[An investigation on the profits from surgery and anaesthesia in Kyushu University Hospital]

We calculated and analyzed the profits from surgery and anaesthesia for a period of one month of September 2006 in Kyushu University Hospital. It was confirmed that 27% of surgery-related profits were earned by anaesthesia. We were also able to confirm that the profits vary significantly depending on the material cost and the length of stay in the operating rooms. We believe that all the surgical workers must realize such fact and each of them is responsible to carry out the operations quickly and efficiently.

[Cost recovery for the treatment of retinal and vitreal diseases by pars plana vitrectomy under the German DRG system]

BACKGROUND

Since 2004 inpatient health care in Germany is paid according to calculated DRGs. Only a few university hospitals participated in distinct cost calculations of clinical treatment. It was the aim of this study to check the cost recovery at a University Eye Hospital for the surgical treatment of retinal and vitreal diseases by pars plana vitrectomy (ppV), which are included in DRGs C03Z and C17Z.

MATERIAL AND METHODS

The performance data for both DRGs were collected for the years 2005 and 2006 using the E1 sheets according to section 21 KHEntG. The mean duration of all procedures was collected by data from the internal controlling. Costs for single operations were calculated from fixed and variable costs for the operation theatre and the ward including costs for personnel and material.

RESULTS

In the 2-year period of 4,721 inpatient procedures 1,307 ppVs were performed. Each ppV had fixed surgical costs of 130.60 EUR; personnel costs varied between 575 EUR (C03Z; including cataract surgery; mean OP duration: 85 min) and 510 EUR (C17Z; no cataract surgery; mean OP duration: 73 min) at a proportion between general anaesthesia and local anaesthesia of 80/20. For a pure ppV material costs were 255 EUR. Additional adjuncts such as an encircling band, perfluorcarbon, ICG, tPA, gas and silicon oil or cataract surgery led to extra costs between 51 EUR and 250 EUR per adjunct und were used in 56% (C03Z) and 74.5% (C17Z) of all procedures. Costs for hospitalisation were about 1765 EUR at a mean residence time of 6.5 days. Thus, the overall costs of a pure basic ppV amounted to 2975 EUR (C03Z) and 2661 EUR (C17Z). In consideration of the current relative DRG weights of 1.08 and 0.957 and a current base rate of 2787.19 EUR in Bavaria, cost recovery is only given for basic ppV but not for complex ppVs having higher material and personnel costs. Additionally, the costs for multiple surgeries as occur in 5.9% of cases are not compensated by the DRG system.

CONCLUSION

The reimbursement for inpatient ppVs in a University environment is not covered for complex procedures requiring more cost-effective material and personnel time. To consider an adequate cost recovery for these procedures a DRG split for both DRGs (C03Z and C17Z) in basic ppVs and complex ppVs is required. We recommend this proposal for the InEK.

Improving operating room efficiency by applying bin-packing and portfolio techniques to surgical case scheduling

BACKGROUND

An operating room (OR) department has adopted an efficient business model and subsequently investigated how efficiency could be further improved. The aim of this study is to show the efficiency improvement of lowering organizational barriers and applying advanced mathematical techniques.

METHODS

We applied advanced mathematical algorithms in combination with scenarios that model relaxation of various organizational barriers using prospectively collected data. The setting is the main inpatient OR department of a university hospital, which sets its surgical case schedules 2 wk in advance using a block planning method. The main outcome measures are the number of freed OR blocks and OR utilization.

RESULTS

Lowering organizational barriers and applying mathematical algorithms can yield a 4.5% point increase in OR utilization (95% confidence interval 4.0%-5.0%). This is obtained by reducing the total required OR time.

CONCLUSIONS

Efficient OR departments can further improve their efficiency. The paper shows that a radical cultural change that comprises the use of mathematical algorithms and lowering organizational barriers improves OR utilization.

Insurance reimbursement in a university-based pediatric weight management clinic

OBJECTIVES

To compare third-party payor reimbursement for patients evaluated in a university-based pediatric weight management clinic in central Kentucky.

STUDY DESIGN

Demographic and reimbursement data were reviewed for 120 patients evaluated January to December 2004. Statistical analysis included Kruskal-Wallis test and Friedman's test.

RESULTS

Overall, median reimbursement was 60%. For new appointments, contracted (56%) and capitated (60%) reimbursements were higher than Medicaid (55%). For established appointments, Medicaid reimbursement (100%) was higher than contracted (37%) and capitated (58%).

CONCLUSION

Our data suggest that reimbursement is influenced by regional factors and is improving in central Kentucky.

