the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS), both of which are maintained by the Agency for Healthcare Research and Quality. Children's use of health care services varies considerably by the type of health insurance coverage, race/ethnicity, and family income. Quality of care, as measured by parents' experience of care, also varies by insurance coverage. There are substantial differences in average length of hospitalization across states in the U.S., ranging from 2.9 to 4.1 days, and rates of hospitalization through the ED vary from 10% to 25%. Injuries are a major reason for hospitalization, accounting for 1 in 6 stays among 10-14 year olds. In the 10-17 age group over 1 in 7 stays are due to mental disorders. Among 15-17 year olds, over one-third of all hospital stays are related to childbirth and pregnancy.

Authors: Elixhauser A, Weinick R, Betancourt J, et al.
Title: Differences in use of hospital procedures for Hispanics and non-Hispanic whites with cerebrovascular disease.
Publication: Ethnicity and Disease 12(1):29-37.
Date: 2002.
Abstract: Disparities in procedure use between racial/ethnic groups in the U.S. have been identified, yet differences between Hispanic and non-Hispanic white patients have been studies less frequently. The purpose of this study was to assess the in-hospital use of diagnostic and therapeutic procedures among Hispanics and non-Hispanic whites with transient cerebral ischemia or cerebrovascular disease. This study uses California and New York HCUP State Inpatient Databases for 1996. Hispanics had higher rates of non-invasive diagnostic testing (head CT scan, head and neck ultrasound, echocardiogram and head MRI). The odds of invasive diagnostic testing (cerebral arteriogram) and therapeutic procedures (carotid endarterectomy) were significantly lower for Hispanics. Most findings remained unchanged in logistic regression models with patient and hospital characteristics. Adding a measure of the concentration of Hispanic patients in the hospital eliminated differences or greatly reduced the level of disparity between Hispanics and non-Hispanic whites. Racial/ethnic differences in diagnostic procedure use may reflect poor communication and cultural/linguistic barriers between patients and providers, where diagnostic testing is used to compensate for an uninformative patient history.

Authors: Romano P, Elixhauser A, McDonald K, Miller M.
Title: The Role of Health Information Professionals in Monitoring Patient Safety.
Publication: American Health Information Management Association (AHIMA), 1-3.
Date: March 2002.
Abstract: Until better medical error reporting systems are implemented, existing administrative data can serve as a case-finding tool for targeted quality improvement efforts. A set of patient safety indicators (PSIs) based on hospital administrative data and ICD-9-CM codes have been developed to help focus on preventable instances of harm to patients, such as surgical complications and other iatrogenic events. These PSIs can be used as a screen for potential quality problems; however, improved coding of complications will increase their utility. Health information management professionals can make a major contribution to the national effort to monitor and prevent medical errors through their application and ongoing refinement of ICD-9-CM.

Authors: Elixhauser A, Macklin S, Zodet MW, et al.
Title: Health care for children and youth in the United States: 2001 annual report on access, utilization, quality, and expenditures.
Publication: Ambulatory Pediatrics 2(6):419-37.
Date: 2001.
Abstract: This report provides an update on insurance coverage, use of health care services and health expenditures for children and youth in the United States. In addition the report provides information on variation in hospitalization for children from a new 22-state hospital discharge data source specifically designed to study children. The study uses the Medical Expenditure Panel Survey (MEPS) and the Healthcare Cost and Utilization Project (HCUP) Database for Pediatric Studies (DPS), later renamed the Kids' Inpatient Database (KID), both of which are maintained by the Agency for Healthcare Research and Quality. Children's use of health care services varies considerably by what type of health insurance coverage they have. Expenditures for children entail a substantial out-of-pocket component, which may be quite large for children with major health problems and which may have a significant burden on low-income families. The data also show substantial differences in average length of hospitalization across states in the U.S., ranging from 2.7 to 4.0 days, and rates of hospitalization through the ED vary from 9% to 23%. Injuries are a major reason for hospitalization, accounting for 1 in 6 stays among 10-14 year olds. In the 10-17 age group, over 1 in 7 stays are due to mental disorders. Among 15-17 year olds, over one-third of all hospital stays are related to childbirth and pregnancy.

