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Canellas MM, Jewell M, Edwards JL, Olivier D, Jun-O'Connell AH, Reznek MA. Measurement of Cost of Boarding in the Emergency Department Using Time-Driven Activity-Based Costing. Ann Emerg Med 2024; 84:376-385. [PMID: 38795079 DOI: 10.1016/j.annemergmed.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/20/2024] [Accepted: 04/09/2024] [Indexed: 05/27/2024]
Abstract
STUDY OBJECTIVE Boarding admitted patients in emergency departments (EDs) is a national crisis that is worsening despite potential financial disadvantages. The objective of this study was to assess costs associated with boarding. METHODS We conducted a prospective, observational investigation of patients admitted through an ED for management of acute stroke at a large, urban, academic, comprehensive stroke center hospital. We employed time-driven activity-based costing methodology to estimate cost for patient care activities during admission and aggregated results to estimate the total cost of boarding versus inpatient care. Primary outcomes were total daily costs per patient for medical-surgical (med/surg) boarding, med/surg inpatient care, ICU boarding, and ICU inpatient care. RESULTS The total daily cost per patient with acute stroke was US$1856, for med/surg boarding versus US$993 for med/surg inpatient care and US$2267, for ICU boarding versus US$2165, for ICU inpatient care. These differences were even greater when accounting for costs associated with traveler nurses. ED nurses spent 293 min/d (mean) caring for each med/surg boarder; inpatient nurses spent 313 min/d for each med/surg inpatient. ED nurses spent 419 min/d caring for each ICU boarder; inpatient nurses spent 787 min/d for each ICU inpatient. Neurology attendings and residents spent 25 and 52 min/d caring for each med/surg boarder versus 62 minutes and 90 minutes for each med/surg inpatient, respectively. CONCLUSION Using advanced cost-accounting methods, our investigation provides novel evidence that boarding of admitted patients is financially costly, adding greater urgency for elimination of this practice.
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Affiliation(s)
- Maureen M Canellas
- Department of Emergency Medicine, University of Massachusetts T.H. Chan School of Medicine, Worcester, MA; Department of Emergency Medicine, UMass Memorial Health, Worcester, MA.
| | - Marcella Jewell
- University of Massachusetts T.H. Chan School of Medicine, Worcester, MA
| | - Jennifer L Edwards
- Department of Emergency Medicine, University of Massachusetts T.H. Chan School of Medicine, Worcester, MA; Department of Emergency Medicine, UMass Memorial Health, Worcester, MA
| | - Danielle Olivier
- Department of Emergency Medicine, University of Massachusetts T.H. Chan School of Medicine, Worcester, MA; Department of Emergency Medicine, UMass Memorial Health, Worcester, MA
| | - Adalia H Jun-O'Connell
- Department of Neurology, University of Massachusetts T.H. Chan School of Medicine, Worcester, MA; Department of Neurology, UMass Memorial Health, Worcester, MA
| | - Martin A Reznek
- Department of Emergency Medicine, University of Massachusetts T.H. Chan School of Medicine, Worcester, MA; Department of Emergency Medicine, UMass Memorial Health, Worcester, MA
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Ayoung-Chee PR, Gore AV, Bruns B, Knowlton LM, Nahmias J, Davis KA, Leichtle S, Ross SW, Scherer LR, Velopulos C, Martin RS, Staudenmayer KL. Value in acute care surgery, part 3: Defining value in acute surgical care-It depends on the perspective. J Trauma Acute Care Surg 2024; 97:e53-e57. [PMID: 38706096 DOI: 10.1097/ta.0000000000004347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
ABSTRACT The prior articles in this series have focused on measuring cost and quality in acute care surgery. This third article in the series explains the current ways of defining value in acute care surgery, based on different stakeholders in the health care system-the patient, the health care organization, the payer and society. The heterogenous valuations of the different stakeholders require that the framework for determining high-value care in acute care surgery incorporates all viewpoints. LEVEL OF EVIDENCE Expert Opinion; Level V.
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Affiliation(s)
- Patricia R Ayoung-Chee
- From the Department of Surgery (P.R.A.-C.), Morehouse School of Medicine, Atlanta, Georgia; Department of Surgery (A.V.G.), Rutgers New Jersey Medical School, Newark, New Jersey; Department of Surgery (B.B.), University of Texas, Southwestern Medical Center, Dallas, Texas; Department of Surgery (L.M.K., K.L.S.), Stanford University School of Medicine, Palo Alto; Department of Surgery (J.N.), University of California, Irvine, California; Department of Surgery (K.A.D.), Yale School of Medicine, New Haven, Connecticut; Department of Surgery (S.L.), Inova Fairfax Medical Campus, Falls Church, Virginia; Department of Surgery (S.W.R., R.S.M.), Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Surgery (L.R.S.), Idaho College of Osteopathic Medicine, Meridian, Idaho; and Department of Surgery (C.V.), University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
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Nabelsi V, Plouffe V. Assessing cost and cost savings of teleconsultation in long-term care facilities: a time-driven activity-based costing analysis within a value-based healthcare framework. BMC Health Serv Res 2024; 24:1064. [PMID: 39272121 PMCID: PMC11401374 DOI: 10.1186/s12913-024-11578-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 09/11/2024] [Indexed: 09/15/2024] Open
Abstract
BACKGROUND Quebec's healthcare system faces significant challenges due to labour shortage, particularly in long-term care facilities (CHSLDs). The aging population and increasing demand for services compound this issue. Teleconsultation presents a promising solution to mitigate labour shortage, especially in small CHSLDs outside urban centers. This study aims to evaluate the cost and cost savings associated with teleconsultation in CHSLDs, utilizing the Time-Driven Activity-Based Costing (TDABC) model within the framework of Value-Based Healthcare (VBHC). METHODS This study focuses on CHSLDs with fewer than 50 beds in remote regions of Quebec, where teleconsultation for nighttime nursing care was implemented. Time and cost data were collected from three CHSLDs over varying periods. The TDABC model, aligned with VBHC principles, was applied through five steps, including process mapping, estimating activity times, calculating resource costs, and determining total costs. RESULTS Teleconsultation increased the cost per minute for nursing care compared to traditional care, attributed to additional tasks during remote consultations and potential technical challenges. However, cost savings were realized due to reduced need for onsite nursing staff during non-eventful nights. Overall, substantial savings were observed over the project duration, aligning with VBHC's focus on delivering high-value healthcare. CONCLUSIONS This study contributes both theoretically and practically by demonstrating the application of TDABC within the VBHC framework in CHSLDs. The findings support the cost savings from the use of teleconsultation in small CHSLDs. Further research should explore the long-term sustainability and scalability of teleconsultation across different CHSLD sizes and settings within the VBHC context to ensure high-value healthcare delivery.
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Affiliation(s)
- Véronique Nabelsi
- Department of Administrative Sciences, Université du Québec en Outaouais, C.P. 1240, Succ. Hull, Gatineau, J8X 3X7, Canada.
| | - Véronique Plouffe
- Department of Accounting, Université du Québec en Outaouais, C.P. 1240, Succ. Hull, Gatineau, J8X 3X7, Canada
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Thomas TL, Goh GS, Beredjiklian PK. Direct Variable Cost Comparison of Endoscopic Versus Open Carpal Tunnel Release: A Time-Driven Activity-Based Costing Analysis. J Am Acad Orthop Surg 2024; 32:777-785. [PMID: 38684127 DOI: 10.5435/jaaos-d-23-00872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/11/2023] [Indexed: 05/02/2024] Open
Abstract
INTRODUCTION To improve the delivery of value-based health care, a deeper understanding of the cost drivers in hand surgery is warranted. Time-driven activity-based costing (TDABC) offers a more accurate estimation of resource utilization compared with top-down accounting methods. This study used TDABC to compare the facility costs of open carpal tunnel release (OCTR) and endoscopic carpal tunnel release (ECTR). METHODS We identified 845 consecutive, unilateral carpal tunnel release (516 open, 329 endoscopic) surgeries performed at an orthopaedic specialty hospital between 2015 and 2021. Itemized facility costs were calculated using a TDABC algorithm. Patient demographics, comorbidities, surgical characteristics, and itemized costs were compared between OCTR and ECTR. Multivariate regression was used to determine the independent effect of endoscopic surgery on true facility costs. RESULTS Total facility costs were $352 higher in ECTR compared with OCTR ($882 versus $530). ECTR cases had higher personnel costs ($499 versus $420), likely because of longer surgical time (15 versus 11 minutes) and total operating room time (35 versus 27 minutes). ECTR cases also had higher supply costs ($383 versus $110). Controlling for demographics and comorbidities, ECTR was associated with an increase in personnel costs of $35.74 (95% CI, $26.32 to $45.15), supply costs of $230.28 (95% CI, $205.17 to $255.39), and total facility costs of $265.99 (95% CI, $237.01 to $294.97) per case. DISCUSSION Using TDABC, ECTR was 66% more costly to the facility compared with OCTR. To reduce the costs related to endoscopic surgery, efforts to decrease surgical time and negotiate lower ECTR-specific supply costs are warranted. LEVEL OF EVIDENCE Economic and Decision Analysis Level II.
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Affiliation(s)
- Terence L Thomas
- From the Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA (Thomas, Beredjiklian), and the Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA (Goh)
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da Silva Etges APB, Schneider NB, Roos EC, Marcolino MAZ, Ozelo MC, Midori Takahashi Hosokawa Nikkuni M, Elvira Mesquita Carvalho L, Oliveira Rebouças T, Hermida Cerqueira M, Mata V, Polanczyk CA. Cost of hemophilia A in Brazil: a microcosting study. HEALTH ECONOMICS REVIEW 2024; 14:62. [PMID: 39105856 PMCID: PMC11305066 DOI: 10.1186/s13561-024-00539-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Accepted: 07/16/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND Patients with Hemophilia are continually monitored at treatment centers to avoid and control bleeding episodes. This study estimated the direct and indirect costs per patient with hemophilia A in Brazil and evaluated the cost variability across different age groups. METHODS A prospective observational research was conducted with retrospective data collection of patients assisted at three referral blood centers in Brazil. Time-driven Activity-based Costing method was used to analyze direct costs, while indirect costs were estimated based on interviews with family and caregivers. Cost per patient was analyzed according to age categories, stratified into 3 groups (0-11;12-18 or older than 19 years old). The non-parametric Mann-Whitney test was used to confirm the differences in costs across groups. RESULTS Data from 140 hemophilia A patients were analyzed; 53 were 0-11 years, 29 were 12-18 years, and the remaining were older than 19 years. The median cost per patient per year was R$450,831 (IQR R$219,842; R$785,149; $174,566), being possible to confirm age as a cost driver: older patients had higher costs than younger's (p = 0.001; median cost: 0-11 yrs R$299,320; 12-18 yrs R$521,936; ≥19 yrs R$718,969). CONCLUSION This study is innovative in providing cost information for hemophilia A using a microcosting technique. The variation in costs across patient age groups can sustain more accurate health policies driven to increase access to cutting-edge technologies and reduce the burden of the disease.
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Affiliation(s)
- Ana Paula Beck da Silva Etges
- National Institute of Science and Technology for Health Technology Assessment (IATS) - CNPq/Brazil (project: 465518/2014-1), Ramiro Barcelos, 2350, Building 21- 507, Porto Alegre, 90035-903, Brazil
- Graduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul School of Medicine, Porto Alegre, RS, Brazil
| | - Nayê Balzan Schneider
- National Institute of Science and Technology for Health Technology Assessment (IATS) - CNPq/Brazil (project: 465518/2014-1), Ramiro Barcelos, 2350, Building 21- 507, Porto Alegre, 90035-903, Brazil
- Graduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul School of Medicine, Porto Alegre, RS, Brazil
| | - Erica Caetano Roos
- National Institute of Science and Technology for Health Technology Assessment (IATS) - CNPq/Brazil (project: 465518/2014-1), Ramiro Barcelos, 2350, Building 21- 507, Porto Alegre, 90035-903, Brazil
- Graduate Program in Industrial Engineering, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Miriam Allein Zago Marcolino
- National Institute of Science and Technology for Health Technology Assessment (IATS) - CNPq/Brazil (project: 465518/2014-1), Ramiro Barcelos, 2350, Building 21- 507, Porto Alegre, 90035-903, Brazil
- Graduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul School of Medicine, Porto Alegre, RS, Brazil
| | - Margareth Castro Ozelo
- Hemocentro UNICAMP, Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | | | | | | | | | | | - Carisi Anne Polanczyk
- National Institute of Science and Technology for Health Technology Assessment (IATS) - CNPq/Brazil (project: 465518/2014-1), Ramiro Barcelos, 2350, Building 21- 507, Porto Alegre, 90035-903, Brazil.
- Graduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul School of Medicine, Porto Alegre, RS, Brazil.
