Compare Hospital Costs Research Articles

Treatment cost development of patients undergoing remission induction chemotherapy: a pharmacoeconomic analysis before and after introduction of posaconazole prophylaxis

Prior clinical trials have demonstrated efficacy and effectiveness of posaconazole in the prophylaxis of invasive fungal diseases in high-risk patients. Controversy exists about the cost-effectiveness of this approach. We performed an analysis comparing the direct costs of posaconazole prophylaxis against polyene mouthwash (thrush) prophylaxis in patients with acute myelogenous leukaemia (AML). Data of AML patients receiving remission-induction chemotherapy were extracted from the CoCoNut (Cologne Cohort of Neutropenic Patients) database to compare hospital costs of patients before (2003-2005) and after (2006-2008) introduction of posaconazole prophylaxis. Treatment on general ward, intensive care unit (ICU), mechanical ventilation, diagnostic procedures, and all anti-infectives were calculated. Patient groups were well matched according to age, gender and duration of neutropenia. The mean costs per patient in the posaconazole group (n=76) and the polyene mouthwash group (n=81) were €21040 (95% confidence interval (CI): €18204-€23876) and €23169 (95% CI: €19402-€26937) per patient. Antifungal treatment costs were €4580 (95% CI: €3678-€5482) and €4019 (95% CI: €2825-€5214). Duration on the ICU was 2582 (95% CI: 984.1-4181.7) and 5517 (95% CI: 2206-8827.3) min. In our hospital, primary antifungal prophylaxis by posaconazole was cost-effective. There was a trend towards cost savings, which was primarily caused by a shorter overall length of stay and the less frequent ICU treatment.

Comparing Costs of Robotic, Laparoscopic, and Open Partial Nephrectomy

Abstract Background and Purpose: Laparoscopic and robot-assisted partial nephrectomy (LPN and RPN) are common minimally invasive alternatives to open partial nephrectomy (OPN) for management of renal tumors. Cost discrepancies of these approaches warrants evaluation. We compared hospital costs associated with RPN, LPN, and OPN. Costs were captured for 25 patients in each group who underwent RPN, LPN, or OPN at our institution between November 2008 and September 2010. Variable costs included operating room (OR) time, supplies, anesthesia, and inpatient care costs. Fixed costs included equipment purchase and maintenance. Impact of variable and fixed costs were estimated using sensitivity analysis. Overall variable costs were similar for RPN, LPN, and OPN ($6375 vs $6075 vs $5774, P=0.117, respectively). OR supplies contributed a greater cost for RPN and LPN than OPN ($2179 vs $1987 vs $181, P<0.0001, respectively), while inpatient stay costs were higher for OPN compared with LPN and RPN ($2418 vs $1305 vs $1274, P<0.0001, respectively). Sensitivity analysis of variable costs demonstrates that RPN and LPN can represent less costly alternatives to OPN if hospital stay for RPN and LPN is ≤2 days and OR time <195 and 224 minutes, respectively. Inclusion of fixed costs made OPN less expensive than LPN and RPN unless use of the robot increases and operative times are reduced. By minimizing OR time and hospital stay, RPN and LPN can be cost equivalent to OPN regarding variable costs. When including fixed costs, RPN and LPN were more costly than OPN, but equivalence may be possible with improvements in efficiency.

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Introduction: The need for prolonged mechanical ventilation (MV) may contribute significantly to hospital costs. ICD-9 MV codes classify patients by less than 96 hours (short-term) and greater than or equal to 96 hours (prolonged) of ventilator time and track to Medicare-severity diagnosis-related group (MS-DRG) designations and payments. The purpose of this study is to compare hospital costs with MS-DRG payment rates for short-term and prolonged ventilation cases. Hypothesis: Our hypothesis is that MS-DRG payments do not adequately compensate hospitals for short-term or prolonged ventilator care. Methods: We selected all adult Medicare inpatient discharges from the Premier Database for CY2010. Outliers were trimmed at 5th and 95th percentile of total costs. We identified short-term and prolonged acute ventilation using Medicare Severity Diagnosis Related Groups (MS-DRG). We compared the mean total hospitalization costs reported in the Premier Database with average MS-DRG payment rates (wage index = 1; geographic adjustment factor = 1) for 2010. We also compared the mean department level costs for the two ventilation groups. Results: Total hospital costs for the short-term ventilation group averaged $16,165 (N=9371, SD±8423) and for the prolonged acute ventilation group, $37,585 (N=4347, SD±16613). The mean length of stay for the short-term group was 6.6 (SD±4.3) days; for the prolonged ventilation group it was 14.5 (SD±7.0) days. More than half the total costs came from room and board costs and about one-eighth of the costs were pharmacy costs. Medicare payment for the short-term group was $13,560 and for the prolonged ventilation group was $31,405. Conclusions: The difference between average payments and average costs for ventilation cases means that hospitals risk an average loss of nearly 16.1% in the care of short-term mechanically ventilated patients and 16.4% in the care of long-term mechanically ventilated patients. Interventions targeting reduction in days of acute MV and optimization of hospital resources in the care of MV patients may have economic implications for the hospital as well as clinical benefits for the MV patient.