Authors: Miller M, Elixhauser A, Zhan C and Meyer G.
Title: Patient Safety Indicators: Using administrative data to identify potential patient safety concerns.
Publication: Health Services Research 36 (part II): 110-32.
Date: 2001.
Abstract: This study describes the development of Patient Safety Indicators (PSIs) to identify potential in-hospital patient safety problems for the purpose of quality improvement. The data source was the 1997 Healthcare Cost and Utilization Project New York State Inpatient Database. PSI algorithms were developed using systematic literature reviews of indicators and hand searches of the ICD-9-CM code book. The prevalence of PSI events and associations with patient-level and hospital-level characteristics, length of stay, in-hospital mortality, and hospital charges were examined. PSIs were developed for 12 distinct clinical situations and an overall summary measure. The 1997 event rates per 10,000 discharges varied from 1.1 for foreign bodies left during procedures to 84.7 for birth trauma. Compared with discharge records without PSI events, discharge records with PSI events had 2-3 fold longer hospital stays, 2-20 fold higher rates of mortality in the hospital, and 2-8 fold higher total charges. Multivariate logistic regression revealed that PSI events were primarily associated with increasing age, hospitals performing more inpatient surgery, and hospitals with a higher percentage of beds in intensive care units. The PSIs provide an efficient tool to identify potential in-hospital patient safety problems for targeted quality improvement efforts. Until better error reporting systems are developed, the PSIs can serve to shed light on the problem of medical errors.

Authors: Friedman B., Devers K., Steiner C., Fox, S.
Title: The Use of Expensive Health Technologies in the Era of Managed Care: The Remarkable Case of Neonatal Intensive Care.
Publication: Journal of Health Politics, Policy and Law 27(3)441-64.
Date: 2002.
Abstract: The use of neonatal intensive care (NIC) continued to rise rapidly in the 1990s despite the concerns of observers about cost-effectiveness of NIC in some cases and better outcomes in facilities with high volume and capabilities. The study tested the effects of insurance type, competition among hospitals, and market pressure from managed care plans on the supply and cost of NIC. Key findings are that the decision of a hospital to offer NIC was associated with teaching status, the proportion of infants in the market area with high documented risk, and the market concentration of major competitors. The market share of managed care plans, and the concentration of enrollment, was not associated with NIC being offered or the standardized charges. Whether a particular patient was admitted to a NICU depended on patient risk factors, whether a NICU was present, but not on payer group. The results are consistent with the hypothesis that young insured parents (with the advice of their obstetricians) prefer hospitals with NIC, and also are relatively profitable enrollees for health plans.

Authors: Friedman B, De La Mare J, Andrews R, McKenzie D.
Title: Estimating Hospital Cost for Discharged Patients—Practical Options in an Era of Data Restrictions.
Publication: Journal of Healthcare Finance 29(1):1-13.
Date: 2002.
Abstract: Analysts often estimate the cost of hospital services by applying cost/charge ratios from Federal or State data sources to the charges provided on hospital discharge records. Recently, a number of sources of discharge data are not permitting release of hospital identities. This study compares several sources of cost/charge data for use in the restricted environment. Accounting data from four State systems and from files of the federal Health Care Financing Administration (HCFA) are employed. In one analysis hospitals are grouped by selected characteristics. Cost/charge varies by state and characteristics. Some HCFA and State measures track each other closely. A wider analysis of hospital-specific data for 51 states offers a separate test and extension of the initial results. The study supports a practical policy option of releasing grouped cost/charge ratios attached to discharge records when identity must be masked.

Authors: Fleishman J, Hellinger F.
Title: Trends in HIV-Related Inpatient Admissions and Deaths: A Seven-State Study.
Publication: Journal of Acquired Immune Deficiency Syndromes 28(1):73-80.
Date: 2001.
Abstract: Reports of declining HIV-related inpatient utilization since the introduction of combination antiretroviral therapy have typically been based on data from a single institution or locality. This study examines trends in HIV-related inpatient admission rates from 1993 through 1997, using a negative binomial analysis of comprehensive data from seven states. We used comprehensive hospital discharge data from seven states, from the State Inpatient Database of the Healthcare Costs and Utilization Project. HIV-related inpatient admission rates rose between 1993 and 1995, but then showed sharp and steady declines starting in late 1995. This general pattern was observed for all seven states, and did not differ by patients' gender or race/ethnicity. Admission rates were highest for black males and lowest for white females. The rate at which HIV-related admissions ended in the death of the patient also declined steadily after 1995. The inpatient death rate for women was lower than that for men, but racial/ethnic differences in death rates were not significant. These results confirm and extend previous reports of reduced HIV-related inpatient utilization subsequent to the advent of combination antiretroviral therapy.

