Wide Variation In Cost Research Articles

Wide variation in cost of surgical care for parathyroidectomy: is there a need for standardization of practice?

BackgroundIdentifying hospital and provider variation in surgical cost is a potent method for controlling rising healthcare expenditure and delivering cost-effective care. The purpose of this study was to examine the variation of hospital cost by providers for parathyroidectomy in a single academic institution. MethodsWe retrospectively evaluated 894 consecutive parathyroidectomies under 8 surgeons in our institution between September 2011 and July 2016. Total duration of stay and cost were evaluated using nonparametric tests. Categorical variables were evaluated with χ2. ResultsThe median total hospital cost for parathyroidectomy was $4,863.28 (interquartile range: 4,196–5,764), but the median costs per provider varied widely from $4,522.30 to $12,072.87. The median duration of stay was 0 days (IQR: 0–1) and demonstrated a wide variation among providers. Longer duration of practice was associated with lower cost. Despite the variation, only 2% was readmitted after discharge with no patient mortality. ConclusionWe found substantial variation in hospital cost among providers for parathyroidectomy despite practicing in the same academic institution, with some surgeons spending 4 time more for the same operation. Implementing institutional standards of practice could be a method to decrease variation and costs of surgical care.

Too Big, Too Small, or Just Right? Cost-Efficiency of Environmental Inspection Services in Connecticut.

To assess optimal activity size/mix of Connecticut local public health jurisdictions, through estimating economies of scale/scope/specialization for environmental inspections/services. Connecticut's 74 local health jurisdictions (LHJs) must provide environmental health services, but their efficiency or reasons for wide cost variation are unknown. The public health system is decentralized, with variation in organizational structure/size. We develop/compile a longitudinal dataset covering all 74 LHJs, annually from 2005 to 2012. We estimate a public health services/inspections cost function, where inputs are translated into outputs. We consider separate estimates of economies of scale/scope/specialization for four mandated inspection types. We obtain data from Connecticut Department of Public Health databases, reports, and other publicly available sources. There has been no known previous utilization of this combined dataset. On average, regional districts, municipal departments, and part-time LHJs are performing fewer than the efficient number of inspections. The full-time municipal departments and regional districts are more efficient but still not at the minimum efficient scale. The regional districts' elasticities of scale are larger, implying they are more efficient than municipal health departments. Local health jurisdictions may enhance efficiency by increasing inspections and/or sharing some services.

Variation in the cost of 5 common operations in the United States

Health care costs are an important policy focus in the United States. The magnitude and drivers of variation in the costs of common operative procedures are not well understood. We sought to characterize variation in costs across hospitals. We used data from the Nationwide Inpatient Sample from 2001-2011 for 5 elective operations: colectomy, coronary artery bypass graft, total knee arthroplasty, cesarean section, and lung resection. Hospitals were benchmarked for each using hierarchical risk- and reliability-adjustment methods to generate an observed-to-expected cost ratio, which was adjusted for patient demographics, comorbidity, wage index, and procedure complexity. Hospitals were divided into quintiles. Characteristics of high- and low-quintile hospitals and their adjusted outcomes were examined. Cost observed-to-expected ratios ranged widely for all 5 procedures: 14.9-fold for colectomy, 5.5-fold for coronary artery bypass graft, 12.5-fold for lung resection, 10.6-fold for total knee arthroplasty, and 28.0-fold for cesarean section. Comparing highest to lowest cost quintiles of hospitals, high-cost hospitals were more likely to serve minority and Medicaid patients. Mortality was elevated significantly in high-cost hospitals for colectomy, coronary artery bypass graft, and lung resection (adjusted odds ratio 1.99, 1.32, 2.57; respectively). Service lines were correlated at low-cost hospitals. There was a significant association between greater procedure volume and low-cost hospitals for colectomy, coronary artery bypass graft, and total knee arthroplasty. Despite robust adjustment, there is wide cost variation for common operative procedures in the United States. High-cost hospitals may need to focus on cost reduction at the hospital level to reduce cost across service lines. Benchmarking costs may identify significant opportunities to promote value, or the balance between cost and quality, in operative care in the United States.