Economic Implications of Rasburicase Treatment in Adult Patients with Tumour Lysis Syndrome

Rasburicase is a recombinant urate-oxidase enzyme used to reduce high levels of plasma uric acid (PUA) resulting from tumour lysis syndrome (TLS). Rasburicase reduces PUA levels within 4 hours of administration, thereby minimizing the risk of serious complications from TLS. Treatment pattern analyses indicate rasburicase is often used in combination with allopurinol; however, no studies have evaluated the clinical and economic consequences of this pattern of care. The purpose of this study was to compare hospitalization costs, overall length of stay (LOS), and critical-care LOS in patients receiving rasburicase with or without allopurinol. Hospital claims data from the Premier Perspective Database™ were used to conduct this retrospective analysis. Patients in the Premier hospital database who were administered rasburicase or combination therapy (rasburicase + allopurinol) within 2 days of hospital admission were eligible for study inclusion. Patients were excluded if they were <18 years of age or received haemodialysis (or any other renal replacement therapy support) on admission. Rasburicase patients were propensity-score-matched to combination therapy patients based on gender, race, hospital type (urban/rural, teaching), provider type, payer type, admission source, use of electrolyte modification therapy, critical-care admission and presence of a cancer diagnosis. Differences in healthcare costs, overall LOS and critical-care LOS were assessed using γ-distributed generalized linear models with a log-link function. The study population comprised 66 patients receiving rasburicase monotherapy matched to 66 patients receiving combination therapy. Mean age was 62.9 years, and 29% were female. Patients initiated on combination therapy had a shorter mean duration of rasburicase administration than patients initiated on monotherapy (2.1 vs 2.7 days) [p = 0.0059]. Additionally, rasburicase monotherapy incurred an average total cost of $US35 843 per hospitalization, compared with $US46 672 for those receiving combination therapy (p = 0.0820). Rasburicase monotherapy patients also had a shorter mean overall LOS (10.0 days vs 15.4 days; p = 0.0067). The mean critical-care LOS was similar in both cohorts (2.4 days rasburicase vs 2.9 days combination therapy; p = 0.3389). Examination of claims data showed that combination therapy (rasburicase + allopurinol) trended toward higher total hospitalization costs than rasburicase monotherapy. In addition, combination therapy was associated with significantly longer overall LOS compared with upfront rasburicase monotherapy in patients at risk for developing TLS.

Reduced Costs for Staphylococcus aureus Carriers Treated Prophylactically with Mupirocin and Chlorhexidine in Cardiothoracic and Orthopaedic Surgery

BackgroundA multi centre double-blind randomised-controlled trial (M-RCT), carried out in the Netherlands in 2005–2007, showed that hospitalised patients with S. aureus nasal carriage who were treated prophylactically with mupirocin nasal ointment and chlorhexidine gluconate medicated soap (MUP-CHX), had a significantly lower risk of health-care associated S. aureus infections than patients receiving placebo (3.4% vs. 7.7%, RR 0.42, 95% CI 0.23–0.75). The objective of the present study was to determine whether treatment of patients undergoing elective cardiothoracic or orthopaedic surgery with MUP-CHX (screen-and-treat strategy) affected the costs of patient care.MethodsWe compared hospital costs of patients undergoing cardiothoracic or orthopaedic surgery (n = 415) in one of the participating centres of the M-RCT. Data from the ‘Planning and Control’ department were used to calculate total hospital costs of the patients. Total costs were calculated including nursing days, costs of surgery, costs for laboratory and radiological tests, functional assessments and other costs. Costs for personnel, materials and overhead were also included. Mean costs in the two treatment arms were compared using the t-test for equality of means (two-tailed). Subgroup analysis was performed for cardiothoracic and orthopaedic patients.ResultsAn investigator-blinded analysis revealed that costs of care in the treatment arm (MUP-CHX, n = 210) were on average €1911 lower per patient than costs of care in the placebo arm (n = 205) (€8602 vs. €10513, p = 0.01). Subgroup analysis showed that MUP-CHX treated cardiothoracic patients cost €2841 less (n = 280, €9628 vs €12469, p = 0.006) and orthopaedic patients €955 less than non-treated patients (n = 135, €6097 vs €7052, p = 0.05).ConclusionsIn conclusion, in patients undergoing cardiothoracic or orthopaedic surgery, screening for S. aureus nasal carriage and treating carriers with MUP-CHX results in a substantial reduction of hospital costs.

