Thesis (M.P.H.M. (Primary Health Care Management))--Mahidol University, 2005.

Th. sc. écon. Neuchâtel, 2001. / Bibliogr.

Abstract The aim of this population-based cohort study was to evaluate prenatal and child outcome and costs resulting from prenatal and neonatal care after in vitro fertilization (IVF) in comparison to those after natural conception using a cohort of 304 IVF exposed children born between 1990–1995 in Northern Finland, and two cohorts of unexposed control children (I: n = 569, representing general population in proportion of multiple births; II: n = 103, matched for plurality). The control children were randomly chosen from the Finnish Medical Birth Register (FMBR) and matched for sex, year of birth, area of residence, parity, maternal age and socioeconomic status. Analyses were performed by comparing the whole IVF population with controls representing general population as well as stratifying by singleton or twin status. IVF mothers carried a higher risk for vaginal bleeding, threatened preterm birth and intrahepatic cholestasis of pregnancy than control mothers, and they used specialized antenatal care more than others. Neonatal outcome was also poorer after IVF in terms of gestational age, birthweight, morbidity and intensive care treatment. The prevalence of congenital heart malformations (septal defects) was 4-fold for IVF children in comparison to controls. The three year follow-up showed delayed growth and increased morbidity for IVF children, but their psychomotor development was similar to that of the control children. Health care costs were 1.3-fold for IVF singletons in comparison to control singletons, but for twins the costs were equal. Multiple births increased the costs ∼3-fold when compared to singleton births. IVF increased the health risks for the pregnancies and the offspring, seen mostly in the comparison between the whole IVF population and controls representing natural proportion of multiple births, indicating that multiple birth is the strongest determinant of medical outcome after IVF. The effects of fertility therapy and maternal characteristics related to infertility cannot be ruled out at this point. The increased health care costs after IVF were mostly due to the high proportion of multiple births. In order to improve the outcomes and to reduce the health care costs after IVF, the amount of multiple births should be limited to a minimum by using single embryo transfer when possible.

In many countries the focus of the employer's health policy has shifted from the emphasis of treating the disease to the preventative paradigm, which focuses more on the promotion of employees' health. Literature indicates that health promotion programmes have various positive consequences. The aim of this research is therefore to establish some physical, physiological and bio-chemical health profiles of colliery executives in South Africa as well as to determine the effect of a physical and a combined physical and health promotion intervention programme on the parameters mentioned above. Finally, this study aims to determine the effect of a physical and a combined physical and health promotion intervention programme on coronary prone South African colliery executives. In this study an availability, non-randomized sample of 143 white male executives from five collieries, aged 26-58 (x 41.7, ± 7.98 years), was used. These collieries are spread over two South African provinces namely Mpumalanga and Gauteng. Subjects who were on medication that could affect their cholesterol, blood pressure and aerobic fitness values were excluded from the study. The following parameters were used in this study: aerobic fitness, shoulder/arm, strength/endurance (push-ups) abdominal strength/endurance (sit-ups), flexibility, fat percentage, waist-and-hip circumference, body mass index, blood pressure, cholesterol, smoking and leisure-time physical activity participation. ANOVA was used for statistical data analysis - providing descriptive and summarising statistics. One-way analysis of variance was used to determine relationships between variables. The Tukey post-hoc test was used to determine whether certain groups differed statistically significant from each other. It is clear from the descriptive data that flexibility (56.7%), sit-ups (39.7%), aerobic fitness (44.8%), fat percentage (31.4%), BMI (35.7%) and WHR (44.7%) fall into the undesired