Quantifying the Burden of Interhospital Cost Variation in Pediatric Surgery

Practice variation is believed to be a driver of excess health care spending, although few objective data exist to guide the prioritization of comparative effectiveness research (CER) in pediatric surgery. To identify high-priority general pediatric surgical procedures for CER on the basis of the following 2 complementary measures: the magnitude of interhospital cost variation as a surrogate for the need for and potential effect of CER at the patient level and the cumulative fiscal burden of this cost variation when considering the case volume from all hospitals as a surrogate for public health relevance. This was a cohort study of patients undergoing 1 of the 30 most costly pediatric surgical operations at 45 children's hospitals between January 1, 2014, and September 30, 2015. Cost data were extracted from the Pediatric Health Information System database and adjusted for differences in unit-based costing at the hospital level and for differences in case mix and disease severity at the patient level. First, the width of the interquartile range (WIQR) of the adjusted procedure-specific median cost across hospitals. Second, the procedure-specific cost variation burden, which was calculated as the aggregate sum of absolute cost differences between the overall adjusted median cost derived from all patients treated at all hospitals and the adjusted cost of each individual patient treated at all hospitals. A total of 92 535 encounters were analyzed. The median number of encounters per hospital was 2011 (interquartile range [IQR], 1224-2619), and the median number of encounters per procedure was 610 (IQR, 442-2610). In the final cohort, 66.9% (n = 61 933) of the patients were male, and the median age was 7 years (IQR, 1.9-12.3 years). Cost variation at the hospital level was greatest for gastroschisis (WIQR, $48 471; median, $111 566 [IQR, $91 195-$139 936]), congenital diaphragmatic hernia (WIQR, $43 948; median, $154 730 [IQR, $129 764-$173 712]), tracheoesophageal fistula/esophageal atresia (WIQR, $39 206; median, $105 259 [IQR, $87 335-$126 541]), and total colectomy for ulcerative colitis (WIQR, $24 497; median, $34 910 [IQR, $28 815-$53 312]). The following 5 diagnoses accounted for 52.5% of the cumulative cost variation burden from all 30 conditions: uncomplicated appendicitis (18.0% [$66 205 117]), complicated appendicitis (14.1% [$51 702 402]), gastroschisis (9.5% [$34 940 331]), gastrostomy (5.8% [$21 227 436]), and small-intestinal atresia (5.1% [$18 840 546]). Neonatal cases contributed 3.6% of the case volume and accounted for 26.8% of the cumulative cost variation burden from all 30 conditions. A small number of procedures account for most of the cost variation burden in pediatric surgery, with some demonstrating wide cost variation among hospitals. Gastroschisis and small-intestinal atresia may be particularly high-yield targets for multidisciplinary CER efforts, while the management of appendicitis and gastrostomy should be considered high-priority conditions among pediatric surgeons.

Cost and performance of some carbon capture technology options for producing different quality CO2 product streams

A techno-economic assessment of power plants with CO2 capture technologies with a focus on process scenarios that deliver different grades of CO2 product purity is presented. The three leading CO2 capture technologies are considered, namely; oxyfuel combustion, pre-combustion and post-combustion capture. The study uses a combination of process simulation of flue gas cleaning processes, modelling with a power plant cost and performance calculator and literature values of key performance criteria in order to evaluate the performance, cost and CO2 product purity of the considered CO2 capture options. For oxyfuel combustion capture plants, three raw CO2 flue gas processing strategies of compression and dehydration only, double flash system purification and distillation purification are considered. Analysis of pre-combustion capture options is based on integrated gasification combined cycle plants using physical solvent systems for capturing CO2 and sulfur species via three routes; co-capture of sulfur impurities with the CO2 stream using Selexol™ solvent, separate capture of CO2 and sulfur impurities using Selexol™, and Rectisol® solvent systems for separate capture of sulfur impurities and CO2. Analysis of post-combustion capture plants was made with and without some conventional pollution control devices. The results highlight the wide variation in CO2 product purity for different oxyfuel combustion capture scenarios and the wide cost variation for the pre-combustion capture scenarios. The post-combustion capture plant with conventional pollution control devices offers high CO2 purity (99.99mol%) for average cost of considered technologies. The calculations performed will be of use in further analyses of whole chain CCS for the safe and economic capture, transport and storage of CO2.

Surgeon-Directed Cost Variation in Isolated Rotator Cuff Repair.

