[Costs of health care resources of ambulatory-care patients diagnosed with Alzheimer's disease in Spain]

BACKGROUND

The annual consumption and costs of the health care resources used by ambulatory Alzheimer's disease patients were estimated. Patients were classified according to the degree of severity of the disease using Folstein's Mini Mental State Examination scale. The sociodemographic characteristics of both patients and their careers were described.

PATIENTS AND METHODS

Patients with an established diagnosis of Alzheimer's disease according to NINCDS/ADRDA criteria were included in the study. Information on the use of health and non-health care resources consumed during the last 12 months was recorded. The following scales were administered: MMSE, Global Deterioration Scale, Rapid Disability Rating Scale and Hachinski's scale modified by Rosen. Finally, the time dedicated by careers to look after the Alzheimer's disease patients was recorded.

RESULTS

A total of 337 patients were considered to be valid for the analysis with an average of 72 (8.4) years and with an average duration of the disease of 48.3 (35.7) months. The average annual cost per patient was 3,194,664 ptas. The average cost per patient in the group with MMSE > 18 was 2,119,889 ptas; 2,723,159 ptas. in those with MMSE 12-18 and 3,676,707 ptas. in the MMSE < 12 group.

CONCLUSIONS

In patients with Alzheimer's disease an increase in cost directly related to functional cognition state was observed. The most important cost component was that imputed to value time dedicated by principal career.

Estimating time and travel costs incurred in clinic based screening: flexible sigmoidoscopy screening for colorectal cancer

OBJECTIVES

To identify the characteristics of mode of travel to screening clinics; to estimate the time and travel costs incurred in attending; to investigate whether such costs are likely to bias screening compliance.

SETTING

Twelve centres in the trial of flexible sigmoidoscopy screening for colorectal cancer, drawn from across Great Britain.

METHOD

Analysis of 3525 questionnaires completed by screening subjects while attending clinics. Information supplied included sociodemographic characteristics, modes of travel, expenses, activities foregone owing to attendance, and details of companions.

RESULTS

More than 80% of subjects arrived at the clinics by car, and about two thirds were accompanied. On average, the clinic visit involved a 14.4 mile (22.8 km) round trip, requiring 130 minutes. Mean travel costs amounted to 6.10 Pounds per subject. The mean gross direct non-medical and indirect cost per subject amounted to 16.90 Pounds, and the mean overall gross cost per attendance was 22.40 Pounds. Compared with the Great Britain population as a whole, non-manual classes were more strongly represented, and the self employed less strongly represented, among the attendees.

CONCLUSIONS

In relation to direct medical costs, the time and travel costs of clinic based screening can be substantial, may influence the overall cost effectiveness of a screening programme, and may deter potential subjects from attending.

Relocation for treatment for leukaemia: a description of need

As rural Queenslanders are isolated geographically due to dispersed population patterns, they are often required to travel long distances to access services, especially services of a specialist nature. The distress of this relocation for treatment is particularly intensified for patients with leukaemia and associated haematological disorders and their carers, as they must often relocate for long periods of time and face invasive and demanding treatments away from the comfort of their own homes. Because such treatments are now highly technical and specialised, even patients from more urbanised areas are also required to relocate for prolonged specialist treatment not available locally. Consequently, for many rural and urban patients with leukaemia, relocation for specialist treatment is a major concern. This discussion presents findings from recent research on a Queensland Government initiative, the Patient Transit Assistance Scheme, designed to address this concern. These findings indicate a high level of hardship for these patients and their families who must travel long distances, often relocate for long periods, and endure additional financial burdens at a time when a majority are dependent on government assistance.

