Variation In Total Costs Research Articles

Center Related Variation in Hospitalization Cost for Patients Undergoing Percutaneous Left Atrial Appendage Occlusion

BackgroundThe commercial use of percutaneous LAAO with the Watchman device is increasing in the United States. The purpose of this study was to evaluate center related variation in total hospital costs for Watchman device implantation and identify factors associated with high hospital costs at a national level. MethodsAll adults undergoing elective LAAO with Watchman were identified in the 2016 to 2018 National Inpatient Database. Mixed models were used to evaluate the impact of center on total hospital costs adjusting for patient and center characteristics, and length of stay. ResultsA total of 30,175 patients underwent Watchman device implantation at a median cost of $24,500 and demonstrated significant variability across admissions (inter-decile range, $13,900-37,000). Nearly 13% of the variability in patient-level costs was related to the center performing the procedure rather than patient factors. Higher volume centers had lower total costs and demonstrated lesser total cost variation. Centers with low procedural volume, occurrence of procedural complications, congestive heart failure, and length of stay were independent predictors of a high-cost hospitalization. Though complications were associated with increased expenditure, they did not explain the observed cost variation related to the center. ConclusionA significant proportion of variation in total hospital cost was attributable to the center performing the procedure. Addressing variability of Watchman-related costs is necessary to achieve high-quality value-based care.

Variation in the Cost of Hip Arthroscopy for Labral Pathological Conditions: A Time-Driven Activity-Based Costing Analysis.

Despite growing interest in delivering high-value orthopaedic care, the costs associated with hip arthroscopy remain poorly understood. By employing time-driven activity-based costing (TDABC), we aimed to characterize the cost composition of hip arthroscopy for labral pathological conditions and to identify factors that drive variation in cost. Using TDABC, we measured the costs of 890 outpatient hip arthroscopy procedures for labral pathological conditions across 5 surgeons at 4 surgery centers from 2015 to 2022. All patients were ≥18 years old and were treated by surgeons who each performed ≥20 surgeries during the study period. Costs were normalized to protect the confidentiality of internal hospital cost data. Descriptive analyses and multivariable linear regression were performed to identify factors underlying cost variation. The study sample consisted of 515 women (57.9%) and 375 men (42.1%), with a mean age (and standard deviation) of 37.1 ± 12.7 years. Most of the procedures were performed in patients who were White (90.6%) or not Hispanic (93.4%). The normalized total cost of hip arthroscopy per procedure ranged from 43.4 to 203.7 (mean, 100 ± 24.2). Of the 3 phases of the care cycle, the intraoperative phase was identified as the largest generator of cost (>90%). On average, supply costs accounted for 48.8% of total costs, whereas labor costs accounted for 51.2%. A 2.5-fold variation between the 10th and 90th percentiles for total cost was attributed to supplies, which was greater than the 1.8-fold variation attributed to labor. Variation in total costs was most effectively explained by the labral management method (partial R2 = 0.332), operating surgeon (partial R2 = 0.326), osteoplasty type (partial R2 = 0.087), and surgery center (partial R2 = 0.086). Male gender (p < 0.001) and younger age (p = 0.032) were also associated with significantly increased costs. Finally, data trends revealed a shift toward labral preservation techniques over debridement during the study period (with the rate of such techniques increasing from 77.8% to 93.2%; Ptrend = 0.0039) and a strong correlation between later operative year and increased supply costs, labor costs, and operative time (p < 0.001 for each). By applying TDABC to outpatient hip arthroscopy, we identified wide patient-to-patient cost variation that was most effectively explained by the method of labral management, the operating surgeon, the osteoplasty type, and the surgery center. Given current procedural coding trends, declining reimbursements, and rising health-care costs, these insights may enable stakeholders to design bundled payment structures that better align reimbursements with costs. Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

Economic costs and Predictors of occupation-related Injuries in Ethiopian sugar industries from the Employer’s perspective: top-down approach and friction method