Background:As value becomes a larger component of heath care decision making, cost data can be evaluated for regional and physician variation. Value is determined by outcome divided by cost, and reducing cost increases value for patients. “Third-party spend” items are individual selections by surgeons used to perform procedures. Cost data for third-party spend items provide surgeons and hospitals with important information regarding care value, potential cost-saving opportunities, and the total cost of ownership of specific clinical decisions.Purpose:To perform a cost review of isolated rotator cuff repair within a regional 7-hospital system and to document procedure cost variation among operating surgeons.Study Design:Economic and decision analysis; Level of evidence, 4.Methods:Current Procedural Terminology (CPT) codes were used to retrospectively identify subjects who received an isolated rotator cuff repair within a 7-hospital system. Cost data were collected for clinically sensitive third-party spend items and divided into 4 cost groups: (1) suture anchors, (2) suture-passing devices and needles, (3) sutures used for cuff repair, and (4) disposable tools or instruments.Results:A total of 62 isolated rotator cuff repairs were performed by 17 surgeons over a 13-month period. The total cost per case for clinically sensitive third-party spend items (in 2015 US dollars) ranged from $293 to $3752 (mean, $1826). Four surgeons had a mean procedure cost that was higher than the data set mean procedure cost. The cost of an individual suture anchor ranged from $75 to $1775 (mean, $403). One disposable suture passer was used, which cost $140. The cost of passing needles ranged from $140 to $995 (mean, $468). The cost per repair suture (used to repair cuff tears) varied from $18 to $298 (mean, $61). The mean suture (used to close wounds) cost per case was $81 (range, $0-$454). A total of 316 tools or disposable instruments were used, costing $1 to $1573 per case (mean, $624).Conclusion:This study demonstrates significant cost variation with respect to cost per case and cost of individual items used during isolated rotator cuff repair. Suture anchors represent the most expensive and variable surgeon-directed cost. The wide cost variation seen in all cost categories illustrates both the effect of surgeon choice in procedure cost and the opportunity for significant cost savings in cases of isolated rotator cuff repair. Engaging surgeons in discussion on cost can positively influence the value of care provided to patients if costs can be reduced without affecting the quality of patient outcomes.

Complications and Cost of Syndactyly Reconstruction in the United States: Analysis of the Pediatric Health Information System.

Syndactyly is one of the most common congenital differences of the upper extremity and offers an exceptional opportunity to evaluate value-based care in pediatric orthopedic surgery. We designed a study to characterize complications and cost associated to syndactyly surgery among US pediatric hospitals. A total of 2047 patients were identified for syndactyly surgery at 38 pediatric hospitals from 2009 to 2012 using the Pediatric Health Information System (PHIS) database. We examined costs as well as complication rates across hospitals stratified by patient and hospital variables. The postoperative complication rate was 1.9% (95% confidence interval [CI]: 1.3%-2.5%). Postoperative infection rate was 1.6% and surgical complication rate was 0.3%. Median adjusted standardized cost was $4112.5 (interquartile range: $2979-$6049). Patients with more than 1 diagnosis had 19 times higher risk of complications and were associated with 13% more hospital cost than those with syndactyly as single diagnosis ( P < .001). Finally, there was a wide variation in cost across hospitals; 8 (21%) yielded confidence limits above the benchmarked value. In the United States, it is important to recognize variations in practice of syndactyly surgery in hopes of developing quality improvement strategies in pediatric orthopedic surgery.

Surgeon and hospital cost variability for septoplasty and inferior turbinate reduction.

Septoplasty and turbinate reduction (STR) is a common procedure for which cost reduction efforts may improve value. The purpose of this study was to identify sources of variation in medical facility and surgeon costs associated with STR, and whether these costs correlated with short-term complications. An observational cohort study was performed in a multifacility network using a standardized cost-accounting system to determine costs associated with adult STR from January 1, 2008 to July 31, 2015. A total of 4007 cases, performed at 21 facilities, by 72 different surgeons were included in the study. Total costs, variable costs, operating room (OR) time, and 30-day complications (eg, epistaxis) were compared among surgeons, facilities, and specialties. Total procedure cost: (mean ± standard deviation [SD]) $2503 ± $790 (range, $852 to $10,559). Mean total variable cost: $1147 ± $423 (range, $400 to $5,081). Intersurgeon and interfacility variability was significant for total cost (p < 0.0001) and OR time (p < 0.0001). Intersurgeon OR supply cost variability was also significant (p < 0.0001). Otolaryngologists had less total cost (p < 0.0001), OR time/cost (p < 0.0001), and complications (p = 0.0164), but greater supply cost (p < 0.0001), than other specialties. There is wide variation in cost associated with STR. Significant variance in OR time and supply cost between surgeons suggests these are potential areas for cost reduction. Although no increased 30-day complications were seen with faster and less costly surgeries, further research is needed to evaluate how time and cost relate to quality of care.

