Target For Cost Reduction Research Articles

Endovascular aneurysm repair delivery redesign leads to quality improvement and cost reduction

Endovascular aneurysm repair (EVAR) is now a mainstay of therapy for abdominal aortic aneurysm, although it remains associated with significant expense. We performed a comprehensive analysis of EVAR delivery at an academic medical center to identify targets for quality improvement and cost reduction in light of impending health care reform. All infrarenal EVARs performed from April 2011 to March 2012 were identified (N = 127). Procedures were included if they met standard commercial instructions for use guidelines, used a single manufacturer, and were billed to Medicare diagnosis-related group 238 (n = 49). By use of DMAIC (define, measure, analyze, improve, and control) quality improvement methodology (define, measure, analyze, improve, control), targets for EVAR quality improvement were identified and high-yield changes were implemented. Procedure technical costs were calculated before and after process redesign. Perioperative services and clinic visits were identified as targets for quality improvement efforts and cost reduction. Mean technical costs before the intervention were $31,672, with endograft implants accounting for 52%. Pricing redesign in collaboration with hospital purchasing reduced mean EVAR technical costs to $28,607, a 10% reduction in overall cost, with endograft implants now accounting for 46%. Perioperative implementation of instrument tray redesign reduced instrument use by 32% (184 vs 132 instruments), saving $50,000 annually. Unnecessary clinic visits were reduced by 39% (1.6 vs 1.1 clinic visits per patient) through implementation of a preclinic imaging protocol. There was no difference in mean length of stay after the intervention. Comprehensive EVAR delivery redesign leads to cost reduction and waste elimination while preserving quality. Future efforts to achieve more competitive and transparent device pricing will make EVAR more cost neutral and enhance its financial sustainability for health care systems.

Hospital readmission of patients with diabetes.

Hospital readmission is a high-priority health care quality measure and target for cost reduction. Despite broad interest in readmission, relatively little research has focused on patients with diabetes. The burden of diabetes among hospitalized patients, however, is substantial, growing, and costly, and readmissions contribute a significant portion of this burden. Reducing readmission rates of diabetic patients has the potential to greatly reduce health care costs while simultaneously improving care. Risk factors for readmission in this population include lower socioeconomic status, racial/ethnic minority, comorbidity burden, public insurance, emergent or urgent admission, and a history of recent prior hospitalization. Hospitalized patients with diabetes may be at higher risk of readmission than those without diabetes. Potential ways to reduce readmission risk are inpatient education, specialty care, better discharge instructions, coordination of care, and post-discharge support. More studies are needed to test the effect of these interventions on the readmission rates of patients with diabetes.

VESS6. Healthcare Delivery Redesign for EVAR Leads to Quality Improvement and Cost Reduction

Endovascular aneurysm repair (EVAR) is now a mainstay of therapy for abdominal aortic aneurysm, although it remains associated with significant expense. We performed a comprehensive analysis of EVAR delivery at an academic medical center to identify targets for quality improvement and cost reduction in light of impending health care reform. All infrarenal EVARs performed from April 2011 to March 2012 were identified (n = 127). Procedures were included if they met standard commercial instructions for use guidelines, used a single manufacturer, and were billed to Medicare Diagnosis-Related Group 238 (n = 49). Using DMAIC (define, measure, analyze, improve, control) quality improvement methodology, targets for EVAR quality improvement were identified, and high-yield changes were implemented. Procedure technical costs were calculated before and after process redesign. Perioperative services and clinic visits were identified as targets for quality improvement efforts and cost reduction. Mean technical costs before the intervention were $31,672, with endograft implants accounting for 52%. Pricing redesign in collaboration with hospital purchasing reduced mean EVAR technical costs to $28,607, a 10% reduction in overall cost, with endograft implants now accounting for 46%. Perioperative implementation of instrument tray redesign reduced instrument use by 32% (184 vs 132 instruments), saving $50,000 annually. Unnecessary clinic visits were reduced by 39% (1.6 vs 1.1 clinic visits per patient) through implementation of a preclinic imaging protocol. There was no difference in mean length of stay after the intervention (2.85 vs 2.45 days, P = NS). Comprehensive EVAR delivery redesign leads to cost reduction and waste elimination, while preserving quality. Future efforts aimed to achieve more competitive and transparent device pricing will make EVAR more cost neutral and enhance its financial sustainability for healthcare systems.

