Variable Direct Costs Research Articles

Using a Validated Middle-Age and Geriatric Risk Tool to Identify Early (

(1) To demonstrate that a validated trauma triage score for middle-aged and geriatric patients could identify those at high risk of mortality within the first 2 days of hospitalization and (2) determine the cost of care for this cohort of patients. Prospective cohort study. Single level 1 trauma center. Patients 55 years of age and older who were evaluated in the emergency department setting by orthopaedics or who met the American College of Surgeons Tier 1-3 criteria. Calculation of validated trauma triage score, Score for Trauma Triage in Geriatric and Middle-aged patients, using patient's demographic, injury severity, and functional status; main outcome measurements: length of stay, inpatient mortality, time between presentation and time of death, and direct variable costs of hospitalization. A total of 1470 consecutive patients (mean age of 72.2 ± 11.9 years) were enrolled in this study, 17 of whom died within 48 hours of presentation to the emergency department. These patients had a significantly higher trauma triage score than the rest of the cohort with a score of 50.9% ± 37.2% versus 3.3% ± 9.5%, P < 0.001 indicating that they had a mean risk of inpatient mortality of over 50%. Mean total cost per day was much higher in the cohort of patients who died within 48 hours of admission compared with all other trauma patients [$49,367 ± $79,057 vs. $3966 ± $2897 (P = 0.031)]. To achieve value-based care in this high-risk cohort, targeted cost savings while improving patient outcomes and/or expediting goals-of-care and end-of-life goals is necessary and the STTGMA score allows for stratification of these patients in both mortality risk and cost profile.

Cost analysis of Omega-3 supplementation in critically ill patients with sepsis

Nutritional supplement of omega-3 fatty acids have been proposed to improve clinical outcomes in critically ill patients. While previous work have demonstrated that omega-3 supplementation in patients with sepsis is associated with reduced ICU and hospital length of stay, the financial impact of this intervention is unknown. Perform a cost analysis to evaluate the impact of omega-3 supplementation on ICU and hospital costs. We extracted data related to ICU and hospital length of stay from the individual studies reported in a recent systematic review. The Cochrane Collaboration tool was used to assess the risk of bias in these studies. Average daily ICU and hospital costs per patient were obtained from a cost study by Kahn etal. We estimated the ICU and hospital costs by multiplying the mean length of stay by the average daily cost per patient in ICU or Hospital. Adjustments for inflation were made according to the USD annual consumer price index. We calculated the difference between the direct variable cost of patients with omega-3 supplementation and patients without omega-3 supplementation. 95% confidence intervals were estimated using bootstrap re-sampling procedures with 1000 iterations. A total of 12 RCT involving 925 patients were included in this cost analysis. Septic patients supplemented with omega-3 had both lower mean ICU costs ($15,274 vs. $18,172) resulting in $2897 in ICU savings per patient and overall hospital costs ($17,088 vs. $19,778), resulting in $2690 in hospital savings per patient. Sensitivity analyses were conducted to investigate the impact of different study methods on the LOS. The results were still consistent with the overall findings. Patients with sepsis who received omega-3 supplementation had significantly shorter LOS in the ICU and hospital, and were associated with lower direct variable costs than control patients. The 12 RCTs used in this analysis had a high risk of bias. Large-scaled, high-quality, multi-centered RCTs on the effectiveness of this intervention is recommended to improve the quality of the existing evidence.

The impact of reducing intensive care unit length of stay on hospital costs: evidence from a tertiary care hospital in Canada

To use theoretical modelling exercises to determine the effect of reduced intensive care unit (ICU) length of stay (LOS) on total hospital costs at a Canadian centre. We conducted a retrospective cost analysis from the perspective of one tertiary teaching hospital in Canada. Cost, demographic, clinical, and LOS data were retrieved through case-costing, patient registry, and hospital abstract systems of The Ottawa Hospital Data Warehouse for all new in-patient ward (30,483) and ICU (2,239) encounters between April 2012 and March 2013. Aggregate mean daily variable direct (VD) costs for ICU vs ward encounters were summarized by admission day number, LOS, and cost centre. The mean daily VD cost per ICU patient was $2,472 (CAD), accounting for 67.0% of total daily ICU costs per patient and $717 for patients admitted to the ward. Variable direct cost is greatest on the first day of ICU admission ($3,708), and then decreases by 39.8% to plateau by the fifth day of admission. Reducing LOS among patients with ICU stays ≥ four days could potentially result in an annual hospital cost saving of $852,146 which represents 0.3% of total in-patient hospital costs and 1.2% of ICU costs. Reducing ICU LOS has limited cost-saving potential given that ICU costs are greatest early in the course of admission, and this study does not support the notion of reducing ICU LOS as a sole cost-saving strategy.