Effects of a fix-payment method per outpatient on the procedures, in university hospitals, Turkey

The effects of payment methods on clinical practice are not well understood, in Turkey. In the middle of 2006, a fix-payment method for hospitals was implemented, and 5 months later was cancelled. The aim of the study was to evaluate the effects of the payment method on the clinical practice in the University hospitals. The data in this study was retrospectively obtained from six university hospital records. Main outcome measure is procedure number per outpatient. The overall mean procedure number per outpatient was found as 12.2. A significant decrease was observed in the mean procedure number during the period of fix-payment method (p<0.05). While the mean number remained at the level of 13.4+/-6.3 during the other months of the year (p<0.05), it came down to the level of 10.3+/-4.8 during the period of fix-payment method. A decrease of 23% in procedures was calculated during the new method. It was concluded that payment model for hospitals was an effective factor on clinical practice.

[Comparing individual costs for treatment in acute day and inpatient care--results from a randomised controlled trial]

OBJECTIVE

Individual costs of non-pharmacological treatments in acute day and inpatient care were assessed within a randomised controlled trial.

METHODS

For 37 modes of treatment used by 191 patients during their index-hospitalization (92 in day, and 99 in inpatient care) personnel costs were calculated. Data were analysed with non-parametric Mann-Whitney-U-tests and regression-analytic models for cost prediction.

RESULTS

Day care patients caused mean costs of 1559.41 euro per person and received a mean of 198.8 treatments, whereas inpatients caused 947.22 euro and received 138.0 treatments. As concerns inpatient treatment, length of stay, the diagnosis of an ICD-10 F4-disorder, and the level of positive symptoms at admission could be identified as predictors of individual costs. For day hospital treatment, length of stay and illness chronicity contributed significantly to the prediction of individual costs.

CONCLUSION

The direct health care cost advantage of acute day care--found in several trials which had performed unit-cost analyses--did not appear if personnel costs of the individually received non-pharmacological treatments were used as calculation basis.

[Active clinical surveillance for detection of Legionnaires' disease: implications for health care structures]

In an university hospital of about 900 beds, a clinical surveillance was activated to detect cases of Legionnaires' disease in patients affected by community and/or nosocomial-acquired pneumonia. In the hospital Legionella spp was detected in the hot water distribution system and various disinfecting and control procedures were adopted to reduce contamination. Contemporary, the clinical surveillance began with the systematic detection of Legionella urinary antigen among recovered pneumonia, seroconversion as confirmation test and the collection of respiratory secretions or other biological materials to isolate the microorganism in patients positive to the urinary antigen. From September 2003 to May 2005, 486 pneumonia were followed, 98 of which considered of nosocomial origin. In total, 15 cases of community-acquired Legionnaires' disease were detected by the urinary test, whereas no cases of nosocomial origin were found. The characteristics of the detected cases are described in comparison with the other pneumonia and the surveillance cost was evaluated. The systematic clinical surveillance for Legionella infections is feasible with limit costs, allows to detect community-acquired cases otherwise unknown and to ascertain the absence/presence of nosocomial-acquired pneumonia, irrespective of the environment contamination.

Introduction of diagnosis-related groups in Germany: evaluation of impact on in-patient care in a dermatological setting

BACKGROUND

German diagnosis-related groups (G-DRG) have been introduced in Germany as a reimbursement system for in-patient care. The aim of this study was to report data-based experiences from the introduction process and to evaluate the impact on in-patient dermatology.

METHODS

A quantitative analysis including clinical data from two large university centres of dermatology over a time period of 4 years (2003-06) has been performed. Characteristics and trends of case-mix index, number of cases, average age, length of stay (LOS), surgical and medical treatments and in-patient case groups were studied in detail.

RESULTS

It was found that the case-mix index values increased after the introduction period, but subsequently declined on the initial value. At the same time, an increase of dermatological hospital admissions can be noticed parallel to a significant reduction of LOS (P < 0.001) and a moderate increase of average age (P < 0.001). Analysis of DRG assignment revealed an initial significant decline of surgical in-patient procedures and increasing medical treatments, however, without obvious long-term changes. Furthermore, a growing importance for dermatological oncology and inflammable skin diseases within the in-patient setting could be observed.

CONCLUSIONS

The introduction of the G-DRG system in Germany induced changes in in-patient care affecting hospital admission rates, LOS and cases treated in an in-patient setting. In-patient activities have not been reduced with the DRG introduction; however, long-term interdisciplinary research approaches are needed to explore the future impact on health care providing and quality of health care in depth.

Making a difference

Mary Beth Briscoe believes healthcare finance professionals are in a unique position to make a positive impact on the world around them. As HFMA's new chairman, she's encouraging members to use their talents for the good of their organizations, their communities, and their profession.

