Cost Outliers Research Articles

Analysis of high cost outliers in a polish reference hospital

The growing fi nancial problems of healthcare institutions contribute to the search of methods in properly distributing and clearly justifying resources. One of these is detecting outliers accounting for an important share of hospital costs. The aim of the study is to identify the factors facilitating identifi cation of cost outliers in one of the Polish reference hospitals in northeast Poland. We have analyzed 4,570 patients. Cost analysis was done retrospectively using accountancy and statistical data from the hospital. To select the outliers, we used the interquartile method using the median and the interquartile distance. To evaluate the factors that infl uence the patient being a cost outlier, we considered: age, length of stay, gender, type of admission, reason of discharge, and type of department. Univariate analysis and multivariable logistic regression were used in the study. Our study revealed that the small percentage of the patients is responsible for the signifi cant level of costs. The total cost outliers comprised 9% of the study sample. They accounted for almost 37% of total hospital costs, 40% of direct costs, and 34% of indirect costs. We discovered that age, gender, length of stay, reason of discharge, and type of department has a signifi cant infl uence on being the cost outlier. The study revealed that the probability of being the CO increased more than 6 times for the surgical patients. This is consistent with the analysis of CO by ICD 10. The analysis revealed that almost all patients suffered from diseases related to high proportion of CO, required surgery treatment. It is concluded that identifying the cost outliers can contribute to better knowledge by managers about the nature of the costs outliers and can be especially valuable in the fi nancing systems where high costs outliers are separately paid.

Analiza bezpośrednich, pośrednich i całkowitych kosztów leczenia pacjentów szczególnie drogich w szpitalu specjalistycznym w Polsce

Celem badań była identyfikacja czynników powodujących, że koszty bezpośrednie, pośrednie i całkowite leczenia pacjentów są szczególnie wysokie. W toku badań zidentyfikowano pacjentów o skrajnie wysokich kosztach leczenia (TCO), pacjentów o skrajnie wysokich kosztach bezpośrednich leczenia (DCO) oraz pacjentów o skrajnie wysokich kosztach pośrednich leczenia (ICO). Przeanalizowano koszty leczenia 4570 pacjentów. Czynniki kosztotwórcze leczenia wyodrębnionych grup pacjentów zidentyfikowano spośród następujących zmiennych: wiek, czas hospitalizacji, płeć, tryb przyjęcia do szpitala, tryb wypisu ze szpitala, rodzaj oddziału. W badaniu posłużono się wieloczynnikową analizą regresji logistycznej. Pacjenci o szczególnie wysokich całkowitych kosztach leczenia stanowili 9% badanej populacji. Odsetek pacjentów o szczególnie wysokich bezpośrednich kosztach leczenia był nieznacznie wyższy (10%), a pacjentów o szczególnie wysokich pośrednich kosztach leczenia był nieznacznie niższy (8%). TCO odpowiadali za niemal 37% kosztów całkowitych, 40% kosztów bezpośrednich, i 34% kosztów pośrednich. DCO odpowiadali za niemal 45% kosztów bezpośrednich, natomiast ICO za 35% kosztów pośrednich. Badania wykazały, że koszty hospitalizacji mężczyzn są istotnie statystycznie wyższe. Ryzyko, że koszty leczenia pacjentów będą szczególnie wysokie, rośnie w przypadku pacjentów skierowanych do dalszego leczenia i tych, w przypadku których odnotowano zgon w toku leczenia. Tryb przyjęcia istotnie statystycznie jest związany z ICO. Ryzyko, że czas pobytu pacjenta będzie szczególnie długi, znacząco rośnie w przypadku ICO (ponad 580 razy), natomiast w znacznie mniejszym stopniu w przypadku DCO (3.81 razy) oraz TCO (13.79 razy). Przeprowadzone badania wskazują, że w kontekście ponoszonych kosztów w szpitalu na uwagę menedżerów zasługują nie tylko pacjenci o skrajnie wysokich całkowitych kosztach leczenia, lecz także pacjenci o skrajnie wysokich bezpośrednich kosztach leczenia oraz pacjenci o skrajnie wysokich pośrednich kosztach leczenia.

