Diem Costs Research Articles

Patient Cost Savings When Using Telehealth for Management of Myeloproliferative Neoplasms

Introduction: Telemedicine has been widely utilized in the healthcare marketplace since the beginning of the COVID-19 pandemic. Over the last 3 years, virtual care has been widely employed in the care of patients with polycythemia vera (PV), essential thrombocythemia (ET) and myelofibrosis (MF) at Mayo Clinic. These rare disorders have few experts; therefore, telemedicine becomes an optimal approach for patients receive expert care even when they are not close to the medical center. 1 Additionally, telemedicine reduces financial burden for the patients. We aim to estimate potential cost savings to patients utilizing telemedicine. Methods: We identified patients with MPN seen at Mayo Clinic, Arizona who have had at least 2 visits (1 or more virtual visits) between March 2020 and June 2022. We extracted retrospective data from electronic medical records (EMR) including sociodemographic data, disease related data and number of visits - both virtual and in person - of the patients identified. The address recorded from the EMR was assumed to be the patient's location at the time of virtual visit. Driving distances were determined using zip codes in Google Maps and the patients were stratified into quartiles based on round trip travel distances. Patients in quartiles 1 through 3 were assumed to have driven while patients in quartile 4 were assumed to have traveled by plane. Patients in quartile 1 were assumed to have 1 travel day including the follow-up visit and no accommodation, patients in quartile 2 were assumed to have 2 travel days including the follow up visit and 1 night of accommodation whereas patients in quartiles 3 and 4 were assumed to have 2 travel days, 1 day for the follow up visit and 2 nights of accommodation. Mileage rate costs were based on US Internal Revenue Service (IRS) standard mileage rates for medical or moving purposes for 2021. 2 Owing to extreme variability in flight costs, flying costs were assumed to be equal to the driving costs. Per diem costs for accommodation and meals and incidentals were based on the US General Services Administration (GSA) 2021 rates for Phoenix 3 with the cost being 75% of the full per diem rate on traveling days via GSA formulaic approach. Results: One hundred and eight patients having 282 virtual visits were identified. Patients ranged from 30 - 87 years with the mean and median age of 65 years and 67 years respectively. Majority of the patients were female (62%) and white (98%) with gender distribution varying by distance. Descriptive statistics of the estimated out-of-pocket costs for patients by distance quartiles are summarized in Table 1a. Mean estimated cost savings ranged from $46.8 to $877.3 with the savings of $43.8 - $1372.2 at extremes. The total cost savings by all patients was $90,306.7. The breakdown of costs by category for each quartile is shown in Table 1b which shows that the majority of costs saved by patients in quartile 1 were due to avoiding costs spent on meals and incidentals (~90% of mean costs) whereas costs saved due to meals and incidentals for patients in quartile 4 were only ~16% of the mean costs. Conclusions: Our research highlighted telemedicine as a cost-effective approach for patients with MPN who received virtual care from March 2020 - June 2022. Study limitations included not weighing costs for childcare or accompanying individuals and using driving costs instead of flying costs, however, these considerations potentially underestimate the actual cost savings to the patient. Additionally, since the median age of this population was 65, we didn't include loss of wages to the analysis, which may further underestimate the costs. Despite concerns over billing, reimbursement, and state licensure, virtual care is being established as a critical part of medicine moving forward. 1. Doolittle, G.C. and A.O. Spaulding, Providing Access to Oncology Care for Rural Patients via Telemedicine. Journal of Oncology Practice, 2006. 2(5): p. 228-230. 2. Internal Revenue Service. Standard mileage rates for 2021. Available at: https://www.irs.gov/tax-professionals/standard-mileage-rates 3. US General Services Administration. Per diem rates. Available at: https://www.gsa.gov/travel/plan-book/per-diem-rates/per-diem-rates-results?action=perdiems_report&fiscal_year=2021&state=AZ&city=&zip=85054

Modelling the Clinical and Economic Impacts of Foundation-Funded versus Staff-Driven Quality Improvement Mental Health Strategies