Cost comparison of robotic, laparoscopic, and open partial nephrectomy.

394 Background: Laparoscopic and robotic partial nephrectomy (LPN and RPN) are increasingly common minimally invasive alternatives to open partial nephrectomy (OPN) for management of renal tumors. The cost discrepancies of these approaches warrants evaluation. We compared hospital costs associated with RPN, LPN, and OPN. Methods: Variable hospital costs including operating room (OR) time, supplies, anesthesia, inpatient care, radiology, pharmacy, and laboratory charges were captured for 25 patients who underwent OPN, LPN, and RPN at our institution between 11/2008 -9/2010. Fixed costs of acquisition of a laparoscopic suite and a robotic system (including maintenance) were amortized over 7 years. We considered alternative scenarios through one-way and multi-way sensitivity analysis. Results: We found similar overall variable costs for OPN, LPN, and RPN. Sensitivity analysis demonstrated that RPN and LPN are more cost effective than OPN (excluding fixed costs) if the average hospital stay is &lt; 2 days, or OR time less is than 204 and 196 mins, respectively. By including fixed costs of equipment, RPN and LPN are always more costly than OPN. Conclusions: There was no difference among variable hospital costs of OPN, LPN, and RPN. Minimizing OR time and hospital stay reduces RPN and LPN costs to levels comparable to OPN. Inclusion of fixed costs makes LPN and RPN more expensive than OPN, but increased utilization and efficiency can decrease cost per case. [Table: see text]

Comparison of outcomes and costs between laparoscopic distal pancreatectomy and open resection at a single center

The cost implications of laparoscopic distal pancreatectomy (LDP) and a detailed breakdown of hospital expenditures has not been presented in the literature to date. This study aimed to compare hospital costs and short-term clinical outcomes between LDP and open distal pancreatectomy (ODP). The authors evaluated all the distal pancreatic resections performed at their center between January 2004 and March 2010. Parametric and nonparametric statistical analysis was used to compare hospital departmental and total hospital costs as well as oncologic and surgical outcomes. A total of 118 cases (42 laparoscopic resections, including 5 conversions, and 76 open resections) were analyzed. The demographic characteristics were similar between the groups except for a predominance of females in the laparoscopic group (P = 0.036). The indications for surgery differed by a paucity of malignant tumors being approached laparoscopically (P < 0.001). Intraoperatively, there were no differences in estimated blood loss, operating room time, or transfusion requirement. The pathologic outcomes did not differ significantly. The median hospital length of stay (LOS) was 5 days (range 3-31 days) for the LDP cohort and 7 days (range 4-19 days) for the ODP cohort (P < 0.001). Postoperative pancreatic fistula occurred for 22 patients, with a higher proportion observed in the LDP group (28.57%; n = 12) than in the open group (13.16%; n = 10; P = 0.05). However, the rates for grade B and higher grade fistula were higher in the ODP group (0 LDP and 4 ODP). The median preadmission and operative costs did not differ significantly. The ODP cohort had significantly higher costs in all other hospital departments, including the total cost. LDP is both a cost-effective and safe approach for distal pancreatic lesions. This series showed a shorter LOS and lower total hospital costs for LDP than for ODP, accompanied by equivalent postoperative outcomes.

Video-Assisted Thoracoscopic Lobectomy Is Less Costly and Morbid Than Open Lobectomy: A Retrospective Multiinstitutional Database Analysis

The Premier Perspective Database (Premier Inc, Charlotte, NC) was used to compare hospital costs and perioperative outcomes for video-assisted thoracoscopic surgery (VATS) and open lobectomy procedures in the United States. Eligible patients underwent a lobectomy for cancer by a thoracic surgeon, by VATS or open thoracotomy and were captured in the database between third quarter of 2007 and through 2008. Multivariable logistic regression analyses were performed for binary outcomes. Ordinary least-squares regressions were used to estimate continuous outcomes. All models were adjusted for patient and hospital characteristics. A total of 3,961 patients underwent a lobectomy by a thoracic surgeon by open (n = 2,907) or VATS (n = 1,054) approach. Hospital costs were higher for open versus VATS; $21,016 versus $20,316 (p = 0.027). Adjustment for surgeon experience with VATS over the 6 months prior to each operation showed a significant association between surgeon experience and cost. Average costs ranged from $22,050 for low volume surgeons to $18,133 for high volume surgeons. For open lobectomies, cost differences by surgeon experience were not significant and both levels were estimated at $21,000. Length of stay was 7.83 versus 6.15 days, for open versus VATS (p = 0.000). Surgery duration was shorter for open procedures at 3.75 versus 4.09 for VATS (p = 0.000). The risk of adverse events was significantly lower in the VATS group, odds ratio of 1.22 (p = 0.019). Lobectomy performed by the VATS approach as compared with an open technique results in shorter length of stay, fewer adverse events, and less cost to the hospital. Economic impact is magnified as the surgeon's experience increases.

