Physician adoption of a practice guideline: Effect on the cost of medical care for adult patients with diabetes

In the demanding environment of healthcare reform, reduction of unwanted physician practice variation is promoted, often through evidence-based guidelines. Guidelines represent innovations that direct change(s) in physician practice; however, compliance has been disappointing. Numerous studies have analyzed guideline development and dissemination, while few have evaluated the consequences of guideline adoption. The primary purpose of this study was to explore and analyze the relationship between physician adoption of the glycated hemoglobin test guideline for management of adult patients with diabetes, and the cost of medical care. The study also examined six personal and organizational characteristics of physicians and their association with innovativeness, or adoption of the guideline. ^ Cost was represented by approved charges from a managed care claims database. Total cost, and diabetes and related complications cost, first were compared for all patients of adopter physicians with those of non-adopter physicians. Then, data were analyzed controlling for disease severity based on insulin dependency, and for high cost cases. There was no statistically significant difference in any of eight cost categories analyzed. This study represented a twelve-month period, and did not reflect cost associated with future complications known to result from inadequate management of glycemia. Guideline compliance did not increase annual cost, which, combined with the future benefit of glycemic control, lends support to the cost effectiveness of the guideline in the long term. Physician adoption of the guideline was recommended to reduce the future personal and economic burden of this chronic disease. ^ Only half of physicians studied had adopted the glycated hemoglobin test guideline for at least 75% of their diabetic patients. No statistically significant relationship was found between any physician characteristic and guideline adoption. Instead, it was likely that the innovation-decision process and guideline dissemination methods were most influential. ^ A multidisciplinary, multi-faceted approach, including interventions for each stage of the innovation-decision process, was proposed to diffuse practice guidelines more effectively. Further, it was recommended that Organized Delivery Systems expand existing administrative databases to include clinical information, decision support systems, and reminder mechanisms, to promote and support physician compliance with this and other evidence-based guidelines. ^

Effect of primary care availability and health insurance coverage on risk and cost of Preventable Hospitalizations in Harris County

Preventable Hospitalizations (PHs) are hospitalizations that can be avoided with appropriate and timely care in the ambulatory setting and hence are closely associated with primary care access in a community. Increased primary care availability and health insurance coverage may increase primary care access, and consequently may be significantly associated with risks and costs of PHs. Objective. To estimate the risk and cost of preventable hospitalizations (PHs); to determine the association of primary care availability and health insurance coverage with the risk and costs of PHs, first alone and then simultaneously; and finally, to estimate the impact of expansions in primary care availability and health insurance coverage on the burden of PHs among non-elderly adult residents of Harris County. Methods. The study population was residents of Harris County, age 18 to 64, who had at least one hospital discharge in a Texas hospital in 2008. The primary independent variables were availability of primary care physicians, availability of primary care safety net clinics and health insurance coverage. The primary dependent variables were PHs and associated hospitalization costs. The Texas Health Care Information Collection (THCIC) Inpatient Discharge data was used to obtain information on the number and costs of PHs in the study population. Risk of PHs in the study population, as well as average and total costs of PHs were calculated. Multivariable logistic regression models and two-step Heckman regression models with log-transformed costs were used to determine the association of primary care availability and health insurance coverage with the risk and costs of PHs respectively, while controlling for individual predisposing, enabling and need characteristics. Predicted PH risk and cost were used to calculate the predicted burden of PHs in the study population and the impact of expansions in primary care availability and health insurance coverage on the predicted burden. Results. In 2008, hospitalized non-elderly adults in Harris County had 11,313 PHs and a corresponding PH risk of 8.02%. Congestive heart failure was the most common PH. PHs imposed a total economic burden of $84 billion at an average of $7,449 per PH. Higher primary care safety net availability was significantly associated with the lower risk of PHs in the final risk model, but only in the uninsured. A unit increase in safety net availability led to a 23% decline in PH odds in the uninsured, compared to only a 4% decline in the insured. Higher primary care physician availability was associated with increased PH costs in the final cost model (β=0.0020; p<0.05). Lack of health insurance coverage increased the risk of PH, with the uninsured having 30% higher odds of PHs (OR=1.299; p<0.05), but reduced the cost of a PH by 7% (β=-0.0668; p<0.05). Expansions in primary care availability and health insurance coverage were associated with a reduction of about $1.6 million in PH burden at the highest level of expansion. Conclusions. Availability of primary care resources and health insurance coverage in hospitalized non-elderly adults in Harris County are significantly associated with the risk and costs of PHs. Expansions in these primary care access factors can be expected to produce significant reductions in the burden of PHs in Harris County.^

University research: effect of indirect cost revisions and options for future changes.

