Direct Care Costs Research Articles

Direct costs of hospital care of self-harm: A national register-based cohort study.

To estimate national direct hospital costs associated with treatment of self-harm and to analyse whether costs differ with respect to demographic and clinical characteristics. A cohort design was applied to register data on all people living in Denmark (5.8million inhabitants) from Jan 1, 2012 to Dec 31, 2016. Self-harm presentations at all hospitals by persons aged 10years and older were included. Total costs and costs related to somatic and psychiatric care and treatment setting (inpatient, emergency department and outpatient) were calculated (in US dollars). The association between specific characteristics and somatic inpatient costs was analysed adjusted using generalized linear models and expressed as Odds Ratios (OR). In all, 42,634 (97.3%) self-harm presentations by 30,366 persons were included. Annual somatic and psychiatric costs amounted to $25,241,518 and $34,696,388, respectively, and the median cost per episode was $2248 (IQR: $1553-$4138). Predictors of high somatic inpatient costs were: admission to intensive care (OR = 15.6; 95% CI, 13.7-17.9), particularly dangerous methods of self-harm, such as being hit by moving objects (OR = 6.5; 95% CI, 2.7-15.7) and shooting (OR = 6.0; 95% CI, 3.4-10.7), and age ≥75years (OR = 1.8; 95% CI, 1.5-2.2). A small group of persons (0.7%) with ≥10 presentations accounted for 8.2% of somatic and 15.3% of total hospital costs. Substantial hospital costs were noted for inpatient treatment. Although one-time presenters accounted for the major share of costs, smaller patient groups accounted for considerable shares. Hospital costs of self-harm should be included in evaluation of initiatives for prevention and treatment.

Hospitalist Co-Management of a Vascular Surgery Service Improves Quality Outcomes and Reduces Cost

Hospitalists can be instrumental in management of inpatients with multiple comorbidities requiring complex medical care such as vascular surgery patients, as well as an expertise in health care delivery. We instituted a unique hospitalist co-management program and assessed length of stay, 30-day readmission rates and mortality, and performed an overall cost-analysis. Hospitalist co-management of vascular surgery inpatients was implemented beginning April 2019, and data was studied until March 2020. We compared this data to an eight-month period prior to implementing co-management (7/2018 - 3/2019). Patient-related outcomes that were assessed include length of stay, re-admission index, mortality index, case-mix index. Cost-analysis was performed to look at indirect and direct cost of care. A total of 1,062 patients were included in the study 520 pre co-management and 542 patients were post-comanagement. Baseline case-mix index was 2.47, and post-comanagement was 2.46 (P >0.05). In terms of average length of stay (aLOS), the baseline aLOS was 5.16 days per patient, while after co-management it was significantly decreased by 1.25 days to 3.91 days (P <0.05). This improvement in length of stay opened an average of 2.4 telemetry beds per day. Similarly, excess days per patient which reflects the expected length of stay based on comorbidities, improved from -0.59 to -1.65, an improvement of -1.46. Hospitalist co-management improves outcomes for vascular surgery inpatients, decreases length of stay, re-admission and mortality while providing a significant cost-savings. The overall average variable direct cost decreased by $1,732 per patient.

Periodontal care attendance in Denmark in 2012–2016 – a nationwide register-based study

Objective Planning and evaluation of oral healthcare systems rely on monitoring of care patterns. Monitoring periodontal care patterns provide information on the burden and occurrence of periodontitis in the population and on the direct financial cost. The aims of the study were to describe patterns in periodontal care among dental care attenders that might incite subsequent investigation and revised treatment guidelines. Secondly, to estimate the direct societal costs of periodontal care. Material and methods A retrospective register-based study utilising data from the Danish Public Health Insurance which includes all dental care attenders in 2012–2016, three years before and one year after a national risk-based recall maintenance program was rolled out in Denmark. Results The 2.7 million yearly dental care attenders corresponded to ∼60% of the eligible population and in the range of 20–24% received periodontal care. Total expenditure for periodontal care in Denmark increased by 13% from 2012 to 2016, from €78 to €88 million. The proportion of total healthcare funding spent on periodontal care was 0.61% in 2016. Conclusions Patients with periodontitis have large out-of-pocket yearly expenses for periodontal care. Despite small changes in periodontal clinical practice that may indicate improved targeting of patients in need of periodontal care, challenges of reaching non-attenders and non-adherence to care are unsolved. More research into outcomes from periodontal therapy in daily practice, seen from both normative and patient perspectives, would help establish knowledge of the efficiency of existing periodontal care systems and help identify barriers and facilitators for attending care in Denmark.