Early vs. late tracheostomy in intensive care settings: Impact on ICU and hospital costs

IntroductionUp to 12% of the 800,000 patients who undergo mechanical ventilation in the United States every year require tracheostomies. A recent systematic review showed that early tracheostomy was associated with better outcomes: more ventilator-free days, shorter ICU stays, less sedation and reduced long-term mortality. However, the financial impact of early tracheostomies remain unknown. ObjectivesTo conduct a cost-analysis on the timing of tracheostomy in mechanically ventilated patients. MethodsWe extracted individual length of hospital stay and length of ICU stay data from the studies included in the systematic review from Hosokawa et al. We also searched for any recent randomized control trials on the topic that were published after this review. The weighted length of stay was estimated using a random effects model. Average daily hospital and ICU costs per patients were obtained from a cost study by Kahn et al. We estimated hospital and ICU costs by multiplying LOS with respective average daily cost per patient. We calculated difference in costs by subtracting hospital costs, ICU costs and total direct variable costs from early tracheotomy to late tracheotomy. 95% confidence intervals were estimated using bootstrap re-sampling procedures with 1000 iterations. ResultsThe average weighted cost of ICU stay in patients with an early tracheostomy was $4316 less when compared to patients with late tracheostomy (95% CI: 403–8229). Subgroup analysis revealed that very early tracheostomies (<4days) cost on average $3672 USD less than late tracheostomies (95% CI: –1309, 10,294) and that early tracheostomies (<10days but >4) cost on average $6385 USD less than late tracheostomies (95% CI: –4396–17,165). ConclusionThis study shows that early tracheostomy can significantly reduce direct variable and likely total hospital costs in the intensive care unit based on length of stay alone. This is in addition to the already shown benefits of early tracheostomy in terms of ventilator dependent days, reduced length of stays, decreased pain, and improved communication. Further prospective studies on this topic are needed to prove the cost-effectiveness of early tracheostomy in the critically ill population.

Regional variation in the cost of infrainguinal lower extremity bypass surgery in the United States

BackgroundLower extremity bypass (LEB) remains the gold standard revascularization procedure in patients with peripheral arterial disease. The cost of LEB substantially varies based on patient's characteristics and comorbidities. The aim of this study was to assess regional variation in infrainguinal LEB cost and to identify the specific health care expenditures per service that are associated with the highest cost in each region. MethodsWe identified adult patients who underwent infrainguinal LEB in the Premier database between June 2009 and March 2015. Generalized linear regression models were used to report differences between regions in total in-hospital cost and service-specific cost adjusting for patient's demographics, clinical characteristics, and hospital factors. ResultsA total of 50,131 patients were identified. The median in-hospital cost was $13,259 (interquartile range, $9308-$19,590). The cost of LEB was significantly higher in West and Northeast regions with a median cost of nearly $16,000. The high cost in the Northeast region was driven by the fixed (indirect) cost, whereas the driver of the high cost in the West region was the variable (direct) cost. The adjusted total in-hospital cost was significantly higher in all regions compared with the South (mean difference, West, $3752 [95% confidence interval (CI), 3477-4027]; Northeast, $2959 [95% CI, 2703-3216]; Midwest, 1586 [95% CI, 1364-1808]). ConclusionsIn this study, we show the marked regional variability in LEB costs. This disparity was independent from patient clinical condition and hospital factors. Cost inequality across the US represents a financial burden on both the patient and the health system.

Evaluating the Economic Impact of Palliative and End-of-Life Care Interventions on Intensive Care Unit Utilization and Costs from the Hospital and Healthcare System Perspective.

