Increased Care Costs Research Articles

Cost-effectiveness of expanding national health insurance coverage for composite resin restorations in cancer patients in South Korea

ObjectivesCancer patients often have compromised oral health, making them vulnerable to severe dental caries and restoration failures. Due to the nature of cervical or anterior caries in cancer patients, the use of adequate restorative materials is important. However, public dental insurance coverage for composite treatments varies among countries and only glass ionomer cements (GICs) are covered in all age groups in South Korea. This study examined the cost-effectiveness of expanding national health insurance coverage to include resin composite (RC) restorations as compared with GIC in cancer patients. MethodsData from cancer patients who received direct restoration using GIC were identified from the National Health Screening Cohort. The relative effect of RC compared to GIC was determined through a meta-analysis, which was then utilized in calculating corresponding transition probabilities within a multi-state model. A Markov-chain Monte Carlo microsimulation was performed to estimate useful life-years and total treatment costs at the tooth level. The incremental cost-effectiveness ratio (ICER) of RC versus GIC was calculated, considering scenarios with and without expanded national health insurance coverage. The robustness of the results was confirmed through various sensitivity analyses. ResultsBetween the two materials, RC resulted in a 0.4-year longer useful life. From a limited societal perspective, it cost $9.6 less with expanded coverage but $24.3 more without expansion, resulting in an ICER of -$25.2 and $63.9 per tooth-year, respectively. From a patient's perspective, the ICER values were -$72.7 versus $138.8 per tooth-year, respectively, translating into $200 more in savings with the expansion. Various sensitivity analyses consistently demonstrated a smaller ICER when insurance coverage was expanded. ConclusionsThe expansion of national health insurance coverage to include RC restorations for cancer patients appears to be clearly cost-effective. This emphasizes the need for further policy considerations to ensure access to dental care for cancer patients. Clinical SignificanceTimely management of dental caries is crucial for cancer patients, as untreated caries can escalate into severe oral conditions, negatively impacting treatment outcomes and increasing care costs. Expanding a national health insurance coverage for cancer patients in the treatment of early dental lesions is necessary to prevent advanced dental diseases.

Seroma incidence and risk factors in women undergoing mastectomies as surgical breast cancer treatment.

Seroma is the most common early complication following surgical breast cancer treatment. Its development is associated with pain, scar complications, adjuvant therapy delays, the need for outpatient visits, and increased care costs. Assess seroma incidence and risk factors in women undergoing mastectomies. This study comprises a prospective cohort encompassing women aged 18 or over undergoing mastectomies as a breast cancer treatment. Patients underwent physiotherapy on the 1st, 7th, and 30th postoperative days for kinetic-functional, skin, and wound healing assessments and were attended to by nurses for surgical wound care, draining liquid on the 7th, 14th, and 21st postoperative days. Seroma was defined as the presence of local fluctuations requiring puncture, regardless of the punctured volume. A total of 249 women were evaluated, with a mean age of 57.5 (SD = 11.8). A total of 77.1% were classified as overweight or obese, 60.2% were hypertensive, 21.3% were diabetic, 66.7% underwent neoadjuvant chemotherapy and 62.7% underwent axillary lymphadenectomies. Seroma incidence was 71.1%, requiring, on average, two aspiration punctures until condition resolution. Overweight or obese women and those who underwent axillary lymphadenectomies exhibited 1.92- and 2.06-fold higher risk for seroma development (OR = 1.92; 95% CI 1.02-3.61; p = 0.042; and OR = 2.06; 95% CI 1.17-3.63; p = 0.012), respectively. Seroma incidence was very high. Being overweight or obese and undergoing axillary lymphadenectomy comprise independent seroma development risk factors. This study is part of a randomized clinical trial evaluating the effectiveness of applying compressive taping to prevent post-mastectomy seroma, which was approved by the Brazilian National Cancer Institute, Research Ethics Committee (2,774,824), and it is registered in the ClinicalTrials.gov (NCT04471142, on July 15, 2020).

Using Next-Generation Sequencing to Understand Infection Prevention in Surgical Treatment of Upper Extremity Fractures-A Prospective Cohort Study.

