Activity-based Funding Research Articles

Impact of the Astra Zeneca COVID-19 vaccine on an emergency department.

To assess the impact of the AstraZeneca (AZ) vaccine roll-out on an ED. Primary outcomes are ED length of stay (LOS), investigation ordering and costs. Secondary measures are compliance with the Thrombosis and Haemostasis Society of Australia and New Zealand (THANZ) Vaccine-Induced Thrombotic Thrombocytopaenia Syndrome (VITT) guidelines. This retrospective observational study examined a level 5 ED in Sydney, Australia. Triages mentioning the AZ vaccine between 7 July 2021 and 8 November 2021 were reviewed. Cases were limited to a single day of the week. Researchers reviewed clinical notes to identify patients that presented due to AZ vaccine concern and abstracted relevant data. Costings were calculated using an ED activity-based funding algorithm. One thousand three hundred and fifty cases were identified, with 167 analysed (12%) and 97 presented (7%). Median LOS was 195 min (IQR: 152-232 min, 95% CI [184, 217]). Median age was 43 years (IQR: 35-65 years, 95% CI [44, 51]). Median Australian Triage Category was 4. Ninety-eight percent were discharged directly home. Ninety-four percent underwent pathology and 41% radiology. Compliance with the THANZ guidelines was 16%. No findings were related to VITT. AZ vaccine concern contributed 12% of August ED caseload. Over the 16-week study period a cost of AUD$486 747.99 was extrapolated. A high number of young, low acuity patients presented to the ED with AZ vaccine concerns and were associated with financial and workload implications. The quantity of ED presentations appears to be associated with vaccine administration rates. There was poor compliance with the THANZ guidelines, and they appear to have contributed to the high volume of investigations.

Cultures of Activity, Cultivating Resistance.

The problem of antimicrobial resistance (AMR) is often viewed through biomedical and/or behavioral lenses, with the underlying economic principles and "headwinds" shaping resistance less visible. In this paper, we focus on how healthcare funding models structure the ways AMR is perceived and addressed as an institutional priority. Specifically, we explore how activity-based funding reflects and operationalizes ingrained assumptions about what is valuable and/or worthwhile within the organizational ecology of the hospital. Drawing on interviews with 36 executives from several hospital clinical care settings across two Australian states, we illuminate the ways the activity-based funding paradigm works against efforts to combat AMR. Concerningly, we further observe how activity-based funding models can inadvertently position rising rates of resistance as a benefit-at least in the short term-as the new and intensified interventions required to address resistant infections require more "activity" and thus deliver higher reimbursement at the level of annualized budgets. In failing to recognize the (social and economic) value of reduced activity, activity-based funding risks contributing to AMR, rather than working to resolve it.

Impact of an Outpatient Word Catheter Program for Bartholin cysts and abscesses: A retrospective cohort study.

To assess the impact of an Outpatient Word Catheter Program (OWCP) on outcomes in women presenting with Bartholin cysts or abscesses (BC/BAs). . This retrospective cohort study reviewed 408 women presenting with BC/BAs to our tertiary unit from 2017-2022. Analysis of medical records, with subgroup analysis of pregnant patients, and comparative analysis between pre- and post-intervention groups, was completed. Financial impact analysis using national activity-based funding pricing guidance to estimate cost was conducted. Pre-intervention, 65% (n = 34) of procedures were completed in theater, but after the introduction of OWCP, 61% (n = 213) of cases were treated in the day ward (χ2 = 67.43, P <0.001). Similarly, inpatient admissions reduced; 94.2% (n = 49) pre-intervention versus 26% (n = 92) post-intervention (χ2 = 92.25, P <0.001). The mean all patient admission duration decreased from 1.52 ± 0.89 days to 0.69 ± 0.59 days (P <0.001). The mean cost for those women attending in the pre-OWCP period was €4798, versus €2704 in the women who attended post-OWCP introduction (P < 0.001). After OWCP introduction, there were significant decreases in inpatient admissions, surgical procedures in theater, general anesthetic exposure, and duration of admission. Financial impact analysis revealed a significant cost reduction of ~€2100 per patient. Outpatient or day-care Word catheter programs are feasible, affordable and acceptable services to provide to women presenting withBC/BAs.

