Mean Cost Of Care Research Articles

Characteristics of Female Genital Restoration Surgery for Congenital Adrenal Hyperplasia Using a Large-scale Administrative Database

To analyze nationwide information on the timing of surgical procedures, cost of surgery, hospital length of stay following surgery, and surgical complications of female genital restoration surgery (FGRS) in females with congenital adrenal hyperplasia (CAH). We used the Pediatric Health Information System database to identify patients with CAH who underwent their initial FGRS in 2004-2014. These patients were identified by an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis code for adrenogenital disorders (255.2) in addition to a vaginal ICD-9 procedure code (70.x, excluding vaginoscopy only) or perineal ICD-9 procedure code (71.x), which includes clitoral operations (71.4). A total of 544 (11.8%) females underwent FGRS between 2004 and 2014. Median age at initial surgery was 9.9 months (interquartile range 6.8-19.1 months). Ninety-two percent underwent a vaginal procedure, 48% underwent a clitoral procedure, and 85% underwent a perineal procedure (non-clitoral). The mean length of stay was 2.5 days (standard deviation 2.5 days). The mean cost of care was $12,258 (median $9,558). Thirty-day readmission rate was 13.8%. Two percent underwent reoperation before discharge, and 1 (0.2%) was readmitted for a reoperation within 30 days. Four percent had a perioperative surgical complication. Overall, 12% of girls with CAH underwent FGRS at one of a national collaborative of freestanding children's hospitals. The majority underwent a vaginoplasty as a part of their initial FGRS for CAH. Clitoroplasty was performed on less than half the patients. Overall, FGRS for CAH is performed at a median age of 10 months and has low 30-day complication and immediate reoperation rates.

Epidemiology of Eczema Herpeticum in Hospitalized U.S. Children: Analysis of a Nationwide Cohort

Eczema herpeticum (EH) is characterized by viral infection of a preexisting inflammatory dermatosis and is associated with considerable morbidity. In this cross-sectional study, we sought to determine the incidence, risk factors, comorbidities, costs of care, length of stay, and mortality in hospitalized U.S. children with EH. The Nationwide Inpatient Sample 2002-2012, containing a 20% sample of all U.S. hospitalizations, was analyzed. We used a validated approach involving InternationalClassification of Diseases, Ninth Revision-Clinical Modification codes to identify patients primarily admitted for EH (n= 4,655 weighted). The mean annual incidence of hospitalization for EH per million children ranged from 4.03 to 7.30, increasing significantly from 2008 to 2012. EH was associated with younger age (odds ratio [95% confidence interval] for 3-4 years= 1.29 [1.02-1.64]) and nonwhite race/ethnicity (black= 2.93 [2.35-3.66], Asian= 4.41 [3.34-5.83], Native American= 2.96 [1.51-5.78]) but was less likely to occur in areas with lower income quartiles (quartile 1, 0.66 [0.53-0.84]; quartile 2,= 0.68 [0.54-0.87]; quartile 3, 0.70 [0.56-0.88]). EH was associated with atopic dermatitis (11.72 [9.48-14.49]). Increased length of stay and costs of care were associated with Asian race. Mean length of stay was 3.86 ± 0.09 days, and mean cost of care was $5,237.6 ± 160.6. Overall mortality was 0.1%. EH in hospitalized children poses a substantial burden to the health care system.

Management of Febrile Neutropenias in Adolescents and Young Adults: A Cost-Minimization Analysis Between Adult Versus Pediatric Units.

Management of adolescents and young adults (AYAs) differs between adult and pediatric units, especially regarding febrile neutropenia (FN). In our previous study, we found that AYAs treated in adult units were significantly less hospitalized for FN than in pediatric units, without difference in morbimortality. The objective of this work was to assess the economic impact of these practices. This study retrospectively collected data from the medical records of AYAs treated at the Comprehensive Cancer Center Léon Bérard, Lyon, France, in the Euro-E-W-I-N-G99 protocol between September 1, 2000 and May 31, 2013. We focused on FN occurring after VIDE (vincristine, ifosfamide, doxorubicin, etoposide) courses. Costs were calculated using a micro-costing technique from the hospital's perspective (in 2014-Euro); the time horizon was the induction period. Multivariate analyses were performed on the total cost and cost of FN. Uncertainty was captured by sensitivity analyses. Forty-four AYAs (18 in the adult sector, 26 in the pediatric sector) received 260 courses of VIDE. Mean cost of care was €37,544 in the pediatric sector, including €11,948 (32%) for FN (€11,851 in hospitalization), versus €34,677 in the adult sector, including €6,143 (18%) for FN (€5,789 in hospitalization). Cost for FN was significantly higher in pediatric units (difference in mean cost of €5,830 per patient, 95% bootstrapped confidence interval [1,939.1; 10,028.9]). In multivariate analysis, the only factor significantly influencing this cost difference was the sector of care. The most sensitive parameter was the unit cost of conventional hospitalization. These results support the adult sector strategy, in agreement with the results of our first work showing comparable effectiveness.