Postoperative fracture site infection can lead to notable patient morbidity, increase cost of care, and further contribute to healthcare disparities globally. Dogma suggests surgical blades as a vehicle for introducing bacteria into the surgical site; however, there is a paucity of literature to support this claim. This study uses advanced DNA sequencing to detect bacterial DNA on surgical blades used in upper extremity fracture surgeries. This was a prospective study, conducted at a high-volume level 1 trauma center. All acute, closed upper extremity fractures requiring surgical stabilization were consecutively enrolled in a prospective fashion. The primary end point was the presence of bacterial DNA on the surgical blade using next-generation sequencing (NGS). At the time of surgery, two blades were sterilely opened. One blade served as the control while the other was used for the initial skin incision. Two negative control blades were opened directly into a sterile container. Two positive control blades were used for skin incision through known infections. All samples were sent for NGS analysis. Forty patients were enrolled in this study. The median age was 33.5 years, and 30% were female; the median body mass index was 26.52. Humerus fractures were the most common injury (N = 17, 42.5%), followed by clavicle fractures (13, 32.5%) and radius/ulna fractures (10, 25.0%). NGS analysis revealed no contamination of test blades used for skin incision. Three control blades tested positive for bacterial DNA. Negative control blades tested negative for bacterial DNA (0/2); the positive control blades resulted positive for bacterial DNA contamination (2/2). Surgical blades used for skin incision in the upper extremity are not contaminated with bacterial DNA as analyzed by NGS. This finding challenges previous surgical dogma regarding surgical blade contamination and supports that the same surgical blade can safely be used for deeper dissection. Level II study: IRB approval-IRB#848938.

Relationship Between Complications and Readmissions in Type 2 Diabetes Mellitus Patients in Aceh, Indonesia

Introduction: Complications in diabetes mellitus patients are among the causes of hospital readmissions. Readmissions negatively impact patients’ quality of life and increase health and care costs. This study aims to explore the relationship between complications and readmissions in type 2 diabetes mellitus patients. Methods: A correlational study was utilized with a cross-sectional design. A total of 184 readmission patients with type 2 diabetes mellitus were selected as the sample using the accidental sampling technique. Data were collected through a questionnaire consisting of the Diabetes Early Readmission Risk Indicators (DERRI™) and the Readmission Questionnaire providing 4 answer choices, i.e. ≤ 30 days; > 30–60 days; > 60–90 days; and > 90 days. The Chi-square test was employed for data analysis. Results: Of all respondents, the majority are in late adulthood (50-61 years), totaling 70 individuals (38.0%) with a mean age of 57.3 years; 111 individuals (60.3%) are male; 99 (53.8%) have completed elementary education; 102 (55.4%) work as farmers/laborers/fishermen; and 67 (36.4%) use Humalog as their insulin. Moreover, 69 respondents (37.5%) have experienced the third readmission, which is the highest number of readmissions. The bivariate analysis reveal that there is a significant relationship between complications of type 2 diabetes mellitus and patient readmission (p=0.000). Conclusion: The findings demonstrate complications as a factor associated with readmissions of type 2 diabetes mellitus patients. The complications leading to the readmissions include hypoglycemia, hypertension, heart problems, kidney problems, diabetic ulcers, and strokes. Also, age contributes as a factor increasing the readmission risk of patients with type 2 diabetes mellitus. The results emphasize the need to re-evaluate health service strategies and nursing interventions by providing effective discharge planning to prevent complications or reduce readmissions in type 2 diabetes mellitus patients.

Prevalence of Older Hospitalised Adults with Sustained Fractures after a Fall in Regional Australian Hospitals.

