Background: While trauma systems improve the outcome of injury in children, there is a paucity of information regarding trauma regionalization system function amid dramatic changes in the financial structure of health care.

Objective: To describe the distribution of acute hospitalization of children with severe trauma by level of hospital trauma care designation in California.

Methods: Retrospective observational study of a population-based cohort from 1998 to 2004. The California Office of Statewide Health Planning and Development (OSHPD) patient Discharge Data Set 1998-2004 was used. Patients were included if: age 0-19 years, trauma International Classification of Diseases, 9th Edition (ICD-9) diagnostic codes, and e-codes (n = 127,841). Differential rates of hospitalization in trauma-designated hospitals vs. non-trauma-designated hospitals were calculated for death and injury severity score. Injury severity scores (ISSs) were calculated from ICD-9 codes. Primary outcomes were hospitalization in a trauma center and death.

Results: From 1998 to 2004, 55%-60% of children 0-14 years and 55%-70% of children 15-19 years with trauma requiring hospitalization were discharged from trauma-designated hospitals. Children with severe injury were consistently hospitalized in trauma-designated hospitals (70%-78%) at a rate higher than children with moderate (60%-70%) and mild (50%-60%) injury. Trends for hospitalization in trauma-designated hospitals increased over the time span of the study (p 0.05). Approximately 20% of hospitalized children who died (I = 1,426) died 2 or more days after injury in non-trauma-designated hospitals.

Conclusions: A majority of children with trauma were cared for in trauma-designated hospitals over the study period. However, 20% of children with severe injuries and 20% of pediatric deaths greater than 2 days after injury were cared for in non-trauma-designated hospitals. Further investigation is warranted in order to enhance clinical protocols and policies that ensure access to appropriate regional trauma care for all children in need.

Objective: Despite evidence and recommendations encouraging the delivery of high-risk newborns in hospitals with subspecialty or high-level NICUs, increasing numbers are being delivered in other facilities. Causes for this are unknown. We sought to explore the impact of diffusion of specialty or midlevel NICUs on the types of hospitals in which low birth weight newborns are born.

Design: We used birth certificate, death certificate, and hospital discharge data for essentially all low birth weight, singleton California newborns born between 1993 and 2000. We identified areas likely to have been affected by the opening of a new nearby midlevel unit, analyzed changes over time in the share of births that took place in midlevel NICU hospitals, and compared patterns in areas that were and were not likely affected by the opening of a new midlevel unit. We also tracked the corresponding changes in the share of births in high-level hospitals and in those without NICU facilities (low-level).

Results: The probability of a 500- to 1499-g infant being born in a midlevel unit increased by 17 percentage points after the opening of a new nearby unit. More than three quarters of this increase was accounted for by reductions in the probability of birth in a hospital with a high-level unit (15 points), and the other portion was resulting from reductions in the share of newborns delivered in hospitals with low-level centers (2 points). Similar patterns were observed in 1500- to 2499-g newborns.

Conclusions: The introduction of new midlevel units was associated with significant shifts of births from both high-level and low-level hospitals to midlevel hospitals. In areas in which new midlevel units opened, the majority of the increase in midlevel deliveries was attributable to shifts from high-level unit births. Continued proliferation of midlevel units should be carefully assessed.

Objective:

To assess the effectiveness and cost-effectiveness of treating HIV-infected injection drug users (IDUs) and non-IDUs in Russia with highly active antiretroviral therapy HAART.

Design and Methods:

A dynamic HIV epidemic model was developed for a population of IDUs and non-IDUs. The location for the study was St. Petersburg, Russia. The adult population aged 15 to 49 years was subdivided on the basis of injection drug use and HIV status. HIV treatment targeted to IDUs and non-IDUs, and untargeted treatment interventions were considered. Health care costs and quality-adjusted life years (QALYs) experienced in the population were measured, and HIV prevalence, HIV infections averted, and incremental cost-effectiveness ratios of different HAART strategies were calculated.