Effects of a Community-Based Program for Oral Health and Nutrition on Cost-Effectiveness by Preventing Disability in Japanese Frail Elderly: A Quasi-Experimental Study Using Propensity Score Matching

ObjectiveIn the Japanese Long-Term Care Insurance (LTCI) system, a community-based program for oral health and nutrition (OHN program) has been implemented with the aim of reducing incident disability and care costs. However, the effectiveness of this program has not been confirmed epidemiologically. The purpose of the present study was to test the hypothesis that the OHN program does reduce incident disability and care costs. DesignA prospective study with a 28-month follow-up period was conducted using data from administrative databases at Tagajo City, Japan. Among frail elderly persons (aged 65 years or more) who were enrolled in the LTCI program in Tagajo, 64 participants in the OHN program and 128 controls (nonparticipants) were selected by propensity score matching. MeasurementsWe used 2 types of outcome measure: composite outcome (incident disability and death) and care cost. Data on incident disability were retrieved from the public LTCI database. Care cost was defined as the total amount of LTCI service cost added to medical care cost. ResultsThe hazard ratio of composite outcome was significantly lower for the intervention group than for the control group (hazard ratio = 0.32, 95% confidence interval 0.12–0.82). Even when we set incident disability as an outcome, the hazard ratio for the intervention group did not change (hazard ratio = 0.33, 95% confidence interval 0.11–0.97). The mean cumulative care cost during the 28 months tended to be lower for the intervention group ($4893) than that for the control group ($5770), but this was not statistically significant by the gamma regression model (cost ratio = 0.85, P = .513). The mean care cost per unit follow-up period (1 month) for the intervention group was significantly lower (cost ratio = 0.54, P = .027). ConclusionsThe results of this study suggest that the OHN program is effective for preventing incident disability and, consequently, for saving care costs per unit survival period.

Incidence and average cost per toxicity in patients treated with nivolumab.

93 Background: Recently approved PD-1 inhibitors such as nivolumab have demonstrated clear efficacy in metastatic melanoma and other cancers, but also come at a high cost and with the potential for severe side effects. However, most of the data available comes from clinical trials rather than patients treated in clinical practice as standard-of-care. This study reports the incidence of severe toxicities in a number of cancer types and estimates the per patient cost of managing these toxicities. Methods: Patients with metastatic melanoma, non-small cell lung cancer, renal cell carcinoma, and Hodgkin’s lymphoma treated with nivolumab between January 1, 2014 through April 30, 2016 were identified at Moffitt Cancer Center (N=74). Toxicities occurring during treatment or within 2 months of stopping treatment were identified by a chart review and each toxicity graded using the CTCAE 4.0 criteria. A cost of care analysis was performed to estimate the cost of serious toxicities (Grade 3-5) compared to a control group who experienced no or minor adverse events (Grade 0-2). Billing data was used to estimate the mean cost of care for each group. Costs were subcategorized by service line, e.g., pharmacy costs, radiology, laboratory services. Results: The most common severe toxicities were anemia, dyspnea, renal failure, colitis, fatigue, and pneumonitis (Table 1). The average cost of care for patients experiencing grade 3-5 toxicities was $2,036 higher than those without toxicity. Conclusions: The incidence of toxicity in our population was similar to that reported in clinical trials. Costs were higher for patients with toxicities, driven by additional outpatient care (19% higher cost per patient) as well as additional pharmacy costs (22% higher per patient). Though small in comparison to the cost of nivolumab, over $6,000 per dose, these costs should not be dismissed, particularly when performing cost effectiveness and value research. [Table: see text]

Abstract 070: A Precision Medicine Test Influenced Costs of Care Among Patients Presenting With Stable Symptoms Suggestive of Obstructive Coronary Artery Disease: Economic Endpoint Analysis From the PRESET Registry