Predictors of unplanned readmission in patients undergoing lumbar decompression: multi-institutional analysis of 7016 patients.

Unplanned hospital readmission represents a large financial burden on the Centers for Medicare and Medicaid Services, commercial insurance payers, hospitals, and individual patients, and is a principal target for cost reduction. A large-scale, multi-institutional study that evaluates risk factors for readmission has not been previously performed in patients undergoing lumbar decompression procedures. The goal of this multicenter retrospective study was to find preoperative, intraoperative, and postoperative predictive factors that result in unplanned readmission (UR) after lumbar decompression surgery. The National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed to identify all patients who received lumbar decompression procedures in 2011. Risk-adjusted multivariate logistic regression analysis was performed to estimate independent predictors of UR. The overall rate of UR among patients undergoing lumbar decompression was 4.4%. After multivariate logistic regression analysis, anemia (odds ratio [OR] 1.48), dependent functional status (OR 3.03), total operative duration (OR 1.003), and American Society of Anesthesiologists Physical Status Class 4 (OR 3.61) remained as independent predictors of UR. Postoperative complications that were significantly associated with UR included overall complications (OR 5.18), pulmonary embolism (OR 3.72), and unplanned reoperation (OR 56.91). There were several risk factors for UR after lumbar spine decompression surgery. Identification of high-risk patients and appropriate allocation of resources to reduce postoperative incidence may reduce the readmission rate.

Development of an electrotransformation protocol for genetic manipulation of Clostridium pasteurianum.

BackgroundReducing the production cost of, and increasing revenues from, industrial biofuels will greatly facilitate their proliferation and co-integration with fossil fuels. The cost of feedstock is the largest cost in most fermentation bioprocesses and therefore represents an important target for cost reduction. Meanwhile, the biorefinery concept advocates revenue growth through complete utilization of by-products generated during biofuel production. Taken together, the production of biofuels from low-cost crude glycerol, available in oversupply as a by-product of bioethanol production, in the form of thin stillage, and biodiesel production, embodies a remarkable opportunity to advance affordable biofuel development. However, few bacterial species possess the natural capacity to convert glycerol as a sole source of carbon and energy into value-added bioproducts. Of particular interest is the anaerobe Clostridium pasteurianum, the only microorganism known to convert glycerol alone directly into butanol, which currently holds immense promise as a high-energy biofuel and bulk chemical. Unfortunately, genetic and metabolic engineering of C. pasteurianum has been fundamentally impeded due to lack of an efficient method for deoxyribonucleic acid (DNA) transfer.ResultsThis work reports the development of an electrotransformation protocol permitting high-level DNA transfer to C. pasteurianum ATCC 6013 together with accompanying selection markers and vector components. The CpaAI restriction-modification system was found to be a major barrier to DNA delivery into C. pasteurianum which we overcame by in vivo methylation of the recognition site (5’-CGCG-3’) using the M.FnuDII methyltransferase. With proper selection of the replication origin and antibiotic-resistance marker, we initially electroporated methylated DNA into C. pasteurianum at a low efficiency of 2.4 × 101 transformants μg-1 DNA by utilizing conditions common to other clostridial electroporations. Systematic investigation of various parameters involved in the cell growth, washing and pulse delivery, and outgrowth phases of the electrotransformation procedure significantly elevated the electrotransformation efficiency, up to 7.5 × 104 transformants μg-1 DNA, an increase of approximately three order of magnitude. Key factors affecting the electrotransformation efficiency include cell-wall-weakening using glycine, ethanol-mediated membrane solubilization, field strength of the electric pulse, and sucrose osmoprotection.ConclusionsC. pasteurianum ATCC 6013 can be electrotransformed at a high efficiency using appropriately methylated plasmid DNA. The electrotransformation method and tools reported here should promote extensive genetic manipulation and metabolic engineering of this biotechnologically important bacterium.

Hospital readmission after a pancreaticoduodenectomy: an emerging quality metric?