Mode of access: Internet.

Study of the effect of the increased cost of living on salaries of county employees, with emphasis upon those receiving less than $140.00 per month.

Prepared by Howard E. Earl, staff member. cf. p. 10.

The effect of operating temperature on the cost of energy from solar thermal electric power plants /

"Prepared for the U.S. Dept. of Energy, under contract DE-AC04-76-DP00789."

Report of the President's Private Sector Survey on Cost Control : hearing before the Committee on Environment and Public Works, United States Senate, Ninety-eighth Congress, second session, on the effect of the report of the President's Private Sector Survey on Cost Control, on Titles V and X of S. 1739, the Water Resources Development Act of 1983, February 22, 1984.

Mode of access: Internet.

The cost of sin:the effect of social norms on audit pricing

In this paper we provide evidence for the effects of social norms on audit pricing by studying companies belonging to the alcohol, firearms, gambling, military, nuclear power, and tobacco industries,which are often described as “sin” companies. We hypothesize that the disparities between “sin” firms operations and prevailing social norms create an adverse context which heightens the client's business risk assessment by auditors and is, thereby, reflected in the pricing decisions for audit and consulting services. Having controlled for the impact of variables relating to client attributes, auditor attributes and engagement attributes, we demonstrate that audit firms charge significantly higher audit and consulting fees to companies that deviate from prevailing social norms. Additionally,we show that audit pricing levels within the “sin” group depend both on prevailing political views and on the level of “vice” exhibited by “sin” companies.

Operating cost based cruise speed reduction for ground delay programs: Effect of scope length

Ground delay programs typically involve the delaying of aircraft that are departing from origin airports within some set distance of a capacity constrained destination airport. Long haul flights are not delayed in this way. A trade-off exists when fixing the distance parameter: increasing the ‘scope’ distributes delay among more aircraft and may reduce airborne holding delay but could also result in unnecessary delay in the (frequently observed) case of early program cancellation. In order to overcome part of this drawback, a fuel based cruise speed reduction strategy aimed at realizing airborne delay, was suggested by the authors in previous publications. By flying slower, at a specific speed, aircraft that are airborne can recover part of their initially assigned delay without incurring extra fuel consumption if the ground delay program is canceled before planned. In this paper, the effect of the scope of the program is assessed when applying this strategy. A case study is presented by analyzing all the ground delay programs that took place at San Francisco, Newark Liberty and Chicago O’Hare International airports during one year. Results show that by the introduction of this technique it is possible to define larger scopes, partially reducing the amount of unrecovered delay.

Effect of wind on operating cost based cruise speed reduction for delay absorption

En route speed reduction can be used for air traffic flow management (ATFM), e.g., delaying aircraft while airborne or realizing metering at an arrival fix. In previous publications, the authors identified the flight conditions that maximize the airborne delay without incurring extra fuel consumption with respect to the nominal (not delayed) flight. In this paper, the effect of wind on this strategy is studied, and the sensitivity to wind forecast errors is also assessed. A case study done in Chicago O’Hare airport (ORD) is presented, showing that wind has a significant effect on the airborne delay that can be realized and that, in some cases, even tailwinds might lead to an increase in the maximum amount of airborne delay. The values of airborne delay are representative enough to suggest that this speed reduction technique might be useful in a real operational scenario. Moreover, the speed reduction strategy is more robust than nominal operations against fuel consumption in the presence of wind forecast uncertainties.