Assessment of the Influence of Test Characteristics on the Clinical and Cost Impacts of Methicillin-ResistantStaphylococcus aureusScreening Programs in US Hospitals

To compare the impacts of different methicillin-resistant Staphylococcus aureus (MRSA) screening test options (eg, polymerase chain reaction [PCR], rapid culture) and program characteristics on the clinical outcomes and budget of a typical US hospital. We developed an Excel-based decision-analytic model, using published literature to calculate and compare hospital costs and MRSA infection rates for PCR- or culture-based MRSA screening and then used multivariate sensitivity analysis to evaluate key variables. Same-day PCR testing for a representative 370-bed teaching hospital in the United States was assessed in different populations (high-risk patients, intensive care unit [ICU] patients, or all patients) and compared with other test options. Different screening program populations (all patients, high-risk patients, ICU patients, or patients with previous MRSA colonization or infection only) represented a potential savings of $12,158-$76,624 per month over no program ($188,618). Analysis of multiple test options in high-risk population screening indicated that same-day PCR testing of high-risk patients resulted in fewer infections over 1,720 patient-days (2.9, compared with 3.5 for culture on selective media and 3.8 for culture on nonselective media) and the lowest total cost ($112,012). The costs of other testing approaches ranged from $113,742 to $123,065. Sensitivity analysis revealed that variations in transmission rate, conversion to infection, prevalence increases, and hospital size are important to determine program impact. Among test characteristics, turnaround time is highly influential. All screening options showed reductions in infection rates and cost impact improvement over no screening program. Among the options, same-day PCR testing for high-risk patients slightly edges out the others in terms of fewest infections and greatest potential cost savings.

Endoscopic stenting versus surgical colostomy for the management of malignant colonic obstruction: comparison of hospital costs and clinical outcomes

BackgroundAlthough stent placement is increasingly performed, colostomy still is considered the gold standard for emergent relief of malignant colonic obstruction (MCO). This study aimed to compare hospital costs and clinical outcomes between patients undergoing colostomy and those undergoing stenting for the management of MCO.MethodsA retrospective claims analysis of the Medicare Provider Analysis and Review (MedPAR) data set was conducted to identify inpatient hospitalizations for colostomy or stent placement for the treatment of colon cancer (2007–2008). The outcomes evaluated using MedPAR compared the total length of hospital stay (LOS) and the costs associated with both techniques. Because MedPAR is a claims data set that does not provide outcomes at a patient level, a single-institution retrospective case–control study was conducted in which each stent placement patient was matched with two colostomy patients during the same period. Outcome measures (institutional data) were used to compare rates of treatment success, postprocedure LOS, and reinterventions between the two cohorts.ResultsThe MedPAR data evaluated 778 stent placements and 5,868 colostomy hospitalizations. There were no differences in gender, age distribution, or comorbidity between the two groups. Compared with colostomy, the median LOS (8 vs. 12 days; p < 0.0001) and the median cost ($15,071 vs. $24,695; p < 0.001) per claim were significantly less for stent placement. Stent placement was more commonly performed at urban versus rural hospitals (84% vs. 16%; p < 0.0001), teaching versus nonteaching hospitals (56% vs. 44%; p = 0.0058) and larger versus smaller institutions (mean bed capacity, 331 vs. 227; p < 0.0001). The institution data included 12 patients who underwent stent placement and 24 who underwent colostomy. Although both methods were technically successful, the median postprocedure LOS (2.17 vs. 10.58 days; p = 0.0004) and the rate of readmissions for complications (0% vs. 25%; p = 0.01) were significantly lower for stent placement.ConclusionAlthough the technical and clinical outcomes for colostomy and stent placement appear comparable, stent placement is less costly and associated with shorter LOS and fewer complications. Dissemination of stent placement beyond large teaching hospitals located in urban areas as a treatment for MCO is important given its implications for patient care and resource use.Electronic supplementary materialThe online version of this article (doi:10.1007/s00464-010-1523-y) contains supplementary material, which is available to authorized users.

Examining cost variation across hospital departments–a two-stage multi-level approach using patient-level data

Studies of hospital efficiency seldom lead to changes in practice, partly because recommendations are unspecific or results are not seen as robust. We describe a method to compare hospital costs that utilises patient-level data. We perform a two-stage analysis in which we first consider factors that explain costs among patients and then across hospital departments. We illustrate our approach by examining the costs and characteristics of almost one million patients admitted to 136 English NHS hospital obstetrics departments in 2005/2006. We identify those departments with significantly higher costs that need to take action.