Cost variation study of antidepressant drugs

Background: Depression and anxiety disorders are the most common mental illnesses, each affecting in excess of 10-15% of the population at some time in their lives. Approximately 10-15% of those with severe depression attempt suicide at some point of time. Thus, it is important that symptoms of depression be recognized and treated appropriately. Methods: The prices of 15 antidepressant drugs, available in 43 different formulations were analyzed. Costs of different brands of a particular generic antidepressant drug being manufactured by different companies, in the same strength and dosage forms were used to calculate cost ratio and percentage cost variation. Results: This study shows that there is a wide variation in the prices of different brands of same antidepressant drug in Indian market. The highest cost ratio and percent cost variation was found for amitriptyline 50 mg, followed by bupropion 25 mg, amitriptyline 75 mg and dosulepin 50 mg. Highest number of brands of antidepressant drugs available in Indian market are for escitalopram 10 mg followed by escitalopram 5 mg and 20 mg. Conclusions: There is wide price variation of different brands of the same generic antidepressant drug in Indian market. Cost of a drug plays an important role in treatment of depression as it follows a long course and adherence to the treatment is related with drug cost. To decrease the wide cost variation among different brands of antidepressant drugs; it is high time to generate physician awareness about impact of cost effectiveness of drug regimen and for regulation of drug prices by the concerned agencies.

Cost variation analysis of antidyslipidemic drugs

Background: Dyslipidemia is the most common cause of premature coronary atherosclerosis manifesting as ischemic heart disease. Hyperlipidemia has a major role in the causation of atherosclerosis and atherosclerosis-induced conditions, such as ischemic cerebrovascular disease, coronary heart disease (CHD) and peripheral vascular disease.Methods: The prices of 07 antidyslipidemic drugs, available in 19 different formulations marketed in 260 brands and 03 fixed dose combinations available in 11 different formulations marketed in 75 brands were analyzed. Costs of different brands of a particular generic antidyslipidemic drug being manufactured by different companies, in the same strength and dosage forms were used to calculate cost ratio and percentage cost variation.Results: In this study, it was found that there exists a wide cost variation among the different brands of same antidyslipidemic drugs in Indian market. Among individual antidyslipidemic drugs, highest cost ratio and percent cost variation was found for atorvastatin 20 mg, followed by atorvastatin 10 mg and atorvastatin 5 mg. Among fixed dose combinations for antidyslipidemic drugs, highest cost ratio and percent cost variation was found for atorvastatin 20 mg+fenofibrate 160 mg, followed by atorvastatin 10 mg+ezetimibe 10 mg and atorvastatin 20 mg+ezetimibe 10 mg. Highest number of brands of antidyslipidemic drugs available in Indian market are for atorvastatin 10 mg followed by atorvastatin 20 mg and rosuvastatin 10 mg. Highest number of brands of fixed dose combinations of antidyslipidemic drugs available in Indian market are for atorvastatin 10 mg+ezetimibe 10 mg and atorvastatin 10 mg+fenofibrate 160 mg.Conclusions: In Indian market, there is very wide price variation of different brands of the same generic antidyslipidemic drug. Treatment of dyslipidemia has long course of treatment. For long term adherence to the treatment, cost of a drug plays an important role for successful drug treatment. Various steps are needed to reduce this wide price variation of different brands of the same generic antidyslipidemic drug.

Costs, and cost-outcome of school feeding programmes and feeding programmes for young children. Evidence and recommendations

Our objectives for this study were to provide updated, realistic data on the costs and cost-outcomes of school feeding in Low and Middle Income Countries. We also aimed to identify factors that may influence effectiveness and therefore, cost effectiveness of the interventions. To do this, we combined data on effect sizes for physical and psychosocial outcomes from two Cochrane systematic reviews with new data on the costs of school feeding. We simulated the costs of preschool feeding based on the school feeding costs. We found that he average for low- and middle-income countries combined was US$72, with large variations across countries. We also found a wide variation in costs for different outcomes. We suggest several ways in which effectiveness may be improved and cost-per outcome lowered for both programmes.

