Document 6422136

hstitmo Tormato Di Tella
P r o m de Posgrado en
-isis
& P o l l t i a s R%lit:is
11 de Septienbrre 2139
1428 Buenos Aires
Comparative analysis of
productivity in pi1blic and
private Chilean hospitals
Jorge Rodriguez *
Santiago, a g o s t o d e 1 9 8 5
* Chr
achowled~emntto Paul k o , Willy tk Ce!r,dt, ?hujim Qata md
h d r a s Uthaf f for t h e i r suggestions and valuable convents, and'to
the Wardl Bank-for sponsoring this research.
**
Gltric.st
93 a e r c e n t of t h e Chi l e a n hcssoi t a l s '
uauacity
t>eic.nos t o
uaver-nr~runt s e r v i c e s . This Means t h a t f o r
a ntmeat
r,la,]c~ri t y o f
t h e p a 9 o u l a cion
h e a i t n c a t - e deDendr msrst ly
con t h e
nark v f
the
0ub1.c sector. On
t h e c l t h r r hand, ~t rs a f a c t
t h a t the health
~ 1 . 1 l l i sector
c
has beera stagnated i n F e r n i s o f
~ n v e s t r t i e r ~ It h n a s p i t a l s
and ~ a u i p r i e n t ) f o r nlore t h a n a decade.
I r . u t . s t m ~ r , t i r ~h e a l t h
h a s been 5 0 p e r c e n t lmbder In t h e p e t - l n a
1574-1982
than
it
was. durirrg
1963-70
(1)
nhat - . i s a l 2 p c - ~ r rit-toed
f
by
t h e decrear ing i n d i c a t o e ' bed? l p h r c a p i t a ' [ Z 3 '
in 1960 to 2.9 i n 19821.
..
Consequently,
rectn~r, b e i n g
import ant
if
considered.
effectiveness and
productiv.ity
lrr
this
o f concern, b e c o n i e s m u c h mm-a
,,the d i m i n l s h i n g
resources p e r
c a p ~ t e are
normally a n l a t t e r
F o l 1 o w a ng
some
ind i c a t n r s
such
as
i n farlt
nmrt a 1 1 t y
-which
has sisteniat icalIy
decreased
since
the 6 s a n d
significantiy d i m i n i s h e d
in the
l a s t ten years- a s well as
other
health
i n d i c a t o r s . Chat s h o w t h a t
tubcrculnsis and
ir~Fantdiarrhea.
a b 0 t . t iorr and
i n f e c t ions h a v e redticcb t h e r r
i m o . = r t ~ ~ n cae5 rnairr c a u s e o f d e a t h , t h e h e a l t h sector seems to
have
a q r e a t e r e f f e c t l v e n e s 5 w h i c h can p r y b a b l y be derived
from a
motme pr'eventive emphasis
g i v e r by t h e
h e a l t h policy,
t-athe?' t h a n
a curative o r e .
Hawever
the
C h i l e a n health
s i t * a t ion is not: fr-ce f r o m
b a c k w a r d i n d l c a tot-5 in s o m e a r e a s
o r deterioraticwts as* is t h e case w i t h the
situations o f t h e
hospital
systerr~. Among
the
backward
~ n d ~ r a t o r sare t h e
i n c r e a ~ eo f enteric i n f e c t ~ ~ > u sd i s e a s e s such a s T y o h u x d fever.
and
H e p a t i t is,
which
increased
in t Z O and. 7 5 0 ~ p r c e n t
r e s v e c t i v e l y d u r i n g - the last
years. E a u a i 1y
rrl t h e
case o f
rlialnutr-ition i n
children under
6 years 1
,
where
the
s t a g n a t l ~ ~ r and
l
i r~c?-ement i s observed
b e t ween 1982 a n d 1983
12).
In the case o f h o s p i t a l s ,
w h i c h i s the s u b j e c t
#sf t h i s
study. t h e
p u b 1 . i ~s e c t o r shms an r v i d e n t d e l a y
ccgntna?'ed to
t h e p r i v a t e sector,
and t h i s is conf irrned by
t h e strpng d r o p
i n t h e i n v e s t n i e r t t , as nienf ioned above.
On t h e
o f her
hand
d u t - i n g 1379 and 1383 t h e p r i v a t e
sector
a l l o c a t e d at
least
US8 iCjCl n i i l l i u n s i n e q u i p m e n t f c r i t s Z . G O ( j b e d s .
-+-+--+-------------
( 1 I CastaXeda, T . ,
" C & n t e u t : u soc lcreconbmico y causas del
desccnsm de
la t n o r t a l i d a d infant11 a Chile", Decun!cnt.s
de f r a b a l r 3 NG* 28. CEP. 1984.
2 ) Jirnenez, J.,
" L a salud
p Q b l ~ c s en
Chile en
1985". R e v i s t a V i d a
M & d i c a 9 Vol. 97, No. I;Harzo
1985.
1
' J r : n ~ f . h l l y t r , ~~! t r~d . ' I r>t7+r.CJed t C m ~ - L s lc r ~ rnu n t h - - f f c c t r
a-.L,
,..,c.+d
'
Ly
t h e c e c ~ t . C t . a I ~ : ~ r ~ ; . no a l ~ c v on t h e hcmsoitat
I
I
that
I . 6 5 b c n : r ~ Drc-cecls C , ~ T ' I C P1':'"5.
The a i n i was t 3
L c =.it
t3r
iivibd:.:r~.?s i 3 t h a t
A I,I.:.~..E ilerer.t k - a i I ;EJ
~ ~ i a c h b p e f i l e nef
t
I
I
1 :i
le-d5 to a r.:-ns l d ~ at b l e
r r + > n r . . > s v s ~ ~ ~r erar ~tin c
trc, .;:! a1
r - a i f e c t iver,cs-,
over
thac
?or.
hcssai t a l r
in the
t
:
.
I
1
%
;
rtcln.
Rs E
11idLt e r
af
fact,
k , s c . > i tE : s
u
the
rle*r
s y s t t n l al-e Planaged . b y '
~t-ivate
r
- .
t
,.,r.!,.afir -a:: 1 C n r t 6 t r , ~ t t-,encfle
f I stir 1 r + s s c o ~ ~ ~ ' c ersn i ~ r h
rbdnrar+.>,
i:+c l v
t hLrn i
u ~ t b l c nc s o i t E i s drc-nnd I rq d i I-ect l y on
:he !iat Iajc.zti 5 , i t r r r ~ c * f kiua l t n fer v l r e s .
.
.
!
: r r ' :.t hi.t 1 c f , r 6 , k r : e i . : c . :...hli;ai.f.
11 5
f otll itlEFr w k t n
t - , . , , t l : - :
,:,!;u-,
a r . ~t h e f i r ~ u a t e . : , v ~ c ~ r , I * ~ f . j r - r ~ ; a l ' ~ cw~dn5
:li.we~er
~ . r , ! \ ~ c t i r d ~I-C'IO
nt.5r,at+1s
I
~cccrrtt-a;lsed
n~ar,aEerrrer~tsrd
f rorri p t ' ~
v a t @ el l n ics c h o s e n because
of t h e i r
s i = e and o t h e r e n a t - a c t e r t s t i c s wnacn h ~ a d e thprn s l r n i l a r
in
t e r m s of case m i x t o small general public hospitals.
f
C~:;v~.-i;.or:r:ltl~. t h i s
s t t i d y covel*% t h e p r l v a t e
eector a n d
p ~ i r : I- = cra=,.snTt-a1 iteo
o n p . <..jr.re r,rt i o n a 1 stat 1st ~ c s are
~ r , a l : & u ; et o r e f e r k 0 t h e pun1 IC
k c ~ s d l t a l myatern,
but t h e y
,
e
o b ~ - i c * v s l y npt %nau!~h to meet
the r e a u i r e m e n t s o f
, i n f s r . i , ~ a t i o n i n i t i a l l y cr;.nsideredtar
A
~ n c s t 4 . 1 3 ~1s
,:~t'na?ai:ed
ivd t r ~f ~ l l o w ~ hr ?
eGtior<s. I n
ssctlrsf 1: a
m~:cc?l. for n o s n i t a l p r ~ ~ a u c t i v r t yI S out'llneci.
IZ
a o a ~ n i v6 e s c r - i b k c ,kt.= *lay x r , t h a t f o l ~ r - v A l m l a O C S , i.e., , pat i e r ~ t
5 c ~ rI i; * ~ c + ~ Y IIoC~ I ~ 1 e v e 1, 3at ient
l 1 l rress iever 1 t y ,
p a t i ertt doe,
a ~ d ~ ~ e d ~1 rc, w~l ~ ti r .
hvoc~tr~G
~ tc aly
l
itmf ': u e r ~ c e
nger
the
pa*icr,t'a I e r , h t h
o f stay.
T h i s latter
varlahle ic t a k e n as
tnE
LrtvergL C C
nusplb al
qr-oduct k v b t v
nheascrr-ee as ' p e t acrat
d iseharor p e r
husoi t a l hed iyr m c e t - t a i r , p e r r c b d In s a c k iors
1 x 1 w e pruserlt t n e r n a ~ r r c h a r - a c t m b a r t i c s o f t n t 1,137 ~ s t x e n t s
sur-veved
thrcnu~h t h e
sar~iole.
Ue
Focused
on
these
charsctcr-1st L S L w h L C ~
re1evar.t
to t h e lflibdct
~ .nfo s p l t al
o r - i ~ d u r t 1 ~ 1 t y .S n e c j a l
a t t e n t ion is
piveri
to t h e case m i x
I s s u e . bctweerl h ~ : t e a i t a l s . I n sectlon
I V t h e hiadel is d p ~ ~ l ~ e d
w i t h p a t i e r ~ t ' sd a t a
C a r t h r b o r d i fret-ent cl ~ r ~ ~ cC a
P ~l- V ~ C ( F S ,
' t h r t are O b s t r t r - ~ c s ana Gyneculogy.
S u r g e r y , and
Internal
Mtclicine. In
each of
t h e s e c l inical
set-vices t h e
data fronr
thu F i v m h O s p a % a J s w a s
puoleo t a g e t h e r
a f t e r checkang
for
hOblOUenelt!,
at s r t l m a t e d cueffielents.
This
led
t n the
deLerr~blrbatiorr
rsf
s i m a l a r i t ~ e s aria
differ-cracu~
bctucrn
h ~ r p i t n l s ' ~ r - 0 d 1 l C t r v i t y . - f ireally,
~n
sectifin V
t h e ualn
pol i t y emncl LIS I o r l & at-e p r e s e n t e d .
r
I I . A n9D'L
FOR HOSP I T2L
PRODdCT I V: TY
The gross p r o d u c t o f a hospital c a n b e r - s a s u r o d b y t h e
number
of p a t i e n t s
d i s c h a r g e d durlng
a c e r t a i n p e r i o d ( I1 .
Were a1 1
the c a s e s
o f t h e same
n r d a c a l cocpl e : j~ty,
h a d a1 1
h o s p i t a l s the s a m e technology,
human enkcwnent end e q u i p n u n t .
then productivity b e t w e e n h c a p l T a l s could b e e a n i ly c a a p a r z a .
O n p i n d i c 3 t o r a f such
p r o d u c t i v i t y cau!d k z p a t : e n t d:zzLa-;z
p e r bed really used in a g i v e n period.
.
1 ) Z)AP
Fatient d l s c h a r q r
ij
c'
d
----+--------,,,--~3
*
OR
i
THC
,
. .
F'atl ent-
- tat&I
Gi
.
scnar.?e
ij
,,,,-------patients =ray
i~
2
j
where " i " idontif i e s t h e h o s p i t a l ,
'
4,
J' # indicates t h e year,
OAP Daily a v e r a g e p r o d u c t i v i t y p e r bqd i n use.
OR Occupancy r e t e o f h o s p i t a l i i n t h e y e a r j ( i n
percen t2g.e)
THC Tatal h o s 2 i t a l c e g s c i t y which .in a year i s e q u a l to
3t5
number of beds.
It i s easy to see t h a t t h e i n v e r s e to t h l r rndiC&tor of
productivity c o r r e s p o n d t o t h e average l e n q t h nf
s t a y ILDS)
and o b v i o c r s l y
t h e l a r g e r - the LOS
the l o ~ e r p r o d u c t i v i t y is
-'
,
'
*
attained.
, For any
in-patient
stages: d i a g n o s i s
(Dl,
his
LOS
m i g h t bc composed
medical treatment
( T 1 , and
of
three
recovpry
( R ) such that
However, while T has to
b e -itccrrnplikhed as i n 2 p a t i e n t ,
and R at l e a s t p a r t i a l l y can be accomplished as o u t - p a t i e n t .
D
If w e still assume cases o f t h a same m e d ~ c a l r o m p l e h ~ t y ,
what e l e m e n t 5 can
i n f l u e n c e nver D and R such t h a t d i f f e r e n t
LOS are a t t a i n e d 7
The s o c i o e c o n o m i c
level
a+ t h e p a t i e n t seems t o b e
crucial
t o e : : p l d i n that differences. brleFl y , let us t ' i r s t
_--&--4*_-_--_----_---,-
(11 L e t u s assume f a r simplicity
exists.
that no out-patient s e r v i c e
I '
e x p l a i n the price s y s t e m at public and privste h u s p i t a l s . For
1
C h i l e a h emp l ~ y e e s , e r ~ r al lm e n t to t h e soci a1
securi t y
s y s t e m f 6 mandatory.
The s o c i a l
security system
provides
d i f f e r e n t benefits among which r e t i r e m e n t p e n s i o n s
and health
insurance a r e t h e most
important.
Wi tk r e s p e c t to h e a l t h
insurance t h r e e
d i f f e r e n t systems
a r e avaiIable.
For t h o s e
w o r k e r s e n r o l Led
at the "Serviclo d e Seguro Socral" ( S S S ) ,
usually t h e p a o v e ~ t ones, f r e e s e r v i c e at
pctblie h o s p i t a l i s
avai l a b 1 e.
For
t h o s e u o r k e r s enrol led
at
ather
soci a1
, ~ Y C iUt y~
i n s t i t u t i o n s two
options fur
h e a l t h i n s u r a n c e are
a v a i 1aLle:
on t h e one h a n d ,
t h e "Fondc Nacional de 'Salud"
-;CFONASAI, a p c a b l i c i n 5 t i t u t i o n which
p a y s p a r t o f t h e nrrd:c;l
expenses o f i t s rnembe-5 a c c u r d i d ~ gto a p r c - f i ; : c d p r i c e syszern;
on t h e u t h e r , t h e " I n s t i t c k t c s de Salud F ' r e v i s i a ? s l "
(IsAk'REj.
p r i v a t e i n s t i t u t i o n c , w h ctl
~
h a v e d a + $ ~ r e n ; h e a l t h icsur?n'cs
s c h e m ~ z dzpendinq
or,
the monthly
paymrnt
t h a t z a c n rsrwer
does. L n y of t h e 555 u a r l e r s
is allowed to b~ ~ r 1 ~ 0 l l e:
e b:?a?
t n t h e F'DFl43A o r to t h e ISQF'RES b u t t o use a n y o f t h z m h e t 8 ? s
t w pay mor,e t h a n what: he c u r r e n t l y daer.
A E +Fop FOPIASG he
g i v e s &%,of h l s s a l a r y each month &nd p a y s
SO
ta 75% of t h e
cnst a C ~ a c hs e r v i c e he g e t s . A s f o r t h e ISAPEE he would h r v e
to p a y a h i g h e r m ~ n t hyI charge, and p a y 0% t o 40% o+ medxcal
care services he r e c e j v e c . B r s l d e r , r n y n n e can go to a punlic
haspitdl a n d will o e chzrw+d d e p e n d i n g
on h i s
inconre l e v e l .
Pub1 ic
h o s l i t a l s a c c e p t FC!1G5a p a t 1 ents and a c c e p t FO:.IASA
p r j c e 5 . P r i v a t e a l s o a c c e p t FOr4ASA'
patients but t h e y usually
c h a r u e mare t h a n FOt4ASL o r i c e c - and i n t h a t c a c 4 +he differenct
is t h e p a t l e n t ' s responsibility.
T h e r e f o r e , t h e socioeconamic level determines t h e t y p e a f
health insurance t h a t any f o r m a 1 w a r r - e r is f o r c e d "ta b u y "
thl'augh a payroll ta::, and s i r n u 1 t a n e o u s l y t h e type- a+ hospltal
w h e r e to go eventually.
fn T a b l e 11.1 it is possible to check
t h i 5 statement.
Looking at unpublished d a t a f r o m a s u r v e y over 1500
admilies i n S a n t r a g o c o n d u c t e d b y t h e m i d o f 1985, i t is
possible to realile t h z t t h e ISAFRE i n s u v a n c e is h i g h i n c o m e
oriented,
w h i l e the F D N R S A one is
m o s t 1y
m i d d l e income
the
SNSS
health
' o r i e n t e d , and
the SSS and direct u s e 0 5
t h a s e people +ram
r o v e r a g e is low income o r i e n t e d . Eesides,
period
the survey
who h a p p e n t o b e hospitali=ed d u r i n g t h e
- o f three months p r i o r
t a t h e survey a t t e n d e d to p r i v a t e
hospitals
as
long
a5
they
en~ayed high
incod~~e. w h l l e
m i d d l e and
I o n income p e o p l e a t t e n d e d SNSS and other p u b l i c
hdspi t a l r .