Activity‐based funding reform and the performance of public hospitals: The case of Queensland, Australia

AbstractThis study investigates the impact of activity‐based funding (ABF) on the performance of hospitals by exploiting a natural experiment that happened in the state of Queensland, Australia. To examine the outcome of the reform, the performance of hospitals is measured by the technical efficiency estimated from data envelopment analysis (DEA) models. We try to identify the causal effect of ABF on the technical efficiency of hospitals by incorporating difference‐in‐differences approach in the popular two‐stage DEA framework. We find empirical evidence that ABF improves the technical efficiency of hospitals.

Developing enabling cost information during the COVID-19 crisis

ABSTRACT In this paper, we build upon the crisis literature and theorisation of enabling design principles to examine how cost information was calculated and used in response to the COVID-19 crisis in public hospitals in New South Wales (NSW) Australia. This study analyses how various actors sought to respond to demands for cost information that was immediate, intense, and dynamic as the pandemic unfolded. In response, we observed two costing processes emerging. One focussed on the immediate pandemic funding requirements whilst the second addressed future activity-based funding requirements. The crisis created a situation in which matters present in business-as-usual costing practice became more visible. The four enabling design principles help us to theorise the complex interactions between how cost information might be constructed differently to relate to different purposes relating to both internal and global transparency.

Piloting a Hospital Pharmacy Performance Model in the Face of Province-Wide Implementation of Activity-Based Funding in Quebec Health Care Centres.

In the face of province-wide implementation of activity-based hospital funding in Quebec, a need arose to effectively measure pharmacists' contributions along the patient care trajectory and to enable pharmacy benchmarking using valid performance indicators. A 3-phase project was initiated to measure the performance and impact of pharmacists and pharmacy departments. Phases 2 and 3, described here, focused on gradually implementing, in various health care centres, the priority indicators selected in phase 1. The project involved multiple committees overseeing the implementation, data collection, analysis, and documentation of 18 performance indicators. Specific tools were developed to facilitate data collection and encourage pharmacists' participation. A feedback survey was used to document pharmacists' experiences. Substantial data were gathered over 3 years (2017 to 2020), involving 358 pharmacists from 6 health care centres. The overall contribution rate to the daily data collection from front-line pharmacists was 55%. The feedback survey revealed that, of the various communication tools used to promote the project, in-person events were better perceived by the front-line pharmacists than online tools. Of the 183 respondents to the survey, most (94%, n = 172) believed it was important to collect data to document pharmacists' activities, and 82% (n = 150) saw the project as relevant to the upcoming activity-based funding system. Despite challenges, progress was made in defining relevant indicators, adjusting the list generated during phase 1, and reaching a consensus on 16 indicators. Stakeholders expressed interest, emphasizing the importance of documenting pharmacists' activities. The project has laid the foundation for demonstrating the value of pharmacists along the patient care trajectory and measuring pharmacy departments' performance. However, more integrated technological solutions are needed for province-wide implementation.

Population Analysis of SABR/SRS for the Treatment of Metastatic Cancer in a Jurisdiction of 15 Million People