[The costs of treating HIV-infected children in Abidjan, Ivory Coast, 1996-1997]

Little is known about the costs of treating HIV-infected children in Africa. However, this is one of the factors that must be taken into account when assessing the cost-effectiveness of strategies aimed at reducing the transmission of HIV from mother to child. The aim of this study was to estimate the direct costs of the treatment of African children born to HIV-infected mothers and the additional costs of treating those children who are themselves infected with the virus. We assessed the direct costs of care for a sample of children born in 1996 to HIV-positive mothers participating in a clinical trial to evaluate the efficacy of administering a short course of zidovudine to the mother in the peri-partum period, in Abidjan, Ivory Coast (DITRAME ANRS 049a). We systematically reviewed the medical records of these children and recorded drug prescriptions, clinical investigations, consultations with medical specialists, hospital admissions and transportation costs during their first year of life. This study included 78 children, 15 of whom were HIV-positive. The mean cost of treatment was 1,671 FF (254 Euros) per child-year for infected children, 709 FF (108 Euros) more than the mean cost of treatment for HIV-negative children born to HIV-positive mothers. Thus, HIV infection resulted in a 74% increase in treatment costs. The mean cost of a drug prescription was 50 FF (7.6 Euros), and could have been halved if only generic drugs had been prescribed. This study was limited to the direct costs of pediatric HIV infection and did not take into account the cost of health service provision in Ivory Coast or the indirect costs for the family. These results were obtained in the context of a prospective clinical trial within a system providing free and unlimited access to health care. In a city where the mean salary of a civil servant is 900 FF (137 Euros) per month, the expenditure necessary to pay for the basic care of one HIV-infected child is high. Health-care services in sub-Saharan Africa should make more use of generic drugs and pediatric HIV infection provides a clear example of the benefits to be obtained by such a rational strategy for the use of scarce health resources.

Appropriateness of ambulance transportation to a suburban pediatric emergency department

OBJECTIVE

To assess the appropriateness of ambulance use in patients presenting to a pediatric emergency department (ED), with regard to both medical necessity and insurance status.

METHODS

The authors conducted a one-year retrospective chart analysis of all patients (age range 2 weeks to 19 years) who were transported via ambulance in 1994 to a suburban children's hospital ED. ED records of all patients who arrived by ambulance were abstracted for demographic data, type of insurance, chief complaint, medical interventions, discharge diagnosis, and disposition. Ambulance transportation was deemed unnecessary unless the medical record revealed any of the following criteria: 1) requiring cardiopulmonary resuscitation, 2) respiratory distress, 3) altered mental status or seizure, 4) immobilization, 5) inability to walk, 6) admission to intensive care, 7) ambulance recommended by medical personnel, 8) motor vehicle collision, or 9) parents not on scene.

RESULTS

43% of the ambulance patients were insured by Medicaid, compared with 29% of the overall ED population. Thus, Medicaid patients were significantly more likely to use ambulance transportation than were patients with commercial insurance (p<0.001). 28% of patients who arrived by ambulance were judged to have used the ambulance transportation unnecessarily. Of the unnecessary transports, 60% were insured by Medicaid. Thus, Medicaid patients were significantly more likely to have used ambulance transportation unnecessarily (p<0.001). The most common reason for appropriate ambulance use was seizure activity; the most common reason for inappropriate use was fever.

CONCLUSION

Inappropriate use of ambulance transportation is common in this pediatric population, with Medicaid patients accounting for a significant majority of the misuse.

Cost implications of regionalizing open heart surgery units

This study calculated the potential change in costs from regionalizing open heart surgery units in a geographic network of the Department of Veterans Affairs (VA). It used data from the VA's cost accounting system, and the authors conducted a sensitivity analysis. Under consolidation, savings from closing an open heart surgery unit would be partially offset by the costs of treating nonemergency cases at other VAs, treating emergency cases at non-VA hospitals, and transporting patients to regionalized facilities. Nevertheless, the potential savings from consolidation would exceed $3 million, or 18% of the network's costs of treating open heart surgery patients.

Cost-minimization analysis: A follow-up study of a telemedicine program

OBJECTIVE

To present the follow-up findings to a cost-benefit analysis of telemedicine subspecialty services provided between the Powhatan Correctional Center (PCC) of the Virginia Department of Corrections and the Medical College of Virginia Campus of Virginia Commonwealth University (MCV Campus).

METHODS

Costs included those of operating the telemedicine system, transportation, litigation avoidance, and the medical care itself.