BackgroundFor many industrial workers, occupational injuries are a common health and safety concern. However, sufficient information on the economic costs and predictors of occupation-related injuries from the perspective of employers is lacking in developing countries, including Ethiopia. The objective of this study was to close this gap by quantifying the economic costs and predictors of occupation-related injuries in Ethiopian manufacturing industries from the employer’s perspective.MethodsA cross-sectional study was employed to estimate the employer-side economic cost of occupation-related injuries from December 2021 to March 2022. This study used a top-down approach to compute direct costs, while the friction method was used for indirect cost estimation. Injury data were obtained from the Bureau of Labour and Social Affairs and the industries, while cost data were from workers’ compensation records. The insurance company’s injury compensation record was triangulated with industries’ data. The study collected primary data via an interview-administered, semi-structured questionnaire from 1136 randomly selected injured cases. Statistical analysis was carried out with STATA version 14 software. The study employed a generalized linear model to identify predictors of total cost by considering the non-normal distribution of the total cost. Exponentiate coefficients with a 95% confidence interval were used to express the direction and strength of the association.ResultsThe survey participation rate was 100%. From the perspective of the employers, the total cost of occupation–related injury was 22,587,635.32 Ethiopian birr (537,800.84 $).Indirect and direct costs accounted for 65.86 and 34.14% of the overall expenses, respectively. Long-term absence from work (exp (b) = 0.85), having a sleeping disorder (exp (b) = 0.90), co-morbidity (exp (b) = 0.85), and severity (type) of injury (exp (b) = 1.11) were predictors significantly associated with the total cost variability in the fully adjusted model.ConclusionsEmployers’ toll of occupation-related injuries has severe economic implications. The influential factors that elevated the total cost variation were: long-term absence from work, unsafe acts of the workers, having a sleeping disorder, co-morbidity, and severity (type) of injury. Therefore, the identified modifiable factors are the areas of intervention to reduce the cost of occupation-related injuries.

Strategies for spinal surgery reimbursement: bundling in the working-age population

IntroductionBundled payments for spine surgery, which is known for having high overall cost with wide variation, have been previously studied in older adults. However, there has been limited work examining bundled payments in working-age patients. We sought to identify the variation in the cost of spine surgery among working age adults in a large, national insurance claims database.MethodsWe queried the TRICARE claims database for all patients, aged 18–64, undergoing cervical and non-cervical spinal fusion surgery between 2012 and 2014. We calculated the case mix adjusted, price standardized payments for all aspects of care during the 60-, 90-, and 180-day periods post operation. Variation was assessed by stratifying Hospital Referral Regions into quintiles.ResultsAfter adjusting for case mix, there was significant variation in the cost of both cervical ($10,538.23, 60% of first quintile) and non-cervical ($20,155.59, 74%). Relative variation in total cost decreased from 60- to 180-days (63 to 55% and 76 to 69%). Index hospitalization was the primary driver of costs and variation for both cervical (1st-to-5th quintile range: $11,033–$19,960) and non-cervical ($18,565–$36,844) followed by readmissions for cervical ($0–$11,521) and non-cervical ($0–$13,932). Even at the highest quintile, post-acute care remained the lowest contribution to overall cost ($2070 & $2984).ConclusionsThere is wide variation in the cost of spine surgery across the United States for working age adults, driven largely by index procedure and readmissions costs. Our findings suggest that implementing episodes longer than the current 90-day standard would do little to better control cost variation.

PSXI-13 Effect of performance indicators, food expenses and interest rate on lamb production cost

Abstract This study aimed at comparing the influence of zootechnical performance and main cost items over the total production cost of lambs. A representative production system of São José do Rio Preto region, Brazil, designed in a panel meeting, was used as a study basis. We calculated lamb production costs, including variable costs, fixed costs, and income of factors, using the data from December 2019. We then estimated elasticities for the variables: feed expense, interest rate, carcass yield, lamb survival rate, and fertility rate. This way we compared the variation in total cost per year and per carcass caused by increases of 1% in each of the considered variables. In the base scenario, production costs per year and unit were, respectively, US$ 33,367.34 and US$ 4.81. Feed expenses, annual interest rate, mean carcass yield, lamb survival rate, and fertility rate were, respectively, US$ 22,316.74, 4.50%, 48.00%, 88.00%, and 85.00%. Regarding annual cost, changing each variable caused variations of +0.67%, +0.05%, 0.00%, +0.33% and +0.33%. Concerning cost per unit, the variations were +0.76%, +0.07%, -0.98%, -0.61% and -0.64%, respectively. Increasing lamb survival and fertility rates were also effective strategies to lower unitary cost. The cost component with feed represented 66.88% of the total production cost, but measures to reduce feed costs must be well conducted to not affect the zootechnical performance of the animals. Farmers must consider cost per unit when thinking about lowering production costs, instead of the annual cost. Increasing lamb carcass yield had a greater impact on reducing unitary cost than cutting feed expenses. Improving performance indicators demand good nutritional status for lambs and ewes, and cutting off feed expenses may have deleterious effects on animal performance, therefore increasing cost. Elasticity analysis is a useful tool to calculate such trade-offs at the farm level.

