Direct Care Costs Research Articles

Consumption and direct costs of dental care for patients with head and neck cancer: A 16-year cohort study.

Patients with head and neck (H&N) cancer are commonly treated with surgery and/or radiotherapy, which can increase the risk of oral infection, dental caries, and periodontal disease. The present study investigated dental care consumption and costs in patient with H&N cancer before and after the cancer diagnosis. Data from Swedish regional and national registers were used to follow up dental care utilization and dental procedure costs. The analysis included 2,754 patients who had been diagnosed with H&N cancer (exposed cohort) in Stockholm County, Sweden, during 2000–2012 and 13,036 matched persons without cancer (unexposed cohort). The exposed cohort was sub-grouped into irradiated and non-irradiated patients for analysis. The exposed cohort underwent a moderately higher number of dental procedures per year than the unexposed cohort in both the year of the cancer diagnosis and the year after cancer diagnosis; in addition, these numbers were higher in the irradiated than in the non-irradiated subgroup of the exposed cohort. Dental care consumption and costs in the exposed cohort declined over time but remained at a slightly higher level than in the unexposed cohort over the long term (more than two years). Examinations and preventive procedures accounted for most of the higher consumption in the short term (2 years) and at the longer term follow-up. Swedish national insurance subsidized costs for dental treatment, which were highest in the irradiated subgroup and lowest in the unexposed cohort. Direct costs to the patient, however, were similar among the groups. Swedish national health insurance protects patients with H&N cancer from high dental expenditures. Further studies on the cost-effectiveness of preventive dental care for patients are needed.

Association between Hospice Spending on Patient Care and Rates of Hospitalization and Medicare Expenditures of Hospice Enrollees.

Care at the end of life is increasingly fragmented and is characterized by multiple hospitalizations, even among patients enrolled with hospice. To determine whether hospice spending on direct patient care (including the cost of home visits, drugs, equipment, and counseling) is associated with hospital utilization and Medicare expenditures of hospice enrollees. Longitudinal, observational cohort study (2008-2010). Medicare beneficiaries (N = 101,261) enrolled in a national random sample of freestanding hospices (N = 355). We used Medicare Hospice Cost reports to estimate hospice spending on direct patient care and Medicare claim data to estimate rates of hospitalization and Medicare expenditures. Hospice mean direct patient care costs were $86 per patient day, the largest component being patient visits by hospice staff (e.g., nurse, physician, and counselor visits). After case-mix adjustment, hospices spending the most on direct patient care had patients with 5.2% fewer hospital admissions, 6.3% fewer emergency department visits, 1.6% fewer intensive care unit stays, and $1,700 less in nonhospice Medicare expenditures per patient compared with hospices spending the least on direct patient care (p < 0.01 for each comparison). Ninety percent of hospices with the lowest spending on direct patient care and highest rates of hospital use were for-profit hospices. Patients cared for by hospices with lower direct patient care costs had higher hospitalization rates and were overrepresented by for-profit hospices. Greater investment by hospices in direct patient care may help Centers for Medicare and Medicaid Services avoid high-cost hospital care for patients at the end of life.

Cost effectiveness of integrated care in patients with acquired brain injury

Introduction : Integrated care and Rehabilitation following acquired brain injury improves health outcomes, reduces disability, and improves quality of life. We assessed the cost effectiveness of inpatient rehabilitation after brain injury in individuals with brain injury admitted to the Irish national tertiary specialist rehabilitation centre in 2011. The brain injury team – which consists of a specialist multidisciplinary team including Doctors, nurses, physiotherapists, occupational therapists, speech and language therapists, psychologists, clinical nutritionists, pharmacists and medical social workers – work with patients and their families and carers to achieve the best possible outcome for the patient with a person centred inpatient programme tailored to meet each patient's individual needs. Methods : The study included all patients discharged between 1 January 2011 and 31 December 2011 from the NRH Brain Injury Programme under one of the NRH rehabilitation consultants(AC).Patients’ score on the Disability Rating Scale (DRS) was recorded on admission and at discharge after intensive inpatient rehabilitation. Cost savings attributed to the rehabilitation programme were calculated as the difference between direct care costs on admission and discharge. Direct costs of care were calculated as the weekly cost of the care-assistant hours required to care for patients on the basis of their level of disability or daily nursing-home bed cost when this was required. Results : Of 63 patients, complete DRS information for admission and discharge was available for 41. DRS scores, and therefore average levels of functioning, differed significantly at admission (2.3, between mildly and moderately dependent) and discharge (1.1, independent in special environments, p Average weekly care costs fell from €629 to €242, with costs recouped within 30 months. Discussion : Although the cost of inpatient rehabilitation in this group is expensive initially, in the medium term these costs are covered by the savings in care costs. Ceiling and floor effects of dependency scales can result in underestimation of cost-effectiveness of rehabilitation.Thus, substantial savings result from inpatient rehabilitation, and these savings could have been greater had we considered also the economic benefit of enabling patients to return to employment. Limitations : A randomised controlled trial of rehabilitation versus no rehabilitation would provide more information but would generate an ethical dilemma, in that it would necessitate denying treatment, which is considered standard and has sufficient evidence to support its use, to a group of individuals. We have looked only at financial savings in this study. An analysis of gains in quality of life would clearly provide a more accurate reflection of the value of inpatient rehabilitation. Conclusion : This is the first analysis of the cost effectiveness of inpatient rehabilitation in an Irish setting. We have shown that, on average, the cost of inpatient rehabilitation is covered by the savings resulting from reductions in dependency within 30 months. Inpatient rehabilitation seems to be most cost effective in individuals with brain injury who are markedly dependent on admission, with only 15.6 months required to cover the inpatient cost in this group. After this time, calculated savings of over €50,000 per patient annually can be expected.