BACKGROUND Employing a valid and reliable clinical measurement system established in 2002 within our regional Child and Adolescent, Addictions, Mental Health, and Psychiatry Program, we have been able to measure the effect of the general service system, a novel pre-admission initial family group session to orient families to treatment, and an acute at home care service deigned to divert admissions from emergency to in-home support rather than inpatient admission. Additionally, the modelled clinical effect and economic impact of two community programs; one school-based mental health literacy program and one primary care physician training and education program focusing on the management of children's mental health problems. In this paper, we present an established clinical measurement system combined with standardized cost evaluation strategy to assess the respective cost/benefit impacts of four service innovations. METHODS The clinical measurement system has been described in detail, as has its role in measuring the impact of community-level training on the quality of referrals. Our financial department developed standardized per diem cost references for levels of care within our system. The cost references permitted comparison of groups that were exposed and unexposed to the system innovations before and after the initiation of service and community innovations. The school-based mental health literacy program was a regional implementation of a national program (https://mentalhealthliteracy.org/). The primary care physician education was an internationally develop program from the United States (https://thereachinstitute.org). The other two projects were accomplished on a somewhat smaller local scale and at lower overall cost. The pre-admission initial family group session was a bottom-up, staff-designed and developed quality improvement project. The acute at home project, while funded by the children’s hospital foundation as were the two national and international projects. the acute at home project was a top-down director-designed project with one manager and a coordinator. RESULTS The four innovations were evaluated employing the same model. In each case the clinical space created by each innovation was measured in terms of the cost saved comparing the same outcomes (re-admission rates and lengths of stay) over comparable time intervals between and within pre/post exposed and unexposed groups, whilst controlling for clinical effects of exposure and time. The clinical measurement system helped determine group effects to ensure that the target groups were comparable within each initiative’s exposed and unexposed groups and were appropriately distinct between initiatives (eg, appropriate clinical groups were served by each initiative). While four projects were different and served somewhat different patient groups, the pre-admission initial family group session was the most cost effective. The physician training program was both effective and cost neutral. The school-based mental health literacy program was the least evaluable due to the direction of implementation and tended to increase referrals rather than create clinical space for more affected youth, as might be expected. The acute at home project successfully diverted less suicidal patients away from inpatient readmission over the evaluation period. DISCUSSION The main implications for mental health policy derives from linking standardized cost and clinical measurement models permitting economic evaluation of system and community level innovations. Pre and post clinical and cost measurements within and between exposed and unexposed groups for each innovation or project permitted estimation of benefits and cost. CONCLUSIONS The projects varied in focus together with the evaluability of each project, yet this provided important information for health system innovation and renewal within the context of fiscal constraint. The ranking of the projects in terms of their overall benefits and costs may guide decision-making where maximum return on investment makes the most sense.

Analysis of the Cost and Case-mix of Post-acute Stroke Patients in China Using Quantile Regression and the Decision-tree Models.

PurposePost-acute care is fast developing in China, yet a payment system for post-acute care has not been established. As stroke is the leading cause of mortality and disability in China, patients constitute a large share of post-acute-care patients among all hospitalized patients. This study was to identify the cost determinants and establish a case-mix classification of the post-acute care system for stroke patients in China.Patients and MethodsA total of 5401 post-acute stroke patients in seven hospitals of Jinhua City from January 2018 to December 2020 were selected. Demographic characteristics, medical status, functional measures (eg, the Barthel Index, Mini-Mental State Examination, Gugging Swallowing Screen, Hamilton Depression Scale), and cost data were extracted. Generalized linear model (GLM) and quantile regression (QR) were conducted to determine the predictors of cost, and a case-mix classification model was established using the decision-tree analysis.ResultsThe GLM regression revealed that gender, tracheostomy, complication or comorbidity (CC), activities of daily living (ADL), and cognitive impairment were the main variables significantly affecting the hospitalization expenses of post-acute stroke patients. The QR model showed that the gender, tracheostomy and CC factors had a more significant impact on per diem costs on the upper quantiles. In contrast, cognitive impairment had a more substantial effect on the lower quantiles, and ADL significantly impacted the central quantile. Using tracheostomy, CC, and ADL as node variables of the regression tree, 12 classes were generated. The case-mix classification performed reliably and robustly, as measured by the reduction in the variation statistic (RIV=0.46) and class-specific coefficients of variation (CV less than 1.0; range: 0.18–0.81).ConclusionQR has strengths in comprehensively identifying cost predictors across cost groups. Tracheostomy, CC, and ADL significantly can predict the expenses of post-acute care for stroke patients. The established case-mix classification system can inform the future payment policy of post-acute care in China.

Cost-Efficiency Analysis of the Improved Web-Based Planning, Budgeting, and Reporting System (PlanRep) in Tanzania.

Information systems offer unlimited potential for innovation and digitalization of management functions to facilitate citizen participation and improve accountability, transparency, and efficiency in government operations and service delivery. In line with this, for more than one decade, Tanzania implemented an integrated planning, budgeting, and reporting system (PlanRep) that was used to prepare plans and budgets at the local government authorities (LGAs) using a desktop application. In 2017, PlanRep was upgraded to a Web-based system to address several challenges, including poor coordination and high cost involved in the preparation of plans and budgets. However, operational evidence regarding the cost-efficiencies and benefits of shifting to Web-based PlanRep has not been explored. This study aims to address this gap by assessing efficiency gains (in terms of cost and time) of shifting to a Web-based PlanRep system as a tool for the preparation of LGA plans and budgets. The study applied a retrospective before-and-after study design whereby quantitative data was used to assess the amount of time and the cost incurred by LGAs when preparing their budget 1 year before the introduction of PlanRep and 1 year after. Parallelly, qualitative data were collected through key informant interviews with selected LGA officials, Regional Secretariats (RSs), President's Office Regional Administration and Local Government (PORALG), and system end-users such as heads of health facilities and schools (primary and secondary). Secondary data was analyzed by comparing time and cost used before and after Web-based PlanRep, while thematic analysis was employed for qualitative data. The analysis showed a 53% reduction (from USD 3.8 million in 2017/18 to USD 1.8 million in 2018/19) in the total costs LGAs incurred during planning and budgeting after introducing the Web-based PlanRep. The main efficiency gain was related to per diem costs. The analysis also showed significant time saving from an average of 87 days in 2017/18 to only 8 days in 2018/19. PlanRep system end-users also acknowledged that the introduction of Web-based PlanRep has significantly saved their time and costs in preparation of LGA plans and budget. The introduction of the Web-based planning, budgeting, and reporting systems has resulted in tremendous cost reduction, time savings, transparency, accountability, and workload reduction. The findings offer operational evidence to guide the implementation and scale up of similar systems in countries that share equivalent circumstances like Tanzania.