Nurse Family Partnership: Comparing Costs per Family in Randomized Trials Versus Scale-Up.

The literature that addresses cost differences between randomized trials and full-scale replications is quite sparse. This paper examines how costs differed among three randomized trials and six statewide scale-ups of nurse family partnership (NFP) intensive home visitation to low income first-time mothers. A literature review provided data on pertinent trials. At our request, six well-established programs reported their total expenditures. We adjusted the costs to national prices based on mean hourly wages for registered nurses and then inflated them to 2010 dollars. A centralized data system provided utilization. Replications had fewer home visits per family than trials (25 vs. 31, p = .05), lower costs per client ($8860 vs. $12,398, p = .01), and lower costs per visit ($354 vs. $400, p = .30). Sample size limited the significance of these differences. In this type of labor intensive program, costs probably were lower in scale-up than in randomized trials. Key cost drivers were attrition and the stable caseload size possible in an ongoing program. Our estimates reveal a wide variation in cost per visit across six state programs, which suggests that those planning replications should not expect a simple rule to guide cost estimations for scale-ups. Nevertheless, NFP replications probably achieved some economies of scale.

PCN106 - The Economics of the Treatment and Follow-Up of Patients with Glioblastoma

To summarize the existing literature regarding the medical cost associated with treatment and follow-up of glioblastoma. PubMed was used as search engine to retrieve publications in Medline using the search terms “(glioblastoma) AND (cost)” with a publication date filter (from January 1st 2000 up to September 1st2014) and language filter (English). This search yielded 107 publications of which 14 were relevant for this review. Costs were recalculated in Euros (€) using the June 5 2015 currency rate of $1 = €0.8914, CA$1 = €0.7131 and 1£ = €1.3667. Two studies calculated the average total medical cost of glioblastoma treatment including direct hospital centered costs from diagnosis to death and one study included healthcare payer perspective cost from diagnosis to two years of follow-up. The cost ranged between €12,229 - €43,894 (median: €39,000). Two studies calculated the average cost of the combination of surgery and chemoradiotherapy which varied from €16,007 per patient in Canada to €41,744 per patient in Switzerland. The addition of temozolomide to radiotherapy prolongs survival and improves quality of life. The incremental cost-effectiveness ratio (ICER) of temozolomide plus radiotherapy as compared to radiotherapy alone ranged from €49,054 (UK) to €77,854 (China) per quality adjusted life years (QALY) and €37,361 per life years gained (LYG)(Europe and Canada). One French study showed an improvement in survival of 4 months between 2004 and 2012, with an ICER of €54,355 per LYG, due to an increased use of temozolomide and bevacizumab. The literature on the cost of treatment and follow up of glioblastoma patients and on the cost-effectiveness of treatment modalities used in glioblastoma is scarce. Wide variations in cost are reported, probably reflecting the variation in health care systems.

Cost-effectiveness of reductions in greenhouse gas emissions from High-Speed Rail and urban transportation projects in California

A rising trend in state and federal transportation finance is to invest capital dollars into projects which reduce greenhouse gas (GHG) emissions. However, a key metric for comparing projects, the cost-effectiveness of GHG emissions reductions, is highly dependent on the cost-benefit methodology employed in the analysis. Our analysis comparing California High-Speed Rail and three urban transportation projects shows how four different accounting framings bring wide variations in cost per metric tonne of GHG emissions reduced. In our analysis, life-cycle GHG emissions are joined with full cost accounting to better understand the benefits of cap-and-trade investments. Considering only public subsidy for capital, none of the projects appear to be a cost-effective means to reduce GHG emissions (i.e., relative to the current price of GHG emissions in California’s cap-and-trade program at $12.21 per tonne). However, after adjusting for the change in private costs users incur when switching from the counterfactual mode (automobile or aircraft) to the mode enabled by the project, all investments appear to reduce GHG emissions at a net savings to the public. Policy and decision-makers who consider only the capital cost of new transportation projects can be expected to incorrectly assess alternatives and indirect benefits (i.e., how travelers adapt to the new mass transit alternative) should be included in decision-making processes.

