Marsha G. Goldfarb

Quality Indicators Using Hospital Discharge Data: State and National Applications

BACKGROUND Demand for information about the quality of health care has escalated. Yet many organizations lack well-specified quality measures, statistical expertise, or the requisite data to produce such information. The Healthcare Cost and Utilization Project Quality Indicators (HCUP QIs) represent one approach to measuring health care quality using readily available data on hospital inpatients. METHODS The HCUP QIs, developed in 1994, address clinical performance rather than other dimensions of quality such as satisfaction or efficiency. The 33 indicators produce rates that represent measures of outcomes (mortality and complications), utilization, and access. In lieu of complex multivariate techniques, two methods were used: (1) restrictions in defining patient subgroups to isolate homogeneous at-risk populations and (2) standardization when populations are diverse. Stratified analyses are recommended when patient or hospital factors are believed to influence the outcome. A simple method for making statistical comparisons to national rates was developed. The HCUP QI software, available in both mainframe and microcomputer applications, have enabled organizations to use their own data to produce comparative statistics and examine trends over time. Results summarized at the individual hospital or aggregate level are being used to stimulate continuous quality improvement initiatives. CONCLUSIONS The HCUP QIs offer a low-cost alternative for organizations that have access to administrative data. Current users include hospital associations, state health departments, statewide data organizations, and individual hospitals. Although the HCUP QIs are intended to serve as indicators, not definitive measures, of quality, they were designed to highlight quality concerns and to target areas for more intensive study.

Changing returns to education in Taiwan: 1978-1991

Abstract We find that private rates of return in Taiwan are highest for higher education levels (for example, university) and lowest for lower education levels (for example, junior high school), and that private returns are higher for women than men at all education levels. Unlike most other studies of changing returns to education over time in developing countries, we find that private returns for all education levels are remarkably stable during 1978–1991 in Taiwan.

DRGs and disease staging for reimbursing Medicare patients.

Beginning October 1, 1983, Medicare began reimbursing many hospitals on the basis of a set of fixed fees tied to Diagnosis-Related Groups (DRGs). Using 1979–1981 Maryland data for Medicare patients, this paper compares the DRG system with the Disease Staging patient classification system in terms of 1) structure, 2) explanation of resource consumption (length of stay) of hospital patients, and 3) impact on reimbursement by type of hospital. The two systems are conceptually and empirically different in classifying patients. Further, Disease Staging and DRGs perform similarly in explaining length-of-stay variation among Maryland patients. However, the two systems generate substantially different reimbursements by type of hospital. Surprisingly, large hospitals (including urban, not-for-profit, teaching hospitals) fare better under a DRG-based reimbursement system than under Disease Staging, a severity-of-illness system that excludes procedures as a basis of classification. These results imply that reimbursement policy based on Disease Staging would create disincentives to perform surgery compared with the current DRGs.

Making Sense of Competing Nursing Shortage Concepts

Widespread and continuing discussions of nursing shortages frequently involve divergent concepts of shortage that can have differing policy implications. This article explains the shortage concepts used by economists, hospital administrators, and government policy makers. It discusses measurement problems and suggests possible improvements. It then sets forth the divergent policy implications of competing shortage concepts. The articles aim is to promote greater clarity in analyses of nursing shortages and more fruitful conversations among participants who use different notions of shortages.

Determinants of hospital use: a cross-diagnostic analysis.

This article estimates the effects of personal, clinical, physician, and hospital characteristics in a simultaneous equations model of length of stay and ancillary services use for five narrowly defined medical and surgical conditions. These are tonsillectomy and adenoidectomy, gastroenteritis and colitis, inguinal hernia, coronary heart disease, and cholelithiasis. The data are derived from a sample survey of medical and financial records of patients discharged from any of 63 New England short-term general hospitals during the period July 1, 1969 through June 30, 1970. The results confirm the importance of a simultaneous equations formulation of utilization analysis and of inclusion of detailed measures of severity. Length of stay and ancillary services are significantly interrelated for all five conditions, corroborating results of a previous study of obstetric cases. Results for patients employment status and value of time, attending physician specialty and mode of practice, and hospital size, control, and nature of teaching activities were less conclusive, but suggest differential effects across diagnoses, thus emphasizing the importance of a diagnostic-specific approach to utilization analysis.

Patterns of Obstetrical Care in Hospitals

This article examines the determinants of length of stay and ancillary service use for a single diagnostic category: normal delivery. Data for a systematic sample of 945 obstetrical admissions to 48 New England hospitals during 1969-70 are used to estimate a simultaneous equations model. The exogenous variables include socioeconomic and medical characteristics of the mother, medical condition of the newborn, type of labor and delivery, and hospital and physician characteristics. The important findings are threefold: First, evidence is found supportive of a simultaneous relationship between length of stay and ancillary services for normal deliveries. Second, the results show the importance of controlling for the performance of surgery, the presence of complications, the length of labor and the death of the baby in analyzing obstetrical utilization patterns. Third, holding maternal medical and socioeconomic factors constant, hospital size, teaching status, control and location, as well as physician mode of practice and relationship to the hospital, are important determinants of hospital use. It is concluded that the diagnostic-specific approach to utilization analysis is appropriate and useful. Only within such a narrowed focus can researchers disentangle the confounding effects of the attributes of the disease itself from the impact of hospital and physician characteristics on hospital use.

Behavior of the multiproduct firm. A model of the nonprofit hospital system.

This article presents a hospital model that recognizes the multiproduct nature of hospital output and incorporates trade-offs among various competing goals. A utility function for the hospital is defined over quantity, quality and the net revenues associated with the treatments produced. Utility is constrained by epidemiological factors and by availability of beds. The model is used to draw comparative statics implications, from which econometric hypotheses are developed and tested. This is accomplished by a set of equations that predict variations in patient-mix, diagnosis-specific lengths of stay, admissions, expenses per admission, and occupancy rates. Empirical results are generally consistent with predictions. The model has a variety of policy applications, and these are illustrated.