Estimated direct costs of renal cancer by stage and care phase: a whole disease modeljuj

Abstract Background Renal cell carcinoma (RCC) is the seventh most common neoplasm in high-income countries. New clinical pathways have been developed to deal with this tumor, which include costly drugs that pose an economic threat to the sustainability of healthcare services. This study provides an estimate of the direct costs of care for patients with RCC by stage of disease (early vs advanced) at diagnosis, and disease management phase along the pathway recommended by local and international guidelines. Methods Considering the clinical pathway for RCC adopted in the Veneto region (north-east Italy) and the latest guidelines, we developed a very detailed “whole-disease” model that covers the probabilities of all potentially necessary diagnostic and therapeutic action involved in the management of RCC. Based on the cost of each procedure according to the Veneto Regional Authority's official reimbursement tariffs, we estimated the total and average per-patient costs by stage of disease (early or advanced) and phase of its management. Results In the first year after diagnosis, the mean expected cost of a patient with RCC is €12,991 if it is localized or locally-advanced, and reaches €40,586 if it is advanced. For early disease, the main cost is incurred by surgery, whereas medical therapy (first and second line) and supportive care become increasingly important for metastatic disease. Conclusions It is crucially important to examine the direct costs of care for RCC, and to predict the burden on healthcare services of new oncological therapies and treatments, as the findings could be useful for policy-makers planning the allocation of resources. Key messages An estimation of the direct costs of renal cell carcinoma, and in general for cancer, appears fundamental to predict the burden of new oncological therapies and treatments on healthcare services. Our model could represent a useful tool for policy-makers in the optimization of resources allocation, especially in a time of budget constraints.

Characterizing demographics, comorbidities, and costs of care among populations with Duchenne muscular dystrophy with Medicaid and commercial coverage.

BACKGROUND: Duchenne muscular dystrophy (DMD) is a severe X-linked progressive neurodegenerative disease characterized by loss of ambulation, cardiomyopathy, respiratory insufficiency, and early mortality. Few data are available that describe the direct medical costs among patients with DMD in the United States. OBJECTIVE: To characterize the demographics, comorbidity burden, and direct monthly costs of care among patients with DMD with Medicaid and with commercial insurance coverage. METHODS: IBM MarketScan Commercial and Multi-State Medicaid claims (2013-2018) were used to identify males aged 30 years or under with diagnostic codes for muscular dystrophy or DMD; additional exclusion criteria were applied to identify those with probable DMD. Baseline characteristics and comorbidities were tabulated. The frequency of health care resource use and median (interquartile range [IQR]) monthly costs (in 2018 USD) were estimated from those with at least 12 months of continuous follow-up. RESULTS: Median (IQR) baseline ages were similar between the Medicaid (14 [9-20] years; n = 2,007) and commercial (15 [9-21] years; n = 1,964) DMD cohorts. The frequency of comorbidities over the period was slightly higher with those on Medicaid. The median duration of follow-up was 3.1 years among members of the Medicaid DMD cohort and 1.7 years among the commercial DMD cohort. Median monthly resource use was generally higher among the Medicaid DMD cohort; nonetheless, median (IQR) monthly costs were similar at $1,735 ($367-$5,281) for the Medicaid DMD cohort vs $1,883 ($657-$6,796) for the commercial DMD cohort. CONCLUSIONS: The demographic characteristics and median direct medical costs were similar between patients with commercial vs Medicaid coverage, even though patients with Medicaid coverage had higher resource use. Despite challenges in definitively identifying DMD patients using claims data, these findings help characterize contemporary DMD populations in the United States and the related direct economic burden to the payer. DISCLOSURES: This study was funded by Sarepta Therapeutics, Inc. Klimchak and Gooch are employees of Sarepta Therapeutics Inc. Szabo, Qian, and Popoff are employees of Broadstreet HEOR, which received funds from Sarepta Therapeutics, Inc., for work on this study. Iannaccone has received research funding or consulting fees from Avexis, Biogen, Fibrogen, Mallinkrodt, Regeneron, Sarepta Therapeutics, Inc., Scholar Rock, PTC Therapeutics, Pfizer, MDA, CureSMA, NIH, Genentech-Roche, and BCBS. Publication of the study results was not contingent on the sponsor's approval or censorship of the manuscript. Information from this study was presented, in part, at the AMCP Virtual Annual Meeting, April 21-24, 2020.