Perioperative antibiotic prophylaxis and cost in a Turkish University Hospital

Although surgical site infections have decreased with the use of prophylactic antibiotics, inappropriate surgical antibiotic prophylaxis is still a world-wide problem. In this retrospective study, perioperative antibiotic prophylaxis was evaluated in a university hospital. All surgical procedures (total 2038) performed in the year 2002 were included. The study setting was the Anesthesiology and Reanimation unit in Pamukkale University Medicine Faculty Hospital. A total of 1902 patients received antibiotic prophylaxis. Ninety-two percent of all procedures were elective, 8% emergencies. Approximately 85.7% were clean surgery, 8.5% clean-contaminated, 5.3% contaminated, and 0.5% dirty. Approximately 93.3% of patients received antibiotic prophylaxis. Although timing of prophylaxis was appropriate in all procedures, duration was optimal in only 29.0% of all cases. Sulbactam/ampicillin (33.2%), cefepime (23.4%), ceftriaxone (15.1%), ciprofloxacin (12.6%) and cefazolin (11%) were the most commonly used antibiotics. Instead of an estimated optimal cost of perioperative antibiotic prophylaxis ranging between US$2.6 and 7.8 according to guidelines, the average cost was US$62 per patient. We believe that compliance regarding the optimal choice, frequency and duration of perioperative antibiotic prophylaxis is inadequate, thereby making additional efforts necessary.

Clinical and economic impact of multidrug resistance in nosocomial Acinetobacter baumannii bacteremia

OBJECTIVE

To investigate the impact of antimicrobial resistance on clinical and economic outcomes among hospitalized patients with multidrug-resistant (MDR) Acinetobacter baumannii bacteremia.

DESIGN

A retrospective, matched-cohort study.

SETTING

A tertiary care university teaching hospital.

METHODS

A matched case-control (1 : 1) study was conducted to compare the differences in clinical and economic outcomes of patients with MDR A. baumannii bacteremia and patients with non-MDR A. baumannii bacteremia. Case patients were matched to control patients on the basis of sex, age, severity of underlying and acute illness, and length of hospital stay before onset of bacteremia.

RESULTS

Forty-six (95.8%) of 48 cases with MDR A. baumannii bacteremia were eligible for the study and matched with appropriate controls. The sepsis-related mortality rate was 34.8% among cases and 13.0% among controls, for an attributable mortality rate of 21.8% (adjusted odds ratio, 4.1 [95% confidence interval, 1.1-15.7]; P=.036). After the onset of bacteremia, cases and controls had a significantly different length of hospital stay (54.2 vs 34.1 days; P=.006), hospitalization cost (US$9,349 vs US$4,865; P=.001), and antibiotic therapy cost (US$2,257 vs US$1,610; P=.014). Thus, bacteremia due to MDR A. baumannii resulted in 13.4 days of additional hospitalization and US$3,758 of additional costs, compared with bacteremia due to non-MDR A. baumannii.

CONCLUSIONS

Patients with MDR A. baumannii bacteremia had a higher mortality rate and incurred greater medical costs than patients with non-MDR A. baumannii bacteremia.

Intermediate care at a community hospital as an alternative to prolonged general hospital care for elderly patients: a randomised controlled trial

Background

Demographic changes together with an increasing demand among older people for hospital beds and other health services make allocation of resources to the most efficient care level a vital issue. The aim of this trial was to study the efficacy of intermediate care at a community hospital compared to standard prolonged care at a general hospital.

Methods

In a randomised controlled trial 142 patients aged 60 or more admitted to a general hospital due to acute illness or exacerbation of a chronic disease 72 (intervention group) were randomised to intermediate care at a community hospital and 70 (general hospital group) to further general hospital care.

Results

In the intervention group 14 patients (19.4%) were readmitted for the same disease compared to 25 patients (35.7%) in the general hospital group (p = 0.03). After 26 weeks 18 (25.0%) patients in the intervention group were independent of community care compared to seven (10.0%) in the general hospital group (p = 0.02). There were an insignificant reduction in the number of deaths and an insignificant increase in the number of days with inward care in the intervention group. The number of patients admitted to long-term nursing homes from the intervention group was insignificantly higher than from the general hospital group.

Conclusion

Intermediate care at a community hospital significantly decreased the number of readmissions for the same disease to general hospital, and a significantly higher number of patients were independent of community care after 26 weeks of follow-up, without any increase in mortality and number of days in institutions.

