Hospital benchmarking analysis and the derivation of cost indices

This paper reports work undertaken for the UK Department of Health to explore approaches to measuring and comparing hospital productivity. The purpose of the cost indices produced in this paper has been to use them to derive productivity scores for English NHS Trusts in order to benchmark them against one another to help identify poorer performers. The work builds on previous deterministic ‘efficiency indices’ by using statistical regression adjustment techniques. This work describes the derivation of three cost indices (CCI, 2CCI and 3CCI), each with increasing adjustment in terms of case mix, factor prices and environmental factors. The analysis uses data for the year 1995/6 and specifically examines acute Trusts. The CCI cost index is a deterministic index that takes into account case mix as measured by Healthcare Resource Groups (HRGs) and inpatient, first outpatient and accident and emergency (A & E) activity. It is a weighted index of actual / expected costs where expected costs are measured as average national costs per respective attendance. 2CCI takes factors into account such as additional adjustments for case mix, age and gender mix, transfers in and out of the hospital, inter-specialty transfers, local labour and capital prices and teaching and research costs for which Trusts might be over or under compensated. The 3CCI makes additional adjustments over and above those in the 2CCI for hospital capacity, including number of beds, and number of sites, scale of inpatient and non-inpatient activity and scope of activity. It therefore tries to capture institutional characteristics amenable to change in the long, but not the short run. 2CCI and 3CCI indices are obtained from a short-run regression model using CCI as the dependent variable, and productivity scores are obtained from the residuals of the regressions. The results suggest that the statistical adjustments reduce estimates of productivity variation between providers considerably, such that there is relatively little difference between providers in terms of fully adjusted (short-run) productivity scores (3CCI). This suggests that savings from bringing poorer performers up to those with higher productivity scores, may in fact be quite small. In the long run there may be more scope for productivity enhancement and savings than in the short run, by optimising capacity and activity levels. Productivity benchmarking results should always be tempered against judgements on the quality and effectiveness of service provision which these indices are currently unable to measure. Implicitly equating high cost to inefficiency, as these indices do, may also be problematic. The paper suggests that the use of panel data and the application of alternative methodologies (such as stochastic frontiers and Data Envelopment Analysis) would be a valuable way to extend this work.cost index, productivity

Taxation of the South African tobacco industry : with special reference to its employment effects

Bibliography: pages 82-87.This study examines the economic impact of cigarette excise taxes in South Africa. In particular, it looks at the economic impact of increasing excise taxes, or in effect, reducing consumption, and the resultant impact on output and employment in the economy. Real cigarette excise taxes in South Africa have steadily declined over the period 1970 to 1995. As a result there has been a concomitant decrease in the real retail cigarette price, caused primarily by the tax component. The South African government has however, since 1995, despite vociferous opposition from the industry, effected tax increases greater than expected inflation to adjust the cigarette duty back to its former levels. The tobacco industry has argued that such actions will result in job losses. The industry has argued that, regardless of its effects on physical health, tobacco plays an important role in the communities' economic health, generating employment and contributing vital revenues to government coffers, which in a country like South Africa with high unemployment, has strong political appeal. This study examines these arguments. The first part of the paper looks at the effect of taxation on consumption and government revenue. Using a price elasticity estimate of -0.6 for South African cigarette consumption, a simulation model of the government's tax policy is run. This shows that the government's policy on tobacco taxes has been non-optimal and revenue could have increased by 2 percent, had the government maintained the real value of excise duties. The results suggest that an optimal tax for the government could be set at a level higher than the current 52 percent of retail price which, contrary to industry arguments would maximise government revenue. The second part of the paper, then addresses the question of employment losses in the economy in the wake of increases in excise taxes by government. An input-output model is used and the methodology is based on the assumption that expenditure switching will occur from cigarettes to other goods and services in the economy. The model is tested using 1995 data. The study looks at the impact on output and employment from this alternative spending and examines the argument that increased excise taxes will result in job losses. The results suggest that the economic effects of increased excise taxes on cigarettes, which would result in a change in personal consumption behaviour away from cigarettes, will not have the harmful effects on employment that the industry claims. South Africa as a whole would have gained net increases in output and employment if smokers quit their habit completely or even partially during 1995. The government's current taxation policy therefore bodes well for public health, public finance, and the economy

Spatial variation of epoxyscillirosidine concentrations in Moraea pallida (yellow tulp) in South Africa

Moraea pallida (yellow tulp) poisoning is economically the most important intoxication of livestock in South Africa. Poisoning varies according to locality, climatic conditions and growth stage of the plant. The primary objective of this study was to determine the concentration of the toxic principle, epoxyscillirosidine, in yellow tulp leaves and to ascertain the variability of epoxyscillirosidine concentrations within and between different locations. A secondary objective was to utilise Geographic Information Systems in an attempt to explain the variability in toxicity. Flowering yellow tulp plants were collected at 26 sampling points across 20 districts of South Africa. The leaves of five plants per sampling point were extracted and submitted for liquid chromatography/mass spectrometry analysis. A large variation in mean epoxyscillirosidine concentrations, ranging from 3.32 μg/g – 238.27 μg/g, occurred between different geographical regions. The epoxyscillirosidine concentrations also varied tremendously between individual plants (n= 5) collected at the same sampling point, with up to a 24 times difference between the lowest and highest concentration detected. No generalised correlation between epoxyscillirosidine concentrations and soil elemental concentrations could be established. However, samples obtained from the north-eastern part of the sampling region tended to have higher epoxyscillirosidine concentrations compared to samples obtained from the south-western part of the sampling region. Higher toxin concentrations in the northeast were associated with statistically significant higher soil concentrations of iron, bismuth, bromide, cadmium, chromium, rubidium, tellurium, thallium, titanium and zinc, whilst soil concentrations of strontium and soil pH, were significantly lower. This study corroborated the contention that epoxyscillirosidine concentration in yellow tulp fluctuates and may explain the variability in toxicity