Results:

With no incremental HAART programs, HIV prevalence reached 64% among IDUs and 1.7% among non-IDUs after 20 years. If treatment were targeted to IDUs, over 40 000 infections would be prevented (75% among non-IDUs), adding 650 000 QALYs at a cost of USD 1501 per QALY gained. If treatment were targeted to non-IDUs, fewer than 10 000 infections would be prevented, adding 400 000 QALYs at a cost of USD 2572 per QALY gained. Untargeted strategies prevented the most infections, adding 950 000 QALYs at a cost of USD 1827 per QALY gained. Our results were sensitive to HIV transmission parameters.

Conclusions:

Expanded use of antiretroviral therapy in St. Petersburg, Russia would generate enormous population-wide health benefits and be economically efficient. Exclusively treating non-IDUs provided the least health benefit, and was the least economically efficient. Our findings highlight the urgency of initiating HAART for both IDUs and non-IDUs in Russia.

We review the rise, stabilization, and decline of employment-based insurance; discuss its transformation from quasi-social insurance to a system based on actuarial principles; and suggest that the presence of Medicare and Medicaid has weakened political pressure for universal coverage. We highlight employment-based insurances flaws: high administrative costs, inequitable sharing of costs, inability to cover large segments of the population, contribution to labor-management strife, and the inability of employers to act collectively to make health care more cost-effective. We conclude with scenarios for possible trajectories: employment-based insurance flourishes, continues to erode, or is replaced by a more comprehensive system.

Abstract

The authors introduce economic evaluation with particular attention to cost-effectiveness analysis. They begin by establishing why health care decisions should be guided by economics. They then explore different types of economic evaluations. To illustrate how to conduct and evaluate a cost-effectiveness analysis, a hypothetical study about the treatment of posttraumatic stress disorder with psychotherapy versus pharmacotherapy is considered. The authors conclude with recommendations for increasing the strength and relevance of economic evaluations.

We investigated the determinants of inpatient rehabilitation costs in the Department of Veterans Affairs (VA) and examined the relationship between length of stay (LOS) and discharge costs using data from VA and community rehabilitation hospitals. We estimated regression models to identify patient characteristics associated with specialized inpatient rehabilitation costs. VA data included 3,535 patients discharged from 63 facilities in fiscal year 2001. We compared VA costs to community rehabilitation hospitals using a sample from the Uniform Data System for Medical Rehabilitation of 190,112 patients discharged in 1999 from 697 facilities. LOS was a strong predictor of cost for VA and non-VA hospitals. Functional status, measured by Functional Independence Measure (FIM) scores at admission, was statistically significant but added little explanatory value after controlling for LOS. Although FIM scores were associated with LOS, FIM scores accounted for little variance in cost after controlling for LOS. These results are most applicable to researchers conducting cost-effectiveness analyses.

State public employee health plans (PEHPs) provide health benefits for millions of state and local workers, retirees, and their dependents nationwide. This paper explores major issues and challenges that PEHP leaders and state policymakers are addressing. These include the perennial challenge of funding benefits for a diverse and aging workforce; new accounting standards affecting public employers; and the changing relationship between states, retired public employees, and the Medicare program. Interviews with PEHP executives explored whether these are incremental challenges to which states can effectively adapt, or whether these challenges will catalyze broader and lasting change in the public employee and retiree health benefits arena.

This issue of CHP/PCOR's quarterly newsletter, which covers news from the summer 2006 quarter, includes articles about:

• research by CHP/PCOR investigators that influenced the Centers for Disease Control and Prevention to recommend widespread voluntary HIV screening for all Americans ages 13 to 64 -- a significant change from the CDC's previous HIV screening guidelines;
• a CHP/PCOR study on patient safety culture in U.S. hospitals -- the largest effort to date to measure hospitals' safety culture and seek to improve it through an intervention that gets hospital executives out of their offices and on to the hospital floors;
• an early-stage project in which CHP/PCOR is collaborating with the Center on Democracy, Development and the Rule of Law to study the relationship between health interventions, governance and development;
• an evidence report examining the challenges of diagnosing and treating anthrax in children, prepared by the Stanford-UCSF Evidence-based Practice Center; and
• a study by CHP/PCOR fellow Kate Bundorf which found that depending on the definition of "affordability" that is used, health insurance is "affordable" to between one-quarter and three-quarters of the uninsured -- and many of those who can't afford insurance purchase it anyway.