PSXI-21 Program Chair Poster Pick: Performance indicators of animal production and prices over the cost of feedlot beef cattle

Abstract The aim of this study was to analyze the influence of the zootechnical performance indicators and the price main cost items on the total production cost of feedlot beef cattle. We used a mathematical model of the production cost, which considered the cost of the items according to the Economic Theory. Costs were allocated into: i) variable costs, ii) fixed costs, and iii) factor income. A survey was carried out in 2015, with ten farmers in the state of São Paulo, to define the technical indicators of production. The representative property was defined with 27 thousand animals slaughtered per year. The spot prices used in our analysis were collected in December 2019. Elasticity was calculated and expressed as a relationship between two interrelated functional variables. We estimated elasticities for the variables: animals purchase of 355 kg ($1.78/kg), feed price ($0.17/kg of dry matter), interest rate (4.5%), average daily gains (1.616 kg), and carcass yield (55.46%). This way we compared the variation of total cost per carcass kilo caused by increases of 1% in each of the considered variables. In the base scenario, production cost was US$ 3.11/kg and the variable cost of the activity represented 94.9% of the total costs, which of purchase animals, feed and variable taxes were 69.5%, and 20.6% and 3.8%, respectively. Increases of 1% in each of those variables caused variations of, respectively, +0,71%, +0,21%, 0,01%, -0,98%, and -0,98% on production cost unit. In conclusion, the purchase price of animals for feedlot activity is interrelated to the total cost. The average daily gains and carcass yield is also a zootechnical performance that presented a direct relation with the reduction of total costs. Thus, this demonstrates that farmers should improve management practices in the purchase of inputs and the performance of animal production.

CT planning studies for robotic total knee arthroplasty.

The aim of this study was to analyze the true costs associated with preoperative CT scans performed for robotic-assisted total knee arthroplasty (RATKA) planning and to determine the value of a formal radiologist's report of these studies. We reviewed 194 CT reports of 176 sequential patients who underwent primary RATKA by a single surgeon at a suburban teaching hospital. CT radiology reports were reviewed for the presence of incidental findings that might change the management of the patient. Payments for the scans, including the technical and professional components, for 330 patients at two hospitals were also recorded and compared. There were 82 incidental findings in 61 CT studies, one of which led to a recommendation for additional testing. Across both institutions, the mean total payment for a preoperative scan was $446 ($8 to $3,870). The mean patient payment was $71 ($0 to $2,690). There was wide variation in payments between the institutions. In Institution A, the mean total payment was $258 ($168 to $264), with a mean patient payment of $57 ($0 to $100). The mean technical payment in this institution was $211 ($8 to $856), while the mean professional payment was $48 ($0 to $66). In Institution B, the mean total payment was $636 ($37 to $3,870), with a mean patient payment of $85 ($0 to $2,690). The total cost of a CT scan is low and a minimal part of the overall cost of the RATKA. No incidental findings identified on imaging led to a change in management, suggesting that the professional component could be eliminated to reduce costs. Further studies need to take into account the patient perspective and the wide variation in total costs and patient payments across institutions and insurances. Cite this article: Bone Joint J 2020;102-B(6 Supple A):79-84.

Economic Evaluation of Chimeric Antigen Receptor T-Cell Therapy by Site of Care Among Patients With Relapsed or Refractory Large B-Cell Lymphoma