Falls commonly occur in hospitals, particularly among older adults. Fractures in the older population can cause major morbidity, which can result in long hospital admissions and increased care costs. This study aimed to characterise the demographics of patients aged 65 years and over who fell in hospital and to determine the type of fractures they sustained. A descriptive study was undertaken to examine hospital data of older inpatients who had a fall during admission in two regional Queensland hospitals in Australia over a 2.5-year period. The prevalence of inpatient falls was 1.28%. Most falls were unwitnessed (77.34%) and they had an average of seven medical comorbidities. The mean age was 80.4 years and 63% were male. Women who fell were significantly older than men (p = 0.004). The mean length of stay of in-hospital fallers was 22.77 days and same admission mortality was 9.3%. Thirty-three fall events (3.8%) resulted in fractures, some with multiple injuries. The most common fracture was neck of femur, followed by rib, femur, and facial fractures. In conclusion, this study identifies the incidence of falls increased with age, most falls were unwitnessed, as well as provides evidence that patients with falls had multiple comorbidities and long hospital admissions. The data could be used to optimise fall prevention strategies and to refine post-fall assessment pathways.

Technological Perception with Rural and Urban Differentiation and Its Influence on the Quality of Life of Older People with Age-Related Macular Degeneration

The past decade has seen a global increase in population age, especially in developed countries, where aging involves visual diseases such as age-related macular degeneration (AMD), which severely affect quality of life (QoL) and mental health, as well as increase isolation and care costs. This study investigated how persons with AMD perceive the impact of technology use on their QoL, focusing on potential disparities between urban and rural contexts in Spain. Using a cross-sectional observational design, data from the 2020 National Statistics Institute’s Disability, Personal Autonomy, and Dependency Situations Survey were analyzed, focusing on QoL aspects based on the WHO items of the WHOQOL-100 scale. The results revealed a generally positive perception of technology among participants, with urban residents perceiving technology’s positive impact more favorably. Sex discrepancies in technology perception were also observed, as women exhibited a more positive outlook on technology’s influence on QoL. The analysis of QoL aspects, such as ‘Visibility’, ‘Learning’, ‘Mobility’, and ‘Domestic life’, highlighted distinct challenges faced by rural and urban populations, underscoring the importance of context-specific approaches in technology interventions. However, these perceptions were intertwined with comorbidities, which can exacerbate AMD-related issues. Furthermore, this study explored the role of technology in enhancing QoL among older adults with AMD, examining how it influences daily activities and independence, particularly in the context of AMD management. This study concluded that developing more-inclusive policies tailored to the specific needs of persons with AMD, with special attention to environmental and sex differences, is imperative to enhance the positive impact of technology on their QoL.

Burden of delirium on mortality and healthcare resource utilization in geriatric patients hospitalized for inflammatory bowel disease

Background Delirium is prevalent in elderly patients, linked to elevated mortality rates, heightened healthcare resource use, and caregiver burden. Inflammatory bowel disease (IBD) poses various delirium risk factors, yet the impact on geriatric IBD patient outcomes remains unexplored. Methods Using 2016–2019 National Inpatient Sample data, we identified ≥65-year-old patients admitted for IBD (Crohn’s, ulcerative colitis) management stratified by delirium presence as a secondary diagnosis. The study aimed to assess delirium’s impact on geriatric IBD patient outcomes. Results Among 67,534 elderly IBD admissions, 0.7% (470) developed delirium. The delirium group had a 4.8-fold increase in in-hospital mortality risk (odds ratio 4.80, P < 0.001, 95% confidence interval [CI] 1.94–11.8). IBD patients with delirium experienced prolonged length of stay (adjusted mean difference 5.15 days, 95% CI 3.24–7.06, P < 0.001) and increased care costs (adjusted mean difference $48,328, 95% CI $26,485–$70,171, P < 0.001) compared to those without delirium. Conclusion Elderly IBD patients with delirium face higher mortality risk, prolonged hospitalization, and increased healthcare costs. Clinicians should recognize delirium’s detrimental effects in this vulnerable group and adhere to preventive protocols for improved care.

Informing Personalised Gamification Interventions Through a Novel Gamified Quiz.

Nonadherence to medical interventions and other advice leads to increased care costs and poorer health outcomes across a range of medical fields. An approach to increasing adherence is gamification. To maximize the benefits of gamification, a more structured and informed implementation is required. In this paper, a novel web-based personality determiner has been outlined, the integration of which could provide the personalisation required for an optimized gamification implementation.

Growth factor use in patients with breast cancer treated with docetaxel, carboplatin, trastuzumab, and pertuzumab (TCHP) regimen: Cost implications in a safety-net system.