1
I d l l r 1l.i
r:xT!l
IhI?'ALr;:E
:M
TYPE OF )t?;PITAL nTTEsZil B l
RiwTIL,L:UlIC5D,1~83
(EOL171N mCiM765EI
SW3Ci: J. hdrigvr:, llA?E5, Scrvrr cn socirl txpenditwr
IUnputl! rhtd ?ablel; 1793.
1 1 h p r t v i t e h n s ? ~ t a i!i;e;~al:z~d i n i d m r 4t:::t-::l..
b l lilituy md pubti: university h o s p i t i ! ~ .
lncore dirtribution,
-
t h e socioeconomic
level ef t h e p a t j e n t a s a
uhich i n f l u ~ n c e over
D and R the argument is t h e
4aliawing. A h i g h income p a t i e n t can pay p r i v a t e a m b u l a t o r y
diaqnosi s (medicrl out-patient care, - X-ray,
l a b o r a t o r y eaarrs
and c t h e r
diagnostic
procedures)
which
is
available a n d
e r f i c i e n t in medical terms.
This
means
that
he c a n b e
hospitalized w i t h p a r t o r a11 of D f u l f i l l e d .
B e s i d e s , he can
e n j o y good h e a l t h care
at home w h i c h m e a n s that H c a n b e
shorter.
O n t h e contrary, a low i n c o m e patient whose o n l y
alternative i s the p u b l i c s y s t e m
w h i c h is crowded at a l l
levels of
h e a l t h care-,
wi 1 1 b e h o s p i tar ized without a l a r q e
p a r t o f D a l r e a d y done. Even more, h e probably does n a t
have
the
opportunity
of
adequate
c o n v e : eeze-,ce
at home w h a t
.influences o v e r R .
Thus, f o r t h e s a m e r 1 iness, the follawing
would b e e x p e c t e d :
Regardin?
factor
-
where Y
r
patient's
incame.
T h i s h y p o t h e s ~ sassume5 an r n t ~ a c t ~ process
~ n
between
patients and d o c t u r s t h r o u g h whr =h s e v e r a l alternatives a r e
discussed and declded, p a r t of
t h e m b c b e d o n m e d i c a l criteria
and t h e
other
based an
the p a t r e n t ' s ,
and/or
his health
i n s u r a n c e , d i s p u s i tion L o p a y .
A second
element that should
icf I u e n c e a v e r LOS a r e t h e
medical
inputs
(MI)
w h i c h patients receive
for
the
same
disease. Tha hypothesis is t h a t t h e a m r e m e d i e a l
rare that
he gets t h e
fastest
the
Hay
he r e c c v e r s .
T h i s hypcthssis
should S e constrained
to ca;.?s
W ~ E - ehealth
care i s given
e : r c l u s i v e l y to c u r e t h e patj_ant, because w h e n o t h e r o b j e c t l v e z
a r e p r e s e n t . ' f a r ifistnrbce n ~ r d i c a l trsining. m o r e medicaL care
'might n o t necers+ri l y m e a n J s h n r t e r L C E ( 1 ) .
I n t h e Chilean
case, h o w e v e r ,
i t i s extramel y
d i f f rcult t a compare p r i v a t e
and
public h o s p i t a ! ~ l o c a t e d
in
the
Metropolitan h-ea
e r c l udrng those
i n s t 1t u t l o n s
which
bave
medical t r a 1 r . i np
prmgrams.
fn
f a c t , a l m u s t all public k , o s p z t a l s
in Santisgo.
t h a l ~ q hnat , t e a c h i n g t i n s p i t a l s ,
h s v ~ ~irtiall
y somz t r a i n i n q
proqrans.
T h e r e f o r e , some r e g a r d m u s t
3 e t a b , e n w i t h rE!+e==
k o t h e v a r i a b l e M I when analyzing a gublic h o s p i t a l . t n
terms
of t h e model and b e i n g a w a r e of some a m b i g u i t y between M I and
LPS, i t ' i s po?sahle to say that
A t h i r d element t h a t ehauLd
b e ' considered i s t h e r o l e oF
patient's age ( A l
o v e r LOS. In t h i s case i t
is convenient to
d i st1 a q u i sh-between o b s t e t r i c s and t h e other h a s p i t a l cases.
-In the r a s p o f o b s t e t r i c s rt i s possible to expect less
problematic deliveries, w i t h less c o m p l i c a t i o n s i n women w i t h
p r e v i o u s p a r t u r i ti ons. On t h e c o n t r ir y , i n n u n - o b s t e t r 1 . c cases
o n e w ~ u I de x p e c t t h a t the o l d e r t h e
patient
the longest
the
recovery (6)
that he h a s . It la n e c e e s a r y to p o i n t out t h a t
the
l a t e s t h y p o t h e s i s should b e t r u e for a b s t e t r i c s e x c e p t
for t h e $act t h a t
fertility n o r m a l l y s t o p i n w o m e n i n t h e i r
1 a t e thirties.
(11
One m i g h t also
t h i n k t h a t i n t h e case of
ph.ysicians p a i d
p e r visit, medical v ~ s i t sm i g h t 1ncrear.P j u s t
f o r p r o f it
reasons. T h i s might be relevant p a r t l r u l a r l y
i n some
of
t h e i n t e r n a l m e d t c i n e c a s e s at p r : v a t e
c l i n i c s because o f
t h e paymrnt s y s t e m .
1
2
-- --
r
o b s t e t r i c cases
r r c + n - - i O s t e t r ~ c cases
Firdlly,
a fourth elerner~t r n u s t
be : r 8 c : ~ = e d i n tnc nc.de1.
illness s e v e r i t y (15) w h i c h i s e n z x t e d t m x n c r e r s e
the
l i m i t . t h a t 1 5 w h e n c , e v e r q l F > :s
ext*-erale and t n p
p a t l e n t deceased, LuS is o b v z ~ u s l yi r ~ t e r - T- = ' . ~ c ' . b a ~ t w h i ie k t r e
p a t lent 1s alive. illness s e v e r r t y
a l o . s r L - F L S .:her+ D
irno 3.
T h i s 1s
LOS. f n
Thus,
Then,
the m c d e l
hlLght
b e pt+eSe*ted
as f c . 1 i c . w ~ :
7 ) LOS = f ( Y , M I , h , l S )
.
However-, uo t o t n i s ooint n o t h l n o
P I ~ E seer1 s a i d
ancbalt
funct iurral re1 at i c l n s h i D a m o n ! t h e rnaeo>r,cer-t \ * a t - l a b l e s . A s a
m a t t e r c.f f a c t . some r e l a t i o r r s a r e
oreelc:ea.
Fcnr i r t s t a n c e
b e t w e e n age
arrd i l l r , e = s severity
(151
:rr terms t h a t t n e
o l d e r t h e oatient tne h i p h e r t h e p r o n a c i ! : t v c . & IS. T h a t i s .
Besiaes.
it
1% r ' ~ a s o r + a b l et o
exoecf
'%at
{MI) increase w r t h illness severrty 1 1 s ) and
Thus,
m e d i c a l inouts
(R).
u a t h Qgt
Finally, ~t 1s also ~ o s 5 l b l eCo g r e d l c t a functional
r e l a t ~ c n s hDi b e t w e e n i r # c . > m e l e v e l of tne o a t r e n t ( Y ) and t h e
medical i n p u t s ( m 1 ) t h a t h e recerves. T h ~ s ,
d(MII
111
-----
,O
d tY1
,
Therefora.
t h e total differentia? .:i
I n t h e fc,l?owinq
~ t - a a za l l
( 7 1 lzads ts
t h r s ~tla';:u?ns a r e d e s c r - : 3 ~ 3 .
Graph 11.1.
hp1ana:ory Variables
S t a q a z as i n - p a r l e n t
OIL.O.S.
Illness severity
stay
\Patient
Age
,
(4
b
Recovery
in-pat tent
1
a\
P.*~ILC
and p r l v a t ~p a t i e n t s a n d raclo$:on~w~c s t a t u s
T h e i?dy
c i e a r l y shoruc G;,C I o e t c + h ~ n l d 1 f f e r ~ . n t e sh e t w r e r ,
hosu; tais a c i o r d ~ r n g
tc
theit*
p a t lecra* chafacterist its,
I)lf i e r e n t
v a t . $eb1c.s c a n
b e I J j r e ta pt-OWE i E . t i s t t - L C ~ at
pat r r r b t s 3 1
1 5
one
the,^.
bat &
u.btained Frc.rrt
i U r . i v ~ r - s ~ t y0 :
C h i l ~ el
y
%boded
the
fol l c ~ i r ~ ;
~ r . f o r f ~ s r r c r n o r , , a v i ~ e c ~ e f ~ f ~ 1j i
1~CsYnt
hy
fist 1.0 ~ r u :
it h n
.
8:-f
F-
d l SFI-act.
-
'b
t.4
r.:
LC*
t o
1.5
0.9
+,>
ial Pdtlw,t~' w i ~ : nrsrly fro6 Corrhdii.
Ibl Patianksy urlprr, from Nuns and t i Prim
Ic1 Pat lmts' a 1 l ; I n fma Providencll Arm C i s Comn
~ . ?i rt. n t = , 17
c 0 w p a r e d w ~ k k average F a n - i l y
drstrlcts, i t crearl* 5 ~ . . - ~ 5
pr'lvacr r l c b s p r ~ a l s
p r e f e r a b l ~ cor~cerbtr'ate o r h p a t a e n r s F*..:r~l :> 1 an LnclS'rllC areas,
whereas a u b l lc hcnsoit a 1 s Inlbire
t h e oouosl t o d i r - e c t iarr, T P , l s
s i t y a t 1.x-a c a r , b e r e g a t - ( l e d fr-~irbi
w,:,rnt
.:.f
view
by
c u r ~ s i d e r r n g tne
t v n e m1.f P a t l e r a r s ' s l c i a i
-ecb~r.itv. C b v l c ~ u s l y
the
ecc,nmrr%ic i e v E l
c f those
d f f l 1 biked till
the Set+*.~cl~
de
j
S e g u r c , S D F I . : ~ ~ (5551
15
1L.wer
thar,
tnr
levri of thcase
b e l o n g ~ n g to FONGSR t F N S ) a n d t n ~ s l r , t u t - n i s Ib:blrerthar, t h e
IF
rncame
eric:r? # s f
by
-
level rif
t h m - F b e l a n g r n g to
ISAFRE ( 1 ) .
On t h e
other h a n d ,
~t c o r ~s e t i t - a t c d t h a t t h o s e without scrral sscuri t y t h a t
v i s i t ~ J Ii ~ a l * C I i n l i ~ h
- ove a high
i n c ; ~ e l ~ v e l ,' s ~ n c et h e y
h:>ve
'
rwch marc
t t ~ e r et y ~ n l n pub! lc
h ~ s p i t a l = .a n d
those no?
havlng
social
security
2nd
v l t ~ t x n g public
hospit,als
have a
l o w kncome
level ~ l n c e t ? , e y a r e a d m i t t e d
{ r e p 1 y or p a y i n g m ~ c hless.
.
Table
iTI.2
.
--.
--
.
-
P a t i e n t s b y t y p e o f social s e c u r i G l 1 7 . 1
Type of r o c a a l
secur I t y
--
P r i v d t e H~spltals
F'H2
Pub1I
c Hnspi tals
PIJB?
' SSS
32.4
10.5
1.4
CfdS
I SLC.FF
O t h a r cirr,c5
57.0
h.
O
9.0
2.7
SL.4
4.3
Final l y , i f
ecanorni c acti v l t y o f p a t i e n t s
is consi,dered
t b a same situatiun is $our,d. In t h e f o l l o w ~ n gt a b l e . i t can b e
<howad
t h a t a g r e a t e r r a t e of p r o f e s s i caals,
white-collar
and
entrepreneurs
go
to p r i v a t e
to i t ,
a g r e a t e r , r a t e of
blue-collar
,self-emplayed g o ta p u b l i c h o s p i t a l s .
e m p l o)/r.cs
apposite
-------------------
LZ:
inics,
and
~ o r k ~ - r s
and
(11 Trad~tionall
y blue-collar w o r k e F s a f f i l l a t e to the s o c i a l
s e c u r i t y " y s t e n i E S S I ; white-collar ~ m p l o y e e s to F O N A S A ( F N S )
and h i g h ~ n c o m e + r \ r n l l ~ e s
to ISAPRES.
Fatipnts economic a c t i v i t y
( F e r c e n t a g e o+ t.he answers o > t e : - & a ,
Activity
;Private H e s p i t a l
PRI
35.0
1z.o
4.0
% of
nd- answer
i
PF":
15.0
12.0
I
Z.0
?-blic H o ~ p i t ~ l
4.0
2 . '7
-
1b.G'
1.0
10.0
1.0
4.0
47.0
0.7
b1.b
5Z.O
cmploycd
l n a c t 1ve
PRZ
-
13.3
I
]
10.3
bP. i
Z. 0
39.0
Up to t h i s p o i n t , n o t h i n g new h a s b s ~ q> r o v e d . i . e . , t h a t
pub1 it
hospitals
preferably
assist p s c r
patlents
whereas
p r i v a t e h o s p i t a l s a d m i t p a t i e n t s o f medium a - d h i g h incomes.
The
s i g n 1 f icance of
thls
f a c t lie; In t w o
hypotheses
true,
could influence t k e productivity
of
f rrst
Dne 1 5 t h a t
pat:e-:s
having
better
'xnc3mes a r e
a b l e to get
to t h e hasoi t r l ur t h m o s t
o f their
diagnostic e : c a m i n a t i o n s d o n e The secann one I S
that f o r t h e
paore5t patients, hame r e c o v e r y
I m p l i e s r r s k s of infection mr
bad qua1 i t y c a r e ,
what
can b e
awoided i f
their stay i n the
h o s p i t a l i s l o n g e r . Naturally
both h y p o t h e s e s ga f o r g r e a t e r
. i n d e x e s of patient's stay in p u b l i c has;itaLs.
'
that,
i f p-oved
h a s p ~ t a l s . l'he
1
ackno~ledginq t h a t p a r t a <
such h y p a t h e s i s
can be argued i n v e r s e l v , t h a t
it i s l i k e l y
that
the
c o s t f a c t o r , being
absent a i t n e doctor's
m i n d rn
the p u b l i c
haspi tal
(I!,
may
1 ead
to procedures and
habi'tr, t h a t u n n a c e s s n r l l y increase t h e l e n a t k of s t a y .
Hawever,
isreasanable,
and
it
----does
( 1 ) What
he
p r i v a t e clinic.
take
int9
accourt
w n e n working at a
-
b l Pubiic vs.
P r ~ v a t eP a t i e n t s and L e n g t h o f
Stay
One
of t h e
most r e l e v a n t
s t a t ~ s t i c o
i btained
from t h e
o-length
of
s t a y of
~ : t : e l t s . Next
T ~ b l s
stw:,ny
i s tn-t
r o n l . r a s t them b y t , o s p ~ t a l and s e r v i c e s . ( 1 )
L b l q t h Of s t a v p ' i r p - t l e n t
(LOS), s t a ~ d a r dd c v l a t ~ o n (5Dl and
i t s r c l a t ~ o n s h x pb y h o s p i t a l and s c r v l c e s (pre-surgical days
xn b r a c i e t s ) .
It i s c l e a r t h a t i n o b s t e t r i c s and g y n e c o l o g y t h e l e n g t h
of stay
i s similar
among a l l
the institutions.
However, i t
must b e n o t e d t h a t p u o l i c
i l u s p l t a : ~ r e g l s t e r a h i g h number of
a b o r t i o n s and
other s i t u a t i o n s
r e l a t e d t o pregnancy
t h a t do
not
end
in
childbirth,
what p a r t i a l l y
explains
the
high
deviatxons.
I f
such cases
are
values
for
t h e i r standard
eailuded, the
1,ength
of s t a y f o r d e l l v e r y a r e
3.58 and 2 . 4 4
for
hospitals
PUB1 and
PUB2
respectively.
I n the
latter.
....................
(11 D i f f e r e n t s e r v i c e s
or
departments
have
different
k i n d s of p r o b l e m s and t h e y c a r r y w i t h them p a r t i c u l a r p a t t e r n s
of behaviour
among
ddctors.
Surgeons
have
an
"activist"
they
don't
b r h a v l o u r , t h e y f r e i t h e y must " d o s u m s f h i n g " and
l i k e t o be p a s i v e observers.
Internal
medlrine
doctors
are
a l w a y s i n s e a r c h f o r dxagnosis; t h e y p r i v l~e g e more . i n t e l e c t u a l
and academic d i s c u r i s l o n t h a n s u r g e o n s and t h e y t e n d t o b e l e s s
prone
to
action
than
them.
