BACKGROUND: There is continued attention towards using patient demographic and clinical characteristics available in health administrative data when case mix adjusting the measurement of length of stay (LOS) for hospitalized children. However, little is known about what proportion of children’s LOS is explained by these characteristics. OBJECTIVES: The objectives of the study were to quantify the amount of variation in LOS within and across hospitals that is explained by demographic and clinical factors of hospitalized pediatric patients. METHODS: A retrospective cohort analysis was completed of 818,848 hospitalizations for any reason occurring from 1/1/2014 to 12/31/2014 in one of 44 freestanding children’s hospitals in the Pediatric Health Information Systems (PHIS) dataset. A generalized linear model was derived to simultaneously regress demographic factors [age, race/ethnicity, payer, rural residence, health professional shortage area (HPSA) residence, income, and distance traveled], and clinical factors (severity of illness, type and number of chronic conditions) on LOS. The percentage of LOS attributable to each characteristic within each hospital was quantified using the covariance test of the hospital random effect. RESULTS: The factors with the greatest impact on LOS were severity of illness and chronic condition type and number, with a median (interquartile range) of 16.8% (IQR 15.0%-19.4%) and 4.0% (IQR 2.9%-4.5%) of LOS, respectively, explained by these characteristics across hospitals. LOS varied significantly (p<0.05) with both severity of illness and chronic condition type and number for all 44 hospitals in the cohort. All patient demographic factors, (age, race/ethnicity, payer, rural residence, HSPA residence, income, and distance traveled) had minimal impact on LOS, with <0.1% of LOS explained by each characteristic. Across hospitals, 78.3% (IQR 75.8-80.2%)] of LOS remained unexplained by the patient characteristics under study. CONCLUSIONS: Patients’ clinical characteristics ascertained from administrative data account for approximately one-fifth of LOS whereas their demographic characteristics account for a negligible amount. Efforts to optimize the efficiency of inpatient care for hospitalized children might benefit from uncovering how much of the vast amount of unexplained LOS is due to modifiable aspects of care quality. / 2018-06-16T00:00:00Z

Medicaid Disproportionate Share Hospital (DSH) payment is one of the major funds supporting health care providers as they treat low-income patients. However, Medicaid DSH payments have been targeted for major budget cuts in many health policy reforms. This study examines the association between the changes in Medicaid DSH payments resulting from the BBA policy changes and hospital outcomes, in terms of hospital provision of uncompensated care and quality of care. Economic theory of non-profit hospital behavior is used as a conceptual framework, and longitudinal data for California short-term, non-federal general acute care hospitals for 1996-2003 are examined. California was especially affected by DSH changes because it is one of the states with highly concentrated DSH payments and high uninsured rate. Economic theory suggests that hospitals would change their uncompensated care provision as well as quality of care when confronted with a reduction in public payments. Hospital uncompensated care costs and percent of operating costs devoted to uncompensated care are used to measure the provision of hospital uncompensated care. Six AHRQ’s Patient safety indicators (PSIs) and one composite measure are selected to measure hospital quality of care provided for Medicaid and uninsured patients as well as privately insured patients. The key independent variable is Medicaid DSH payments received by individual hospitals. This study also includes control variables such as other governmental financial subsidies, market characteristics, and hospital characteristics. The primary data sources include the detailed hospital annual financial data and Medicaid annual report data at the county level from California Office of Statewide Health Planning and Development, Healthcare Cost and Utilization Project (HCUP) state inpatient data (SID), American Hospital Association Annual Survey, Area Resource File, Interstudy HMO Data and Medicare cost report data. After controlling for different factors, the study findings suggest that not-for-profit hospitals may reduce their provision of uncompensated care in response to reductions of Medicaid DSH payments. The results, however, do not support the hypotheses that for-profit hospitals may reduce uncompensated care by a smaller degree than not-for-profit hospitals for a comparable DSH decline. With respect to quality of care model, the overall study findings do not strongly support there is an association between net Medicaid DSH payments and patient adverse events for both Medicaid/uninsured and privately insured.