Authors: Hellinger F, Fleishman J.
Title: Location, Race, and Hospital Care for AIDS Patients: An Analysis of Ten States.
Publication: Inquiry 38:319-30.
Date: Fall 2001.
Abstract: This study is the first statewide comparison of hospital utilization and inpatient mortality rates for persons with Acquired Immune Deficiency Syndrome (AIDS). Data from 120,772 hospital discharge abstracts for all AIDS-related admissions in 10 states (California, Colorado, Florida, Iowa, Kansas, Maryland, New Jersey, New York, Pennsylvania, and South Carolina) in 1996 were combined with data on the number and the racial and ethnic characteristics of all persons living with AIDS (PLWAs) in each state. These data were used to derive population-based estimates of the utilization of hospital services per PLWA and of inpatient mortality rates in each state. Multivariate analyses examined sources of variation in inpatient length of stay and inpatient mortality. The primary finding of this study is that hospital utilization rates and inpatient mortality rates for persons with AIDS vary substantially across states and among racial and ethnic groups within states even after adjusting for severity of illness. Blacks and Hispanics had longer hospital stays and were more likely to die in the hospital than whites. State-level policies, such as home and community-based waiver programs and enhanced HIV reimbursement rates, significantly affected hospital use.

Authors: Farquhar, C.M, Steiner, C.A.
Title: The Impact of Endometrial Ablation on Hysterectomy Rates in Women with Benign Uterine Conditions in the U.S.
Publication: International Journal of Technology Assessment in Health Care 2002, 18:3
Date: Summer 2002
Abstract: This study assesses the impact of endometrial ablation on the utilization of hysterectomy in women with benign uterine conditions. Data are from the State Inpatient Database and Ambulatory Surgery Database of the Healthcare Cost and Utilization Project (HCUP) for 6 States, 1990-97. Women who underwent hysterectomy and endometrial ablation and had benign uterine conditions were extracted using ICD-9 coding. Comparative rates, length of stay, total charges, age, payer, location of hospital and teaching status of the hospital for hysterectomy and endometrial ablation were studied. The rates of hysterectomy decreased in three States (Colorado 37 percent, Maryland 18 percent, New Jersey 11 percent), were static in two States (Connecticut and New York) and increased in one State (Wisconsin, 11 percent increase). In contrast, the rates for endometrial ablation have increased in all states. The ratio of hysterectomy to endometrial ablation rates fell in each state and in two States (New York and New Jersey) the rate of endometrial ablations was equivalent to the rate of hysterectomies during the eight years studied. The total combined rate for hysterectomy and endometrial ablation for women with benign uterine conditions for each state increased by more than 10 percent with the exception of Maryland which had an increase of only 4 percent, and Colorado which had a decline of 23 percent. In the six States studied, the diffusion of endometrial ablation has had a varying impact, although overall it appears ablation is an additive rather than substitutive technology.

Authors: Farquhar C, Steiner C.
Title: Hysterectomy Rates in the United States 1990-1997
Publication: Obstetrics & Gynecology 99:229-34.
Date: 2002.
Abstract: This study assesses national hysterectomy rates, type of hysterectomy and other factors associated within the United States from 1990 to 1997. A descriptive statistical analysis of national discharge data was undertaken. Data from the Nationwide Inpatient Sample of HCUP (from which national estimates are generated based on a 20 percent stratified sample of U.S. community hospitals) were used for the 1990-97. All women who underwent hysterectomy were identified using ICD-9-CM procedure codes. Rates and type of hysterectomy, age of patients, length of stay, total hospital charges and diagnostic categories were determined. We found that the rates of hysterectomy have not changed significantly over 1990-97. Rates for hysterectomy in 1990 were 5.5 per 1,000 women and increased slightly by 1997 to 5.6 per 1,000 per women. It appears that introduction of alternative techniques for controlling abnormal uterine bleeding such as endometrial ablation have not had an impact on hysterectomy rates. The type of hysterectomy has changed, with laparoscopic hysterectomy (LAVH) accounting for 9.9 percent of cases by 1997, with a concomitant decline in abdominal hysterectomy but no substantial change in vaginal hysterectomy rates. Length of stay decreased and total charges increased for all types of hysterectomy. Vaginal hysterectomy and laparoscopic hysterectomy are associated with shorter length of stay than abdominal hysterectomy. Abdominal hysterectomy remains the most common procedure (63.0 percent in 1997).