Hospital direct cost of stroke in sub Saharan Africa: The case of Senegal

Stroke is a major public health problem because of its frequency, severity and cost. The aim of this study was to estimate the direct cost of care for stroke in hospital for clinical neuroscience of Fann Hospital in Dakar and to identify associated factors.

Exploring the home healthcare workforce in Alzheimer's disease and related dementias: Utilization and cost outcomes in US community dwelling older adults

ObjectiveThis study assessed home health care use associated with Alzheimer's Disease and related dementias (ADRD) in US community dwelling older adults, including workforce, intensity, and cost outcomes. Materials and methodsMedical Expenditure Panel Survey (2010–2018) household and home care event files were used to identify adults ≥ 65 years with ADRD. Outcomes included home health care provider type, intensity of care use, and annual direct home care cost. All analyses applied person weights for national estimates. ResultsAmong the 20,443 eligible older adults, 4.2% (n = 843) reported ADRD. Among all professional and non-professional health care workers, nurse practitioners (NPs, 38.5%) and home health care aids (35.6%) were most used. Comparing ADRD vs non-ADRD: the annual per-person average number of days in home care was 110 vs. 64 (p<0.001) and home care costs accounted for 30.8% vs. 7.5% of total health care costs. After adjusting for participants' characteristics, those with ADRD were more likely to use home health care (OR = 4.32, 95% CI=3.29 – 5.68) and showed 229% (95% CI = 175% - 297%) higher associated costs than controls (p<0.001). ConclusionThe study provides insight into the home care workforce. Of the professional workforce NPs were most often used and home care aides dominated the non-professional workforce. As expected, ADRD increased the likelihood and intensity of home health care utilization and associated direct home care costs significantly.

Cost of Type 2 Diabetes Patients with Chronic Kidney Disease Based on Real-World Data: An Observational Population-Based Study in Spain

This study analyzed the prevalence, costs and economic impact of chronic kidney disease CKD in patients with T2D in a Spanish Health District using real-world data. Observational cross-sectional study in adult patients with T2D was through data extracted from the information systems of the Valencia Clínico–La Malvarrosa Health District in the year 2015. Patients were stratified with the KDIGO classification for CKD. Additionally, patients were assigned to Clinical Risk Groups (CRGs) according to multimorbidity. Direct costs of primary and specialized care, and medication were estimated. The prevalence of T2D in the database population (n = 28,345) was 10.8% (mean age (SD) = 67.8 years (13.9); 51.5% male). Up to 14.935 patients (52.6%) had data on kidney function. According to the KDIGO classification, 66.2% of the patients were at low risk of CKD, 20.6% at moderately increased risk, 7.9% at high risk, and 5.2% at very high risk. The average healthcare costs associated with these four risk groups were EUR 3437, EUR 4936, EUR 5899 and EUR 7389, respectively. The large number of T2D patients with CKD in the early stages of the disease generated a significant increase in direct healthcare costs. The economic impact could be mitigated by early and comprehensive therapeutic approaches.