Obstetrlclans
are
more l l k e
surgeons, t h e i r p r o b l e m s a r e s l m p l e r and compl l c a t i o n s
fewer.
T h i s i s an input t o u n d e r s t a n d why
L.O.S.
tends t o . b e
longer
i n
Internal
M e d ~ r i n e than
i n
Surgery,
and
shorter
in
Obstetrics.
c.f
o e I ~ \ , e v - : . ? s6-,.3*% :-1y .:lrle
:a"
i.f % t a w .
the
re::
ef
+me
5urvey~o
h e x p ~ t a l s . R!l t h s p a ; l ~ r ~ r s u r , d e r . : k i t c ~ r c u m s t a ni ~~ ~c k e ?,l:I
=o.cia; s a c u r i t v
a-,e c . n i r i m ~ n o , ? . r t yh a d 555.
tb,nevnr-. t i l s
n.:.splral
e v e , c u s t a c p r c ~ c r . i s t.: ;
.
c . = r - a l ~ s c + r ~ ~h .~?, s 0 1 t a l 54
hc,ur5
t
:
l
L ' ~ : i v e r v ar,o
7 .
17, t n e ci,cs
r.f
ctr:--ar-car:
S r c r i o n C , l r l t l i :?e ~ . a t . t h a l < a - e
*:ar.ch 19.35) ( 1 ) .
i
=ere
t
a
:
r
a
-
2
F
t
;ne
O D S ~ ~ V O C
:
.
1:
3 . . 8 ~ i lb
~~ = ? l : a ! s ?T~,w
,
Ir.
T?E
c i z e .:.f
:
r . 4 a
I
I C , - , C ~ P!-e r , g r n s
511,-CZ?.y,
J . i V - - '
+i
in
.:.=
r
;ri.
=.
5 . .
e
!
n:rdic~r,e.
i t . r n ;?F ~ ~ - 2 v a t e
.- -....
....?.t,.,el . v a,>
c s t ~ z < , z&
s\F,-IVS
,
In t C
pm.,cl '.:
x i c
:a:: r e 2 . 2 er,c 2 . 6
i o ' P 2 b l end 7;-2
t-eioectlve!~.
.C
. iniivi:.
of
tqe
re: i t l , : , ? 5 h i ~ ' a v e ~ . a o e d a v s i s t a r a a r - o
c e i : i r l e , r # ' shl:,rs
that
t b , e r , e 1 5 o r r a t e r i:,r l e s s or.co,:,rtlc.:, c i ; i s - %
,,ear-r h e
aver~an(r.st r;+:escrr-ily
i n d i c a t ln" t h e
5 1 s t r 1 >LI:IC,?
cnf freouertcies).
TCxs r,rt&rls t h a t
a hxgh
reia:l,:.nshlo
:
at
a
0,-eater
o-,s2,-r'; 1i.n o f c r s e s w i t h
ienptn
o f s : a ~ -bo.d.t t c t n n a v e r a o a .
Fov- x r r s t a n c e .
xn t h e c z s e
of c,octetr-:;c
i-c
?yriecslr,pv ~CICT,
I T , C :=a t o ? - s n > w z
that in
t h e ~ ? . r v i t c irs::t u: rons n m r e w c , m c n
st.?" r o c r 0 ~ 1 r n a t e l . v 3 d a v s t h a r ,
ln tie o . . , 3 i l c
hasoitals. I f
lt is c . , r . ; ; t i e r e c
:hat
ln
t h e r i ~ ~ c l lnc : = ~ : ~ i . -: h, e - e
are ccsas
t h r : d 7 . l r!Ot 6 E i ~ v c r - v . 5 1 ~ ~ :?elat l . : . i l S 9 1 C s e C ! > 1 5 r e a s c . r t a 0 1 e .
I n
frct.
0 7 - i v a c e i n s t l t u ; l.:,ns
have
s 50:
~ . wl:,re
f
hor~~~penec,cts
C ~ = . E F a r d t he-e+r,r.e
tnelr
s t a n e a r - d :er: ?: 1 3 , . :G ic,wer..
i r,
: 3 : = 8 07 It.
57.ICl7
a r l Z . l v S l 5 a C o l l C C t,:, S i . - = e , - " S~,:.WS d C e P C l l n
roed~c>-,e. I r ~ s t e a d . p l ~ b l l c
2 s l l n i l a ~ i t y ar.rm.-,ng
h ~ ~ s o i t a l s .In
h"soitais
have a
'days I
standavd
O e v l a t ~ a n ' relaki.:.nshio
higher- t h a n
o r l v a t e ,.-hnes
( o a r - t z c u i a t - 1 v ,: t h r - e s ~ e c t t c . P R l
and
PRZ),
arsd a s i a l i l a r
relat i n n s h l o
:=tween
them.
wh l c h
e greater- h,smogeneity
,sf
c a s e s . c.r
a l t e r r ~ a 1t v e l y
sumpest5
5:syl
o f eoua! lenoth. belng
r a t h e r incs=cr.acrmt f r - c . r t h e t y a e
of
cases. T h e l s t t e k - v n r t l d
c,bvroi.bs!y v-e.ea1
a guest~onable
use
of t h e i n s t a l l e d c a o a c i t v .
m:,?
*:::,
CI
how
...I,%.;
3 ) . 8 5 ! : ~ - ; ! Teal
.:f
r-,.
.
mc.5ot:r.s
P m ~ b l i cV S .
;;-
.
oavs.
whey
Y:OC-.
:-.ST
:
.;=.on.:.i:s
ale?-rpr :
7
--
PI-ivate Patients'
age
of
oatients
ll!u5t
lay a r o l e in t h e l e n p t h Of
The
soe
s:.=.y,
s i r m c e ~t d o e s p l a y i t I T , h e a l t h . I n t h i s c a s e i t
shol.nld
b e e x o e c t e d t h a t t h e cclder
the oatient.
t h e
q t - e a t e r care h e
reocir--5. 1 . e . .
l , : , ~ : ~s ~
t >.)-. , U:L.:P.I?-- 1 .
. . <A:?
if C?CC?D
with a r r ' o n i l S ~ ? C ~ ~ ~ C ~ ~o ~Of f~ e :b ~- e~n ~c eI c~. C ;: s ? , = , u l d b e said t n a t
pr.r.bab!~ l n 0ec.ple
c , l d e r or t h e sarne s , e ,
t n e
r i s k i s higher.
anlc,nQ t h e o c m r .
---
-- - -- - - - - -- - - -- - - - -.
11)
I t 15 rer>nlnded t h a t
l a s t o u a r - t e r . o f 1'354.
t h i s svrvev was
taken durlno t n c
In
t h e following
T a b l e patient's
clinical s e r v i c e i s shown.
a g e by h o s p i t a l a n d
Table 1 1 1 2
Average patient's
a g e and s t a n d a r d d e v i a t i o n by h o s p i t a i
clinical s e r v i c e .
S u rq er y
UEj 1
28.9
27.5.
27.9
25.8
24.7
4.22
4.38
4.92
5.56
5.95
and
Internal
Medicine
46.6
4
.
:
4
In t h e c a s e of
o b s t e t r i c s and g y n e c o l o g y
patients' a g e
s i m i l a r r a n g i n g f r o m 25 t o 29 y e a r s old. In s u r g e r y
' t h e r e a r e n o c o n s i d e r a b l e d i f f e r e n c e s e i t h e r , s i n c e patients'
2.3"
C l u c t u a t ? ~ beth?en
4':
and
45' f e a r s .
Instead.
in
47 and
medicine a
signiiicant distance
is observed between
6 3 y e a r s old. In g e n e r a l , it c a n b e s t a t e d t h a t
p a t i e n t s in
pub1 ic h o s p i t a l s a r e y o u n g e r t h a n i n p r i v a t e institution,^.
is very
d ) P r i v a t e vs.
Pub1 ic P a t i e n t s a n d M e d i c a l A s s i s t a n c e
Statistics on
medical
assistance,
.examinations
pharmacy give an idea o n t h e processes undergone
by
patient
either regarding intensity of t h e treatment or
t y p e of t r e a t m e n t done.
Medical
visits,
especially t h e daily
. i n t e n s i t y of c a r e t h e p a t i e n t i s s u b j e c t to.
ones,
show
and
the
the
the
1
T a b l e 111.6
Average Medical V i s i t s p e r P a t i e n t d i s c h a r g e d by H o s p i t a l and
Service. ( I t s d a i l y equivalent i n brackets)
1.
O b s t e t r i c s a n d Gynec.
Medical v i s i t s p e r
patient -
-
Surgery
Pled. V i s i t s
per patient
I n t e r n a l Wed.
Pled. v i s i t s
per patient
1--------------------
6 g r e a t s i m i l a r i t y is s e e n i n o b s t e t r i c s and gynecology,
w h i l e i n S u r g e r y and Medicine where t o t a l medical v i s i t s p e r
patient
are
oftener
in public hospitalst
their
daily
e q u i v a l e n t a r e less i n s u r g e r y a n d
among
the
lowest
in
more. d a y s o f
stay but
not
more
medicine.
This
implies
i n t e n s i t y o f t h e m e d i c a l work, i n p u b l i c h o s p i t a l s .
i s considered
as
If
volume of
l a b o r a t o r y e x a m i ~ a t 3-1s
:
w e l l as x - r a y s a n d
d i a g n o s i s p r o c e d u r e s by p a t i e n t , e x p r e s s e d
i n e q u a l p r i c e s b y u s i n g FONASA f e e v a ; u s s , i t is n o t e d t h a t
-public hospitals a r e l o c a t e d
among t h o s e
using m o r e exams
w h i l e t h e p a t i e n t is i n t h e h o s p i t a l .
.
T a b l e 111.7
L a b o r a t o r y - exams, x - r a y s and d i a g n o s l s p r o c e d u r e s
b y p a t i e n t , h o s p i t a l a n d s e r v i c e ( a n u n i t s of f e e
and v a l u e d a t t h e s a m e p r i c e s y s t e m ) ( * I
O b s t e t r i c s and
Gynecal ogy
Surgery
Internal
Medicine
---------------------------------------------FFi 1
2.55
PR2
PR3
PUB 1
5.58
4.67
5.54
6-73
PUB?
-------------.------------------------------------------------
:2.C'7
19.54
13-82
17.12
33.2
45.85
56.33
33.29
106.56
35.41
(*I
1 u n i t of f e e ( u n i d a d a r a n c e l a r i a ) e a u a l s S 160 C h i l e a n
p e s o s a t t h e moment o f t h e s u r v e y ( 1 9 8 4 ) .
is
It
should
be
noted
that there
some
relationship
betu:.en
the percentage o f patients t h a t a r r i v e d
i n
emergency
and t h e
amount
of
exams
registered
( c f . Table
111.7 a n d
111.8).
The p r i v a t e h o s p i t a l FR2 t h a t shows m o r e
cnam~nations
has
the
highest
percentage i n
urgencies,
and
a similar
sl t u a t l o n h a p p e n s i n t h e p u b l i c h o s p l t a ! s .
T a b l e 111.8
P a t l r n t s a d m i t t e d i n emergency s i t u a t i o n s b y h o s p i t a l
and s c r v l c e .
(Percentage over t o t a l )
O b s t e t r i c s and
Medi~ine
PR I
PFtZ
F'R3
PUB1
PUD2
--
1.4
21.7
4.4
26.2
27.7
11.
20.0
a.
n.a.
n.a.
Pharmacy c o s t f o r p a t i c n t , by h o s p i t a l and s e r v i c e s .
p r i c e s of " F o r m u l a r i o N a c l o n a l " , i n u n i t s of fees1
(Common
lnformatlon
about
pharmacy
does
not
allow
t o
infer
cornparat1 v e
conclus~
ons
between
prlvatc
and
publlc
x n s t ~ t u t ~ o n s .I n n o n e
of
t h e c l l n ~ c a ! services s t u d l e d
i t
stands
o u t becau-e
of
some
common c h a r a c t e r l s t l c .
Ins~de
each o e r v l c e
a n d hospital t h 1 5
variable w l l l i n d e e d
b e used
as l n d l c a t o r o f i l l n e s s
s e v e r l t y i n t h e following econometric
anslysls.
e) T h e c a s e mix issue
Hospitals a r e like
multiproduct
firms.
Almost
each
patient i s a different case. Therefore any c r o s s hospital
indicator of productivity, cost, and s o o n h i d e s a c a s e mix
which is crucial for hospital comparison purposes. Case-mix
i s t h e frequency of diseases with i t s n a m e s or classification,
grouped with certain criteria, that a r e observed in a given
4..~spital. In .certain sense t h e c a s e mix
with its pertentages
d e f i n e s t h e profile and most
important a r e a s of work of .a
hospital
--
.
T h e selection o f t h e eight h o s p i t a l s which constituted
o u r initial
sample was done based on t h l s concern. All t h e s e
h o s p i t a l s are "general hospitals" in t h e s e n s e that they h a v e
at least three of t h e following basic departments: internal
medicine,
surgery, obstetrics, or p e d ~ a t r i c s . Besides,
the
study discriminates between c a s e s belonging t o each of t h o s e
departments and
in that sense it r e d u c e s but d o e s not
overcome
t h e c a s e complexity.
In order
t o establish a n
explicative c a s e
mix,
each d i s e a s e n a y
b e classified
according to:
a- System o r part of t h e body involved.
b- Severity of t h e disease.
c- C m c u r r e n c e o f other complicating diseases.
A c a s e mix s o worked will
g i v e t o t h e analyst a better
insight of t h e kind of hospital with
r h i c h h e is wokking.
T h i s because some kind of diseases w i t h c e r t a i n complications
and with a given severity, will
imply different costs,
logistics and professional demands.
I n t h i s study we have made our Case-mix with t h e criteria
described above. W e determined:
a) Four levels of severity f o r surgical
interventions
according t o its technical complexity and organ (s) involved.
b) Three levels of
severity
for
inter-rial
medicine
diagnosis according t o its mortality risk.
c ) Presence or absence of additional d i a g n o s i s and i t s
participation in aggravating t h e main o r principal condition.
T?se
- i ~a n d lenqth o f
stay
Each department has a distribution of f r e q u e n c i e s of
clinical diagnosis according t o i t s s t r u c t u r e and population.
T h e s e frequencies a r e called c a s e mix.
Departments of surgery, mediclne and obstetrics of t h e
d i v e analyzed
hospitals have been
grouped
in order t~
c o m p a r e them.
From
the pulnt
of
vlew of
t h e c*se
m ~ x i t has
been
attrrpted
t o Obtaln
sorne
eAplanat1ons f o r
t h e average
and
d t s p r r s ~ o n si n
the
d a y s of s t a y i n t h e
c l l n ~ c z lservices of
the i t u d l c d hospl t a l s .
coef f > = l e n t h a s
been d e f l n e d
for
~ h e r r f o > e a s p e c l f lc
each depa-tnment u h ~ c hr e l a t e s a v e r a g e d a y s o f s t a y u ~ t h t h e ~ r
rorrespondlng standard devl atlon. L e t
u s c a l l i t "coef f ~ z ~ e n t
2 " w h l c h is t h e
lrverse
of ' t h e
so
call-d
roefflclent
of
var,at,on:
-
Z
= X days of
Y
s t a y / S t a n d a r d deviation
- .
i s that the greattr'
t h e "7." r o e f f l c i e n t ,
roncentratlon of
cases wxth
tendency t o
a
days of s t a y i n t h e g l v e n h o s p t t a l .
,he h y p o t h c i l s
the
greater the
s i m ~ l a r number o f
z . 5aC
i n o b s t e t r i c s a r d qy.~=Irlgy
I n t h e case of o b s t e t r i c s
and g y n c c o l o g y , t a k e n f r o m t h e
maternity
depertnlent,
there
i s
an
already
mentioned
d~fferenre
u h ~ r h r s
that uhile
p u b l ~ c hospitals
include
t h e i r case-PL::,
private o n e s
do
g y n e ~ o l o g 1 ~ a ld l a g n o s l 5 ~n
it,
b u t - c o n c e n t r a t e exclusively
on
the
obatetr~c
not
do
aspart.
We i n c l u d e d
anyway
a l l gynecological
cases i n
the
ob-.tetrirs
department
care
mlx
of
private
clinics
for
anal y t l c a l purposes.
The a v e r a g E d a y s o f s t a y a r e s l m l l a r when c o m p a r i n g c a s e s
some c a s e s . a l d e r
a g e means
e x c l u s i v e l y o b s t e t r ~ c a l , and i n
i n
shorter
stay. Thls
1s o z v ~ s i t e t o
what h a s
been f o u n d
-internal medlcine
and s u r g e r y
w h e r e o l d e r age
i s positively
correlated
to
length
of
stay.
The
e:.planat~on of
thls
d x f f e r e n c e may b r t h a t o l d e r
age i n obstetrics l o v e r 30 y e a r s
old)
1s
related
t o
more
than
one
previous
dellvery
or
nlultlparity.