health zone. Regarding the physiological parameter blood pressure, 16.8% (systolic blood pressure) and 21.7% (diastolic blood pressure) fall into the undesired health zone; regarding the bio-chemical parameter cholesterol, 53.2% falls into the undesired health zone. With regard to some parameters, it appears that the experimental group showed statistically significant changes from Test 1 to Test 3, while the control group showed no statistically significant changes. The reason for this may vary from respondent to respondent already showing "normal" baseline values, probably due to their relative young age (Z=41 years) as to programme preferences and programme adherence. It must, however, be kept in mind that only physical, physiological and bio-chemical parameters were assessed. The health promotion activities focused more on the participants' knowledge empowerment. If these parameters were also included in the assessments the "enriched" programme might have provided some advantages that may have led to long term commitment and behaviour change. Physical fdness intervention (control group) is equally effective in addressing the primary coronary risk factors compared to a programme enriched with health promotion activities (experimental group). However, it seems that the experimental group showed a better response as far as lifestyle change (smoking) and physical activity were concerned. Assessment of other psycho-emotional parameters might indicate a different picture. Respectively 11.7% and 7.6% of the experimental and control group stopped smoking while 20.8% and 16.3% of the experimental and control group respectively reported a higher leisure-time physical activity participation. Regarding aerobic fitness and blood pressure, the average baseline values moved from the high risk category to the "normal" category, while the total cholesterol concentration in the post training values decreased with 12.5% and 14.8% in the experimental and control group respectively. / Thesis (Ph.D. (Human Movement Science))--North-West University, Potchefstroom Campus, 2007.

The implication of increasing consumption of functional foods, such as pulse-containing products, reveals the potential to reduce the incidence of type 2 diabetes (T2D) and coronary heart disease (CHD) and thereby achieves the cost savings associated with treatment and productivity loss. This research investigates the economic impact of such an important aspect of dietary pulse intake. The objective of the research is to determine the potential annual healthcare savings resulting from pulse flour consumption at Health Canada’s recommended daily rates. This study employs a four-step cost-of-illness approach to estimate such savings: 1) estimation of success rate of the healthy food; 2) determination of lower glycemic index, insulin concentration reduction, and lower cholesterol; 3) assumption of reduction in prevalence of T2D and CHD; 4) calculation of cost savings with regard to reduced occurrence of T2D and CHD. The findings demonstrate that annual cost savings ranging from $ 43.8 to 317.8 million (T2D category) and $ 154.9 to 958.0 million (CHD category) can be achieved for the Canada’s health budgetary framework with the increased consumption of dietary pulses. The estimations of cost savings are contingent on four scenarios: ideal, optimistic, pessimistic, and very pessimistic. People susceptible to higher blood glucose, higher insulin, and higher total cholesterol could benefit considerably by substituting pulse-containing foods for unhealthy foods. The adaptation to a dietary pattern that includes pulses will result in significant expenditure reductions in Canada’s publicly funded health care system, lessening the economic burden of illness in Canada. / October 2016