Background: Because of diagnostic uncertainty, patients with symptoms suggestive of obstructive coronary artery disease (CAD) are referred at high rates to cardiologists and advanced cardiac testing. This evaluation process may also expose patients to appreciable costs and health risks. A previously validated, blood-based test incorporating age, sex and genomic expression into an algorithmic score (1-40) has shown clinical validity in assessing the likelihood of obstructive CAD (≥50% luminal diameter stenosis by quantitative coronary angiography) early in the cardiac workup. This test has also shown clinical utility in association with decision making around cardiac referrals and helping clinicians determine the current likelihood of obstructive CAD in symptomatic patients. Hypothesis: We hypothesized that use of the age/sex/gene expression score (ASGES) test would influence cost of care in the diagnosis and management of symptomatic patients with suspected obstructive CAD. Methods: The prospective PRESET Registry (NCT01677156) enrolled stable, non-acute adult patients presenting with symptoms suggestive of obstructive CAD to 21 US primary care practices from September 2012 to August 2014. Primary care clinicians provided pre- and post-ASGES diagnosis and evaluation plans for each patient. Demographics, clinical factors, and ASGES results (predefined as low [ASGES ≤ 15] or elevated [ASGES > 15]) were collected, as were management plans post-ASGES testing, including referrals to cardiology or further functional/anatomic testing. The economic analysis for cost of care after ASGES testing was based on the cost of cardiovascular-related tests, invasive procedures, office visits, emergency room visits, and hospital admissions during 1-year follow-up. Results: This sub-analysis cohort included 560 patients, with 50% females and median age 56 years. Patients had a median ASGES score of 18, with 246 (44%) patients with ASGES < 15. The mean cost of care for patients in the year following ASGES testing was $234 (SD ±$707) in the low ASGES versus $1,296 (SD ±$5230) in the elevated ASGES group (p=0.03 by Wilcoxon rank test). Multivariate analysis incorporating patient demographics and clinical covariates showed that low ASGES was associated with a 51% reduction in cost of follow-up care compared to elevated ASGES group (p<0.001 by log-linear regression). Conclusion: In this community-based cardiovascular registry, the ASGES influenced costs in the evaluation of patients with suspected obstructive CAD. Low score patients had approximately half the cardiovascular costs of elevated score patients in one year follow-up. Our work provides evidence supporting the economic value of using precision medicine in the delivery of cardiovascular care.

The costs of providing antiretroviral therapy services to HIV-infected individuals presenting with advanced HIV disease at public health centres in Dar es Salaam, Tanzania: Findings from a randomised trial evaluating different health care strategies.

BackgroundUnderstanding the costs associated with health care delivery strategies is essential for planning. There are few data on health service resources used by patients and their associated costs within antiretroviral (ART) programmes in Africa.Material and methodsThe study was nested within a large trial, which evaluated screening for cryptococcal meningitis and tuberculosis and a short initial period of home-based adherence support for patients initiating ART with advanced HIV disease in Tanzania and Zambia. The economic evaluation was done in Tanzania alone. We estimated costs of providing routine ART services from the health service provider's perspective using a micro-costing approach. Incremental costs for the different novel components of service delivery were also estimated. All costs were converted into US dollars (US$) and based on 2012 prices.ResultsOf 870 individuals enrolled in Tanzania, 434 were enrolled in the intervention arm and 436 in the standard care/control arm. Overall, the median (IQR) age and CD4 cell count at enrolment were 38 [31, 44] years and 52 [20, 89] cells/mm3, respectively. The mean per patient costs over the first three months and over a one year period of follow up following ART initiation in the standard care arm were US$ 107 (95%CI 101–112) and US$ 265 (95%CI 254–275) respectively. ART drugs, clinic visits and hospital admission constituted 50%, 19%, and 19% of the total cost per patient year, while diagnostic tests and non-ART drugs (co-trimoxazole) accounted for 10% and 2% of total per patient year costs. The incremental costs of the intervention to the health service over the first three months was US$ 59 (p<0.001; 95%CI 52–67) and over a one year period was US$ 67(p<0.001; 95%CI 50–83). This is equivalent to an increase of 55% (95%CI 51%–59%) in the mean cost of care over the first three months, and 25% (95%CI 20%–30%) increase over one year of follow up.

Regional Variation of Cost of Care in the Last 12 Months of Life in Switzerland: Small-area Analysis Using Insurance Claims Data.