Cost of thoracic endovascular aortic repair versus open repair and implications for the US health care system

Following the 2005 FDA approval of the TAG endograft (W. L. Gore & Associates, Inc, Flagstaff, Ariz), thoracic endovascular aortic repair (TEVAR) utilization increased dramatically.1Orandi B.J. Dimick J.B. Deeb G.M. et al.A population-based analysis of endovascular versus open thoracic aortic aneurysm repair.J Vasc Surg. 2009; 49: 1112-1116Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar The clinical trial leading to approval of the Gore-TAG thoracic stent graft demonstrated beneficial effects for early morbidity and mortality, with similar long-term survival compared with open repair.2Makaroun M.S. Dillavou E.D. Wheatley G.H. Cambria R.P. Five-year results of endovascular treatment with the Gore TAG device compared with open repair of thoracic aortic aneurysms.J Vasc Surg. 2008; 47: 912-918Abstract Full Text Full Text PDF PubMed Scopus (310) Google Scholar However, there remains a paucity of data comparing the costs of TEVAR versus open repair. This study compared hospital costs and physician relative value units (RVUs) between TEVAR and open repair at a US academic institution. Records from patients undergoing elective TEVAR and open repair of distal arch and proximal descending thoracic aneurysms between January 2005 and December 2007 at a single academic institution were analyzed. The hospital cost accounting system was used to compare mean costs in the following categories: total hospitalization, total day of surgery, operating room, grafts, anesthesia, imaging, pharmacy, laboratory, and respiratory services. Costs were adjusted to 2007 dollars using the consumer price index. Cost ratios are reported because hospital restrictions prohibited reporting actual values. Age, gender, comorbidities, length of stay (LOS), operating room time, and physician RVUs were examined. Student t test was used for age, RVUs, and cost category variables. Mann-Whitney test was used for median LOS. Pearson chi-square and Fischer exact test were used for gender and comorbidity comparisons (v17.0 SPSS, Chicago, Ill). Twenty-nine patients having open repair and 28 patients having TEVAR were identified. Patients having TEVAR were older, but comorbidities were similar between groups (Table 1). Despite shorter surgical times for TEVAR (168 vs 465 minutes, P < .001), TEVAR operating room costs were 2.03 times greater than open repair (P < .001). Increased operating room costs for TEVAR were secondary to TEVAR graft costs, which were 22.2 times higher than open repair. TEVAR grafts accounted for 74% of TEVAR day of surgery costs, which were 1.32 times higher than open repair (Figure 1). However, the total hospitalization costs remained 1.55 times greater for open repair versus TEVAR. Longer median LOS for open repair (20 days vs 6 days, P < .001) led to greater utilization of hospital services. Anesthesia costs were 4.00 times greater for open repair versus TEVAR (P < .001). Overall imaging costs were 1.78 times greater for open repair versus TEVAR (P = .023). Pharmacy costs were 5.74 times greater for open repair versus TEVAR (P = .001). Laboratory costs were 4.94 times greater for open repair versus TEVAR (P < .001). Respiratory services were 4.89 times greater for open repair versus TEVAR (P = .001). Despite shorter surgical times, average RVUs were greater for TEVAR versus open repair (97.74 vs 92.97, P = 0.616).Table 1Patient demographics and comorbidities in comparison groups TEVAR versus open repairTEVAROpen repairP valueAge73.2162.28<.001Female42.86% (12/28)34.48% (10/29).516Hypertension78.57% (22/28)89.66% (26/29).251Coronary artery disease32.14% (9/28)27.59% (8/29).707COPD42.86% (12/28)20.69% (6/29).072CKD0% (0/28)17.24% (5/29).052TEVAR, Thoracic endovascular aortic repair; COPD, chronic obstructive pulmonary disease; CKD, chronic kidney disease. Open table in a new tab TEVAR, Thoracic endovascular aortic repair; COPD, chronic obstructive pulmonary disease; CKD, chronic kidney disease. In conclusion, TEVAR day of surgery costs are much greater due to high endograft costs, although overall hospital costs are greater for open repair. Assessment of in-hospital costs reveals TEVAR to be a cost-effective treatment alternative in the short term. The cost-effectiveness of TEVAR should improve if endograft costs decrease with dissemination of this technology. Importantly, this study does not address the long-term costs of TEVAR. TEVAR patients require lifelong monitoring similar to patients having endovascular repair of abdominal aneurysms (EVAR). Analyses of the long-term costs of EVAR are concerning and warrant similar apprehensions for TEVAR. For example, one analysis of the 5-year EVAR postprocedural costs revealed a 44% incremental increase in the global cost compared with the initial implantation cost.3Noll Jr., R.E. Tonnessen B.H. Mannava K. et al.Long-term postplacement cost after endovascular aneurysm repair.J Vasc Surg. 2007; 46 (discussion 15): 9-15Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar Further investigation of TEVAR long-term costs is imperative for understanding current and future impacts on the US health care system.