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Busschaert SL, Kimpe E, Gevaert T, De Ridder M, Putman K. Deep Inspiration Breath Hold in Left-Sided Breast Radiotherapy: A Balance Between Side Effects and Costs. JACC CardioOncol 2024; 6:514-525. [PMID: 39239337 PMCID: PMC11372305 DOI: 10.1016/j.jaccao.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 04/10/2024] [Accepted: 04/29/2024] [Indexed: 09/07/2024] Open
Abstract
Background Deep inspiration breath hold (DIBH) is an effective technique for reducing heart exposure during radiotherapy for left-sided breast cancer. Despite its benefits, cost considerations and its impact on workflow remain significant barriers to widespread adoption. Objectives This study aimed to assess the cost-effectiveness of DIBH and compare its operational, financial, and clinical outcomes with free breathing (FB) in breast cancer treatment. Methods Treatment plans for 100 patients with left-sided breast cancer were generated using both DIBH and FB techniques. Dosimetric data, including the average mean heart dose, were calculated for each technique and used to estimate the cardiotoxicity of radiotherapy. A state-transition microsimulation model based on SCORE2 (Systematic Coronary Risk Evaluation) algorithms projected the effects of DIBH on cardiovascular outcomes and quality-adjusted life-years (QALYs). Costs were calculated from a provider perspective using time-driven activity-based costing, applying a willingness-to-pay threshold of €40,000 for cost-effectiveness assessment. A discrete event simulation model assessed the impacts of DIBH vs FB on throughput and waiting times in the radiotherapy workflow. Results In the base case scenario, DIBH was associated with an absolute risk reduction of 1.72% (95% CI: 1.67%-1.76%) in total cardiovascular events and 0.69% (95% CI: 0.67%-0.72%) in fatal cardiovascular events over 20 years. Additionally, DIBH was estimated to provide an incremental 0.04 QALYs (95% CI: 0.05-0.05) per left-sided breast cancer patient over the same time period. However, DIBH increased treatment times, reducing maximum achievable throughput by 12.48% (95% CI: 12.36%-12.75%) and increasing costs by €617 per left-sided breast cancer patient (95% CI: €615-€619). The incremental cost-effectiveness ratio was €14,023 per QALY. Conclusions Despite time investments, DIBH is cost-effective in the Belgian population. The growing adoption of DIBH may benefit long-term cardiovascular health in breast cancer survivors.
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Affiliation(s)
- Sara-Lise Busschaert
- Research Centre on Digital Medicine, Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Radiation Oncology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Eva Kimpe
- Research Centre on Digital Medicine, Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium
| | - Thierry Gevaert
- Department of Radiation Oncology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Mark De Ridder
- Department of Radiation Oncology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Koen Putman
- Research Centre on Digital Medicine, Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Radiation Oncology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Cusumano LR, Rink JS, Callese T, Maehara CK, Mathevosian S, Quirk M, Plotnik A, McWilliams JP. Cost Comparison of Prostatic Artery Embolization Between In-Hospital and Outpatient-Based Lab Settings. Cureus 2024; 16:e67433. [PMID: 39310461 PMCID: PMC11415309 DOI: 10.7759/cureus.67433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2024] [Indexed: 09/25/2024] Open
Abstract
Purpose This study aimed to determine the costs associated with prostatic artery embolization (PAE) performed in hospital and outpatient-based lab (OBL) settings. Methods Procedures were performed in similarly equipped procedure suites located within a tertiary hospital or OBL. Time-driven activity-based costing (TDABC) was utilized to calculate procedural costs incurred by the institution. Process maps were created describing personnel, space, equipment, and materials. The time duration of each procedural step was recorded independently by a nurse caring for the patient at the time of the procedure, and mean values were included in our model. Using institutional and publicly available financial data, costs, and capacity cost rates were determined. Results Thirty-seven PAE procedures met inclusion criteria with a mean patient age of 70.4 (+/- 6.7) years and a mean prostate gland size of 129.7 (+/-56.4) cc. Twenty-six procedures were performed within the hospital setting, and 11 procedures were performed within the OBL. Reduction in International Prostate Symptom Score (IPSS) was not significantly different following hospital and OBL procedures (57.2% vs. 82.4%, P = 0.0796). Mean procedural time was not significantly different between the hospital and OBL settings (136.6 vs. 147.3 minutes, P = 0.1893). However, the duration between admission and discharge was significantly longer for procedures performed in a hospital (468.8 vs. 325.4 minutes, P <0.0001). Total costs for hospital-based procedures were marginally higher ($3,858.28 vs. $3,642.67). Conclusion Total PAE cost was similar between the hospital and OBL settings. However, longer periprocedural times for hospital-based procedures and differences in reimbursement may favor the performance of PAE in an OBL setting.
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Affiliation(s)
- Lucas R Cusumano
- Department of Radiological Sciences, David Geffen School of Medicine at University of California, Los Angeles, USA
| | - Johann S Rink
- Department of Clinical Radiology and Nuclear Medicine, Mannheim University Medical Centre, Mannheim, DEU
| | - Tyler Callese
- Department of Radiological Sciences, David Geffen School of Medicine at University of California, Los Angeles, USA
| | - Cleo K Maehara
- Department of Radiological Sciences, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, USA
| | - Sipan Mathevosian
- Department of Radiological Sciences, David Geffen School of Medicine at University of California, Los Angeles, USA
| | - Matthew Quirk
- Department of Radiological Sciences, David Geffen School of Medicine at University of California, Los Angeles, USA
| | - Adam Plotnik
- Department of Radiological Sciences, David Geffen School of Medicine at University of California, Los Angeles, USA
| | - Justin P McWilliams
- Department of Radiological Sciences, David Geffen School of Medicine at University of California, Los Angeles, USA
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van den Berg M, van Elten H, Spaan J, Franx A, Ahaus K. Exploring cost changes with time-driven activity-based costing after service delivery redesign in Dutch maternity care. Health Serv Manage Res 2024:9514848241265770. [PMID: 39041951 DOI: 10.1177/09514848241265770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
The implementation of Value-Based Healthcare (VBHC) has spread across international healthcare systems, aiming to improve decision-making by combining information about patient outcomes and costs of care. Time-Driven Activity-Based Costing (TDABC) is introduced as a pragmatic yet accurate method to calculate costs of care pathways. It is often applied to demonstrate value-improving opportunities, such as interventions aimed at service delivery redesign. It is imperative for healthcare managers to know whether these interventions yield the expected outcome of improving patient value, for which TDABC is also suitable. However, its application becomes more complex and labour intensive if the intervention extends beyond activity-level changes in existing care pathways, to the implementation of entirely new care pathways. The complexity arises from the potential influence of such interventions on the costs of related care pathways. To fully comprehend the impact of such interventions on organizational costs, it is important to include these factors in the cost calculation. Given the substantial effort required for this analysis, this may explain the limited number of prior TDABC studies with similar objectives. This methodological development paper addresses this gap by offering a pragmatic enrichment of the TDABC methodology. This enrichment is twofold. First, it provides guidance on calculating a change in costs without the need for a total cost calculation. Second, to secure granularity, a more detailed level of cost-allocation is proposed. The aim is to encourage further application of TDABC to conduct financial evaluations of promising interventions in the domain of VBHC and service delivery redesign.
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Affiliation(s)
- Maud van den Berg
- Health Services Management & Organisation, Erasmus School of Health Policy and Management, Erasmus Universiteit Rotterdam, Rotterdam, Netherlands
| | - Hilco van Elten
- Department of Accounting, Vrije Universiteit Amsterdam School of Business and Economics, Amsterdam, Netherlands
| | - Julia Spaan
- Department of Obstetrics and Gynecology, Amphia Hospital, Breda, Netherlands
| | - Arie Franx
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Kees Ahaus
- Health Services Management & Organisation, Erasmus School of Health Policy and Management, Erasmus Universiteit Rotterdam, Rotterdam, Netherlands
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Garg S, Tripathi N, Bebarta KK. Cost of Care for Non-communicable Diseases: Which Types of Healthcare Providers are the Most Economical in India's Chhattisgarh State? PHARMACOECONOMICS - OPEN 2024; 8:599-609. [PMID: 38630363 PMCID: PMC11252103 DOI: 10.1007/s41669-024-00489-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/27/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Non-communicable diseases (NCDs) affect a large number of people globally and their burden has been growing. Healthcare for NCDs often involves high out-of-pocket expenditure and rising costs of providing services. Financing and providing care for NCDs have become a major challenge for health systems. Despite the high burden of NCDs in India, there is little information available on the costs involved in NCD care. METHODS The study was aimed at finding out the average monthly cost of outpatient care per NCD patient. The average cost was defined as all resources spent directly by government and citizens to get a month of care for a NCD patient. The cost borne by the government on public facilities was taken into account and activity-based costing was used to apportion it to the function of providing outpatient NCD care. For robustness, time-driven activity-based costing and sensitivity analyses were also performed. The study was conducted in Chhattisgarh State and involved a household survey and a facility survey, conducted simultaneously at the end of 2022. The surveys had a sample representative of the state, covering 3500 individuals above age of 30 years and 108 health facilities. RESULTS The average monthly cost per NCD patient was Indian Rupees (INR) 688 for public providers, INR 1389 for formal for-profit providers and INR 408 for informal private providers and they managed 53.5, 34.3 and 12.0% of NCD patients respectively. The disease profile of patients handled by different types of providers was similar. The average cost per patient was lowest for the primary care facilities in the public sector. CONCLUSIONS The average direct cost of NCD care for government and citizens put together was substantially higher in case of formal for-profit providers compared with public facilities, even after taking into account the government subsidies to public sector. This has implications for allocative efficiency and the desired public-private provider mix in health systems.
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Affiliation(s)
- Samir Garg
- State Health Resource Centre, Raipur, Chhattisgarh, India.
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Yalamanchi P, Marentette LJ, Fendrick AM, Chinn SB, Prince MEP, Rosko AJ, Shuman AG, Spector ME, Stucken CL, Malloy KM, Casper KA. Application of Time-Driven Activity-Based Costing for Head and Neck Microvascular Free Flap Reconstruction. Otolaryngol Head Neck Surg 2024; 171:73-80. [PMID: 38643408 DOI: 10.1002/ohn.739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 01/22/2024] [Accepted: 02/05/2024] [Indexed: 04/22/2024]
Abstract
OBJECTIVE Traditional hospital accounting fails to provide an accurate cost of complex surgical care. Here we describe the application of time-driven activity-based costing (TDABC) to characterize costs of head and neck oncologic procedures involving free tissue transfer. STUDY DESIGN Retrospective cohort study. SETTING Single tertiary academic medical center. METHODS An analysis of head and neck oncologic procedures involving microvascular free flap reconstruction from 2018 to 2020 (n = 485) was performed using TDABC methodology to measure cost across operative case and postoperative admission, using quantity of time and cost per unit of each resource to characterize resource utilization. Univariate and generalized linear mixed models were used to examine associations between patient and hospital characteristics and cost of care delivery. RESULTS The total cost of care delivery was $41,905.77 ± 21,870.27 with operating room (OR) supplies accounting for only 10% of the total cost. Multivariable analyses identified significant cost drivers including operative time, postoperative length of stay, number of return trips to the OR, postoperative complication, number of free flaps performed, and patient transfer from another hospital or via emergency department admission (P < .05). CONCLUSION Operative time and postoperative length of stay, but not operative supplies, were primary drivers of cost of care for head and neck oncology cases involving free tissue transfer. TDABC offers granular cost characterization to inform cost optimization through unused capacity identification and postoperative admission efficiencies.
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Affiliation(s)
- Pratyusha Yalamanchi
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lawrence J Marentette
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - A Mark Fendrick
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan, USA
| | - Steven B Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Mark E P Prince
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Andrew J Rosko
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Andrew G Shuman
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Matthew E Spector
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Chaz L Stucken
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Kelly M Malloy
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Keith A Casper
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Jarrett CD, Dawes A, Abdelshahed M, Cil A, Denard P, Port J, Weinstein D, Wright MA, Bushnell BD. The impact of prior authorization review on orthopaedic subspecialty care: a prospective multicenter analysis. J Shoulder Elbow Surg 2024; 33:e336-e342. [PMID: 37993089 DOI: 10.1016/j.jse.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 09/21/2023] [Accepted: 10/18/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Prior authorization review (PAR), in the United States, is a process that was initially intended to focus on hospital admissions and costly high-acuity care. Over time, payors have broadened the scope of PAR to include imaging studies, prescriptions, and routine treatment. The potential detrimental effect of PAR on health care has recently been brought into the limelight, but its impact on orthopedic subspecialty care remains unclear. This study investigated the denial rate, the duration of care delay, and the administrative burden of PAR on orthopedic subspecialty care. METHODS A prospective, multicenter study was performed analyzing the PAR process. Orthopedic shoulder and/or sports subspecialty practices from 6 states monitored payor-mandated PAR during the course of providing routine patient care. The insurance carrier (traditional Medicare, managed Medicare, Medicaid, commercial, worker's compensation, or government payor [ie, Tricare, Veterans Affairs]), location of service, rate of approval or denial, time to approval or denial, and administrative time required to complete process were all recorded and evaluated. RESULTS Of 1065 total PAR requests, we found a 1.5% (16/1065) overall denial rate for advanced imaging or surgery when recommended by an orthopedic subspecialist. Commercial and Medicaid insurance resulted in a small but statistically significantly higher rate of denial compared to traditional Medicare, managed Medicare, worker's compensation, or governmental insurance (P < .001). The average administrative time spent on a single PAR was 19.5 minutes, and patients waited an average of 2.2 days to receive initial approval. Managed Medicare, commercial insurance, worker's compensation, and Medicaid required approximately 3-4 times more administrative time to process a PAR than to traditional Medicare or other governmental insurance (P < .001). After controlling for the payor, we identified a significant difference in approval or denial based on geographic location (P < .001). An appeal resulted in a relatively low rate of subsequent denial (20%). However, approximately a third of all appeals remained in limbo for 30 days or more after the initial request. CONCLUSIONS This is the largest prospective analysis to date of the impact of PAR on orthopedic subspecialty care in the United States. Nearly all PAR requests are eventually approved when recommended by orthopedic subspecialists, despite requiring significant resource use and delaying care. Current PAR practices constitute an unnecessary process that increases administrative burden and negatively impacts access to orthopedic subspecialty care. As health care shifts to value-based care, PAR should be called into question, as it does not seem to add value but potentially negatively impacts cost and timeliness of care.