Health care spending increases sharply at the end of life. Little is known about variation of cost of end of life care between regions and the drivers of such variation. We studied small-area patterns of cost of care in the last year of life in Switzerland. We used mandatory health insurance claims data of individuals who died between 2008 and 2010 to derive cost of care. We used multilevel regression models to estimate differences in costs across 564 regions of place of residence, nested within 71 hospital service areas. We examined to what extent variation was explained by characteristics of individuals and regions, including measures of health care supply. The study population consisted of 113,277 individuals. The mean cost of care during last year of life was 32.5k (thousand) Swiss Francs per person (SD=33.2k). Cost differed substantially between regions after adjustment for patient age, sex, and cause of death. Variance was reduced by 52%-95% when we added individual and regional characteristics, with a strong effect of language region. Measures of supply of care did not show associations with costs. Remaining between and within hospital service area variations were most pronounced for older females and least for younger individuals. In Switzerland, small-area analysis revealed variation of cost of care during the last year of life according to linguistic regions and unexplained regional differences for older women. Cultural factors contribute to the delivery and utilization of health care during the last months of life and should be considered by policy makers.

A Population-Based Study of Care at the End of Life Among People With HIV in Ontario From 2010 to 2013.

Aging and increasing comorbidity is changing the end-of-life experience of people living with HIV (PLHIV) in the developed world. We quantified, at a population level, the receipt of health care services and associated costs across a comprehensive set of sectors among decedents with and without HIV. We conducted a retrospective population-level observational study of all decedents in Ontario and their receipt of health care services, captured through linked health administrative databases, between April 1, 2010 and March 31, 2013. We identified PLHIV using a validated algorithm. We described the characteristics of PLHIV and their receipt of health care services and associated costs by health care sector in the last year of life. We observed 264,754 eligible deaths, 570 of whom had HIV. PLHIV were significantly younger than those without HIV (mean age of death 56.1 years vs. 76.6 years, [P < 0.01]). PLHIV spent a mean of 20.0 days in an acute care hospital in the last 90 days of life compared with 12.1 days for decedents without HIV (P < 0.01); after adjustment, HIV was associated with 4.5 more acute care days (P < 0.01). Mean cost of care in the last year was significantly higher among PLHIV ($80,885.62 vs. $53,869.77), mostly attributable to acute care costs. PLHIV in Ontario are dying younger, spending more time and dying more often in hospital, and incur significantly increased costs before death. Greater involvement of community-based palliative care may improve the dying experience for this complex population.

Longer Length of Stay and Higher Costs in Opioid Treated Patients: Evidence from a Real-World Analysis

Introduction: Opioids are frequently used to treat chronic nonmalignant pain. Constipation is an adverse side effect often experienced by users. Research has focused on examining treatment of opioid induced constipation (OIC) in ambulatory patients; few studies analyzed the prevalence and impact of OIC in the inpatient population. The objective of this study is to analyze and assess data from a regional integrated delivery network (IDN) on opioid and laxative utilization in an inpatient hospital setting and to quantify the impact of OIC on cost of care and the length of stay. Methods: This retrospective study was conducted using electronic medical record data from a single regional IDN. Qualifying patients were ≥18 years old who were administered opioids during an inpatient hospital stay between January 1, 2010, and August 31, 2014. Exclusion criteria were any existing diagnoses of inflammatory bowel disease, neurogenic bowel, or cancer. Data were compared for patients with and without constipation, including cost of care and length of stay. Patients were considered constipated with diagnosis code for constipation, obstruction, or impaction, or a constipationrelated procedure. Patients were also considered constipated if the first laxative was provided more than 24 hours after receiving opioid. Descriptive statistics were generated with mean provided for continuous variables. T-tests were used to compare continuous outcomes and Fisher's exact test to compare categorical outcomes. Results: A total of 4,844 patients met inclusion criteria; 2,696 had constipation and 2,148 did not. Patients with constipation cost an additional $3,920 per visit and stayed in the hospital an average of 3 days longer than those without. The mean cost of care and mean length of stay for patients with and without constipation according to the most common clinical conditions associated with their inpatient hospital stay are shown in the table below. Significant increases in cost of care and length of stay were observed among patients with constipation across all conditions.Table 1: Cost of Care and Length of Stay in Patients With and Without Constipation by Clinical ClassificationConclusion: This real world analysis demonstrates that in an inpatient U.S. population of patients receiving opioid treatment, patients with constipation had significantly higher cost of care and longer length of hospital stay than those without constipation. In this study the presence of constipation was associated with increased costs and length of stay.

Cost analysis of Healthcare in a Private sector Neonatal Intensive Care Unit in India.