A Case-Mix System for Children and Youth With Developmental Disabilities.

Limited funding across health and social service programs presents a challenge regarding how to best match resources to the needs of the population. There is increasing consensus that differences in individual characteristics and care needs should be reflected in variations in service costs, which has led to the development of case-mix systems. The present study sought to develop a new approach to allocate resources among children and youth with intellectual and developmental disabilities (IDD) as part of a system-wide Medicaid payment reform initiative in Arkansas. To develop the system, assessment data collected using the interRAI Child and Youth Mental Health-Developmental Disability instrument was matched to paid service claims. The sample consisted of 346 children and youth with developmental disabilities in the home setting. Using automatic interactions detection, individuals were sorted into unique, clinically relevant groups (ie, based on similar resource use) and a standardized relative measure of the cost of services provided to each group was calculated. The resulting case-mix system has 8 distinct, final groups and explains 30% of the variance in per diem costs. Our analyses indicate that this case-mix classification system could provide the foundation for a future prospective payment system that is centered around stability and equitability in the allocation of limited resources within this vulnerable population.

Requiem for a heavyweight - can anything more be learned from homing pigeons about the sensory and spatial-representational basis of avian navigation?

The homing pigeon (Columba livia) has long served as a study species to exhaustively investigate the sensory and spatial (map)-representational mechanisms that guide avian navigation. However, several factors have contributed to recent questioning of whether homing pigeons are as valuable as they once were as a general model for the study of the sensory and map-like, spatial-representational mechanisms of avian navigation. These reservations include: the success of this research program in unveiling navigational mechanisms; the burgeoning of new tracking technologies making navigational experiments on long-distance migratory and other wild birds much more accessible; the almost complete loss of the historically dominant, large-scale pigeon loft/research facilities; and prohibitive university per diem costs as well as animal care and use restrictions. Nevertheless, I propose here that there remain good prospects for homing pigeon research that could still profoundly influence how one understands aspects of avian navigation beyond sensory mechanisms and spatial-representational strategies. Indeed, research into neural mechanisms and brain organization, social/personality influences and genetics of navigation all offer opportunities to take advantage of the rich spatial behavior repertoire and experimental convenience of homing pigeons. Importantly, research in these areas would not necessarily require the large number of birds typically used in the past to study the sensory guidance of navigation. For those of us who have had the opportunity to work with this remarkable animal, one research door may be closing, but a window into exciting future opportunities lies ajar.

Economic modelling of telehealth substitution of face-to-face specialist outpatient consultations for Queensland correctional facilities.

Objective The provision of healthcare services to inmates in correctional facilities is costly and resource-intensive. This study aimed to estimate the costs of transporting prisoners from 11 Queensland correctional facilities to the Princess Alexandra Hospital Secure Unit (PAHSU) in Brisbane for non-urgent specialist outpatient consultations and identify the cost consequences that would result from the substitution of face-to-face visits with telehealth consultations. Methods A 12-month retrospective review of patient activity at the PAHSU was conducted to obtain the number of transfers per correctional facility. The total cost of transfers was calculated with estimates for transport vehicle costs and correctional staff escort wages, per diem and accommodation costs. A cost model was developed to estimate the potential cost savings from substituting face-to-face consultations with telehealth consultations. A sensitivity analysis on the cost variables was conducted. Costs are reported from a government funding perspective and presented in 2016 Australian dollars (A$). Results There were 3539 inmate appointments from July 2015 to June 2016 at the PAHSU, primarily for imaging, general practice, and orthopaedics. Telehealth may result in cost savings from negligible to A$969731, depending on the proportion, and travel distance, of face-to-face consultations substituted by telehealth. Wages of correctional staff were found to be the most sensitive variable. Conclusions Under the modelled conditions, telehealth may reduce the cost of providing specialist outpatient consultations to prisoners in Queensland correctional facilities. Telehealth may improve the timeliness of services to a traditionally underserved population. What is known about the topic? Specialist medical services are located in only a few metropolitan centres across Australia, which requires some populations to travel long distances to attend appointments. Some face-to-face specialist outpatient consultations can be substituted by telehealth. What does this paper add? Prisoners from correctional facilities represent one specific population that requires complex travel arrangements for specialist medical appointments. Transportation of prisoners for specialist health appointments represents a substantial cost to the government. This paper quantifies the annual cost in Queensland for transporting prisoners, taking into account fuel and vehicle costs, staff wages, per diem rates, and accommodation. In addition, it quantifies the costs of substituting face-to-face consultations with telehealth consultations. What are the implications for practitioners? This research encourages practitioners to consider using telehealth services for prisoners, as well providing an argument for tertiary centres to include telehealth as a model of care for this population. Telehealth can result in major cost savings and state and federal governments should consider implementation especially in Australia where correctional facilities and specialist services are separated by great geographic distances.