Stereotactic Ablative Radiotherapy (SABR) or Stereotactic Radiosurgery (SRS) for oligometastatic cancer or oligoprogression of metastatic cancer is supported by an expanding body of evidence in the literature. The degree of uptake of these techniques, supplanting traditional and potentially less resource-intensive techniques in this patient population, would be of interest to clinicians and administrators alike. A review of provincial date for Ontario, Canada (population ∼ 15 million) was performed to quantify the use of SABR/SRS to metastases either in the brain or elsewhere in the body. Data was obtained from a new (April 2022) activity-based hospital funding model, responsible for ALL radiation treatment remuneration at all facilities across the province (i.e., single payer system). Funding is triggered when a patient is treated as per 1 or more of the ∼270 provincial radiation protocols, defined as a "protocol instance". Protocols were developed by clinicians across Ontario according to a consensus-based iterative process, considering provincial, national and international guidelines and/or evidence-based practice. Prerequisite information for remuneration included (but was not limited to): patient demographics, identification of whether a primary tumor or metastasis(es) was treated, protocol, radiation technique, dose/fractionation, and encounter dates. Submission of data was performed by the 17 hospitals who provide radiation services and logic checked centrally by the provincial cancer agency following submission. Validation of data is performed by ongoing iterative processes. From April 1 to November 30, 2022, a total of 31,916 radiation protocol instances were funded for 27,298 patients. Of these, 4,156 (13%) were SABR/SRS protocols. When only treatment to metastases were considered, the total number of SABR/SRS protocol instances was 3,024 (9.5% of total) and 29.4% of the total number of protocol instances delivered to metastases (10,271). The 29.4% was split further as 1567 protocol instances (15.3%) to brain metastases and 1457 protocol instances elsewhere in the body, most often to lung (3.9%), spine (3.4%), non-spine bone (2.2%) and liver (1.7%), with a further 2.9% to unspecified extra-cranial metastases. Data for all 17 Ontario treatment facilities revealed a range of SABR/SRS usage for metastases from 1.8 to 59.8% (median 23.2%, IQ range 16.9%). On review of recently submitted data, nearly 1/3 of all radiation treatments to metastases in Ontario are delivered using a SABR/SRS technique. There is wide regional variation in the use of these techniques. Reasons for this variation require further investigation.

The applications of Australian-coded ICD-10 and ICD-10-AM data in research: A scoping review of the literature.

Background: Australia uses the International Classification of Diseases (ICD-10) for mortality coding and its Australian Modification, ICD-10-AM, for morbidity coding. The ICD underpins surveillance (population health, mortality), health planning and research (clinical, epidemiological and others). ICD-10-AM also supports activity-based funding, thereby propelling realignment of the foci of clinical coding and, potentially, coded data's research utility. Objective: To conduct a scoping review of the literature exploring the use of ICD-10 and ICD-10-AM Australian-coded data in research. Research questions addressed herein: (1) What were the applications of ICD-10(-AM) Australian-coded data in published peer-reviewed research, 2012-2022? (2) What were the purposes of ICD-10(-AM) coded data within this context, as classified per a taxonomy of data use framework? Method: Following systematic Medline, Scopus and Cumulative Index to Nursing and Allied Health Literature database searches, a scoping literature review was conducted using PRISMA Extension for Scoping Reviews guidelines. References of a random 5% sample of within-scope articles were searched manually. Results were summarised using descriptive analyses. Results: Multi-stage screening of 2103 imported articles produced 636, including 25 from the references, for extraction and analysis; 54% were published 2019-2022; 50% within the largest five categories were published post-2019; 22% fell within the "Mental health and behavioural" category; 60.3% relied upon an ICD-10 modification. Articles were grouped by: research foci; relevant ICD chapter; themes per the taxonomy; purposes of the coded data. Observational study designs predominated: descriptive (50.6%) and cohort (34.6%). Conclusion: Researchers' use of coded data is extensive, robust and growing. Increasing demand is foreshadowed for ICD-10(-AM) coded data, and HIM-Coders' and Clinical Coders' expert advice to medical researchers.

Hospital response to Activity-Based Funding and price incentives: Evidence from Ireland

Activity-Based Funding (ABF) is a funding policy incentivising hospitals to deliver more efficient care. ABF can be complemented by additional price incentives to further drive hospital efficiency. In 2016, ABF was introduced for public patients admitted to Irish public hospitals. Additionally, a price incentive to perform laparoscopic cholecystectomy as day-case surgery was introduced in 2018. Private patient activity in public hospitals was subject to neither ABF nor price incentive. Using national Hospital In-Patient-Enquiry activity data 2013–2019, we evaluated the impact of ABF and the price incentive for laparoscopic cholecystectomy surgery in Ireland. We exploit variation in hospital payment for public and private patients treated in public acute Irish hospitals and employ a Propensity Score Matching Difference-in-Differences approach. We estimate the funding change impacts across outcomes measuring the proportion of day-case admissions and length of stay. We found no significant impact for either outcomes linked to ABF introduction. Similarly, no impacts linked to the price incentive were observed. It appears providers of laparoscopic cholecystectomy in Irish public hospitals did not react to the new funding mechanisms. The implementation of the funding policies did not improve hospital efficiency. Further strengthening of these new funding mechanisms are required to deliver more efficient care.