Chimeric antigen receptor (CAR) T-cell therapies are currently administered at a limited number of cancer centers and are primarily delivered in an inpatient setting. However, variations in total costs associated with these therapies remain unknown. To estimate the economic differences in the administration of CAR T-cell therapy by the site of care and the incidence of key adverse events. A decision-tree model was designed to capture clinical outcomes and associated costs during a predefined period (from lymphodepletion to 30 days after the receipt of CAR T-cell infusion) to account for the potential incidence of acute adverse events and to evaluate variations in total costs for the administration of CAR T-cell therapy by site of care. Cost estimates were from the health care practitioner perspective and were based on data obtained from the literature and publicly available databases, including the Healthcare Cost and Utilization Project National Inpatient Sample, the Medicare Hospital Outpatient Prospective Payment System, the Medicare physician fee schedule, the Centers for Medicare and Medicaid Services Healthcare Common Procedure Coding System, and the IBM Micromedex RED BOOK. The model evaluated an average adult patient with relapsed or refractory large B-cell lymphoma who received CAR T-cell therapy in an academic inpatient hospital or nonacademic specialty oncology network. The administration of CAR T-cell therapy. Total cost of the administration of CAR T-cell therapy by site of care. The costs associated with lymphodepletion, acquisition and infusion of CAR T cells, and management of acute adverse events were also examined. The estimated total cost of care associated with the administration of CAR T-cell therapy was $454 611 (95% CI, $452 466-$458 267) in the academic hospital inpatient setting compared with $421 624 (95% CI, $417 204-$422 325) in the nonacademic specialty oncology network setting, for a difference of $32 987. After excluding the CAR T-cell acquisition cost, hospitalization and office visit costs were $53 360 (65.3% of the total cost) in academic inpatient hospitals and $23 526 (48.4% of the total cost) in nonacademic specialty oncology networks. The administration of CAR T-cell therapy in nonacademic specialty oncology networks was associated with a $29 834 (55.9%) decrease in hospitalization and office visit costs and a $3154 (20.1%) decrease in procedure costs. The potential availability of CAR T-cell therapies that are associated with a lower incidence of adverse events and are suitable for outpatient administration may reduce the total costs of care by enabling the use of these therapies in nonacademic specialty oncology networks.

Variability in Hospital Costs of Adult Spinal Deformity Care.

Retrospective, single-center analysis. To calculate the total clinical hospital cost of the Adult Spinal Deformity (ASD) care trajectory, to explain cost variability by patient and surgery characteristics, and to identify areas of process improvement opportunities. ASD is associated with a high financial and clinical burden on society. ASD care thus requires improved insights in costs and its drivers as a critical step toward the improvement of value, i.e., the ratio between delivered health outcome and associated costs. Patient characteristics and surgical variables were collected following ethical approval in a cohort of 139 ASD patients, treated between December, 2014 and January, 2018. Clinical hospital costs were calculated, including all care activities, from initial consultation to 1 year after initial surgery (excl. overhead) in a university hospital setting. Multiple linear regression analysis was performed to analyze the impact of patient and surgical characteristics on clinical costs. 75.5% of the total clinical hospital cost (&OV0556;27,865) was incurred during initial surgery with costs related to the operating theatre (80.3%), nursing units (11.9%), and intensive care (2.9%) being the largest contributors. 57.5% of the variation in total cost could be explained in order of importance by surgical invasiveness, age, coronary disease, single or multiple-staged surgery, and mobility status. Revision surgery, unplanned surgery due to complications, was found to increase average costs by 87.6% compared with elective surgeries (&OV0556; 44,907 (± &OV0556; 23,429) vs. &OV0556; 23,944 (± &OV0556; 7302)). This study identified opportunities for process improvement by calculating the total clinical hospital costs. In addition, it identified patient and treatment characteristics that predict 57.5% of cost variation, which could be taken into account when developing a payment system. Future research should include outcome data to assess variation in value. 4.

Replenishment policy for deteriorating items with trade credit and allowable shortages under inflationary environment

In this paper we have developed an inventory model for deteriorating items in which demand of the product is a function of expiration date. In such cases the demand for the product generally decreases as the product is nearer to its expiration date. The different cases based on the allowed trade credit period have been discussed under inflationary environment. Shortages are allowed and partially backlogged. To exemplify this model numerical examples for all the cases and sensitivity analysis with respect to important parameters have been provided. The convexities graphs and the variation in total cost with the changes in parameters are represented with the help of the graph. The objective of this paper is to find out the optimal ordering quantity by which one can minimise the total associated cost of the system.

Replenishment policy for deteriorating items with trade credit and allowable shortages under inflationary environment

In this paper we have developed an inventory model for deteriorating items in which demand of the product is a function of expiration date. In such cases the demand for the product generally decreases as the product is nearer to its expiration date. The different cases based on the allowed trade credit period have been discussed under inflationary environment. Shortages are allowed and partially backlogged. To exemplify this model numerical examples for all the cases and sensitivity analysis with respect to important parameters have been provided. The convexities graphs and the variation in total cost with the changes in parameters are represented with the help of the graph. The objective of this paper is to find out the optimal ordering quantity by which one can minimise the total associated cost of the system.