To study the actual cost of care per patient in private-sector level IIIa Neonatal Intensive Care Unit (NICU). Prospective cost-analysis study. Cost incurred by the family on the treatment of baby, separately for every newborn for entire length of hospitalization, was calculated. 126 newborns were enrolled; High level of intervention was needed for 25.4% babies. The mean cost of care was US $ 90.7 per patient per day. Bulk of the cost of care was the hospital bill.

The inpatient burden of psoriasis in the United States

Although psoriasis has been linked to increased inpatient cardiovascular mortality, little is known about hospitalization for psoriasis and its inpatient burden in the United States in terms of frequency and cost. We sought to determine risk factors for hospitalization for psoriasis and quantify cost of care, length of stay, and in-hospital mortality. We conducted a cross-sectional study of the Nationwide Inpatient Sample from 2002 to 2012, containing a representative 20% sample of all US hospitalizations. Hospitalization for psoriasis was associated with nonwhite race (Asian odds ratio [OR] 2.08, 95% confidence interval [CI] 1.55-2.78; black OR 1.65, 95% CI 1.43-1.89; and multiracial/other OR 1.54, 95% CI 1.13-2.11) and insurance status (Medicare OR 1.33, 95% CI 1.26-1.40; Medicaid OR 1.32, 95% CI 1.25-1.40; and uninsured OR 1.94, 95% CI 1.64-2.30). Mean cost of care was lower for a primary diagnosis of psoriasis in comparison with patients without psoriasis ($7433±$254 vs $9956±$76; P=.002). Length of stay was significantly prolonged for patients with a primary diagnosis of psoriasis compared with no psoriasis (5.4±0.2 vs 4.6±0.02days; P<.0001). Mean adjusted in-hospital mortality was 0.4% and 1.8% for a primary or no diagnosis of psoriasis, respectively. We were unable to look at medication usage and its impact on hospitalization. Information regarding the severity of psoriasis and how this may have affected in-hospital procedures was not available. There are racial and health care disparities in hospitalization for psoriasis, stressing the need for improved access to dermatologic care for all patients.

164 The inpatient burden of psoriasis: A nationwide analysis

Psoriasis is associated with substantial morbidity and even mortality. Little is known about risk factors for hospitalization in psoriasis. We sought to determine the inpatient burden of psoriasis in the United States. We analyzed the 2002-2012 Nationwide Inpatient Sample, containing a representative 20% sample of all US hospitalizations. Psoriasis was determined by a validated algorithm using ICD-9-CM codes. The mean prevalence of a primary or secondary diagnosis of psoriasis was 31.7 and 2155.5 per million hospitalized patients per year, respectively. For patients with a secondary diagnosis of psoriasis, hospitalization rates continuously increased between 2002 and 2012 (analysis of variance with Tukey correction, P<0.0001 for all). In multivariate logistic regression models controlling for sociodemographic factors, hospitalization for psoriasis was associated with race (odds ratio [95% confidence intervals] for Asian: 2.08 [1.55-2.78]; black: 1.65 [1.43-1.89]; multiracial/other: 1.54 [1.13-2.11]) and insurance status (Medicare: 1.33 [1.26-1.40]; Medicaid: 0.74: [0.66-0.82]; uninsured: 1.94 [1.64-2.30]). Mean cost of care was lower for a primary diagnosis of psoriasis ($7433±254) but higher for a secondary diagnosis ($11,711±107) compared to $9956±76 for patients without psoriasis. Length of stay was significantly prolonged for patients with a primary (5.4±0.2 days; P<0.0001) or secondary (5.2±0.1; P<0.0001) diagnosis of psoriasis compared to no psoriasis (4.6±0.2). After adjusting for demographic factors, psoriasis was associated with obesity (2.15 [2.10-2.19]), alcohol use disorder (1.73 [1.69-1.77]), depression (1.53 [1.50-1.57]), HIV/AIDS (2.15 [1.96-2.37]), and liver cancer (1.37 [1.23-1.54]) in the inpatient setting. Adjusted mortality was 0.28%±0.3 and 0.99%±0.2 for a primary and secondary diagnosis of psoriasis, respectively, in comparison to 1.78%±0.02 for patients without psoriasis. The inpatient burden of psoriasis is substantial, with numerous comorbid health conditions and significantly prolonged hospitalization, but lower mortality than patients without psoriasis.

Does hospital academic status impact colon cancer care value?