This
means
that
those milthers
uho
have
had
rIn-r.11
d c l i r e ; i t r . :,, : . : r .
t
. mnr ,- i h ' 1 i t y til :h:lrtr;l
t t , ~
p r o c e i i . aild a v o l d c o n i p l i r a t l o n i .
Gynecology
includes a b o r t i o n
i n
our r a s e
m i x , and
it
a p p a a r s o n l y I n PUB hospitals and i n FR3. I t m u s t b e s a i d t h a t
abortion i s
l e g a l l v forbidden i n
Chlle, but i t
1 s performed
+
7
1
.a^.?
+
are
the
raucr
for
hospltal
a d m x s s l o n s . P r i v a t e h o s p ~ t a l s t e n d t o disguise t h i s
kind of dlagnos~n.
:+-
Re-grchuood o b s t e t r - i c a l - o y n e c o l o o i c a l d i a o n o s i s
( R b s o l ut e nurnser-s a n d oer-cent does)
Hosoital
Case
I-
luc~r-r~iz
i d c l i v.
ZE 46. 7
6 10. 3
or-csvs d e l .
,rAsar-eai-8 S e e .
2E. Z33. 7
0 0
23or-t 1 or.
- t e c n a n c v C.:seol. 0
C;
P c s t -oartun1
0 Cj
omo? i c a t i o r t s
Other- Gynec.
7 9.3
-------------- -------79 100
----------------------
TOTRL
Case Nix. i n Suroerv
When t h e
sicst ft'eouent
c a s e s w e r e grouoed
according t o
pet-cent a o e o f
occurrence,
13 d i f f e t - e n t .
catepor-ies
were
established in
t h e s ~ l r g i c a la c t i v i t y .
These c a n be
found i n
the
Table
111. 11.
Most
conlrnot-I cases
are b i l i a r y tract,
her-ni as,
ao0endeCt bmies,
qastrointest inal,
u r o l o g lc,
a n d trauma to lo^ i c a l o p e r a t i o n s .
..
1 n t h e c a s e o f s u r g e r y , it is ~ u i t e r e m a r k a b l e t h a t t h e
PUBl
hosoital g e t s t o a very high
p e r c e n t a o e (67.9%)
with
on1y S d i f f e r e n t k i n d s - o f d i a g r ~ o s i s : g a l l b l a d d e r , h e r n i a s a n d
(1)
This
greater
concentr a t ion
i s
oer ioherrl
vascular.
korrelated with a
" Z " c o e f f i c i e n t o f 1.83
in the
case of t h e
b i !per o f
the five
s e r v i c e s cc~rhoar-ed. Wher~ a c e u m u l a t irtg t h e
f i v e h i g h e r f r e a u e n c i e s of diagrtc.sis,
PUBl g e t 6 t o a 7 7 . 4 % o f
its t o t a l c a r e s .
PR3 a n d
PUB2
hosoi t als r e a c h
the
next
accclmu 1 a t i v e
percentages
w i t h 45.7% a n d 44.2% r e s p e c t i v e l y i n t h e f i r s t 3
c a s e s and
"2"
ccneff i c i e n t e s
of
1.0
a n d 1.40.
In
these
cases, t h e t e n d e n c y t o w a r d s h i g h e r " Z l ' ccref f i c i e n t s is m o r e o r
less ambig#-lous
s i r l c e h o s ~ i t a l PR2
hms
almc~st t h e
same
concentr-at ion
in
t h e case-mix
in
i t s f i r s t gr-oup o f cases
while i t h a s a Z c c , e f f i c i e n t o f 1.44.
------------- -------
(1) T h i s i s t h e us#-(a1 c a s e mix i n s u r o i c a l d e o a r t m e n t s o f
were
30 t o
42% o f s u r g e r y i s
public hosoitals
i n Chile,
bi 1i a r y t r a c t
?-elated
( C s e n d e s et d l , R e v i s t a M e d i c a , Ch 1 le,
1 1 1 : 1065-074,
1383).
,
It
must
be
noted
that
PUB1
i s a tyoical
surgery
d e o a r t r m r ~ tc a s e i n a o u b l l c h o s o i t a l i n w h i c h c e r t a i n s l J r p i c a 1
act i v i t i e s a r e e x c l u d e d ,
s u c h as:
u r o l o g y , traurnatc.logy.
utc.r-h i n o 1 a r y n p c - l o p y a n d
oyneculogy,
which have t h e i r c ~ w n
a e r - v i c e s a n d f a c i l i t i e s . The o r i v a t e h m s o i t a i s
t e n d t~ o b t a i n
a c a s e - m i x rnore v a r i e d , t h e r e f o r e t o s o r e a d i t .
.
F i n a l l y , i t is c o n v e n i e n t t o D r o v e t h e d i f f e r e n c e b e t w e e n
I n t h i s s e n s e . b y a n a l y z i n o t h e cases f r o n i t h e
d i f fer-ent h o s o i t a l s i t c o u l d be
r h t e d t h a t case. m i x e s ar'e n o t
s t r - i c f l y s i m i l a r . : On
o n e hand. PUB1 c o r t c e r t t r a t e s o n 3 o r o u P s
o f c a s e s , t _ q ! - ~ a k h 66% cbf t h e t o t a l a n d o n l y a r l e o f
t h e m is
fr-eauent
fW-.Cne o r - i v a t e h c - s o i t a l s ( b i l i a r y
t r a c t ) . On t h e ,
o t h e r h a n d , a t t h i s l e v e l PR2 a n d P R 3 s h o w c e r t a i n s i m i l a r i t y
'with
PUB2.
It
is p o s s i b l e .
therefore.
that
the different
case-mix e x o l a i n s p a r t o f t h e uneaual l e n g t h s o f s t a y (1).
hcgsai t a l s.
/
,
Table 111.11
G i - o u ~ e d D i a g n o s i s irt S u r q e r y
f r - e a u e n c i e ; t o t a l 1 i n g +/- &OX o f c a s e s )
.
-First Freauency
Pratology
(16.a
(13.61
(12.7) Trauma
Urolo(y
0 . k a d Facial (11.1)
Trau~toloay (11.11
PeriDheric Vase (11.1.)
T9ird ireouency
Fourth Freouercy
Biliary Tract
(
1
Biliary Tract (16.6) Eiliary Tract
Traumatology li6.61
(Zi.91 Biliary Tract (15.7
3ipes:ive
(15.7
ilawndcctwy il2.511 krrtias
(25.01 t m r
(
9.51 Biliary Tract (10.61
Hernias
1
RPwndectwy
, Roctoloay
.
(
(
7.61
7.6)
7.61
Hernras
Roctology
6.31
1.6.3)
(
-
Umlwy
-Coefficient
r OdyS ~ i a y /
St. Dev.
-------------- ------
( 1 ) T h e cases
of
b i 1 i a r - y t r a c t s u r - g e r y i n PR3 h a v e a n
c b v i o u s l y e w o l a i r l s why
aver-age l e n g t h stay o f 7 . 2 5 d a y s what
t h a t h o s p i t a l h a s t h e h i g h e s t a v e r a g e s t a y , and i n t h i s s e n s e ,
i t tends t o p r o v e
the
idea that
t h e c a s e niix
of
public
h o s p i t a l s h e l p t o g e t t o h i g h s t a y s also.
1 8.6)
s t a y i n d a y s oer d i a g n c . s t i c crounz i n o r r ~ l i c
h c . s o i t a l s a n d a v e r a D e f . ~ r~ r i v a t e9 m s ~ r t a l s
( S u r g e r y d e o a r t m e r ~st )
i e r ~ t h so f
C a s e s i,n S u r g e r y
------.-----t.
----------
G ~ r ~ e c c * l o ~ ~
Pr-oc-t rsi szso y
Ot rqrn i t-16
Pl a s t ic
Fi l i a r y T r a c t
Car~cer
V a s c u 1a r o e r i f .
Card i o v a s c u l a r
Neck
Digestive
Hernia
E n d o c r i n o 1 ug y
Urcalno_y
T r a u m a k Rheurna
Thrvrax
Mastol o ~ y
R e s ~t i- a t o r y
Q o o e n d e c t omy
Other
Oftalrnolog ical
;
Infect ious
, Renal
I
PUP. 1 .
------7; 00
9.75
5.5G
4.67
9.30
9.75
9.00
17.86
6.50
lS.;OO
6.04
(
PRIVFITE
---------
3-00
-
7.03
3.00
14.27
18.00
6.00
-
-
10. 50'
7.30
-
9.33
11.50
3. 50
2.00
12.00
4.00
8.33
5-28
4.00
3.00
-
-
17.00
-
PUB. 2
-------
-
5.50
13.00
5.30
10.00
26.30
3-48
4-26
1.2
.
2-52
6.85
4.11
2.71
4.00
1.67
7.50
3.00
- 1.06
2.62
4.03
15.00
-
2.66
4.94
2.36
-
-----------------------------------------------------------. .
average
6.757373
9.800677
S i ~ n u l a t e dQ v e r a o e ( a )
4.341 111
4.820847
: (a) C a s e s a b s e n t i n p r i v a t e h o s p i t a l s are e x c l u d e d .
'
I f we a c c e ~ tt h a t g i v e n d i a o n m s e s ar-e c l c ~ s eyl r e l a t e d t o
l e n g t h of
s t a y and
simulate pyivate
a v e r a o e s i n t h e two
p l ~ b l i c h o s o i t a l s , t h e mean l e n g t h
of s t a y
of these
falls
down t
4.34
a n d 4.82 r e s p e c t i v e l y .
B o t h f i g u r e o comoare
then with t h a t
o f PR3
(4.69) w h a t
shows t h a t
their case
mix, d e f i n e d a t t h e d e t a i l
l e v e l used h e r e , would n o t j u s t i f y
s u c h a b i g d i f f e r e n c e o f s t a y as t h e one f o u n d . I t would b e
necessary,
however-,
for- a
finer- cornoatison,
t o poke' m o r e
d e e ~ l yi n t o t h e h e a l t h
s t a t u s of p a t i e n t s .
It
is a c c e p t e d
lerqth of stay
t h a t t h e r e i s a r e l a t i o n betiueert s e v e r - : : j arrd
in a positive
s e r ~ s e . I f w e would a s s u m e t h a t o u b l i c h o s p i t a l s
h a d r3iur-e cornpl i c a t e d a n d s e v g r e cases, t h e big d i f f e r e n c e w i t h
t h e lenoth of s t a y observed
in private hosoitals
would
not
be e x p l a i n e d f u l l y .
Eve'n m o r e , i r ~ h y o ~ t h e itc a l s i t u a t i o n s o f
enclusively
s e v e r e c a s e s i n p u b 1 ic h o s ~tials, w h i c h o f c o u r - s e
is n o t
real,
it
would
not
account
for t h e
difference in
conirnent.
. r m e li:e t L m rb 1 i 5 F . e ~ -~ ~ - E O I . I E I . C ~ ~i n
C _ t 2 e
irate>-na:
a
, t
t
r
e
:islte i s i t s
e x L r a , : , ? . d l r r a r - v s l r n l : a r ~ i t ) . ~n a i l h , r . s n ~ t s l l a .
r:ht,n r.e
1 . 1 ~ 1 1 c l n(e
:I<)
C 3 r . d ~ . ~ . v - ~ s c * . c l da rj -s e . - s c s .
a c c . x , l n t :cbr- mr_re t h i r , a o i a z r - t e r
In f o u r
.rf ,aur- f i v e h c . s o l t c : s armd
t h e f n i l c . w i n ~ 1 o v c . u o s ar-e
i
t v
anri r r s o i r . + t , : m ! . v ln s ? l b l ~ t, o n e .
In
t h e r,'ert
tih!e.
f ~ - e o i l e n c , r sa n d
its p r e c e d e n c e s r - e
t h e ;I*i d f c i . ~ - t r , ~ . ? r 1r1
~ : ~t h e h,:so:tsls
that w e studied.
S h i . ~ r r i f:,v
d l a g n r , z ~ s; r l N e d i c i n e
f v e q i t e n c i e s u p t o . r o o t - o x . 65% o f c a s e s )
Gv-ouped
IDerreaiing
-
.
US,,
_ _
Name
.... .
.
.
.
.
.
.
.
I
wz
PR~
t.!
Ill
.
.
.
.
.
.
.
ieroiratory li0.21
18.21
_
.......
.93
-
-
-
Car-?
Neurologic
110.41
lofectlous 1 1.01
Cancer
61.11
,.
pa3
111
M. 51
Cancer
1 7.01
75% __-.1100Ll
1.46-
70.41
110Jl
64
1.0
In t h e m ' e c e d i r t p
T a b l e l t is s e e r s
that publlc hospitals
cortcentrate iri few
cases r - e a c h ~ n p r a p i d l y
o v e r - 60% o f t h e ; ) . .
r - e s o ~ c it v e
tc,tiis.
'This i s a1s.r clear.
i r
thr
coof C i c i r r l t s
w h i c h a r e h i g h f o r - P i l P h i , a o i t a l s 1 1 . 6 3 a r . d 1. 5 C l a n d s m a l l f r , r P R i a r f d PRZ
9
a
8
.
fiithi.i~on t h e 5 e
c a s e s a r e a:%.f r e q u e n t i n p r i v a t e h ~ s o i t a l st h e y a v r l e s s c i , n c e n : r a t e d .
In or-tier- t . 2 s p e c i f y ra,x-e t h e o , , s s l b l e e f f e c t ,:,f t h e case
on t h e
stay,
t h e a ~ s t . b l a t ~ a n p e r - f c , r - i l ~ e d f i . r s , . ~ r g e r . y is
repeated,
which char'gcs
t h e avevaqe stay
by
c a s e ,:.f t h e
b e %*en I*.
p r i v a t e h n s o i t a l s tc, t h e p l . \ S l i c h o s o l t a l s . I t c a r ,
t h e next
T a b l e t h a t i.lrlders v c h c i r c * ~ n l s t a n c e s , t h e "lea*, s t a y
rinx
..-. ..
.
.
um*:ld f a l i
t o 6 . 15 a n d 5. 13 r - e s p e c t l v r l v . :f
these a v e r - a g s r
a r e cc.r41;a?-ec u i t h ~ r - : v a t s . Qnes. i t
is v e r ; f i e ; !
? L a $ =1.(31: C
h o s o i t a l s c o i ~ r o e t ea g a i n w i t h P P 3 (5.373 L.o-.np t h i s r..-te butwecro
b o t h FtlF.
T a b l e Ii1.14
i e r t g t h of s t a y u e l d i a p n o s t i c p r o u o s i n > u > l i c h o s o i t e t l s a r d
avar-aGs o f o? i v a t o ( I n - L e t - r ~ a lMzd i c a l 3,oar.t : ~ , s r : t s f
I
.
-- - -- ----- ----- ---
PUB. ?
Xheclrtia
.~ e u r c e l oc~ail
B 1o o d
Cancer
Rena 1
Cardiovascular
Respiratory
Digestive
Infectious
Endocrine
Other
Skin'
Hernia
Tracmatology
Urology
Gi r ~ e c o ? o g y
Oftalmolooy
------------------.
I
average
Simulated averape
Consequently. at
t h i s level
of d e t a i l
t h e case n i i x csf
p u b l i c h c ~ s o i t a l d o n o t show e v i d e n c 6 s w h i c h
j u s t i f y the gacs
found w i t h
the
private hosuitals,
a l t h c > u g h , a5 n l e r ~ t i o r ~ e i :
before for surgery,
a rllore d e t a i l e d a n a l y - i s
o f each p a t i e n t
c o u l d prove a l o n g e r s t a y , but h a r d l y at t b e o r e s e n t l e v e l .
n c c o r d i r 8 q t o t h e mqdel
f o r h u s D i t a l Productivity d e f i n e d
a f l ~ n c t ~ oo n
f patient
i n s r - c t i s n 11, L e r i g t h o f S t a y
(LOS) a s
p a t i e r ~ t ' sage
socjr,ccurnornic : e v e 1
l y ) , rnedical
i n p u t s (MI),
( A ) . and I I l n e s s s e v e r i t y (IS).
T h i s q c n e r a l model is a d a p t e d
f o r eilch
c l ~ n i c a ls e r v i c e t o
t a C e i r ~ t sa c c o u n t
some s p e c i a l
c a s e s . I n , > ? . d e r t.-, d ~ r 8 l h n l s h t h e c a s e
rnix d i f f e r e r ~ c e sb e t w n e r l
in
each c i l n i c a l
deoartllerat
several
steps were
Ilospi t a l s
r c c c ~ r n p lI s n c d :
.
.