Estimating Direct Cost of Cystic Fibrosis Care Using Irish Registry Healthcare Resource Utilisation Data, 2008-2012.

Understanding the determinants of cost of cystic fibrosis (CF) care and health outcomes may be useful for financial planning for the delivery of CF services. Registries contain information otherwise unavailable to healthcare activity/cost monitoring systems. We estimated the direct medical cost of CF care using registry data and examined how cost was affected by patient characteristics and CF gene (CF Transmembrane Conductance Regulator [CFTR]) mutation. Healthcare resource utilisation data (2008-2012) were obtained for CF patients enrolled with the Irish CF Registry by 2013 from linked registry and national hospitalisation database records. Mean annual hospitalisation and medication per-patient costs were estimated by demographic profile, CFTR mutation, clinical status, and CF co-morbidity, and were presented in 2014 euro values. A mixed-effects regression model was used to examine the effect of demographic, CFTR mutation, and clinical outcomes on the log10 cost of direct medical CF care. Using 4261 observations from 1100 patients, we found that the median annual total cost per patient increased over the period 2008-2012 from €12,659 to €16,852, inpatient bed-day cost increased from €14,026 to €17,332, and medication cost increased from €5863 to €12,467. Homozygous F508-CFTR mutation (class II) cost was highest and milder mutation (class IV/V) cost was 49% lower. Baseline estimated cost in 2008 for a hypothetical underweight, homozygous F508del-CFTR 6-year-old female without chronic Pseudomonas aeruginosa/Staphylococcus aureus, CF-related diabetes (CFRD) or methicillin-resistant S.aureus (MRSA), and with a poor percent predicted forced expiratory volume in 1s (ppFEV1) was €10,113, and was €21,082 in a 25-year-old with the same hypothetical profile. Chronic P. aeruginosa infection increased baseline cost by 39%, CF co-morbidity diabetes by 18%, and frequency of pulmonary exacerbation by 15%. Underweight, declining ppFEV1, chronic S. aureus colonisation, and time also influenced cost. CFTR mutation is an important factor influencing the cost of CF care. Costs differ among cohorts of CF patients eligible to access new and emerging CFTR repair therapies. These findings support the evaluation of outcome-associated cost in CFTR mutation-specific CF patient groups.

Health Literacy, Health Care Utilization, and Direct Cost of Care Among Linguistically Diverse Patients with Type 2 Diabetes Mellitus