Do higher-volume hospitals provide better value in revision hip and knee arthroplasty?

The purpose of this study is to determine if higher volume hospitals have lower costs in revision hip and knee arthroplasty. We questioned the Centres for Medicare and Medicaid Services (CMS) Inpatient Charge Data and identified 789 hospitals performing a total of 29 580 revision arthroplasties in 2014. Centres were dichotomised into high-volume (performing over 50 revision cases per year) and low-volume. Mean total hospital-specific charges and inpatient payments were obtained from the database and stratified based on Diagnosis Related Group (DRG) codes. Patient satisfaction scores were obtained from the multiyear CMS Hospital Compare database. High-volume hospitals comprised 178 (30%) of the total but performed 15 068 (51%) of all revision cases, including 509 of 522 (98%) of the most complex DRG 466 cases. While high-volume hospitals had higher Medicare inpatient payments for DRG 467 ($21 458 versus $20632, p = 0.038) and DRG 468 ($17 003 versus $16 120, p = 0.011), there was no difference in hospital specific charges between the groups. Higher-volume facilities had a better CMS hospital star rating (3.63 versus 3.35, p < 0.001). When controlling for hospital geographic and demographic factors, high-volume revision hospitals are less likely to be in the upper quartile of inpatient Medicare costs for DRG 467 (odds ratio (OR) 0.593, 95% confidence intervals (CI) 0.374 to 0.941, p = 0.026) and DRG 468 (OR 0.451, 95% CI 0.297 to 0.687, p<0.001). While a high-volume hospital is less likely to be a high cost outlier, the higher mean Medicare reimbursements at these facilities may be due to increased case complexity. Further study should focus on measures for cost savings in revision total joint arthroplasties. Cite this article: Bone Joint J 2017;99-B:1611-17.

Fundamental amino acid mass distributions and entropy costs in proteomes

We examine whether the frequency of amino acids across an organism's proteome is primarily determined by optimization to function or other factors, such as the structure of the genetic code. Considering all available proteins together, we first point out that the frequency of an amino acid in a proteome negatively correlates with its mass, suggesting that the genome preserves a fundamental distribution ruled by simple energetics. Given the universality of such distributions, one can use outliers, cysteine and leucine, to identify amino acids that deviate from this simple rule for functional purposes and examine those functions. We quantify the strength of such selection as the entropic cost outliers pay to defy the mass-frequency relation. Codon degeneracy of an amino acid partially explains the correlation between mass and frequency: light amino acids being typically encoded by highly degenerate codon families, with the exception of arginine. While degeneracy may be a factor in hard wiring the relationship between mass and frequency in proteomes, it does not provide a complete explanation. By examining extremophiles, we are able to show that this law weakens with temperature, likely due to protein stability considerations, thus the environment is essential.

Cost-effectiveness of preventive case management for parents with a mental illness: a randomized controlled trial from three economic perspectives.

BackgroundThe children of parents with a mental illness (COPMI) are at increased risk for developing costly psychiatric disorders because of multiple risk factors which threaten parenting quality and thereby child development. Preventive basic care management (PBCM) is an intervention aimed at reducing risk factors and addressing the needs of COPMI-families in different domains. The intervention may lead to financial consequences in the healthcare sector and in other sectors, also known as inter-sectoral costs and benefits (ICBs). The objective of this study was to assess the cost-effectiveness of PBCM from three perspectives: a narrow healthcare perspective, a social care perspective (including childcare costs) and a broad societal perspective (including all ICBs).MethodsEffects on parenting quality (as measured by the HOME) and costs during an 18-month period were studied in in a randomized controlled trial. Families received PBCM (n = 49) or care as usual (CAU) (n = 50). For all three perspectives, incremental cost-effectiveness ratios (ICERs) were calculated. Stochastic uncertainty in the data was dealt with using non-parametric bootstraps. Sensitivity analyses included calculating ICERs excluding cost outliers, and making an adjustment for baseline cost differences.ResultsParenting quality improved in the PBCM group and declined in the CAU group, and PBCM was shown to be more costly than CAU. ICERs differ from 461 Euros (healthcare perspective) to 215 Euros (social care perspective) to 175 Euros (societal perspective) per one point improvement on the HOME T-score. The results of the sensitivity analyses, based on complete cases and excluding cost outliers, support the finding that the ICER is lower when adopting a broader perspective. The subgroup analysis and the analysis with baseline adjustments resulted in higher ICERs.ConclusionsThis study is the first economic evaluation of family-focused preventive basic care management for COPMI in psychiatric and family services. The effects of the chosen perspective on determining the cost-effectiveness of PBCM underscore the importance of economic studies of interdepartmental policies. Future studies focusing on the cost-effectiveness of programs like PBCM in other sites and studies with more power are encouraged as this may improve the quality of information used in supporting decision making.Trial registrationNTR2569, date of registration 2010-10-12.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1498-z) contains supplementary material, which is available to authorized users.