6 Background: Given the high cost of cancer care, delivery of high-value care is crucial. The effect of hospital academic status on value of care for patients with stage II and III colon cancer is unknown. Methods: SEER-Medicare cohort study of 20,118 patients age 66+ with stage II or III colon cancer diagnosed 2000-2005 and followed through December 31, 2007. Patients were assigned to a treating hospital based on hospital affiliation of the primary oncologist. We constructed Kaplan-Meier curves to assess unadjusted overall survival. We estimated a Cox proportional hazards model to assess adjusted overall survival. To examine associations between hospital academic status and mean cost of care we estimated a generalized linear model (GLM) with log link and gamma family. We estimated quantile regression models to examine associations between hospital teaching status and cost at various quantiles (25th, 50th, 75th, 90th, 95th, 99th, 99.5th, 99.9th). Standard errors were adjusted to account for clustering of patients within hospitals. Results: 4449/20,118 (22%) patients received care from providers affiliated with academic hospitals. There was no significant difference in unadjusted median survival based on hospital academic status for patients with stage II (academic 6.4 yrs vs. non-academic 6.3 yrs, p=0.711) or stage III disease (academic 4.2 yrs vs. non-academic 4.2 yrs, p=0.81). After adjustment, treatment at academic hospitals was not associated with significantly reduced risk of death from colon cancer (stage II HR 1.05, 95% CI: 0.97 - 1.13; p=0.23; stage III HR 0.99, 95% CI: 0.94-1.07; p=0.98). Excepting stage III patients at the 99.9th percentile of costs, there were no significant differences in adjusted costs between academic and non-academic hospitals. Conclusions: We find no difference in overall survival for patients with stage II or stage III colon cancer based on academic status of the treating hospital. Furthermore, costs of care are similar between academic and non-academic hospitals across virtually the full range of the cost distribution. Most colon cancer patients do not receive cancer care at academic hospitals. Our findings indicate that for patients with stage II or III disease, this inequity does not impact the value of care.

P0139 Cost trend analysis of initial cancer treatment in Taiwan

Background We aimed to identify causes of change in cancer treatment costs over time. Methods This study used trend analyses to assess the percentage of cancer patients who had received a specific treatment type and the mean cost of care for patients who had received that treatment. Findings Analyses of patients diagnosed in 2007 showed that the National Health Insurance (NHI) system paid, on average, $10,780 for initial care of a gastric cancer patient and $10,681 for initial care of a lung cancer patient, which were inflation-adjusted increases of $6234 and $5522, respectively, over the 1996 care costs. During the same interval, the mean NHI payment for initial care for five specific cancers increased significantly (p Interpretation In 2007, NHI payments for initial care for the studied five cancers exceeded $12 billion, and gastric and lung cancers accounted for the largest share. Therefore, the NHI must accurately predict the economic burden of new chemotherapy agents and radiation therapies and may need to develop programmes for stratifying patients according to their potential benefit from these expensive treatments.

Trends in chemotherapy-related treatment of advanced-stage colorectal (CRC) cancer.

258 Background: New drugs and technology are primary drivers of health care costs, but their marginal benefit is questionable, particularly in patients with incurable cancer. We examined trends in population-based treatment following diagnosis for metastatic colon and rectal cancer in elderly adults. Methods: We used the Surveillance, Epidemiology, and End Results (SEER) – Medicare linked database to identify persons aged 65 and older diagnosed with distant stage colon (N=16,086) and rectal cancer (N=4,003) between 2000 and 2009. For each year, we report the percent of patients who received cancer directed surgery, chemotherapy, antiemetics/premedications related to the chemotherapy, and hematopoietic growth factors, and the mean cost of care. All estimates are adjusted for patient characteristics, SEER region, survival, and year of diagnosis. Results: The percent of patients who had cancer directed surgery declined 12 and 11 percentage points for colon and rectal cancer patients, respectively. The percent of patients who received chemotherapy increased from 41% to 46% for colon patients and from 52% to 57% for rectal patients. Chemotherapy treatment intensified from 2000 to 2009, with longer duration in chemotherapy and more agents given. Over a third of colon and rectal cancer patients received three or more agents in 2009, often including oxaliplatin and/or bevacizumab. The percent of patients who received hematopoietic growth factors rose appreciably from 4% to 19% for colon patients and from 6% to 21% for rectal patients. Antiemetics/premedication use increased approximately 20 percentage points for all patients. Total costs of care rose from a mean of $61,171 to $74,567 per colon patient and from $68,213 to $82,031 per rectal patient. The percentage of costs due to hospitalizations declined for colon (56% to 47%) and rectal (47% to 40%) cancer patients. Conclusions: The use and intensity of chemotherapy, along with cost of care, for patients with advanced cancer increased markedly from 2000 to 2009. The inclusion of newer more expensive agents shifted the bulk of treatment costs from hospitalizations to the outpatient setting. The value of these treatments for advanced stage elderly patients is unknown.