Use of Western Medicine and Traditional Korean Medicine for Joint Disorders: A Retrospective Comparative Analysis Based on Korean Nationwide Insurance Data.

This study aimed to compare the usage of Western medicine and traditional Korean medicine for treating joint disorders in Korea. Data of claims from all medical institutions with billing statements filed to HIRA from 2011 to 2014 for the four most frequent joint disorders were used for the analysis. Data from a total of 1,100,018 patients who received medical services from 2011 to 2014 were analyzed. Descriptive statistics are presented as type of care and hospital type. All statistical analyses were performed using IBM SPSS for Windows version 21. Of the 1,100,018 patients with joint disorders, 456,642 (41.5%) were males and 643,376 (58.5%) were females. Per diem costs of hospitalization in Western medicine clinics and traditional Korean medicine clinics were approximately 160,000 KRW and 50,000 KRW, respectively. Among costs associated with Western medicine, physiotherapy cost had the largest proportion (28.78%). Among costs associated with traditional Korean medicine, procedural costs and treatment accounted for more than 70%, followed by doctors' fees (21.54%). There were distinct differences in patterns of medical care use and cost of joint disorders at the national level in Korea. This study is expected to contribute to management decisions for musculoskeletal disease involving joint disorders.

Integrated care network for long term care in Portugal: cost estimation and patient’s characteristics

Background: Portugal began the implementation of an integrated care network for Long Term Care (LTCIN) in 2006. Its main objective is to deliver services of health and social support including post-acute and long term care. There are four different types of inpatient LTC units: Palliative Care Units (PCU), Convalescent Care Units (CCU), Medium Stay and Rehabilitation Care Units (MSRCU) and Long-Stay and Maintenance Care Units (LSMCU) (1). These units are financed both by the Ministry of Health and the Ministry of Social Affairs.In 2014 LTC represented roughly 0.1% of Portuguese GDP. Despite the rapid growth verified (in 2014 the available beds were ten times higher than in 2006), LTC resource allocation was still far from 1% of GDP verified in developed countries such as Australia, UK or Germany (2, 3, 4).The growing demand for LTC, the increase need of public funding, budget constraints and fourth age demographic pressure triggered the need for rethinking the structure of care provision (5). The knowledge of analytical costs per episode and the specific factors that influence cost variation is a relevant issue to the development of alternative ways for resource allocation.Purpose: The main objective of this study was to estimate LTC episode costs and assess their association to patient characteristics and inpatient unit types.Methods: A cross sectional retrospective study was conducted. Data was collected from LTCIN information system including administrative inpatient data (gender and age), physical autonomy and cognitive status of patients from 2010 to 2012. Cost Information (Balance Sheets and Profit and Loss Statement) was provided voluntarily by seventeen LTC providers. To meet the purpose of the analysis we included inpatient episodes only and excluded palliative care units due to organizational issues.Submitted financial data allowed the estimation of costs of 1.856 distinct episodes, roughly 4.1% of all inpatient LTC episodes reported within the timeframe.A top-down cost accounting method was adopted and average per diem cost was estimated for each provider. Each episode cost was achieved multiplying the per diem cost by the LOS of the specific episode.In order to assess the association between costs and patient characteristic and provider type a Multiple Linear Regression (MLR) analysis with stepwise variable adoption approach was performed and the following formula was adopted:Model 1: Cost i=β_0+β_1 〖Gender〗_i+β_2 〖Age〗_i+β_3 〖PhisicalAutonomy〗_i+β_4 〖CognitiveStatus〗_i+〖β_5 〖ProviderType〗_i+u〗_iTo isolate the effect of patient characteristic per se the same method was used in Model 2 excluding the variable provider type.Results: Per diem average cost of each inpatient episode was 84.28€. Costs differ according to type of unit considered; CCU (96,85€); (MSRCU) (84,84€); LSMCU (67,85€).Results from Model 1 shows that provider type is relevant for explaining cost variation. MSRCU has average per diem costs more than two times higher than CCU. Cognitive status is not relevant for explaining cost variation except for patients with poor cognitive status which have smaller average per diem costs. Results from Model 2 show that even when we exclude provider type patients’ characteristics remain not relevant for explaining cost variation.Discussion: Provider type is the most relevant variable for explaining cost variation. This suggests that supply characteristics are more relevant than considered demand characteristics to define resource allocation and costs. The referral to specific type of provider according to treatment plan seems to drive the cost and, according to it, patients with similar characteristics may represent different per diem LTC costs.During the study we found some limitations. The most relevant is the absence of detailed cost information and complete diagnosis data. We used the best information available (Balance Sheet and Profit & Loss Statement), which are the legal economic documents imposed by the fiscal system. We recognize that the adoption of standardized minimum dataset of financial elements for LTC providers or bottom-up patient costing method (recommended solution), would allow us a better cleaner picture on what is relevant for explaining cost variation.Despite limitations and recognizing that different results could be found if different methods were adopted, we believe in our study’s relevance. As far as we know It is the first study in Portugal that aims explaining LTC cost variation at episode level, , reinforces the need for the adoption of a robust cost accounting method and concludes that further research is required.Conclusion: The subject LTC is receiving increasing attention because of demographic trends and the pressures on public finances. Identifying the factors that may influence costs is a relevant issue to inform decision makers on resource allocation planning and ultimately to ensure that healthcare system organization does not promote negative externalities such as access barriers, moral hazard behaviours or resource allocation inequity.

