Trends in perinatal regionalization and the role of managed care

OBJECTIVE: To describe trends in regionalization of perinatal care and identify factors that predict the extent of regionalization. METHODS: Data were drawn for four states for every year between 1989 and 1998. Panel data models estimated the effect of managed care enrollment on site of delivery for low, very low, and extremely low birth weight neonates. RESULTS: Strong evidence for regionalization over time was observed for North Carolina and Illinois, with little change in site of delivery in Washington. A shift from level III to level II hospitals was observed for low and very low birth weight neonates in California. Although managed care enrollment increased substantially in all four states, managed care had no effect on site of delivery; that is, the effect of managed care was near zero and not statistically significant in any state. CONCLUSION: Evidence supports the delivery of high-risk neonates at tertiary care centers. Despite changes in site of delivery, the percentages of very low birth weight neonates delivered at level III hospitals were substantially lower than the goal of 90% set by Healthy People 2010. Financial pressures introduced by managed care cannot be blamed for the failure to meet this goal. LEVEL OF EVIDENCE: II-2

Managed care and perinatal regionalization in Washington State

OBJECTIVE: To determine if an association exists between managed care penetration and perinatal deregionalization in Washington State. METHODS: The proportions of low birth weight (LBW) and very low birth weight (VLBW) deliveries were tabulated for each hospital in Washington State for the years 1989, 1993 and 1996. Level of perinatal care, degree of health maintenance organization (HMO) penetration, and maternal demographic characteristics including age, race, smoking, and Medicaid status were derived from state and national databases. Multiple linear regression analysis was performed for each hospital level to evaluate the association between change in proportion of LBW and VLBW deliveries and change in HMO penetration per hospital between each of the 3 years. RESULTS: From 1989 through 1993, the proportion of LBW deliveries significantly declined at level III hospitals and rose at level I and II hospitals. This trend reversed between 1993 and 1996. Very low birth weight deliveries demonstrated more limited and somewhat contrary results, significantly decreasing, then increasing in level I hospitals, and significantly increasing in level III hospitals from 1989 to 1993. After controlling for changes in maternal characteristics over time, changes in HMO penetration at the hospital level were not significantly associated with an increasing proportion of LBW or VLBW deliveries at nonlevel III hospitals. In some analyses, increasing HMO penetration actually was significantly associated with decreasing LBW and VLBW deliveries at nonlevel III hospitals. CONCLUSION: Despite continued growth in HMOs throughout the state, the trend toward deregionalization in Washington State noted in the early 1990s has not continued. At the hospital level, the increasing presence of HMOs is not significantly associated with perinatal deregionalization

Mucositis in Head and Neck Cancer: Economic and Quality-of-Life Outcomes

Outcomes research typically assesses three major health care outcomes, including quantity of life, quality of life (QOL), and health care cost. This article highlights the im-pact of treatment-associated mucositis on health care costs and QOL. After a background description of the economic analyses of overall cancer treatment costs and of the incre-mental costs associated with other treatment side effects, data from a retrospective study of mucositis-specific costs are presented. The second half of this article reviews current knowledge about the effect that mucositis has on QOL. Be-cause the empirical work that specifically evaluates mucosi-tis and QOL is quite limited, studies examining proxies for mucositis grading are described. These include studies com-paring the QOL of patients currently undergoing treatment, in which symptoms likely to be associated with mucositis ar