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Affiliation(s)
- Claudius D Jarrett
- Wilmington Health Orthopaedics and Sports Medicine, Wilmington, NC, USA.
| | | | | | - Akin Cil
- Department of Orthopaedic Surgery, University of Missouri Kansas City School of Medicine, Kansas City, MO, USA
| | - Patrick Denard
- Oregon Shoulder Institute, Southern Oregon Orthopedics, Medford, OR, USA
| | - Joshua Port
- Altoona Curve AA Baseball, University of Pittsburgh Medical School, Altoona, PA, USA
| | - David Weinstein
- Colorado Center for Orthopaedic Excellence, Colorado Springs, CO, USA
| | - Melissa A Wright
- MedStar Union Memorial Hospital/MedStar Orthopedic Institute, Division of Shoulder & Elbow Surgery, Baltimore, MD, USA; Department of Orthopedic Surgery, Georgetown University School of Medicine, Washington, DC, USA
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Kenny C, Chavrimootoo S, Priyadarshini A. Cost of treating rheumatoid arthritis in the primary care public health system in Ireland: A time-driven activity-based cost analysis. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2024; 14:100439. [PMID: 38655193 PMCID: PMC11035073 DOI: 10.1016/j.rcsop.2024.100439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/11/2024] [Accepted: 04/03/2024] [Indexed: 04/26/2024] Open
Abstract
Background Chronic diseases are at epidemic proportions and continuing to increase in both incidence and prevalence globally. Therefore, there is a growing need to assess and improve on the value currently provided within chronic care pathways. Examining the costs associated with care pathways is a critical part of assessing this value in order to better understand and introduce potential cost-saving interventions. Objectives Examining one such chronic disease, Rheumatoid Arthritis (RA), this study aimed to assess the cost associated with RA in primary care within the Health Service Executive (HSE) in Ireland. Methods Following mapping of the care pathway, patient vignettes based on exemplar RA patient types were used to conduct semi-structed interviews with every member (N = 21) of the primary care RA pathway. Time-Driven Activity-Based Costing (TDABC) was then used to calculate the overall cost of each patient (vignette) type. Results RA is an expensive condition regardless of disease stage. However, newly diagnosed patients as well as those with advanced disease in need of surgical interventions demonstrated the highest costs in terms of primary care personnel use. Additionally, patients prescribed Biological Disease-Modifying Anti-Rheumatic Drugs (bDMARDs) cost significantly more than those on Conventional Synthetic Disease-Modifying Anti-Rheumatic Drugs (csDMARDs) regardless of disease stage or personnel resource use. Conclusion RA and a subset of RA patients that exert the highest healthcare costs are growing in prevalence. Therefore, this study contributes by assessing the costs associated with RA in HSE primary care that can facilitate better understanding the current value being provided and improve upon the current care pathway to cut future costs.
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Affiliation(s)
- Christina Kenny
- College of Business, Technological University Dublin, Aungier Street, Dublin 2, Ireland
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13
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Dean MC, Cherian NJ, Beck da Silva Etges AP, Dowley KS, LaPorte ZL, Torabian KA, Eberlin CT, Best MJ, Martin SD. Variation in the Cost of Hip Arthroscopy for Labral Pathological Conditions: A Time-Driven Activity-Based Costing Analysis. J Bone Joint Surg Am 2024:00004623-990000000-01112. [PMID: 38781316 DOI: 10.2106/jbjs.23.00500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND Despite growing interest in delivering high-value orthopaedic care, the costs associated with hip arthroscopy remain poorly understood. By employing time-driven activity-based costing (TDABC), we aimed to characterize the cost composition of hip arthroscopy for labral pathological conditions and to identify factors that drive variation in cost. METHODS Using TDABC, we measured the costs of 890 outpatient hip arthroscopy procedures for labral pathological conditions across 5 surgeons at 4 surgery centers from 2015 to 2022. All patients were ≥18 years old and were treated by surgeons who each performed ≥20 surgeries during the study period. Costs were normalized to protect the confidentiality of internal hospital cost data. Descriptive analyses and multivariable linear regression were performed to identify factors underlying cost variation. RESULTS The study sample consisted of 515 women (57.9%) and 375 men (42.1%), with a mean age (and standard deviation) of 37.1 ± 12.7 years. Most of the procedures were performed in patients who were White (90.6%) or not Hispanic (93.4%). The normalized total cost of hip arthroscopy per procedure ranged from 43.4 to 203.7 (mean, 100 ± 24.2). Of the 3 phases of the care cycle, the intraoperative phase was identified as the largest generator of cost (>90%). On average, supply costs accounted for 48.8% of total costs, whereas labor costs accounted for 51.2%. A 2.5-fold variation between the 10th and 90th percentiles for total cost was attributed to supplies, which was greater than the 1.8-fold variation attributed to labor. Variation in total costs was most effectively explained by the labral management method (partial R2 = 0.332), operating surgeon (partial R2 = 0.326), osteoplasty type (partial R2 = 0.087), and surgery center (partial R2 = 0.086). Male gender (p < 0.001) and younger age (p = 0.032) were also associated with significantly increased costs. Finally, data trends revealed a shift toward labral preservation techniques over debridement during the study period (with the rate of such techniques increasing from 77.8% to 93.2%; Ptrend = 0.0039) and a strong correlation between later operative year and increased supply costs, labor costs, and operative time (p < 0.001 for each). CONCLUSIONS By applying TDABC to outpatient hip arthroscopy, we identified wide patient-to-patient cost variation that was most effectively explained by the method of labral management, the operating surgeon, the osteoplasty type, and the surgery center. Given current procedural coding trends, declining reimbursements, and rising health-care costs, these insights may enable stakeholders to design bundled payment structures that better align reimbursements with costs. LEVEL OF EVIDENCE Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Michael C Dean
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota
| | - Nathan J Cherian
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Orthopaedic Surgery, University of Nebraska, Omaha, Nebraska
| | - Ana Paula Beck da Silva Etges
- Avant-garde Health, Boston, Massachusetts
- National Institute of Science and Technology for Health Technology Assessment (IATS/CNPq), Porto Alegre, Brazil
- Graduate Program in Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Kieran S Dowley
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Zachary L LaPorte
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Kaveh A Torabian
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Christopher T Eberlin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Orthopaedic Surgery, University of Iowa, Iowa City, Iowa
| | - Matthew J Best
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Scott D Martin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
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14
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Etges APBDS, Jones P, Liu H, Zhang X, Haas D. Improvements in technology and the expanding role of time-driven, activity-based costing to increase value in healthcare provider organizations: a literature review. Front Pharmacol 2024; 15:1345842. [PMID: 38841371 PMCID: PMC11151087 DOI: 10.3389/fphar.2024.1345842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 04/19/2024] [Indexed: 06/07/2024] Open
Abstract
Objective This study evaluated the influence of technology on accurately measuring costs using time-driven activity-based costing (TDABC) in healthcare provider organizations by identifying the most recent scientific evidence of how it contributed to increasing the value of surgical care. Methods This is a literature-based analysis that mainly used two data sources: first, the most recent systematic reviews that specifically evaluated TDABC studies in the surgical field and, second, all articles that mentioned the use of CareMeasurement (CM) software to implement TDABC, which started to be published after the publication of the systematic review. The articles from the systematic review were grouped as manually performed TDABC, while those using CM were grouped as technology-based studies of TDABC implementations. The analyses focused on evaluating the impact of using technology to apply TDABC. A general description was followed by three levels of information extraction: the number of cases included, the number of articles published per year, and the contributions of TDABC to achieve cost savings and other improvements. Results Fourteen studies using real-world patient-level data to evaluate costs comprised the manual group of studies. Thirteen studies that reported the use of CM comprised the technology-based group of articles. In the manual studies, the average number of cases included per study was 160, while in the technology-based studies, the average number of cases included was 4,767. Technology-based studies, on average, have a more comprehensive impact than manual ones in providing accurate cost information from larger samples. Conclusion TDABC studies supported by technologies such as CM register more cases, identify cost-saving opportunities, and are frequently used to support reimbursement strategies based on value. The findings suggest that using TDABC with the support of technology can increase healthcare value.
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Affiliation(s)
- Ana Paula Beck Da Silva Etges
- PEV Healthcare Consulting, São Paulo, Brazil
- Avant-garde Health, Boston, MA, United States
- Programa de Pós-graduação em Epidemiologia da Escola de Medicina da Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | - Harry Liu
- Avant-garde Health, Boston, MA, United States
| | | | - Derek Haas
- Avant-garde Health, Boston, MA, United States
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Padilha FVDQ, Rodrigues DLG, Belber GS, Maeyama MA, Spinel L, Pinho APNM, Vitti A, Otero MS, Pompermaier GB, Damas TB, Oliveira Junior H. Analysis of the costs of teleconsultation for the treatment of diabetes mellitus in the SUS. Rev Saude Publica 2024; 58:15. [PMID: 38716927 PMCID: PMC11037897 DOI: 10.11606/s1518-8787.2024058005433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 09/22/2023] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVE To present the results of a cost analysis of remote consultations (teleconsultations) compared to in-person consultations for patients with type 2 diabetes, in the Brazilian public healthcare system (SUS) in the city of Joinville, Santa Catarina (SC). In addition to the costs from the local manager's perspective, the article also presents estimates from the patient's perspective, based on the transportation costs associated with each type of consultation. METHOD Data were collected from 246 consultations, both remote and in-person, between 2021 and 2023, in the context of a randomized clinical trial on the impact of teleconsultation carried out in the city of Joinville, SC. Teleconsultations were carried out at Primary Health Units (PHU) and in-person consultations at the Specialized Health Center. The consultation costs were calculate by the method time and activity-based costing (TDABC), and for the estimate of transportation costs data was collected directly from the research participants . The mean costs and time required to carry out each type of consultation in different scenarios and perspectives were analyzed and compared descriptively. RESULTS Considering only the local SUS manager's perspective, the costs for carrying out a teleconsultation were 4.5% higher than for an in-person consultation. However, when considering the transportation costs associated with each patient, the estimated value of the in-person consultation becomes 7.7% higher and, in the case of consultations in other municipalities, 15% higher than the teleconsultation. CONCLUSION The results demonstrate that the incorporation of teleconsultation within the SUS can bring economic advantages depending on the perspective and scenario considered, in addition to being a strategy with the potential to increase access to specialized care in the public network.
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Affiliation(s)
- Frederica Valle de Queiroz Padilha
- Hospital Alemão Oswaldo Cruz. Departamento de Sustentabilidade e Responsabilidade Social. São Paulo, SP, Brasil
- Instituto de Estudos de Políticas de Saúde. São Paulo, SP, Brasil
| | | | - Gisele Silvestre Belber
- Hospital Alemão Oswaldo Cruz. Departamento de Sustentabilidade e Responsabilidade Social. São Paulo, SP, Brasil
| | | | - Lígia Spinel
- Hospital Alemão Oswaldo Cruz. Departamento de Sustentabilidade e Responsabilidade Social. São Paulo, SP, Brasil
| | | | | | | | | | | | - Haliton Oliveira Junior
- Hospital Alemão Oswaldo Cruz. Departamento de Sustentabilidade e Responsabilidade Social. São Paulo, SP, Brasil
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16
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Weng J, Mesko S, Chronowski G, Lee P, Choi S, Das P, Koong AC, French K, Aloia T, Ehlers R, Elrod-Joplin D, Kerr A, Smith R, Martinez W, Bloom E, Shah SJ, Ning MS, Liao Z, Herman J, Moningi S, Moreno AC, Nguyen QN. Optimizing Outpatient Radiation Oncology Consult Workflow by Using Time-Driven Activity-Based Costing: Efficiency and Financial Impacts. JCO Oncol Pract 2024; 20:732-738. [PMID: 38330252 PMCID: PMC11225068 DOI: 10.1200/op.23.00037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 08/31/2023] [Accepted: 01/03/2024] [Indexed: 02/10/2024] Open
Abstract
PURPOSE Clinical efficiency is a key component of value-based health care. Our objective here was to identify workflow inefficiencies by using time-driven activity-based costing (TDABC) and evaluate the implementation of a new clinical workflow in high-volume outpatient radiation oncology clinics. METHODS Our quality improvement study was conducted with the Departments of GI, Genitourinary (GU), and Thoracic Radiation Oncology at a large academic cancer center and four community network sites. TDABC was used to create process maps and optimize workflow for outpatient consults. Patient encounter metrics were captured with a real-time status function in the electronic medical record. Time metrics were compared using Mann-Whitney U tests. RESULTS Individual patient encounter data for 1,328 consults before the intervention and 1,234 afterward across all sections were included. The median overall cycle time was reduced by 21% in GI (19 minutes), 18% in GU (16 minutes), and 12% at the community sites (9 minutes). The median financial savings per consult were $52 in US dollars (USD) for the GI, $33 USD for GU, $30 USD for thoracic, and $42 USD for the community sites. Patient satisfaction surveys (from 127 of 228 patients) showed that 99% of patients reported that their providers spent adequate time with them and 91% reported being seen by a care provider in a timely manner. CONCLUSION TDABC can effectively identify opportunities to improve clinical efficiency. Implementing workflow changes on the basis of our findings led to substantial reductions in overall encounter cycle times across several departments, as well as high patient satisfaction and significant financial savings.