BackgroundHospital readmission has attracted attention from policymakers as a measure of quality and a target for cost reduction. The aim of the study was to evaluate the frequency and patterns of rehospitalization after a pancreaticoduodenectomy (PD). MethodsThe records of all patients undergoing a PD at an academic medical centre for malignant or benign diagnoses between January 2006 and September 2011 were retrospectively reviewed. The incidence, aetiology and predictors of subsequent readmission(s) were analysed. ResultsOf 257 consecutive patients who underwent a PD, 50 (19.7%) were readmitted within 30 days from discharge. Both the presence of any post‐operative complication (P = 0.049) and discharge to a nursing/rehabilitation facility or to home with health care services (P = 0.018) were associated with readmission. The most common reasons for readmission were diet intolerance (36.0%), pancreatic fistula/abscess (26.0%) and superficial wound infection (8.0%). Nine (18.0%) readmissions had lengths of stay of 2 days or less and in four of those (8.0%) diagnostic evaluation was eventually negative. ConclusionApproximately one‐fifth of patients require hospital readmission within 30 days of discharge after a PD. A small fraction of these readmissions are short (2 days or less) and may be preventable or manageable in the outpatient setting.

Editorial: Cervical spondylotic myelopathy

The authors of this study are to be commended for their efforts at determining the cost-effectiveness/ cost utility of surgical treatment of cervical spondylotic myelopathy (CSM).1 We are moving from an age in which the question was “does the surgery work?” to one in which the question is “what is the value of the surgery?” In the current health care environment, we have significantly constrained resources and nearly unlimited requirements for treatment. In order for health care policy makers to make rational decisions, they will have to compare the value of treatments in different categories in order to determine the best approaches for the money spent. This will start out as a very utilitarian process and then will move into a political process, involving such issues as whether we should spend more on treating the elderly or treating children with varying disease processes. However, the basis for discussion will be the relative cost per quality-adjusted life year (QALY) of any intervention. Those interventions that deliver high value—that is, significant improvement for low numbers of dollars spent— will be the first that are reliably covered and accepted. Cervical spondylotic myelopathy represents a troubling condition because of its profound impact on quality of life for patients who suffer from it. This research group has been doing excellent work in tracking the outcomes of the treatment of CSM. They have now looked at the costs associated with this treatment, and they have done this in an appropriate fashion. The study is based on Canadian metrics, a choice that is certainly reasonable, but Canadian metrics may represent lower values on the cost side of the equation than similar US metrics. However, given that cost per QALY ends up being benchmarked against the cost of renal dialysis, their analysis is still quite valid and appropriate. Initially, surgeons will have trouble with cost per QALY issues because we are not very good on the cost side of the equation. There are 2 sets of variables that go into this whole process, and these are the variables of change and health-related quality of life outcome, and the variable of cost. There certainly is a range of improvement that is experienced by any patient population undergoing any set of treatments, and similarly there is a range of costs that are incurred by these varying groups. Risk stratification becomes challenging in this environment, and the uncertainty in the parameter estimates remains high. However, this is the new metric that will be used, and we must be prepared to accept the uncertainty and move forward. In the absence of such data, decisions still have to be made by policy makers and certainly will be made. The data are and necessarily will remain somewhat imprecise; still they do give us the ability to make informed versus uninformed health care policy choices. The authors and surgeons who have contributed to this CSM cost-utility study are all university based, and the challenge will be to generalize their findings to the community at large. I would ask the authors to share their thoughts about the generalizability of this information, as that will be the perspective that policy makers will ultimately need to take. I would also ask the authors to project into the future as we look at how to take unnecessary costs out of the system, what portions of the care pathway are targets for cost reduction, and what items in the pathway of care are opportunities for improvements in outcome compared to what they have generated to date. Finally, again, I applaud the authors for their important step forward in this domain and look forward to their reply as well as their continued work. (http://thejns.org/doi/abs/10.3171/2012.5.AOSPINE12351)

A Novel Approach to Identifying Targets for Cost Reduction in the Emergency Department

This article introduces a novel framework that classifies emergency department (ED) visits according to broad categories of severity, identifying those categories of visits that present the most potential for reducing costs associated with the ED. Although cost savings directly attributable to the ED are apt to be an important emphasis of organizations operating under reformed payment systems, our framework suggests that a focus on diverting low-acuity visits away from the ED would result in far less savings compared with strategies aimed at reducing admissions and to a lesser extent improving the efficiency of ED care for intermediate or complex conditions. We conclude that targeting these categories, rather than minor injuries/illnesses, should be the primary focus of cost-reduction strategies from the ED. Given this understanding, we then discuss the implications of these findings on the financing of an emergency care system that needs to account for the required fixed costs of "stand-by capacity" of the ED and explore ways in which the ED can be better integrated into a patient-centered health care system.