Resource use and economic burden of eye injuries in Southern Finland

ObjectiveTo estimate resource use and the costs of eye injuries in 2011–2012 in the Helsinki University Eye Hospital (HUEH), which covers 1.6 million people in Southern Finland.MethodsThis population-based study consisted of all new patients (1,151) with eye injuries in one year. The data were from hospital records, internal HUEH accountancy, and prospectively from questionnaires. The costs of direct health care, transportation, and lost productivity were obtained and estimated for the follow-up period of three months. The estimated future costs were discussed.ResultsDuring the follow-up, the total cost was 2,899,000 Euros (EUR) (= EUR 1,870,300/one million population), including lost productivity (EUR 1,415,000), direct health care (EUR 1,244,000), and transportation (EUR 240,000). The resources used included 6,902 days of lost productivity, 2,436 admissions and transportations, 314 minor procedures, 313 inpatient days, 248 major surgeries, and 86 radiological images. One open globe injury was the costliest (EUR 13,420/patient), but contusions had the highest overall cost (EUR 1,019,500), due to their high occurrence and number of follow-ups.ConclusionsEye injuries cause a major burden through high costs of direct health care and lost productivity: the imminent costs were EUR 1,870,000/one million population, and the future costs were estimated to EUR 3,741,400/one million population. Prevention remains the main factor to consider for better cost-efficiency.

Cost‐effectiveness analysis of responsive neurostimulation for drug‐resistant focal onset epilepsy

We evaluated the incremental cost-effectiveness of responsive neurostimulation (RNS) therapy for management of medically refractory focal onset seizures compared to pharmacotherapy alone. We created and analyzed a decision model for treatment with RNS therapy versus pharmacotherapy using a semi-Markov process. We adopted a public payer perspective and used the maximum duration of 9years in the RNS long-term follow-up study as the time horizon. We used seizure frequency data to model changes in quality of life and estimated the impact of RNS therapy on the annual direct costs of epilepsy care. The model also included expected mortality, adverse events, and costs related to system implantation, programming, and replacement. We interpreted our results against societal willingness-to-pay thresholds of $50000, $100000, and $200000 per quality-adjusted life year (QALY). Based on three different calculated utility value estimates, the incremental cost-effectiveness ratio (ICER) for RNS therapy (with continued pharmacotherapy) compared to pharmacotherapy alone ranged between $28825 and $46596. Multiple sensitivity analyses yielded ICERs often below $50000 per QALY and consistently below $100000/QALY. Modeling based on 9years of available data demonstrates that RNS therapy for medically refractory epilepsy very likely falls within the range of cost-effectiveness, depending on method of utility estimation, variability in model inputs, and willingness-to-pay threshold. Several factors favor improved cost-effectiveness in the future. Given the increasing focus on delivering cost-effective care, we hope that this analysis will help inform clinical decision-making for this surgical option for refractory epilepsy.

Financial impact of healthcare-associated infections on intensive care units estimated for fifty Brazilian university hospitals affiliated to the unified health system

Studies show that healthcare-associated infections (HAIs) represent a crucial issue in healthcare and can lead to substantial economic impacts in intensive care units (ICUs). To estimate direct costs associated with the most significant HAIs in 50 teaching hospitals in Brazil, affiliated to the unified health system (Sistema Único de Saúde: SUS). A Monte Carlo simulation model was designed to estimate the direct costs of HAIs; first, epidemiologic and economic parameters were established for each HAI based on a cohort of 949 critical patients (800 without HAI and 149 with); second, simulation based on three Brazilian prevalence scenarios of HAIs in ICU patients (29.1%, 51.2%, and 61.6%) was used; and third, the annual direct costs of HAIs in 50 university hospitals were simulated. Patients with HAIs had 16 additional days in the ICU, along with an extra direct cost of US$13.892, compared to those without HAIs. In one hypothetical scenario without HAI, the direct annual cost of hospital care for 26,649 inpatients in adult ICUs of 50 hospitals was US$112,924,421. There was an increase of approximately US$56 million in a scenario with 29.1%, and an increase of US$147 million in a scenario with 61.6%. The impact on the direct cost became significant starting at a 10% prevalence of HAIs, where US$2,824,817 is added for each 1% increase in prevalence. This analysis provides robust and updated estimates showing that HAI places a significant financial burden on the Brazilian healthcare system and contributes to a longer stay for inpatients.

Supervised maintenance programmes following pulmonary rehabilitation compared to usual care for chronic obstructive pulmonary disease.