Authors: Jiang HJ, Begun JW. Title: Dynamics of Change in Local Physician Supply: An Ecological Perspective. Publication: Social Science and Medicine 54(10):1525-41. Date: 2002. Abstract: An ecological framework was proposed that explains the growth of a physician population by four mechanisms—the intrinsic properties of this physician population; the local market's carrying capacity, determined by three environmental dimensions (munificence, concentration, diversity); competition within the same physician population; and interdependence between different physician populations. The study period is from 1985 to 1994, during which dramatic changes occurred in the health care sector—an unprecedented growth in managed care, increased hospital consolidation and organized physician practice. MSA level data were compiled from ARF, the AHA Annual Surveys of Hospitals, the AMA Census of Medical Groups, the InterStudy National HMO Census, and the U.S. County Business Patterns. Both changes in the number and percentage of physicians in a particular specialty population were examined. Variables measuring three environmental dimensions were found to have significant and differential effects on change in the size of different specialty populations. For instance, hospital consolidation and managed care penetration both showed significant positive effects on growth of the generalist population but suppressing effects on growth of the specialist population. MSAs with higher percentages of for-profit hospitals had significant increases in the percentage of specialists.

Authors: Romano P, Elixhauser A, McDonald K, Miller M.
Title: The Role of Health Information Professionals in Monitoring Patient Safety.
Publication: American Health Information Management Association (AHIMA), 1-3.
Date: March 2002.
Abstract: Until better medical error reporting systems are implemented, existing administrative data can serve as a case-finding tool for targeted quality improvement efforts. A set of patient safety indicators (PSIs) based on hospital administrative data and ICD-9-CM codes have been developed to help focus on preventable instances of harm to patients, such as surgical complications and other iatrogenic events. These PSIs can be used as a screen for potential quality problems; however, improved coding of complications will increase their utility. Health information management professionals can make a major contribution to the national effort to monitor and prevent medical errors through their application and ongoing refinement of ICD-9-CM.

Authors: Jiang HJ, Ciccone K, Urlaub CJ, et al.
Title: Adapting the HCUP Quality Indicators for Hospital Use: The Experience in New York State.
Publication: The Joint Commission Journal on Quality Improvement 27(4):200-15.
Date: 2001
Abstract: The Healthcare Association of New York State (HANYS) has adapted the HCUP QIs to produce comparative reports for more than 200 member hospitals since 1997. Risk adjustment was added to the complication measures to control for demographic and clinical factors. Indirect standardization of demographics and payer status was applied to measures of utilization and access to care. Each hospital received its own report with comparisons to statewide norms, regional, and peer group averages. Specifically designed for internal use, the reports have provided valuable information for individual hospitals to assess quality of care and target potential areas for improvement. The reports also provided hospitals a broad perspective to look beyond their own institutions and develop community-based quality improvement initiatives. Nevertheless, given the limitations common with administrative databases and the lack of standard risk adjustment methods, the HCUP QIs are best used for internal purposes and not for public reporting.

Authors: Jiang HJ, Lagasse R, Ciccone K, et al.
Title: Factors Influencing Hospital Implementation of Acute Pain Management Practice Guidelines.
Publication: The Journal of Clinical Anesthesia 13(4):268-76.
Date: 2001.
Abstract: Undertreatment of postoperative acute pain is well documented in the medical literature. Pain management practice guidelines developed by national entities have not been consistently implemented at the local level. To identify barriers and incentives to guideline implementation, two separate surveys were administered to 220 hospitals in New York State. One survey was addressed to each hospital's chief executive officer (CEO); the second survey was addressed to the clinical director of the Department of Anesthesiology or Acute Pain Service. Survey results show that only 27 percent of the responding hospitals were using a published pain management practice guideline. Factors predictive of guideline adoption include resource availability and belief in the benefits of using guidelines to improve quality of care or to achieve economic/legal advantages. Guideline implementation, however, does not necessarily include applying all key elements recommended by AHRQ guideline. For example, a collaborative, interdisciplinary approach to pain control was used in only 42 percent of the hospitals. Resource availability, particularly staff with expertise in pain management and existence of a formal quality assurance program to monitor pain management, was significantly predictive of compliance with key guideline elements.

