Caryl E. Carpenter

The Impact of Intra-DRG Severity of Illness on Hospital Profitability: Implications for Payment Reform

We examined the relationship between variations in intra-DRG severity of illness classifications and hospital profitability. Unlike in previous studies, we created a direct hospital-level measure of severity, formed from MedisGroup severity scores. We estimated separate regression equations for total margin, operating margin, net revenue per admission, and expense per admission. We examined data for 201 Pennsylvania hospitals and found that hospital profits were inversely related to the severity of illness index. Expense per admission was positively related to severity; however the relationship between severity and net revenue per admission was not significant. The results suggest that hospitals with a more severe case mix may not recover the full costs of providing services. Thus payment reform should include adjustments for severity of illness.

The Impact of Climcal Guidelines On Practice Patterns: Doing More versus Doing Less:

This study examined the determinants of compliance with clinical guidelines for glucocyte colony-stimulating factor (GCSF), a biotechnology product designed to re duce postchemotherapy infections. The pattern of com pliance did change over time. After the guidelines were disseminated, appropriate use of GCSF increased. However, inappropriate use also increased. Patients who were younger and had an attending physician who was an oncologist or hematologist were more likely to re ceive GCSF whether they met the guideline criteria or not. Our findings suggest that older patients may be treated less aggressively than others and that physicians who are the most knowledgeable about guidelines may feel the most qualified to override the guidelines when they believe they do not apply. Our findings also demon strate that it is easier to encourage physicians to do more for patients rather than less.

Ondansetron: costs and resource utilisation in a US teaching hospital setting.

A retrospective pharmacoeconomic analysis was conducted to compare lengths of hospital stay for, and usage of hospital resources by, patients (850 admissions) who received either ondansetron or standard antiemetic therapy during hospital admissions for cancer chemotherapy. Average hospital costs for patients admitted to a 720 bed academic medical centre for maintenance chemotherapy between October 1990 and September 1991 were analysed using the hospitals online computerised clinical financial management system. A separate prospective time-and-motion study was used to evaluate specific costs of nursing care associated with episodes of severe nausea and vomiting. In addition, patient perception of quality of life and satisfaction with therapy were evaluated for 27 chemotherapy patients using quality-of-life measurements on the Functional Living Index-Cancer (FLIC) scale. The results of these studies showed that the average length of hospital stay was shorter for patients who received ondansetron rather than standard antiemetic therapy, but that average hospital costs were not significantly different. The reduced hospitalisation costs offset the higher acquisition cost of ondansetron. Mean quality-of-life scores decreased significantly after chemotherapy for patients receiving either ondansetron or standard therapy, but the changes in scores were not strongly associated with the antiemetic agents used or with any of the clinical or demographic variables measured in this study.

Development of a scalar hospital-specific severity of illness measure

Cost-function analysis of hospitals has been criticized for not including severity adjustments. We tested a scalar hospital-specific severity index, derived from Admission MedisGroup Scores. Alternative versions (i.e., linear/nonlinear) of the index were evaluated by estimating cost functions on a sample of 201 Pennsylvania hospitals. The scalar index was a strong predictor of costs. The results also suggest that the omission of a severity variable in a hospital cost function may cause a specification error.

Evaluating the cost containment potential of clinical guidelines.

New expensive biotechnology products create financial as well as clinical dilemmas for hospitals. Clinical guidelines that govern the use of these new products are often viewed as the best response to these dilemmas. This article describes a prospective analysis of the impact of one new drug and the guidelines developed to control its use. A simple model of clinical decision making is used to evaluate alternative scenarios. The analysis illustrates the importance of evaluating the cost containment potential of clinical guidelines before they are implemented.

Older-Worker-Friendly Policies and Affective Organizational Commitment

In the United States the Baby Boomer generation is advancing toward retirement age and many are choosing to stay in the workforce. This study develops and analyzes a model of the impact of older-worker-friendly (OWF) policies in organizations on job satisfaction, strain-based work/family conflict, and affective organizational commitment in older workers. The data included 368 full-time employed persons age 50 years or older who participated in a telephone survey. Linear regression was used to analyze the hypothesized relationships. Results indicated that the model was supported. Older workers who were employed at organizations with more older-worker-friendly policies had higher levels of job satisfaction and lower levels of strain-based work/family conflict, which led to higher levels of affective organizational commitment.

Clinical evaluation units: a research agenda.

A new model for evaluating quality rests on the tripod of outcomes research, practice pattern analysis, and the tenets of continuous quality improvement. The hospital-based locus for this tripod could be clinical evaluation units. This article describes the conceptual framework, study design, and research challenges associated with an ongoing project whose purpose is to assess the current status of these clinical evaluation units in academic medical centers nationwide.