Prevalence, clinical and economic burden of mucormycosis-related hospitalizations in the United States: a retrospective study.

BackgroundMucormycosis is a rare but devastating fungal infection primarily affecting immunocompromised patients such as those with hematological malignancy, bone marrow and solid organ transplantation, and patients with diabetes, and, even more rarely, immunocompetent patients. The objective of this study was to assess the prevalence and burden, both clinical and economic, of mucormycosis among hospitalized patients in the U.S.MethodsThis is a retrospective study using the Premier PerspectiveTM Comparative Database, with more than 560 participating hospitals covering 104 million patients (January 2005-June 2014). All hospitalizations in the database were evaluated for the presence of mucormycosis using either an ICD-9 code of 117.7 or a positive laboratory result for Mucorales. Hospitalizations were further required to have prescriptions of amphotericin B or posaconazole to be considered as mucormycosis-related hospitalizations. The prevalence of mucormycosis-related hospitalizations among all hospital discharges was estimated. Mortality rate at discharge, length of hospital stay, and readmission rates at 1 and 3 months were evaluated among mucormycosis-related hospitalizations. Cost per hospital stay and average per diem cost (inflated to 2014 USD) were reported.ResultsThe prevalence of mucormycosis-related hospitalizations was estimated as 0.12 per 10,000 discharges during January 2005-June 2014. It increased to 0.16 per 10,000 discharges if the definition of mucormycosis was relaxed to not require the use of amphotericin B or posaconazole. The median length of stay was 17 days, with 23% dead at discharge; readmission rates were high, with 30 and 37% of patients readmitted within one and three months of discharge, respectively. The average cost per hospital stay was $112,419, and the average per diem cost was $4,096.ConclusionsThe study provides a recent estimate of the prevalence and burden of mucormycosis among hospitalized patients. The high clinical and economic burden associated with mucormycosis highlights the importance of establishing active surveillance and optimizing prophylactic and active treatment in susceptible patients.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-016-2023-z) contains supplementary material, which is available to authorized users.

PTH-104 Hospital Admissions and Associated Costs of Alcoholic Liver Disease in Scotland Between 1991 and 2011

Introduction Alcoholic liver disease and its associated hospitalisations due to acute and chronic liver disease is a significant worldwide problem with Scotland having worse statistics than most European and Western countries with regards to health burden including mortality and healthcare costs. This SC ottish A lcoholic L iver disease E valuation (SCALE) study was set up to identify a cohort of people hospitalised for the first time with Alcoholic Liver Disease (ALD) in Scotland from 1991 to 2011 and identify trends in these incident admissions, in-hospital mortality, readmissions and mortality after discharge as well as life time costs compared to controls. Methods Hospital records from 1981 to 2011 were used to identify cases of ALD presenting 1991–2011 with no prior hospitalisation due to ALD. These incident cases were classified by sex, age group, socio-economic deprivation and study year as well as decompensated or not decompensated ALD. In-hospital mortality, time to all cause death, readmissions and related hospital costs were calculated by length of stay and hospital-specific per diem cost and compared to matched controls. Parametric survival analysis was used to estimate remaining life expectancy and remaining lifetime hospitalisation related costs were calculated. Results We identified 35,208 incident ALD admissions over the period 1991 to 2011. Incident ALD hospitalisation rates decreased between 2002 and 2011(Men: 63 to 54; Women: 27 to 24 per 100,000). Inpatient mortality was 17.4% during the index admission. 5 (10) year mortality post-discharge was 59% (74%) for patients with decompensated ALD and 49% (65%) without. The mean (median) number of readmissions per year was 3.1 (1.3). The estimated annual cost of hospitalisation for the remaining life of a man, aged 50, living in the most deprived SIMD fifth with an incident ALD admission in 2011 was £ 118,000 higher compared to matched controls. Conclusion After a peak in 2007 / 2008 incident rates of ALD fell in Scotland but remain high in comparison to the epidemiological literature. Prognosis for incident cases of ALD is poor and costs associated with incident ALD cases are very high compared to matched controls.