Introduction: Atypical Antipsychotics (AAPs) are approved by the Food and Drug Administration (FDA) for the treatment of schizophrenia and bipolar disorder. AAPs are commonly used off-label to treat depression, post-traumatic stress disorder and neuropsychiatric symptoms in dementia due to lack of alternative treatment options and treatment resistance. Concerns for off-label use arise since AAPs increase the risk of cardiovascular events and death. The objectives were 1) describe patterns of RU and costs among off-label AAPs users in a nationally representative population 2) identify prevalence of off-label use in the Medicare population 3) compare RU and costs between off-label AAPs users and non-users with mental health conditions in Medicare. Methods: For the first objective, the Medical Expenditure Panel Survey (MEPS) datasets were used. AAPs users greater than 18 years were identified in this cross-sectional study. Generalized Linear Models (GLM) were used to estimate costs among users and non-users after controlling for age sex, gender, insurance type, marriage status, income and comorbidity index. For the second and third objective, Medicare datasets were used to identify prevalence, RU, and costs of off-label use in Medicare beneficiaries 18 years and older. RU and costs between propensity score matched AAPs user and non-user cohorts were compared in a retrospective cohort study. Results: The adjusted odds of having an office-based outpatient (OR=2.47, 95%CI: 1.55-3.92) or inpatient (OR=1.63, 95%CI: 1.26-2.10) visit were significantly higher among off-label AAPs users. Adjusted office-based visit ($1,943 vs. $1,346), prescription ($4,153 vs. $1,252) and total ($10,694 vs. $4,823) costs were significantly higher among users (p<0.0001). Among Medicare beneficiaries, approximately 37% of AAPs users had no FDA approved diagnosis. The typical off-label user was a white 70-year-old male. Common off-label uses were depression, anxiety and neurotic disorders and dementia. Off-label AAPs users had significantly higher mental health outpatient ($461 vs $297), prescription ($2,349 vs $282) and total ($3,665 vs $1,297) costs per beneficiary than non-users. About 30% of AAPs users had at least one mental health outpatient visit during the year versus 23% of non-users; no significant differences were found in inpatient visits. AAPs non-users had significantly higher all-cause inpatient costs ($6,945 vs. $4,841) per beneficiary (p Conclusion: In a nationally representative population comprising a younger age group AAPs users had higher all-cause RU and total costs than non-users. Off-label prescribing of AAPs continued to be a prevalent practice affecting 37% of Medicare AAPs users. Off-label AAPs users had higher mental health costs but no significant differences in all-cause total health care costs in a Medicare population. Off-label use of AAPs can be a cost-effective option if future research shows off-label use is associated with increased effectiveness, which offsets any additional costs.

A oxigenoterapia domiciliar é uma terapêutica de extrema importância na faixa etária pediátrica que visa garantir o desenvolvimento pôndero-estatural e cognitivo de crianças hipoxêmicas, bem como prevenir e atenuar o desenvolvimento da hipertensão pulmonar secundária (HPS). OBJETIVO: Descrever a população de crianças e adolescentes em oxigenoterapia domiciliar prolongada (ODP), quanto às suas características demográficas, clínicas, laboratoriais, relativas ao uso do oxigênio (O2) e tempo de sobrevida após início da ODP. Comparar os grupos de pacientes com e sem HPS, em relação às características supracitadas e analisar comparativamente os custos em relação ao uso do concentrador versus cilindro de O2. MÉTODOS: Trata-se de um estudo descritivo retrospectivo de uma coorte de 165 pacientes, cujos dados relativos a um período 2002-2009 foram coletados de prontuários e de questionários aplicados aos pacientes e/ou acompanhantes. Os dados sobre custos foram cedidos pelo Núcleo de Assistência Domiciliar Interdisciplinar do HC-FMUSP. A variável contínua (idade de início do uso de O2) foi descrita através de sua mediana, valores máximo e mínimo. As demais variáveis (nominais), foram descritas através de suas frequências. As análises do tempo de uso do O2 e sobrevida foram feitas através da curva de Kaplan-Meier. Na comparação dos subgrupos com e sem HPS, as frequências (período de uso do O2 e intensidade do fluxo) foram comparadas através do teste do Qui-quadrado; e as curvas de Kaplan-Meier, por meio do teste Logrank. Nas análises, foi usado o software estatístico SPSS 13.0 e adotado um nível de significância de 5%. O custo médio mensal do programa foi calculado a partir das médias mensais de pacientes, segundo o tipo de sistema utilizado (concentrador ou cilindro) no período de um ano. RESULTADOS: A maioria dos pacientes (68%) residia no Município de São Paulo; 53% eram do sexo masculino e a idade de início da ODP variou de 0,1 a 21, 5 anos (mediana: 3,6 anos), sendo que cerca de um terço da casuística