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Affiliation(s)
- Julius Weng
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Shane Mesko
- Division of Radiation Oncology, Scripps MD Anderson Cancer Center, San Diego, CA
| | | | - Percy Lee
- Department of Radiation Oncology, City of Hope National Medical Center, Los Angeles, CA
| | - Seungtaek Choi
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Prajnan Das
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Albert C. Koong
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Katy French
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Thomas Aloia
- Surgical Oncology, Ascension Health, Pearland, TX
| | - Richie Ehlers
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, Houston, TX
| | | | - Ashley Kerr
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Regina Smith
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Wendi Martinez
- Institute for Cancer Care Innovation, MD Anderson Cancer Center, Houston, TX
| | - Elizabeth Bloom
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Shalin J. Shah
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Matthew S. Ning
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Zhongxing Liao
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Joseph Herman
- Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY
| | - Shalini Moningi
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Amy C. Moreno
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Quynh-Nhu Nguyen
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
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Allen AE, Sakheim ME, Mahendraraj KA, Nemec SM, Nho SJ, Mather RC, Wuerz TH. Time-Driven Activity-Based Costing Analysis Identifies Use of Consumables and Operating Room Time as Factors Associated With Increased Cost of Outpatient Primary Hip Arthroscopic Labral Repair. Arthroscopy 2024; 40:1517-1526. [PMID: 37977413 DOI: 10.1016/j.arthro.2023.10.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 10/02/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE To use time-driven, activity-based costing (TDABC) methodology to investigate drivers of cost variation and to elucidate preoperative and intraoperative factors associated with increased cost of outpatient arthroscopic hip labral repair. METHODS A retrospective analysis of data from January 2020 to October 2021 was performed. Patients undergoing primary hip arthroscopy for labral repair in the outpatient setting were included. Indexed TDABC data from Avant-garde Health's analytics platform were used to represent cost-of-care breakdowns. Patients in the top decile of cost were defined as high cost, and cost category variance was determined as a percent increase between high and low cost. Analyses tested for associations between preoperative and perioperative factors with total cost. Surgical procedures performed concomitantly to labral repair were included in subanalyses. RESULTS Data from 151 patients were analyzed. Consumables made up 61% of total outpatient cost with surgical personnel costs (30%) being the second largest category. The average total cost was 19% higher for patients in the top decile of cost compared to the remainder of the cohort. Factors contributing to this difference were implants (36% higher), surgical personnel (20% higher), and operating room (OR) consumables (15% higher). Multivariate linear regression modeling indicated that OR time (Standardized β = 0.504; P < .001) and anchor quantity (standardized β = 0.443; P < .001) were significant predictors of increased cost. Femoroplasty (Unstandardized β = 15.274; P = .010), chondroplasty (Unstandardized β = 8.860; P = .009), excision of os acetabuli (unstandardized β = 13.619; P = .041), and trochanteric bursectomy (Unstandardized β = 21.176; P = .009) were also all independently associated with increasing operating time. CONCLUSIONS TDABC analysis showed that OR consumables and implants were the largest drivers of cost for the procedure. OR time was also shown to be a significant predictor of increased costs. LEVEL OF EVIDENCE Level IV, economic analysis.
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Affiliation(s)
- A Edward Allen
- Tufts University School of Medicine, Boston, Massachusetts, U.S.A
| | - Madison E Sakheim
- Boston Sports and Shoulder Research Foundation, Waltham, Massachusetts, U.S.A
| | | | - Sophie M Nemec
- Boston Sports and Shoulder Research Foundation, Waltham, Massachusetts, U.S.A
| | - Shane J Nho
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A
| | | | - Thomas H Wuerz
- New England Baptist Hospital, Boston Sports and Shoulder Research Foundation, Waltham Massachusetts, U.S.A..
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Derendorf L, Stock S, Simic D, Shukri A, Zelenak C, Nagel J, Friede T, Herbeck Belnap B, Herrmann-Lingen C, Pedersen SS, Sørensen J, Müller And On Behalf Of The Escape Consortium D. Health economic evaluation of blended collaborative care for older multimorbid heart failure patients: study protocol. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2024; 22:29. [PMID: 38615050 PMCID: PMC11015692 DOI: 10.1186/s12962-024-00535-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/21/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND Integrated care, in particular the 'Blended Collaborative Care (BCC)' strategy, may have the potential to improve health-related quality of life (HRQoL) in multimorbid patients with heart failure (HF) and psychosocial burden at no or low additional cost. The ESCAPE trial is a randomised controlled trial for the evaluation of a BCC approach in five European countries. For the economic evaluation of alongside this trial, the four main objectives were: (i) to document the costs of delivering the intervention, (ii) to assess the running costs across study sites, (iii) to evaluate short-term cost-effectiveness and cost-utility compared to providers' usual care, and (iv) to examine the budgetary implications. METHODS The trial-based economic analyses will include cross-country cost-effectiveness and cost-utility assessments from a payer perspective. The cost-utility analysis will calculate quality-adjusted life years (QALYs) using the EQ-5D-5L and national value sets. Cost-effectiveness will include the cost per hospital admission avoided and the cost per depression-free days (DFD). Resource use will be measured from different sources, including electronic medical health records, standardised questionnaires, patient receipts and a care manager survey. Uncertainty will be addressed using bootstrapping. DISCUSSION The various methods and approaches used for data acquisition should provide insights into the potential benefits and cost-effectiveness of a BCC intervention. Providing the economic evaluation of ESCAPE will contribute to a country-based structural and organisational planning of BCC (e.g., the number of patients that may benefit, how many care managers are needed). Improved care is expected to enhance health-related quality of life at little or no extra cost. TRIAL REGISTRATION The study follows CHEERS2022 and is registered at the German Clinical Trials Register (DRKS00025120).
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Affiliation(s)
- Lisa Derendorf
- Faculty of Medicine and University Hospital of Cologne, Institute of Health Economics and Clinical Epidemiology, University of Cologne, Cologne, Germany.
| | - Stephanie Stock
- Faculty of Medicine and University Hospital of Cologne, Institute of Health Economics and Clinical Epidemiology, University of Cologne, Cologne, Germany
| | - Dusan Simic
- Faculty of Medicine and University Hospital of Cologne, Institute of Health Economics and Clinical Epidemiology, University of Cologne, Cologne, Germany
| | - Arim Shukri
- Faculty of Medicine and University Hospital of Cologne, Institute of Health Economics and Clinical Epidemiology, University of Cologne, Cologne, Germany
| | - Christine Zelenak
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Centre, Göttingen, Germany
| | - Jonas Nagel
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Centre, Göttingen, Germany
| | - Tim Friede
- German Centre for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
- Department of Medical Statistics, University Medical Centre Göttingen, Göttingen, Germany
| | - Birgit Herbeck Belnap
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Centre, Göttingen, Germany
- Center for Behavioral Health, Media, and Technology, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Christoph Herrmann-Lingen
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Centre, Göttingen, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Susanne S Pedersen
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Jan Sørensen
- Healthcare Outcomes Research Centre, Dublin, Ireland
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Reis J, Koo KSH, Shivaram GM, Shaw DW, Iyer RS. Time-Driven Activity-Based Cost Comparison of Osteoid Osteoma Ablation Techniques. J Am Coll Radiol 2024; 21:567-575. [PMID: 37473855 DOI: 10.1016/j.jacr.2023.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 01/27/2023] [Accepted: 02/07/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE Compare the cost of performing an osteoid osteoma ablation using cone beam CT (CBCT) with overlay fluoroscopic guidance to ablation using conventional CT (CCT) guidance and microwave ablation (MWA) to radiofrequency ablation (RFA). METHODS An 11-year retrospective study was performed of all patients undergoing osteoid osteoma ablation. Ablation equipment included a Cool tip RFA probe (Covidien, Minneapolis, Minnesota) or a Neuwave PR MWA probe (Ethicon, Rariton, New Jersey). The room times as well as immediate recovery time were recorded for each case. Cost analysis was then performed using time-driven activity-based costing for rate-dependent variables including salaries, equipment depreciation, room time, and certain supplies. Time-independent costs included the disposable interventional radiology supplies and ablation systems. Costs were reported for each service providing care and using conventional cost accounting methods with variable and fixed expenditures. RESULTS A total of 91 patients underwent 96 ablation procedures in either CBCT (n = 66) or CCT (n = 30) using either MWA (n = 51) or RFA (n = 45). The anesthesia induction (22.7 ± 8.7 min versus 15.9 ± 7.2 min, P < .001), procedure (64.7 ± 27.5 min versus 47.3 ± 15.3 min; P = .001), and room times (137.7 ± 33.7 min versus 103.9 ± 22.6. min; P < .001) were significantly longer for CBCT procedures. The procedure time did not differ significantly between MWA and RFA (62.1 ± 27.4 min versus 56.1 ± 23.3 min; P = .27). Multiple regression analysis demonstrated lower age (P = .046), CBCT use (P = .001), RFA use (P = .02), and nonsupine patient position (P = .01) significantly increased the total procedural cost. After controlling for these variables, the total cost of CBCT ($5,981.32 ± $523.93 versus $5,378.93 ± $453.12; P = .001) remained higher than CCT and the total cost of RFA ($5,981.32 ± $523.93 versus $5,674.43 ± $549.14; P = .05) approached a higher cost than MWA. CONCLUSION The use of CBCT with overlay fluoroscopic guidance for osteoid osteoma ablation resulted in longer in-room times and greater cost when compared with CCT. These cost considerations should be weighed against potential radiation dose advantage of CBCT when choosing an image guidance modality. Younger age, RFA use, and nonsupine patient position additionally contributed to higher costs.
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Affiliation(s)
- Joseph Reis
- Director of Interventional Radiology Enteric Access Service, Department of Radiology, Seattle Children's Hospital, Seattle, Washington; Co-Medical Director of Vascular Access Service, and Medical Director of Clinical Strategy in Radiology, Department of Radiology, Seattle Children's Hospital, Seattle, Washington; Section Chief of Pediatric Interventional Radiology, Department of Radiology, Seattle Children's Hospital, Seattle, Washington.
| | - Kevin S H Koo
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington; Vice Chair of Education, Department of Radiology, University of Washington School of Medicine; Panel Chair, ACR Appropriateness Criteria-Pediatrics; Chair, ACR Strategic Planning and Compliance Committee, Commission on Publications and Lifelong Learning
| | - Giri M Shivaram
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington; Vice Chair of Education, Department of Radiology, University of Washington School of Medicine; Panel Chair, ACR Appropriateness Criteria-Pediatrics; Chair, ACR Strategic Planning and Compliance Committee, Commission on Publications and Lifelong Learning
| | - Dennis W Shaw
- Director of Magnetic Resonance Imaging, Department of Radiology, Seattle Children's Hospital, Seattle, Washington
| | - Ramesh S Iyer
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington; Vice Chair of Education, Department of Radiology, University of Washington School of Medicine; Panel Chair, ACR Appropriateness Criteria-Pediatrics; Chair, ACR Strategic Planning and Compliance Committee, Commission on Publications and Lifelong Learning
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Hartsell J, Wilson FA, Shoaf K, Dunn A, Samore MH, Staes CJ. An economic evaluation of the expansion of electronic case reporting in an academic healthcare setting. JAMIA Open 2024; 7:ooad102. [PMID: 38223408 PMCID: PMC10784733 DOI: 10.1093/jamiaopen/ooad102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/04/2023] [Accepted: 11/29/2023] [Indexed: 01/16/2024] Open
Abstract
Objectives Determine the economic cost or benefit of expanding electronic case reporting (eCR) for 29 reportable conditions beyond the initial eCR implementation for COVID-19 at an academic health center. Materials and methods The return on investment (ROI) framework was used to quantify the economic impact of the expansion of eCR from the perspective of an academic health system over a 5-year time horizon. Sensitivity analyses were performed to assess key factors such as personnel cost, inflation, and number of expanded conditions. Results The total implementation costs for the implementation year were estimated to be $5031.46. The 5-year ROI for the expansion of eCR for the 29 conditions is expected to be 142% (net present value of savings: $7166). Based on the annual ROI, estimates suggest that the savings from the expansion of eCR will cover implementation costs in approximately 4.8 years. All sensitivity analyses yielded a strong ROI for the expansion of eCR. Discussion and conclusion Our findings suggest a strong ROI for the expansion of eCR at UHealth, with the most significant cost savings observed implementing eCR for all reportable conditions. An early effort to ensure data quality is recommended to expedite the transition from parallel reporting to production to improve the ROI for healthcare organizations. This study demonstrates a positive ROI for the expansion of eCR to additional reportable conditions beyond COVID-19 in an academic health setting, such as UHealth. While this evaluation focuses on the 5-year time horizon, the potential benefit could extend further.