Effect of Earnings Volatility on Cost of Debt: The case of Swedish Limited Companies

The paper empirically tests the relationship between earnings volatility and cost of debt with a sample of more than 77,000 Swedish limited companies over the period 2006 to 2013 observing more than 677,000 firm years. As called upon by many researchers recently that there is very limited evidence of the association between earnings volatility and cost of debt this paper contributes greatly to the existing literature of earnings quality and debt contracts, especially on the consequence of earnings quality in the debt market. Earnings volatility is a proxy used for earnings quality while cost of debt is a component of debt contract. After controlling for firms’ profitability, liquidity, solvency, cashflow volatility, accruals volatility, sales volatility, business risk, financial risk and size this paper studies the effect of earnings volatility measured by standard deviation of Earnings Before Interest, Taxes, Depreciation and Amortization (EBITDA) on Cost of Debt. Overall finding suggests that lenders in Sweden does take earnings volatility into consideration while determining cost of debt for borrowers. But a deeper analysis of various industries suggest earnings volatility is not consistently used by lenders across all the industries. Lenders in Sweden are rather more sensitive to borrowers’ financial risk across all the industries. It may also be stated that larger borrowers tend to secure loans at a lower interest rate, the results are consistent with majority of the industries. Swedish debt market appears to be well prepared for financial crises as the debt crisis seems to have no or little adverse effect borrowers’ cost of capital. This study is the only empirical evidence to study the association between earnings volatility and cost of debt. Prior indirect research suggests earnings volatility has a negative effect on cost debt (i.e. an increase in earnings volatility will increase firm’s cost of debt). Our direct evidence from the Swedish debt market is consistent for some industries including media, real estate activities, transportation & warehousing, and other consumer services.

Triboelectric Effect As A New Strategy For Sealing And Controlling The Flow In Paper-based Devices.

We reported here for the first time that triboelectric charges on PET sheets can be used to seal and control the flow rate in paper-based devices. The proposed method exhibits simplicity and low cost, provides reversible sealing and minimizes the effect of sample evaporation.

Effect of insertion method on knoop hardness of high viscous glass ionomer cements

The aim of this study was to assess the Knoop hardness of three high viscous glass ionomer cements: G1 - Ketac Molar; G2 - Ketac Molar Easymix (3M ESPE) and G3 - Magic Glass ART (Vigodent). As a parallel goal, three different methods for insertion of Ketac Molar Easymix were tested: G4 - conventional spatula; G5 - commercial syringe (Centrix) and G6 - low-cost syringe. Ten specimens of each group were prepared and the Knoop hardness was determined 5 times on each specimen with a HM-124 hardness machine (25 g/30 s dwell time) after 24 h, 1 and 2 weeks. During the entire test period, the specimens were stored in liquid paraffin at 37ºC. Significant differences were found between G3 and G1/G2 (two-way ANOVA and Tukey's post hoc test; p<0.01). There was no significant difference in the results among the multiple ways of insertion. The glass ionomer cement Magic Glass ART showed the lowest hardness, while the insertion technique had no significant influence on hardness.

Cost-effectiveness of Sick Leave Policies for Health Care Workers with Influenza-like Illness, Brazil, 2009

We describe the effect of influenza-like illness (ILI) during the outbreak of pandemic (H1N1) 2009 on health care worker (HCW) absenteeism and compare the effectiveness and cost of 2 sick leave policies for HCWs with suspected influenza. We assessed initial 2-day sick leaves plus reassessment until the HOW was asymptomatic (2-day + reassessment policy), and initial 7-day sick leaves (7-day policy). Sick leaves peaked in August 2009: 3% of the workforce received leave for ILI. Costs during May October reached R$798,051.87 (approximate to US $443,362). The 7-day policy led to a higher monthly rate of sick leave days per 100 HCWs than did the 2-day + reassessment policy (8.72 vs. 3.47 days/100 HCWs; p<0.0001) and resulted in higher costs (US $609 vs. US $1,128 per HCW on leave). ILI affected HCW absenteeism. The 7-day policy was more costly and not more effective in preventing transmission to patients than the 2-day + reassessment policy.