Determinants of per diem Hospital Costs in Mental Health.

IntroductionAn understanding of differences in hospital costs between patient groups is relevant for the efficient organisation of inpatient care. The main aim of this study was to confirm the hypothesis that eight a priori identified cost drivers influence per diem hospital costs. A second aim was to explore further variables that might influence hospital costs.MethodsThe study included 667 inpatient episodes consecutively discharged in 2014 at the psychiatric hospital of the Medical Centre- University of Freiburg. Fifty-one patient characteristics were analysed. Per diem costs were calculated from the hospital perspective based on a detailed documentation of resource use. Mixed-effects maximum likelihood regression and an ensemble of conditional inference trees were used to analyse data.ResultsThe study confirmed the a priori hypothesis that not being of middle age (33–64 years), danger to self, involuntary admission, problems in the activities of daily living, the presence of delusional symptoms, the presence of affective symptoms, short length of stay and the discharging ward affect per diem hospital costs. A patient classification system for prospective per diem payment was suggested with the highest per diem hospital costs in episodes having both delusional symptoms and involuntary admissions and the lowest hospital costs in episodes having neither delusional symptoms nor somatic comorbidities.ConclusionAlthough reliable cost drivers were identified, idiosyncrasies of mental health care complicated the identification of clear and consistent differences in hospital costs between patient groups. Further research could greatly inform current discussions about inpatient mental health reimbursement, in particular with multicentre studies that might find algorithms to split patients in more resource-homogeneous groups.

Estimating the cost-savings of a comprehensive hospital-based palliative care program.

2 Background: In FY 2012, Johns Hopkins Medicine (JHM) established a palliative care inpatient unit (PCU). The PCU received patients as transfers and direct admissions. PCUs can improve care (Roza K, et al. JPM 2015) and lower per diem costs compared to usual care (Smith TJ, et al. JPM 2003; Goldstein J, et al. JPSM 2015). This project studied the financial impact of the PCU and PC program on JHM. Methods: Using one fiscal year of admissions, the team calculated the per day variable cost of pre-transfer in to palliative care (from ED) and palliative care transfer. These fees were multiplied by the number of patients transferred to the PCU (153) and by the average length of stay in the PCU (5.11 days). These variable costs were added together to reach the combined savings. Consultation savings were estimated using established methods (Morrison RS, et al. Arch Int Med 2008; adjusted to 2014 dollars). Results: The PCU operated at 54% occupancy in the first year. The daily loss pre-transfer of $1,672 was reduced 59% to $785 post-transer. Over 60% of transfers came from the ICU, freeing beds. The PCU saved JHM $367,751 in direct costs; additional cost savings for PC consultation were estimated at $4.3M (1,335 live discharges × $2,374, 165 decedent discharges × $6,872) and $370,000 was collected in professional fees, for a total contribution of approximately $5M. Conclusions: The PCU and PC program had a favorable impact on the health system. As JH moves to an acountable care organization model being both provider and insurer, such improved quality, cost savings, and increased ICU availability are desirable.

Extra length of stay and costs because of health care–associated infections at a German university hospital

Health care-associated infections (HAIs) can be associated with increased health care costs. We examined extra length of hospital stay (LOS) and associated per diem costs attributable to HAIs in a large academic medical center. Data for analysis were acquired in a preinterventional phase of a prospective cohort study (ALERTS) conducted over 12months in 27 general and 4 intensive care units at Jena University Hospital. HAIs were identified among patients hospitalized for ≥48hours with at least 1 risk factor for HAI and new antimicrobial therapy; the diagnosis was confirmed by U.S. Centers for Disease Control and Prevention criteria. Extra LOS was estimated by multistate modeling, and associated extra costs were based on average per diem costs for clinical units sampled. Of a total of 22,613 patients hospitalized for ≥48hours, 893 (3.95%) experienced 1,212 episodes of HAI during 12months. The associated mean extra LOS ± SEM in general units was 8.45±0.80days per case and 8.09±0.91days for patients treated in both general and intensive care units. Additional costs attributable to HAIs were €5,823-€11,840 ($7,453-$15,155) per infected patient. HAIs generated substantial extra costs by prolonging hospitalization. Potential clinical and financial savings may be realized by implementing effective infection prevention programs.

Is perioperative home the future of surgical patient care?

Is perioperative home the future of surgical patient care?