Background:Low functional health literacy (HL) has been associated with poor self-management of chronic conditions, including type 2 diabetes mellitus (T2DM), an inefficient use of health services, and higher health care costs. Low functional HL and limited English language proficiency both independently predict poor glycemic control among Latino and Chinese immigrants in the United States, and is more common among patients with diabetes with limited HL.Objective:This study investigated the relationship between low functional HL, health care utilization, and costs of health care among a cohort of low-income patients with T2DM whose primary language was English, Spanish, or Cantonese (N = 277).Methods:Patient data were collected from Medicaid administrative health care records as part of a low-income managed care program administered by the San Francisco Health Plan between April 2009 and March 2011. HL was measured with the Brief Questions Screening Tool for Health Literacy, administered via telephone survey. We used negative binomial regression with robust standard errors to estimate the effect of low functional HL on health care utilization, adjusting for demographic, socioeconomic, and health covariates. Results were reported as rate-ratios (RRs). We used two-part regression models to estimate the marginal difference in cost per patient associated with low functional HL. Utilization and cost models were also estimated, stratified by patient language.Key Results:We observed a nonsignificant association between low functional HL and lower health care utilization, and lower total health care costs (−$1,493.53, 95% confidence interval [CI]: $3,602 to $615). While we observed a nonsignificant trend for low functional HL and lower utilization and total cost among people who speak English and Cantonese, low functional HL was significantly associated with more outpatient visits among patients who spoke Spanish (RR 1.31, 95% CI 1 to 1.72).Conclusions:The relationship between low functional HL and health care utilization among this linguistically diverse cohort of patients with T2DM varied by patient language. Further research is needed to determine if lower utilization and costs in certain linguistic subgroups is indicative of barriers to access. [Health Literacy Research and Practice. 2017;1(3):e116–e126.]Plain Language Summary:This study attempts to understand the relationship between health literacy, health care utilization, and costs of health care among an ethnically and linguistically diverse cohort of low-income patients with type 2 diabetes mellitus. We observed differences that could be due to actual differential effects of low HL by language status, or could be explained by unmeasured differences in health-seeking behaviors, access to care, degree of acculturation, or comorbidities.

Hospitalizations in Patients with Systemic Lupus Erythematosus in an Academic Health Science Center.

Hospitalization occurs in about 10% of patients with systemic lupus erythematosus (SLE) each year and accounts for most of the direct cost of SLE patient care. We aimed to determine the frequency of admissions of patients with SLE and describe their causes and outcomes. We identified all hospitalizations at University Health Network in the periods 2011-2012 and 2013-2015 with an International Classification of Diseases, 10th ed. code of M32 (SLE). A retrospective chart review of these patients categorized them based on SLE care provider and cause of admission. Frequency of emergency room visits and duration of hospitalization were ascertained. Poisson and linear regressions were performed to determine factors associated with frequency and duration of hospitalizations. There were 247 unique patients with SLE who were hospitalized a total of 491 times: 87.4% were women, average age of 43.9 ± 17.9 years, and disease duration 13.7 ± 12.3 years. Incidental causes were most common (35.6%); 21.4% and 22.4% of admissions were because of active SLE and infection, respectively. The patients with SLE averaged 1.6 hospitalizations lasting 8.5 days. Thirteen percent of hospitalizations resulted in intensive care unit admission, and 2.8% of hospitalizations resulted in death. Patient employment was associated with fewer hospitalizations during 2011-2015. Antimalarial use was associated with fewer hospitalizations as well as shorter length of stay during 2011-2012. The presence of damage correlated with increased hospitalizations. Higher educational level and antimalarial use correlated with shorter length of stay. Patients with SLE are frequently hospitalized, often because of active SLE or infection, and re-hospitalized within a short period of time.

Measuring cost in the value equation using time-driven activity-based costing (TDABC) at The University of Texas MD Anderson Cancer Center, Division of Radiation Oncology.

e18305 Background: The cost of a full cycle of radiation therapy at MD Anderson Cancer Center has not been determined using a bottom-up measurement approach. Due to the complexity and variation in clinical processes, typical costing strategies do not provide the level of detail necessary to evaluate the value equation, defined as outcomes over cost. To address this limitation, we designed and implemented a practice-wide Time-Driven Activity-Based Costing (TDABC) strategy to capture our total direct cost of care for all treatment modalities within each of 9 disease site-specific services. Methods: Process maps were created for each of the 9 disease site-specific services. Care delivery times were captured by treatment modality for each service as determined by multidisciplinary teams routinely performing each step of the process. The data were entered into a standardized tool, which calculated step costs based upon capacity cost rates for each human resource. The costing tool also calculated total direct labor costs for specific treatment plans based on modality, complexity, and fractionation. Results: The analysis took six months to complete and required the use of approximately 1,000 administrative hours, 250 physician hours, 250 clinical staff hours and 100 medical physics hours. Approximately 17 process maps were created for each of the 9 services with each process map receiving further analysis based upon radiation treatment modality. As a result of observed variation in costs between disease-site services, best practices were identified and 15 standardization opportunities were discovered. Additionally, the cost-benefit analysis between high profile modalities within each disease-site service, such as Proton Therapy and Intensity Modulated Radiation Therapy (IMRT) on the Head and Neck service, were easier to complete. Conclusions: Time-Driven Activity-Based Costing is a valid method for calculating direct costs in a large academic radiation oncology practice. Standardized clinical outcome data can be used to complete the value equation and ultimately provide insight for better clinical and administrative decision making.