ICU length of stay (LOS) and associated costs of care are common and important outcome measures, but must be analyzed properly to yield valid conclusions. There is significant variation in costs by day of stay in the ICU with only modest differences between an ICU day at the end of a stay and the first day on the acute care floor; this variation must be appropriately accounted for analytically. Furthermore, reporting direct variable costs, in addition to total ICU costs, is needed to understand short-term and long-term impact of a reduction in LOS. Importantly, incentives for the hospital to realize savings vary depending on reimbursement policies. ICU utilization and costs are common outcomes in studies evaluating palliative care interventions. Accurate estimation and interpretation are key to understanding the economic implications of palliative care interventions.

Technology that achieves the Triple Aim: an economic analysis of the BrainPath™ approach in neurosurgery.

BackgroundThe Triple Aim is defined as: improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care. The purpose of this analysis was to evaluate the economic value of a new neurosurgical technique, the BrainPath™ approach, for use in patients with subcortical tumors and intracerebral hemorrhage (ICH).MethodsInpatient length of stay (LOS) data were collected for ICH and brain tumor surgical patient cases between August 2013 and November 2015. Patient cases were separated into two groups; BrainPath approach (n = 28) and conventional techniques, such as craniotomy, (n = 208). The average intensive care unit (ICU) LOS was calculated for each group by diagnosis-related group and compared between groups.ResultsThe new surgical technology resulted in surgical intervention in 14 ICH cases which otherwise would have been medically managed due to the hemorrhage location or size of the ICH. A reduction in ICU LOS was seen in this group. Based on the variable direct cost per day in the neuro critical care unit at this academic medical center, 14 patient cases incurred ~ US$210,000 less in direct ICU costs. Surgical resection was possible in two tumor patient cases which would have been biopsied, rather than surgically resected, also due to location of the abnormalities. A total net value of > US$329,000 is attributable to the analyzed approach over a 28-month period.ConclusionThis analysis shows positive economic value for the new technology group when ICU LOS and reimbursement are considered against equipment costs, thus achieving Triple Aim objectives.

PC132 The Institutional Cost of Ruptured Aneurysms: Implications for Tertiary Care Medical Centers

As care of vascular emergencies becomes more regionalized, the cost of providing emergency care to patients with ruptured aneurysms rests largely on tertiary medical centers. These lifesaving procedures may place excessive fiscal strain on an already overtaxed system. The objective of this study was to define and quantify the cost of repairing ruptured aneurysms and compare treatment modalities. From 2013 to 2015, 82 ruptured abdominal and thoracic aortic aneurysms were treated operatively at our 734-bed tertiary referral center. For each case, total hospital payments, overall cost, and hospital margin were calculated. Direct variable costs were itemized and included operating room costs, anesthesia, operating room supplies/implants, imaging, medications, emergency department costs, and room and board. Case-mix index and length of stay were recorded and benchmarked against other large (≥500 bed) academic medical centers using risk-adjusted University Health System Consortium data. The 82 ruptured aortic aneurysms treated over the 2-year period included 55 abdominal aneurysms (rAAA) and 27 thoracic aneurysms (rTAA). Of the rAAA patients, 41 were treated with endovascular repair (EVAR) and 12 underwent open repair. The mean overall cost of EVAR was $39,341, with a hospital margin of $1462 for the admission. The mean overall cost of open repair was $49,280, with a hospital margin of $5465 for the admission. The highest direct variable costs for EVAR were implants (48%) and room/board (32%); the highest for open was room/board including intensive care unit (45%). Case-mix indices were comparable (4.1 for EVAR vs 4.5 for open repair). Mean length of stay was 9.2 days in the EVAR group and 16.7 days in the open repair group. There overall length of stay for rAAA was similar between our institution and other large academic medical centers (10.9 vs 10.6 days). Emergency ruptured aneurysm repair at a tertiary care center is an expensive endeavor with a narrow margin. Despite increased length of stay and higher overall costs, hospital reimbursement was substantially better for open rAAA repair (profit margin 11.1% vs 3.6% for EVAR). Without reform of reimbursement for emergent procedures, repair of ruptured aneurysms may be difficult to sustain in the era of cost containment.