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Affiliation(s)
- Joel Hartsell
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT 84112, United States
- Department of Public Health Informatics, Epi-Vant, Salt Lake City, UT 84092, United States
| | - Fernando A Wilson
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT 84112, United States
- Department of Economics, University of Utah, Salt Lake City, UT 84112, United States
- Matheson Center for Health Care Studies, University of Utah Health, Salt Lake City, UT 84112, United States
| | - Kimberley Shoaf
- Division of Public Health, University of Utah, Salt Lake City, UT 84112, United States
| | - Angela Dunn
- Salt Lake County Health Department, Salt Lake City, UT 84112, United States
| | - Matthew H Samore
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States
- Veteran Affairs, Salt Lake City, UT, United States
| | - Catherine Janes Staes
- College of Nursing, University of Utah, Salt Lake City, UT 84112, United States
- Department of Biomedical Informatics, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT 84108, United States
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Wang H, Sun H, Fu Y, Cheng W, Jin C, Shi H, Luo Y, Xu X, Wang H. A comprehensive value-based method for new nuclear medical service pricing: with case study of radium [223 Ra] bone metastases treatment. BMC Health Serv Res 2024; 24:397. [PMID: 38553709 PMCID: PMC10981283 DOI: 10.1186/s12913-024-10777-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 02/23/2024] [Indexed: 04/01/2024] Open
Abstract
IMPORTANCE Innovative nuclear medicine services offer substantial clinical value to patients. However, these advancements often come with high costs. Traditional payment strategies do not incentivize medical institutes to provide new services nor determine the fair price for payers. A shift towards a value-based pricing strategy is imperative to address these challenges. Such a strategy would reconcile the cost of innovation with incentives, foster transparent allocation of healthcare resources, and expedite the accessibility of essential medical services. OBJECTIVE This study aims to develop and present a comprehensive, value-based pricing model for new nuclear medicine services, illustrated explicitly through a case study of the radium [223Ra] treatment for bone metastases. In constructing the pricing model, we have considered three primary value determinants: the cost of the new service, associated service risk, and the difficulty of the service provision. Our research can help healthcare leaders design an evidence-based Fee-For-Service (FFS) payment reference pricing with nuclear medicine services and price adjustments. DESIGN, SETTING AND PARTICIPANTS This multi-center study was conducted from March 2021 to February 2022 (including consultation meetings) and employed both qualitative and quantitative methodologies. We organized focus group consultations with physicians from nuclear medicine departments in Beijing, Chongqing, Guangzhou, and Shanghai to standardize the treatment process for radium [223Ra] bone metastases. We used a specially designed 'Radium Nuclide [223Ra] Bone Metastasis Data Collection Form' to gather nationwide resource consumption data to extract information from local databases. Four interviews with groups of experts were conducted to determine the add-up ratio, based on service risk and difficulty. The study organized consultation meeting with key stakeholders, including policymakers, service providers, clinical researchers, and health economists, to finalize the pricing equation and the pricing result of radium [223Ra] bone metastases service. MAIN OUTCOMES AND MEASURES We developed and detailed a pricing equation tailored for innovative services in the nuclear medicine department, illustrating its application through a step-by-step guide. A standardized service process was established to ensure consistency and accuracy. Adhering to best practice guidelines for health cost data analysis, we emphasized the importance of cross-validation of data, where validated data demonstrated less variation. However, it required a more advanced health information system to manage and analyze the data inputs effectively. RESULTS The standardized service of radium [223Ra] bone metastases includes: pre-injection assessment, treatment plan, administration, post-administration monitoring, waste disposal and monitoring. The average duration for each stage is 104 min, 39 min, 25 min, 72 min and 56 min. A standardized monetary value for medical consumables is 54.94 yuan ($7.6), and the standardised monetary value (medical consumables cost plus human input) is 763.68 yuan ($109.9). Applying an agreed value add-up ratio of 1.065, the standardized value is 810.19 yuan ($116.9). Feedback from a consultation meeting with policymakers and health economics researchers indicates a consensus that the pricing equation developed was reasonable and well-grounded. CONCLUSION This research is the first study in the field of nuclear medicine department pricing methodology. We introduce a comprehensive value-based nuclear medical service pricing method and use radium[223Ra] bone metastases treatment pricing in China as a case study. This study establishes a novel pricing framework and provides practical instructions on its implementation in a real-world healthcare setting.
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Affiliation(s)
- Haode Wang
- Shanghai Health Development Research Center, (Shanghai Medical Information Center), Minhang District, No. 181 Xinbei Road, Shanghai, 201199, People's Republic of China
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, S10 2TN, United Kingdom
| | - Hui Sun
- Shanghai Health Development Research Center, (Shanghai Medical Information Center), Minhang District, No. 181 Xinbei Road, Shanghai, 201199, People's Republic of China
- National Health Commission Key Laboratory of Health Technology Assessment, School of Public Health, Fudan University, Shanghai, 200032, China
| | - Yuyan Fu
- Shanghai Health Development Research Center, (Shanghai Medical Information Center), Minhang District, No. 181 Xinbei Road, Shanghai, 201199, People's Republic of China
| | - Wendi Cheng
- Shanghai Health Development Research Center, (Shanghai Medical Information Center), Minhang District, No. 181 Xinbei Road, Shanghai, 201199, People's Republic of China
| | - Chunlin Jin
- Shanghai Health Development Research Center, (Shanghai Medical Information Center), Minhang District, No. 181 Xinbei Road, Shanghai, 201199, People's Republic of China
| | - Hongcheng Shi
- Department of Nuclear Medicine, Zhongshan Hospital, Shanghai Medical College, Department of Nuclear Medicine, Shanghai Cancer Center, Fudan University, Shanghai, 200032, China
| | - Yashuang Luo
- Shanghai Health Development Research Center, (Shanghai Medical Information Center), Minhang District, No. 181 Xinbei Road, Shanghai, 201199, People's Republic of China
| | - Xinjie Xu
- School of Rehabilitation Medicine, Shandong University of Traditional Chinese Medicine, Jinan, 250355, China
| | - Haiyin Wang
- Shanghai Health Development Research Center, (Shanghai Medical Information Center), Minhang District, No. 181 Xinbei Road, Shanghai, 201199, People's Republic of China.
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Sethi R, Louie P, Bansal A, Gilbert M, Nemani V, Leveque JC, Drolet CE, Ohlson B, Kronfol R, Strunk J, Cornett-Gomes K, Friedman A, LeFever D. Monthly multidisciplinary complex spine conference: a cost-analysis utilizing time-driven activity-based costing. Spine Deform 2024; 12:433-442. [PMID: 38103094 DOI: 10.1007/s43390-023-00798-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 11/18/2023] [Indexed: 12/17/2023]
Abstract
PURPOSE To understand costs and provide an initial framework associated with conference implementation as it pertains to complication prevention. METHODS Team members' time spent on conference preparation, presentation, and follow-up tasks was recorded and averaged to determine the time required to prepare and present one patient. Using 2022 hourly wage rates based on our urban hospital setting, wage values were calculated for each personnel type and applied to their time spent. The total cost of the conference was annualized and calculated from the time spent in the three phases of the conference multiplied by the wage rate. Published data on complication rates and associated costs before and after conference implementation were used to calculate total cost reduction. RESULTS With 3 active spine surgeons and 108 patients per year, the total time investment was 104.04 min per patient, costing $21,791 annually. Total RN equivalent value per patient was 5.25 for all three phases. Using a historical model, this multidisciplinary approach for adult spinal deformity reduced complications by 51% at 30 days, resulting in cost savings of $418,518 per year. Thus, the model demonstrates that implementation of this approach resulted in a potential total savings of $396,726/year. CONCLUSION Implementing a cost-saving tool for managing complex spinal disorders is a responsibility of the spine team, who should lead a multidisciplinary conference. The combination of TDABC and lean methodology can effectively demonstrate the variable costs associated with this multidisciplinary effort and models provide evidence of potential cost-savings when applied to a multidisciplinary adult spinal deformity conference. These findings should encourage clinicians and administrators to allocate resources to improve patient care by reducing complications and costs.
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Affiliation(s)
- Rajiv Sethi
- Department of Neurosurgery, Center for Neuroscience and Spine, Virginia Mason Medical Center, Seattle, WA, USA.
- Schools of Medicine and Public Health, University of Washington, Seattle, WA, USA.
- Division of Health Economics, Radboud University Medical Center, Nijmegen, Netherlands.
| | - Philip Louie
- Department of Neurosurgery, Center for Neuroscience and Spine, Virginia Mason Medical Center, Seattle, WA, USA
| | - Aiyush Bansal
- Department of Neurosurgery, Center for Neuroscience and Spine, Virginia Mason Medical Center, Seattle, WA, USA
| | - Michelle Gilbert
- Department of Neurosurgery, Center for Neuroscience and Spine, Virginia Mason Medical Center, Seattle, WA, USA
| | - Venu Nemani
- Department of Neurosurgery, Center for Neuroscience and Spine, Virginia Mason Medical Center, Seattle, WA, USA
| | - Jean-Christophe Leveque
- Department of Neurosurgery, Center for Neuroscience and Spine, Virginia Mason Medical Center, Seattle, WA, USA
| | - Caroline E Drolet
- Department of Neurosurgery, Center for Neuroscience and Spine, Virginia Mason Medical Center, Seattle, WA, USA
| | - Brooks Ohlson
- Department of Neurosurgery, Center for Neuroscience and Spine, Virginia Mason Medical Center, Seattle, WA, USA
| | - Richard Kronfol
- Department of Neurosurgery, Center for Neuroscience and Spine, Virginia Mason Medical Center, Seattle, WA, USA
| | - Joseph Strunk
- Department of Neurosurgery, Center for Neuroscience and Spine, Virginia Mason Medical Center, Seattle, WA, USA
| | - Kelly Cornett-Gomes
- Department of Neurosurgery, Center for Neuroscience and Spine, Virginia Mason Medical Center, Seattle, WA, USA
| | - Andrew Friedman
- Department of Neurosurgery, Center for Neuroscience and Spine, Virginia Mason Medical Center, Seattle, WA, USA
| | - Devon LeFever
- Department of Neurosurgery, Center for Neuroscience and Spine, Virginia Mason Medical Center, Seattle, WA, USA
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van der Poort EKJ, Kidanemariam M, Moriates C, Rakers MM, Tsevat J, Schroijen M, Atsma DE, van den Akker-van Marle ME, Bos WJW, van den Hout WB. How to Use Costs in Value-Based Healthcare: Learning from Real-life Examples. J Gen Intern Med 2024; 39:683-689. [PMID: 38135776 DOI: 10.1007/s11606-023-08423-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/07/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Healthcare organizations measure costs for business operations but do not routinely incorporate costs in decision-making on the value of care. AIM Provide guidance on how to use costs in value-based healthcare (VBHC) delivery at different levels of the healthcare system. SETTING AND PARTICIPANTS Integrated practice units (IPUs) for diabetes mellitus (DM) and for acute myocardial infarction (AMI) at the Leiden University Medical Center and a collaboration of seven breast cancer IPUs of the Santeon group, all in the Netherlands. PROGRAM DESCRIPTION AND EVALUATION VBHC aims to optimize care delivery to the patient by understanding how costs relate to outcomes. At the level of shared decision-making between patient and clinician, yearly check-up consultations for DM type I were analyzed for patient-relevant costs. In benchmarking among providers, quantities of cost drivers for breast cancer care were assessed in scorecards. In continuous learning, cost-effectiveness analysis was compared with radar chart analysis to assess the value of telemonitoring in outpatient follow-up. DISCUSSION Costs vary among providers in healthcare, but also between provider and patient. The joint analysis of outcomes and costs using appropriate methods helps identify and optimize the aspects of care that drive desired outcomes and value.