Optimising vitrectomy operation note coding with machine learning.

The accurate encoding of operation notes is essential for activity-based funding and workforce planning. The aim of this project was to evaluate the procedural coding accuracy of vitrectomy and to develop machine learning, natural language processing (NLP) models that may assist with this task. This retrospective cohort study involved vitrectomy operation notes between a 21-month period at the Royal Adelaide Hospital. Coding of procedures were based on the Medicare Benefits Schedule (MBS)-the Australian equivalent to the Current Procedural Terminology (CPT®) codes used in the United States. Manual encoding was conducted for all procedures and reviewed by two vitreoretinal consultants. XGBoost, random forest and logistic regression models were developed for classification experiments. A cost-based analysis was subsequently conducted. There were a total of 1724 procedures with individual codes performed within 617 vitrectomy operation notes totalling $1 528 086.60 after manual review. A total of 1147 (66.5%) codes were missed in the original coding that amounted to $736 539.20 (48.2%). Our XGBoost model had the highest classification accuracy (94.6%) in the multi-label classification for the five most common procedures. The XGBoost model was the most successful model in identifying operation notes with two or more missing codes with an AUC of 0.87 (95% CI 0.80-0.92). Machine learning has been successful in the classification of vitrectomy operation note encoding. We recommend a combined human and machine learning approach to clinical coding as automation may facilitate more accurate reimbursement and enable surgeons to prioritise higher quality clinical care.

The importance of good governance in hospital payment reform – A case study from Ukraine

In 2005, Ukraine embarked on hospital financing reforms that included the introduction of a Diagnosis Related Group (DRG) based payment system for acute inpatient care. The primary purpose of introducing activity-based funding was to provide incentives for hospitals to use their limited resources more efficiently.Following an extended period of preparation and planning during which technical assistance was provided by various development agencies, Ukraine took action to implement the DRG system at a national level in April 2018, through a World Bank project. While some progress was made, the execution of the reform faced challenges with the organisation and administration of the implementation process, and duplication of effort. The consequence of these shortcomings was that the newly introduced system was not capable of measuring inpatient DRG activity at a level of accuracy necessary for the determination of hospital performance and the subsequent calculation of payments.If the expected outcomes of DRG implementation in Ukraine are to be realised, stakeholders including both beneficiary agencies and development organisations, will need to improve program governance through better coordination of their activities towards a common goal.

Valuing rural hospitals - the Australian experience.

Over many years in Australia, public hospitals were funded on historical grounds with about 40% of running costs provided by the national government. In 2010, a national reform agreement established the Independent Hospital Pricing Authority (IHPA) to put in place activity-based funding, where the national government contribution was based on activity and National Weighted Activity Units (NWAU) and a National Efficient Price (NEP). Rural hospitals were exempted from this on the assumption that they were less efficient and activity more variable. IHPA developed a robust system of data collection for all hospitals including rural hospitals. Initially this was based on historic data but with increasing sophistication of data collection, a predictive model was developed that is termed the National Efficient Cost (NEC). The cost of hospital care was analyzed. The very smallest hospitals that saw fewer than 188 standardized patient equivalents (NWAU) per year were excluded as there were very few very remote hospitals with justified variation in their costs. A number of models were tested for their predictive value. The selected model successfully balances simplicity, policy considerations, and predictive power. The selected model combines an activity-based payment with a flag fall:Low volume (less than 188 NWAU) are paid a set amount of A$2.2M;Those between 188 and 3500 NWAU are paid a diminishing flag fall + activity payment; andThose above 3500 NWAU are paid on activity alone (same as larger hospitals)Discussion: The last 10 years has seen an increasing sophistication in measurement of hospital costs and activity allowing a deeper understanding of these aspects. The funding of hospitals by the national government is still distributed by the states but there is now as a greater transparency of cost, activity and efficiency. The presentation will highlight this and consider the implication and possible next steps.