A Web-Based Computer-Tailored Alcohol Prevention Program for Adolescents: Cost-Effectiveness and Intersectoral Costs and Benefits

BackgroundPreventing excessive alcohol use among adolescents is important not only to foster individual and public health, but also to reduce alcohol-related costs inside and outside the health care sector. Computer tailoring can be both effective and cost-effective for working with many lifestyle behaviors, yet the available information on the cost-effectiveness of computer tailoring for reducing alcohol use by adolescents is limited as is information on the costs and benefits pertaining to sectors outside the health care sector, also known as intersectoral costs and benefits (ICBs).ObjectiveThe aim was to assess the cost-effectiveness of a Web-based computer-tailored intervention for reducing alcohol use and binge drinking by adolescents from a health care perspective (excluding ICBs) and from a societal perspective (including ICBs).MethodsData used were from the Alcoholic Alert study, a cluster randomized controlled trial with randomization at the level of schools into two conditions. Participants either played a game with tailored feedback on alcohol awareness after the baseline assessment (intervention condition) or received care as usual (CAU), meaning that they had the opportunity to play the game subsequent to the final measurement (waiting list control condition). Data were recorded at baseline (T0=January/February 2014) and after 4 months (T1=May/June 2014) and were used to calculate incremental cost-effectiveness ratios (ICERs), both from a health care perspective and a societal perspective. Stochastic uncertainty in the data was dealt with by using nonparametric bootstraps (5000 simulated replications). Additional sensitivity analyses were conducted based on excluding cost outliers. Subgroup cost-effectiveness analyses were conducted based on several background variables, including gender, age, educational level, religion, and ethnicity.ResultsFrom both the health care perspective and the societal perspective for both outcome measures, the intervention was more costly and more effective in comparison with CAU. ICERs differed for both perspectives, namely €40 and €79 from the health care perspective to €62 and €144 for the societal perspective per incremental reduction of one glass of alcohol per week and one binge drinking occasion per 30 days, respectively. Subgroup analyses showed, from both perspectives and for both outcome measures, that the intervention was cost-effective for older adolescents (aged 17-19 years) and those at a lower educational level and, from a health care perspective, the male and nonreligious adolescent subgroups.ConclusionsComputer-tailored feedback could be a cost-effective way to target alcohol use and binge drinking among adolescents. Including ICBs in the economic evaluation had an impact on the cost-effectiveness results of the analysis. It could be worthwhile to aim the intervention specifically at specific subgroups.Trial RegistrationNederlands Trial Register: NTR4048; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4048 (Archived by Webcite at http://www.webcitation.org/6c7omN8wG)

Real-time stereo matching using extended binary weighted aggregation

This paper presents an accurate real-time stereo matching method, which is based on the extended binary weighted aggregation. The accuracy of the proposed stereo matching method was significantly enhanced by extending its binary weighted aggregation so that remote connections of support regions can be allowed for aggregation. The extended binary weighted aggregation is based on the following two new ideas. First, the extended binary weighted aggregation connects distant regions over color boundaries, making them one large support region for a given pixel. This approach induces more aggregation targets, and, thus, makes the aggregation step more robust. Second, it excludes cost outliers in the support region to prevent them from being propagated during the aggregation step, making a quality support region. With the extended binary weighted aggregation, the proposed stereo matching method obtains more accurate disparity maps than existing stereo matching methods using binary weighted aggregation methods, while maintaining the speed advantage of binary weighted aggregation. Experimental results illustrated that the proposed stereo matching method outperformed all existing real-time stereo matching methods in terms of accuracy, providing the average bad pixel rate of 5.12%, for the Middlebury stereo test images. The proposed stereo matching method was implemented on a CUDA platform with a high-end GPU. The implemented system operated at up to 300 fps for the stereo images with 320×240 pixel resolution and a disparity range of 32 pixels.