Depuis le début des années 2000, les traitements anticancéreux oraux (TAO) sont en développement croissant, notamment dans le cancer du sein. Ils permettent aux patients la prise de comprimés par voie orale à domicile améliorant la qualité de vie. On estime que 10 à 34% des tumeurs du sein sur-expriment la protéine HER2 (HER2+) qui augmente le risque de métastases. Deux thérapies ciblées anti-HER2 sont actuellement disponibles : le trastuzumab, anticorps monoclonal administré par voie intraveineuse et le lapatinib, inhibiteur de tyrosine kinase administré par voie orale. D’après les recommandations de l’Agence Nationale d’Accréditation et d’Evaluation en Santé (ANAES, 2003), les TAO devraient être privilégiées par rapport aux formes intraveineuses prises à l’hôpital lorsque leur efficacité est équivalente. Dans la pratique courante des oncologues, les TAO semblent néanmoins sous-utilisées dans certains cas. En plus des freins médicaux connus (adhésion thérapeutique, gestion des effets indésirables), les TAO induisent une consommation de ressources hopitalières supplémentaires qui n’est pas valorisée dans le modèle de tarification à l’activité (T2A) des établissements hospitaliers, lequel repose sur la nature et la quantité d’activité médicale réalisée. Nous supposons que le modèle de T2A représente un frein économique à l’utilisation des TAO entrainant une disparité d’accès entre les traitements anticancéreux oraux et intraveineux. L’objectif de ce travail de thèse était donc de déterminer le rôle de la T2A dans l’accès des patients aux TAO au moyen d’une évaluation médico- économique de l’impact économique et organisationnel des TAO sur le système de soins. Une revue de littérature a permis de mettre en évidence le rôle du mode de financement des soins sur l’accès aux TAO en France et aux Etats-Unis. L’analyse des bases de données nationales hospitalières du Programme Médicalisé des Systèmes d’Information (PMSI) a permis de quantifier l’enjeu économique de la chimiothérapie pour les établissements de soins et qui représente la deuxième activité des hôpitaux en volume après l’hémodialyse. Le bénéfice lié aux séances de chimiothérapie a ainsi été estimé à 108 millions d’Euros en 2010 pour l’ensemble des établissements publics et privés en France. L’analyse a également permis de simuler le transfert d’allocation de ressources de l’hôpital vers les soins de ville induit par la substitution des séances de chimiothérapie par l’utilisation des TAO. Un modèle comparant le coût du traitement intraveineux (trastuzumab) aux TAO (lapatinib et capécitabine) dans le cancer du sein métastatique HER2+ a confirmé des coûts moindres pour les TAO (17 165€ versus 36 077€ par an et par patient) liés à une économie sur les transports médicalisés mais surtout sur les consommations hospitalières et ce, malgré un coût d’acquisition plus élevé des TAO. Malgré cet impact budgétaire négatif pour les hôpitaux, une étude de préférences (Méthode des Choix Discrets) conduite auprès d’un échantillon de 203 médecins hospitaliers et libéraux a montré que l’efficacité d’un traitement anticancéreux restait le déterminant principal de la décision thérapeutique (β=2,214, p<0,0001). L’étude a toutefois révélé que, aux stades avancés du cancer, la voie d’administration et son coût étaient également associés au choix du traitement (β=0,612, p=0,035 ;β=0,506, p<0,0001). Les résultats montrent donc que le modèle de financement de l’activité hospitalière influence le choix des modalités de traitement même si les critères d’ordre médicaux et environnementaux du patient demeurent des déterminants essentiels dans le choix du recours aux TAO (profil clinique du patient, adhésion thérapeutique, préférences du patient, environnement familial et socio-économique, conditions d’accès à l’offre de soins) / Since the early 2000’s, oral anticancer drugs (OADs) are increasingly available especially for the treatment of breast cancer. This route of chemotherapy administration allows patients to take oral tablets at home improving their quality-of-life. We estimate that 10 to 34% of breast tumors over-express the HER2 protein (HER2+) that increases the risk of developing metastasis. Two anti-HER2 targeted therapies are currently available: trastuzumab, a monoclonal antibody administered intravenously and lapatinib, a tyrosine kinase inhibitor administered orally. According to the recommendations of the National Agency for Accreditation and Evaluation in Health (ANAES, 2003), OADs should be administered when their efficacy is equivalent to the one of intravenous forms taken at hospital. In the current practice of oncologists, OADs seem to be underused in some cases. The medical brakes to the use of OADs (i.e. adherence, management of side effects) are well known. Nonetheless, OADs induce additional hospital healthcare resources which are not taken into account in the hospital payment system that is based on the nature and the quantity of medical activities performed (i.e. per-case payment system (PPS)). We assume that the current model of PPS represents an economic barrier to the use of OADs and which induces a disparity of access between oral and intravenous cancer treatments. The objective of this thesis was to determine the role of the PPS on the patient access to OADs based on a medico-economic evaluation of the economical and organizational impacts of OADs on the health care system. A literature review has highlighted the role of the funding of care on the access to OADs in the French and US healthcare systems. From an analysis of the national hospital database (PMSI database), we have quantified the economic implications of chemotherapy administration that is the second hospital activity in volume after hemodialysis. Earnings associated with chemotherapy sessions have been estimated at 108 million Euros in 2010 for all private and public institutions in France. This analysis also allowed us to simulate the transfer of resources allocation from hospital to community setting induced by the substitution of chemotherapy sessions by the use of OADs. A model comparing the cost of intravenous anticancer drug (trastuzumab) to OADs (lapatinib and capecitabine) in the treatment of HER2+ metastatic breast cancer confirmed the lower costs for OADs (€ 17,165 versus € 36,077 per year per patient). The higher acquisition cost of OADs was offset by the cost savings in terms of medical transportation and hospital resources. Despite this negative budget impact for hospitals, a preference study (Discrete Choice Experiment) conducted among 203 physicians showed that the efficacy of cancer treatment remained the main determinant of the therapeutic decision (β=2.214, p<0.0001). The study has also revealed that, in the advanced stages of cancer, the route of administration and its associated cost was also associated with the treatment choice (β=0.612, p= 0.035; =β0.506, p<0.0001). Overall, the results show that the hospital payment system influences the choice of treatment modalities. Nonetheless, medical criterions related to the patient remain essential in the choice of using OADs (clinical profile of the patient, adherence, patient preferences, familial and socio-economic environment, and conditions of access to health care)