Health Care Costs Associated with Contemporary Chronic Myelogenous Leukemia (CML) Therapy Compared to Other Hematologic Malignancies (HEM)

Introduction: CML accounts for 15-20% of leukemias. Tyrosine kinase inhibitor (TKI) therapy has led to significant improvement in survival rates, approaching the life expectancy of the general public in some settings, with less than three life years lost in a recent Swedish registry study.[1] Understanding cost associated with CML care compared to HEM in the setting of long-term survival on prolonged therapy can aid with resource allocation and clinical decision making. Methods: A retrospective cohort was constructed from OptumLabs® Data Warehouse using claims data between 2000-16. Eligible patients had ≥2 claims for CML and were continuously enrolled for ≥6m prior to diagnosis and ≥1y afterwards. CML patients were compared with HEM and general patients without history of cancer (GEN). As the CML group was the primary group of interest, the HEM and GEN groups were each frequency-matched on an approximate 4:1 ratio to the CML group on the basis of age (10-year increments), sex, year of diagnosis (3-year increments), geographic region (10 US census divisions), and insurance (commercial vs. Medicare Advantage). Follow-up data were available for this analysis through October 31, 2017. The primary outcome was total mean annualized health care costs including medical and outpatient drugs paid by health plan and patient (inflation adjusted to 2017). We used generalized linear models (GLM) to assess the variation in total costs in the three cohorts, using a gamma distribution and a log link. Models were adjusted for frequency-matched factors (sex, age, year of diagnosis, geographic region, insurance). Within the CML cohort, GLM was also used to examine the influence of factors hypothesized to be associated with costs: sex, age at index year, index year, race/ethnicity, insurance, modified Charlson comorbidity index, percent (%) days with TKI prescription, stem cell transplant, and number of inpatient and ambulatory days per year. Results: We identified 1909 enrollees with CML; mean diagnosis age 56y. They were matched with 7,268 HEM patients and 7,636 GEN patients. Mean annualized costs for CML were $82,054, $25,000 more than HEM and approximately $75,000 more than GEN (p&lt;0.001 in 3-way and pairwise comparisons; Table 1). This difference persisted after multivariate adjustment, with cost $25,471 higher in the CML population versus the HEM (95% CI: $20,808 to 30,133). Costs for CML care increased over each 5-year diagnostic interval until 2015 ($64,158 in 2000-04, peaking at $91,990 in 2010-14) (Table 1). Following index date, the trend in costs differ by cancer with HEM costs decreasing after the first six months post index date (Figure 1). In multivariable analysis, % days on a tyrosine kinase inhibitor had the greatest influence on cost among CML treatment factors. After adjustment for additional demographic and treatment factors, there was an association with increased cost by percent of days on a TKI (trend p&lt;0.001); for those with 75% of days on a TKI, the cost was $110,790 more than those without TKIs. Other factors associated with cost included receipt of stem cell transplant compared to no transplant ($55,549, 95% CI: $30,077 to 81,021), greater number of inpatient days ($148,664 for greater than 7 days versus none, 95% CI: $120,628 to 176,699) and greater number of ambulatory visits (20+ visits in one year versus &lt;5, $62,255, 95% CI $52,969 to 71,541) Conclusions: Contemporary CML costs exceed the cost of treatment for other hematologic malignancies. This is primarily driven by the use of TKIs. The plateau in CML costs in those diagnosed between 2015-16 needs further evaluation for associations with TKI availability and the introduction of generics. [1] Bower H et al. JCO 2016 Aug 20; 34(24):2851-7 Disclosures Lyman: G1 Therapeutics, Halozyme Therapeutics, Partners Healthcare, Hexal, Bristol-Myers Squibb, Helsinn Therapeutics, Amgen Inc., Pfizer, Agendia, Genomic Health, Inc.: Consultancy; Generex Biotechnology: Membership on an entity's Board of Directors or advisory committees; Janssen Scientific Affairs, LLC: Research Funding; Amgen Inc.: Other: Research support, Research Funding.