Costs of an outbreak of meticillin-resistant Staphylococcus aureus

An outbreak of meticillin-resistant Staphylococcus aureus (MRSA) occurred in surgical and internal medicine units of a 1752-bed Finnish tertiary care hospital during 2003-2004. In order to analyse the costs of this 14-month outbreak, patients were categorized as follows: patients with MRSA infections; patients with MRSA colonization; patients exposed to MRSA but whose MRSA status remained inconclusive; and exposed patients who were negative for MRSA. We reviewed a sample of patients' charts to determine the types of clinical infections and interviewed staff about the practical implementation of control measures. The number of patients and patient-days involved in the outbreak were identified from the hospital's databases, with the administrative database supplying unit costs of work and materials. Loss of income due to closed beds was analysed. A total of 266 MRSA-positive patients (114 with infections and 152 colonized) and 797 patients exposed to MRSA were identified (11,744 contact isolation days). There were 1240 patients negative after screening (9880 contact isolation days). Total additional costs of MRSA were 386,062 euro (70% for screening and 25% for contact isolation). Costs due to meticillin resistance in treatment of MRSA infections were 16,000 euro. The income loss for this hospital due to closed beds was 1,183,808 euro. The high cost of MRSA screening underlines the importance of appropriate screening methods. Our model of analysing costs might be useful for other hospitals after adapting variables such as local control measures.

Projekt Partnerschaft – Universitätsklinik und Krankenhaus der Grund- und Regelversorgung

Over the last 20 years, urgently needed changes in the German health care system have forced hospitals to make a flexible adjustment to rising costs and the single handed, almost unmanageable dynamics of technical innovation in medicine. The partnership between the Salem Hospital and the Heidelberg University Hospital represents a pioneering management concept for the future. The alliance between a university surgical department with a basic peripheral hospital provides large advantages to patients, staff, hospitals and cost carriers.

Bigger, yes, but better? UnitedHealth Group's planned acquisition of Sierra Health leaves some wary of a trend that could disrupt service, payment

"Oh no. Not again." That was one CEO's reaction to UnitedHealth's deal for Sierra, Nevada's top health insurer. Recent takeovers, including the WellPoint/Anthem deal, have left bad memories. "Since then, the race downward on payments has been dramatic, so you can see why these kinds of mergers create a lot of anxiety", says Lawrence Matheis, left.

[Evaluation and performance-based budgeting of the Halle University Outpatient Clinics]

The Medical School of Halle has fundamentally restructured the university hospital's outpatient clinics. This required a detailed analysis of costs, income, and organization, as well as a prospective survey. In a representative month, more than 15,000 consultations were documented. Of all visits, 9% were part of clinical trials, and 19% part of the teaching and training of students and young doctors. 52% of all appointments were follow-up consultations. Operative and non-operative specialties as well as general and specialist consultations displayed considerable differences. Clinics with a high rate of follow-up consultations attended to fewer trial participants than others. In comparison to a district covered by statutory health insurance physicians the proportion of oncological diagnoses in the university hospital outpatient clinics was markedly higher. Costs for the different specialties' outpatient clinics varied significantly; a positive correlation was noted between the percentage of oncological diagnoses and secondary costs. The outpatient clinics' commitment to the outpatient care of cancer patients exceeds by far the scientific focus of the Medical School of Halle and contributes greatly to the provision of regional health care services. Within the scope of the project, the annual faculty allowances to the outpatient clinics were reduced by 25%. Since 2003, 60% of the remaining total allowances have been made available to the departments as an output-related grant. It was crucial to the acceptance of this budgeting that the expenses saved were dedicated to the support of young scientists, that the budgeting was comprehensible and that scientific achievements and in future also high quality teaching will continue to help regain some of the money "lost".

The effects of a prospective case payment system on hospital charges for total hip arthroplasty in Taiwan

We evaluate the effects of instituting prospective case payment system (PPS) system on total hip arthroplasty (THA) charges and compare our university hospital THA cost structure with comparable health care institutions in the United States. The study consisted of 5009 patients who received a primary THA in 24 hospitals between 1995 and 2001. After adjusting for inflation, the average total charge of THA for pre-PPS was 4762 US dollars and 4054 US dollars for post-PPS. The average cost for prostheses accounted for 61% of total costs at our hospital, as compared with the US studies ranging from 27% to 34%. As United States, PPS achieved the purpose of cost containment and changed practice patterns of orthopedic surgeons and hospital resource use in Taiwan.