- .
l a ) A11
gyrlecclogical ,cases
in theG;vices
of surgery
er;d
interrlal
n l n d ~ c i n e* e v e
transferred
t o
the service
of
o b - , t t L r i c s and
pyrbec~mlogy.T h i s
affected mainly
the private
case m i x
since
they
almost
did
not
have
hosp~tals'
g y r l e c o l o g i c a l c a s e s rurlder t h e l a t t e r c l i n i c a l d e p a r t r n e r a t w h i l e
t h e o p p o s i t e mas t r u e i n t h e p u b l i c h o s p i t a l s .
as u e l l a s i n
l a ) I n t h e c l i n i c a l departrncret
of s u r g e r y
i n l e t - r l a l r~wdi c i r e ,
sc*nle c a s e s u e r e e l l n ~ i n a t e d . T h e c r i t e r i u n
was
Ln
bee0 under
analysis
nraly
those cases,
grouped
by
principal
diagnostic
( s e e T a b l e s 111. 1 2 and 111.14)
which
w e r e presermt
si89ultar~eollsly i n
e a c h p l ~ b l i c h o s p i t a l and ir,
a whole.
This
meant t h e e x c l u s i o n o f
the
t h e p r i v a t e ' s as
diagnosis.
In surgery: otorhinu,
follor,ing
cases
by
main
card'r.vascular, neck,
endocrine,
rerjpiratc.ry.
eppendectunny,
ofLalrz?olagy, xr.fectxnrts,
renal,
arid
without classification.
In
internal
mediclno:
b1oc.d.
cancer,
sk.in.
hernias.
trauolatslogy,
urc,lc.gy,
oftalmulc~gy
(between
the
private
-hospitals o n l y o n e u f t h e
cases l e f t
i s
n u t pr-esent
i n one
of
t h e m : i n f e c t z n t ~ sd i s e a s e s ) .
.
Nn f u r - t h e r
e x c l u s i , j r # s w e r e rslade b e c a u s e
t h e sarnple s i z e
w o u l d h a v e d ~ n i n i s h e d considerably i n t h e cases
o f t h e s e two
cl x n i c a l d e p a r t m e r t t s .
E e s ~ d e s , ir,
c . r d e r tc. t c 3 t t h e
h y , l o t t ~ e s i so f d i f F e r s n c n 5
in
p r o d u c t i v i t y between
nuspitals, several
Cnow t e s t s
were
applied t o
c h e c k for.
h o r n u g e r l e i t y r.f
estimated ccsefficients.
Fop. t h a t p u r p o s e ,
i n each
cllr8ical s e r v l c e
a s p e c i f i c nlc,del
and
explains
was
adapted
which
applied
t o all'. h o s p i t a l s
Lerlgth o f S t a y .
I V . 1,
O_&S_e_tr i cs an_d_Aynecoln a y
T h e s p e c i f i c rnodel
a p p l i e d i n t h i s c l i r ~ i c a ld e p a r t r n c r ~ t
includes t h e variables:
d a i l y r a ~ e d i c r lv l s i t s , p a t i e n t age.
exams,
pharuracy,
and d i f f r r e n t
slope
for
pharrnacy i n t h e
s u r g i c a l cases ( C a e s s a r e a n o r o t h e r g y n e c o l o g i c a l
diagnosis).
The f o l l o w i n g
e q u a t i o n was e s t i m a t e d
for all
hospitals
t o g e t h e r w h i c h f u l f i l l t h e Chow test
criterion
in o r d e r o f
a c c e p t a n c e of t h e n u 1 1 h y p o t h e s i s .
-
--
-.
--4.z
TRFLE IV. 1
D e p e r ~ d e n t v a r i ab,&
: L e n g t h of S t a y
Independent V a r i a b l s
C o r ~ sant
t
D a i l y Medical V i s i t s
P a t i e n t 9 s Flge
Exams
Pharmacy
P h a r r n a c y * S u r g i c a l cases
D
m
-v
;
;
4.77 ( 4 )
-.TI5 ( 4 )
a -.031
a
-063
: .003
:
.035
(4)
(4)
(4)
V a r i a b l e s f o r H o s ~ i t a l PR3_
.c o n a t a n t
Pat i e n t ' s a g e
Pharrnacy
Durlimv ~ d r i a b l e sf o r P u b l i c H o s ~ i t a l s
Const a n t
Pharr~iacy
P h a r r n a c y * S u r g i c a l cases
a -1.12
(4)
a
(4)
.%
.034
<^)
Dummy V a r i a b l e s f o r PUB2
~wahs
Pharmacy
Phar-rmcy
*
a
:
Surg ic a 1 Cases
:
.091
.049
-.132
(4)
(++)
(*)
T h i s eoua: i o n s u p o e s t e - s c v e r a : c o m m e n t s . ;1n a 1 l h r a s o it m! s
variable
Daily
Kebical
Visits
(the l a b u r
i n s u t ) has &
rtn:_;ati v e c Q e f f i c i e r , t w h i c h i s s t a t i s t i c a l l v s i o n i f i c a n t . T h e r e
e x i e t c , no
sionificant
difference
i r ~ this
v a r i s b ; s between
is
na
difference
extieri
t h e c a s e cf
: ~ c * z n i t a i s . 7her.r
o a t i e n t a c e e n c c o t f o r - h o s r s i t a l 233
where t h e
a b s c . l u t e vp Lee
o f t h a t c - > e f f i c i e n t i s n a s i t i v e b u t n e a r z e r o (0.0:8). I n t h e
o t h e t - h r a s o i ta! -, t h a t v a r i a b l e
h a s a n e o a t i v e c o e f f i c i e n t what
r ~ i i i j r ~ rt e f l e c ~t h e ~ f f r c t o f or-evlol.ls n : a t e r n a l
ewoerience over
the lr-r,oth o f s t a v .
the
1-he
variable
exarns h a 3
a o n s i t i v e and s t a t i s t i c a l l y
e i o r ~fii c a n t c c ~ e f ' Lf C l e n t w l i i c h r:ieans 5 e f - t d d l a g n c n s t i c e x a r n s w i t h
at h o c o i t a ! i r 1 3 ~ l v a longer- s t a y .
This
the
c m r i e r ~ ts t a v i n a
e f f e c t is h i g h e r - i n t h e c a s e o f une o u b l i c h c l s p i t a l (PURE).
o h a r m a c y v a r i a b l e i s s u o o c t s e d t o nieas?tr-e t h e i n o u t o f
l e v e l over- t h e l e n o t h c - f s t a y . B e s i d e s , t h e d i f f e r e n t
t o nleasur-e t h e i r n o a c t
o r oat ierlts with
sur-get-y
try
f~icbr-e s e v e r e c a s e s . I n t h e cases of n r - i v a t e h c s s p i t a l s
PRl and .PRS o n 1 y
t h e ~ h a r r n a c yf o r s u r g i c a l o a t i e n t s
shows
a o c ~ s i it v e . a n d s t a t i s t i c a l l y s i ~ n i f i c a n tc o e f f i c i e n t .
In the
other
hcosoi t a l s.
the
ohar-r~~acyv a r i a b l e
shows
a
~ oi s
tive
P R 3 and
P'JP1).
Resides, i n
c o e f f i c i e n t ( a l r n o s t t h e sar17e f o r
t e r r n s o f s u r ~ i c a lc a s e s t h a t . v a r i a b l e i s s t i 1 1 h i p h e r
i n PR3
a n d rLIH1. I n t h e case o f
PUP2
i t i s o c . s i t i v e b u t l o w e r - than
t h e c o e f f i c i e n t f o r nun s u r g i c a l o a t i ~ n t s .
The
sever-ity
slc~oes f
of those
-
'
F r n a l l y , w i t h r-esoect
h a v e n o s ~ e c iifc c o m m e n t s .
t o t h e c o n s t a r ~ t terr~;d i f f e r e r ~ c c sw e
Fls l o r l g as i n t h i s c l i r ~ i c a l d e o a r t r n e r l t
no s i g n i f i c a t i v e
difference
in
ter-r.?s
of
p a t i e n t l e r r g t h cef s t a y w a s d e t e c t e d
between h o s p i t a l 5, it
i s
r-easortabie
that
the
orodirct i v i t y
do
not
differ.
anlong
them
either,
exceot
for
feu
modpl
c h a r A c t e r l s t i c s . P e s i d e s i t r ~ i c t s t b e r e m e m b e r e d t h a t o n e 01-ibl i c
hosnital
(PUBZ)
had
availabie
convalescence
b e d s forlow
i n c o n i e *rrJrnen a f t e r - c h i l d d e l i v e r - y w h i c h e l i r ~ i i n a t e scane
of the
o o s s i b l e c a u s e s o f p a t i e r ~ t ' s lcanper s t a y .
..~
# h e f-.l
> c l w ~ r c. n ; d e l
su,.csr...
LOC =
=
NS
-
DM')
PO
=
Ex
=
=
UES =
DIS =
Ph
;ri
a:!
uss
a a o l ~ e d ti.
t,e
dcoa,-tn;er,t i
C
h.>s31ti!s.
i P r , c t n .cf s t a y
O f
5 'Lll'UeCTIE
.
h , i r r,?rd,ca! v i s , t s
F z t 1erlt'% ape
Etan;s
..
Dnor-macv
D8~rm>rnv v s r ~ a b l efor- cases. o i e x t r e r . ~ esever-, t y.
Durllnly v a r i a b l e for- c a s e s o f ~ r ~ t e r - " l e d l a tsee v e r i t y .
--
IU~:81>91-
Tni5 m m e l atternilts t c a
t
e t h e :r-,:urnrs
c.f d i a g n c . s ~ c _
eran16.
r n l e d ~ c a l lrvpS.its,
p a t i e n t ' s age,
and I l l n e s a
severity
and
c o : n o l r r l t y fiver t h e Length
cbf S t a ~ . T h e l a s t variable I S
i n c l uoed
thr-c,uuh *;he
nunlber ,>f s x ~ r - o e ? r : c . ena,.r.iacy,
a r m <t wc,
dtlrl81nler 13-5 a n d G ! S ) w h ~ c h d i f fry-enc l a r e s I c s p e s i n erarns and
oha~-r.ldcy.
F;f:e?.
sever-:
Chc.w
tests t h e
fa!:quir,c
e o a t a t ~ o n was
- e s t ~roated.
T h i s e q u a t i o n shows sever.21
e ~ f f e r e r ~ c ebet.icerl
s
t h e nc.soi t a l s undel' an.? l y s ~ s .
F i t - s t . w h i l e t h e or.lvate.5
have a ccmstant
ten-m e o ~ . i i
zel-0. t h e
o u b l i c ' s have
a conztant eoval
t c , 2.83.
S x n c e ~n
the
c a s e c.f o r i v a t e h,:,soxtals r l i l ~ ~ z ~nsot a r e - s u r . g i r a l
s t a y was
detectpd
whale i n
plrbllc
h u s p l t a : ~ tha:
var-,able
tcfik
t h e
vaim.te
c.f
a n o r c ~ x ~ r a a t r l y3
days,
r'ie;,
the
cc,r,stant
tern,
d i i i t - v c n c e c,?u;d b e s s l c . c l a t e d w l t h t h a t v a r - l a 3 i e .
- - + i c h i s ori? c.f t n e
S e r ..\nc!. w b i l e d a l i y r n s d i c a i visits
o a l xcy v a r l a b l e
~ t r m d ~an.1~515
r
takes
t n e value
-.f
in
o r - l v a t e h n ~ ~ x t a l s~t
.
t a k e s t L e v a l u e nf
-1.713
ir,
p u b i ~ c h.:,so1ta15.
!i i t
i s
ass~uolec t h a t
t h l s
vatlable
reot-eser.rs
ntedical
labur
ornductrvltv
tken ' the
f o l 103lne
hyor,thes~s can
oe
made.
i f n l e < ~ c a : lec.?ri s
scmbrect
:I
Jecvia6~1,g r e t 1 l 8 - r ~ ~
t n~e r ~ G ! - a ~ n il
rear-esents
the
esoected
functi,:,na;
r.el+ti.:.r-,
hetwner, d a l l y
i81idical vksxts
arid L e r ~ ~ t h
of
titav.
The
d ~ f f e # ' e r , t slc.ee
e s t ~ r n a t e d fr,?- o u b l ~ c 2nd
o r ~ v a t ei t . ~ . s p l t z l sr i l u l d b e
r.eor.eser,: 1 1 t - e s1:uot I n n s saowed
~n o c , ~ n t s X arid Y. The
f i r s t c.ne c,:.r.r.eso:rds
t a a l,:.we?- l r , h , ~ t t
and a : i , r d e r or'adm.>ct i s x n c e r # l l r l ~ r n . i n i
l 13S . 5
f-et.:t?r'i.
T h e :l:lirer.
s l o o e a t i.r,~r,t Y w . ~ , . ~ l d
r e o r e s e n t t h a t n c r - e ; n o u t l i a l o ; x e s rc,..e
n-od~lct but
at a
d e c r - e a ~ l n,.ate.
~
'i.>ueve-.
l t rn11S.t
b e said
a
-.'3?1
-.
that
there exists
for simplicity a n additional
assumption
behind Graph
FI i n
terrns of
considering the
s a r ~ i ep r o d u c t i o r l
c u r v e f o r b o t h t y p e o f h o s p i t a l s w h i c h is p r - o b a b l y f a l s e .
G r a p h R:
Med i c a l
L a b o r P r c ' d u c t i v i t y q@-Lenqt
h c.f
Stav
~
L.O.S,
C -
L.O.S.
I
I 1-a
\
d
D.M.Visits
T h i r d , t h e p r e s e n c e o f e x a m s d u r i n g t h e p a t i e n t ' s s t a y is
definitely
linked
with
a
longer
stay.
Even
though
the
its coefficient
in
each
different
values
that
assume
h o s ~ i t a l , its high
and p o s i t i v e
currelat ion with
pharrnacy
(.66)
n i a k e s vet-y
difficult to
ccertcl u d e a r ~ y t irtg
h
useful for
also t h e medical
corn~aring purposes. B e s i d e s
there
exists
evidence
of
l i n k s betweera arnr~unt o f
exams
and
type
of
di.agr~cvsis,
that
is,
the
case
mix
differences
probably
influence
over
the
s p e c i f ic
value
of
this
coefficient.
the
variables
Sornething
siniilar
hapner~s with
respect, to
n u e i b e r cqf s u r q e o r ~ s a n d p h a r r n a c y . W h a t
doer it
mean t h a t f o r
hospital
PUB2 t h e c o e f f i c i e n t . o f
n u r ~ i b e ro f
s u r g e o n s is
so
h i a h (compared with t h e
o n e for
the ather
hospitals) while
t h e pharrnacy
c o e f f i c i e n t is n e g a t i v e ? On1 y
in
that hosoital
t h e c o r r e l a t i o r ~ c r v e f f i c i e r ~ tb e t w e e r 1 t h o s e v a r i a b l e s
is l a r g e
(.49) scrch
that
the
probability
of
multicollinearity
is
reascenable. Fclr-tl-ir~ately t h e s e t w o
variables only
atterri~tto
captur-e
the effect
of i l l r ~ e s s severity over
t h e length
of
stay.
For
that
reasor, t h e
policy
c93ncll~sions a r e not
s a c r i f ied
because
of
the
difficulties
ir~volved
in
the
i n t e r p r e t a t i o n o f t h e s e corf f i c i e n t s .
Dependent
of S t a y
: Length
variable
--I n d e p e r ~ d e n t V a r i a b l e s
Const a n t
N u r ~ i b e r of s u r g e o n s
Daily Medical V i s i t s
P a t i e n t ' s Rge
Exams
Exams
E x t r-erne S e v e r i t y
Exarns + I r ~errlied
t
ia te Severity
Pharrnacy
P h a r r n a c y + E x t rerne S e v e r i t y
Pharmacy
Intermediate Severity
purnrnv V a r i a b l e s f o r - Hcrspi t a l PR3
Exarns
Exarns + E x t r e r n e S e v e r i t y
Exams * I n t e r m e d i a t e S e v e r i t y
Pharmacy
Pharniacy
Ext r-erne S e v e r i t y
P h a p r r ~ a c y* I n t e r r n e d i a t e S e v e r i t y
: -235 ( * )
:-.257 (*I
:-.267 ( * I
030 ( A )
: 131 C * )
:
137 (*I
:-.
.
.
Dumniy V a r i a b l e s f o r P l ~ b il c H o s p i t a l s
C o r ~ sat n t
Daily Medical V i s i t s
Exams
E x a r ~ i sE x t r e m e S e v e r i t y
Exams I n t e r m e d i a t e S e v e r i t y
Durnmv V a r i a b l e s f o r P u b l i c 1
Pharrnacy
Phar- nary a E n t r-t.r;ic
. Pharrnacy
-l!y
*
Severity
I r ~ t e r r ~ i e d iea tS e v e r
Variables
Public 2
Nurnber af s u r g e o n s
: 2.154 ( + )
- -- , * j
:
Ph a r r t i a c y
Pharmacy * Extrerne S e v e r i t y
:
166 l * )
P h a r r ~ i a c y + I n t e r r ~ i e di a t e S e v e r i t y :
OC4
-.
.
-.
::<.
R 2 = 77.36;
n d j . RE = 75.17;
(a) P t - e d e f A n e d corlst a n t t e r a i s .
F = 35.27.