RESULTS

Over a 12-month study period, the total number of consults completed through telemedicine was 290. The cost per visit of treating inmates at the MCV Campus clinics was $401. The cost per visit of treating inmates at PCC via telemedicine was $387, a net saving of $14 per visit with the use of telemedicine.

CONCLUSION

As a result of implementing telemedicine, the Department of Corrections for the State of Virginia was able to achieve a cost saving of $14 per visit. Nonmonetary cost savings, such as greater security and increased access to care, should be considered a net benefit as well.

Quality improvement for a hospital patient transportation system

This article describes a method for organizing and staffing a hospitalwide patient transportation system in such a way as to minimize patient waiting times. The method stems from a quality improvement project and includes a centralized communication system, a queuing model to determine staffing requirements, and a computerized data collection and monitoring system. A case study demonstrates improvements in waiting times, costs, and customer satisfaction.

Use of EMS for seriously ill children in the office: a survey of primary care physicians

OBJECTIVES

To describe how primary care physicians (PCPs) transport seriously ill children from their offices to emergency departments (EDs).

METHODS

The authors conducted a mail survey of PCPs in upstate New York.

RESULTS

The response rate was 60% (119/199). Sixty-six percent (79/119) of the physicians had transferred at least one child from their office to an ED via EMS. Forty-five percent (53/119) had encountered a case of suspected epiglottitis in the office. EMS was used to send 45% (24/53) of suspected epiglottitis cases to the ED, while 40% (21/53) transferred children with possible epiglottitis via family auto. Similarly, the family's auto was used to transport 26% (6/23) of the patients with suspected foreign body aspiration, 46% (32/70) with severe asthma, 59% (30/51) with severe dehydration, and 37% (14/38) with suspected meningococcemia. In contrast, the family's auto was never used for patients with active seizures. The physicians denied that they would call EMS more often if transport time were shorter (58%) or if costs were less (64%). Sixty percent of the PCPs were not sure whether EMS personnel are skilled in pediatric emergencies.

CONCLUSION

The PCPs often failed to call EMS for seriously ill children seen in the office and, instead, used the family's auto for emergency transportation. In this survey, transport time and cost were not barriers to use of EMS. The physicians expressed a lack of confidence in EMS providers' pediatric skills. Targeting educational programs to PCPs that highlight 1) the availability, training, and skill of EMS personnel and 2) the medicolegal risks of family transportation may result in more appropriate use of EMS for children.

Intrahospital transport of critically ill patients

BACKGROUND

This review on the current literature of the intrahospital transport of critically ill patients addresses type and incidence of adverse effects, risk factors and risk assessment, and the available information on efficiency and cost-effectiveness of transferring such patients for diagnostic or therapeutic interventions within hospital. Methods and guidelines to prevent or reduce potential hazards and complications are provided.

METHODS

A Medline search was performed using the terms 'critical illness', 'transport of patients', 'patient transfer', 'critical care', 'monitoring' and 'intrahospital transport', and all information concerning the intrahospital transport of patients was considered.

RESULTS

Adverse effects may occur in up to 70% of transports. They include a change in heart rate, arterial hypotension and hypertension, increased intracranial pressure, arrhythmias, cardiac arrest and a change in respiratory rate, hypocapnia and hypercapnia, and significant hypoxaemia. No transport-related deaths have been reported. In up to one-third of cases mishaps during transport were equipment related. A long-term deterioration of respiratory function was observed in 12% of cases. Patient-related risk indicators were found to be a high Therapeutic Intervention Severity Score, mechanical ventilation, ventilation with positive end-expiratory pressure and high injury severity score. Patients' age, duration of transport, destination of transport, Acute Physiology and Chronic Health Evaluation II score, personnel accompanying the patient and other factors were not found to correlate with an increased rate of complications. Transports for diagnostic procedures resulted in a change in patient management in 40-50% of cases, indicating a good risk:benefit ratio.