10 Background: Growth factor (G-CSF) support has been shown to reduce the incidence of neutropenic complications after chemotherapy; however, it can be associated with a significant increase in cost of care. Here, we reviewed G-CSF use in breast cancer patients receiving docetaxel, carboplatin, trastuzumab, and pertuzumab (TCHP) regimen at a safety-net system. Methods: Parkland Health is the safety-net system that provides care to primarily uninsured/underinsured patients in Dallas County, Texas. The majority of patients treated at Parkland belong to racial and ethnic minorities. We reviewed electronic medical records of patients with HER-2 positive breast cancer who were treated with TCHP between 01/01/2017 and 12/31/2022 at Parkland. Data on patient demographics, treatment history, laboratory values, and treatment related complications were collected. Results: A total of 171 consecutive patients underwent neoadjuvant/adjuvant treatment with TCHP for HER-2 positive breast cancer. Forty-one patients (24.0%) received G-CSF for primary prophylaxis, as per discretion of treating physician. In the 130 patients (76.0%) who did not receive primary prophylaxis, G-CSF was added later in 41 patients (32.5%). Febrile neutropenia (FN), neutropenic treatment delays, and infections not meeting FN criteria accounted for the majority of cases where G-CSF was added later in the course of treatment. Overall, 529 cycles of TCHP were administered without G-CSF vs. 372 cycles with G-CSF. Without primary prophylaxis, 18.5% (24/130) of the patients developed FN vs 2.4% (1/41) for those who received primary prophylaxis, p=0.011. FN was a complication in 4.5% (24/529) of chemotherapy cycles without G-CSF vs. 1.1% (4/372) of cycles administered with G-CSF, p=0.003. In patients treated without G-CSF, the majority of FN episodes (71%) occurred within the first 3 cycles. FN resulted in a total of 150 days (median 5 days) of hospital stay resulting in $1.2 million (M) in charges (median $36,000 per admission). Universal G-CSF use in our patient population could have prevented 21 episodes of febrile neutropenia with an estimated saving of $1.05 M (hospital admission charges), at an extra cost of $1.8M (based on the pegfilgrastim Medicare average sales price (ASP) from 2017-2022). However, based on the 2023 Medicare ASP, by substituting pegfilgrastim for biosimilars, the estimated cost would have been $603,000. Conclusions: Our study did not show an FN rate &gt;20% to warrant routine addition of G-CSF for primary prophylaxis as recommended by the NCCN. During the study period, the cost of G-CSF was prohibitive for its universal use. However, the recent introduction of G-CSF biosimilars has significantly reduced the cost burden and justifies routine G-CSF prophylaxis as a cost saving measure.

Assessment of outpatient chemotherapy and unplanned emergency department visits in a large community hospital system.