Evaluation of the cost of atrial fi brillation during emergency hospitalization

Objective The number of hospitalizations for atrial fi brillation has increased dramatically. This increase, in the number of hospital stays will continue, given the growth projections based on epidemiological data, and will contribute to signifi cantly increase expenses for the social security system. The objective of this study was to evaluate the length of hospital stay, the average cost borne by social security, and the types of hospital stay expenditures for patients admitted through the emergency department for atrial fi brillation.Methods Patients were identifi ed by using the minimal clinical summaries of seven general hospitals in Belgium in 2008. Only hospitalized patients having as primary diagnosis code ICD-9-CM 42731 ‘atrial fi brillation’ were selected for this study. Hospital billing fi les were analysed in order to isolate the costs borne by social security. Outliers were isolated in order not to have results infl uenced by patients having an atypical length of stay.Results Results show that the mean length of stay was 8.6 days and the mean cost charged to social security was €3,066.02 per hospital stay. The mean cost of care was strongly associated with the degree of severity index related to the APR-DRG. Approximately 85% of the total cost was related to the cost of hospital days and medical procedures with medical imaging and laboratory tests being the two main cost inductors. 18% of patients had cardioversion during their hospital stay, including 4% who had only that treatment. 19% of patients used amiodarone. Flecainide and propafenone were also used, but less frequently.Conclusions The mean cost of care for AF patients admitted via the emergency department is strongly associated with the degree of severity. Approximately 85% of the total cost is related to the cost of hospital days and medical procedures. Hypertension is the most common secondary diagnosis. An optimal treatment of this risk factor could help to reduce the risk of atrial fi brillation, and thereby reduce the morbidity and costs associated with this disease.

Does the cost of care differ for patients with fee-for-service vs. capitation of payment? A case–control study in gastroenterology

There is growing evidence to demonstrate overuse of medical resources in fee for service (FFS) payment models (in which physicians are reimbursed according to volume of care provided) compared to capitation payment models (in which physicians receive a fixed salary regardless of level of care provided). In this medical centre, patients with and without insurance are admitted through the same access point (emergency room) and cared for by the same physicians. Therefore, apart from insurance status, all other variables influencing delivery of care are similar for both patient groups. However, physician reimbursement differs for both groups: FFS for patients with private insurance (i.e. the admitting physician's reimbursement escalates progressively with each day that the patient spends in hospital) and base salary irrespective of care provided for patients with universal insurance (capitation payment model). All admitting physicians are aware of the patient's insurance status and the duration of hospitalization is at the discretion of the admitting physician. This study aimed to compare cost of care of patients with and without insurance admitted to a teaching hospital with a primary gastroenterology or hepatology (GIH) diagnosis. All hospital inpatients admitted between January 2008 and December 2009 with a primary GI-related diagnosis related group (DRG) were identified. Patients were classified as uninsured (state-funded) or privately insured. Only DRGs with at least five patients in both the insured and uninsured patient groups were analyzed to ensure a precise estimate of inpatient costs. Patient level costing (PLC) was used to express the total cost of hospital care for each patient; PLC comprised a weighted daily bed cost plus cost of all medical services provided (e.g. radiology, pathology tests) calculated according to an activity-based costing approach, cost of medications were excluded. An overall mean cost of care per patient was calculated for both groups. All costs were discounted to 2009 values. In total, 630 patients were admitted with one of 11 GIH DRGs, 181 (29 %) with private insurance. Pooled mean cost of care was higher for uninsured (6,781 euros/patient) compared to insured patients (6,128 euros/patient). Apart from patients with 'non-cirrhotic non-alcoholic liver disease (non-complex)' in whom mean cost was higher for insured patients, there were no significant differences in mean cost of care nor mean patient age for insured and uninsured groups for any other diagnoses. Inpatient hospital costs were equivalent for patients with and without private health insurance when care was provided in a single hospital. Provision of care for all patients in a common hospital setting regardless of health insurance status may reduce disparities in healthcare utilization.

Is coronary CT angiography useful in diagnosing acute coronary syndromes in the Emergency Department?