CONCLUSIONS

To prevent adverse effects of intrahospital transports, guidelines concerning the organization of transports, the personnel, equipment and monitoring should be followed. In particular, the presence of a critical care physician during transport, proper equipment to monitor vital functions and to treat such disturbances immediately, and close control of the patient's ventilation appear to be of major importance. It appears useful to use specifically constructed carts including standard intensive care unit ventilators in a selected group of patients. To further reduce the rate of inadvertent mishaps resulting from transports, alternative diagnostic modalities or techniques and performing surgical procedures in the intensive care unit should be considered.

Inappropriate use of emergency medical services transport: comparison of provider and patient perspectives

OBJECTIVES

To determine the extent of inappropriate ambulance use from the perspectives of both emergency medical services (EMS) providers and patients utilizing EMS transport, assess level of agreement, and identify variables associated with inappropriate ambulance use.

METHODS

A prospective cross-sectional study was done of a consecutive sample of patients arriving by ambulance during the month of February 1997 at an urban university hospital ED. EMS providers and patients completed a survey with questions regarding their perceptions of whether the need for ambulance transport was an emergency or a nonemergency. Patient demographic information and availability of alternate means of transportation to the hospital were also evaluated.

RESULTS

Eight hundred eighty-seven patients were included in the study. EMS providers thought that 501 patient transports were appropriate and represented true emergencies, whereas 689 patients believed their medical problems were true emergencies. A significant number of patients (n=415, 47%) had access to alternative transportation to the hospital. Blunt traumatic injury and altered mental status were the most common reasons for EMS transport. Patient characteristics significantly associated with EMS provider perception of a true emergency were male gender, age >51 years, higher education, chest pain/cardiac complaints, shortness of breath/respiratory complaints, and Medicare insurance. Characteristics significantly associated with patients who perceived themselves to have true emergencies were black ethnicity, higher education, shortness of breath/respiratory complaints, and Medicare insurance. There was 75% agreement between EMS providers and patients on appropriateness of ambulance transport (kappa=0.84).

CONCLUSION

Inappropriate ambulance use is a significant problem from both EMS provider and patient perspectives. Certain patient characteristics are associated with a higher probability of appropriate and inappropriate uses of EMS transport. A large number of patients transported by ambulance have alternative means of transportation but elect not to use them.

Active detection of chronic obstructive pulmonary disease and asthma in the general population. Results and economic consequences of the DIMCA program

The aim of this prospective study was to detect subjects in the general population with objective signs of chronic obstructive pulmonary disease (COPD) or asthma at an early stage. This was done by means of a two-stage protocol involving screening and a subsequent 2-yr monitoring of all subjects with positive results of screening. The study was done in 10 general practices located in the eastern part of the Netherlands. A random sample was taken from the general population aged 25 to 70 yr. All known COPD and asthma patients were excluded. A total of 1,749 subjects met the inclusion criteria: 1,155 subjects (66%) agreed to participate in the screening stage of the study. A total of 604 subjects (52.3%) showed symptoms or objective signs of COPD or asthma during the screening and were considered "positive." Of those with positive screening results, 384 subjects (64%) agreed to participate in the second, 2-yr monitoring stage of the study. The costs involved in detection were calculated for three different scenarios, as follows: (1) The detection of subjects with persistently decreased lung function or an increased level of bronchial hyperresponsiveness (BHR) during 6 mo of monitoring; (2) Scenario 1 plus the detection of subjects with a rapid decline in lung function with signs of BHR during 12 mo of monitoring; (3) Scenario 2 plus the detection of subjects with a moderate increase in the decline in lung function or signs of BHR during 24 mo of monitoring. The costs of lung function assessments, organization, transportation, and patient time were included. The costs were converted to United States dollars on the basis of purchasing power (1 United States dollar = 2.08 Netherlands guilders). During the second stage, 252 subjects were detected with objective signs of COPD or asthma at an early stage. Smoking status as a screening criterion was neither sensitive nor specific. Because there was no evidence of biased recruitment or selection during the program, the proportions of subjects found to have objective signs of COPD or asthma at an early stage could be extrapolated to the general population. Of the general population, 7.7% showed persistently reduced lung function or increased BHR. Another 12.5 % of the general population showed a rapid decline in lung function (> 80 ml/yr) in combination with signs of BHR, and a further 19.4% of the general population showed mild objective signs of COPD or asthma. The average costs per detected case varied from US$953 (Scenario 1) to US$469 (Scenario 3). In conclusion, detection of COPD or asthma at an early stage by means of a two-stage protocol was feasible at relatively little expense in comparison with other mass screening programs. Persistently decreased lung function or a rapid decline in lung function (Scenario 2) was observed in approximately 20% of the general adult population.