Financial Impact of the Robotic Approach in Liver Surgery: A Comparative Study of Clinical Outcomes and Costs Between the Robotic and Open Technique in a Single Institution

Background: One of the perceived major drawbacks of minimally invasive techniques has always been its cost. This is especially true for the robotic approach and is one of the main reasons that has prevented its wider acceptance among hospitals and surgeons. The aim of our study was to evaluate the clinical outcomes and economic impact of robotic and open liver surgery in a single institution.Methods: Sixty-eight robotic and 55 open hepatectomies were performed at our institution between January 1, 2009 and December 31, 2013. Demographics, perioperative data, and postoperative outcomes were collected and compared between the two groups. An independent company performed the financial analysis. The economic parameters comprised direct variable costs, direct fixed costs, and indirect costs.Results: Mean estimated blood loss was significantly less in the robotic group (438 versus 727.8 mL; P = .038). Overall morbidity was significantly lower in the robotic group (22% versus 40%; P = .047). Clavien III/IV complications were also lower, with 4.4% in the robotic versus 16.3% in the open group (P = .043). The length of stay in the intensive care unit (ICU) was shorter for patients who underwent a robotic procedure (2.1 versus 3.3 days; P = .004). The average total cost, including readmissions, was $37,518 for robotic surgery and $41,948 for open technique.Conclusions: Robotic liver resections had less overall morbidity, ICU, and hospital stay. This translates into decreased average costs for robotic surgery. These procedures are financially comparable to open resections and do not represent a financial burden to the hospital.

COST-VOLUME-PROFIT ANALYSIS AS A SOURCE OF INFORMATION FOR MAKING MANAGERIAL DECISIONS

The issues of calculation of cost and the registration of expenditures have always been topical, especially that they are intended to the reorientation of the accumulated experience of accounting at the direction of the solution of new problems. The decisions of the managing circle can be effective if they are based on the analysis of the relationships between cost, volume and profit. During the analytical research, we have studied “cost-volume” and “cost-volume-profit” relations among the most important indices characterizing the industrial activities of the organization, whose analysis has a great role in the matter of the management and control of costs. The analysis of the production cost structure is an important tool to make managerial decisions about the production and sales of output. This allows to estimate the relationships among products selling price, production and sales volumes, marginal profit, direct variable costs per unit of output and fixed costs. Its practical application, in our opinion, will lead to the provision of information for making managerial decisions on the following issues related to the production and economic activity: assessment of marginal profit, contribution margine and financial stability, decisions on the expediency of continuing or stopping the production of the given product, make or buy decisions connected to the raw materials, pricing decisions for the new products, decisions on selection and renewal of production technologies, development of a more effective manufacturing and sales plan.

Improving the Efficiency of Care for Pediatric Patients Hospitalized With Asthma

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

Direct variable cost of the topical treatment of stages III and IV pressure injuries incurred in a public university hospital

Aimto estimate the direct variable costs of the topical treatment of stages III and IV pressure injuries of hospitalized patients in a public university hospital, and assess the correlation between these costs and hospitalization time. Materials and methodsForty patients of both sexes who had been admitted to the São Paulo Hospital, São Paulo, SP, Brazil, from 2011 to 2012, with pressure injuries in the sacral, ischial or trochanteric region were included. The patients had a total of 57 pressure injuries in the selected regions, and the lesions were monitored daily until patient release, transfer or death. The quantities and types of materials, as well as the amount of professional labor time spent on each procedure and each patient were recorded. The unit costs of the materials and the hourly costs of the professional labor were obtained from the hospital's purchasing and human resources departments, respectively. Spearman's correlation coefficient and the Mann-Whitney and Kruskal-Wallis tests were used for the statistical analyses. ResultsThe mean topical treatment costs for stages III and IV PIs were significantly different (US$ 854.82 versus US$ 1785.35; p = 0.004). The mean topical treatment cost of stages III and IV pressure injuries per patient was US$ 1426.37. The mean daily topical treatment cost per patient was US$ 40.83. There was a significant correlation between hospitalization time and the total costs of labor and materials (p < 0.05). There was no significant difference between hospitalization time periods for stages III and IV pressure injuries (40.80 days and 45.01 days, respectively; p = 0.834). ConclusionThe mean direct variable cost of the topical treatment for stages III and IV pressure injuries per patient in this public university hospital was US$ 1426.37.