Pulmonary rehabilitation benefits patients with chronic obstructive pulmonary disease (COPD), but gains are not maintained over time. Maintenance pulmonary rehabilitation has been defined as ongoing supervised exercise at a lower frequency than the initial pulmonary rehabilitation programme. It is not yet known whether a maintenance programme can preserve the benefits of pulmonary rehabilitation over time. Studies of maintenance programmes following pulmonary rehabilitation are heterogeneous, especially regarding supervision frequency. Furthermore, new maintenance models (remote and home-based) are emerging. To determine whether supervised pulmonary rehabilitation maintenance programmes improve health-related quality of life (HRQoL), exercise performance, and health care utilisation in COPD patients compared with usual care. Secondly, to examine in subgroup analyses the impact of supervision frequency and model (remote or in-person) during the supervised maintenance programme. We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, PEDro, and two additional trial registries platforms up to 31 March 2020, without restriction by language or type of publication. We screened the reference lists of all primary studies for additional references. We also hand-searched conference abstracts and grey literature through the Cochrane Airways Trials Register and CENTRAL. We included only randomised trials comparing pulmonary rehabilitation maintenance for COPD with attention control or usual care. The primary outcomes were HRQoL, exercise capacity and hospitalisation; the secondary outcomes were exacerbation rate, mortality, direct costs of care, and adverse events. Two review authors independently screened titles and abstracts, extracted data, and assessed the risk of bias. Results data that were similar enough to be pooled were meta-analysed using a random-effects model, and those that could not be pooled were reported in narrative form. Subgroup analyses were undertaken for frequency of supervision (programmes offered monthly or less frequently, versus more frequently) and those using remote supervision (e.g. telerehabilitation versus face-to-face supervision). We used the GRADE approach to assess the certainty of evidence. We included 21 studies (39 reports) with 1799 COPD patients. Participants ranged in age from 52 years to 88 years. Disease severity ranged from 24% to 88% of the predicted forced expiratory volume in one second. Programme duration ranged from four weeks to 36 months. In-person supervision was provided in 12 studies, and remote supervision was provided in six studies (telephone or web platform). Four studies provided a combination of in-person and remote supervision. Most studies had a high risk of performance bias due to lack of blinding of participants, and high risk of detection, attrition, and reporting bias. Low- to moderate-certainty evidence showed that supervised maintenance programmes may improve health-related quality of life at six to 12 months following pulmonary rehabilitation compared to usual care (Chronic Respiratory Questionnaire total score mean difference (MD) 0.54 points, 95% confidence interval (CI) 0.04 to 1.03, 258 participants, four studies), with a mean difference that exceeded the minimal important difference of 0.5 points for this outcome. It is possible that supervised maintenance could improve six-minute walk distance, but this is uncertain (MD 26 metres (m), 95% CI -1.04 to 52.84, 639 participants, 10 studies). There was little to no difference between the maintenance programme and the usual care group in exacerbations or all-cause hospitalizations, or the chance of death (odds ratio (OR) for mortality 0.73, 95% CI 0.36 to 1.51, 755 participants, six studies). Insufficient data were available to understand the impact of the frequency of supervision, or of remote versus in-person supervision. No adverse events were reported. This review suggests that supervised maintenance programmes for COPD patients after pulmonary rehabilitation are not associated with increased adverse events, may improve health-related quality of life, and could possibly improve exercise capacity at six to 12 months. Effects on exacerbations, hospitalisation and mortality are similar to those of usual care. However, the strength of evidence was limited because most included studies had a high risk of bias and small sample size. The optimal supervision frequency and models for supervised maintenance programmes are still unclear.

Unbalanced Treatment Costs of Breast Cancer in China: Implications From the Direct Costs of Inpatient and Outpatient Care in Liaoning Province.