Recent observations showed that contrast enhanced coronary CT angiography (CCTA) has high sensitivity and specificity for the detection of clinically significant coronary artery disease, and may facilitate triage of low-risk patients with typical acute chest pain and inconclusive biomarkers or ECG testing results [1, 2]. Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography (ROMICAT)-II Study [3] is a randomized, controlled multicenter trial that compared the effectiveness of a diagnostic strategy including early CCTA with that of standard evaluation in Emergency Department(ED) in stable patients with chest pain. The primary study end point was the length of stay in the hospital, defined as the time from ED presentation to discharge order. Secondary end points included time to diagnosis, rates of direct discharge from the ED, resource utilization, and cumulative costs. Safety end points were undetected acute coronary syndromes (ACS) (defined as an unexpected cardiovascular event within 72 h after hospital discharge in patients with a hospital stay of \24 h), and major adverse cardiovascular events (death, myocardial infarction, unstable angina, or urgent coronary revascularization) at 28 days. Of 1,000 patients (aged 54 ± 8 years, male 53 %, more than half with 2 or 3 cardiovascular risk factors), enrolled during weekday daytime hours at nine centers, 501 were randomly assigned to CCTA and 499 to a standard evaluation. All patients were included in the intention to treat analysis. CCTA was performed in 473 patients. Complete follow-up at 28 days was achieved in 99 % of patients. Seventy-five patients (8 %) had a final diagnosis of ACS. Average length of stay was significantly decreased by 7.6 h in patients randomized to CCTA (23.2 ± 37 vs. 30.8 ± 28 h, P \ 0.001). In addition, patients in the CCTA group had significantly shorter time to diagnosis (10.4 ± 12.6 vs. 18.7 ± 11.8 h, P \ 0.001) and were more often directly discharged from ED (47 vs. 12 % P \ 0.001) as compared with standard evaluation group. No cases of undetected ACS were identified in both study groups. Eight major adverse cardiovascular events were recorded at 28 days follow-up, two in the CCTA group. In both cases, CCTA detected clinically significant coronary artery disease but patients were initially treated with medical therapy because of negative stress test results. Regarding resource utilization, significantly more diagnostic tests were performed in CCTA group than in standard evaluation group (P \ 0.001). Both overall rate of coronary angiography and revascularization were higher among patients in the CCTA group, without significant differences as compared with standard evaluation group. Since almost all patients in CCTA group underwent computed tomography, cumulative radiation exposure was significantly higher in this group (P \ 0.001). Detailed costs analysis was available only for a subgroup of patients. The mean cost of care from initial ED visit through 28 days follow-up was similar in the two groups (4,289 ± 7,110 vs. 4,060 ± 5,452 $, P = 0.65). Authors conclude that incorporating early CCTA in ED evaluation strategy improves the efficiency of clinical decision making process for triage of patients with suspect ACS, without increased risk of undetected cardiovascular events. F. Dipaola (&) Clinica Medica, Medicina 4, Humanitas Clinical and Research Center, Via Manzoni, 56, Rozzano, Milan 20089, Italy e-mail: francadipaola@yahoo.it

Epidemiology of workplace-related fall from height and cost of trauma care in Qatar

Background:This study was designed to identify the incidence, injury patterns, and actual medical costs of occupational-related falls in Qatar, in order to provide a reference for establishing fall prevention guidelines and recommendations.Settings and Design:Retrospective database registry review in Level 1 Trauma Center at Tertiary Hospital in Qatar.Materials and Methods:During a 12-month period between November 1st 2007 and October 31st 2008, construction workers who fell from height were enrolled. A database was designed to characterize demographics, injury severity score (ISS), total hospital length of stay, resource utilization, and cost of care.Statistical Analysis:Data were presented as proportions, mean ± standard deviation or median and range as appropriate. In addition, case fatality rate and cost analysis were obtained from the Biostatistics and finance departments of the same hospital.Results:There were 315 fall-related injuries, of which 298 were workplace related. The majority (97%) were male immigrants with mean age of 33 ± 11 years. The most common injuries were to the spine, head, and chest. Mean ISS was 16.4 ± 10. There was total of 29 deaths (17 pre-hospital and 12 in-hospital deaths) for a case fatality rate of 8.6%. Mean cost of care (rounded figures) included pre-hospital services Emergency Medical Services (EMS), trauma resuscitation room, radiology and imaging, operating room, intensive care unit care, hospital ward care, rehabilitation services, and total cost (123, 82, 105, 130, 496, 3048,434, and 4418 thousand United States Dollars (USD), respectively). Mean cost of care per admitted patient was approximately 16,000 USD.Conclusions:Falling from height at a construction site is a common cause of trauma that poses a significant financial burden on the health care system. Injury prevention efforts are warranted along with strict regulation and enforcement of occupational laws.