Characterising the Burden of Chronic Lymphocytic Leukemia in Fludarabine-Ineligible Patients in Spain, Italy, and the United Kingdom (UK): A Retrospective Observational Study

Chronic lymphocytic leukemia (CLL) is the most common leukemia in the western world, accounting for approximately 30% of adult leukemias. The majority of CLL patients are elderly and have co-existing medical conditions. This limits therapeutic options and precludes many from receiving the recognized standard of care regimen, fludarabine, cyclophosphamide and rituximab (FCR). A number of recent studies have evaluated alternative chemoimmunotherapies for these patients. The objective of this study was to describe patient characteristics, treatment patterns, and resource utilization for patients who are unfit for a standard fludarabine-based regimen as first-line treatment for CLL in Spain, Italy, and the UK.A retrospective chart review was undertaken at 18 sites in Spain, 16 in Italy, and 17 in the UK, to identify CLL patients who initiated treatment between January 2011 and December 2012, with a target sample size of 150 per country. Eligible patients were defined as those who initiated first-line CLL treatment that did not include fludarabine (UK and Spain) or standard-dose fludarabine (Italy) which ensured that elderly patients with comorbidities were included. The variability in definitions was due to increased use of reduced-dose fludarabine regimens in Italy for patients not otherwise suitable for a standard dose of fludarabine. Data on demographic and disease-related characteristics, treatment patterns, and health resource utilization were abstracted from diagnosis until December 2013.Among eligible patients (Spain, n=127, Italy, n=121, UK, n=94), the mean age at treatment initiation was 75.9, 73.8, and 76.8 years, respectively. In the UK, 89.4% had 2 or more comorbidities compared to 74.8% in Spain and 65.3% in Italy. In all countries, chlorambucil monotherapy was the single most common regimen, prescribed to 59.6% of patients in the UK, 38.6% in Spain, and 30.6% in Italy. Bendamustine plus rituximab was the next most common regimen in the UK (17.0%) and Italy (23.1%). In Spain, the second-most common regimen was chlorambucil plus rituximab (18.9%). In Italy, 9.9% of patients received the reduced-dose fludarabine regimen, FCR-Lite.In both Spain and the UK, 40% of patients were hospitalized during the follow-up period, compared to 27% in Italy. Emergency room use ranged from 2% in the UK to 40% in Spain. A large majority of patients in all countries utilized outpatient services and laboratory monitoring, with more frequent of visits in Spain and Italy relative to the UK. Hospitalization costs were the largest cost driver (€3284 in Spain, €1312 in Italy, €10291 in the UK). Observed differences in hospital costs across countries were due to variation in: the proportion of individuals being hospitalized, with hospitalizations less common in Italy; length of hospital stay, with a minority of long and costly hospital stays in the UK; and hospital per diem costs. In Spain, outpatient visits comprised the second largest category of costs, while in Italy the second largest category was laboratory tests. In the UK, the second largest category was hospice care, although this was heavily influenced by a small number of individuals with very lengthy hospice stays. For the majority of UK patients, outpatient care was the second-highest category of costs.In conclusion, CLL patients who initiated first-line therapy during 2011 and 2012, with a regimen that did not include fludarabine (UK and Spain) or did not contain standard-dose fludarabine (Italy), were elderly, with 2 or more comorbidities. The most frequently administered treatment was chlorambucil monotherapy. Resource utilization patterns varied across countries; while some differences may have resulted from differences in patient and disease characteristics, they likely also reflect variation in management strategies between these countries. These results provide valuable baseline data to understand the potential impact of future treatments for this patient population. Abstract 2646. Table 1SpainItalyUK% with utilizationMean annual cost per patient (€)% with utilizationMean annual cost per patient (€)% with utilizationMean annual cost per patient (€)Hospitalization40.5328426.9131240.410291Hospice008.42055.36380Emergency room40.311515.01072.24Laboratory95.052899.052687.178Outpatient95.0116794.021968.8874Transfusions25.25117.04330.1226 DisclosuresDelgado:Roche: Consultancy, Honoraria, Research Funding; Gilead: Consultancy, Research Funding, Speakers Bureau; GSK: Consultancy, Honoraria, Research Funding; Mundipharma: Consultancy, Honoraria; Celgene: Honoraria; Novartis: Consultancy, Honoraria. Rossi:Amgen: Membership on an entity’s Board of Directors or advisory committees, Research Funding; Janssen: Membership on an entity’s Board of Directors or advisory committees, Research Funding. Raine:GSK: Employment. Haiderali:GSK: Employment.

Total joint Perioperative Surgical Home: an observational financial review.

BackgroundThe numbers of people requiring total arthroplasty is expected to increase substantially over the next two decades. However, increasing costs and new payment models in the USA have created a sustainability gap. Ad hoc interventions have reported marginal cost reduction, but it has become clear that sustainability lies only in complete restructuring of care delivery. The Perioperative Surgical Home (PSH) model, a patient-centered and physician-led multidisciplinary system of coordinated care, was implemented at UC Irvine Health in 2012 for patients undergoing primary elective total knee arthroplasty (TKA) or total hip arthroplasty (THA). This observational study examines the costs associated with this initiative.MethodsThe direct cost of materials and services (excluding professional fees and implants) for a random index sample following the Total Joint-PSH pathway was used to calculate per diem cost. Cost of orthopedic implants was calculated based on audit-verified direct cost data. Operating room and post-anesthesia care unit time-based costs were calculated for each case and analyzed for variation. Benchmark cost data were obtained from literature search. Data are presented as mean ± SD (coefficient of variation) where possible.ResultsTotal per diem cost was $10,042 ± 1,305 (13%) for TKA and $9,952 ± 1,294 (13%) for THA. Literature-reported benchmark per diem cost was $17,588 for TKA and $16,267 for THA. Implant cost was $7,482 ± 4,050 (54%) for TKA and $9869 ± 1,549 (16%) for THA. Total hospital cost was $17,894 ± 4,270 (24%) for TKA and $20,281 ± 2,057 (10%) for THA. In-room to incision time cost was $1,263 ± 100 (8%) for TKA and $1,341 ± 145 (11%) for THA. Surgery time cost was $1,558 ± 290 (19%) for TKA and $1,930 ± 374 (19%) for THA. Post-anesthesia care unit time cost was $507 ± 187 (36%) for TKA and $557 ± 302 (54%) for THA.ConclusionsDirect hospital costs were driven substantially below USA benchmark levels using the Total Joint-PSH pathway. The incremental benefit of each step in the coordinated care pathway is manifested as a lower average length of stay. We identified excessive variation in the cost of implants and post-anesthesia care.