Incorporating Safety and Quality Measures Into Australia's Activity-Based Funding of Public Hospital Services.

In a bid to improve quality of care, numerous countries have incorporated rewards and penalties into the funding and pricing of hospital services. This paper outlines recent advances in Australia to incorporate financial penalties for hospital acquired complications (HACs) and avoidable hospital readmissions (AHRs) adjustments into the funding of public hospital services. It describes the work in the development of suitable measures to identify episodes, the design of the analytical approach used for risk adjustment and the calculation of the funding implications including dampening effects to account for the level of risk. Using the 2019 to 20 round of data collection, this paper reports on the risk adjustment analysis, incremental costs of HACs and AHRs, and the funding dampening effects, the paper further discusses the implementation strategies undertaken by the Independent Health and Aged Care Pricing Authority (IHACPA) to ensure transparency, stakeholder consultation and engagement. The paper argues that both the technical development and its implementation strategies have been central to making safety and quality an integral and accepted part of Australia's public hospital funding arrangements.

Characterizing the Impact of Procedure Funding on the Covid-19 Generated Procedure Gap in Ontario: A Population-Based Analysis.

Surgical procedures in Canada were historically funded through global hospital budgets. Activity-based funding models were developed to improve access, equity, timeliness, and value of care for priority areas. COVID-19 upended health priorities and resulted in unprecedented disruptions to surgical care, which created a significant procedure gap. We hypothesized that activity-based funding models influenced the magnitude and trajectory of this procedure gap. Population-based analysis of procedure rates comparing the pandemic (March 1, 2020-December 31, 2021) to a prepandemic baseline (January 1, 2017-February 29, 2020) in Ontario, Canada. Poisson generalized estimating equation models were used to predict expected rates in the pandemic based on the prepandemic baseline. Analyses were stratified by procedure type (outpatient, inpatient), body region, and funding category (activity-based funding programs vs. global budget). In all, 281,328 fewer scheduled procedures were performed during the COVID-19 period compared with the prepandemic baseline (Rate Ratio 0.78; 95% CI 0.77-0.80). Inpatient procedures saw a larger reduction (24.8%) in volume compared with outpatient procedures (20.5%). An increase in the proportion of procedures funded through activity-based programs was seen during the pandemic (52%) relative to the prepandemic baseline (50%). Body systems funded predominantly through global hospital budgets (eg, gynecology, otologic surgery) saw the least months at or above baseline volumes, whereas those with multiple activity-based funding options (eg, musculoskeletal, abdominal) saw the most months at or above baseline volumes. Those needing procedures funded through global hospital budgets may have been disproportionately disadvantaged by pandemic-related health care disruptions.

Recording adverse events following orthopaedic trauma: Financial implications and validation of an adverse event assessment form in an Irish regional trauma unit

BackgroundIn Ireland, funding of orthopaedic trauma is based on an activity-based funding (ABF) model. Clinically similar cases are split into diagnostic-related groups (DRG), with base funding per DRG provided. Increased complexity of cases (length of stay; complications incurred; occurrence of adverse events) attracts additional remuneration to the base funding. In our institution these adverse events are recorded via retrospective chart-abstraction methods by administrative staff. Incidences which are not included from this review affect both follow up with family physicians and patient care; as well as skewing budgetary decisions that impact fiscal viability of the service. The aim of this study was to compare a prospectively implemented adverse events form with the current national retrospective chart abstraction method. Our outcomes in terms of pay-by-results financial implications. MethodsAn adverse events database adapted from a similar validated model was used to prospectively record complications in 216 patients admitted via the orthopaedic trauma service. Data was contemporaneously collected via a GDPR compliant secure medical messaging platform. Results were compared with the same cohort using an existing data abstraction method. Both data sets were coded in accordance with current standards for case funding. ResultsOverall, 49 adverse events were recorded during the study through prospective charting of adverse events, compared with 26 events documented by customary method (p<0.01).Anaemia requiring blood transfusion n = 11 22.4%) was the most common complication, followed by delirium n = 6 (12%), acute kidney injury n = 6 (12%), and pneumonia n = 5 (10.2%). Missed appropriate funding through conventional methods totalled €40,293 . ConclusionThis pilot study demonstrates the ability to improve capture of adverse events through use of a well-designed assessment form. Proper perioperative data handling is a critical aspect of financial subsidies, enabling optimal allocation of funds.