Impact of health care information technology on hospital productivity growth: a survey in 17 acute university hospitals

The quantification of the added value of information technologies (IT) in the health sector is a major issue for decision-makers and health care professionals. This paper relates the application of an economic production function in hospitals with different integration levels of their clinical information systems (CIS). The study concerns 17 university hospitals within the Assistance Publique Hôpitaux de Paris group that were followed from 1998 to 2005. Using an extended Cobb-Douglas production function, yearly incomes (Y) were correlated with three inputs: capital (K), labor (L) and IT expenses (T). The results indicate that incomes are significantly and positively associated with the three input variables with elasticity coefficients: alpha, beta and gamma of 0.81, 0.17, and 0.09 that appear to be in the range of values found in secondary and tertiary sectors. The IT elasticity coefficient (gamma) is higher in the subgroup of 6 hospitals that integrate, or started to integrate, a complete CIS within the study period than in the 11 reference hospitals. In a general production function, hospital costs appear to be positively connected to the level of IT expenses, capital and labor. Calculations in two subgroups of AP-HP hospitals divided according to the importance of the IT integration level seem to indicate that the more the clinical information system is integrated, the more its influence is positive in hospital production. The results of this first survey are sufficiently encouraging to try to refine them (better granularity) and to spread them in time (over a longer period) and space (to other hospital structures).

Hospitalization rates and costs of care of patients with sickle-cell anemia in the state of Maryland in the era of hydroxyurea

The multicenter study of hydroxyurea (MSH) in sickle-cell anemia (SCA) demonstrated that patients treated with hydroxyurea (HU) had a 44% decrease in hospitalizations when compared with those taking placebo. A subsequent study looking at the cost-effectiveness of HU showed that decreased hospitalizations for painful crisis accounted for the majority of cost savings in those taking HU. The purpose of this study was to examine whether the expected decrease in hospital utilization occurred after the approval of HU in Maryland. We used data collected by the Maryland Health Services Cost Review Commission to obtain SCA discharge data for Maryland from FY1995 through FY2003. We also reviewed the inpatient and outpatient charts of all adults with SCA admitted to a large university hospital during 2003. Hospitalization rates for adults with SCA in Maryland have increased significantly since approval of HU. While the total costs of inpatient care in Maryland are estimated to have increased by 31% above inflation from 1995 to 2003, the costs of inpatient care for adult SCA patients has increased by almost 60% above inflation. By comparison, there has been no significant increase in the pediatric hospitalization rate. We found that 70% of patients in one hospital who were appropriate candidates for HU were not taking the medication. Hospital utilization among adults with SCA has increased significantly. There are likely many factors that have played a role in this increase. One factor that appears to be involved is the underutilization of HU.

Trends in diagnostic imaging utilization in a university hospital in Turkey

OBJECTIVES

The aim of this study was to evaluate utilization trends of the diagnostic imaging examinations during the past decade in a university hospital in Turkey.

METHODS

Patient registries of a university hospital were used for the years 1995 and 2003. The data set consisted of patients' admissions, social security status, and diagnostic imaging tests.

RESULTS

When compared with 1995 data, the total number of diagnostic imaging examinations and patient admissions increased 65.9 percent and 81.6 percent, respectively, in the year 2003. Although the total number of diagnostic imaging tests decreased 9.0 percent, there was a 145.4 percent increase in magnetic resonance imaging (MRI) examinations. Nevertheless, radiological diagnostic procedures consisted of 12.8 percent of the total hospital revenues in 1995 and 9.4 percent in 2003.

CONCLUSIONS

This study shows that approximately one third of inpatients underwent MRI and computed tomography examinations in 2003. The utilization rates of diagnostic imaging procedures, especially new technologies, need to be considered carefully with respect to appropriateness of procedures and planning of services.

[Effects of self-adapting G-DRG system 2004 to 2006 on in-patient services payment in pediatric hematology and oncology patients of a university hospital]

BACKGROUND

Reimbursement of inpatient treatment by daily constant charges is replaced by diagnosis- and procedure-related group system (G-DRG) in German acute care hospitals excerpt for psychiatry since 2004. Re-designs of G-DRG system were undertaken in 2005 and 2006. Parallel to implementation requirement- and resource-based self-adjustment of this new reimbursement system has been established by law. Adjustments performed in 2005 and 2006 are examined with respect to their effect on reimbursements in treatments of children with oncological, hematological, and immunological diseases.

PATIENTS AND METHODS

An unchanged population of 349 patients associated with 1,731 inpatient stays of a Clinic of Pediatric Oncology, Hematology, and Immunology in 2004 was analyzed by methods and means of G-DRG systems 2004, 2005, and 2006. DRGs and additional payments for drugs and procedures eligible for all and/or individual hospitals were calculated.