Validation and Extension of the Ventral Hernia Repair Cost Prediction Model

BackgroundRepair of ventral and incisional hernias remains a costly challenge for health care systems. In a previous study of a single surgeon's elective open ventral hernia repair (VHR) practice, a cost model was developed, which predicted over 70% of hospital cost variation. The purpose of the present study was to evaluate the ventral hernia cost model with multiple surgeons' elective open VHR cases and extending to include nonelective and laparoscopic VHR. Materials and methodsWith the University of Kentucky Institutional Review Board approval, elective and emergent cases of open and laparoscopic VHR performed by multiple surgeons over 3 y were identified. Perioperative variables were obtained from the local American College of Surgeons National Surgery Quality Improvement Program database and electronic medical record review. Hospital cost data were obtained from the hospital cost accounting system. Forward multivariable regression of log-transformed costs identified independent cost drivers (P for entry < 0.05, and P for exit > 0.10). ResultsOf the 387 VHRs, 74% were open repairs; mean age was 55 y, and 52% of patients were female. For open, elective cases (n = 211; mean cost of $19,145), the previously reported six-factor cost model predicted 45% of the total cost variation. With all VHRs included, additional variables were found to independently drive costs, predicting 59% of the total cost variation from the base cost. The biggest cost drivers were inpatient status (+$1013), use of biologic mesh (+$1131), preoperative systemic inflammatory response syndrome/sepsis (+$894), and preoperative open wound (+$786). ConclusionsVentral hernia repair cost variability is predictable. Understanding the independent drivers of cost may be helpful in controlling costs and in negotiating appropriate reimbursement with payers.

Leprosy services in primary health care in India: comparative economic cost analysis of two public‐health settings

ObjectivesThe WHO recommends inclusion of post‐exposure chemoprophylaxis with single‐dose rifampicin in national leprosy control programmes. The objective was to estimate the cost of leprosy services at primary care level in two different public‐health settings.MethodsIngredient‐based costing was performed in eight primary health centres (PHCs) purposively selected in the Union Territory of Dadra and Nagar Haveli (DNH) and the Umbergaon block of Valsad district, Gujarat, India. All costs were bootstrapped, and to estimate the variation in total cost under uncertainty, a univariate sensitivity analysis was performed.ResultsThe mean annual cost of providing leprosy services was USD 29 072 in the DNH PHC (95% CI: 22 125–36 020) and USD 11 082 in Umbergaon (95% CI: 8334–13 830). The single largest cost component was human resources: 79% in DNH and 83% in Umbergaon. The unit cost for screening the contact of a leprosy patient was USD 1 in DNH (95% CI: 0.8–1.2) and USD 0.3 in Umbergaon (95% CI: 0.2–0.4). In DNH, the unit cost of delivering single‐dose of rifampicin (SDR) as chemoprophylaxis for contacts was USD 2.9 (95% CI: 2.5–3.7).ConclusionsThe setting with an enhanced public‐health financing system invests more in leprosy services than a setting with fewer financial resources. In terms of leprosy visits, the enhanced public‐health system is hardly more expensive than the non‐enhanced public‐health system. The unit cost of contact screening is not high, favouring its sustainability in the programme.

Time-Driven Activity-Based Costing to Identify Patients Incurring High Inpatient Cost for Total Shoulder Arthroplasty.

As payment models shift toward a focus on value, an accurate understanding of surgical costs and preoperative correlates of high-cost patients is important for effective implementation of cost-saving strategies. This study used time-driven activity-based costing (TDABC) to explore inpatient cost of total shoulder arthroplasty (TSA) and to identify preoperative characteristics of high-cost patients. Using TDABC, we calculated the cost of inpatient care for 415 patients undergoing elective primary TSA between 2016 and 2017. Patients in the top decile of cost were defined as high-cost patients. Multivariable logistic regression modeling was employed to determine preoperative characteristics (e.g., demographics, comorbidities, American Society of Anesthesiologists [ASA] score, and American Shoulder and Elbow Surgeons [ASES] score) associated with high-cost patients. Implant purchase price was the main driver (57%) of total inpatient costs, followed by personnel cost from patient check-in through the time in the operating room (20%). There was a 1.3-fold variation in total cost between patients in the 90th percentile for cost and those in the 10th percentile; the widest cost variation was in personnel cost from the post-anesthesia care unit through discharge (2.5-fold) and in medication cost (2.4-fold). High-cost patients were more likely to be women and chronic opioid users and to have diabetes, depression, an ASA score of ≥3, a higher body mass index (BMI), and a lower preoperative ASES score than non-high-cost patients. After multivariable adjustment, the 3 predictors of high-cost patients were female sex, an ASA score of ≥3, and a lower ASES score. Total inpatient cost correlated strongly with the length of the hospital stay but did not correlate with operative time. Our study provides actionable data to contain costs in the perioperative TSA setting. From the hospital's perspective, efforts to reduce implant purchase prices may translate into rapid substantial cost savings. At the patient level, multidisciplinary initiatives aimed at reducing length of stay and controlling medication expenses for patients at risk for high cost (e.g., infirm women with poor preoperative shoulder function) may prove effective in narrowing the existing patient-to-patient variation in costs. Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

Estimated cost of asthma in outpatient treatment: a real-world study.