The patient level cost of asthma in adults in south central Ontario. Pharmacy Medication Monitoring Program Advisory Board

OBJECTIVE

To assess the annual cost of asthma per adult patient from the perspectives of society, the Ontario Ministry of Health and the patient.

DESIGN

Prospective cost of illness evaluation.

SETTING

Ambulatory out-patients residing in southern central Ontario.

POPULATION STUDIED

Nine hundred and forty patients with asthma over 15 years of age studied between May 1995 and April 1996.

OUTCOME MEASURES

Direct costs, such as respiratory-related visits to general/family practitioners, respiratory specialists, emergency rooms, hospital admissions, laboratory tests, prescription medications, dispensing fees, devices and out-of-pocket expenses, were calculated. Indirect costs, such as absences from work or usual activities, and travel and waiting time, were studied.

MAIN RESULTS

Unadjusted annual costs were $2,550 per patient. Hospitalizations and medications each accounted for 22% of the total cost and indirect costs 50% of the total costs. More severe disease, older age, smoking, drug plan availability and retirement were significant predictors of costs. Annual costs per patient varied from $1,255 (95% CI $1,061 to $1,485) in young nonsmokers with no drug plan and mild disease to $5,032 (95% CI $4,347 to $5,825) in older smokers with drug plans and severe disease. Clinically important reductions in the quality of life occurred with increasing severity.

CONCLUSIONS

Interventions aimed at reducing productivity losses, admissions to hospital and medication costs may result in savings to society, the provincial government and the patient. The quality of policy and allocation decisions may be enhanced by cost of illness estimates that are comprehensive, precise and incorporate multiple perspectives.

Simulation methodology for estimating financial effects of telemedicine in West Virginia

Understanding the full financial effects of telemedicine systems on payers, providers, and patients has been hampered by the lack of data from full-fidelity systems operating at a steady state. The vast majority of telemedicine systems in the United States have yet to achieve their full potential in serving their target populations and are operating well below capacity. The purposes of this research are two-fold: (1) to develop a methodology that compensates for the limited availability of empirical data on the financial effects of telemedicine; and (2) to test this methodology in a comprehensive telemedicine system in West Virginia. The proposed methodology utilizes simulation modeling techniques for evaluating the financial performance of a mature telemedicine system. It is particularly suitable for analyzing large, complex systems that have not yet achieved steady-state operation. Although complex, the methodology can be described simply as consisting of two major steps. The first is the identification of all of the relevant variables and parameters for modeling. The second consists of simulating "real world" decision situations involving all relevant variables and parameters. The relation among the variables and parameters are described in terms of mathematical equations. The ability of the researcher to estimate the financial effects of a given telemedicine system is a function of the extent to which the resulting model approximates conditions of the real world; i.e., the fit between model and reality.

A critical analysis of on-scene helicopter transport on survival in a statewide trauma system

BACKGROUND

Recently, questions have been raised regarding the effectiveness of helicopters in trauma care. We conducted a retrospective study to evaluate the effect of on-scene helicopter transport on survival after trauma in a statewide trauma system.

METHODS

Data were obtained from a statewide trauma registry of 162,730 patients treated at 28 accredited trauma centers. Patients transported from the scene by helicopter (15,938) were compared with those transported by ground with advanced life support (ALS) (6,473). Interhospital transfers and transports without ALS were excluded. Statistical analysis was performed using one-way analysis of variance and logistic regression.