Validación de la prueba de extensión en bípedo de los isquiotibiales (PEBI) para el diagnóstico diferencial del dolor lumbar inespecífico mecánico (DLIM)

BackgroundMechanical origin low back pain (MLBP) is the leading cause of work disability and the largest generator of direct and indirect care costs of any health system. There is no medical test to diagnose MLBP, although a test was designed in 2004 for the clinical diagnosis of MLBP. Materials and methodsA prospective cohort study was conducted on 183 patients with non-radicular back pain and had a positive Hamstring Biped Extension Test (HBET) from 2004 to 2014. All (100%) of the patients included in the cohort were rehabilitated using the McKenzie protocol until the pain disappeared, or the patients were unable to improve their rehabilitation process. Additionally, the presence of related anatomical pain generating factors was assessed using various diagnostic imaging tests (MRI, scintigraphy, etc.). ResultsAll patients had a positive HBET when they were included in the cohort. All had diagnostic imaging performed. The pain measured on a visual analogue scale (VAS) had a mean of 7.7 (range 2-10/10). There was a mean follow-up time of 2.24 months (range 1-6 months), with a mean of 20.94 (range 10-60) physiotherapy sessions. A negative result was obtained for the HBET in 100% of patients (P=.05). There was a mean improvement of 0.84 (range 0-3/10, P=.05) on the VAS pain measurement at discharge. DiscussionThe HBET is a useful clinical test for the diagnosis of MLBP, with a positive predictive value of 100%. Low back pain was not associated with diagnostic image tests findings in our cohort in the presence of a positive HBET. Evidence levelII.

Paper #24 - Factors influencing direct clinical costs of outpatient arthroscopic rotator cuff repair surgery

Background: Understanding the cost of healthcare delivered is critical to understanding the overall value provided. Billing charges are often confused with the cost of delivering care and are often inaccurate estimates of the actual costs incurred. Overall, there is limited information on the “true cost” of care delivered or direct clinical care costs. Very limited information exists as to what variables affect the direct clinical care costs of rotator cuff repair surgery. The purpose of this study was to determine the direct clinical care cost of outpatient arthroscopic rotator cuff repair surgery utilizing a unique Value-Driven Outcomes (VDO) tool which was designed to identify and track direct costs of all aspects of clinical care; and to identify various patient and treatment-related variables affecting cost. Methods: Arthroscopic rotator cuff repairs performed at an outpatient academic medical center by three surgeons were included in the analysis from 3/2014 to 6/2015. Cost data was derived for all cases during this period using the VDO tool developed and validated at our institution. Cost data included overall total cost, and was further broken down to identify facility utilization costs, indirect costs, medication costs, supply costs and other ancillary costs. Patient and surgical data collected included attending surgeon, smoking status, BMI, ASA health status, tear severity (partial thickness versus full thickness), repair construct (single row versus double row), if a subscapularis repair was performed, if a subacromial decompression was performed, if a distal clavicle excision was performed, if a biceps tenodesis was performed, the overall numbers of anchors utilized per case, anteroposterior size of the tear (mm), tear retraction (mm) and supraspinatus and infraspinatus muscle quality (Goutallier grade). Univariate and multivariate regressions were performed to determine the affect of various factors on cost. P < .05 was considered statistically significant. Results: 170 arthroscopic rotator cuff repairs were performed during the study period. There were 17 active smokers. 31 patients were considered to have severe systemic disease based upon their ASA classification. 138 full thickness tears and 32 partial thickness tears were repaired. A single row repair was performed on 128 patients and double-row repair on 42 patients. The average total number of anchors used per case overall was 3. The average tear size was 21 mm. The average tear retraction was 18 mm.The average Goutallier grade for the supraspinatus and infraspinatus were 0.9 and 0.4 respectively. Subscapularis repair and subacromial decompression were performed in 37 cases and 106 cases respectively. Distal clavicle excision was performed in 19 cases. A biceps tenodesis was performed in 66 cases and a tenotomy in 26 cases. In the univariate analysis, higher overall total cost was correlated with the presence of subscapularis repair being performed (P < .0001), a bicep tenodesis being performed (P = .043) and a greater total number of anchors used per case (P < .0001). Multivariate analysis results showed continued significant correlations between higher total cost and the presence of a subscapularis repair being performed (P = .015) and total number of anchors utilized (P < .0001). Smoking status, attending surgeon, BMI, ASA classifications, partial versus full-thickness tear, single row vs double row construct, the addition of a subacromial decompression or distal clavicle excision, tear size and retraction and muscle quality were not significantly associated with total cost. (P > .05) Discussion: Direct clinical care costs associated with arthroscopic rotator cuff repair are related to the overall number of suture anchors utilized and the addition of concomitant procedures (biceps tenodesis, subscapularis repair). Implementation of strategies to reduce overall costs should focus on reducing overall anchor quantity and/or potentially using alternative surgical techniques that may result in equivalent clinical results (biceps tenotomy vs. tenodesis; debridement of partial thickness upper border subscapularis tears vs. repair).