Comparing hospital costs: What is gained by accounting for more than a case-mix index?

We explore what effect controlling for various patient characteristics beyond a case-mix index (DRG) has on inferences drawn about the relative cost performance of hospital departments. We estimate fixed effect cost models in which 3754 patients are clustered within six Danish vascular departments. We compare a basic model including a DRG index only with models also including age and gender, health related characteristics, such as smoking status, diabetes, and American Society of Anesthesiogists score (ASA-score), and socioeconomic characteristics such as income, employment and whether the patient lives alone. We find that the DRG index is a robust and important explanatory factor and adding other routinely collected characteristics such as age and gender and other health related or socioeconomic characteristics do not seem to alter the results significantly. The results are more sensitive to choice of functional form, i.e. in particular to whether costs are log transformed. Our results suggest that the routinely collected characteristics such as DRG index, age and gender are sufficient when drawing inferences about relative cost performance. Adding health related or socioeconomic patient characteristics only slightly improves our model in terms of explanatory power but not when drawing inferences about relative performance. The results are, however, sensitive to whether costs are log transformed.

The economic implications of rasburicase treatment in adult tumor lysis syndrome patients

e17503 Background: Rasburicase is a recombinant urate-oxidase enzyme used to reduce high levels of plasma uric acid (UA) resulting from tumor lysis syndrome (TLS). Rasburicase reduces UA levels within 4 hours of administration, minimizing risk of serious complications from TLS. Treatment pattern analyses indicate rasburicase is often used in combination with allopurinol; however, no studies have evaluated clinical and economic consequences of this pattern of care. The purpose of the study was to compare hospitalization costs, length of stay (LOS), and duration of critical care in patients receiving rasburicase with or without allopurinol. Methods: Patients in the Premier hospital database administered rasburicase or combination therapy within 2 days of hospital admission were eligible for study inclusion. Patients were excluded if they were &lt;18 years of age or received hemodialysis on admission. Patients were propensity score matched to rasburicase patients based on gender, race, hospital type, provider type, payer type, admission source, use of electrolyte modification therapy, critical care admission, and comorbid diagnoses. Differences in health care costs, LOS, and duration of subsequent critical care were assessed using exponentially distributed generalized linear models with a log link function. Projection weights are used to produce national projected patient counts. Results: There were 280 rasburicase and 310 combination patients matched in the analysis. Mean age of the sample was 65.2, with 31% being female. There were no statistical differences in matched covariates across the cohorts. Rasburicase patients incurred an average total cost of $39,474 per hospitalization compared to $52,047 for combination patients (p = 0.0029). Rasburicase patients also had a lower LOS (10.5 days) compared to combination therapy (16.4 days, p &lt; 0.0001). Duration of critical care was similar in both cohorts (rasburicase = 1.4 days vs 1.8 days, p = 0.1222). Conclusions: Combination therapy of rasburicase and allopurinol resulted in higher total hospitalization costs and longer LOS compared to rasburicase monotherapy. [Table: see text]

Prospective study comparing hospital costs and DRG reimbursement of inpatient treatment of febrile neutropenia during adjuvant anthracycline-based CTX for primary breast cancer

e11570 Background: Febrile neutropenia (FN) is an undesired effect of myelosuppressive chemotherapy (CTX). To date limited data on costs of FN management is available. We compared costs and reimbursement of FN in a study of BC patients during adjuvant anthracycline (AC)-based CTX. Methods: Prospective, observational, longitudinal study in primary BC patients, enrolled 1–12/2006 consecutively before start of CTX in a German university clinic. FN was defined as fever &gt;38ºC + ANC &lt;1x109/L. Clinical and resource use data + DRG reimbursement were analyzed from medical charts. Costs for inpatient therapy of FN were compared to DRG reimbursement and results are presented from provider's perspective. Results: Of all patients approached (n=61), n=54 signed informed consent (88.5%), n=2 withdraw (3.3%) and n=2 were excluded from evaluation because of non-AC-based CTX. Patients were on avg. 57.4 (32–74) years and otherwise healthy ECOG 1 (n=50; 100%). Tumor classification was T1 n=25, T2 n=19, ≥T3 n=5 and pTx n=1. Chemo regimen was either AC-based n=29 (58.0%) or AC+taxane-based n=21 (42.0%). 12 episodes of FN occurred (24.0%) in 11 patients, one patient had 2 episodes; n=11 were treated as inpatients, n=1 as outpatient. Hospital stay for inpatients was on avg. 5.4 days (4–8), 0.7 days below average according to G-DRG catalog. Mean cost per FN episode requiring hospital treatment was 1.827 €, SD ±795 € (95%CI: 1293, 2361). Basic hospital costs were 83%, drug treatment 9% and diagnostics 8% of total direct costs. DRG reimbursement for inpatient FN was 2.145 € per episode, thus cost covering for the provider. Avg. reimbursement rate/day was 417 € (253–665 €). Inadequately DRG coding (n=4) resulted in a loss of 1.069 €/case (-42.2%). Conclusions: Costs for FN treatment vary among patients and DRG reimbursement does not necessarily reflect providers’ costs. Main cost drivers are hospitalization, length of stay, diagnostics and antibiotics. Surprisingly, inpatient treatment of FN under current therapy regimen is cost covering if adequately coded. This prospective evaluation and calculation of provider's costs and reimbursement helps understanding the allocation of resources for rational and cost-covering therapy. [Table: see text]