Health Care Expenditures for University and Academic Medical Center Employees Enrolled in a Pilot Workplace Health Partner Intervention.

To evaluate the impact of a pilot workplace health partner intervention delivered by a predictive health institute to university and academic medical center employees on per-member, per-month health care expenditures. We analyzed the health care claims of participants versus nonparticipants, with a 12-month baseline and 24-month intervention period. Total per-member, per-month expenditures were analyzed using two-part regression models that controlled for sex, age, health benefit plan type, medical member months, and active employment months. Our regression results found no statistical differences in total expenditures at baseline and intervention. Further sensitivity analyses controlling for high cost outliers, comorbidities, and propensity to be in the intervention group confirmed these findings. We find no difference in health care expenditures attributable to the health partner intervention. The intervention does not seem to have raised expenditures in the short term.

Nursing: Essential to Healthcare Value

Nursing is a practice discipline and occurs as 1 nurse and 1 patient, family, or community at a time. The encounter between a nurse and patient forms a fundamental bond that defines, not only nursing as a profession, but each individual nurse as a provider of care. Nursing practice drives value, and nurses have a direct and intimate influence on the quality, safety, and costs of patient-centered care. If we define nursing value as the function of outcomes divided by costs,1 there is a need to better define the measures and analytics for patient-level costs and outcomes of nursing care. This fundamental shift to capture the patient or consumer impact of nursing care is an important expansion of how nursing value is quantified. This will require rethinking how we view nursing care delivery beyond solely measuring nursing in terms of tasks or ratios and staffing levels, to one that recognizes the individual and collective accomplishments and results provided by each nurse across the broad spectrum of care. True nursing value can only be described by measurement of the clinical and financial impact of nursing care.

Abstract 253: Bottom up Costing Ventricular Assist Device Therapy And Optimal Medical Management-first Steps To Establishing Cost Effectiveness.

Background: Since Left Ventricular Assist Devices were approved in the US for destination therapy, there has been a rapid increase in their use. Information on the cost of advanced heart failure management (AHF), transplant (HTX) and VAD programs is variable across health systems, as most cost data is derived from casemix costing, charges or claims against insurers. This weakens comparative studies as eligible AHF patients are cost outliers in the broader heart failure population. We outline a cost effectiveness study of VAD therapy vs AHF as part of an HTX program, using Time Driven Activity Based Costing of identified models of care in an Australian setting. Methods: All patients activated to the HTX waitlist between 07/2009 and 06/2012 (n=101) were screened and 86 included (62 AHF, 24 VAD). Models of care were defined through 13/86 file reviews, clinician interviews and analysis of activity. Detailed costing was undertaken for 5 VAD and 8 AHF patients for 12 months pre and post HTX listing or VAD implant and included medical, allied health, nursing activities, inpatient care and clinic visits (ClinV), consumables, drugs, pathology, medical imaging, and prosthetics. Results: Mortality at 1 yr was 12% (3/24) for VADs post implant and 11% (7/62) for AHF post HTX activation. 148 service activities were identified in 13 file reviews ranging from basic documentation to ECMO insertion. The two groups were matched for age, AHF etiology and gender. In house database interrogation yielded a median pathology cost per patient of $4811 in 17/24 Pre VAD, and $12,294 in 20/24 Post VAD patients,. Median allied Health cost for 19/24 Pre VAD patients was $545 and in 23/24 Post VAD was $2938 ($AUD) Hospitalisations and costs borne beyond the transplant center made comparison between VAD therapy and AHF incomplete. Conclusion: The BTT VADs were sicker, with more days hospitalized pre and post VAD. From an institutional and health system perspective, correct identification of, and reimbursement for activities related to best practice models of care is crucial. Cost effectiveness, capturing costs borne at other hospitals as well as federal, drug and GP reimbursements should be addressed in this cohort.