Methodology for estimating total direct costs of comprehensive care for non-communicable diseases

RESUMEN Diseases like diabetes mellitus (DM) and hypertension (HT) generate high costs and are the most common cause of mortality in the Americas. In the case of Peru, given demographic and epidemiological changes, particularly the alarming increase in overweight and obesity, the burden of these diseases is constantly increasing, resulting in the need to budget more financial resources to the health services. The total care costs of these diseases and their complications represent a financial burden that should be considered very carefully by health institutions when they draft their budgets. With this aim, the Pan American Health Organization has assisted the Ministry of Health (MINSA) with a study to estimate these costs. This article graphically describes the methodology developed to estimate the direct costs of comprehensive care for DM and HT to the health services of MINSA and regional governments.

Resource Utilization and Cost Effectiveness of Negative Pressure Wound Therapy (NPWT) Versus Moist Wound Therapy (MWT) in Management of Diabetic Foot Transmetatarsal Amputation (TMA)

To evaluate resource utilization and direct economic costs of care for patients treated with negative pressure wound therapy (NPWT) in comparison with standard moist wound therapy (MWT) for preparation of diabetic foot TMA wounds for skin grafting. We retrospectively analyzed 56 patients who underwent transmetatarsal amputation (TMA) for infected diabetic foot from January 2014 to April 2015 at Jain Institute of Vascular sciences (JIVAS), Bangalore. Twenty-eight patients received negative pressure wound therapy (NPWT) (VAC® KCI, TX, USA) dressing while 28 received standard MWT daily. Resource utilization, revascularization procedures, number of secondary procedures (debridement), and total cost for wound bed preparation were calculated in both groups. There was no significant difference in both groups regarding age, gender, comorbidities, and number of revascularization procedures. All patients were having ankle brachial index (ABI) more than 0.8 or ankle pressures more than 80 mmHg before enrolling to study group. MWT group required more debridement (15 vs. 2; P = 0.0001). Average number of dressing changes performed per patients were 25 (range 20–32) for MWT versus 3 (range 2–5) in NPWT group. MWT group had more OPD visits compare to NPWT (14 vs. 2; P value =0.0001). Mean duration for wound bed preparation was 24.61 ± 3.20 days (range 20–32 days) in MWT group and significantly higher than NPWT group 9.11 ± 2.38 days (range 6–15 days) (P = 0.0001; 95% CI difference 13.99 to 17.01). The average total cost for wound bed preparation of TMA wound was Rs 26,875 ± 6810.5 in MWT group and was significantly higher than compared to Rs 23,089.29 ± 6637.5 in NPWT group (P = 0.03; 95% CI difference 182.54 to 7388.89). NPWT resulted in lower resource utilization, reduced costs, and acceleration of wound bed preparation for diabetic foot TMA wound in comparison to standard MWT.

Access to care in cancer: Barriers and challenges.

33 Background: In the current climate of health care reimbursement, coverage reform, and escalating health care costs, navigating cancer care becomes increasingly complex for patients and caregivers. Given the truly fluid marketplace and many payment and care models being established sans engagement with or even information from the patient, it is imperative to assess the ongoing reality of patient access to comprehensive, quality cancer care: care that includes biomedical as well as psychosocial care. Methods: We launched an online research survey project to further explore the cancer patient experience as it relates to accessing health care and living within a new and evolving system of health care. The analysis is based upon a cross-sectional survey of adults (18 years old and older) affected by cancer. The survey was conducted online between June and August of 2016. 1,218 cancer survivors completed survey questions regarding access to insurance, services, and providers as well as direct and indirect costs of care. Results: 78% of patients with cancer either have not or do not recall discussing costs with their health care team prior to treatment. 53.5% of survey respondents reported not knowing the meaning of the term “Clinical Practice Guidelines,” and 73% of participants had never heard the term “Clinical Pathway.” 25% of patients experienced delays in accessing cancer care, 18% of patients reported that costs inhibited them from filling prescription drugs to treat their cancer, 22% of patients chose not to get some of the healthcare services they needed due to high out-of-pocket costs, and 53% reported not receiving social or emotional support. Conclusions: These findings demonstrate that despite progress being made in expanding access to health care, many patients still experience significant barriers and challenges to accessing care. We also find there is a gap in patient knowledge about practice guidelines and payment policies. To create a system where all patients have access to high-quality and comprehensive cancer care, educational efforts are needed to enhance patient understanding of information about practice guidelines and payment policies, including information regarding health risk and benefits, costs, patient health, and quality-of-life outcomes.