ABSTRACTOBJECTIVE To estimate the cost of diagnosis and treatment of asthma.METHODS We used the perspective of society. We sequentially included for 12 months, in 2011-2012, 117 individuals over five years of age who were treated for asthma in the Pneumology and Allergy-Immunology Services of the Piquet Carneiro Polyclinic, Universidade do Estado do Rio de Janeiro. All of them were interviewed twice with a six-month interval for data collection, covering 12 months. The cost units were identified and valued according to defined methods. We carried out a sensitivity analysis and applied statistical methods with a significance level of 5% for cost comparisons between subgroups.RESULTS The study consisted of 108 patients, and 73.8% of them were women. Median age was 49.5 years. Rhinitis was present in 83.3% of the individuals, and more than half were overweight or obese. Mean family income was U$915.90/month (SD = 879.12). Most workers and students had absenteeism related to asthma. Total annual mean cost was U$1,291.20/patient (SD = 1,298.57). The cost related to isolated asthma was U$1,155.43/patient-year (SD = 1,305.58). Obese, severe, and uncontrolled asthmatic patients had higher costs than non-obese, non-severe, and controlled asthmatics, respectively. Severity and control level were independently associated with higher cost (p = 0.001 and 0.000, respectively). The direct cost accounted for 82.3% of the estimated total cost. The cost of medications for asthma accounted for 62.2% of the direct costs of asthma.CONCLUSIONS Asthma medications, environmental control measures, and long-term health leaves had the greatest potential impact on total cost variation. The results are an estimate of the cost of treating asthma at a secondary level in the Brazilian Unified Health System, assuming that the treatment used represents the ideal approach to the disease.

Center variation in episode-of-care costs for adult spinal deformity surgery: results from a prospective, multicenter database

Background ContextAdult spinal deformity (ASD) surgery is associated with significant resource utilization, costing more than $958 million in charges for Medicare patients and more than $1.7 billion in charges for managed care population in the last decade. Given the recent move toward bundled payment models, it is important to understand the various care components a patient receives over the course of a defined clinical episode, its associated cost, and the proportion of cost for each component toward the bundled payment. PurposeTo examine the degree and determinants of variation in inpatient episode-of-care (EOC) cost, resource utilization, and patient-reported outcomes for patients undergoing ASD surgery across four spine deformity centers in the United States. Study Design/SettingRetrospective analysis of prospective, multicenter database. Patient SampleConsecutive patients enrolled in an ASD database from four spinal deformity centers. Outcome MeasuresTotal in-patient EOC costs and Short Form (SF)-6D. MethodsThe study used a multicenter database of 210 consecutively enrolled operative patients from 2008 to 2013 at four participating centers in the United States. Demographic, surgical, and direct cost data, expressed in 2013 dollars, for the entire inpatient EOC were obtained from administrative databases from the respective hospitals. Mixed models and multivariable linear regression were used to evaluate the impact of center on total costs adjusting for patient characteristics, length of stay (LOS), and surgical factors. ResultsA total of 126 patients with complete baseline and 2-year follow-up data were included. The percentages of patients from each center were 36.5%, 7.1%, 24.6%, and 31.7%. Overall, the mean patient age was 58.4±12.6 years, 86% were women, and 94% were Caucasian. The proportion of total cost variation explained by the center at which the patient was treated was 17%. After adjusting for patient, LOS, and surgical factors the cost variation reduced to 4%. In multivariable analysis, each additional level fused increased total cost variation by $2,500, whereas recombinant human bone morphogenetic protein-2 (BMP) use and posterior-only surgical approach lowered total EOC costs by $10,500 and $9,400, respectively. No significant difference was observed in 2-year quality-adjusted life year across centers. ConclusionsTotal EOC costs for ASD surgery varied significantly by center. Levels fused, BMP use, and surgical approach were the primary drivers of cost variation across centers. Differences in resource utilization had no impact on 2-year quality-adjusted life year improvement across centers.

Exploiting sets of independent moves in VRP

Most heuristic methods for VRP and its variants are based on the partial exploration of large neighborhoods, typically by means of single, simple moves applied to the current solution. In this paper we define an extended concept of independent moves and show how even a very standard heuristic method can significantly improve when considering the simultaneous application of carefully chosen sets of moves. We show in particular that, when choosing a set such that the total cost variation is equal to the sum of the variations induced by each single move, the quality of solutions obtained is in general very high. When compared with numerical results obtained by some of the best available heuristics on challenging, large scale, problems, our simple algorithm equipped with the application of optimally chosen independent moves displayed very good quality.