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Affiliation(s)
- Esmée K J van der Poort
- Department of Biomedical Data Sciences, Section of Medical Decision-Making, Leiden University Medical Center, Leiden, The Netherlands.
| | - Martha Kidanemariam
- Department of Biomedical Data Sciences, Section of Medical Decision-Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Christopher Moriates
- Department of Internal Medicine, Dell Medical School, University of Texas, Austin, TX, USA
- Department of Medical Education, Dell Medical School, University of Texas, Austin, TX, USA
| | - Margot M Rakers
- National eHealth Living Lab, Leiden University Medical Center, Leiden, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Joel Tsevat
- Department of Medicine and ReACH Center, Joe R. & Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Marielle Schroijen
- Department of Internal Medicine, Section of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
| | - Douwe E Atsma
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - M Elske van den Akker-van Marle
- Department of Biomedical Data Sciences, Section of Medical Decision-Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine, Section of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Wilbert B van den Hout
- Department of Biomedical Data Sciences, Section of Medical Decision-Making, Leiden University Medical Center, Leiden, The Netherlands
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Mangenah C, Sibanda EL, Maringwa G, Sithole J, Gudukeya S, Mugurungi O, Hatzold K, Terris-Prestholt F, Maheswaran H, Thirumurthy H, Cowan FM. Provider and female client economic costs of integrated sexual and reproductive health and HIV services in Zimbabwe. PLoS One 2024; 19:e0291082. [PMID: 38346046 PMCID: PMC10861069 DOI: 10.1371/journal.pone.0291082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/22/2023] [Indexed: 02/15/2024] Open
Abstract
A retrospective facility-based costing study was undertaken to estimate the comparative cost per visit of five integrated sexual and reproductive health and HIV (human immuno-deficiency virus) services (provider perspective) within five clinic sites. These five clinics were part of four service delivery models: Non-governmental-organisation (NGO) directly managed model (Chitungwiza and New Africa House sites), NGO partner managed site (Mutare site), private-public-partnership (PPP) model (Chitungwiza Profam Clinic), and NGO directly managed outreach (operating from New Africa House site. In addition client cost exit interviews (client perspective) were conducted among 856 female clients exiting integrated services at three of the sites. Our costing approach involved first a facility bottom-up costing exercise (February to April 2015), conducted to quantify and value each resource input required to provide individual SRH and HIV services. Secondly overhead financial expenditures were allocated top-down from central office to sites and then respective integrated service based on pre-defined allocation factors derived from both the site facility observations and programme data for the prior 12 months. Costs were assessed in 2015 United States dollars (USD). Costs were assessed for HIV testing and counselling, screening and treatment of sexually transmitted infections, tuberculosis screening with smear microscopy, family planning, and cervical cancer screening and treatment employing visual inspection with acetic acid and cervicography and cryotherapy. Variability in costs per visit was evident across the models being highest for cervical cancer screening and cryotherapy (range: US$6.98-US$49.66). HIV testing and counselling showed least variability (range; US$10.96-US$16.28). In general the PPP model offered integrated services at the lowest unit costs whereas the partner managed site was highest. Significant client costs remain despite availability of integrated sexual and reproductive health and HIV services free of charge in our Zimbabwe study setting. Situating services closer to communities, incentives, transport reimbursements, reducing waiting times and co-location of sexual and reproductive health and HIV services may help minimise impact of client costs.
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Affiliation(s)
- Collin Mangenah
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Euphemia L. Sibanda
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Galven Maringwa
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | | | | | - Karin Hatzold
- Population Services International, Washington DC, United States of America
| | | | | | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Frances M. Cowan
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Sanghvi J, Qian D, Olumuyide E, Mokuolu DC, Keswani A, Morewood GH, Burnett G, Park CH, Gal JS. Scoping Review: Anesthesiologist Involvement in Alternative Payment Models, Value Measurement, and Nonclinical Capabilities for Success in the United States of America. Anesth Analg 2024:00000539-990000000-00734. [PMID: 38324349 DOI: 10.1213/ane.0000000000006763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
The US healthcare sector is undergoing significant payment reforms, leading to the emergence of Alternative Payment Models (APMs) aimed at improving clinical outcomes and patient experiences while reducing costs. This scoping review provides an overview of the involvement of anesthesiologists in APMs as found in published literature. It specifically aims to categorize and understand the breadth and depth of their participation, revolving around 3 main axes or "Aims": (1) shaping APMs through design and implementation, (2) gauging the value and quality of care provided by anesthesiologists within these models, and (3) enhancing nonclinical abilities of anesthesiologists for promoting more value in care. To map out the existing literature, a comprehensive search of relevant electronic databases was conducted, yielding a total of 2173 articles, of which 24 met the inclusion criteria, comprising 21 prospective or retrospective cohort studies, 2 surveys, and 1 case-control cohort study. Eleven publications (45%) discussed value-based, bundled, or episode-based payments, whereas the rest discussed non-payment-based models, such as Enhanced Recovery After Surgery (7 articles, 29%), Perioperative Surgical Home (4 articles, 17%), or other models (3 articles, 13%).The review identified key themes related to each aim. The most prominent themes for aim 1 included protocol standardization (16 articles, 67%), design and implementation leadership (8 articles, 33%), multidisciplinary collaboration (7 articles, 29%), and role expansion (5 articles, 21%). For aim 2, the common themes were Process-Based & Patient-Centric Metrics (1 article, 4%), Shared Accountability (3 articles, 13%), and Time-Driven Activity-Based Costing (TDABC) (3 articles, 13%). Furthermore, we identified a wide range of quality metrics, spanning 8 domains that were used in these studies to evaluate anesthesiologists' performance. For aim 3, the main extracted themes included Education on Healthcare Transformation and Policies (3 articles, 13%), Exploring Collaborative Leadership Skills (5 articles, 21%), and Embracing Advanced Analytics and Data Transparency (4 articles, 17%).Findings revealed the pivotal role of anesthesiologists in the design, implementation, and refinement of these emerging delivery and payment models. Our results highlight that while payment models are shifting toward value, patient-centered metrics have yet to be widely accepted for use in measuring quality and affecting payment for anesthesiologists. Gaps remain in understanding how anesthesiologists assess their direct impact and strategies for enhancing the sustainability of anesthesia practices. This review underscores the need for future research contributing to the successful adaptation of clinical practices in this new era of healthcare delivery.
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Affiliation(s)
| | | | | | - Deborah C Mokuolu
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Aakash Keswani
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gordon H Morewood
- Department of Anesthesiology, Temple University Health System, Philadelphia, Pennsylvania
| | - Garrett Burnett
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Chang H Park
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jonathan S Gal
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Busschaert SL, Kimpe E, Barbé K, De Ridder M, Putman K. Introduction of ultra-hypofractionation in breast cancer: Implications for costs and resource use. Radiother Oncol 2024; 190:110010. [PMID: 37956888 DOI: 10.1016/j.radonc.2023.110010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/14/2023] [Accepted: 11/04/2023] [Indexed: 11/15/2023]
Abstract
PURPOSE A shift towards (ultra-)hypofractionated breast irradiation can have important implications for the practice of contemporary radiation oncology. This paper presents a systematic analysis of the impact of different fractionation schedules on multiple key performance indicators, namely resource use, costs, work times, throughput and waiting times. MATERIALS AND METHODS Time-driven activity-based costing (TD-ABC) is applied to calculate the costs and resources consumed where the perspective of the radiotherapy department in adopted. Three fractionation regimens are considered: ultra-hypofractionation (5 x 5.2 Gy, UHF), moderate hypofractionation (15 x 2.67 Gy, HF) and conventional fractionation (25 x 2 Gy, CF). Subsequently, a discrete event simulation (DES) model of the radiotherapy care pathway is developed and scenarios are compared in which the following factors are varied: distribution of fractionation regimens, patient volume and operating hours. RESULTS The application of (U)HF can permit radiotherapy departments to reduce the use of scarce resources, realise work time and cost savings, increase throughput and reduce waiting times. The financial advantages of (U)HF are, however, reduced in cases of excess capacity and cost savings may therefore be limited in the short-term. Moreover, although an extension of operating hours has favourable effects on throughput and waiting times, it may also reduce cost differences between fractionation schedules by increasing the capacity of resources. CONCLUSION By providing an in-depth analysis of the consequences associated with a shift towards (U)HF in breast cancer, the present study demonstrates how a DES model based on TD-ABC costing can assist radiotherapy professionals in making data-driven decisions.
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Affiliation(s)
- Sara-Lise Busschaert
- Department of Public Health, Vrije Universiteit Brussel, Laarbeeklaan, 101 - 1090 Brussels, Belgium.
| | - Eva Kimpe
- Department of Public Health, Vrije Universiteit Brussel, Laarbeeklaan, 101 - 1090 Brussels, Belgium
| | - Kurt Barbé
- Department of Public Health, Vrije Universiteit Brussel, Laarbeeklaan, 101 - 1090 Brussels, Belgium
| | - Mark De Ridder
- Department of Radiotherapy, Universitair Ziekenhuis Brussel, Laarbeeklaan, 101 - 1090 Brussels, Belgium
| | - Koen Putman
- Department of Public Health, Vrije Universiteit Brussel, Laarbeeklaan, 101 - 1090 Brussels, Belgium; Department of Radiotherapy, Universitair Ziekenhuis Brussel, Laarbeeklaan, 101 - 1090 Brussels, Belgium
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Iachecen F, Dallagassa MR, Portela Santos EA, Carvalho DR, Ioshii SO. Is it possible to automate the discovery of process maps for the time-driven activity-based costing method? A systematic review. BMC Health Serv Res 2023; 23:1408. [PMID: 38093275 PMCID: PMC10720189 DOI: 10.1186/s12913-023-10411-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 11/30/2023] [Indexed: 12/17/2023] Open
Abstract
OBJECTIVES The main objective of this manuscript was to identify the methods used to create process maps for care pathways that utilized the time-driven activity-based costing method. METHODS This is a systematic mapping review. Searches were performed in the Embase, PubMed, CINAHL, Scopus, and Web of Science electronic literature databases from 2004 to September 25, 2022. The included studies reported practical cases from healthcare institutions in all medical fields as long as the time-driven activity-based costing method was employed. We used the time-driven activity-based costing method and analyzed the created process maps and a qualitative approach to identify the main fields. RESULTS A total of 412 studies were retrieved, and 70 articles were included. Most of the articles are related to the fields of orthopedics and childbirth-related to hospital surgical procedures. We also identified various studies in the field of oncology and telemedicine services. The main methods for creating the process maps were direct observational practices, complemented by the involvement of multidisciplinary teams through surveys and interviews. Only 33% of the studies used hospital documents or healthcare data records to integrate with the process maps, and in 67% of the studies, the created maps were not validated by specialists. CONCLUSIONS The application of process mining techniques effectively automates models generated through clinical pathways. They are applied to the time-driven activity-based costing method, making the process more agile and contributing to the visualization of high degrees of variations encountered in processes, thereby making it possible to enhance and achieve continual improvements in processes.
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Affiliation(s)
- Franciele Iachecen
- Graduate Program in Health Technology, Pontifícia Universidade Católica do Paraná., 1155, Imaculada Conceição st., Curitiba, Paraná, 80215-90, Brazil.
| | - Marcelo Rosano Dallagassa
- Graduate Program in Health Technology, Pontifícia Universidade Católica do Paraná., 1155, Imaculada Conceição st., Curitiba, Paraná, 80215-90, Brazil
| | | | - Deborah Ribeiro Carvalho
- Graduate Program in Health Technology, Pontifícia Universidade Católica do Paraná., 1155, Imaculada Conceição st., Curitiba, Paraná, 80215-90, Brazil
| | - Sérgio Ossamu Ioshii
- Graduate Program in Health Technology, Pontifícia Universidade Católica do Paraná., 1155, Imaculada Conceição st., Curitiba, Paraná, 80215-90, Brazil
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Denis A, Montreuil J, Bouklouch Y, Reindl R, Berry GK, Harvey EJ, Bernstein M. Hospital episode-of-care costs for hip fractures: an activity-based costing analysis. OTA Int 2023; 6:e295. [PMID: 38053755 PMCID: PMC10695580 DOI: 10.1097/oi9.0000000000000295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/14/2023] [Indexed: 12/07/2023]
Abstract
Background Despite the large impact of hip fracture care on hospital budgets, accurate episode-of-care costs (EOCC) calculations for this injury remains a challenge. The objective of this article was to assess EOCC for geriatric patients with hip fractures using an activity-based costing methodology and identify intraoperative, perioperative, and patient-specific factors associated with higher EOCC. Material and Methods This is a retrospective cohort study involving a total of 109 consecutive patients with hip fracture treated surgically at a Canadian level-1 trauma center from April 2018 to February 2019. Clinical and demographic data were extracted through the institution's centralized data warehouse. Data acquisition also included direct and indirect costs per episode of care, adverse events, and precise temporal data. Results The median total EOCC was $13,113 (interquartile range 6658), excluding physician fees. Out of the total cost, 75% was attributed to direct costs, which represented a median expenditure of $9941. The median indirect cost of the EOCC was $3322. Based on the multivariate analysis, patients not operated within the 48 hours guidelines had an increased length of stay by 5.7 days (P = 0.003), representing an increase in EOCC of close to 5000$. Higher American Society of Anesthesiology (ASA) scores were associated with elevated EOCC. Conclusion The cost of managing a patient with geriatric hip fracture from arrival in the emergency department to discharge from surgical ward represented $13,113. Main factors influencing the EOCC included adherence to the 48-hour benchmark surgical delay and ASA score. High-quality costing data are vital in assessing health care spending, conducting cost effectiveness analyses, and ultimately in guiding policy decisions. Level of Evidence Level III (3), retrospective cohort study.