RESULTS

Patients transported by helicopter were significantly (p < 0.01) younger, were more seriously injured, and had lower blood pressure. They were also more likely to be male and to have systolic blood pressure < 90 mm Hg. Logistic regression analysis revealed that when adjusting for other risk factors, transportation by helicopter did not affect the estimated odds of survival.

CONCLUSION

A reappraisal of the cost-effectiveness of helicopter triage and transport criteria, when access to ground ALS squads is available, may be warranted.

Paediatric echocardiography by telemedicine--nine years' experience

In 1987 we established a realtime echocardiography service by telemedicine from the paediatric cardiology department of a tertiary-care hospital in Halifax. The service was initially provided to single regional hospital but was expanded to six regional hospitals in the three Canadian Maritime Provinces. The system used a dial-up broadband video-transmission service provided by the telephone companies. Records of all transmissions were kept prospectively and reviewed to January 1997. A total of 324 transmissions were made. During 1995-96 there were 135 studies: 69 (51%) were urgent examinations of newborn children and 30 (22%) were urgent examinations of older children; repeat studies and postoperative checks (usually for pericardial effusion) accounted for the other 36 studies (27%). The images were of broadcast quality except in five cases where problems with transmission or poor sedation occurred. A comparison of 26 transmitted studies with repeat, 'in person' studies showed no important discrepancies in diagnosis. During the two-year study period, the cost of the network (equipment leasing costs and telecommunications costs) was C$90,000. Use of the telemedicine network saved unnecessary patient transfer in 31 cases. The cost of the transportation avoided was C$100,000-C$118,000. This review confirms our preliminary findings that broadband echocardiography transmission provides a service comparable in availability and accuracy to that provided in our paediatric cardiology division.

An economic analysis of teleconsultation in otorhinolaryngology

A cost comparison of three different methods of providing consultations for ear, nose and throat (ENT) problems was carried out. The study was based on the delivery of ENT examination and treatment to a small primary-care centre without an ENT specialist in northern Norway. The three alternatives evaluated were teleconsultation, a visiting specialist and patient travel to the nearest secondary-care centre. Patient travel was cheaper for patient workloads below 56 per year. For patient workloads above 56 and below 325 patients per year teleconsultation was the cheapest alternative. Above 325 patients per year, the visiting specialist service cost less than either teleconsultation or patient travel. Transfer of medical skills from the specialist to the general practitioner was also accounted for, separately from the main cost calculation. Teleconsultation then became cost-effective for patient workloads above 52 patients per year.

Financial analysis of savings from telemedicine in Ohio's prison system

The Ohio Department of Rehabilitation and Corrections (ODRC) implemented a telemedicine pilot project in March of 1995. The project brought together the Southern Ohio Correctional facility in Lucasville, the Corrections Medical Center in Columbus, and The Ohio State University Medical Center, also located in Columbus. Its purpose was to evaluate the use of two-way interactive video for the delivery of health services. With two-way interactive video, physicians in one location established audio and video links with inmates hundreds of miles away. Data were collected on the potential savings as a result of telemedicine usage in the Ohio prison system. Costs associated with telemedicine and those incurred without telemedicine were determined on per-consult basis for comparison. The cost for a medical consult to be performed at the Corrections Medical Center averaged $263.51 per inmate. The cost for a medical consult via telemedicine varied from month to month, depending on the utilization volume. The ODRC experienced savings for telemedicine usage when 129 or more consults were performed each quarter. During the third quarter, 145 telemedicine consults were performed. The cost per consult for telemedicine usage during this quarter was $255.19. There was a savings of $8.48 per consult, resulting in a quarterly savings of $1206. As the utilization of telemedicine continued to increase in the fourth quarter, the amount of savings increased.

[The Munich intensive care transport system. Patient transport and intensive care conditions]

In November 1990 a new program for transporting critically ill patients by a 24-h specialized intensive care transportation system at the Munich Hospital Grosshadern was established. All medical equipment similar to that in the ICU allows invasive and non-invasive monitoring, drug administration, and a sophisticated respiratory therapy, provided by a Siemens Servo 300 ventilator. Even extracorporal lung augmentation (ECLA) and cardiac pump assistance by special mobile devices are possible during the transport.