The health and economic implications of the use of tanning devices

ObjectivesWe estimated the numbers of cases of health care conditions that are causally associated with exposure to tanning devices in the United States, and calculated the costs of medical care for treating these cases. MethodsThe principal unit of analysis for this study is the number of individuals living in the United States who sought treatment for basal cell carcinomas (BCC), squamous cell carcinomas (SCC), or melanomas. To estimate the percentage of these cases that are attributable to exposure to tanning devices, we calculated the Population Attributable Risk (PAR) for each disease. We calculated annual medical costs on a per-case basis as well as indirect productivity costs, using Years of Potential Life Lost. ResultsThere were nearly 9000 incident cases of melanoma, and more than 86,600 cases of SCC and 168,000 cases of BCC, attributable to exposure to tanning devices in the U.S. in 2015. The cost of direct medical care for these cases is $343.1 million annually, and they will lead to a total economic loss of $127.3 billion over the lifetime of the individuals affected. ConclusionsThe use of tanning devices is a significant contributor to illness and premature mortality in the U.S., and also represents a major economic burden in terms of the costs of medical care and lost productivity.

Probabilistic Return-on-Investment Analysis of Single-Family Versus Open-Bay Rooms in Neonatal Intensive Care Units-Synthesis and Evaluation of Early Evidence on Nosocomial Infections, Length of Stay, and Direct Cost of Care.

There is increasing evidence that the physical environment of neonatal intensive care units (NICUs), including single-family rooms (SFRs) versus open-bay rooms (OPBYs), has tangible effects on vulnerable patients. The objective of this study was to illustrate the financial implications of SFR versus OPBY units by synthesizing and evaluating the evidence regarding the benefits and costs of each unit from a hospital perspective. We assumed a hypothetical NICU with 40 beds in OPBY rooms, to be replaced with a new NICU with 32 SFRs and 8 OPBYs. We synthesized evidence regarding the comparative benefit of each option on 3 outcomes-nosocomial infections, length of stay, and direct costs. We calculated incremental benefit-cost ratio separately considering each outcome over an analysis period of 5 years. A ratio of more than 1 indicates that the investment is worthwhile. Input parameters were assigned probability distributions representing the degree of uncertainty around their true values. Monte Carlo simulation with 5000 iterations was used to quantify the distribution of benefits and costs. The mean value of the incremental benefit-cost ratio was 0.730 (95% credible interval: 0.724-0.735) when nosocomial infections were considered, 1.298 (1.282-1.315) when reduced length of stay was considered, and 1.794 (1.783-1.804) when direct costs of care were compared. The probability of a benefit-cost ratio of lower than 1 was about 91%, 31%, and 2% in each case, respectively. Cost savings associated with SFR units would justify additional construction and operation costs compared to OPBY units only when evidence on inclusive outcomes such as length of stay or direct costs of care is considered. A specific outcome such as infection rate potentially fails to capture all benefits of SFRs. As more evidence becomes available on full benefits and hazards of SFRs versus OPBYs, future studies should investigate the broader return-on-investment outcomes.