Author: Basu J, Friedman B.
Title: Hospitalization of Children for Ambulatory Care Sensitive Conditions: Determinants of Patient Flows in a Large State.
Publication: Health Economics 10(1)67-78.
Date: 2001.
Abstract: The study examines the influence of key policy variables such as types of insurance, and local supply of primary care, and patient characteristics such as race, and severity of illness, among others, on out-of-area use of hospitals by children with diagnoses defined as ambulatory care sensitive (ACS) conditions. Hospital discharge data for New York residents admitted to hospitals in New York, Pennsylvania, New Jersey or Connecticut in 1994 are used. Patient-level data are merged with the Area Resource file (ARF), and American Hospital Association (AHA) surveys. Hypotheses are developed from a model that links the choices of families residing in a local area, supply considerations of ambulatory care providers, HMOs and hospitals, determining the admissions to hospitals for ACS conditions in an out-of-area hospital. The study uses logistic regression to predict travel out of the local area for ACS admission. The study finds that HMOs do not especially take members outside the area when hospital care is needed. Inadequate primary care could cause significant patient flows. Severity of illness significantly affects flows out of the local area and children with nonwhite race tend to stay in. The implications of these findings might be that a greater availability of local primary care physicians could reduce the movement of children outside the county. This could be more effective in areas with more nonwhites and Medicaid patients because those are the areas associated with higher occurrence rates, and a higher likelihood of patients to stay locally. Future research will compare patient flows for ACS conditions with other conditions such as those treated with elective procedures, use other age groups, and examine the time trends for ACS conditions.

Authors: Andrews R, Elixhauser A.
Title: Access to Major Therapeutic Procedures: Are Hispanics Treated Differently than Non-Hispanic Whites?
Publication: Ethnicity & Disease 10 (Autumn), 59-69.
Date: 2000.
Abstract: This study examines, for patients hospitalized with one of a wide range of conditions, whether Hispanics and non-Hispanic whites receive major therapeutic procedures at the same rates. The study examined hospital stays of Hispanic and non-Hispanic white adults using 1993 discharge abstract data from the Healthcare Cost and Utilization Project State Inpatient Databases. Data were for California, Florida and New York—States containing half the Hispanic population in the country. Logistic regression modeling was used to identify the effect of ethnicity on the likelihood of receiving a major therapeutic procedure separately for 63 conditions, controlling for age, gender, disease severity, health insurance, income level of patient's community and hospital characteristics.

Hispanics are less likely than non-Hispanic whites to receive major therapeutic procedures for 38 percent of the 63 conditions examined and more likely for 6 percent of the conditions. This study identified many conditions with apparent variations in treatment based on patient ethnicity. Future studies should examine reasons for disparities between ethnic groups, why these disparities occur for some conditions and not others, and appropriateness of procedures received.
Availability: AHRQ Publication No. 01-R016 is available from the AHRQ Publications Clearinghouse.

Author: Brooks JM, McClellan M, Wong HS.
Title: The Marginal Benefits of Invasive Treatments for Acute Myocardial Infarction: Does Insurance Coverage Matter?
Publication: Inquiry 37(1):75-90.
Date: 2000.
Abstract: This paper applies instrumental variable (IV) techniques and estimates the average benefits of invasive surgical treatments for marginal acute myocardial infarction (AMI) patients by insurance coverage (i.e., Medicare, Medicaid, privately-insured non-HMO, privately-insured HMO, and self-pay) using data from Healthcare Cost and Utilization Project (HCUP), State Inpatient Database for the State of Washington, for 1988-93. The authors observed differences in average benefits for marginal patients across insurance subpopulations that cannot be explained by differences in measured clinical circumstances. The empirical results show that the insurance subpopulation with the greatest estimated marginal benefits are those with the lowest expected payment generosity to providers. Because of the relatively weak explanatory power of the instruments for three insurance subpopulations and because many of the parameter estimates across the insurance subpopulations are not statistically different from each other, policy recommendations should be approached cautiously, according to the authors. While more precise estimates are needed to make policy recommendations, application of IV estimation techniques to AMI patients demonstrates the usefulness of this approach to estimate treatment effects across patient populations (e.g., across types of insurance coverage) for medical conditions of interest to policymakers. These estimates may help determine whether treatments are over- or underutilized.
Availability: AHRQ Publication No. 00-R039 is available from the AHRQ Publications Clearinghouse.