RESULTS

G-DRG system 2005 resulted in overall reimbursement loss of 3.77 % compared to G-DRG 2004. G-DRG 2006 leads to slightly improved overall reimbursements compared to G-DRG 2005 by increasing DRG-based revenues. G-DRG 2006 effects 2.40 % reduction in overall reimbursement compared to G-DRG 2004. This loss includes ameliorating effects of additional payments for drugs and blood products already. Despite introduction of additional payments especially designed for children and teenagers in 2006, additional payment volume is decreased by 21.71 % from 2005 to 2006. G-DRG 2006 yields over-all reimbursement losses of 1.45 % in comparison to G-DRG 2004. Overall reimbursements include introduced additional payments for drugs and blood products. (Reimbursements resulting out of DRG payment alone drop by 14.73 % from 2004 to 2005, and increase by 3.26 % from 2005 to 2006 (2004 vs. 2006 11.95 %). Introduction of additional payments for drugs and blood products on a Germany-wide basis introduced in 2005 dampens DRG-based reimbursement losses. Despite introduction of dosage intervals specifically designed for children and adolescents in 2006, reimbursement of additional payments for drugs and blood products decrease by 21.71 % from 2005 to 2006. An important revenue-balancing function is attributed to additional charges individual for each hospital according to Par. 6 Section 2 (New diagnostic and therapeutic methods) and Section 2 a KHEntgG (German Hospital Reimbursement Law) with respect to financing tertiary care focusses. If possible to attain, those charges may partially equalize losses. Including these additional charges per individual hospital balance of summarized additional charges is -3.89 % from 2005 to 2006. However, fraction of additional payments on total reimbursements increases from 0.64 % in 2004 to 11.98 % in 2005, and 11.24 % in 2006, respectively.

CONCLUSIONS

The G-DRG system in its versions 2005 and 2006 results in lowering overall reimbursements of a pediatric hematology, oncology, and immunology department compared to initial status in 2004. The growing chargeability of additional payments ameliorate this effect.

[What's the point of cost management in clinical laboratories?]

Clinical laboratories need to know and manage the costs of laboratory tests, because they need financial data (1) to estimate costs per patient, (2) to request a budget to buy equipment, and (3) to improve their work; however, less than 40% laboratories practice cost management. In 2002, Shinshu University Hospital began to assess the costs of laboratory tests, but it was difficult to evaluate the quality of our cost management because there are few data and papers about the costs of laboratory tests in Japan. In this article, we practiced cost analysis using Shinshu University Hospital's data for 3 years (2002-2004), and studied the features of laboratory test costs and the problems of laboratory cost management. As a result, we listed 7 points to check cost management in clinical laboratories. This check list was established using only one data from our hospital. So, we suggest the benchmarking laboratory test costs between laboratories of the same type of hospitals or various laboratories.

Cost and Reimbursement for Three Fibroid Treatments: Abdominal Hysterectomy, Abdominal Myomectomy, and Uterine Fibroid Embolization

PURPOSE

To compare costs and reimbursements for three different treatments for uterine fibroids.

METHODS

Costs and reimbursements were collected and analyzed from the Thomas Jefferson University Hospital decision support database from 540 women who underwent abdominal hysterectomy (n = 299), abdominal myomectomy (n = 105), or uterine fibroid embolization (UFE) (n = 136) for uterine fibroids during 2000-2002. We used the chi-square test and ANOVA, followed by Fisher's Least Significant Difference test, for statistical analysis.

RESULTS

The mean total hospital cost (US dollar) for UFE was 2,707 dollars, which was significantly less than for hysterectomy (5,707 dollars) or myomectomy (5,676 dollars) (p < 0.05). The mean hospital net income (hospital net reimbursement minus total hospital cost) for UFE was 57 dollars, which was significantly greater than for hysterectomy (-572 dollars) or myomectomy (-715 dollars) (p < 0.05). The mean professional (physician) reimbursements for UFE, hysterectomy, and myomectomy were 1,306 dollars, 979 dollars, and 1,078 dollars, respectively.

CONCLUSION

UFE has lower hospital costs and greater hospital net income than abdominal hysterectomy or abdominal myomectomy for treating uterine fibroids. UFE may be more financially advantageous than hysterectomy or myomectomy for the insurer, hospital, and health care system. Costs and reimbursements may vary amongst different hospitals and regions.