Improving the Efficiency of Care for Pediatric Patients Hospitalized With Asthma

Asthma exacerbations are a leading cause of hospitalization among children. Despite the existence of national pediatric asthma guidelines, significant variation in care persists. At Duke Children's Hospital, we determined that our average length of stay (ALOS) and cost for pediatric asthma admissions exceeded that of our peers. Our aim was to reduce the ALOS of pediatric patients hospitalized with asthma from 2.9 days to 2.6 days within 12 months by implementing an asthma pathway within our new electronic health record. We convened a multidisciplinary committee charged with reducing variability in practice, ALOS, and cost of inpatient pediatric asthma care, while adhering to evidence-based guidelines. Interventions were tested through multiple "plan-do-study-act" cycles. Control charts of the ALOS were constructed and annotated with interventions, including testing of an asthma score, implementation of order sets, use of a respiratory therapy-driven albuterol treatment protocol, and provision of targeted education. Order set usage was audited as a process measure. Readmission rates were monitored as a balancing measure. The ALOS of pediatric patients hospitalized with asthma decreased significantly from 2.9 days to 2.3 days. Comparing baseline with intervention variable direct cost data revealed a savings of $1543 per case. Improvements occurred in the context of high compliance with the asthma pathway order sets. Readmission rates remained stable throughout the study period. Implementation of an asthma care pathway based on the electronic health record improved the efficiency and variable direct costs of hospital care, reduced variability in practice, and ensured adherence to high-quality national guidelines.

Comparative pharmaco-economic analysis of using enzalutamide, abiraterone and cabazitaxel in post-docetaxel castration-resistant prostate cancer patients

Recently, an increase in the incidence of severe forms of prostate cancer, in particular castration-resistant prostate cancer (CRPC) has been noticed. Treatment of CRPC patients is associated with increasing expenses and thus impacts the healthcare budgets at various levels. The aim was to study the pharmacoeconomic aspects of using enzalutamide, cabazitaxel and abiraterone for the second-line therapy of CRPC (after treatment with docetaxel) in the Russian Federation . Materials and Methods . A cost effectiveness analysis of patient management was conducted for each of the three drugs. The direct costs included the costs of visiting the doctor, the diagnostic tests and procedures, the best supportive therapy with other drugs in accordance with the standards, the treatment of adverse events, the end-of-life palliative therapy in hospital, and the costs of prescribing one of the three drugs in question. Results. The expenses for diagnosing, maintaining the treatment regimen, consulting, monitoring and nurse caring in patients with CRPC were 15-20% lower with enzalutamide compared to abiraterone and two-fold lower than that with cabazitaxel. The general assessment of direct costs without the cost of the above drugs showed that the use of enzalutamide was 10% less expensive than abiraterone and 35% less expensive than cabazitaxel. The pharmacoeconomic advantages of enzalutamide over the two other agents are supported by the «decision tree» model and by the cost/effectiveness ratio. Conclusion. The use of enzalutamide is associated with lower direct costs of care, treatment, diagnostic and supportive procedures as compared with abiraterone and cabazitaxel.

Open lower limb fractures in Major Trauma Centers – A loss leader?

PurposeOpen lower limb fractures are resource intensive injuries. Regardless of the financing model, the cost of treatment is an important consideration for any healthcare provider. MethodsOpen lower limb fractures treated at our centre were identified over a six-month period. Isolated open femur or tibia fractures were included as well as cases with multiple fractures. Direct inpatient care costs were calculated and income was reviewed for each case according to ‘Healthcare Resource Group’ (HRG) cost codes. ResultsA total of 41 open lower limb fractures (32 patients) were identified. There were isolated open fractures in twenty-five and multiple lower limb open fractures in seven patients. Twenty-three patients (72%) were male and nine were female (28%) with an average age of 40 years (range 10–89 years). The fractures were classified according to Gustilo and Anderson (GA) and divided into two main groups; there were 13 mild and 28 severe open fractures. The median direct cost of inpatient treatment for open lower limb fractures was £19,189 per patient. There was a net gain of £6,288 per fracture in the mild group and a loss of £7,582 in the severe group. The total deficit was £149,545 over the six-month period for this cohort of 41 fractures. ConclusionOpen lower limb fractures are expensive to treat at a cost of approximately £19,200 per patient and associated with a significant loss of income in our MTC. Cost codes should reflect the complex and more expensive treatment of these patients to avoid the inadvertent financial ‘penalties’ of treating such patients. This study is the first to calculate the direct inpatient treatment costs of open lower limb fractures in a major trauma centre. It highlights the need for cost saving strategies and for appropriate remuneration in MTCs.