Economic Evaluation of Carotid Artery Stenting Versus Carotid Endarterectomy for the Treatment of Carotid Artery Stenosis

The clinical effectiveness of carotid endarterectomy (CEA) is well established. But the economic impact of CEA and carotid artery stenting (CAS) is still uncertain. The objective of this study was to compare hospital costs and reimbursement for CAS and CEA. We performed a retrospective database analysis on pair-matched patients who underwent CEA (n = 31) and CAS (n = 31) at the Richard M Ross Heart Hospital in Columbus, OH. The hospital's clinical and financial databases were used to obtain patient-specific information and procedural charges. Cost data were generated by applying the hospital's ratio of cost to charges for all DRG charges. The Wilcoxon signed-rank test was used to examine the differences between costs of these procedures. Data are reported as mean +/- SD. The mean age of patients in CAS group was 70.14 years (+/- 1.60 years) versus 68.64 years (+/- 1.75 years) for CEA patients (p < 0.05). The total direct cost associated with CEA ($3,765.12+/-$2,170.82) was significantly lower than the CAS cost ($8,219.71+/-$2,958.55, p < 0.001). The mean procedural cost for CAS ($7,543.61+/-$2,886.54) was significantly higher than that for CEA ($2,720.00+/-$926.38, p < 0.001). The hospital experienced cost savings of $9,690.87 for CEA versus $4,804.79 for CAS from private insurance. Similarly, savings obtained by Medicare-enrolled CEA patients were higher than those for CAS patients ($1,497.79). CAS is significantly more expensive than CEA, with a major portion of cost attributed to the total procedural cost. The hospital experienced significant savings from CEA procedures compared with CAS under all DRG classifications and insurers. Hospitals must develop new financial strategies and improve the efficiency of infrastructure to make CAS financially viable.

Empirical Versus Pre-Emptive Antifungal Therapy in High-Risk Febrile Neutropenic Patients: An Economic Analysis.

Empirical (E) antifungal therapy (ATF) is a standard of care in neutropenic patients with persistent or recurrent fever. However, the safety and cost-effectiveness of the E strategy are challenged by the development of better diagnostic methods and more effective therapies for invasive fungal infection (IFI). An economic analysis was conducted alongside a multicenter open-label randomized non-inferiority trial showing that a pre-emptive (PE) strategy based on clinical symptoms and GM Ag did not reduce the overall survival of prolonged neutropenic patients when compared to a E strategy (details provided in abstract 551005).Objective: The objective of the study was to compare hospital costs between the PE strategy and E strategy.Patients: 293 adult patients with hematologic malignancies and an expected neutropenia (<500 PMN) of ≥ 10 days following chemotherapy were randomized between E or PE strategy with polyens. All were screened 2/w for GM Ag. E patients were given ATFs in case of persistent or recurrent fever, whatever the accompanying symptoms, while PE patients were given ATFs only in case of pneumonia, severe mucositis, septic shock, sinusitis, or skin lesions evocative of filamentous infection, aspergillus colonization, or positive GM Ag.Methods: The economic analysis was conducted from the hospital perspective (€2005). Total medication costs were computed from individual records during hospital stay.Results: Overall, mean medication costs did not differ significantly between the PE and E groups (see Table). In patients in induction phase (n=151), mean medication costs were higher in the PE group than the E group (+921€, [95%CI, −1602 to +3444]) as explained by the significantly higher proportion of IFI in the PE group (16.4% vs. 3.9%, p<0.01) and the significantly higher medication costs in case of IFI (+4224€, [95%CI, +1200 to +7244]). In patients in consolidation phase (n=51) or autologous stem cell transplant (ASCT) (n=91), mean medication costs were significantly lower in the PE group than the E group (−1224€, [95%CI, −233 to −2215]) as explained by the significantly lower proportion of patients receiving ATF in the PE group (31% vs. 50%, p<0.03).Conclusion: Cost comparison between E and PE strategy showed opposite results in induction or consolidation/ASCT phases. This finding is mainly explained by different risks of developing IFI according to the therapeutic phase. (Grants: PRC 2002AOR02028).Table:Comparison of mean(std) medication costs, antifungal therapy costs, and proportion of IFI between PE and E groups (€2005)PE strategyE strategypOverall (n=293)Medication costs3595 (7444), n=1433745 (4768), n=150nsAntifungal therapy costs2218 (6969), n=1432337(4093), n=150nsProportion of IFI9.1% (13/143)2.7% (4/150)<0.02Induction (n=151)Medication costs5714 (9843), n=734793 (5330), n=78nsAntifungal therapy costs3974 (9360, n=733353 (4876), n=78nsProportion of IFI16.4% (12/73)3.9% (3/78)<0.01Consolidation or ASCT (n=142)Medication costs13871807, n=702610 (3795), n=72<0.02Antifungal therapy costs386 (1367), n=701237 (2649), n=72<0.02Proportion of IFI1.4% (1/70)1.4% (1/72)ns

