Journal of health care technology最新文献

Health care providers are currently experiencing a malpractice "crisis" that, in some regions and for some medical specialties, is as serious as the one that occurred a decade ago. Whether providers themselves, the insurance industry, or lawyers and the legal system are seen as responsible for today's crisis depends primarily on the observer. However, evidence indicates that, in health care, negligence by those who provide services (physicians and hospital personnel) is a more important factor in the health care liability crisis than is so for other sectors of society that also face liability-insurance problems (e.g., municipal governments, light aircraft manufacturers, ski-slope operators). While physicians and hospitals can participate in legislative efforts to achieve tort reform and more stringent regulation of liability insurers, this study suggests that they will have more success in reducing malpractice insurance premium rates by concentrating instead on improving the quality of patient care. Towards this end, a number of specific actions are outlined, ranging from greater use of patient-care protocols and algorithms to increased activity by state medical licensing and disciplinary boards.

In view of the upcoming legislative deadline for inclusion of capital costs within the Medicare prospective payment system, both public and private-sector entities have scrutinized various capital payment options and debated key issues relating to appropriate overall payments for capital costs, the nature of the mechanism for allocating payments to hospitals, and the method for transition from the present to the new capital payment system. The new capital payment policy will play an important role in future hospital capital decisions and technology levels. This report describes the nature and magnitude of hospital capital costs, examines alternative proposals for reflecting capital costs in the Medicare prospective payment system, and details each alternative's impact, incentives, and disincentives.

The Swiss Hospital Institute, a nonprofit institution that provides guidance on hospital planning and operation to Switzerland's health care community, conducted in 1984 a comprehensive study of magnetic resonance imaging (MRI) and magnetic resonance spectroscopy via a 17-member commission that examined all aspects of these emerging technologies. Future MRI utilization was estimated by developing five clinical categories of possible MRI use, based on ICD codes, and a probability of MRI utilization was developed for each category. By applying these probabilities to the number of inpatient admissions in each category, an annual nationwide volume of 20,000 scans was estimated. Ten MRI systems were considered adequate for a period of up to five years after the report's promulgation, based on a per-system annual throughput of 1,900-2,000 patients. A superconducting-magnet system with an 0.5-T field strength was deemed the most suitable, with units to be located in university hospitals. [Spectroscopy was considered best left to separate research installations.] The cost of equipment and construction for the 0.5-T superconducting magnet system were calculated as high as 3.6 million Swiss francs (Sfr) (approximately $1.65 million at fall 1985 exchange rates). the annual operating cost was estimated as Sfr 1.3 million ($600,000). On this basis a per-study fee of Sfr 690 ($315) was projected. The study recommended health insurance coverage of MRi use, only in patients with well-proven clinical indications for an MRI scan. The report is expected to aid in the orderly introduction of MRI into Switzerland's health care system.

The growing number of applications for both new and existing technologies will act as a catalyst for major changes in the diagnostic testing field over the next decade. The most important single factor affecting diagnostics, however, will be the increasing restrictions on reimbursement for diagnostic tests as traditional payers become much more cost conscious. After decades of growth, we should see a gradual decline in absolute numbers of diagnostic tests and procedures by the early 1990s. The locations of pathology testing may change as well. Free-standing labs will continue to grow in importance while the number of tests in hospitals will decline as hospital admission volumes fall. The number of tests in the home will grow dramatically but will remain a relatively small part of the whole. In diagnostic imaging, rapid growth will occur in the use of some of the newer specialized procedures, but the use of traditional x-rays is likely to fall off slightly. The share of procedures done in hospitals will drop, and the share done in diagnostic imaging centers will show a corresponding growth. These changes are likely to mean fewer radiologists and pathologists, tougher questions about administrative allocation of flat-rate reimbursements, a shift of focus in medical specialist education, and a shift in the role of medical specialty societies.

The leukocyte or white blood cell (WBC) differential count has been an established laboratory examination for almost a century. In recent years, the number of clinicians' requests for the test has grown steadily, and presently over 1,000,000 WBC differentials are performed daily in the United States. The manual WBC differential count requires tedious and repetitious cell classification, which is prone to subjective bias. Quite understandably, the WBC differential count has been a prime candidate for automation. Manufacturers have developed automated WBC differential counters that are accurate and that more precisely classify WBCs than do experienced morphologists. However, the WBC differential count, initially controversial because of technologists' subjective cell classification, has again become an object of debate following the substitution of automated instruments to perform cell identification. Instead of significantly better test results, automated WBC differential counters have demonstrated that variables inherent in the methodology, which cannot be controlled by automated techniques, limit the validity of information derived from the WBC differential. This report discusses the issues surrounding the use of automated WBC differential counters that need to be addressed by those contemplating acquisition of the technology. More fundamental questions are also explored, i.e., if the acknowledged clinical utility of the WBC differential in its present status is limited, what alternatives are available, and is investment in the currently available technology prudent?

This paper describes the Congressional Office of Technology Assessment's Health Program and the role that its process of program planning has played in the selection of studies and the allocation of Program resources. It discusses the primary areas in which studies have been conducted--assessment methods, specific technologies, environmental health, information technologies, and financing/structural aspects of health care--and examines the changes in relative emphasis placed on the areas over time and the factors that lead to changed emphasis. Internal factors--e.g., judgments of whether a topic is of national importance, fiscal and staff resources available, and whether the issue is appropriate for OTA--and thus program planning have played their strongest role in the areas of assessment methods and of specific technologies. Activities in the financing/structural areas and some types of studies in the environmental health areas are being driven more by external factors--e.g., expressed needs of Congress, availability of data, and developments in science and technology.

A cost-effectiveness analysis of alternative strategies to prevent hepatitis B in hospital workers was developed to compare pre-exposure immunization with post-exposure prophylaxis. The analysis included the impacts of hepatitis B incidence, employee turnover, strategy efficacy, and medical care expenses to determine the economic effectiveness of immunization and prophylaxis for employees at different risks for hepatitis B exposure. The prophylaxis strategy was found to cost $322 per high-risk employee for a five-year period, while the immunization strategy was found to cost $263 per high-risk employee for a five-year period, for a saving of $59 per employee. Sensitivity analysis demonstrated that pre-exposure immunization remained a cost-effective alternative to post-exposure prophylaxis over a wide range of different model assumptions.

Blood has been recognized as the essence of life since ancient times. Bloodletting, however, was performed centuries ago to treat disease and prolong life. Seventy years ago selective removal of blood components from circulating blood was advocated as a therapeutic measure. However, manual procedures for blood removal, separation, and reinfusion were quite cumbersome and did not really lend themselves to daily clinical practice. In the last 15 years, technologies have been developed to allow separation of blood into its component fractions, selective removal of specific elements--either cellular products or liquid plasma--an reinfusion of the remaining blood. Early cell separators were designed to collect specific blood components from healthy donors for subsequent transfusion to critically ill patients. Apheresis techniques were found to reduce the amounts of some normal elements circulating in the donors' blood, and the procedure thus began to be used therapeutically to remove abnormal components and to reduce excessive quantities of otherwise normal blood components. Diffusion of automated cell separators quickly followed and apheresis procedures were applied as treatment for a variety of diseases and conditions. The efficacy of therapeutic apheresis in many rare or exotic diseases is well established. In others, the role of apheresis is less clear. By reviewing the medical benefits of therapeutic apheresis, access to treatment, and the costs resulting from broad applications, this assessment will assist health care professionals and policymakers to evaluate therapeutic apheresis technology.