e18768 Background: Unplanned complications of outpatient chemotherapy can significantly affect patient oncologic outcomes, health, and increase cost of care. CMS rule OP-35 evaluates quality of care for Medicare patients by assessing the risk of emergency department (ED) visit within 30 days after outpatient chemotherapy administration. This study reviews this measure for all oncology patients treated in our community hospital setting. Methods: Patients treated between 02/2012 and 04/2021 were identified. Age at first chemotherapy administration, gender, cancer diagnosis, and chemotherapy regiment were evaluated. Chemotherapy was stratified into cytotoxic therapy, immunotherapy, targeted therapy, and endocrine therapy. ED visits were only those in our hospital system. 30-day risk of ED visit was calculated for individual chemotherapy administrations. Internal results were compared with our CMS OP-35 results for concordance. Results: There were 19,732 patients who received chemotherapy treatments between 02/2012 and 04/2021, with 262,379 chemotherapy administrations. Individual chemotherapy administration had 5.2% risk of a 30 day ED visit. Cumulative risk of a patient having a 30 day ED visit was 32.9%. From ED, patients had 61.2% rate of hospital admission, vs 24.8% rate for general ED population. By age at first chemotherapy administration, the risk of 30 day ED visit was 6.3% for age &lt; 18, 5.4% for age 18-64, and 5.9% for age &gt; = 65. Our rate was relatively stable between 2014 and 2020. Our corresponding CMS score was 5.5% in 2016, 5.5% in 2018, and 5.1% in 2019. By gender, the risk was 5.6% for male and 5.0% for female patients. By chemotherapy category, the risk was 5.9% for cytotoxic chemotherapy, 7.5% for immunotherapy, 4.2% for targeted therapy, and 5.2% for endocrine therapy. Carboplatin/paclitaxel was the most common drug combination administered, with 8.7% risk. Cytarabine/methotrexate combination had the highest risk at 57.0%. By ICD diagnosis, breast cancer accounted for most patients and most chemotherapy administrations, with 30 day ED visit risk of 3.6%. Multiple myeloma had the highest rate of chemotherapy administrations at 26.3 per patient and a risk of 4.0%, compared with 13.3 across the entire population. Stomach cancer had the highest risk of 30 day ED visit at 10.0%. Conclusions: The risk of 30 day unplanned ED visit was elevated in pediatric patients, and was similar in patients 18-64 and &gt; = 65 years of age, and corresponded well to our CMS OP-35 metric, despite only tracking internal ED visits. Immunotherapy had significantly elevated risk compared with cytotoxic therapy, while targeted therapy had the lowest risk of ED visit. There were significant differences depending on disease site. We have established a baseline, and developed a live dashboard in our electronic medical record to monitor this metric globally, and to intervene in patients at high risk of 30 day ED visit.

Identifying dimensions and components affecting the financial knowledge and skills required by hospital managers by using the phenomenological approach

Introduction: At the global level, the provision of health services even in the smallest units is complicated, and organizations providing health services are facing various challenges, including the increase in care costs and the reduction of health and treatment fund. The purpose of this research is to identify effective dimensions and components in the formation of financial knowledge and skills needed by hospital managers.&#x0D; Methods: Based on the exploratory approach, this research was conducted qualitatively through phenomenological method. In terms of the result, it is among developmental studies. Necessary analyses were done using the 7-step Colaizzi technique and with the help of Max Kyuda software. Purposive sampling method was used, and data was collected through interviews with 10 financial experts of Iranian hospitals in 1400. Then, data were analyzed, and finally, dimensions and components were extracted.&#x0D; Results: The main components in determining the financial knowledge of hospital managers included basic information related to financial flow, hospital financing system, financial management and funding, basic accounting and financial information, auditing, management accounting and evaluation, legal and regulatory frameworks in the Islamic Republic of Iran, the payment system, and financial incentives and contracts. In a nutshell, 145 key concepts were extracted.&#x0D; Conclusion: According to the results of the research, it is necessary to compile appropriate topics and develop educational resources to improve the financial knowledge and skills of hospital managers. It is necessary to prepare and formulate a suitable tool to measure knowledge and financial skills of hospital managers and determine their strengths and weaknesses for the purpose of targeted training and also as one of the requirements for the selection of hospital managers. It is recommended to periodically train the managers of the organization by holding in-service training courses.

The reality and future of home visit care from an economic point of view

The imminent care problem in a super-aged society, Korea is likely to increase the burden of national medical expenses and cause a systemic crisis due to a sharp increase in care costs in line with the decline in the economically active population. Home visit medical service can be an effective means to reduce care costs and improve the medical system, which is a treatment-oriented high-cost structure. Promotion of home visit medical service will be helpful to establish a sustainable health and medical welfare system by establishing the community-based integrated care and efficient use of medical expenses.

The impact of Medicaid expansion on spending and utilization by older low-income Medicare beneficiaries.