On t h e o t h e r h a n d , o r e v a r i a b l e w h i c h s h r ~ w e d n o s t a t i s t i c
d i f f e r e n c e b e t w e e n h c n s p i t a l s was t h e
o a t i e n t ' s a g e . F)s i t w a s
assurtied
the older
the patient,
the longer
his stay
at t h e
hospital.
In
T a b l e IV. 3 a
different regression
is p r e s e n t e d .
It
d i f f e r s fr-or11 t h e p r e c e d i n g o n e
j u s t i n a new
dur~tmy v a r i a b l e
t a k e s the
v a l u e 1 when t h e
patient has
state s o c i a l
which
security
o r rla
i n s u r a r ~ c ea t
a 11 but
h e s t a y s at a
public
h o s p i t a l . On t h e c o n t r a r y i t t a k e s
the value O i n the case of
patient-,
that stay
at p r i v a t e h o s p i t a l s ( n o o n e h a s state
social
security
i n
that
case)
and
for
those
at
public
insurance.
T h i s . dunimy
i n s t i t ut ions
who h a v e FONQSFI h e a l t h
tries t o capture t h e patient's socivecur~ornic effect over h i s
s t a y b e i n g 1 f o r t h e p o o r e s t arnorlg t h e p a t i e n t s .
R2,
a d j u s t e d R2 and
The
new
r e g r e s s i o n shows
better
F test t h a n t h e l a t t e r which p r o v e s
the usefulness
of adding
the
new v a r i a b l e .
This one takes
t h e p o s i t i v e v a l u e o f 2.27
uh i c h i s s t a t ist i c a l l y s i g n i f i c a r ~ t a n d t h a t s h o w s t h e l o n g e r
stay of the
poorest
among t h e
pat ients.
Unfortunately due
t o the
exclusiveness
of
pub1 i c h o s p i t a l s
in t e r m s of
poor
is n o t
p o s s i b l e to deterrnine
t h e cause-effect
p a t i e r ~ t si t
relatiorlahip
which
i s
probably
b o t h s i d e o r i e n t e d : is t h e
s t a y at p u b l i c
presence of poor p a t i e n t s t h e
c a u s e of l o r o g e r
hospitals
or- t h e y s t a y s i o r e b e c a u s e
they
go
to p u b l i c
hospitals?
'
TRBLE IV. 3
Deper.dent
v a r i ab-
: L e n g t h of
Stay
Indeoendent V a r i a b l e s
C o r ~ sat n t
Nur~iber- o f s u r g e o n s
Daily Medical V i s i t s
P a t i e n t * s FIge
Exams
Exams
Extreme Severity
Exams
Intermediate Severity
Phar-friary
: -000 <a)
:
.825
.- .a24
: .023
(*)
: .043
(**)
(*)
(*I
: .Oil
:-.
006
:
.04!
(*)
Pharmacy
E x t rerne S e v e r i t y
:-.033 (**)
Pharraacy * Irtterrned i a t e S e v e r i t y
001
Dummy re 1a t i v e P o v e r t y
:Z.Z70 ( * I
:-.
D ~ m v
Variables
f ~ Hro s p i t a l PR3
Exams
: .238
Exarns I+ E w t r-er,ie S e v e r - i t y
:-.E61
Exarns t I r k errned i a t e S e v e r it y
-272
Ph a r r n a c y
:-.030
Pharniacy r E x t reae S e v e r i t y
: 194
Pharniacy
I n t e r n i e d i a t e S e v e r i t y : 139
.-
.
.
(*)
4s)
(*)
(-1
(*I
(*I
w11.rry V a r l a h l e s f o r P u b l i c H r ~ s p i t a l s
Const a n t
Daily Kedical V i s i t s .
'
Exams
,.
Exarns E x t rerne S e v e r it y
Exarns I n t e r r ~ i e d i a t eS e v e r i t y
D>rnrny
Variables for
Pub1i
-
..
-.
a
Pharr~iacy
Pharlnacy + Extrerne S e v e r i t y
P h a r r n a c y + I n t e r r ~ i e d i a t rS e v e r i t y
&nmv
Variables
for
: 2.83- 4 a )
:-2.562
( *1
: .080 i * )
:
143 (41
: -.OlZ
.
: 080 ( * * I
: -241 (*)
: .071 (*+)
P l ~ b l i c 2
Piuriber o f s u r g e o n s
Pharr~lacy
Pharmacy
Extreme S e v e r i t y
Pharmacy
Intermediate Severity
: 1.9%
(+I
:
:
(*)
R 2 = 79.11 ;
= 37.45.
*
R d j . R 2 = 77.00;
(a) P r e d e f i r t e d c o r ~ sat n t t e r m s .
F
:
-..:'c:
-.
163
004
(*I
'
I n t h e c a s e o f t h e U e o a r t r n e r ~ t c.f
: n t ~ r - r ~ a ; Medicine t h e
a o o l led t c - e x r , l a i r t t h e g a t l e r t L 7 B
lei,cth
r ~ fs t a y
b a . 1 . 1 ~r11,:di.l
~nclo.lc'ed t n e
fo? l o w ~ n gv a r i a b l e s b e s ~ d e st !-:D c ~ . r , s t a r , tterr~i:
d a i l v r n ~ e d ~ c avl l s l t s , o a t i e r ~ ta c e , exart?s. cLia?-.,lacy. a n d = l r l ~ e s
forthese two latter
variabls
d i f f e v e r a tl a T e d
acccbt- din^ f c.
focrrleveis
o f 1 llr~ess s e v e r - i t y.
E c o n r ~ r ~ : e t t - i c resh: t s a r e
o r - e s e r ~ t e b1r0 T a b l e I V . 4.
Even t h o u p h t h e C i o w
test allctws t c ~
o~:c~l t h e d a t a ft-cart: o a b l i c h c # = . p i . t a ! s , t n e s a r ~ i e w a s n o t . p o s s i b ; e
w i t h r - r s r ~ e - t tea' o r - i v a t e n o s ~ i t a l s .
'
,
..
secc~nd
kiodel , was
a p 0 1 ied'-h
ich
I
l e d
dl-~r~iniy
vat-lablee
t o
d i ifer-ent i a t e
irit e r c e o - l
fort n r - e e s ~ ~ f ci c:
i 11 rePc:;er,
tl-ie r ~ i o s t f r - e a l - t e n t i n t h ~ s s e r v i c e : c a r - c i c ~ v a s c ~ . ! ; a r ,
r-esoi t-atory,
d i g e s t i v e . The
r - e s u l t s a?-e o r - e s e n t e d i n
Table
IV.5.
I n t h i t s c a s e , ~t is o o s s i b l e t o o r - o u p 2 1 1 h o s p i t a l s b u t
est a b l iBh i n 9 s e v e t - a 1 d i f f e r - e n c e s b e t weer1 thern. Two p r i v a t e
a
h i u h e r - c c ~ e ff i c i e r ~ tf o r t h e
variable daily
h o s o i t a l s show
r~ierlical v i s i t s t h a n
t h e otheru r i v a t e an?
.3ne o f
thrrn h a s
h ~ ? h e r - inter-cent
arld
phar-macy c o e f f i c l e n t s .
art
tho
cuther
high i n t e r c e o t ,
a
hand,
the oublic
hrrsoitals
show
a very
higlier- ' c o e f f i c i e r l t
fcmr- d a i l y
rnedicsl
visits
plus
other
d i f f e r - r r ~ c e swh i c n a e s e r v e sortie a n o i y s is.
FI
I t is
i n t e r - e s t i n p t o rnote t h a t l n h i l e t h e
exar~1s v a r i a b l e
r~i-v s t a t i s t i c a l s i r r l i f i c a r t c e
for- t h e o r ' i v 3 t e h n r - o i t e l s . i t
1r11o1i e s
a
lor~ocr.s t a y
f o r t w o l e v e l s rqf s e v e r i t y
at o ~ ~ b l ~ c
h c v s ~ ti a l s .
Besides. t h e
i n t e r c e o t f o r d i p e s t i v e i 1l n e s s e s is
h a l f of
t h a t frlr. t h e - p u b 1I C
h c n s o i t a l s a s a whols.
birt st i l l
higher- t h a n t h e
c o t - r e s o o r ~ d i r ~ cone
g
c ~ ft h e o r i v a t e ' s
( w h i c h is
r ~ o ts i u n i f i c a n t l v
d i f f e r - e n t frc.rti z e r o it-, t h e case o f ,PR1 a r ~ c i
PRZ, a n d e a u a l t o 3.39 i n t h e c a s e o f PFi3).
h?c,
These
f i n d i n o s w o ~ ~ l ds u o g e s t t h e
sartie h y ~ c a t h e s i s w i t h
I-esoect
t o
daily
rned~cal
visits
rner~ticar~edi n
the
oast
sect i o n .
The h u s o i t a l
PR2
which
or1 a v e r - a q e
shows
the
h i c ~ h e s t r n e d i c a l i r ~ t e r ~ s i thya s
t h e l o w e s t c o e f f i c i e n t o n d a i 1y
rliedical v i s i t s
and t h a t
5loDe grows a s
long a s
w e aoproach
the
public
hosoitals
that
on average
have
lower
medical
intensity.
Fur-therr~im-e, t h e
presence
of
d i a p r m s t ic
exams
c a r r i e d on
while t h e patient
1s s t a y i n g a t
public hasoitals
m e a n s rliore d a y s o f s t a y .
T h e v a r i a b l e o h a r r ~ i a c yw i t h d i f f e r - e r t t
s 1 1 . r ~a ~c c a r d i r , ~ tr. i 1 l n e s s s e v e ? ' : t y s h r w s
a neoat i v e value
In t h e
case of
extreme sever-ity
( s t a t 1st call y s ~ a r ~~ lc fa r t )t
in. p u b l i c hosoltals.
That f i g u r e
h a s nn
l n t e r p r e t a t i o n furus.
(1)
With
r-espect
t o pat ier~t's age,
no
sign~ficant
d i f f e r e n c e b e t weer0 h c e s o i t a l s w a s f o u n d .
--------------------
( 1 ) R h i p h c o r r - e l a t i o n c o e f f iciertt b e t w e e n t h i s v a r i a b l e
i t s c o r r e s o c ~ n d l r ~tg o e x a r ~ ih l i g h t b e o r @ > d u c i n gscurne d e g r e e
and
o f mu1 t i c o l 1 i n e a r i t v .
.
TRBLE I V . 4
I nt e r r l a 1 Pee :z : r.e
V a t - i a b l e : L e . - , ~ t + - z ' 5' r z
Depart rnent of
Dependent
.---
c
Daily W l c a l V ~ i ~ t s
Patient's Ape
E~ams
Exarm fi E1tre.e Severity
E ~ z l l sfi Intermediate S e v e r ~ t y
E n u s Less Sevprity
Raarvacy
harnaey Extreme S p v e r ~ t y
Pharnacy 4 1nterw:late Severity
Fnamrcy Less S e i e r i t y
*
*
k?
RZ m~UStrd
F lest
9.73 I*)
-3.h 1 4 )
.04 1-1
.Oi3 I*)
.04 I**)
-.016 LH)
.06 I*)
-124 I*]
-.Lea
.Mc
-.02
1')
a
F>,.al1 v.
2
.
oi.,:,uv
it'>:?
IIIT;81CPC.
The
15
, - e s 1 : i l$
v a r l a h l e Fop- e z t , e r s t s , : z ~ c . e r : r ~ . - . ~ n
1 ie c. c ?
t t l E 5 ~ 3 1 1 I F ~IIIIIIIIJ3
% :
: LrlCjllCe~' II
at-. s h ~ . w - ,
T a b l e :;'. 5.
D e n s ! - t ! , ~ t . n t c.f
Cr.r,st n i t
Term
Phar-r,~.\cv
.Ph.~r,,,xcv
=
Pt?a?.r.lacv
Ph.~s.r~?i+cv
,I
Int o,.n.?i
;
Med
3.33
lcl
rie
(+I
.
: .I37
E r : , 6 l ~ 1 i ?S c v e r z t y
: -.OSR
Ir.i.es.r,le= > a t e S e v e r i t y :
22 C ' ~ l
L C F C S T , V F Tt- v~
: -.I36
-.
.
Cc.ns t a r ~ t Tet'lt~
Dai l v i f l e d ~ c i t lV i : . i t s
Pat i ent ' s aoc
D ~ A : , : ~ , :Lv a r d
,
i
8c6vasc~.c
1 st-
. g;)zz
. - . _. - . :13
,
D~.:n.rn i i e s o : r - s ta:3t-:v
Dt.trsr~nv Pi c o s t i*.*u
: -.6El
K a rs1 F,
:
.I:)>&
Eltarr.:
Entr-erne 5 e v e 1 - i t v
- ,.I-.: :
E i!ar~:s
I n t - e t ' t ~ i e di a t e Sr?vet- i t y
:
(:)I:,E
E q r ? r n ~ . + ~ . B C S sc?vr-!ri t v
: -.1:,1:
r'r,a!-l,lacv
ti, ,& :
Qh;.r'!nc?Cv
i x t t-orole Sf ve:-i t v
:7,'
"',pt-rt;acv + Triter-rrrnd, at- S ~ v e ri-t v :
(:I:.
PL?r'i,i.-rv
+ L . 6 5 5 S R V ~ I t- v. ~
i ,-,a
38.,i.;r.:,.,:
. - ~ ? !:?
v et P~:,vpt.i;y
: A. ::
-
: 3.33
:
127
Phat-ors.cy r. E x t t - e r n e s e v e r - 1 t v
:- t:133
P h a t - r n a c v U I n t ~ r - ~ a i e d i a tSee v e r - l t v :
2;
P h a r m a c v it L e s s s e v e r i t v
D~r;nmy t.r+ la!; i v e Far~vet'ty
: 4.!C
*
. .
-.
. .
. ..-.
*
-
2 .47
: -.773
**
-*
.
.. .
C o r , s t ant T e r r n
.
.
Pherarecy
.
-.
-. . ---
. A - -
-
The v a t - i a b l e
i s o o s l t i v e and
rte: : c : ~ c a l l vs l g n i f i c o n t .
Eesldes. i t
a b s c , l t . c t e v a l l . ( s 1s - v e r , ;
1:-.
s c e c i a 1 1 ~ .i f
~t -1s
~ . t n d c r - s t a - r n da s d a v s o f s t a v . T h i s f : r t c : - : .
as
1 t was o~er~t~er~rtsr'
in t n e
cast?
sl.tt-oer-v. S ~ C ~ W StLlat.
GI
:-?I i r
hl:is3itb13<, t n e
l ~ > w i r ~ c o r : l eoat i p n t s s t a y i-arooet' t h a r , : p ;.t?et-s.
p:~f
-
Thr
arlalysis
of
the
F I ~ F
hc,scr t a l s
5hc.w
alm,:mst
svrpery
armd
irtterroal
d e f ~ n l t ~ l yt h a t
or-oduct ~ v i t y ln
r,lerlIrir,? i s
1r.ucr i r ,
p u b l i c h : , s p > t a l s cc.nilared
w i t h private
~ n s ttutx.:.r,5
t
as
l.>rlg a c
lerlgth of
s t r y 1 5 taker, as
a p r o ~ y
rileasure c , f p r r , l u r t l v i t y (its i n v e r s e ) .
F ~ r t h e ra r - a l y s l s rllvst be made ar.d h 7 c e f u l l y w l t h a Idt'gPr
all,:,ws fc,r b o t h g e r l u r a l l i a t l o r j
at hospital level
rn.?ln
d ~ a ~ r m o a l si n
r,rdrr
t o
drad
the
5ti~dy uf
s ~ e cf lx c
d
t
rnj7.o
. p i . r t l s e l y t h e cal.ties o f
thx s d i f f e r e n c e .
The
i o v r + r , t .L t ? c
~f
the
k ~ n do f
Sari!ple i.tsed
ir, thzs
resca,.ch
i s
t1.c
analysis
r r f
a
wnole
set-vice 17,
each
thet
i t all.>us
hnapltal.
But i t s
d ~ s a d v a n t a o e is
i t s s ~ z e u h i c h dr,es
not
ri??re w r e c l + e s t u d y
o f rrarr, d L a g r i C 1 5 ~ s . The
case 1 . 1 ~
per-c.ii t a
h ~ t ~ t - o g e n e
L V ,~ t each
~
c l ~ r ~ ~ s
c er rP
v l c a b e t w e e r , h r . s o ~ t a l r ,- d # l e
t o tt.e d l f f e t . e n t
n ~ e d ~ c a prr,cerlu!.e
l
thbt each s o e c l f i ? l l l n e s s
di?rn;r,ds-,
car,? ~ t l j t ~ : ; s pr.:,ble,,3
f , j r t h r . a i l d o t jvr-r.tJss
.;,f
tne
rnannl
for
h-50~
t a l
p - ~ : ~ d , ~ c t l yv l t " v t 11 ried
previuysly.
slrtce i t
i s
The,.efc.r-e,
ever, t h o m r ~ h t h e r e
r x l t s i beneflt
~ o r i s hl l e
t o
d e r IV.