Coalition Cuts 2: Museums

In late 2010 the coalition government set out its plan to reduce Britain’s deficit in the form of the Comprehensive Spending Review (CSR). In that same year, the Department for Culture, Media and Sport (DCMS) had received only 0.8 per cent of the national budget, but was nonetheless targeted for a budget reduction of twenty-four per cent, with severe implications for the UK’s museums sector. The Department’s commitment to free admission at national museums was maintained, but these institutions nevertheless received a fifteen per-cent budget cut, to be implemented across four years. The Museums, Libraries and Archives Council was abolished and responsibility for museums was handed over to Arts Council England, which itself received a cut of thirty per cent. Funding for regional museums was cut by fifteen per cent, and all other DCMS funding for non-national museums has since been withdrawn. Local-authority museums across the UK are also facing their own funding difficulties; local authorities were asked to make savings of twenty-eight per cent across four years, and the museums that they support (as non-statutory services) are easy targets for cost reduction. In the wake of the CSR, a wealth of anecdotal evidence pointed to a dramatic reduction in the quality of cultural provision in the UK. Our report for the Museums Association, The Impact of Cuts on UK Museums (July 2011), 1 while prompted by specific reports of such sector damage, was commissioned to provide, in so far as was possible, an objective and nationally representative picture of conditions across the sector. Identifying national patterns of change (impossible to discern on the basis of individual, localized case studies), the report offers a new, clear perspective on the present circumstances of museums, and simultaneously gives an indication of how future cuts may manifest themselves. The report was produced on the basis of data collected from a sample of 140 UK museums services, encompassing 200 separate sites, and weighted to

Anemia management under a bundled payment policy for dialysis: a preview for the United States from Japan

The goal of a bundled payment policy for dialysis is to decrease overall expenditures and shift financial risk from the payer to the provider. The primary target for cost reduction is invariably erythropoiesis-stimulating agents (ESAs), because of their large costs and potential for dose sparing. Japan succeeded in reducing ESA doses and maintaining stable hemoglobin levels through modest increases in intravenous iron administration. Dialysis providers in the United States have this and other strategies available.

What Are We Anyway? The Role of Pathologists in the 21st Century

What Are We Anyway? The Role of Pathologists in the 21st Century

Early Readmission in Acute Pancreatitis: Incidence and Risk Factors

Early unplanned readmission is a potential target for quality improvement and cost reduction. The aims of this study were to (i) determine the frequency of early readmission following hospitalization for acute pancreatitis (AP) and (ii) identify risk factors for early readmission in patients hospitalized for AP. A retrospective, observational cohort study was performed including all inpatients with AP at a tertiary-care hospital between June 2005 and December 2007. Early readmission was defined as admission to the hospital or reevaluation in the emergency department within 30 days of discharge. We analyzed demographics, etiology, markers of severity (according to Atlanta symposium), comorbidities, complications, therapeutic interventions, and discharge symptoms as potential risk factors for readmission. There were a total of 248 patients discharged with AP during the study period, of whom 19% (47/248) had an early readmission. Median time to readmission was 9 days (interquartile range, 5-15). Median rehospitalization length of stay was 4 days (2.5-8). In multivariate analysis, the strongest risk factors for early readmission included (i) gastrointestinal symptoms (nausea, vomiting, or diarrhea) at discharge (odds ratio (OR) 44.2; 95% confidence interval (CI) 4.1-472.1); (ii) discharge on less than a solid diet (OR 23.8; 95% CI 4.8-118.2); and (iii) moderate to heavy alcohol use (OR 10.1; 95% CI 1.2-82.6). (i) Early readmission is a common occurrence in AP. (ii) Risk factors for early readmission included moderate to heavy alcohol use, persistent symptoms, and diet at the time of discharge.