To examine indirect spillover effects of Affordable Care Act (ACA) Medicaid expansions to working-age adults on health care coverage, spending, and utilization by older low-income Medicare beneficiaries. 2010-2018 Health and Retirement Study survey data linked to annual Medicare beneficiary summary files. We estimated individual-level difference-in-differences models of total spending for inpatient, institutional outpatient, physician/professional provider services; inpatient stays, outpatient visits, physician visits; and Medicaid and Part A and B Medicare coverage. We compared changes in outcomes before and after Medicaid expansion in expansion versus nonexpansion states. The sample included low-income respondents aged 69 and older with linked Medicare data, enrolled in full-year traditional Medicare, and residing in the community. ACA Medicaid expansion was associated with a 9.8 percentage point increase in Medicaid coverage (95% CI: 0.020-0.176), a 4.4 percentage point increase in having any institutional outpatient spending (95% CI: 0.005-0.083), and a positive but statistically insignificant 2.4 percentage point change in Part B enrollment (95% CI: -0.003 to 0.050, p = 0.079). ACA Medicaid expansion was associated with more institutional outpatient spending among older low-income Medicare beneficiaries. Increased care costs should be weighed against potential benefits from increased realized access to care.

Clinical and economic impact of blue light cystoscopy in the management of NMIBC at US ambulatory surgical centers: what is the site-of-service disparity?

Management of non-muscle-invasive bladder cancer (NMIBC) significantly impacts healthcare resource utilization due to requirements for ongoing surveillance. White light cystoscopy (WLC) represents the traditional approach to NMIBC disease surveillance, though physicians utilizing WLC alone may fail to detect all cancerous lesions. The approval of blue light cystoscopy (BLC) as an adjunct to WLC enhances the urologist's ability to more readily detect cancerous tissue. A more complete resection will reduce recurrences and could result in reduced costs for the US healthcare system. This analysis quantifies the clinical and economic impact of the incorporation of BLC in the management of NMIBC in ambulatory surgical centers (ASCs) considering current Center for Medicare Services (CMS) patient-physician coverage and reimbursement. A budget impact model was developed to assess projected ASC costs for a cohort of 50 newly diagnosed bladder cancer patients over a 2-year follow-up comparing WLC alone vs. WLC + BLC. Treatment and surveillance intervals were based on AUA/SUO clinical guidelines. Clinical and cost metrics for staging and biopsy rates were assessed, with cost inputs based on Medicare reimbursement rates. Use of WLC + BLC for NMIBC surveillance resulted in the identification of 5 additional NMIBC recurrences compared to WLC alone. There was an associated increased cost of performing BLC in an ASC setting, with a net increase in the total cost of care for NMIBC of $110 per cystoscopy over a 2-year period. If recurrences missed using WLC alone were to progress prior to detection, the model projects an increase in treatment costs borne by Medicare of $9,097 to $34,538 due to more intensive treatments required for the increased risk of recurrence. Modeled results suggests that the Medicare program will incur increased costs, due to the gap between added costs per cystoscopy due to BLC. The current discrepancy in reimbursement disincentivizes community-based ASCs from adopting BLC, resulting in suboptimal patient care while increasing downstream treatment costs to Medicare, necessitated when missed disease progresses to higher stage/grade disease. The findings have important clinical implications for the optimal management of NMIBC and should inform healthcare policies that promote cost-effectiveness and enhanced patient outcomes.

Motion Sensor–Based Fall Prevention for Senior Care: A Hidden Markov Model with Generative Adversarial Network Approach

Whereas modern medicine has enabled humans to live longer and more robust lives, recent years have seen a significant increase in chronic care costs. The prevention of threats to mobility is critical for chronic disease management. Researchers and physicians often analyze data from wearable motion sensor–based information systems (IS) to prevent falls. However, prior studies on fall prevention often achieve suboptimal performance because of their limited capacities in modeling data distributions. In this study, we adopt the computational design science paradigm to develop a novel fall prevention framework, which includes the hidden Markov model with generative adversarial network (HMM-GAN) that extracts temporal and sequential patterns from sensor signals and recognizes snippet states and a logistic regression that utilizes the snippet states and determines whether and when to trigger protective devices to prevent fall injuries. We evaluate the proposed framework against prevailing fall-prevention models and the HMM-GAN component against state-of-the-art sensor analytics models on large-scale data sets. Through an in-depth case study, we demonstrate how the proposed framework can lead to significantly reduced potentially catastrophic falls. Besides practical health information technology contributions, HMM-GAN offers methodological contributions to the IS knowledge base for scholars designing novel IT artifacts for healthcare applications.