Economic and Operational Implications of a Standardized Approach to Hemodynamic Support Therapy Using Percutaneous Cardiac Assist Devices

Impella 2.5 has been shown to reduce major adverse events for patients undergoing elective high-risk percutaneous coronary intervention. We performed a single-center retrospective study to compare the costs and resource use of Impella 2.5 and intra-aortic balloon pump (IABP) support. All high-risk patients who received Impella 2.5 (n = 35) and IABP (n = 295) support from December 2008 to July 2011 were included. Propensity score matching identified a balanced 1:1 matched cohort (35 Impella vs 35 IABP) based on indications for implantation, preimplantation hemodynamics, and age. Diagnostic, procedural, financial, and resource use data were collected. As compared with IABP, Impella offered a more predictable course of treatment/resource consumption and was not associated with any extreme cost outliers (17.1% vs 0.0%, respectively; P = 0.025). The mean admission and 90-day episode of care total costs for Impella were 5.5% ($67,681 vs $71,608, P = 0.79) and 4.2% ($70,680 vs $73,476, P = 0.85) lesser than that for IABP, respectively. Although not statistically significant, Impella patients had a trend toward lower rehospitalization rates (11.4% vs 20%), lesser mean index length of hospital stay (11.2 vs 13.7), and 90-day (11.7 vs 14.2) episode of care length of hospital stay. Impella support was associated with consistent course of treatment/resource consumption with significantly fewer 90-day extreme cost outliers than was IABP. The lower index and 90-day follow-up cost trends observed for Impella were driven by shorter length of hospital stay and fewer rehospitalizations. As providers strive to improve quality of care by reducing variability, these findings have implications for the development of hemodynamic support algorithms.

Effect of Opioid-Related Adverse Events on Outcomes in Selected Surgical Patients

ABSTRACTPurpose: This retrospective study utilized a large, national hospital database to assess the impact of opioid–related adverse events (ORADE) on patient outcomes following selected surgical procedures known to require postoperative pain control. Methods: Outcomes of patients with administratively documented ORADE were compared to those without. Multivariate regression determined differences in hospital costs; length of stay (LOS); odds of individuals being an outlier in total cost and LOS; and having a 30-day all-cause readmission. Results: Among 319,898 surgeries of interest, 12.2% of patients experienced an ORADE. Patients had higher adjusted mean costs ($22,077 [95% CI 21,823–22,333] vs. $17,370 [95% CI 17,238–17,503]; p < 0.0001) and greater LOS (7.6 [95% CI 7.5–7.6] vs. 4.2 days [95% CI 4.2–4.2]; p <0.0001). Adjusted odds of being a total cost and LOS outlier were 2.8 (95% CI 2.7–2.8) and 3.2 (95% CI 3.1–3.3) times greater in the ORADE group. These patients were more likely to be readmitted (OR 1.06, 95% CI 1.02–1.09). Conclusions: Patients exhibiting a documented ORADE had greater overall costs, longer hospitalizations, and increased likelihood for readmission. These results highlight the economic impact associated with opioid use for postsurgical pain management.

Cost and Quality Implications of Opioid-Based Postsurgical Pain Control in Total Abdominal Hysterectomy: A Study of Cost Outliers and Opioid-Related Adverse Events