iniciou o uso do O2 no primeiro ano de vida. Os principais diagnósticos da doença crônica de base foram: fibrose cística (22%), displasia broncopulmonar (19%), bronquiolite obliterante (15%) e neuropatias crônicas (12%). A ODP foi contínua em 65% dos pacientes, sendo que 87% utilizavam fluxos inferiores a 2 L/min. O dispositivo para administração de O2 mais utilizado foi a cânula nasal (87%), e o sistema provedor foi o concentrador de O2 (58%). A mediana do tempo de uso do O2 foi de 7 anos. A mediana do tempo de sobrevida dos 165 pacientes após início da ODP foi de 13,4 anos. Dos 33 pacientes submetidos aos testes de função pulmonar, 70% apresentaram distúrbio ventilatório obstrutivo grave. O hemograma foi realizado em 150 pacientes. Destes, 37% eram anêmicos e 17%, policitêmicos; os demais apresentaram valores hematimétricos normais. O ecocardiograma foi realizado em 134 pacientes; destes, 51% apresentaram hipertensão pulmonar secundária (HPS). Foi encontrada associação estatisticamente significante entre presença de hipertensão pulmonar e necessidade de maiores fluxos de oxigênio (p = 0,011) bem como presença de hipertensão pulmonar e tempo de uso do O2 mais prolongado (p = 0,0001). O tempo de sobrevida dos grupos com e sem HPS após início da ODP não apresentou diferença estatisticamente significante (p = 0,3445). No tocante aos custos relativos ao tipo de sistema provedor de O2 utilizado, o custo médio mensal do programa utilizando concentradores foi de R$ 4.176,80 e utilizando cilindros foi de R$ 9.396,00. CONCLUSÕES: Nesta casuística a ODP foi empregada em distintas doenças crônicas, com maior frequência de pacientes na faixa etária de lactentes e período pré-escolar. As doenças predominantes foram: fibrose cística, displasia broncopulmonar e bronquiolite obliterante. O tempo de ODP para os pacientes com estas patologias foi relativamente prolongado. A HPS foi frequente nos pacientes em ODP, e a sua presença, comparativamente aos pacientes sem HPS, ocasiona a necessidade de maiores períodos de tratamento e incremento de fluxos de oxigênio, sem interferência na sobrevida. Possivelmente o uso de concentradores de O2, ao invés de cilindros, em programas de ODP para pacientes pediátricos, reduza os custos de maneira significativa / The home oxygen therapy is extremely important in the pediatric age group that aims to ensure the weight, height and cognitive development of hypoxemic children, as well as prevent and mitigate the development of secondary pulmonary hypertension (SPH).OBJECTIVE: This study aimed to describe the population of children and adolescents in prolonged home oxygen therapy (LTOT) as their demographic characteristics, clinical, laboratory, concerning the use of O2, and survival time after onset of ODP. Compare patient groups with and without SPH in relation to the characteristics mentioned above and analyze comparatively the costs in relation to the use of concentrator versus O2 cylinder. Cost data were provided by the Interdisciplinary Center for Home Care. METHODS: This is a retrospective descriptive study of a cohort of 165 patients, whose data covering a period from 2002 to 2009 were collected from medical records and questionnaires applied to patients or caregivers. The continuous variable (age of onset of O2) was described by its median, maximum and minimum values. The other variables (nominal), were described by their frequencies. Analyses of time use of O2 and survival were evaluated by the Kaplan-Meier method. In comparing the groups with and without SPH, the frequency (period of use of O2 and intensity of flow) were compared using the Chi-square and Kaplan-Meier, using log rank test. In the analysis, we used the statistical software SPSS 13.0 and adopted a significance level of 5%. The average monthly cost of the program was calculated from the monthly average of patients, according to the type of system (concentrator or cylinder) during one year. RESULTS: Most patients (68%) resided in Sao Paulo city, 53% were male. The age of onset of LTOT ranged from 0.1 to 21,5 years (median 3.6 years), and about a third of the series initiated the use of O2 in the first year of life. The main diagnoses of chronic illness were: cystic fibrosis (22%), bronchopulmonary dysplasia (19%), bronchiolitis obliterans (15%) and chronic neuropathies (12%). The ODP was continuous in 65% of patients, 87% used flows of less than 2 L/min. The device