Bundled Payment and Care of Acute Stroke: What Does it Take to Make it Work?

With nearly 800 000 strokes occurring a year, stroke remains the leading cause of disability and the fourth most common cause of death in the United States.1 Stroke also imposes an enormous economic burden, including long-term care costs and productivity losses. Total direct medical stroke-related costs to US economy are projected to triple from $71.6 billion in 2012 to $184.1 billion in 2030.1 Although treatment for acute stroke is generally not vividly effective, the type and quality of stroke care can effect outcomes. Appropriate and prompt use of tissue-type plasminogen activator, reducing risk of acute medical complications, such as deep vein thrombosis, prophylaxis, and prevention of aspiration, secondary prevention, such as anticoagulation for atrial fibrillation, and early institution of aggressive rehabilitation can have substantial impacts on survival and disability.1,2 Moreover, given the high cost of disabling strokes, even care that is modestly effective in reducing functional loss can be highly cost-effective.3 Evidence suggests we could treat patients with acute stroke more effectively and at lower cost. A review showed large variation in patient-level cost of strokes (between 2 and 4-fold difference) across hospitals that is not explained by improved process of care or clinical outcomes.4 Other studies found similar wide cost variation.5–7 Substantial variation also exists in clinical outcomes of stroke patients that is unexplained by patient and hospital characteristics.8 Programs such as Get-With-The Guidelines have documented that systematic improvements in stroke care are possible.9 The high variation in costs of stroke and outcomes reflects not only the complex nature of the process of treating and managing stroke patients but also points to inefficiencies in the process of care. It has been argued that these inefficiencies are partly attributable to the current payment system, which is mostly based on …

Understanding variations in pediatric asthma care processes in the emergency department using visual analytics.

Health care delivery processes consist of complex activity sequences spanning organizational, spatial, and temporal boundaries. Care is human-directed so these processes can have wide variations in cost, quality, and outcome making systemic care process analysis, conformance testing, and improvement challenging. We designed and developed an interactive visual analytic process exploration and discovery tool and used it to explore clinical data from 5784 pediatric asthma emergency department patients.

Preferential Assessment for Open Space

Land with little or no development, often referred to as open space, can provide environmental and amenity benefits to society. Twenty-three states use tax expenditures as an incentive to keep land undeveloped. These tax expenditures are the result of preferential assessments that reduce the property taxes on qualifying parcels. The programs vary in many ways, including the method used to determine the tax expenditure on a particular parcel, the conditions necessary for qualification, and the penalty for altering the use of land enrolled in the program. This review examines the programs and discusses the different approaches used. It presents a case study of tax expenditures for open space protection in Georgia, demonstrating the technique used to calculate the expenditure and the wide variation in costs across counties. The methods used to determine the tax expenditure amount and the nature of the benefits received lead to concerns about the efficiency of the programs.

Costes de los servicios sanitarios asociados al tratamiento del cáncer de mama precoz con radioterapia adyuvante

ObjectiveTo assess the healthcare costs associated with six radiation therapy (RT) techniques for the adjuvant treatment of early breast cancer. MethodsA team of six radiation oncologists and a specialist in health economics performed a descriptive cost analysis among the following RT techniques: 3-dimensional conformal RT (3DCRT) using either conventional fractionation (2Gy/fraction) or hypofractionation (2,6Gy/fraction), partial-breast irradiation (PBI) delivered with the use of 3DCRT or brachytherapy (high and low dose rate), and intraoperative RT (IORT). Treatment costs included hospitalization, medical (simulation, contouring, and verification and approval of treatment plans) and nursing consults, radiological examinations, and dosimetry calculation. Costs were obtained from the last update of public prices in the Andalusian Public Health System, updated to 2013. ResultsThe treatment cost for conventional fractionation with 3DCRT was 6,786.75€, whereas the cost of the hypofractionated regimen using the same technology was 4,998.17€. PBI costs were 4,066.10€, 4,797.35€, 4,376.97€ and 7,715.43€ for 3DCRT, low-dose rate brachytherapy, high-dose rate brachytherapy, and IORT, respectively. ConclusionsThere is wide cost variation among RT techniques for the adjuvant treatment of early breast cancer. The technique with the lowest healthcare cost is PBI through 3DCRT. Official government prices should be updated and should also include the new technologies incorporated in recent years.