.
n
ulth
,-esoert
to
plc,bal
r e l l l d l r l i n t e r ~ n so f
t h e l n f luertcr of
pr'i.L:uct i v l t y 5c.181i~ d.>',tts
v a l u e c ~ fs o e c l f r c
t h e d l f frr-ermt h a s o l t a l s '
case r n i x o v e r t h e
c , ~ ef f~ c , e r , t s .
salrnllle t h a t
Roart
frcmm t h a t ,
the
hyp,>theses b e k l r f d
s u ( l p o r - t e d b y t h e e r w p l r ~ c a l f r rmdrrmgs.
t h e model
~
are
mobt l y
The
variable p a t i e r . t 3 s a g e , e x c e p t
for the
service of
c . b s t e t r i c s and
qyrleCC,lOq~. t n e
pr-esr+nce o f
d ~ a g n e s t i cexaals
ln
and
illrmess
severity
(expressed
thv-ough
pharrnacy
and
*U,-"er.y
a150 t h r . l l l g h
t h e r,vrnbcr
Of show p . - ' s , t i v e
statistically s l q n ~ f ~ c a r l c
t clefficients w ~ t h respect t u
and
the
ler.,gth o f
stay.
Tnp
s a r , ~h a p 0 e r . s
W L t n
t h e dui.>n~y f o r
used ~n
t h e eqvatir,ns.
On t h e o t h e r
relative
poverty urirrl
cd t
t
i
1
i ~ c r d i c d lv ~ ~ i t h
hand. t h e
l a b - r - t r , p , ~ ~e
sh,jws
a negative
and
s t a t ~ s t i c a l l ys i g r t l f i c a r l t
coefftcient
w i t h respect t v lerlgth o f stay.
The h v s p i t a l c ~ f a p a r i s o rwas
~
do,,tryxrlg to pool t ~ g e t h e r
tases
wh ~ c h were
pvesent
r l i , ~ ut d
l r l e o u s 1y
i n
each
*\ - n?
\
tn-p:
I!.
b:h:i
t*1*.
in15
,,,car,!
tnc
e r c l u s ~ c , n o f th.-,=s
cases t h a t
were a b s e n t
ln some
of the
17, huvgery ar.d
irlterrlal
, , r c d i c ~ r , e .Under these
five hosnitals
condzt1~3n5 t h e h,:,soital p r ' r , d u c t l v l t y
r,:>del w a s t e s t e d i n e a c h
c.f t h c c ? ~ ; - l c a l s e r - v i c e r r l d
f v r each h o c p l t a l . A f t e r s e v e r a l
t e s t f.2:- t h e a c c e p t a r ~ c eo f t h e
a n a 1 y r . e ~ a n d a o u l y l n r q t h e Chuu
r l s ~ l lh y p . ? t h e s l s t h e d a t a r c > . e p o v l e d t.:,gether- arfd t h e r - s l ~ l t s
Chapter
1V. U h l i e l n t h e departnlerst
of
were
p r e s e r 8 t e d tn
O b s t e t r I C ~ and G~nec1:11cgyno
i r n p ~ rat n t d l f f e r e r ~ , = ewas p r ~ v e d
those
!.r.,
-
between
private
and
public
hc~spitalc,,
ir,
the
ct+~er two
cl i n i c a l deoar-troier~ts s e v c r a 1 d i f f e r ' e r ~ c e s ar-.~.ce.
( r d c c a t :.:e) c ~ o f f1 c : e r . t f o r
In t h e
f it-st p l d c e , a h i g h e r
t h e var-iable
o a i l y nicdical
v i s i t s i r ~o 8 - : 3 : : c Z i s n i t 3 : ~ _ . T n l s
f i n d i n g is
i r l t e r o r e t e d a s t h e lcswer
arc-d11=t:vitv at:+:-sz
at
p u b l i c h o s p i t a l due t o
l o w e r r,iedical i n t e r - s : t y rneas,>r-z= s a l i y
by p a t i e r t t .
If it i s
a s s u r t ~ e d a s 1.1st~a1t h a t ! a S o r ? r o d 8 ~ c C
ivity
grows at
a d e c t - e a s i r ~ gr a t e ,
t h e n t h i s f 1 - 2 1-.p W C Z ~ J : c s - .
=.z e s t
t h a t irlcr-easing
d a i ly rnedical v i s i t s P ~ G ~ . : , + Z - I F L
t lCe z . - : v i . t e
hospital
p a t t e r - r ~ wcsuld
r~iake p o s s i b l e
to
1-crease
; ~ j l i c
h o s p i t a 1 pet-for-r~~ar~ce.
.
--
-.L
-
.
I n t h e s e c o n d p l a c e a s l u r ~ qa s t h e ' p r e s r r , = ~~f d l a ;1s t i c
a n d s i n c e r t F ~ Ji~
c Ih . r . ~ g ; : + : s t h e
exarns imp1 les a lcbr~gers t a y
evider~ces
g e n e r a l 1y
s h ~ w hi gher
c c e f f : tier,: s
ELthat
vat-iable,
t h e p r ~ il c y
S I - l o g e s t lor1
is t o
: r . - > i e f , ~ s r ~a:
:
2 - 2 i ;c
hospitals
a rnore e f f i c i e n t s y s t e r n o f a 1 . 1 5 u : a t o r - y e l < - r s t i c
exarns,
t e c h n o l o o i c a l 1y
a n d adrni r ~ i s t r a ivo!y
t
sgeaC.1-.
Fr-om
t h e pcairtt o f v i e w o f t h e
o r - c c e d u t - e s drmr*e t c . r a t : e r t t s i r c.:t.i!d
b e seer1 t h a t
t h e p u b 1 i c h o s p i t a l s a r e art1~2r~; t h o s s
d i a g r ~ c e i s exams a r e
per-fur-reled. T h i s
t e r m d st o
cn>r,=; r:: t h a t
staoa already
people
a r t - i v e tc.
p r ~ v a t eh o s p i t a l s
with thls
d o n e r ~ h a t i s v e r - i i i e s by
t h e way irn r n e
:~ - 9 s : 9 . - e - 5 - . . i a L a i
! e r ~ g t h o f s t a y a t t h e d e ~ a r * t r n e n tof s u r - g r r y .
I - I I ~ F -
Finally,
the
value
that
takes
the
d > ~ ~ r n .I.-v
.+ > ? e
" r e l a t i v e p o v e r t y " ' t e n d s t.3 sl.!pp.sr-t
tne
hycr.',zps15
S'.&:E=
at
chapter
I I.
In
that
sense
it
is c o n v e r t i e r t
Chat
be
considered f c r
pub1 ic
h o s p i ta: s
ir,
c o n v a l e s c e r ~ c e_ b e d s
ter-ms o f
policy design.
In that
way t h e
hospita:
=;:~r,t
:ai
c a p a c i t y c a n i rtcr-easz w i t h
l o w e r i n v e s t . : e r : t a n d l e s s be-:; b!e
new h c a s p i t a l
beds.
;r;
SscL,
costs
pet- p a t i e n t
cornpared t o
these
d i s c h a r g e pr-ernises
with
a
l e s s s ~ o h i s ~t c a t e - s t a f f
t o r*lot-e b e d s a v a i l a b l e p e r d a y a r ~ d r o t d : = e s s 8 ~ r e
would. l e a d
rec~:nver-y p e r i o d s
u n d e r pr-oper
c a r - e ar::
a:
:2 w e r =:srs p e r
pat i e r ~ t .
There
ar.e
sorne
specific
cases
r
which
;:ss:ble
s u g g e s t i o n a t - i s e i n r e l a t i o n t o p a r t i c u l a r r ~ i e d i c a lprc.2:e-r~.
( a ) C o r ~ i p a ir s o n
b e t w e e n some
aver-sees o f s t a y cf = u b l i c
-crnCat:.d~rabl e
and p r - i v a t e h o s p i t a l s a s i n
t h e case cbf c a r t c e r . ,
forthe
public hospitals
(11. 25
.
,
..=.---. -- . - - - =- :
r n e c e s s a r i 1y
leads
t
c u n c l ~ l d e artd
r - e c o ~ ; r , : s r , a ca-: ;c # J1 a r
policies
that
rnay
irnprove
the
leve:
caf
did:- 1 5 : s
and
treatrlier~t a s an out-pat ierlt f o r
t h e s e p a t : e r ~ t s . I n :n:s
area
t h e r e e x i s t s n o d e r n rtiearls f u r a d v a n c e d d l a c r c s l s artd s L C : c :e r ~ t
t r - e a t r ~ i e r ~tth a t
p r c ~ r i i o t ca
r e d u c e d u s e .>F P _-so:ta: - - ~ s :- ~ c e s .
n;r.d
.>i - . - c ~ l e r n s
C o l l a b o r a t i ~ r ~o f
the
cortir~lur~ity in t h l s
bethcer~ the
ccs71tal
through
i r ~ t e r r ~ l ei a
dte
i r ~ s itt t l t i c ~ r n s
s e r v i c e a n d t h e p a t i e r l t m u s t b e promoted.
ar.alrzlr8? t h e
stat ,st rcs
f
c . b s t e t # - ~ c s arid
Cf
D~.,bl,C
h:~S",td;S.
3b.?rt,.I.r.
2 5
Ln
lalil,;,z.:ariT
c a v s e i,f h . : , c o l t a i
l e a v ~ r , ~T.h i s r,186-,5 t c a t S C ~ I P ~ C ~ I
01.1 xc:c9
,-.r f d m l l y
n i a r , r m l r c ar'e
0c.t r - e a c n l smn
<,fie a f
their
l n d l r i ~ ~ l ll v er5t ~ 1 - cl a , - e d l r l a c , ; . ~ ~ v ~ t rlire
y
C h r le.
t.v
( 0 )
,
CVr,e-.?iIov
Tw.., i a d d i t i c . r . a i
c,:.or,~unt5 must be i r ~ c l f i . # d r d i n t h e s e f ~ n r l
re<,>arrg. F l r ~ t I v .t n e
ar.alrsi6
C.C C n l i e . l r l p t t d l ~ c h . : . s 5 l t a l
f lrlilr,z:r10
s\:;~cI,I
( d e 5 ~ 1 . hed
1
1 7
iririrr
4)
E E L - ~ ~ S t~
be
r c , r , v c r , l r - , t t r ~ , , . ~ ~t t. , e ~ ~ s t r rL ~. .,: . L % r.c.r ~ . - ~ - ~ C AcG
~ Ir Y
. ~ r - i n , m t e t~
~~li.~
~1
'r
- , : , . 1 t r c r l v l t v . T n r s -,*stet,,
orvs
tns
t h : e p ~ t a l s accmx-ding
t 5 r i l ~ c i 8 c " i i c t i,:,ris bl.(t. rlclr f w S O ~ C X
f I C dlign.:is~h case5 ( l l l , e
L!.b.
L. R . i . ' s o r . v : ) .
T:,e=exists rlir i r . c o r l t r v e in s u c h &
th*
S y r _ T t l < l C.:,
1C,-,k
fly?.
the
,:,fit l v , i i l
s e t i.f
r . l e r i ; ~ a l n c f i..,rls
in
e
L.:. c,tr-e t t , e 0i.r l e n t
~n t h e sl,:mst
e f f lcl r r i t 0 c . s s l b i e way
e i L x e , - 1 7 , I.IPL<1 c ~ 1
t n . ! , ~, ~
, v e c c . r , c . ! n l c t r r r n 5 . T:.er.pflr,?e,
~ C . C D It d l
rrfrr:cr,i.
I r, ..I 1
i t ilizlli-nri.,ns r.este ~ r I , ~ ~ ~ .;r,
v e lt n
yc
. kcz.
nosoxtrl
arlo,l~n~str.ct.:,v,s' h a u 1~1 t ~ e s , t h e o r i r s ~ c ~ a r ~ sr 't h
and
0,-.:.f f ~ c i e r , c v ( a s
wel 1
as
th,:,se
,:,f L h e
oat'a<.?ro~cai
1
; , a d . , t h e ur.casm.tre t h a t
cliil:dr,d ~1m1am35es I:.VCIr-art,
,,,sc
2 ta,t,,:,r,.
-
-
sald
wnat wi,-~ld 1: meen
tc. h a v e
ir,:,oi L h e
o ~ i n t i.f
v ~ e w,of
rlllz.re
Ci,:Ci-I,? I Z i d l C . C l l i T r I C C
t n a f c;,ula
toke!
CiiLCb.
1 t tl,t. F.cCil:.nliCV
7 - ~ t r .1 % d . ~ u , ~ l e O c,:,n~:anL.
i 1 0 ~ e r . c e r ~ ft a 1 I
in t h e o a t j e n t s '
? a " YV. I C er,rbIt,
alc,v-c t > a r m II., pe,.cer,t
.:.r 1 n c r . e ~ ~3 r~ t t e
e
e
T n l s . e ~ r , r . e . ; s e o i r . t r - r . ~ ~c.f ~ i c c n s , . g e = ' r ,
i n r r,-.:,m o u o 1 ,c hc.so, t a l s ,
w.:.Jid
f i e
radItr.Jrlai
PC~LCI,:l a 1 ll,:,so~ t a l
ad",, s s l . : , n s . T n a t f l q 4 ~ r . r a o e s
rn,3t % . l t r . o r . ~ s e
li t h e e v o 1 u t ~ c . r c . f d ~ a c h a t ' g e s arid t h e r v e r ' a u e l e r ~ q t ho f
stay
~n
C h ~ l e s ~ n c e 1913
i s
ewa8nined.
In
thls
case
a
gv'sat
cot.>-el a t l,:.rl
is
~ s t a b ~l s n e o . U s a
,,>at t e r - o f F a c t .
lennth O F
stay
tcqethev.
r ~ t nt h e
a v a l l i b ~ l ~ t oyf
h ~ ~ s o i t a bl e d s
h ~ n t o v ~ c a rl v c , l u t ~ o n ~ pf a t i e n t
S a t ~ r f a c t c , r ~ l ye x n l a l r . t h e
A T , ~ ~ E~l H C r , r l s e c u e r l t i y , l i > e a s u r ' r m e r i t s
d i s c h a r - p e s ir, Chx Lc ( s e e
t h e avef.age
length o f sray
slight be
of c l v c l l i
t n a t 8.ctlc.lce
~ r m ~ . ~ t a n
ar.0
c e r a r . be h r u n l y
c o r , s ~ d r r r c la s a l t ? r n a t l v p t 3 r ; w
t n v r r t i l , e r l t s l n h c s m i t a l =,:,-st,-c~ct~on.
3erF.ndiv.
l,i;.xc
'
e
0:.or
i t
s~*.css
~ r r .
1.e
der
.'
.
RNNEX
1
EVE-S.JTY
CRITERIQ
I n o r d e r t o s t u d y t h e e v e n t u a l c o r r e ; a t i c . r s b e t w e e n 1e v e 1
s8~r41e
r,,edical
o f i l l r ~ ~ s csv e t - i t y a r ~ dp a t l e n t l e n g t h o f s t a y ,
c r i t e r - i a o f q r c l u p i ng d i a c r ~ c o s i sw e r e f o r r f l * r : a t e d .
T h i s gr-o~-ipir@g
w a s b a s e d o n t h e f i r - s t d i a g n o s i s w r i t t e n by t h e o h y s i c i a n
on
the
pat i e r ~ t ' s c l i n i c a l
card.
No
farther
d i a g r ~ o s i s was
IJP
to this
point.
Grc.up~rtos were desigrted f o r
considst-ed
s u r g e r y a n d rned i c i n e .
S e v e r i t y of
s ~ ~ t r - q i c ail r ~ t e r v e r i~c t, r ~ s :
EXTREMELY SEVERE
Car-diac, g r e a t v e s s e l s .
t i n - 1 resect i o n s .
VERY SEVERE
Bi 1i a r y d u c t , gastrectr.rny, h i p re~lacer::ertt,
pr0statect~5r~lyh
. y s t e r e c t ~ : ~ r ~ ~byr ,e a s t e x t i r p a t i o n , v a g o t o r n y , l a r y r ~ g e ccsrny.
t
LESS SEVERE
thcsrax,
grand
i n t es-
S a f e n e c t o r t ? y . R e c t a 1 p.1~1y p r c t orny, S p ~ e n d e c fractare
c o r r e c t i r . r ~ s . low
urinary
t r a c t , h e r n i a s , e y e , . t u b a 1 stet-il i z q t i o n .
.tartly,
SIMPLE
@verity
Q b s c e s s e s a r ~ dc y s t s ( s k i n ) , r n i n u r , f r a c t ! . l r e s .
t c m s i 11 e c t #>my. .D 1 a s t ic s u r g e r - y ~f rlase a n d
external ear.
endoscooy
and
1a p a r o s c o p y ,
siraple biopsies.
i r ~I n t e r n a l
Medicine:
-
EXTREMELY SEVERE
Sepsi, Myocardial I n f a r c t ion, Vascular bra i n
strclke,
C a r d i a c f z i lur-e,
Diqest ive t r a c t
b l e e d i n g , Q r t e r i a l thrc,nrbr>sis, Q c u t e pulmo n a r y ederna.
h i p o g l iceniic cc~rtia, e t c . , a o r t i c
a n e u r y s m . l e u k e m i a . oarlcreat i t is. r e s p i r a t o r y
f a i l u r e , c a r d i a c a r r e s t , c a n v ~ ~ l s i o n setc.