A comparison of four quasi-experimental methods: an analysis of the introduction of activity-based funding in Ireland

BackgroundHealth services research often relies on quasi-experimental study designs in the estimation of treatment effects of a policy change or an intervention. The aim of this study is to compare some of the commonly used non-experimental methods in estimating intervention effects, and to highlight their relative strengths and weaknesses. We estimate the effects of Activity-Based Funding, a hospital financing reform of Irish public hospitals, introduced in 2016.MethodsWe estimate and compare four analytical methods: Interrupted time series analysis, Difference-in-Differences, Propensity Score Matching Difference-in-Differences and the Synthetic Control method. Specifically, we focus on the comparison between the control-treatment methods and the non-control-treatment approach, interrupted time series analysis. Our empirical example evaluated the length of stay impact post hip replacement surgery, following the introduction of Activity-Based Funding in Ireland. We also contribute to the very limited research reporting the impacts of Activity-Based-Funding within the Irish context.ResultsInterrupted time-series analysis produced statistically significant results different in interpretation, while the Difference-in-Differences, Propensity Score Matching Difference-in-Differences and Synthetic Control methods incorporating control groups, suggested no statistically significant intervention effect, on patient length of stay.ConclusionOur analysis confirms that different analytical methods for estimating intervention effects provide different assessments of the intervention effects. It is crucial that researchers employ appropriate designs which incorporate a counterfactual framework. Such methods tend to be more robust and provide a stronger basis for evidence-based policy-making.

Predicting the Annual Funding for Public Hospitals with Regression Analysis on Hospital's Operating Costs: Evidence from the Greek Public Sector.

The funding of public hospitals is an issue that has been of great concern to health systems in the past decades. Public hospitals are owned and fully funded by the government, providing in most countries medical care to patients free of charge, covering expenses and wages by government reimbursement. Several studies in different countries have attempted to investigate the potential role and contribution of hospital and clinical data to their overall financial requirements. Many of them have suggested the necessity of implementing DRGs (Diagnosis Related Groups) and activity-based funding, whereas others identify flaws and difficulties with these methods. What was attempted in this study is to find an alternative way of estimating the necessary fundings for public hospitals, regardless the case mix managed by each of them, based on their characteristics (size, specialty, location, intensive care units, number of employees, etc.) and its annual output (patients, days of hospitalization, number of surgeries, laboratory tests, etc.). We used financial and operational data from 121 public hospitals in Greece for a 2-years period (2018–2019) and evaluated with regression analysis the contribution of descriptive and operational data in the total operational cost. Since we had repeated measures from the same hospitals over the years, we used methods suitable for longitudinal data analysis and developed a model for calculating annual operational costs with an R²≈0.95. The main conclusion is that the type of hospital in combination with the number of beds, the existence of an intensive care unit, the number of employees, the total number of inpatients, their days of hospitalization and the total number of laboratory tests are the key factors that determine the hospital’s operating costs. The significant implication of this model that emerged from this study is its potential to form the basis for a national system of economic evaluation of public hospitals and allocation of national resources for public health.

Demystifying the role of anaesthetists in clinical coding in the Australian healthcare system.