Developing a Pathway for High-value, Patient-centered Total Joint Arthroplasty

Total joint arthroplasty (TJA) is one of the most widely performed elective procedures; however, there are wide variations in cost and quality among facilities where the procedure is performed. The purposes of this study were to (1) develop a generalizable clinical care pathway for primary TJA using inputs from clinical, academic, and patient stakeholders; and (2) identify system- and patient-level processes to provide safe, effective, efficient, and patient-centered care for patients undergoing TJA. We used a combination of quantitative and qualitative methods to design a care pathway that spans 14 months beginning with the presurgical office visit and concluding 12 months after discharge. We derived care suggestions from interviews with 16 hospitals selected based on readmission rates, cost, and quality (n = 10) and author opinion (n = 6). A 32-member multistakeholder panel refined the pathway during a 1-day workshop. Participants were selected based on leadership in orthopaedic (n = 4) and anesthesia (n = 1) specialty societies; involvement in organizations specializing in safety and high reliability care (n = 3), lean production/consumption of care (n = 3), and patient experience of care (n = 3); membership in an interdisciplinary care team of a hospital selected for interviewing (n = 8); recent receipt of a TJA (n = 1); and participation in the pathway development team (n = 9). The care pathway includes 40 suggested processes to improve care, 37 techniques to reduce waste, and 55 techniques to improve communication. Central themes include standardization and process improvement, interdisciplinary communication and collaboration, and patient/family engagement and education. Selected recommendations include standardizing care protocols and staff roles; aligning information flow with patient and process flow; identifying a role accountable for care delivery and communication; managing patient expectations; and stratifying patients into the most appropriate care level. We developed a multidisciplinary clinical care pathway for patients undergoing TJA based on principles of high-value care. The pathway is ready for clinical testing and context-specific adaptation. Level V, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Squinting Through Layers of Fog: Assessing the Cost Effectiveness of Treatments for Multiple Sclerosis

Multiple sclerosis (MS) is a chronic neurological disorder, which can lead to a wide range of disabling symptoms. The condition has a significant negative impact on health-related quality of life, and the economic cost of the disease is substantial. Decision-making regarding treatments for MS, and particularly disease-modifying interventions, has been hampered by limitations in the data and evaluative framework for assessing their cost effectiveness. Whilst attention has been drawn to these weaknesses, the scope and extent of the challenges in this area have not been fully set out to date. The aims of this review were to identify all published economic evaluations of MS treatments in order to provide a statement on the scope and characteristics of the cost-effectiveness literature in the area of MS and to provide a basis on which to suggest practical recommendations for future research to aid decision-making. A systematic search was undertaken to identify economic evaluations of treatments for people with MS published in English up to December 2011. Included studies were reviewed to provide a comprehensive description of the characteristics of the currently applied framework for cost effectiveness in MS, with the following key methodological components considered: methods for estimating disease progression, the impact of treatment and health outcomes and costs associated with MS. Thirty-seven papers were identified. Most studies (n = 32) were model-based evaluations of disease-modifying drugs. All models used disability stages defined by the Expanded Disability Status Scale (EDSS) to characterise disease progression, and the impact of treatment was based on data from clinical trials and epidemiological cohorts. Outcomes were primarily based on quality-adjusted life-years (n = 22) and/or related to relapse (n = 14). Estimates for health state utility values (HSUVs), costs and the impact of treatment on the course of MS varied considerably between studies, depending on the data sources used and the methods used to incorporate data into models. The scope of the studies was narrow, with a sparsity of economic evaluations of symptomatic and/or non-pharmacological interventions; exclusion of direct non-medical, indirect and informal care costs from analyses; and a narrow view of the potential impact of treatment, concentrating on disability, according to the EDSS, and relapses. In addition, there were issues concerning how to capture losses in HSUVs due to relapses in a way that reflects their salience to people with MS, the wide variation in costs and outcomes from different sources and from potentially unrepresentative samples and modelling disease progression from natural history data from over 30 years ago. There are many complexities for those designing and reporting cost-effectiveness studies of treatments for MS. Analysts, and ultimately decision makers, face multiple data and methodological challenges. Policy makers, technology developers, clinicians, patients and researchers need to acknowledge and address these challenges and to consider recommendations that will improve the current scenario. There is a need for further research that can constructively inform decision-making regarding the funding of treatments for MS.