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Affiliation(s)
- Antoine Denis
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | | | - Yasser Bouklouch
- McGill University Health Center—Research Institute, Montreal, QC, Canada
| | - Rudolf Reindl
- McGill Division of Orthopaedic Surgery, Montreal, QC, Canada
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Ki Y, McAleavey AA, Moger TA, Moltu C. Cost structure in specialist mental healthcare: what are the main drivers of the most expensive episodes? Int J Ment Health Syst 2023; 17:37. [PMID: 37946305 PMCID: PMC10633930 DOI: 10.1186/s13033-023-00606-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 10/06/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Mental disorders are one of the costliest conditions to treat in Norway, and research into the costs of specialist mental healthcare are needed. The purpose of this article is to present a cost structure and to investigate the variables that have the greatest impact on high-cost episodes. METHODS Patient-level cost data and clinic information during 2018-2021 were analyzed (N = 180,220). Cost structure was examined using two accounting approaches. A generalized linear model was used to explain major cost drivers of the 1%, 5%, and 10% most expensive episodes, adjusting for patients' demographic characteristics [gender, age], clinical factors [length of stay (LOS), admission type, care type, diagnosis], and administrative information [number of planned consultations, first hospital visits, interval between two hospital episode]. RESULTS One percent of episodes utilized 57% of total resources. Labor costs accounted for 87% of total costs. The more expensive an episode was, the greater the ratio of the inpatient (ward) cost was. Among the top-10%, 5%, and 1% most expensive groups, ward costs accounted for, respectively, 89%, 93%, and 99% of the total cost, whereas the overall average was 67%. Longer LOS, ambulatory services, surgical interventions, organic disorders, and schizophrenia were identified as the major cost drivers of the total cost, in general. In particular, LOS, ambulatory services, and schizophrenia were the factors that increased costs in expensive subgroups. The "first hospital visit" and "a very short hospital re-visit" were associated with a cost increase, whereas "the number of planned consultations" was associated with a cost decrease. CONCLUSIONS The specialist mental healthcare division has a unique cost structure. Given that resources are utilized intensively at the early stage of care, improving the initial flow of hospital care can contribute to efficient resource utilization. Our study found empirical evidence that planned outpatient consultations may be associated with a reduced health care burden in the long-term.
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Affiliation(s)
- Yeujin Ki
- Department of Research and Innovation, Helse Førde, Førde, Norway.
| | - Andrew Athan McAleavey
- Department of Research and Innovation, Helse Førde, Førde, Norway
- Department of Health and Caring Sciences, Western Norway University of Applied Science, Bergen, Norway
| | - Tron Anders Moger
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
- Section of Medical Statistics, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Christian Moltu
- Department of Psychiatry, Helse Førde, Førde, Norway
- Department of Health and Caring Sciences, Western Norway University of Applied Science, Bergen, Norway
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Xiang D, Xia X, Liang D. Developing and evaluating an interprofessional shared decision-making care model for patients with perinatal depression in maternal care in urban China: a study protocol. BMC PRIMARY CARE 2023; 24:230. [PMID: 37919671 PMCID: PMC10623702 DOI: 10.1186/s12875-023-02179-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 10/11/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND The majority of patients with perinatal depression (PND) in China do not receive adequate treatment. As forming a therapeutic alliance with patients is crucial for depression treatment, shared decision-making (SDM) shows promise in promoting patients' uptake of evidence-based mental health services, but its impact on patient outcomes and implementation in real-world maternal care remain uncertain. Therefore, this study aims to develop and evaluate an interprofessional shared decision-making (IP-SDM) model for PND to enhance maternal mental health services. METHODS This study contains four research phases: feasibility testing (Phase 1), toolkit development (Phase 2), usability evaluation (Phase 3), and effectiveness evaluation (Phase 4). During the development stage, focus group interviews will be conducted with expectant and new mothers, as well as maternal care providers for feasibility testing. A toolkit, including a patient decision aid along with its user guide and training materials, will be developed based on the findings of Phase 1 and syntheses of up-to-date evidence and appraised by the Delphi method. Additionally, a cognitive task analysis will be used for assessing the usability of the toolkit. During the evaluation stage, a prospective randomized controlled trial embedded in a mixed methods design will be used to evaluate the effectiveness and cost-effectiveness of the IP-SDM care model. The study targets to recruit 410 expectant and new mothers who screen positive for depression. They will be randomly assigned to either an intervention group or a control group in a 1:1 ratio. Participants in the intervention group will receive decision aid, decision coaching, and clinical consultation, in addition to usual services, while the control group will receive usual services. The primary outcome is the quality of decision-making process, and the secondary outcomes include SDM, mental health service utilization and costs, depressive symptoms, and health-related quality of life. In-depth interviews will be used to explore the facilitating and hindering factors of SDM. DISCUSSION This study will develop an IP-SDM care model for PND that can be implemented in maternal care settings in China. This study will contribute to the understanding of how SDM impacts mental health outcomes and facilitate the integration of mental health services into maternal care. TRIAL REGISTRATION ChiCTR2300072559. Registered on 16 June 2023.
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Affiliation(s)
- Defang Xiang
- School of Public Health, National Health Commission Key Laboratory of Health Technology Assessment, Fudan University, Shanghai, China
| | - Xian Xia
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.
| | - Di Liang
- School of Public Health, National Health Commission Key Laboratory of Health Technology Assessment, Fudan University, Shanghai, China.
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Livingston N, Lindahl A, McConnell J, Chouman A, Day CS. Do Orthopaedic Virtual Clinic Visits Demonstrate Cost and Time Efficiencies Compared With In-person Visits? Clin Orthop Relat Res 2023; 481:2080-2090. [PMID: 37624757 PMCID: PMC10566797 DOI: 10.1097/corr.0000000000002813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/14/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND There are numerous reasons for the increased use of telemedicine in orthopaedic surgery, one of which is the perception that virtual visits are more cost-effective than in-person visits. However, to our knowledge, no studies have compared the cost and time investment of virtual versus in-person visits using the time-driven activity-based costing (TDABC) method. Unlike methods that estimate cost based on charges for services rendered, TDABC provides a more precise measurement of costs, which is essential for assessing cost-effective innovations and moving to value-based healthcare. QUESTIONS/PURPOSES (1) Are virtual visits less costly than analogous in-person visits, as measured by TDABC? (2) Does TDABC yield cost estimates that are lower or higher than the ratio of costs to charges (RCC), which is a simple, frequently used costing method? (3) Do the total time commitments of healthcare personnel, and that of the surgeon specifically, vary between the virtual and in-person settings? METHODS Patients for this prospective, observational study were recruited from the practices of the highest-volume virtual-visit surgeons of three subspecialties (joints, hand, and sports) in a multihospital, tertiary-care academic institution in a metropolitan area in the Midwestern United States. Each surgeon had at least 10 years of clinical practice. Between June 2021 and September 2021, we analyzed both in-person and virtual return visits with patients who had an established relationship with the surgeon, because this represented the most frequent type of virtual visits and enabled a direct comparison between the two settings. New patients were not included in the study because of the limited availability of new-patient virtual visits; such patients often benefit from in-person physical examinations and on-site imaging. Additionally, patients seen for routine postoperative care were excluded because they were primarily seen in person by a physician assistant. Data were acquired during this period until 90 in-person and 90 virtual visits were collected according to selection criteria; no patients were lost to follow-up. Distinct process maps, which represent the steps involved in a clinic visit used to measure healthcare personnel time invested, were constructed for in-person and virtual clinic visits and used to compare total personnel and surgeon time spent. To calculate TDABC-derived costs, time allocated by personnel to complete each step was measured and used to calculate cost based on each personnel member's yearly salary. From the accounting department of our hospital, we acquired RCC cost data according to the level of service for a return visit. RESULTS The total median cost, as measured by TDABC, was USD 127 (IQR USD 111 to 163) for an in-person visit and USD 140 (IQR USD 113 to 205) for a virtual visit (median difference USD 13; p = 0.16). RCC overestimated TDABC-calculated direct variable cost in five of six service levels (in-person levels 3, 4, and 5 and virtual levels 3 and 5) by a range of USD 25 to 88. Additionally, we found that virtual visits consumed 4 minutes less of total personnel time (in-person: 17 minutes [IQR 13.5 to 23.5 minutes], virtual: 13 minutes [IQR 11 to 19 minutes]; p < 0.001); however, this difference in personnel time did not equate to cost savings because surgeons spent 2 minutes longer on virtual visit activities than they did on in-person activities (in-person: 6 minutes [IQR 4.5 to 9.5 minutes], virtual: 8 minutes [IQR 5.5 to 13 minutes]; p = 0.003). CONCLUSION Orthopaedic virtual visits did not deliver cost savings compared with in-person visits because surgeons spent more time on virtual visits and participated in virtual visits at the clinical site. Additionally, as anticipated, RCC overestimated costs as calculated by TDABC. These findings suggest that cost is not a primary advantage of transitioning to virtual visits, and that factors such as patient preference and satisfaction should be considered instead. LEVEL OF EVIDENCE Level II, economic and decision analysis.
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Affiliation(s)
| | - Alex Lindahl
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Jack McConnell
- Wayne State University School of Medicine, Detroit, MI, USA
| | - Ahmad Chouman
- Wayne State University School of Medicine, Detroit, MI, USA
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de Silva Etges APB, Liu HH, Jones P, Polanczyk CA. Value-based Reimbursement as a Mechanism to Achieve Social and Financial Impact in the Healthcare System. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2023; 10:100-103. [PMID: 37928822 PMCID: PMC10621730 DOI: 10.36469/001c.89151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 10/15/2023] [Indexed: 11/07/2023]
Abstract
Value-based reimbursement strategies have been considered in the continuous search for establishing a sustainable healthcare system. For models that have been already implemented, success is demonstrated according to specific details of the patients' consumption profile based on their clinical condition and the risk balance among all the stakeholders. From fee-for-service to value-based bundled payment strategies, the manner in which accurate patient-level cost and outcome information are used varies, resulting in different risk agreements between stakeholders. A thorough understanding of value-based reimbursement agreements that views such agreements as a mechanism for risk management is critical to the task of ensuring that the healthcare system generates social impacts while ensuring financial sustainability. This perspective article focuses on a critical analysis of the impact of value-based reimbursement strategies on the healthcare system from a social and financial perspective. A critical analysis of the literature about value-based reimbursement was used to identify how these strategies impact healthcare systems. The literature analysis was followed by the conceptual description of value-based reimbursement agreements as mechanisms for achieving social and financial impacts on the healthcare system. There is no single successful path toward payment reform. Payment reform is used as a strategy to re-engineer the way in which the system is organized to provide care to patients, and its successful implementation leads to cultural, social, and financial changes. Stakeholders have reached consensus regarding the claim that the use of value reimbursement strategies and business models could increase efficiency and generate social impact by reducing healthcare inequity and improving population health. However, the successful implementation of such new strategies involves financial and social risks that require better management by all the stakeholders. The use of cutting-edge technologies are essential advances to manage these risks and must be paired with strong leadership focusing on the directive to improve population health and, consequently, value. Payment reform is used as a mechanism to re-engineer how the system is organized to deliver care to patients, and its successful implementation is expected to result in social and financial modifications to the healthcare system.
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Affiliation(s)
- Ana Paula Beck de Silva Etges
- Avant-garde Health, Boston, Massachusetts
- National Institute of Science and Technology for Health Technology Assessment, Porto Alegre, Brazil
- Graduate Program in Epidemiology Universidade Federal do Rio Grande do Sul School of Medicine, Porto Alegre, Brazil
| | | | | | - Carisi A Polanczyk
- National Institute of Science and Technology for Health Technology Assessment, Porto Alegre, Brazil
- Graduate Program in Epidemiology Universidade Federal do Rio Grande do Sul School of Medicine, Porto Alegre, Brazil
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Acquilano SC, Forcino RC, Schubbe D, Engel J, Tomaino M, Johnson LC, Durand MA, Elwyn G. The Costs of Implementing a Conversation Aid for Uterine Fibroids in Multiple Health Care Settings. Med Care 2023; 61:689-698. [PMID: 37943524 PMCID: PMC10478675 DOI: 10.1097/mlr.0000000000001897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
BACKGROUND Health care organizations considering adopting a conversation aid (CA), a type of patient decision aid innovation, need information about the costs of implementation. OBJECTIVES The aims of this study were to: (1) calculate the costs of introducing a CA in a study of supported implementation in 5 gynecologic settings that manage individuals diagnosed with uterine fibroids and (2) estimate the potential costs of future clinical implementation efforts in hypothetical settings. RESEARCH DESIGN We used time-driven activity-based costing to estimate the costs of CA implementation at multiple steps: integration with an electronic health record, preimplementation, implementation, and sustainability. We then estimated costs for 2 disparate hypothetical implementation scenarios. SUBJECTS AND DATA COLLECTION We conducted semistructured interviews with participants and examined internal documentation. RESULTS We interviewed 41 individuals, analyzed 51 documents and 100 emails. Overall total implementation costs over ∼36 months of activities varied significantly across the 5 settings, ranging from $14,157 to $69,134. Factors influencing costs included size/complexity of the setting, urban/rural location, practice culture, and capacity to automate patient identification. Initial investments were substantial, comprising mostly personnel time. Settings that embedded CA use into standard workflows and automated identification of appropriate patients had the lowest initial investment and sustainability costs. Our estimates of the costs of sustaining implementation were much lower than initial investments and mostly attributable to CA subscription fees. CONCLUSION Initiation and implementation of the interventions require significant personnel effort. Ongoing costs to maintain use are much lower and are a small fraction of overall organizational operating costs.