The increasing incidence of breast cancer and its financial burden highlights the need for controlling treatment costs. This study aimed to assess the direct costs of inpatient and outpatient care for breast cancer patients in Liaoning Province to provide a policy reference for cost containment. Based on the System of Health Accounts 2011 (SHA 2011), systematic data collection was conducted via multistage stratified cluster random sampling. A total of 1160 health institutions, including 83 hospitals, 16 public health institutions, 120 primary health institutions, and 941 outpatient institutions were enrolled in 2017. A database was established containing 20 035 patient-level medical records from the information system of these institutions. Curative care expenditure (CCE)was calculated, and generalized linear modeling was performed to determine cost-related factors. In 2017, the CCE for breast cancer was approximately CNY 830.19 million (US$122.96 million) in Liaoning province (0.7% of the total health expenditure and 9.9% of cancer-related healthcare costs). Inpatient care costs were estimated to be CNY 617.27 million (US$91.42 million), accounting for 74.4% of the CCE for breast cancer, almost three times as large as outpatient costs (25.6%). The average inpatient and outpatient costs for breast cancer were estimated to be CNY 12 108 (US$1793) and CNY 829 (US$123) per visit. Medication cost was the main cost driver, which comprised 84.0% of the average outpatient cost and 37.2% of the mean inpatient cost. Breast cancer imposes a large economic burden on patients and the social health insurance system. Results show an irrational cost pattern of inpatient and outpatient services, with patients relying excessively on inpatient services for treatment. Promoting outpatient care whenever relevant is conducive to cost containment and rational utilization of resources.

The health system costs of post abortion care in Tanzania

BackgroundUnsafe abortion is common in Tanzania. Currently, postabortion care (PAC) is legally provided, but there is little information on the national cost. We estimated the health system costs of offering PAC in Tanzania in 2018, at existing levels of care and when hypothetically expanded to meet all need.MethodsWe employed a bottom-up costing methodology. Between October 2018 and February 2019, face-to-face interviews were conducted with facility administrators and PAC providers in a sample of 40 health facilities located across seven mainland regions and Zanzibar. We collected data on the direct and indirect cost of care, fees charged to patients, and costs incurred by patients for PAC supplies. Sensitivity analysis was used to explore the impact of uncertainty in the analysis.ResultsOverall, 3850 women received PAC at the study facilities in 2018. At the national level, 77,814 women received PAC, and the cost per patient was $58. The national health system cost for PAC provision at current levels totaled nearly $4.5 million. Meeting all need for PAC would increase costs to over $11 million. Public facilities bore the majority of PAC costs, and facilities recovered just 1% of costs through charges to patients. On average PAC patients incurred $7 in costs ($6.17 for fees plus $1.35 in supplies).ConclusionsResources for health care are limited. While working to scale up access to PAC services to meet women’s needs, Tanzanian policymakers should consider increasing access to contraception to prevent unintended pregnancies.

Economic Burden Associated With Management of Paradoxical Vocal Fold Motion Disorder.

Paradoxical vocal fold movement (PVFM) is often misdiagnosed as asthma and tends to have a prolonged time to diagnosis. Study aims were to estimate the time from dyspnea onset to PVFM diagnosis, to estimate associated pre- and postdiagnosis direct and indirect healthcare cost, and to compare the cost of postdiagnosis care among patients who did and did not undergo standard-of-care speech therapy. Patients diagnosed with PVFM were identified retrospectively. Time from dyspnea symptom onset to diagnosis was measured. Direct costs consisting of office visits, procedures, and prescribed pharmaceuticals before and after diagnosis were calculated. Indirect costs associated with lost wages related to healthcare were also estimated. Costs for patients who initiated versus did not initiate speech therapy and who had successful versus unsuccessful therapy were compared. Among 110 patients, median time from dyspnea onset to PVFM diagnosis was 33 months (interquartile range [IQR] 5-60). Direct and indirect prediagnosis median costs were $8,625 (IQR $1,687-$35,812) and $736 (IQR $421-$1,579) while first year following dyspnea symptom onset median direct and indirect costs were $1,706 (IQR $427-$7,118) and $315 (IQR $131-$631). Median direct and indirect costs of care in the postdiagnosis year were $2,062 (IQR $760-$11,496) and $841 (IQR $631-$1,261). Pharmaceuticals were predominant cost drivers in all time periods. Of those who completed speech therapy, 85% had breathing symptom improvement while incurring significant cost savings compared to those whose symptoms persisted. Costs of care leading to diagnosis of PVFM are substantial. More efficient methods of identifying patients with PVFM are essential to reduce prolonged time to diagnosis and associated costs. NA Laryngoscope, 132:142-147, 2022.