Reducing energy consumption in seawater desalination

Water is an increasingly scarce resource and in many regions people are turning to new sources such as seawater and wastewater. Various membrane technology improvements in the last decade have led to a significant cost reduction in reverse osmosis (RO). This has triggered selection of seawater reverse osmosis (SWRO) technology for many large drinking water projects in the world. Since energy cost is the single largest factor in the cost of a seawater system (usually 20–30% of the total cost of water), it is an obvious target for cost reduction. Therefore new membrane developments have to focus on lower energy consumption. This requires the development of high productivity membrane elements and compatible design concepts that enable operation at lower pressure. This publication presents new products with higher flow (7500–9000 gpd at standard test conditions) and high rejection (99.70–99.75%) for the seawater desalination segment. The technical features of these products are explained and possible energy and other cost savings are calculated. It is shown that these products can be used across the entire seawater segment to reduce energy consumption down to levels of 2.0 kWh/m 3 or to reduce the capital cost of the membrane stage by up to 30%. Field data for these new products is presented at the end and confirms both, performance of the presented new products, and significant capital and operational cost savings.

Pharmaco-economic study of intensive chemotherapy with peripheral blood progenitor cell support for advanced breast cancer.

Patients with high-risk breast cancer may benefit from dose-escalated chemotherapy. The rationale for high-dose chemotherapy with stem-cell rescue (HDC-SCR) in breast cancer is based on the principles of dose response and dose intensity. However, several results of properly randomized and prospective studies are necessary to determine the interest of HDC-SCR. The objective of this study, realised in the Anticancer Center of Montpellier, was to evaluate the cost of this type of transplantation. In this retrospective study, we analysed 30 patients treated for an advanced breast cancer between October 1995 and June 1998. We collected the data from the induction chemotherapy cycle (followed by cytapheresis) to the end of the hospitalisation for autograft. The mean total cost was US $25,845 per patient: US $6453 for drugs, US $4720 for transfusions, US $1865 for laboratory services and blood tests, US $5585 for staff pay, US $774 for material, US $1211 for administration cost, US $1111 for logistic cost, US $998 for structure cost and US$1578 for other. Antibiotics, granulocyte-colony stimulating factor, chemotherapy, transfusions and nutrition represent respectively 18% (US $1962), 14% (US $1590), 13% (US $1437), 42% (US $4720), 11% (US $1191) of the medication and blood products cost. The results of this study may help in identifying targets for cost reduction.

The Value of Screening Inpatients with Creatine Kinase Testing

Today’s healthcare environment mandates cost-effective utilization of ancillary services, and routine laboratory test panels are often suggested as a target for cost reduction. Over the last 30 years, large multitest profiles have become routine in medical practice and are used to “screen” patients for disease (1)(2), presumably identifying conditions not part of a patient’s clinical presentation (3)). However, many studies over the last 20 years have suggested that the use of test profiles provides little benefit toward identification of unknown diseases (4)(5)(6)(7)(8)(9)). Indeed, it has been suggested that the widespread use of panels was a function of the available continuous flow analyzers (10)(11)) and the increased profits afforded laboratories before the establishment of diagnosis-related groups. Reagent cost savings from elimination of test panels would be trivial in the overall cost of healthcare operations. However, substantial savings might be realized by decreasing the follow-up of slightly “abnormal” results, which yields few new diagnoses (12)(13)(14)). In the US, the number of “panels” and the number of tests per panel are being minimized to some extent as a result of the new Healthcare Financing Administration-mandated panels and the documentation of medical necessity now required for some forms of reimbursement (15)). We had included a test for total creatine kinase (CK) in a 12-test routine admission panel before May 1, 1996, after which we eliminated several tests from this panel, including CK. One reason for removing CK from this panel was an earlier study that had shown that admission CK tests did not lead to new diagnoses (16)). Here we asked whether the prior presence of CK in the panel facilitated the diagnosis of myocardial infarction (MI) for inpatients. All inpatient admissions to Barnes-Jewish Hospital …