In-hospital Costs of Self-Expanding Nitinol Stent Implantation versus Balloon Angioplasty in the Femoropopliteal Artery (The VascuCoil Trial)

Although several prospective studies have examined the safety and efficacy of stent placement for femoropopliteal arterial disease, the current cost of these procedures is unknown. To estimate and compare hospital costs associated with conventional balloon angioplasty (percutaneous transluminal angioplasty [PTA]) and stent placement for patients with symptomatic peripheral arterial disease, the authors performed a prospective economic evaluation in conjunction with the Intracoil Femoropopliteal Stent Trial (VascuCoil). Between May 1997 and December 1999, 266 patients with stenotic or occluded superficial femoral or popliteal arteries were prospectively randomized to treatment with the IntraCoil stent or PTA. Detailed resource use and cost data for each patient's initial revascularization procedure and ensuing hospitalization were collected and analyzed on an intention-to-treat basis. Compared with conventional balloon angioplasty, stent placement did not improve clinical outcomes but increased procedure duration, equipment costs, and physician services. As a result, initial hospital costs were approximately 3,500 dollars higher for patients randomized to the IntraCoil stent, compared with PTA (8,435 dollars vs 4,980 dollars; P < .001). As performed in the VascuCoil trial, primary stent placement for femoropopliteal disease did not improve clinical outcomes but increased initial treatment costs by more than 3,000 dollars. Because there were no substantial differences in subsequent clinical outcomes between the two treatments, it is unlikely that these increased initial costs would be offset by savings in follow-up costs. These findings suggest that a strategy of routine stent implantation for patients undergoing femoropopliteal PTA is not optimal on economic grounds and that PTA with provisional stent implantation is preferred.

The average hospital

In 1998, the UK government introduced the National Reference Costing Exercise (NRCE) to benchmark hospital costs. Benchmarking is usually associated with “excellence”; the government emphasised the raising of standards in the 1997 White Paper “ The New NHS: Modern, Dependable” that heralded the NRCE. This paper argues that the UK “New Labour” government's introduction of, and increasing reliance on, hospital cost benchmarking is promoting “averageness”. Average hospitals will be cheaper to run and easier to control than highly differentiated ones; they may also score more highly on certain measures of service improvement. The paper aims, through empirical investigation, both to demonstrate how the activities and processes of hospital life “become average” as they are transformed to comply with the cost accounting average and to indicate how the “average” is being promoted as the norm for hospitals to aspire to. To benchmark to average costs, comparisons are necessary. To compare hospital costs involves the creation of categories and classification systems for clinical activities. Empirical evidence shows that as doctors, patients and clinical practices are moulded into costed categories, they become more standardized, more commensurate and the average hospital is created.

Hospital costs of high-burden diseases: malaria and pulmonary tuberculosis in a high HIV prevalence context in Zimbabwe.

This paper explores the measurement of hospital costs and efficiency in a context where data is scarce, incomplete or of poor quality. It argues that there is scope for using tracers to examine and compare hospital cost structures and relative efficiency in such contexts. Two high-burden diseases, malaria and pulmonary tuberculosis, are used as tracers to calculate the average costs of inpatient care at selected tertiary hospitals. This study shows that it is feasible to prospectively collect cost data for specific diseases and explore in detail both patient cost distribution and susceptible areas for efficiency improvement. The present study found that the critical source of efficiency variation in public hospitals in Zimbabwe lies in the way hospital beds are used.