for administration of O2 consisted of a nasal cannula (87%), and the system provider was the O2 concentrator (58%). The median duration of use of O2 was 7 years. The median survival time of 165 patients after initiation of LTOT was 13.4 years. Of the 33 patients tested for lung function, 70% had severe obstructive respiratory disorder. Blood counts were performed in 150 patients. Of these, 37% were anemic,17% polycythemic, and the others showed normal hematological values. Echocardiography was performed in 134 patients, of which 51% had SPH. Statistically significant association was found between the presence of pulmonary hypertension and need for greater flows of oxygen (p = 0.011) and presence of pulmonary hypertension and longer duration of O2 use (p = 0.0001). The survival time of patients with and without HPS after initiating LTOT was not statistically significant (p = 0.3445).Concerning the costs for the type of O2 system provider used, the average monthly cost of the program using concentrators was R$ 4,176.80 and using cylinder was R$ 9,396.00. CONCLUSIONS: In this sample LTOT has been employed in various chronic diseases with a greater frequency of patients in the age range of infants and preschool period. The predominant diseases were: cystic fibrosis, bronchopulmonary dysplasia, and bronchiolitis obliterans. The period of LTOT for patients with these diseases was relatively prolonged. The SPH was common in patients on LTOT, and their presence compared to patients without SPH, causes the need for greater periods of treatment and increase the flow of oxygen, without interference on survival. Possibly the use of O2 concentrators, instead of cylinders in LTOT programs for pediatric patients, may reduce costs significantly

A oxigenoterapia domiciliar é uma terapêutica de extrema importância na faixa etária pediátrica que visa garantir o desenvolvimento pôndero-estatural e cognitivo de crianças hipoxêmicas, bem como prevenir e atenuar o desenvolvimento da hipertensão pulmonar secundária (HPS). OBJETIVO: Descrever a população de crianças e adolescentes em oxigenoterapia domiciliar prolongada (ODP), quanto às suas características demográficas, clínicas, laboratoriais, relativas ao uso do oxigênio (O2) e tempo de sobrevida após início da ODP. Comparar os grupos de pacientes com e sem HPS, em relação às características supracitadas e analisar comparativamente os custos em relação ao uso do concentrador versus cilindro de O2. MÉTODOS: Trata-se de um estudo descritivo retrospectivo de uma coorte de 165 pacientes, cujos dados relativos a um período 2002-2009 foram coletados de prontuários e de questionários aplicados aos pacientes e/ou acompanhantes. Os dados sobre custos foram cedidos pelo Núcleo de Assistência Domiciliar Interdisciplinar do HC-FMUSP. A variável contínua (idade de início do uso de O2) foi descrita através de sua mediana, valores máximo e mínimo. As demais variáveis (nominais), foram descritas através de suas frequências. As análises do tempo de uso do O2 e sobrevida foram feitas através da curva de Kaplan-Meier. Na comparação dos subgrupos com e sem HPS, as frequências (período de uso do O2 e intensidade do fluxo) foram comparadas através do teste do Qui-quadrado; e as curvas de Kaplan-Meier, por meio do teste Logrank. Nas análises, foi usado o software estatístico SPSS 13.0 e adotado um nível de significância de 5%. O custo médio mensal do programa foi calculado a partir das médias mensais de pacientes, segundo o tipo de sistema utilizado (concentrador ou cilindro) no período de um ano. RESULTADOS: A maioria dos pacientes (68%) residia no Município de São Paulo; 53% eram do sexo masculino e a idade de início da ODP variou de 0,1 a 21, 5 anos (mediana: 3,6 anos), sendo que cerca de um terço da casuística iniciou o uso do O2 no primeiro ano de vida. Os principais diagnósticos da doença crônica de base foram: fibrose cística (22%), displasia broncopulmonar (19%), bronquiolite obliterante (15%) e neuropatias crônicas (12%). A ODP foi contínua em 65% dos pacientes, sendo que 87% utilizavam fluxos inferiores a 2 L/min. O dispositivo para administração de O2 mais utilizado foi a cânula nasal (87%), e o sistema provedor foi o concentrador de O2 (58%). A mediana do tempo de uso do O2 foi de 7 anos. A mediana do tempo de sobrevida dos 165 pacientes após início da ODP foi de 13,4 anos. Dos 33 pacientes submetidos aos testes de função pulmonar, 