Objective A retrospective medical record review, case-control study of patients undergoing total abdominal hysterectomy was conducted to determine the relationship between opioid burden, related adverse drug effects (ADEs), and extended length of stay (LOS) and acute care costs cause(s) of LOS outliers. Methods Ninety-seven case patients with extended LOS (≥ 5 days) met the study eligibility criteria and were matched with case controls (patients with a LOS &lt;5 days). The medical records of cases and controls were reviewed to collect information describing pre-established data points: opioid doses and opioid-related ADEs. Difference between cases and controls were compared using McNemar's test for matched pairs, paired t test, and signed rank test. Results Comparisons of opioid-related ADEs revealed the following statistically significant differences compared with controls: respiratory ADEs (eg, hypoxia) in 12% of cases versus 1% of controls ( P &lt; .01) and gastrointestinal ADEs (eg, nausea/vomiting) in 44% of cases versus 19% of controls ( P &lt; .01). Cases received higher doses during the 72 hours following postanesthesia care unit (PACU) discharge ( P = .04). By hospital discharge, cases had received 2.5 times the total opioid dose of controls and, on average, remained hospitalized 132 hours (5.5 days) longer than controls. Approximately 33% of LOS difference between cases and controls occurred prior to operating room admission, whereas approximately 66% occurred between PACU admission and hospital discharge. Conclusions Case patients with unusually long length of hospital stay (LOS outliers) received higher opioid doses and experienced more opioid-related ADEs than controls. These factors appear to contribute to outlier status but cannot completely explain all LOS outliers.

Associations Between Hemoglobin Level, Resource Use, and Medical Costs in Patients With Heart Failure: Findings From HF-ACTION

BackgroundReports that patients with heart failure and anemia incur greater costs and medical resource use have relied largely on data with limited clinical detail. MethodsHF-ACTION, a large trial of exercise training in heart failure, recorded hemoglobin at baseline. Medical resource use and hospital bills for inpatient and emergency department visits were collected throughout the study. We analyzed hemoglobin as a continuous variable to evaluate relationships with medical resource use and costs over 1 year. ResultsAmong 1,763 patients with baseline hemoglobin levels, those with lower hemoglobin levels tended to be older, African American, and women and to have more severe heart failure. Lower hemoglobin was significantly associated with more hospital admissions, inpatient days, outpatient visits, and urgent care or emergency department visits (all P < .005, unadjusted). Although cost outliers influenced estimates, these observations were distributed across hemoglobin levels. Mean 1-year costs across hemoglobin levels defined as ≤11, >11–12, >12–13, >13–14, >14–15, and >15 g/dL were $21,106, $20,189, $16,249, $17,989, $13,216, and $12,492, respectively (P < .001, unadjusted). Significant associations remained after multivariable adjustment. ConclusionsPatients with lower baseline hemoglobin levels experienced progressively greater resource use and higher costs.

PRM51 Nonparametric Regression Analysis Controls Cost Analysis in Data with Outliers

Cost analysis is often complicated to analyze because of skewed data caused by outliers in the upper tail of the distribution. Some of these outlier expenses are a result of extreme expenses before an observation period starts or during an episode of illness. Theil regression is a non-parametric linear regression method that provides accurate estimates of slope and intercept when outliers are present by calculating values based on the median. In a study intended to measure the length of time it took for patient costs to return to normal pre-episode costs after pneumonia, the Theil method was used and compared to Ordinary Least Squares (OLS) results on the same data. The baseline cost was computed as the mean cost for the six months prior to diagnosis, the study allowed for a three month episode period and the OLS and Theil regression methods were computed on the monthly costs for the six months after the episode. High cost outliers during the three month episode led to elevated costs for the first post episode period. This caused an underestimate of cost using the OLS method. Theil regression correctly estimated the increased time to return to normal in 11 of the 21 variables tracked. These differences ranged from 15 to 370 days. OLS found extended time over Theil for 5 of 21 comparisons. These differences ranged from 2 to 26 days. Agreement between OLS and Theil was found for 5 of 21 comparisons. Outliers in regression analysis frequently occur when the variable of interest is cost. Theil regression offers considerable advantages over OLS regression when the outlier is in one of the tails of the distribution. The advantages include more accurate results as well being able to use all the data without exclusion of any data elements.