Economic Feasibility of Staffing the Intensive Care Unit with a Communication Facilitator

In the intensive care unit (ICU), complex decision making by clinicians and families requires good communication to ensure that care is consistent with the patients' values and goals. To assess the economic feasibility of staffing ICUs with a communication facilitator. Data were from a randomized trial of an "ICU communication facilitator" linked to hospital financial records; eligible patients (n = 135) were admitted to the ICU at a single hospital with predicted mortality ≥30% and a surrogate decision maker. Adjusted regression analyses assessed differences in ICU total and direct variable costs between intervention and control patients. A bootstrap-based simulation assessed the cost efficiency of a facilitator while varying the full-time equivalent of the facilitator and the ICU mortality risk. Total ICU costs (mean 22.8k; 95% CI, -42.0k to -3.6k; P = 0.02) and average daily ICU costs (mean, -0.38k; 95% CI, -0.65k to -0.11k; P = 0.006)] were reduced significantly with the intervention. Despite more contacts, families of survivors spent less time per encounter with facilitators than did families of decedents (mean, 25 [SD, 11] min vs. 36 [SD, 14] min). Simulation demonstrated maximal weekly savings with a 1.0 full-time equivalent facilitator and a predicted ICU mortality of 15% (total weekly ICU cost savings, $58.4k [95% CI, $57.7k-59.2k]; weekly direct variable savings, $5.7k [95% CI, $5.5k-5.8k]) after incorporating facilitator costs. Adding a full-time trained communication facilitator in the ICU may improve the quality of care while simultaneously reducing short-term (direct variable) and long-term (total) health care costs. This intervention is likely to be more cost effective in a lower-mortality population.

Impact of Palliative Care Screening and Consultation in the ICU: A Multihospital Quality Improvement Project

ContextThere are few multicenter studies that examine the impact of systematic screening for palliative care and specialty consultation in the intensive care unit (ICU). ObjectiveTo determine the outcomes of receiving palliative care consultation (PCC) for patients who screened positive on palliative care referral criteria. MethodsIn a prospective quality assurance intervention with a retrospective analysis, the covariate balancing propensity score method was used to estimate the conditional probability of receiving a PCC and to balance important covariates. For patients with and without PCCs, outcomes studied were as follows: 1) change to “do not resuscitate” (DNR), 2) discharge to hospice, 3) 30-day readmission, 4) hospital length of stay (LOS), 5) total direct hospital costs. ResultsIn 405 patients with positive screens, 161 (40%) who received a PCC were compared to 244 who did not. Patients receiving PCCs had higher rates of DNR—adjusted odds ratio (AOR) = 7.5; 95% CI 5.6–9.9) and hospice referrals—(AOR = 7.6; 95% CI 5.0–11.7). They had slightly lower 30-day readmissions—(AOR = 0.7; 95% CI 0.5–1.0); no overall difference in direct costs or LOS was found between the two groups. When patients receiving PCCs were stratified by time to PCC initiation, early consultation—by Day 4 of admission—was associated with reductions in LOS (1.7 days [95% CI −3.1, −1.2]) and average direct variable costs (−$1815 [95% CI −$3322, −$803]) compared to those who received no PCC. ConclusionReceiving a PCC in the ICUs was significantly associated with more frequent DNR code status and hospice referrals, but not 30-day readmissions or hospital utilization. Early PCC was associated with significant LOS and direct cost reductions. Providing PCC early in the ICU should be considered.