70% apresentaram distúrbio ventilatório obstrutivo grave. O hemograma foi realizado em 150 pacientes. Destes, 37% eram anêmicos e 17%, policitêmicos; os demais apresentaram valores hematimétricos normais. O ecocardiograma foi realizado em 134 pacientes; destes, 51% apresentaram hipertensão pulmonar secundária (HPS). Foi encontrada associação estatisticamente significante entre presença de hipertensão pulmonar e necessidade de maiores fluxos de oxigênio (p = 0,011) bem como presença de hipertensão pulmonar e tempo de uso do O2 mais prolongado (p = 0,0001). O tempo de sobrevida dos grupos com e sem HPS após início da ODP não apresentou diferença estatisticamente significante (p = 0,3445). No tocante aos custos relativos ao tipo de sistema provedor de O2 utilizado, o custo médio mensal do programa utilizando concentradores foi de R$ 4.176,80 e utilizando cilindros foi de R$ 9.396,00. CONCLUSÕES: Nesta casuística a ODP foi empregada em distintas doenças crônicas, com maior frequência de pacientes na faixa etária de lactentes e período pré-escolar. As doenças predominantes foram: fibrose cística, displasia broncopulmonar e bronquiolite obliterante. O tempo de ODP para os pacientes com estas patologias foi relativamente prolongado. A HPS foi frequente nos pacientes em ODP, e a sua presença, comparativamente aos pacientes sem HPS, ocasiona a necessidade de maiores períodos de tratamento e incremento de fluxos de oxigênio, sem interferência na sobrevida. Possivelmente o uso de concentradores de O2, ao invés de cilindros, em programas de ODP para pacientes pediátricos, reduza os custos de maneira significativa / The home oxygen therapy is extremely important in the pediatric age group that aims to ensure the weight, height and cognitive development of hypoxemic children, as well as prevent and mitigate the development of secondary pulmonary hypertension (SPH).OBJECTIVE: This study aimed to describe the population of children and adolescents in prolonged home oxygen therapy (LTOT) as their demographic characteristics, clinical, laboratory, concerning the use of O2, and survival time after onset of ODP. Compare patient groups with and without SPH in relation to the characteristics mentioned above and analyze comparatively the costs in relation to the use of concentrator versus O2 cylinder. Cost data were provided by the Interdisciplinary Center for Home Care. METHODS: This is a retrospective descriptive study of a cohort of 165 patients, whose data covering a period from 2002 to 2009 were collected from medical records and questionnaires applied to patients or caregivers. The continuous variable (age of onset of O2) was described by its median, maximum and minimum values. The other variables (nominal), were described by their frequencies. Analyses of time use of O2 and survival were evaluated by the Kaplan-Meier method. In comparing the groups with and without SPH, the frequency (period of use of O2 and intensity of flow) were compared using the Chi-square and Kaplan-Meier, using log rank test. In the analysis, we used the statistical software SPSS 13.0 and adopted a significance level of 5%. The average monthly cost of the program was calculated from the monthly average of patients, according to the type of system (concentrator or cylinder) during one year. RESULTS: Most patients (68%) resided in Sao Paulo city, 53% were male. The age of onset of LTOT ranged from 0.1 to 21,5 years (median 3.6 years), and about a third of the series initiated the use of O2 in the first year of life. The main diagnoses of chronic illness were: cystic fibrosis (22%), bronchopulmonary dysplasia (19%), bronchiolitis obliterans (15%) and chronic neuropathies (12%). The ODP was continuous in 65% of patients, 87% used flows of less than 2 L/min. The device for administration of O2 consisted of a nasal cannula (87%), and the system provider was the O2 concentrator (58%). The median duration of use of O2 was 7 years. The median survival time of 165 patients after initiation of LTOT was 13.4 years. Of the 33 patients tested for lung function, 70% had severe obstructive respiratory disorder. Blood counts were performed in 150 patients. Of these, 37% were anemic,17% polycythemic, and the others showed normal hematological values. Echocardiography was performed in 134 patients, of which 51% had SPH. Statistically significant association was found between the presence of pulmonary hypertension