Impact of Online Primary Care Visits on Standard Costs: A Pilot Study

As medical providers seek new ways to control costs, online visits have begun to receive serious consideration. The purpose of this study was to compare the odds of being a cost outlier during a 6-month period after either an online visit or a standard drop-in visit in a conventional medical office setting. Medical records of primary care patients (both adults and children) seen in a large group practice in Minnesota in 2008 were analyzed for this study. Two groups of patients were studied: those who had an online visit (N = 390) and a comparison group who had regular office care for same-day, acute visits (N = 376). Case types were classified as either complex or common, with common being defined as treatment for pinkeye, sore throat, viral illness, bronchitis, or cough. Outliers were defined as patients for whom standard costs exceeded the 75(th) percentile during a 6-month period after the index visit. Multiple logistic regression analysis was used to adjust for differences between groups. The percentage of online visitors who were cost outliers was 21.2 (versus 28.5 in the standard visit group). Median standard costs were $161 for online visits and $219 for same-day acute visits. The adjusted odds of being a cost outlier was lower for the online visit group than for the standard visit group (odds ratio [OR] 0.52, 95% confidence interval [95% CI] 0.35-0.77) after adjusting for number of visits in the previous 6 months, age, sex, and case type. Outpatient visits in the previous 6 months were positively related to outlier status (OR 1.23, 95% CI 1.17-1.29). Online visits appeared to reduce medical costs for patients during a 6-month period after the visit.

Identificación de pacientes hiperconsumidores de farmacia en atención primaria

Objective To identify pharmacy cost outlier patients in Primary Care, describing epidemiological differences between normal users and outliers; and to study the explanatory power of risk adjustment tools based on Adjusted Clinical Groups (ACG) as regards the variability of pharmacy expenditure for both groups of patients. Design Observational, retrospective study. Setting 23 health centres located in the regions of Aragon, Catalonia and the Balearic Islands. Participants The study sample consisted of 286,450 patients who were seen at least once in 2005. Measurements Variables related to demographic features, pharmacy cost, and case-mix (ACG ® 7.1) were collected. Pharmacy cost outliers were selected according to the inter-quartile range method. A linear regression model was developed to measure the explanatory power of ACG. This same model was applied stratifying the population by variables of the physician, the health centre and the region. Results One out of ten patients was classified as an outlier. This group was responsible for 60% of the total pharmacy expenditure. These outlier patients were 26.3 years older than normal users and had a higher comorbidity. The explanatory power of the ACG classification system was markedly lower −3% vs. 26.4% for normal users-. Conclusions Further research should be done on factors causing a lack of adequacy of ACG among pharmacy outlier patients. Although it could be thought that social circumstances might play a role in the clinical state of patients, it is more likely that the applied trimming method does not allow outliers with justifiable clinical reasons for higher costs to be distinguished from those without them.

The variance of length of stay and the optimal DRG outlier payments

Prospective payment schemes in health care often include supply-side insurance for cost outliers. In hospital reimbursement, prospective payments for patient discharges, based on their classification into diagnosis related group (DRGs), are complemented by outlier payments for long stay patients. The outlier scheme fixes the length of stay (LOS) threshold, constraining the profit risk of the hospitals. In most DRG systems, this threshold increases with the standard deviation of the LOS distribution. The present paper addresses the adequacy of this DRG outlier threshold rule for risk-averse hospitals with preferences depending on the expected value and the variance of profits. It first shows that the optimal threshold solves the hospital's tradeoff between higher profit risk and lower premium loading payments. It then demonstrates for normally distributed truncated LOS that the optimal outlier threshold indeed decreases with an increase in the standard deviation.

Pharmacy cost outliers in primary care; multilevel approach based on ACG in the Spanish context

The objective of this study was to analyse variability in pharmacy cost in Primary Care through a multilevel approach including patient, physician and health centre organisation variables. The analysis was carried out separately for normal and outlier patients concerning pharmacy expenditure.

Recognize the many facets of gerontological nursing

Fact: Older adults influence hospital environments. This patient population is now the predominant recipient of services in all healthcare settings—50% of hospital patients, 70% of home care patients, and 90% of ambulatory patients.1 Patients over age 65 account for 48% of critical care unit admissions and more than 50% of critical care days.2 Hospitalized older patients use more resources and have higher charges and longer stays, accounting for up to 70% of cost outliers.3,4 Nurse leaders of hospital units with high percentages of patients over 65 years of age face numerous challenges, including personnel, organizational structure, and regulatory requirements. There's little information, however, on management issues in hospital units that aren't designated specifically for older adults.