PD14-01 VARIATION IN 90-DAY EPISODE PAYMENTS FOR UROLOGICAL CANCER SURGERY: IMPLICATIONS FOR BUNDLED PAYMENT PROGRAMS

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Value of Care: Cost and Outcomes Measures I1 Apr 2017PD14-01 VARIATION IN 90-DAY EPISODE PAYMENTS FOR UROLOGICAL CANCER SURGERY: IMPLICATIONS FOR BUNDLED PAYMENT PROGRAMS Jonathan Li, Zaojun Ye, Hye Sung Min, Deborah Kaye, Lindsey Herrel, James Dupree, David Miller, and Chad Ellimoottil Jonathan LiJonathan Li More articles by this author , Zaojun YeZaojun Ye More articles by this author , Hye Sung MinHye Sung Min More articles by this author , Deborah KayeDeborah Kaye More articles by this author , Lindsey HerrelLindsey Herrel More articles by this author , James DupreeJames Dupree More articles by this author , David MillerDavid Miller More articles by this author , and Chad EllimoottilChad Ellimoottil More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.702AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Aiming to reduce variation in spending for common surgical procedures, Medicare and other payers have moved toward alternative reimbursement models such as episode-based bundled payments. However, little is known about the variation in 90-day episode spending for urological cancer surgery. METHODS Using linked SEER-Medicare data, we identified a study cohort that included all Medicare beneficiaries who underwent cystectomy, prostatectomy, or nephrectomy for cancer from 2008 through 2011. We then calculated total episode payments by aggregating hospital, physician, and post-acute care claims from the index surgical hospitalization through 90 days post-discharge. Total payments were then compared to examine hospital level-variation within each procedure type. Next, we evaluated differences in hospital, physician, and post-acute care payments between the highest and lowest spending quartiles based on mean total episode payments. Finally, we assessed the ″payment signatures″ among the most expensive hospitals for each condition. RESULTS From 2008 through 2011, we identified 90-day episodes of care for 1,768 cystectomies, 8,755 prostatectomies, and 4,305 nephrectomies. We observed wide variation in mean episode payments for all three conditions (cystectomy mean $31,836: range $22,322 to $41,706, prostatectomy mean $9,580: range $7,535 to $15,694, nephrectomy mean $16,554: range $10,857 to $25,675). For cystectomy, payments for the index hospitalization represented 50.1% of the total cost variation, whereas for prostatectomy the primary driver was physician fees (34.6%), and for nephrectomy post-acute care costs varied the greatest (37.7%). Each of the most expensive hospitals demonstrated a unique signature for the payment component that was driving high total episode payments (Figure). CONCLUSIONS Ninety-day episode payments for urological cancer surgery vary widely across hospitals in the United States. The key drivers of payment variation differ for individual procedures and hospitals. Accordingly, hospitals will need individualized data and clinical re-design strategies to succeed with implementation of episode-based payment models for urological cancer care. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e276 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Jonathan Li More articles by this author Zaojun Ye More articles by this author Hye Sung Min More articles by this author Deborah Kaye More articles by this author Lindsey Herrel More articles by this author James Dupree More articles by this author David Miller More articles by this author Chad Ellimoottil More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Search for a new economic optimum in the management of household waste in Tiaret city (western Algeria)

In household waste matters, the objective is always to conceive an optimal integrated system of management, where the terms 'optimal' and 'integrated' refer generally to a combination between the waste and the techniques of treatment, valorization and elimination, which often aim at the lowest possible cost. The management optimization of household waste using operational methodologies has not yet been applied in any Algerian district. We proposed an optimization of the valorization of household waste in Tiaret city in order to lower the total management cost. The methodology is modelled by non-linear mathematical equations using 28 variables of decision and aims to assign optimally the seven components of household waste (i.e. plastic, cardboard paper, glass, metals, textiles, organic matter and others) among four centres of treatment [i.e. waste to energy (WTE) or incineration, composting (CM), anaerobic digestion (ANB) or methanization and landfilling (LF)]. The analysis of the obtained results shows that the variation of total cost is mainly due to the assignment of waste among the treatment centres and that certain treatment cannot be applied to household waste in Tiaret city. On the other hand, certain techniques of valorization have been favoured by the optimization. In this work, four scenarios have been proposed to optimize the system cost, where the modelling shows that the mixed scenario (the three treatment centres CM, ANB, LF) suggests a better combination of technologies of waste treatment, with an optimal solution for the system (cost and profit).