A total cost perspective of type 1 and 2 diabetes mellitus in two South African medical schemes servicing the public healthcare sector.

Diabetes is increasingly becoming a public health concern in South Africa (SA). There are limited available data on the costs of diabetes. To provide a total cost perspective of diabetes using medical scheme claims data from two SA medical schemes servicing the public healthcare sector in 2015 and 2016. We analysed data from 2 363 diabetes patients. Direct diabetes care costs included medication, consumables, hospitalisation and routine laboratory tests. Indirect costs were calculated by allocating economic costs related to disability-adjusted life years. The mean (standard deviation) age was 65.8 (13.4) years and women comprised 51% of the group. Hospitalisation (64.7% in 2015 and 65.5% in 2016) and medication (31.0% in 2015 and 21.1% in 2016) contributed the most to total direct costs. Total direct diabetes care costs mounted to ZAR2 452 per patient in 2015 and ZAR2 486 in 2016. Indirect costs were ZAR17 223 per patient in 2015 and ZAR18 711 in 2016. When direct and indirect costs were combined, the costs accrued to ZAR27.9 billion (ZAR19 675 per patient) in 2015 and ZAR29.9 billion (ZAR21 197 per patient) in 2016, representing 0.688% and 0.689% of the SA gross domestic product over the 2 years, respectively. Diabetes and its associated costs hold significant implications for the healthcare sector and the country's economy. Large numbers of diabetic individuals remain undiagnosed and the true costs of diabetes might even be higher.

Development of the oncology opportunity cost assessment tool.

e13502 Background: While awareness of direct patient-level costs of cancer care are growing, less is known about the patient-level opportunity cost of care. Opportunity costs of care may include time spent seeking care, lost wages, lost leisure time, and other indirect costs associated with seeking care. Despite acknowledgment of the importance of considering patient opportunity costs in care treatment decisions, assessment of opportunity costs experienced by individual patients or caregivers is not routinely performed by healthcare providers in general, or oncology providers in particular. The purpose of this work was to develop an instrument, the Oncology Opportunity Cost Assessment Tool (OOCAT), to evaluate patient opportunity cost of seeking oncology care. Methods: Survey development was an iterative process with multiple rounds of stakeholder engagement. First the research team developed a list of potential opportunity cost themes informed by their own experiences. Next, we met with an established patient advisory group within the cancer center to expand this list of themes. We then conducted focus groups with patients and caregivers to explore in further depth their logistical and financial considerations related to seeking care. Findings were used to further expand the list of opportunity cost themes, with this list reviewed in real time with the focus group participants to ensure perspectives were appropriately captured. We then generated a set of survey items to represent each of the themes listed. We generated two items to represent each unique theme. The first item of the instrument sought to quantify the opportunity cost of the theme (e.g. time spent parking); the second component ascertained the patient-perceived importance of the theme using a 7-point Likert scale. Upon drafting of the initial OOCAT, we performed cognitive interviews with a random sampling of patients in order to ensure content validity and clarity of instrument items. Results: We completed 4 virtual focus groups with a total of 23 participants (17 patients and 6 caregivers) followed by cognitive interviews with 13 patients. The resulting OOCAT consists of 17 items that examine time requirements, financial implications, and logistical and quality of life challenges for both patients and caregivers associated seeking oncology care. Conclusions: The OOCAT is a 17-item instrument designed to quantify patient-level opportunity costs of seeking oncology care. Further studies work is needed to validate the OOCAT survey and assess the impact of incorporating quantified assessment of opportunity cost into decision regarding when and where to seek oncology care.

What are the drivers of high-cost HIV patients?