Comparison of three fall risk assessment tools in older hospitalized patients in Turkey: analysis of sensitivity and specificity.

As a result of falls, older patients experience injury and loss of function, and their length of hospital stay and care costs increase. This study was conducted to determine fall risks and compare the sensitivity and specificity of three fall risk assessment tools. Older patients' fall risk levels were determined according to the Itaki, Hendrich-II, and Morse tools within 2 h following their admission to the wards. A methodological design was used in the study, which included 388 hospitalized elderly patients. The mean age of the patients was 72.29 ± 5.6years, and 57.7% were female. According to the ROC curve values of Sensitivity and 1-Specificity, the cut-off points for the Hendrich-II, Itaki, and Morse fall tools were accepted as 27.5, 8.5, and 6.5, respectively. According to the analysis results, the ratios of the areas under the ROC curve for the Itaki, Morse, and Hendrich-II fall tools were 0.794, 0.773, and 0.724, respectively, which were found to be statistically significant for all three tools (p ≤ 0.001). The Itaki Fall Risk Tool was found to be the most sensitive one among the three instruments in assessing the fall risk of older hospitalized patients. The Itaki Fall Risk Tool was followed by the Morse and Hendrich-II tools, respectively, in terms of sensitivity.

Financial strain of COVID-19 and its impact on willingness-to-pay for equine care.

The novel COVID-19 virus caused a global pandemic disrupting lives, industries, and economies. The result was an impact on prices due to challenges with production and supply chain distribution. This study investigates the financial strain COVID-19 had on equine owners and leasers, what the market for equine care would bear if costs for care increased, and what factors contribute to their willingness-to-pay (WTP) for increasing cost of equine care. An online survey was distributed for 4 weeks to adult US residents. Respondents reported their involvement in the equine industry, financial response to COVID-19, and responses to a double-bound dichotomous choice question on their WTP for care given a randomized increase (1-20%) in their current cost (n = 506). Data were analyzed using interval regression models where a = 0.05 (Stata15). Respondents were separated into 3 groups: owner keeping their horse at their residence, owner boarding their equids, and leaser. Boarders reported mean monthly payments of 23.33 ± 90.37 USD (n = 15) for free board, 236.47 ± 151.92 USD, (n = 75) for partial board, and 514.75 ± 291.71 USD (n = 181) for full board. Results show all owners, leaser, and boarders have different WTP values which range from 18.5% to 26.2% increase in current care costs which extends beyond the presented range due to many respondents responding "yes" to both WTP questions (71% of owners, 6% of boarders, 65% of leasers). Equine owners, with on farm equids from the southern US were WTP 11% less than from other regions (P = 0.015). The current boarding fees from owners that board their equids lowered their WTP by 0.01% (P = 0.029) for each additional dollar paid, whereas current care costs were not a significant factor for other owners (P = 0.370) or leasers (P = 0.395). Those that had a full lease for their equids, housed on farm or at a facility, were WTP 15% higher (P = 0.036) than those that had a partial or no lease. In comparison, boarding status (full, partial, or no boarding) did not significantly (P = 0.51) impact boarder's WTP. Age of respondent and annual household income heterogeneously affected WTP across all groups. These results indicate the market for equine care can bear the increases in cost associated with financial distress related to COVID-19, and may aid equine owners, caregivers, and associated individuals in making informed decisions regarding essential care. Results from this study should be taken in context of the global pandemic and the restrictions in place, or lack thereof, at the time the survey was administered.

The Early Impact of the COVID-19 Pandemic on Hospital Finances.