The Effect of tPA on Inpatient Rehabilitation after Stroke: A Cost Comparison.

Tissue plasminogen activator has been found to significantly improve patient outcomes post stroke. Previous economic evaluations have adjusted for fewer admissions to inpatient rehabilitation but not for decreased length of stay in rehabilitation. Our objective was to estimate the potential cost savings associated with a decreased length of stay in inpatient rehabilitation for patients who receive tissue plasminogen activator compared to those who do not, in a Canadian context. Decreased length of stay in inpatient rehabilitation for patients who received tissue plasminogen activator compared to controls was reported previously in a population of 1962 patients admitted to hospital with an ischemic stroke in Ontario between July 1, 2003 and March 31, 2008. Average per diem cost savings associated with the use of tissue plasminogen activator were calculated using a literature based cost estimate. Sensitivity analysis varying the length of stay in inpatient rehabilitation was performed. The estimated mean per diem cost of inpatient rehabilitation derived from the literature was $626. Based on previously reported estimates for reduced length of stay, receipt of tissue plasminogen activator was estimated to result in savings of $939 per patient during inpatient rehabilitation. Sensitivity analysis suggested that these cost savings could range from $501 to $1377 per patient on average. Future economic evaluations of tissue plasminogen activator should consider adjusting for shortened length of stay in inpatient rehabilitation for patients who receive tissue plasminogen activator.

COMPARISON OF CLOSED FEMUR FRACTURE: SKELETAL TRACTION AND INTRAMEDULLARY NAILING COST-EFFECTIVENESS

Background : Fractures of the femur are common injuries affecting the productive age group. Skeletal traction is the mainstay of treatment in Kenya, hence comparison with operative management, to determine which is more cost-effective. To our knowledge no similar study has been done in Africa. Objective : To determine the cost-effectiveness of skeletal traction compared to intramedullary nailing. Design : Prospective conventional sampling analytical study. Setting : Hospital based study in a referral and teaching institution - Kenyatta National Hospital, orthopaedic wards. Study population : Patients admitted at Kenyatta National Hospital with diaphyseal femur fracture aged between 18 – 50 years. The study was done from October 2012 to May 2013. Materials and methods : A structured data collection sheet was used. It included the patient particulars, hospital stay and per diem cost, the type of injury, type of management and comparing the cost of each, X-ray findings during treatment and at 3 months to assess for union. Data was represented in form of tables, and figures. Results : Males were more affected than females, with a mean age of 31.5 years. The mean length of hospital stay was 11.48 days for the operative group and 66.7 days for the skeletal traction group. The average total hospital cost for the operative group was Kshs 54, 380.44 (US$640) compared to Kshs 67,792 (US$798) for the traction group. In the operative group 24 patients had union with one delayed union while in the traction group 12 patients had union, 9 with mal union and 4 delayed union. Conclusion : Intramedullary nailing is more cost-effective than skeletal traction. It met the dominant strategy, because it was significantly less costly than skeletal traction, with a better outcome.

Cost drivers of inpatient mental health care: a systematic review.

Aims. New reimbursement schemes for inpatient mental health care are imminent in the UK and Germany. The shared intention is to reflect cost differences between patients in reimbursement rates. This requires understanding of patient characteristics that influence hospital resource use. The aim of this review was to show which associations between mental health care per diem hospital costs and patient characteristics are supported by current evidence. Methods. A systematic review of the literature published between 1980 and 2012 was carried out. The search strategy included electronic databases and hand-searching. Furthermore, reference lists, citing articles and related publications were screened and experts were contacted. Results. The search found eight studies. Dispersion in per diem costs was moderate, as was the ability to explain it with patient characteristics. Six patient characteristics were identified as the most relevant variables. These were (1) age, (2) major diagnostic group, (3) risk, (4) legal problems, (5) the ability to perform activities of daily living and (6) presence of psychotic or affective symptoms. Two non-patient-related factors were identified. These were (1) day of stay and (2) treatment site. Conclusions. Idiosyncrasies of mental health care complicated the prediction of per diem hospital costs. More research is required in European settings since transferability of results is unlikely.