Collaborative Care Drives Triple Aim Success in Patients With Uncontrolled Hypertension

Background: We are an outpatient internal medicine practice that has developed a team-based technology-enabled approach to managing chronic medical conditions. Objective: To develop a collaborative approach to managing chronic conditions that is patient-centric, while achieving better outcomes at a lower cost. Methods: We chose to focus on patients with hypertension. Target patients were identified by partner referrals and by our own data registry reports of patients with blood pressure >140/90. Individuals were then invited to participate in a 90-day program with the focused intent of actively engaging the patients in managing their blood pressure. The invitations were either conducted in person, sent via a patient portal, or sent in a mailed letter. Each interested patient was assigned a health advocate and asked to record their blood pressure in an online application daily. There was no charge to the patient. Individual goals were determined by the patient, with the guidance of the physician and health advocate using a shared decision-making tool, and strategy focused on a habit-based behavior change model. Patients either purchased a Bluetooth-enabled digital blood pressure cuff from our office or were permitted to use their own blood pressure cuff, which was calibrated by our nursing staff. Patients communicated with their health care team via an online shared message board as well as through a patient portal. Virtual visits were conducted as needed throughout the 90-day program with either the physician, health advocate, or dietician. Both curated and created educational materials were shared with the patient. Health coaching was ongoing, and communication frequency and modality preference was collaboratively determined by the patient and care team. Results: Overall, we invited 920 patients to participate in our program. Of these, 224 patients enrolled and completed the 90-day program. We tracked metrics including blood pressure values, frequency of in-office and virtual visits, time spent by all team members engaged in the online platform, and money saved by averting office visits. Our hypertension patients visited the primary care office half as often as traditionally managed hypertension patients and achieved their target blood pressure faster. In standard hypertension care, research would tell us that 30% of patients will have a normal blood pressure in 1 year. In this study, 80% of our patients had a controlled blood pressure in 3 months. In the few cases where blood pressure control could not be achieved with the above-mentioned methods, a search for secondary causes of hypertension was initiated by the primary care physician. We also demonstrated US $350 in primary care direct cost savings annually by avoiding an average of 2 office visits over these 90 days. The successes, however, are not only improvement in cost and blood pressure values; 93% of patients in this program report a “very high quality” or “high quality” overall patient experience. Conclusions: Our program achieves higher quality care at a lower cost with higher patient satisfaction than traditional care. We are confident that this approach to hypertension can be applied to other chronic disease states with equally as impressive results.

Financial burden of health care for Buruli ulcer patients in Nigeria: the patients' perspective.

The economic burden of Buruli ulcer for patients has not been well-documented. This study assessed the costs of Buruli ulcer care to patients from the onset of illness to diagnosis and to the end of treatment. This was a cross-sectional cost of illness study conducted among patients with Buruli ulcer in four States in Nigeria between July and September 2015. A structured questionnaire was used to collect data on the patients' characteristics, household income and out-of-pocket costs of care. Of 92 patients surveyed, 54 (59%) were older than 15years, 49 (53%) were males, and 86 (93%) resided in a rural area. The median (IQR) direct medical and non-medical cost per patient was US$124 (50-282) and US$3 (3-6); corresponding to 149% and 4% of the patients' median monthly household income, respectively. The overall direct costs per patient was US$135 (58-327), which corresponded to 162% of median monthly household income, with pre-diagnosis costs accounting for 94.8% of the total costs. The direct costs of Buruli ulcer care were catastrophic for 50% of all patients/households - the rates of catastrophic costs for Buruli ulcer care was 66% and 19% for patients belonging to the lowest and highest income quartiles, respectively. Direct costs of Buruli ulcer diagnosis and treatment are catastrophic to a substantial proportion of patients and their families.

The Direct Cost of Treatment of Traumatic Brain Injury in a Sub-Saharan African Country (Benin).

This is the first socioeconomic study on traumatic brain injury (TBI) undertaken to determine the sociodemographic factors implicated in the occurrence of TBI and to assess the value of the direct cost of the management of TBI at the initial phase in the Hubert Koutoukou Maga National Teaching Hospital of Cotonou. This was a prospective study with descriptive and analytic aim that took place from January 1 to July 31, 2014. An individual approach of each patient's expenditure was undertaken via the use of a questionnaire on which all expenses were identified systematically. The dependent variable was the global direct cost of care. The independent variables were the type of accident, severity of the TBI, the structures of care, the stay in the resuscitation unit, the duration of hospitalization. There were 297 patients with TBI: 258 men (86.9%) and 39 women (13.1%), with a sex ratio of 6.61. The average age of patients was 34.3 ± 12.39 years. The average direct cost of care for TBI was €285.67 ± 310.15. The average cost for severe TBI was €522.08 ± 439.91 versus €188.19 ± 164.83 for mild TBI (odds ratio 5.52; standard deviation: 0.0527-0.6222). The average cost was increased significantly more when the patients went through a peripheral hospital (odds ratio 3.65; standard deviation: 1.819-7.3245). The organization of Benin's health system did not allow for the optimum management of TBI. It seems imperative to develop an insurance system that will allow a proper and effective support for victims of traffic accidents.