Author: Elixhauser A, Yu K, Steiner C, et al.
Title: Hospitalization in the United States. HCUP Factbook No. 1
Publication: Rockville (MD): AHRQ.
Date: 2000.
Abstract: A new report by AHRQ shows that over a third of all hospital patients are initially seen in the emergency department before being admitted. This figure includes 40 percent of all hospitalized children and 55 percent of the very old (80 and older). According to the report, which is based on 1997 data from AHRQ's Nationwide Inpatient Sample, the number one cause of hospital admission through the emergency room was pneumonia. Half of the other top 10 conditions for the admission of emergency room patients involved heart conditions. The other leading conditions for admission through the emergency department were stroke, chronic obstructive lung disease (emphysema or chronic bronchitis), asthma and blood infection (septicemia). The report also provides statistics on the age and gender of hospitalized patients; leading reasons for hospital admission overall and by age; hospital charges; lengths of stay; in-hospital mortality; patients who leave against medical advice; and types of locations to which patients are discharged. The Nationwide Inpatient Sample—the AHRQ database used to develop the report—contains about 7 million records, making it one of the largest publicly available databases for research and policy analysis and the only one that provides information on total hospital charges for all patients, regardless of their type of insurance or other payment source. Users can preview NIS data through HCUPnet, an interactive software tool. HCUPnet can be used to query the database and selected State hospital databases that participate in AHRQ's Healthcare Cost and Utilization Project (HCUP).
Availability: AHRQ Publication No. 00-0031 is available from the AHRQ Publications Clearinghouse.

Authors: Gross P, Steiner C, Bass E, Powe N
Title: Relation Between Prepublication Release of Clinical Trials Results and the Practice of Carotid Endarterectomy.
Publication: JAMA 284:2886-93.
Date: December 13, 2000.
Abstract: This article determined whether prepublication release of carotid endarterectomy trail results via National Institutes of Health Clinical Alerts were associated with a prompt change in patient care that was consistent with the new medical evidence. The study uses several years of data from seven States (NY, CA, PA, FL, CO, IL, and WI) that participate in the Healthcare Cost and Utilization Project. Findings include that the prepublication dissemination of Cost-effectiveness analysis trial results with clinical alerts was associated with prompt and substantial changes in medical practice. However, the results were extrapolated to patients and settings not directly supported by the trials.
Availability: AHCPR Publication No. 01-R017 is available from the AHRQ Publications Clearinghouse.

Author: McCormick MC, Kass B, Elixhauser A, et al.
Title: Annual Report on Access to and Utilization of Health Care for Children and Youth in the United States—1999.
Publication: Pediatrics 105(1 Pt 3):219-30.
Date: 2000.
Abstract: This report is the first in what is anticipated to be an annual series of reports on access to and use of health care services by America's children and youth. The report capitalizes on the existence of two national datasets, the Medical Expenditure Panel Survey (MEPS) and the Healthcare Cost and Utilization Project (HCUP), which have not been widely used by the child health services research community. As background to these new sources of data, the authors have provided a detailed description of the datasets, and reviewed some fundamental tabulations. In future years, as more data are accumulated, these reports will focus on delineation of key trends and analyses addressing policy issues.
Availability: AHRQ Publication No. 00-R014 is available from the AHRQ Publications Clearinghouse.

Author: Young GJ, Desai KR, Hellinger FJ.
Title: Community Control and Pricing Patterns of Nonprofit Hospitals: An Antitrust Analysis.
Publication: Journal of Health Politics, Policy, and Law 25(6):1051-81.
Date: 2000.
Abstract: The traditional control of nonprofit hospitals by the communities they serve has been offered as a justification for restraining antitrust enforcement of mergers involving nonprofit hospitals. Community control is arguably a constraint on a nonprofit hospital's inclination to exercise market power in the form of higher prices. However, community control is likely to be attenuated for hospitals that through merger or acquisition become members of hospital systems, particularly those that operate on a regional or multi-regional basis. In this paper the authors report findings from a study in which they used a panel data set to examine empirically the relationship between market concentration and price growth for three types of nonprofit hospitals: independent (or stand alone) facility, member of local hospital system, and member of non-local hospital system. Study results indicated that (1) all three types of nonprofit hospitals exercised market power in the form of higher prices and (2) hospitals that were members of non local systems were more aggressive in exercising market power than were either independent or local system hospitals. The results have important implications for antitrust enforcement policy.

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