Health care costing: data, methods, current applications. Med Care

H ealth care costs continue to grow rapidly, straining budgets and raising questions about whether consumers are getting good value for the money spent. There has never been a more pressing need for conceptually sound and empirically accurate estimates of health care costs, for a variety of applications. For example, cost estimates are pivotal in the setting of public and private health care budgets at all levels and establishing reimbursement rates; in cost-effectiveness analyses and other economic evaluations; and in assessing the impact of investments in research to prevent, detect, and treat disease. Yet, the development of valid, reliable, feasible, and comparable (across studies) measures of health care cost has proved to be challenging, both in the United States and elsewhere. Substantial variation exists across studies in data and methods, even for cost studies with seemingly a similar intent. One major source of difficulty lies with the data. In most health cost analyses, the data for measuring and valuing resource use were created for purposes other than health care costing (primarily reimbursement) and hence are imperfectly designed for the task at hand. The alternative approach, to collect the cost data de novo, is often expensive, and there is not yet consensus on how best to do it. Health care costs are inherently difficult to measure, whatever the choice of data source(s). For multiple reasons, the posted prices of health care goods and services often do not convey accurate or useful information about economic cost. The health care system produces literally thousands of heterogeneous products, whose individual "prices" are often not observed in the complex maze of pricing for bundled services. Moreover, observed prices may reflect differences in market power between buyers and sellers (as reflected, for example, in negotiated price discounts), efforts to cross-subsidize unprofitable services, and other market imperfections and idiosyncrasies. A second source of difficulties in health care costing is the absence of professional consensus on some data and methods issues. At a general level, there is universal agreement that the cost of any health care activity should be defined in terms of the "economic opportunity costs" of the component resources, with each resource valued in its next best use. In reality, there are substantial variations in how this textbook definition is applied because it provides little specific guidance on a number of practical issues. These include the components (or types) of cost to be included in the analysis, the assignment of opportunity cost values to these components, when and how to combine multiple data sources, key conceptual and study design issues (eg, identifying the cost attributable to a specific disease or activity), statistical challenges (eg, how best to handle heavily right-skewed cost data), and effective approaches for reporting findings. Similarly, within specific arenas of application (eg, cost-effectiveness analysis ͓CEA͔), there may be broad consensus regarding certain operating principles (eg, emphasis on the societal perspective), but little guidance on how best to bring data and From th

Association of Regional Variation in Primary Care Physicians’ Colorectal Cancer Screening Recommendations with Individual Use of Colorectal Cancer Screening

IntroductionStudies show that the recommendations of a primary care physician for colorectal cancer screening may be one important influence on an individual’s use of screening. However, another possible influence, the effect of regional differences in physicians’ beliefs and recommendations on screening use, has not been assessed.MethodsWe linked data from the National Health Interview Survey on the use of colorectal cancer screening by respondents aged 50 years or older, by hospital-referral region, with data from the Survey of Colorectal Cancer Screening Practices on the colorectal cancer screening recommendations of primary care physicians, by region. Our principal independent variables were the proportion of physicians in a region who recommended screening at age 50 and continuing screening at the recommended frequency.Results On average, 53.3% of physicians in a region correctly recommended initiating colorectal cancer screening, and 64.8% advised screening at the recommended frequency. Of adults who lived in regions where less than 30% of physicians correctly recommended initiating screening, 47.3% had been screened, in contrast to 54.8% in areas where 70% or more of physicians made correct recommendations. Seventy-one percent of respondents living in regions where less than 30% of physicians advised screening at the recommended frequency were current on screening, in contrast to 79.9% of respondents living in regions where 70% or more of physicians made this recommendation. These differences were statistically significant after adjustment for individual characteristics.ConclusionStrategies to improve colorectal cancer screening recommendations of primary care physicians may improve the use of screening for millions of Americans

Nonelective coronary artery bypass graft outcomes are adversely impacted by Coronavirus disease 2019 infection, but not altered processes of care: A National COVID Cohort Collaborative and National Surgery Quality Improvement Program analysisCentral MessagePerspective

Objective: The effects of Coronavirus disease 2019 (COVID-19) infection and altered processes of care on nonelective coronary artery bypass grafting (CABG) outcomes remain unknown. We hypothesized that patients with COVID-19 infection would have longer hospital lengths of stay and greater mortality compared with COVID-negative patients, but that these outcomes would not differ between COVID-negative and pre-COVID controls. Methods: The National COVID Cohort Collaborative 2020-2022 was queried for adult patients undergoing CABG. Patients were divided into COVID-negative, COVID-active, and COVID-convalescent groups. Pre-COVID control patients were drawn from the National Surgical Quality Improvement Program database. Adjusted analysis of the 3 COVID groups was performed via generalized linear models. Results: A total of 17,293 patients underwent nonelective CABG, including 16,252 COVID-negative, 127 COVID-active, 367 COVID-convalescent, and 2254 pre-COVID patients. Compared to pre-COVID patients, COVID-negative patients had no difference in mortality, whereas COVID-active patients experienced increased mortality. Mortality and pneumonia were higher in COVID-active patients compared to COVID-negative and COVID-convalescent patients. Adjusted analysis demonstrated that COVID-active patients had higher in-hospital mortality, 30- and 90-day mortality, and pneumonia compared to COVID-negative patients. COVID-convalescent patients had a shorter length of stay but a higher rate of renal impairment. Conclusions: Traditional care processes were altered during the COVID-19 pandemic. Our data show that nonelective CABG in patients with active COVID-19 is associated with significantly increased rates of mortality and pneumonia. The equivalent mortality in COVID-negative and pre-COVID patients suggests that pandemic-associated changes in processes of care did not impact CABG outcomes. Additional research into optimal timing of CABG after COVID infection is warranted