Cesarean delivery on maternal request: wise use of finite resources? A view from the trenches

Cesarean section rates are rising in the United States and were at an all time high of 29 percent in 2004. Within this context, the issue of cesarean section on maternal request has been described as being part of a "perfect storm" of medical, legal and personal choice issues, and the lack of an opposing view. An increasing cesarean section rate adds an economic burden on already highly stressed medical systems. There is an incremental cost of cesarean section compared to vaginal delivery. The issue of cost must also be considered more broadly. Rising cesarean section rates are associated with a longer length of stay and a higher occupancy rate. This high occupancy rate leads to the diversion of critical care obstetric transports and has dramatically reduced patient satisfaction. These diversions, and the resultant inability to provide needed care to pregnant women, represent a profound societal cost. These critical care diversions and reduced patient satisfaction also negatively impact a health care institution's financial bottom line and competitiveness. The impact of a rising cesarean section rate on both short and long-term maternal and neonatal complications, and their associated costs, must also be taken into account. The incidence of placenta accreta is increasing in conjunction with the rising cesarean section rate. The added costs associated with this complication (MRI, Interventional Radiology, transfusion, hysterectomy, and intensive care admission) can be prohibitive. It has also been demonstrated that infants born by scheduled cesarean delivery are more likely to require advanced nursery support (with all its associated expense) than infants born to mothers attempting vaginal delivery. The practice of maternal request cesarean section, with limited good data and obvious inherent risk and expense, is increasing in the USA. Patient autonomy and a woman's right to choose her mode of delivery should be respected. However, in our opinion, based on the current evidence regarding cesarean delivery on maternal request, promotion of primary cesarean section on request as a standard of care or as a mandated part of patient counseling for delivery will result in a highly questionable use of finite resources. As of 2004, 46 million Americans did not even have basic health insurance. It is critical that we not allow ourselves to be dragged into the eye of a "perfect storm." This conference is an important step in the rational and objective analysis of this issue.

Financial and operational impact of a direct-from-PACU discharge pathway for laparoscopic cholecystectomy patients

BACKGROUND

We assessed the operational and financial impact of discharging laparoscopic cholecystectomy (LC) patients directly from the postanesthetic care unit (PACU) in comparison with post-transfer discharge from a hospital bed in a busy academic hospital.

METHODS

We retrospectively compared 6 months of performance (bed utilization; recovery room and hospital length of stay; complications; readmissions; hospital costs, revenue, and margin) after implementation of PACU discharges (case patients) to the corresponding 6 months in the prior year (control patients).

RESULTS

After implementation, 66% of LC case patients were discharged on the day of surgery, compared with 29% in the control group (P < .05). Eighty percent of the day-of-surgery discharges were directly from the PACU. Shifting to PACU discharge saved 1 in-hospital bed transfer and 1 bed-day for each PACU discharge. Recovery room length of stay for PACU discharge patients was 26% longer than for hospital discharge patients (P = NS). Average hospital length of stay for all patients discharged on the day of surgery was 3.2 hours shorter (P < .05) for case patients (80% PACU discharge) than for control patients. There were no readmissions in the PACU discharge group and no difference in complications. While costs, revenue, and net margin for PACU discharge patients were reduced by 40% to 50% (P < .02) relative to floor discharge patients, the hospital's net margin for the combined case patient group was preserved relative to the control group.

CONCLUSIONS

PACU discharge of LC patients significantly reduces bed utilization, decreases in-hospital transfers, and allows congested hospitals to better accommodate patient care needs and generate additional revenue.

Economic Assessment of the General Thoracic Surgery Outpatient Service

BACKGROUND

One aspect of the definition of institutional value for any program is based on the return on investment (ROI) for that program. Program requests for future resource allocations depend, in part, on that information. The purpose of this project was to determine the ROI for initial outpatient visits only for our General Thoracic Surgery (GTS) program.

METHODS

The number of GTS outpatient visits, studies, and requested consultations ordered by GTS surgeons only was determined after review of the hospital database and office records for the calendar year 2003. Only charges associated with the initial outpatient visits (no inpatient or physician charges) were included. Charges were based on hospital finance department data. The ROI for GTS outpatient services was calculated using total hospital costs and hospital collections.

RESULTS

There were 689 initial outpatient GTS visits. The majority were for lung cancer (48%), benign lung diseases (21%), and esophageal diseases (14%). Total outpatient charges were 1.25M dollars and by disease process were lung cancer (644,000 dollars), benign lung disease (90,000 dollars), esophageal disease (159,000 dollars), and other (357,000 dollars). The most significant hospital charges were the following: radiology (850,000 dollars), laboratory studies (82,000 dollars), gastrointestinal medicine studies (59,000 dollars), and cardiology (42,000 dollars). Total operational costs for the GTS clinic were 415,000 dollars and hospital collections were 513,000 dollars, yielding an ROI of 98,000 dollars or an operating margin of 19%.

CONCLUSIONS

An operating margin of 19% for GTS outpatient services is better than most Fortune 500 companies. Acquisition of this type of information by GTS surgeons may be helpful for future program development and institutional resource allocation.