Identification of a novel functional deletion variant in the 5'-UTR of the DJ-1 gene

<p>Abstract</p> <p>Background</p> <p>DJ-1 forms part of the neuronal cellular defence mechanism against oxidative insults, due to its ability to undergo self-oxidation. Oxidative stress has been implicated in the pathogenesis of central nervous system damage in different neurodegenerative disorders including Alzheimer's disease and Parkinson's disease (PD). Various mutations in the <it>DJ-1 </it>(<it>PARK7</it>) gene have been shown to cause the autosomal recessive form of PD. In the present study South African PD patients were screened for mutations in <it>DJ-1 </it>and we aimed to investigate the functional significance of a novel 16 bp deletion variant identified in one patient.</p> <p>Methods</p> <p>The possible effect of the deletion on promoter activity was investigated using a Dual-Luciferase Reporter assay. The <it>DJ-1 </it>5'-UTR region containing the sequence flanking the 16 bp deletion was cloned into a pGL4.10-Basic luciferase-reporter vector and transfected into HEK293 and BE(2)-M17 neuroblastoma cells. Promoter activity under hydrogen peroxide-induced oxidative stress conditions was also investigated. Computational (<it>in silico</it>) <it>cis</it>-regulatory analysis of <it>DJ-1 </it>promoter sequence was performed using the transcription factor-binding site database, TRANSFAC via the PATCH™ and rVISTA platforms.</p> <p>Results</p> <p>A novel 16 bp deletion variant (g.-6_+10del) was identified in <it>DJ-1 </it>which spans the transcription start site and is situated 93 bp 3' from a Sp1 site. The deletion caused a reduction in luciferase activity of approximately 47% in HEK293 cells and 60% in BE(2)-M17 cells compared to the wild-type (<it>P </it>< 0.0001), indicating the importance of the 16 bp sequence in transcription regulation. The activity of both constructs was up-regulated during oxidative stress. Bioinformatic analysis revealed putative binding sites for three transcription factors AhR, ARNT, HIF-1 within the 16 bp sequence. The frequency of the g.-6_+10del variant was determined to be 0.7% in South African PD patients (2 heterozygotes in 148 individuals).</p> <p>Conclusion</p> <p>This is the first report of a functional <it>DJ-1 </it>promoter variant, which has the potential to influence transcript stability or translation efficiency. Further work is necessary to determine the extent to which the g.-6_+10del variant affects the normal function of the <it>DJ-1 </it>promoter and whether this variant confers a risk for PD.</p

Hospital Benchmarking Analysis and the Derivation of Cost

ABSTRACT This paper reports work undertaken for the UK Department of Health to explore approaches to measuring and comparing hospital productivity. The purpose of the cost indices produced in this paper has been to use them to derive productivity scores for English NHS Trusts in order to benchmark them against one another to help identify poorer performers. The work builds on previous deterministic &apos;efficiency indices&apos; by using statistical regression adjustment techniques. This work describes the derivation of three cost indices (CCI, 2CCI and 3CCI), each with increasing adjustment in terms of case mix, factor prices and environmental factors. The analysis uses data for the year 1995/6 and specifically examines acute Trusts. The CCI cost index is a deterministic index that takes into account case mix as measured by Healthcare Resource Groups (HRGs) and inpatient, first outpatient and accident and emergency (A &amp; E) activity. It is a weighted index of actual / expected costs where expected costs are measured as average national costs per respective attendance. 2CCI takes factors into account such as additional adjustments for case mix, age and gender mix, transfers in and out of the hospital, inter-specialty transfers, local labour and capital prices and teaching and research costs for which Trusts might be over or under compensated. The 3CCI makes additional adjustments over and above those in the 2CCI for hospital capacity, including number of beds, and number of sites, scale of inpatient and non-inpatient activity and scope of activity. It therefore tries to capture institutional characteristics amenable to change in the long, but not the short run. 2CCI and 3CCI indices are obtained from a short-run regression model using CCI as the dependent variable, and productivity scores are obtained from the residuals of the regressions. The results suggest that the statistical adjustments reduce estimates of productivity variation between providers considerably, such that there is relatively little difference between providers in terms of fully adjusted (short-run) productivity scores (3CCI). This suggests that savings from bringing poorer performers up to those with higher productivity scores, may in fact be quite small. In the long run there may be more scope for productivity enhancement and savings than in the short run, by optimising capacity and activity levels. Productivity benchmarking results should always be tempered against judgements on the quality and effectiveness of service provision which these indices are currently unable to measure. Implicitly equating high cost to inefficiency, as these indices do, may also be problematic. The paper suggests that the use of panel data and the application of alternative methodologies (such as stochastic frontiers and Data Envelopment Analysis) would be a valuable way to extend this work