Outpatient Alveolar Bone Grafting

Alveolar bone graft (ABG) has traditionally been performed with a postoperative inpatient stay secondary to donor site pain. Upon transitioning from an open iliac bone harvesting technique to an Acumed trephine, the authors observed that donor site pain was reduced eliminating an inpatient stay. This study examines the cost savings associated with outpatient ABG surgery. A retrospective single-institution review was conducted on all patients who had an ABG performed from 2012 to 2015. Patients were categorized based upon hospital stay: inpatient, observation (23-hour), or outpatient. Cost data reported included: total direct cost, total variable direct cost, fixed direct cost, and the sum of total direct costs for both medical/surgical supplies and operating room costs. T tests were used to determine differences in various cost categories between groups of patients. Sixty-two procedures were performed: 7 procedures were inpatient, 16 observation, and 39 outpatient. The total direct costs averaged $4536 for inpatients, $3222 for the observation group, and $3340 for the outpatient group. Inpatient and outpatient costs were significantly different (P <0.01). Total variable direct costs (P <0.05) and fixed direct costs (P <0.01) were significantly lower in the outpatient/observation group. All costs for the observation group were significantly lower than inpatient costs, but were not significantly different than outpatient costs. There were no readmissions reported. Cost of an inpatient stay is significantly higher than outpatient or 23-hour observation for ABG procedures. The Acumed trephine technique allows for same-day discharge. In the face of declining reimbursement, safe and cost-efficient treatments are an appealing option.

The Impact of Palliative Care Consultation in the ICU on Length of Stay: A Systematic Review and Cost Evaluation.

The intensive care unit (ICU) consumes 20% of hospital expenditures and 1% of gross domestic product. Many strategies have been attempted to reduce ICU costs. A systematic review was conducted to evaluate the effect of palliative care (PC) consultations in the ICU on length of stay (LOS) and costs. A literature search was performed using PubMed, MEDLINE, EMBASE, and the Cochrane Library. Randomized controlled trials (RCTs), prospective, and retrospective cohort studies looking at PC consultations in adult ICUs published between January 2000 and February 2016 were selected. Independent reviewers assessed the eligibility of studies, extracted data on ICU, hospital LOS, and mortality, and rated each study's quality. The cost was derived from an existing model in the literature; the primary outcome was ICU LOS and the secondary outcomes were direct variable costs, mortality, and hospital LOS. We reviewed 814 abstracts, but only 8 studies met inclusion criteria and were included. The patients with a PC consultation in the ICU, when compared to those who did not, showed a trend toward reduced LOS. This reduction was statistically significant in the higher quality studies. Mortality was similar in both groups. Palliative care consultations also lead to a reduction in costs in 5 of the 8 eligible trials. On average, ICU costs were USD7533 and USD6406 (control vs PC, P < .05) and hospital direct variable costs were USD9518 and USD8971 ( P < .05) per admission. Due to interstudy heterogeneity, all outcomes were described narratively. This review demonstrates a trend that PC consultations reduce LOS and costs without impacting mortality. However, due to the small sample sizes and varying degrees of quality of evidence, many questions remain. A large multicenter RCT and formal economic evaluation would be needed for more definitive results.

Patterns of Cost for Patients Dying in the Intensive Care Unit and Implications for Cost Savings of Palliative Care Interventions.

Terminal intensive care unit (ICU) stays represent an important target to increase value of care. To characterize patterns of daily costs of ICU care at the end of life and, based on these patterns, examine the role for palliative care interventions in enhancing value. Secondary analysis of an intervention study to improve quality of care for critically ill patients. 572 patients who died in the ICU between 2003 and 2005 at a Level-1 trauma center. Data were linked with hospital financial records. Costs were categorized into direct fixed, direct variable, and indirect costs. Patterns of daily costs were explored using generalized estimating equations stratified by length of stay, cause of death, ICU type, and insurance status. Estimates from the literature of effects of palliative care interventions on ICU utilization were used to simulate potential cost savings under different time horizons and reimbursement models. Mean cost for a terminal ICU stay was 39.3K ± 45.1K. Direct fixed costs represented 45% of total hospital costs, direct variable costs 20%, and indirect costs 34%. Day of admission was most expensive (mean 9.6K ± 7.6K); average cost for subsequent days was 4.8K ± 3.4K and stable over time and patient characteristics. Terminal ICU stays display consistent cost patterns across patient characteristics. Savings can be realized with interventions that align care with patient preferences, helping to prevent unwanted ICU utilization at end of life. Cost modeling suggests that implications vary depending on time horizon and reimbursement models.