;
VERY
N e ~ ~ r ~ l r ~ ar r~, di a
b r r b r z 7I - = . , , . i r _ . r ~ l a . N e f r i t i s ,
c a r d i a c r y t h r n d i s o t - d e r - s , TBC, Neurfln2thorax,
i n t o x i c a t i o n s , brortch i d 1 a s t h m a , g a s t r i c a n d
du~sdenal u l c e r , cororlary
v a s c u 1a r
d i sease,
renal
f r i 1u r e ,
dehydr-at ion,
intestinal
~ c c l u s i o n , e r ~ d o c a r ' d i t i s . etc.
SEVERE
LESS SEVERE
Rheumat01 d
arthrlt x i ,
diabetes
me1 lit u s .
ct~ron~ca
b lr o n c h r t i s , A r t c r i a l h y p e r t e n s ~ o n .
Hepatitis,
pulmgnary
atelectac~c,
finemla,
livercirr-tmoiis, y a i t r i t ~ s ,
d~vertlcullsl;.
hypzrthyro~di5m.
~ i t e r ~a , r l o b s t r u c t i v e
j a u r ~ d ~ r eo, t ~ i t i,
!
mu1 t i n o d u l a r g o i t e r . a c u t e
diarrhea, r t c .
Unavoidably, c l a s s i f i c a t l o n a t t h r s
stags
i s irbitriry.
~ ~ n ct her ? r e a r e borne
d l d g n o z ~ ~
t h a t can have i n them5elves
diffrrerit levels of d i f f L L U ~ ~ ~ P S .
. .-
L e v e l s o f s e v e r i t y c o m p a r e d ~n 5 h o s p i t a l s .
( I n t e r n a l M e d i c i n e and S u r g e r y )
Simple
Sever e
16Z
------
From t h i s c l a s s i f i c a t i o n i t c a n . b e
158
~~
- - - - - --~
said
that
hospital
PLJBI i s t h e o n e h a v i n g more s e v e r e c a s e s 1 5 0 . 5 % ) , f o l l o w e d
by
F'RZ 130.1%) and F'R: ( 2 7 . 7 % ) . F'IJBZ I-. t h e
oppcilte
case w i t h
t h e h i g h e s t percentage of slmple caaoa
140.1%).
The p r i v a t e
h o i p l t a l i s t ~ t d l e dh a v e e x c e l l e n t D e p a r t m e r l t i o f I n t e n s i v e C a r e
w h e r e t h c y asslst t h e m o s t s e v e i r c a s e s . This c o u l d e z p l a l n
.
i t s r e l a t i v e l y l o w e r percentage o f e - t r e m e cases.
Eel ationship of discharges with l e n q t h s of stay
and hospital beds.
In hospital
discharges
..
In average
L O S (days)
-.907
>
(all t
.995)
Data E m p 1 oved
I
Year
hverage L. 0-.S.
(days) (a)
Number of
beds (a)
Hospital (a)
Discharges
Estimated
Nr. of D i s
1Z1.800
187.100
290,100
428.800
666.300
869.800
922.600
655. ZOO
(a) Fuente: E.
Medina,
"Factores q u e c o n d i c i o n a n la
en:
eficacia del
sistema
de
salud",
Desarrollo Social y S a l u d en Chile,
.
H. Lavados ed., CPU, 1982.
.
Tne &.-+a .:,i
c t c t a v ".+%
u e l ~ ~ i ! t e ai r ,
Lne
er,d
to
f ~ v e
~ r ~ b ~ r - j ~
i j fr ~t r tl ss ~ z r a r r - a l l ? e dP Y ~ L I C s r c t h r .
he f ~ v r .h . 1 . 5 ~ l t a i siie,.e 3 U I . L V ~ ~ C &
. ,,a
nubllc
estnbl~shr,ler,ts
ithe ] a l t e r
,rtf r:ec?rltr-a1 I z e o a d m ~ n i s t r - alti . r # l 1 1 ) .
h 1 ? s . o ~ t , 3 i 5 due t,:,
Tn,.r,e
pat tcr,~r.
and
z
e 4 , r l l r n . : . - , u : t ~ l saer,ltc
Grc;,irr.lr,o
t,:,
u r r l c r a l h c s o l t -15.
thsit-
ner.l,>lss!c:,n t , ) z n r - v e 9 t n e l r
char.ic:e,.ist
ics t h e y at-e
biF
Or h e r
1I
!
Ti.t a!
Nurnber
af
beds
I
mu1 t~O , J ~ . L ~ O Sbeds
~
Illl~llt
l plCr'0'3SR he0-
PRI
P C
G
a e L r r ( , ~ i n s d r, , , ~ , , t t ) e r n f
bsspl tzl
by t a l r lr;g
thr
t
r d ~ ~ ~ ~ r f i1
s ve
t r ar te c t ~ r d c .
~~
-------
patler,ts
1
,
f
*as
t
SYV-"eyed i r ~ each
2
1
hqil
P u b l i c c e r ~ t r s l i z p d h c , s o i t a ! s a r e llrar,aocd b y p c m ? r i ' , e l
d~.~er,d~r,
, :g
.n ;he
c
level.
:n t h ~ s c a s e ,
one 1 5
of
OU~IIC
D I - c . D ~ ~ - ~
ad,,ilrl15tr.ated
Y
t ) . ~ + ri.;i~,-Ol-.~.fi t ciit.oiir-at 2l1.n
aria
t h e o t h e r . 1 s p..oper.ty
of a pl-lvate
fljur,dat ~ j r , t h a t
receives
p u b ~ ~ rurlbs
c
tr.
asslat
patler,ts
*ha
Derleflt
from
the
Gc,rer-r,n.ent.
(:I
F u r a r c a l v t leal p i t ~ ~ l l i s e s ~
. ~ ~ , ~ C C I I U R I C I Ica.es
which i n
p v ~ v a t e haspltals often
appeal. u r ~ a c r sur-oe7-y ar,a
,,lea I c x r l e ,
are l a t e r r e - g r i , u p e d u r - a e r c . b s t e t 1 - 1 ~ arid
s
gyne~~rclagy.
(!I
T h ~ r erfc m a n u m b e r o f
was taken. The n e x t T a b l e
s u r v e y e d by s e t - v i c e .
p r e c i s e c a s e s p e r cl i n l c a l s e t - v i c e
s h o w s h o s p i t a l s a n d nl~ralber. o f c a s e s
r
Obstetrics
Iriedical
and gynec.
set-vice
Hospi t a 1
-1
Surgery
Internal I Neonatology
bdicinef
I
1
----
Private1
PrivateZ,
Private3
Public1
F l ~ b ice
l
.70
, t
I
68
103
61
Total
- ..-
70
BE.
105
104
70
I1
j
50
48
57
64
41
C
14
204
0
187
23r ~ ,
.30 1
0
30
33
E 15
The p a t i e n t s w e r e
selected
according
to the clinical
department t h e y belcwqed and without any o t h e r
criterion
bclt
adrniss i o n o r d e r .
Survey
a s u r v e y w a s d e s i g n e d a n d d i s t r i b l ~ t e dt o g e t h e r w i t h a r 8
I n s t r u c t i o n M a n u a l a r ~ i u n gt h e
o f f i c i a l s f o r s t a t i s t i c s i n each
h o s p i t a l . They w e r e
i n s t r u c t e d a b o u t t h e way
o f w r i t i n g down
t h e inforr~iation and completing
t h e a s s i g n e d number
o f cases
'by
service.
The pat i e n t ' s
i d e r ~ it f i c a t i o n
r e ~ u i r e dw a s :
sex,
age,
distl-ict
of r e s i d e n c e ,
e d u c a t i o n , act i v l t y ,
social security
s y s t e h ~a n d
c h a r a c t e r i s t i c s o f t h e C h i e f o f horns.
.
'.
The
infor-mat i o n
referring
the
h o s p i t a l i =at i o n
was:
nurnber
of
rnedical
visits,
exarns
and
processes;
surgical
intervent inns,
type,
amount
of
orevisus
days,
urger~cy,
h o u r s o f d u r a t i o n of
the
surgical
intervent ion;
pharmacy,
t ~ n i t a c yd o s a o e
per dr-up6 d i s c h a r q e d i a g n o s i s ;
lersqth of s t a y
and , p a t i e r t t ' s s t a t e a t t h e f n o r n u t t o f d i s c h a r g e .
GlrlNEX 4:
PRYAENT-EEC&ri_NSMS
FOR HCS P 1T%S_
The C h i l e a n E-.
~oerience
P r c , c e d u r e s by w h l c h r e s o u , - c e s
are a l l o c a t e d to h o s p i t a l s
crucial
in
t
of
cust c o n t r o l
in
the health
services.
seems
T r a d i t i o n a l l y irm C h i l e , p u b l i c
hospitals w e r e assipned a
budget
in
arinual
terlmls
according
t o
elart
of
rnedicai
a c t i v i t i e s . Thxr budget
was giver, ir, m o n t h l y
q u o t a s from t h e
central
governnBent.
This
s y s t ~ m was
c r i t lei z e d
becausr
Nr.
10 o r 11
of t h e y e a r
p l a n n e d b u d g e t went s h u r t a t month
a n d h o s ~ (at l s n e e d e d 5 v p p l e r n e n t a r y a o n e y .
-
.- .
Since
1378 8 a
rirv
s>echanisnr was
established
by
the
Ministry of
Health ( I ) .
T h i s n>echarlism, c a l l e d " F a c t u r a c i O n
por a c c i o r n e s
pv-estadas"
(F. PI.P..),
i r ~ s t r u c t s hospital'
a d m i n i s t r a t i o n s t o l i s t medical
actians,
n r u l t i p l y by a g i v e n
t h e Fendo
Nacior~rl
qrice,
and t o t a l a l l i r , o r d e r t o c h a r g e
de
Salud
IFNS)
!,lonthly. I t r e p r e s e n t s t h e f i r s t
attempt t o
c o r r e l a t e p r o d u c t i v i t y and f i n a n c i n g . The m a i n p r o b l e m though.
wcre
fired
by
FNS
on
erclus~vely
was
that
erices
a d m i n i s t r a t z v e b a s i s a n d w e r e c o n s i d e r e d low and
unreal i s t ic
by e r p e r t s . Over t h e whole o f p . r b l i c
h.;,spital erpertses
this
system
Hprmt p r o q r e s s i v e l y t o a c c o u r , t f o r m o r e o r l e s s
30-35%
balm?
t h e r e s t b a s x c a l l y p a y - r o l l , w h r c h das p a l d d ~ r e c t l yby
FNS t o h o s p i t a l s .
fvr
Slnce January
1 9 8 5 , t h e FOP s y s t e m
, h a s b e e n m u d i f ~ e din t h e f u l l o w ~ n ga s p e c t s . .
-
ouDl l c h o s ~ l t a l s
Pricesare
equivalent
to
l e v e l uns o f
FNS i n
d e M e d l c i n a C u r & t i v a " (2).
Clfter
totalling
all
rnedical
a c t i o n s done
in
p r e v i o u s i l o r ~ t h ,s o m e i ~ , p o r t a n t d e d u c t i u n s a r e made:
a ) C o s t c,f p a y - r o l l
b ) D e p r e c i a t i o r , o f b u i l d i n g arid e s n z p r n e r a t s
c)
PI11
Ottletdirect
furtdings
done
by
FNS t o
huspitals.
its
."Rrancel
------------- --- --
--
the^
the
(1)
Pize,
Ricardo:
l'wecanisrnns
y
P r o c e d i i n i e r l t os
de
OPeraciOn d e l
Fondc
Naclunal
de
salud".
en
H.
Lavados
y
h l u d
e n Chile.
3a.
Parte,
CPU,
"Desarrollo
Social
S a n t i a g o , 1982..
12)
P r i c e llst
constructed
accordirtg t o
a cost
study
done i n
1 9 0 2 c.f "lost o f
m e d i c a l a c t i o r l s , over. 1000,
used t o
(+/.- 25%
of
pay
flledical b i l l s
of
FNS " M e d i c a i d "
pat ierats
C h ~ l e a npopulation).
Preliminary
reoorts s a y t h a t
t h i s -er
systern h a s
m o s t o f C h i l e a n h r ~ s p i t a l st o d e f i c i t a t - y r e s u l t s .
DRC;
Syster!
led
i n t h e U. S.
D i a g n c l s t ic R e l a t e d
G r o t ~ p sis a r ~ e m t h i r d - p a r t y p a y m e r i t
i n t h e U.S. T h i s m e a n s a c c . x - d i n o t o
s y s t e i ~ ib e i n g e s t a b l i s h e d
P o i n t e r & R o s s (1):
" U r ~ i t caf p a y r n e r ~ t f r u r n s e r v i c e s t o s p e c i f i c a l l y
d e f irmed
pr-cd~.!cts or- d - i a g n o s i s - r - e l a t e d
grr.ups
of
i 1 1r e s 5 e s ' .
Secortd,
the
basis
af
p a y r n e r ~ t is
sh i f t i n g
fr-c.w
ccosts
or charges,
to
e s t a b l ished
payrner~t r a t e s . T h i r d ,
payrner~tsi r : t r e a s i n ~ l y w i l l
be d e t e r m i n e d
p r - c l s p e c t i v e l y - t h a t is.
b e f o r e care
is d e l i v e r e d rather
than
r e t r o s p e c t i v e l y,
or.
a f t e r s e r v i c e is g i v e n " .
DRGs are 467, g r o u p e d i n 23 m a j o r d i a g n o s t i c c a t e g o r i e s
a1 1 f o l lowing
t h e I r ~ t e r n alte n a ?
C l a s s i f i c a t i.~r-I o f
(MDC) ,
D i s e a s e s (ICD)
established accord inp
tc t h e organ or systein
o f t h e body
involved.
Each
DRG.
has
a
price
assigned.
and
each
p a t ierlt
currespor~d to
a
g l v e r ~ DRG
accor-61r.;
r o
its
sex,
ags,
p r i n c i pa1
d iagrt.:~sis,
secor~dary
d 1 a ~ r a f i ss,
i
prcrccdures
p e r f o r r ~ i e d artd d i s c h a r - g e
s t a t u s . The
p r - i c e is c a l c u l a t e d o n
cost
for
a Medicare d i s c h a r g e
t h e base
of
the
average
n i u l t i p l i e d b y a w e i g h t e d DRG.
'
I n c e r ~ it v e s a n d t h e F u r ~ d i r ~Soy s t p r f i
The payrner~t
c o n s i d e r a t i orts o n
I
systerns
for
hosoitals
leads
n c e n t i v e s a n d p r - o d u c t i v i t y.
ta.
sc~rfle
'
I n t h e Chi l e a n
c a s e , i t w a s s a i d , f u r ~ d i r ~ gis b e i n g d o r e
by
fixed
gcaver-r~r~ient p a i d
salaries
for
p r o f essir-nroals a n d
c ~ s tD e r s e r v i c e f i n a n c i n g .
auxil iary
persorue1 t o g e t h e r w i t h
T h i s s y s t e r ~ i irnol i e s 1 i'tt l e o r
n o i n c ~ r a~
t v e sf s ~ rm a n D o w e r a n d
t o i r r c r ~ a s et h e r , , . i : n ~ e r r.f s ~ r - v i c e sg i v e n
i r o p o r t a n t i r ~ c e r i~vte
The rliear,ing o f
t h l s two
r o ~ e c h a r t i s r ~ l1
ss to h a v e no
per case.
to hospitals.
r e l a t i o n with t h e outcome o f p a t i e n t s a a r n i t t e d
-- -- -- --- - - - - - - - - - - --
( 1 ) P o i n t e r D. D . R R o s s M. 6. : "DRG, C ~ s to e r c a s e r n a r t a g e r n e r ~ t",
M o d e r n H e a l t h C a r e , F e b r l ~ a r y 15, 1 3 8 4 .
In t h e l o n g run. doctor's
c o n s c i e n c e a n d ngoral s t a t u s
!I),
a n d d e m e n d p r e s s u r e will be t h e o n l y p a r a ~ l e t e r s t o i n f l u e n c e
t h e e f f i c i e n c y uf p u b l i c hospitals.
DRG s y s t e m being i m p l e m e n t e d i n t h e US& seems t o b e a
m o r e rational a p p r o a c h t o t h e p r o b l e m b e c a u s e
it g i v e s a
reasonable
incentive t o
medical
efficiency,
with
the
comp1e::i t y and imp1 i c a t i o n s of t h e p r o b l e m of
d e a l i n g with
h u m a n l i v e s and sufferings.
--------------------
T o g e t h e r with t h e quality of a d m i n i s t r a t i o n and the aaaunr
of p r e s s u r e g i v e n by t h e demand f o r services.
(1)