The COVID-19 pandemic has caused both short- and long-term impacts on every aspect of society. Hospitals are among the most critical frontliners and have had to continually navigate the challenges caused by the pandemic. In this study, we examined hospitals' financial performance following the onset of the pandemic. We used data from the Centers for Medicare & Medicaid Services Healthcare Cost Report Information System. The study sample included all general acute care and critical access hospitals that receive Medicare payments. The primary outcomes included operating margins, net patient revenues, operating expenses, and uncompensated care costs. We tested for average changes from 2019 to 2020 in hospitals' financial outcomes. We also tested for changes in financial outcomes across samples stratified by hospital characteristics: ownership type (investor-owned, nonprofit, and public), Medicaid disproportionate share hospital status, rural status, county uninsured rate quartile, and Medicaid expansion status. Our sample consisted of a balanced panel of 4,059 hospitals (8,118 observations) with data spanning 2019 and 2020. Across the full sample of hospitals, operating margins declined by an average of 5.3 percentage points between 2019 and 2020, equating to a 130% reduction from 2019 levels. Underlying these margin declines, net patient revenues declined by 3.2% on average, while operating expenses increased by 1.5%. We observed no changes in uncompensated care costs despite the large number of job losses that accompanied the pandemic. When stratifying the analysis by hospital characteristics, differences were observed across ownership types. Notably, investor-owned facilities were less affected financially than nonprofit and public hospitals. Although safety-net and rural hospitals generally fared no worse than their non-safety-net and nonrural counterparts, hospitals located in Medicaid expansion states experienced steeper declines in operating margins relative to hospitals located in nonexpansion states, driven by larger relative declines in patient revenues. The operating margin declines we observed can be attributed to supply-chain issues, persistent labor shortages, and suspension of elective services. The Affordable Care Act reforms in health insurance markets likely helped to insulate hospitals from increases in uncompensated care costs. In the shifting context of the pandemic, it is important to understand hospitals' financial performance so that measures can be taken to address further financial distress that may eventually lead to increased consolidation, hospital closures, and lower quality of care. Our findings stress the need for targeted responses that are tailored to underlying hospital characteristics. Temporary and targeted increases in inpatient and outpatient service prices can help offset revenue losses from the deferment of nonurgent care. Other policies can address the ongoing workforce challenges and supply-chain issues.

Meeting today’s healthcare needs: Medicine at the interface

The demographic of Singapore has undergone dramatic change. Historically, younger patients with communicable diseases predominated, whereas patients are now older with chronic multimorbidity and functional impairment. This shift challenges existing health and social care systems in Singapore, which must pivot to meet the changing need. The consequences of mismatched health and social care to patient needs are the fragmentation of care, dysfunctional acute care utilisation and increasing care costs. In Singapore and internationally, there is an inexorable rise in acute care utilisation, with patients facing the greatest point of vulnerability at transitions between acute and chronic care. Recently, innovative care models have developed to work across the boundaries of traditional care interfaces. These "Interface Medicine" models aim to provide a comprehensive and integrated approach to meet the healthcare needs of today and optimise value with our finite resources. These models include Acute Medical Units, Ambulatory Emergency Care, Extensivist-Comprehensivist Care, Virtual Wards, Hospital-at-Home and Acute Frailty Units. We describe these models of care across the acute care chain and explore how they may apply to the Singapore setting. We discuss how these models have evolved, appraise the evidence for clinical effectiveness, point out gaps in knowledge for further study and make recommendations for future progress.

Economic Burden of Diabetes and Hypertension: A Study of Direct and Indirect Cost of Treatment in Southeast Nigeria.

The prevalence of diabetes mellitus and hypertension is increasing yearly in many low- and middle-income countries such as Nigeria. The increasing burden of these noncommunicable diseases has led to an increase in the overall cost of health care. This study aimed at determining the direct and indirect health care costs of diabetes mellitus and hypertension occurring both singly and in co-morbidity. The study was undertaken in the Enugu State University Teaching Hospital (a tertiary hospital) in Enugu State, Southeast Nigeria. Data were collected using a pre-tested questionnaire. Out of 817 patients interviewed, 37% had only diabetes mellitus, 35% had hypertension, and 28% had both diabetes mellitus and hypertension in co-morbidity. Direct costs of treating diabetes mellitus and hypertension in the month before the survey were $28.40 and $19.35, respectively, while the indirect costs of treatment in the month before the study were $7.36 and $5.51, respectively. Direct and indirect costs for diabetes mellitus and hypertension in co-morbidity were $37.00 and $4.62, respectively. A concentration index showed that diabetes mellitus and hypertension were more evident among the poor than the rich. The economic cost when compared with patients' income revealed that >25% of their income is spent monthly on health care.