First year experience of a U.S. community hospital with a European modeled ERAS programme

Objectives: The objective was initiation of an ERAS programme in general surgery patients modeled on published European experiences. The project team sought to reach full penetration into all general surgery practices within one year. Methods: A dedicated project team consisting of two anaesthesiologists, one CRNA, and one ARNP collected evidence-based data on all elements of the ERAS pathway. The specifics of the pathway, including preoperative and postoperative order sets, were designed and placed into an EMR for ease of use by all practitioners. Education meetings were arranged for the anaesthesiologists, surgeons and nurses. The overall programme was presented to management to solicit resource support. An early adopter surgeon was selected to trial the pathway. The initial patient experience was used to recruit other surgeons and anaesthesiologists to the programme. Results: Variable direct costs per case for open colon and small bowel surgery declined significantly, from $10,788 to $6,431. Length of stay was reduced on average by 50%, from 11.4 days to 5.1 days. All surgeons adopted the ERAS programme and reduced their length of stay significantly. Conclusion: Assembling a dedicated team that uses evidence based data to design and oversee an ERAS programme is a successful approach to incorporating this patient care path into a community hospital. Our impression is that adoption of new patterns of practice by physicians requires evidence and a smooth transition to new schemes. The final elements are an early adopter among the surgeons and the anesthesiologists to initiate the programme. Positive results enhance the solicitation of late adopters to use ERAS. Disclosure of Interest: P. Shanahan Speaker Bureau of: Edwards Life Sciences

Estimating the Cost of Operating Theater Services at Assuit University Hospital

Abstract The increasing healthcare costs have forced the healthcare managers to know the cost of different alternatives approaches to providing care. This study aims to estimate the costs of general surgical operating theater services at Assuit University Hospital. Subject& Methods: Subjects of the study included three types :-( patient's records, surgeons, and nurses).The total subjects of this study (Total number=280 patients records), the records of this study scheduled for surgery as follows: Major, Minor, and Technically Advanced Operations. Data collection: was done by using: Retrospective Review Tool of operations Performed in Year (2011) , Monitoring Form for Operating Theater to record activities performed by nursing staff and auxiliary; and Costing and Pricing List Form for Surgical Procedures in Operating theater. Results: direct (variable, fixed) costs and indirect costs were higher for major and technically advanced operations than minor operations. The minor, major operations done under spinal anesthesia were less in their total basic direct variable cost. indirect costs for all surgeries, anesthesia, nursing and operating theaters represents the highest costs among the (indirect costs) for technically advanced operations than in major and minor operations. Recommendations: Increase awareness of nurses about the importance of calculates the cost to maintain cost reduction. Proper utilization of operating theater time by using an organized surgeries list and coordinating activities between the surgical departments and operating theater to reduce the surgery’s waiting time. In-service training programs for newly employed nursing personnel about operating theater services

Cost-minimization analysis favors outpatient quick diagnosis unit over hospitalization for the diagnosis of potentially serious diseases

BackgroundQuick diagnosis units (QDUs) are a promising alternative to conventional hospitalization for the diagnosis of suspected serious diseases, most commonly cancer and severe anemia. Although QDUs are as effective as hospitalization in reaching a timely diagnosis, a full economic evaluation comparing both approaches has not been reported. AimsTo evaluate the costs of QDU vs. conventional hospitalization for the diagnosis of cancer and anemia using a cost-minimization analysis on the proven assumption that health outcomes of both approaches were equivalent. MethodsPatients referred to the QDU of Bellvitge University Hospital of Barcelona over 51 months with a final diagnosis of severe anemia (unrelated to malignancy), lymphoma, and lung cancer were compared with patients hospitalized for workup with the same diagnoses. The total cost per patient until diagnosis was analyzed. Direct and non-direct costs of QDU and hospitalization were compared. ResultsTime to diagnosis in QDU patients (n=195) and length-of-stay in hospitalized patients (n=237) were equivalent. There were considerable costs savings from hospitalization. Highest savings for the three groups were related to fixed direct costs of hospital stays (66% of total savings). Savings related to fixed non-direct costs of structural and general functioning were 33% of total savings. Savings related to variable direct costs of investigations were 1% of total savings. Overall savings from hospitalization of all patients were €867,719.31. ConclusionQDUs appear to be a cost-effective resource for avoiding unnecessary hospitalization in patients with anemia and cancer. Internists, hospital executives, and healthcare authorities should consider establishing this model elsewhere.