Despite the self-evident importance of hospital funding, many anaesthetists remain unsure of exactly how their daily work relates to hospital reimbursement. A lack of awareness of the nuances of the Australian hospital activity-based funding system has the potential to affect anaesthetic department reimbursement and thus resourcing. Activity-based funding relies on clinical coders reviewing clinical documentation and quantifying the care given to a patient during an admission. Errors in funding allocation may arise when there is a disconnect between the work performed and the information coded. In anaesthesia, there are several factors impeding this process, including clinical understanding of coding, system setup and coders' understanding of anaesthesia. This article explores these factors from the clinical anaesthetist's point of view and suggests solutions, such as awareness and education, clinician-coder cooperation and redesign of documentation systems at a systems level that anaesthetic departments can incorporate.

Costs of acute hospitalisation for stroke and transient ischaemic attack in Australia.

Stroke is a high-cost condition. Detailed patient-level assessments of the costs of care received and outcomes achieved provide useful information for organisation and optimisation of the health system. To describe the costs of hospital care for stroke and transient ischaemic attack (TIA) and investigate factors associated with costs. Retrospective cohort study using data from the Australian Stroke Clinical Registry (AuSCR) collected between 2009 and 2013 linked to hospital administrative data and clinical costing data in Queensland. Clinical costing data include standardised assignment of costs from hospitals that contribute to the National Hospital Costing programme. Patient-level costs for each hospital admission were described according to the demographic, clinical and treatment characteristics of patients. Multivariable median regression with clustering by hospital was used to determine factors associated with greater costs. Among 22 hospitals, clinical costing data were available for 3909 of 5522 patient admissions in the AuSCR (71%). Compared to those without clinical costing data, patients with clinical costing data were more often aged <65years (30% with cost data vs 24% without cost data, p < 0.001) and male (56% with cost data vs 49% without cost data, p < 0.001). Median cost of an acute episode was $7945 (interquartile range $4176 to $14970) and the median length of stay was 5days (interquartile range 2 to 10days). The most expensive cost buckets were related to medical (n = 3897, median cost $1577), nursing (n = 3908, median cost $2478) and critical care (n = 434, median cost $3064). Factors associated with greater total costs were a diagnosis of intracerebral haemorrhage, greater socioeconomic position, in-hospital stroke and prior history of stroke. Medical and nursing costs were incurred by most patients admitted with stroke or TIA, and were relatively more expensive on average than other cost buckets such as imaging and allied health. Scaling this data linkage to national data collections may provide valuable insights into activity-based funding at public hospitals. Regular report of these costs should be encouraged to optimise economic evaluations.

Trend in CT utilisation and its impact on length of stay, readmission and hospital mortality in Western Australia tertiary hospitals: an analysis of linked administrative data 2003-2015.

ObjectiveHigh use of CT scanning has raised concern due to the potential ionising radiation exposure. This study examined trends of CT during admission to tertiary hospitals and its associations with length of stay (LOS), readmission and mortality.DesignRetrospective observational study from 2003 to 2015.SettingWest Australian linked administrative records at individual level.Participants2 375 787 episodes of tertiary hospital admission in adults aged 18+ years.Main outcome measuresLOS, 30-day readmissions and mortality stratified by CT use status (any, multiple (CTs to multiple areas during episode), and repeat (repeated CT to the same area)).MethodsMultivariable regression models were used to calculate adjusted rate of CT use status. The significance of changes since 2003 in the outcomes (LOS, 30-day readmission and mortality) was compared among patients with specific CT imaging status relative to those without.ResultsBetween 2003 and 2015, while the rate of CT increased 3.4% annually, the rate of repeat CTs significantly decreased −1.8% annually and multiple CT showed no change. Compared with 2003 while LOS had a greater decrease in those with any CT, 30-day readmissions had a greater increase among those with any CT, while the probability of mortality remained unchanged between the any CT/no CT groups. A similar result was observed in patients with multiple and repeat CT scanning, except for a significant increase in mortality in the recent years in the repeat CT group.ConclusionThe observed pattern of increase in CT utilisation is likely to be activity-based funding policy-driven based on the discordance between LOS and readmissions. Meanwhile, the repeat CT reduction aligns with a more selective strategy of use based on clinical severity. Future research should incorporate in-hospital and out-of-hospital CT to better understand overall CT trends and potential shifts between settings over time.