We aimed to identify "high-cost" patients with HIV (PWH) and determine drivers behind higher costs. All PWH at the Southern Alberta HIV Clinic, Canada, and active in 2017 were included. Sociodemographic, clinical, and healthcare utilization data were collected. The direct care costs from the payers' perspective including antiretroviral drugs (ARV), outpatient visits, and hospital admissions were determined for 2017. Patients' annual total costs were grouped into top 5% (i.e., high-cost), top 20%, middle 60%, and bottom 20%. High-cost patients were older, Caucasian or indigenous Canadian, and more likely acquired HIV from intravenous drug use (all p < 0.05). High-cost patients had lower nadir CD4, more comorbidities, missed more clinic appointments, had more ARV interruptions, and developed more ARV resistance (p < 0.01). The overall median cost of HIV care was US$14,064 [IQR US$13,121-US$17,883] (2017 Cdn$). High-cost patients had a median cost of US$29,902 [IQR US$27,229-US$37,891] and accounted for 14% of total costs and 84% of all inpatient costs. Hospitalizations constituted 58% of costs for high-cost patients. Although heterogeneous, high-cost patients have distinct sociodemographic and clinical characteristics driving their healthcare utilization. Addressing these social determinants of health and using novel ARV administration approaches may preserve health and save costs.

Economic impact on direct healthcare costs of missing opportunities for diagnosing HIV within healthcare settings.

The economic consequences of a missed opportunity for HIV testing at an earlier stage of infection within a healthcare setting are poorly described. For all newly diagnosed HIV patients followed at the Southern Alberta HIV/AIDS Clinic (SAC), Calgary, Canada, between 1 April 2011 and 1 April 2016, all clinical encounters occurring <3years prior to diagnosis within the region were obtained. The direct costs of HIV care after diagnosis to 31 March 2019 were determined from a payers' perspective and reported as mean cost per patient per month (PPPM) in 2019 Canadian dollars (CDN$). Patients with no encounters for 3years prior to diagnosis were compared with patients with encounters, with special attention to patients with HIV clinical indicator conditions (HCICs). Of 388 patients, 60% had one or more prior encounter without HIV testing; 14% had been treated for an HCIC. Females, older patients and heterosexuals were more likely to have prior encounters. At diagnosis, patients with previous encounters presented with lower CD4 counts and higher rates of AIDS. The mean PPPM costs for patients with any prior encounter or for an HCIC-based encounter were 16% and 33% higher, respectively, than for patients with no prior encounters. While mean PPPM costs for antiretroviral drugs and outpatient visits were slightly higher, in-patient costs were 10 times higher for people with HIV who had a previous HCIC encounter vs. those with no encounters (CDN$316 vs. $31, respectively). Any healthcare visit, especially for an HCIC, represents relatively easy opportunities for HIV testing. Not testing can result in poorer health and higher costs. Targeted clinical testing and novel interventions to correct overlooked testing opportunities within healthcare settings may be an easy way to implement cost savings.

994 The Cost of Testicular Torsion Care in Ireland 2009-2018: A Novel Cost Estimation Model Using a National Database

Abstract Introduction Activity-Based Funding (ABF) is a new reimbursement model for public hospitals in Ireland. Little data exists regarding cost estimates for acute surgical admissions in Ireland. This study presents a novel method of direct-cost estimation for Testicular Torsion (TT) care in Ireland. Method Hospital In-Patient Enquiry (HIPE) data, covering all public hospital admissions in Ireland, were analysed to derive annual incidence rates for TT between 2009-2018. The monetary cost of each case was calculated by cross-referencing the Diagnosis-Related Group (DRG) with reference prices for inpatients and day-cases in public hospitals in 2019. Annual cost was adjusted using the Consumer Price Index for Health (Ireland) Results N = 1,746 patients under 25 years underwent orchidectomy or orchidopexy for TT between 2009 and 2018. The direct cost of TT care in public hospitals between 2009 and 2018 was €6,331,402. Costs increased 54% over 10 years, from €513,232 in 2009 to €788,700 in 2018 (2019 Euros). Just over two-thirds of cases (70%, n = 1,230) were reimbursed with public funding Conclusions This novel cost-estimation model may serve as a template for future direct-cost estimates for surgical interventions in Ireland. This will improve the accuracy of future economic evaluation for healthcare interventions in Ireland.