and need for greater flows of oxygen (p = 0.011) and presence of pulmonary hypertension and longer duration of O2 use (p = 0.0001). The survival time of patients with and without HPS after initiating LTOT was not statistically significant (p = 0.3445).Concerning the costs for the type of O2 system provider used, the average monthly cost of the program using concentrators was R$ 4,176.80 and using cylinder was R$ 9,396.00. CONCLUSIONS: In this sample LTOT has been employed in various chronic diseases with a greater frequency of patients in the age range of infants and preschool period. The predominant diseases were: cystic fibrosis, bronchopulmonary dysplasia, and bronchiolitis obliterans. The period of LTOT for patients with these diseases was relatively prolonged. The SPH was common in patients on LTOT, and their presence compared to patients without SPH, causes the need for greater periods of treatment and increase the flow of oxygen, without interference on survival. Possibly the use of O2 concentrators, instead of cylinders in LTOT programs for pediatric patients, may reduce costs significantly

Extended hospital length of stay (LOS) causes increased health care costs and incidence of never events, such as hospital-acquired infections, pressure ulcers, and falls, which are not reimbursed by Medicare. This study examined if there would be a statistically significant decrease in the LOS of patients after the implementation of a discharge process improvement initiative (DPII), The model for improvement and small tests of change concept were used to guide the DPII at a hospital in northern California. Sources of data included archival data obtained from the hospital's quality improvement department that showed LOS prior to and after the implementation of the DPII. The LOS for 2015 and 2017 were compared using the t test for independent samples. The LOS in 2015 was longer (M = 4.59, SD = 3.66) than in 2017 (M = 4.09, SD = 3.81), a statistically significant difference, M = 0.50, 95% CI [0.32, 0.67], t (77) = 5.574, p = .005, d = 1.3, showing that the implementation of the DPII led to a reduction in the LOS. This reduction cannot be attributed solely to the DPII because other projects were implemented at the same time, such as the Clinical Decisions Unit and multidisciplinary rounds. Future research could focus on the relationship between reduced LOS and readmission and the degree of collaboration among health care team members. The implications of this study for social change include the potential to lower health care costs and increase patients' awareness of their responsibility for their own health.

Continued escalation in health care expenditures in the United States has led to an unsustainable model that consumes almost 20% of GDP. Policymakers have recognized the need for industry reform and have taken action through the passage of the Affordable Care Act (ACA). The purpose of this quantitative, longitudinal study was to examine the relationship between the type of health insurance and health care costs. Mechanism theory and game theory provided the theoretical framework. The analysis of secondary data from the Healthcare Cost and Utilization Project included a sample of 1,956,790-inpatient hospital stays from 2007 to 2014. Results of one-way ANOVAs indicated that between 2% and 9% of health care costs could be attributed to type of health insurance, a statistically significant finding. Results also supported the effectiveness of the ACA in stabilizing health care costs. The average annual rate of health care cost increase was 38.6% from 2007 until 2010, decreasing to an average annual increase of 4.3% from 2011 until 2014. Results provide important information to generate positive social change for consumers, providers, and policymakers. This includes improving decisions related to health care costs, improved understanding of the costs of health care services, increased transparency, increased patient engagement, maximizing consumer utility, facilitation of reduction of waste within the industry, and increased understanding of the impact of health policy on health care costs and efficiencies within newly created health policies. Results may also improve transparency of health care costs, which allows consumers, providers, and policymakers to take specific action to reduce health care costs, resulting in a more just and sustainable health care model.