Costs and effects in lumbar spinal fusion. A follow-up study in 136 consecutive patients with chronic low back pain

Although cost-effectiveness is becoming the foremost evaluative criterion within health service management of spine surgery, scientific knowledge about cost-patterns and cost-effectiveness is limited. The aims of this study were (1) to establish an activity-based method for costing at the patient-level, (2) to investigate the correlation between costs and effects, (3) to investigate the influence of selected patient characteristics on cost-effectiveness and, (4) to investigate the incremental cost-effectiveness ratio of (a) posterior instrumentation and (b) intervertebral anterior support in lumbar spinal fusion. We hypothesized a positive correlation between costs and effects, that determinants of effects would also determine cost-effectiveness, and that posterolateral instrumentation and anterior intervertebral support are cost-effective adjuncts in posterolateral lumbar fusion. A cohort of 136 consecutive patients with chronic low back pain, who were surgically treated from January 2001 through January 2003, was followed until 2 years postoperatively. Operations took place at University Hospital of Aarhus and all patients had either (1) non-instrumented posterolateral lumbar spinal fusion, (2) instrumented posterolateral lumbar spinal fusion, or (3) instrumented posterolateral lumbar spinal fusion + anterior intervertebral support. Analysis of costs was performed at the patient-level, from an administrator's perspective, by means of Activity-Based-Costing. Clinical effects were measured by means of the Dallas Pain Questionnaire and the Low Back Pain Rating Scale at baseline and 2 years postoperatively. Regression models were used to reveal determinants for costs and effects. Costs and effects were analyzed as a net-benefit measure to reveal determinants for cost-effectiveness, and finally, adjusted analysis (for non-random allocation of patients) was performed in order to reveal the incremental cost-effectiveness ratios of (a) posterior instrumentation and (b) anterior support. The costs of non-instrumented posterolateral spinal fusion were estimated at DKK 88,285(95% CI 81,369;95,546), instrumented posterolateral spinal fusion at DKK 94,396(95% CI 89,865;99,574) and instrumented posterolateral lumbar spinal fusion + anterior intervertebral support at DKK 120,759(95% CI 111,981;133,738). The net-benefit of the regimens was significantly affected by smoking and functional disability in psychosocial life areas. Multi-level fusion and surgical technique significantly affected the net-benefit as well. Surprisingly, no correlation was found between treatment costs and treatment effects. Incremental analysis suggested that the probability of posterior instrumentation being cost-effective was limited, whereas the probability of anterior intervertebral support being cost-effective escalates as willingness-to-pay per effect unit increases. This study reveals useful and hitherto unknown information both about cost-patterns at the patient-level and determinants of cost-effectiveness. The overall conclusion of the present investigation is a recommendation to focus further on determinants of cost-effectiveness. For example, patient characteristics that are modifiable at a relatively low expense may have greater influence on cost-effectiveness than the surgical technique itself--at least from an administrator's perspective.

Direct patient treatment costs in the Allergology Service of a University Hospital

Health resources are limited and consequently real cost generators must be identified to optimize resources. In the present article, we describe the structure of the Allergy Unit of the University Hospital Virgen de la Arrixaca in Murcia (Spain), the health area in which allergic patients are attended, and the final healthcare products generated. Based on the 2004-2005 budget, variable costing was used to calculate the costs of the healthcare products generated (first visits, subsequent visits, and diverse laboratory tests) by two of the three homogeneous functional groups (HFG), i.e., HFG of the ambulatory service and HFG of complementary tests. The following conclusions can be drawn: 1) the current system of variable costing provides information, which should be useful to health professionals; 2) the real cost generators in the microcosm of daily clinical practice should be identified to allow resource reallocation; 3) the costing system used enables modifications to be made that allow decision making on optimal use of the budget; 4) clinical management and complementary tests should go hand in hand with a view to optimizing resources.

Factors influencing the costs of emergency medical admissions to an Irish teaching hospital

This study examined whether there is a relationship between coded diseases at the time of hospital discharge and costs of hospital re-admission. We carried out a systematic review of data relating to emergency medical patients admitted to St. James' Hospital in Dublin between 1 January 2002 and 31 October 2004. Data on discharges from hospital were analyzed as recorded in the hospital in-patient enquiry (HIPE) system. Of 15,876 episodes recorded among 11,201 patients admitted the number of re-admissions numbered up to 43. Age, year of admission, and frequency of admission were factors associated with increased hospital costs. HIPE coding at first discharge predicted increased costs: codes related to heart failure, pneumonia, stroke, diabetes, malignancy, psychiatric, and anaemia-related codes. Clinical coding using the HIPE database thus strongly predicted hospital costs.