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Lehman VE, Siegel JE, Chiang EN. The Price of Practice Change: Assessing the Cost of Integrating Research Findings Into Clinical Practice. Med Care 2023; 61:675-680. [PMID: 37943522 PMCID: PMC10478678 DOI: 10.1097/mlr.0000000000001873] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
BACKGROUND Clinicians, health care administrators, and implementation scientists know that it takes intentional effort, resources, and implementation strategies to integrate research findings into routine clinical practice. An oft-cited concern for those considering whether and how to implement an evidence-based program is how much it will cost to implement the change. Yet information about the cost of implementation is not often available to health care decision-makers. Teams that received Implementation Award funding from PCORI are conducting implementation projects to promote the uptake of evidence-based practices in health care settings. As part of their implementation efforts, a number of teams have examined the costs of implementation. In this Topical Collection, 5 teams will report their findings on implementation costs and discuss their methods for data collection and analysis. DISCUSSION The teams' costing efforts provide specific information about the costs sites can expect to incur in promoting the uptake of specific evidence-based programs. In addition, the papers illuminate 3 key features of the teams' approaches to measuring the cost of implementation: (1) the use of specific micro-costing methods with time-driven activity-based costing serving as the most popular method; (2) different ways to categorize and organize costs, including a site-based and non-site-based framework; and (3) cost collection challenges experienced by the teams. CONCLUSION The cost of implementation is a critical consideration for organizations seeking to improve practice in accordance with research findings. This Topical Collection describes detailed approaches to providing this type of cost information and highlights insights to be gained from a rigorous focus on implementation cost.
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Ayoub NF, Balakrishnan K, Orloff LA, Noel JE. Time-Driven Activity-Based Cost Comparison of Thyroid Lobectomy and Radiofrequency Ablation. Otolaryngol Head Neck Surg 2023; 169:830-836. [PMID: 37157972 DOI: 10.1002/ohn.360] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/27/2023] [Accepted: 04/15/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Radiofrequency ablation (RFA) of benign thyroid nodules has gained traction for its therapeutic effectiveness, thyroid function preservation, and minimally invasive nature. While a growing body of evidence reports positive outcomes from thyroid RFA, financial comparisons between both procedures remain limited. This analysis aims to more accurately measure the direct cost of thyroid RFA in comparison to thyroid lobectomy. STUDY DESIGN Bottom-up financial cost analysis. SETTING Tertiary endocrine head and neck surgery center. METHODS Time-driven activity-based costing was utilized to obtain unit-based cost estimates. The care cycles for thyroid lobectomy and RFA were defined, and process maps were developed comprising all personnel and work in the care cycle. Time estimates were calculated for all personnel involved, and public government data were used to obtain capacity cost rates for each component of the care cycle. Consumable supply and overhead costs were obtained for both procedures, and overall costs were compared. RESULTS For thyroid lobectomy, total personnel costs were $1087.97, consumable supplies were $942.68, and overhead costs $17,199.10. For thyroid nodule RFA performed in an office setting, the total personnel cost calculated was $379.90, consumable supplies $1315.28, and overhead $7031.20. Overall, the total cost for thyroid lobectomy was $19,229.75 compared to $8726.38 for RFA. CONCLUSION In-office thyroid nodule RFA is associated with lower direct costs than thyroid lobectomy, and overhead is the greatest cost driver for both procedures. If clinical and patient-centered outcomes are comparable, then RFA may provide higher value for appropriately selected patients.
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Affiliation(s)
- Noel F Ayoub
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
- Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Karthik Balakrishnan
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Lisa A Orloff
- Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Julia E Noel
- Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
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Zamorano P, Espinoza MA, Varela T, Abbott T, Tellez A, Armijo N, Suarez F. Economic evaluation of a multimorbidity patient centered care model implemented in the Chilean public health system. BMC Health Serv Res 2023; 23:1041. [PMID: 37773153 PMCID: PMC10543850 DOI: 10.1186/s12913-023-09970-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/26/2023] [Indexed: 10/01/2023] Open
Abstract
Multimorbidity and patient-centered care approaches are growing challenges for health systems and patients. The cost of multimorbidity patients and the transition to a new care strategy is still sightly explored. In Chile, more than 70% of the adult population suffer from multimorbidity, opening an opportunity to implement a Multimorbidity patient-centered care model. The objective of this study was to perform an economic evaluation of the model from the public health system perspective.The methodology used a cost-consequence evaluation comparing seven exposed with seven unexposed primary care centers, and their reference hospitals. It followed three steps. First, we performed a Time-Driven Activity-Based Costing with routinely collected data routinely collected. Second, we run a comparative analysis through a propensity score matching and an estimation of the attributable costs to health services utilization at primary, secondary and tertiary care and health outcomes. Third, we estimated implementation and transaction costs.Results showed savings in aggregate costs of the total population (-0.12 (0.03) p < 0.01) during the period under evaluation. Costs in primary care showed a significant increase, whereas tertiary care showed significant savings. Health outcomes were associated with higher survival in patients under the new care model (HR 0.70 (0.05) p < 0.01). Implementation and transaction costs increased as the number of pilot intervention centers increased, and they represented 0,07% of the total annual budget of the Servicio de Salud Metropolitano Sur Oriente. After three years of piloting, the implementation and transaction cost for the total period was USD 1,838,767 and 393,775, respectively.The study's findings confirm the purpose of the new model to place primary health care at the center of care for people with non-communicable chronic diseases. Thus, it is necessary to consider implementation and transaction costs to introduce a broad health system multimorbidity approach. The health system should assume some of them permanently to guarantee sustainability and facilitate scale-up.
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Affiliation(s)
- Paula Zamorano
- Centro de Innovación en Salud ANCORA UC, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Health Technology Assessment Unit, Center of Clinical Research, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Manuel Antonio Espinoza
- Health Technology Assessment Unit, Center of Clinical Research, Pontificia Universidad Católica de Chile, Santiago, Chile.
- Department of Public health, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Teresita Varela
- Centro de Innovación en Salud ANCORA UC, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Tomas Abbott
- Health Technology Assessment Unit, Center of Clinical Research, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alvaro Tellez
- Centro de Innovación en Salud ANCORA UC, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Department of Family Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Nicolás Armijo
- Health Technology Assessment Unit, Center of Clinical Research, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Suarez
- Unidad de Análisis y Gestión de la información, Servicio de Salud Metropolitano Sur Oriente, Santiago, Chile
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Goh OQM, Xin X, Lim WT, Tan MWJ, Kan JYL, Osman HB, Kee W, Teo TY, Tan WB, Kang ML, Graves N. Economic Evaluation of Novel Models of Care for Patients With Acute Medical Problems. JAMA Netw Open 2023; 6:e2334936. [PMID: 37738050 PMCID: PMC10517377 DOI: 10.1001/jamanetworkopen.2023.34936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 08/13/2023] [Indexed: 09/23/2023] Open
Abstract
Importance During COVID-19, Singapore simultaneously experienced a dengue outbreak, and acute hospitals were under pressure to lower bed occupancy rates. This led to new models of care to treat patients with acute, low-severity medical conditions either at home, in a hospital-at-home (HaH) model, or in a clinic-style setting sited at the emergency department in an ambulatory care team (ACT) model, but a reliable cost analysis for these models is lacking. Objective To compare personnel costs of HaH and ACT with inpatient care. Design, Setting, and Participants In this economic evaluation study, time-driven activity-based costing was used to compare the personnel cost of inpatient care with treating dengue via HaH and treating chest pain via ACT. Participants were patients with nonsevere dengue and chest pain unrelated to a coronary event admitted via the emergency department to the internal medicine service of a tertiary hospital in Singapore. Exposures HaH for dengue and ACT for chest pain. Main Outcomes and Measures A process map was created for the patient journey for a typical patient with each condition. The amount of time personnel spent on delivering care was estimated and the cost per minute determined based on their wages in 2022. The total cost of care was calculated by multiplying the time spent by the per-minute cost of the personnel resource and summing all costs. Results Compared with inpatient care, HaH used 50% less nursing time (418 minutes, 95% uncertainty interval [UI], 370 to 465 minutes) but 80% more medical time (303 minutes, 95% UI, 270 to 338 minutes) per case of dengue. If implemented nationally, HaH would save an estimated 56 828 SGD per year (95% UI, -169 497 to 281 412 SGD [US $41 856; 95% UI, -$124 839 to $207 268]). The probability that HaH is cost saving was 69.2%. Compared with inpatient care, ACT used 15% less nursing time (296 minutes, 95% UI, 257 to 335 minutes) and 50% less medical time (57 minutes, 95% UI, 46 to 69 minutes) per case of chest pain. If implemented nationally, ACT would save an estimated 1 561 185 SGD per year (95% UI, 1 040 666 to 2 086 518 SGD [US $1 149 862; 95% UI, $766 483 to $1 536 786]). The probability that ACT is cost saving was 100%. Conclusions and Relevance This economic evaluation found that the HaH and ACT models decreased the overall personnel cost of care. Reorganizing hospital resources may help hospitals reap the benefits of reduced hospital-acquired infections, improved patient recovery, and reduced hospital bed occupancy rates.
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Affiliation(s)
- Orlanda Q. M. Goh
- Department of Internal Medicine, Singapore General Hospital, Singapore
- Medicine Academic Clinical Programme, SingHealth Duke-NUS, Singapore
- Health Services Research Unit, Singapore General Hospital, Singapore
- SingHealth Duke-NUS Global Health Institute, Singapore
| | - Xiaohui Xin
- Health Services Research Unit, Singapore General Hospital, Singapore
| | - Wan Tin Lim
- Department of Internal Medicine, Singapore General Hospital, Singapore
| | - Michelle W. J. Tan
- Department of Family Medicine and Continuing Care, Singapore General Hospital, Singapore
| | - Juliana Y. L. Kan
- Department of Internal Medicine, Singapore General Hospital, Singapore
| | - Hartini Bte Osman
- Department of Nursing Administration, Singapore General Hospital, Singapore
| | - Wanyi Kee
- Department of Internal Medicine, Singapore General Hospital, Singapore
| | - Tse Yean Teo
- Department of Internal Medicine, Singapore General Hospital, Singapore
| | - Wee Boon Tan
- Population Health and Integrated Care Office, Singapore General Hospital
| | - Mei Ling Kang
- Department of Internal Medicine, Singapore General Hospital, Singapore
- Department of Infectious Diseases, Singapore General Hospital, Singapore
| | - Nicholas Graves
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore
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Jayakumar P, Mills Z, Triana B, Moxham J, Olmstead T, Wallace S, Bozic K, Koenig K. A Model for Evaluating Total Costs of Care and Cost Savings of Specialty Condition-Based Care for Hip and Knee Osteoarthritis in an Integrated Practice Unit. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1363-1371. [PMID: 37236394 DOI: 10.1016/j.jval.2023.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 05/04/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVES The viability of specialty condition-based care via integrated practice units (IPUs) requires a comprehensive understanding of total costs of care. Our primary objective was to introduce a model to evaluate costs and potential costs savings using time-driven activity-based costing comparing IPU-based nonoperative management with traditional nonoperative management and IPU-based operative management with traditional operative management for hip and knee osteoarthritis (OA). Secondarily, we assess drivers of incremental cost differences between IPU-based care and traditional care. Finally, we model potential cost savings through diverting patients from traditional operative management to IPU-based nonoperative management. METHODS We developed a model to evaluate costs using time-driven activity-based costing for hip and knee OA care pathways within a musculoskeletal IPU compared with traditional care. We identified differences in costs and drivers of cost differences and developed a model to demonstrate potential cost savings through diverting patients from operative intervention. RESULTS Weighted average costs of IPU-based nonoperative management were lower than traditional nonoperative management and lower in IPU-based operative management than traditional operative management. Key drivers of incremental cost savings included care led by surgeons in partnership with associate providers, modified physical therapy programs with self-management, and judicious use of intra-articular injections. Substantial savings were modeled by diverting patients toward IPU-based nonoperative management. CONCLUSIONS Costing models involving musculoskeletal IPUs demonstrate favorable costs and cost savings compared with traditional management of hip or knee OA. More effective team-based care and utilization of evidence-based nonoperative strategies can drive the financial viability of these innovative care models.
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Affiliation(s)
- Prakash Jayakumar
- Department of Surgery and Perioperative Care. University of Texas at Austin, Dell Medical School. Austin, TX, USA.
| | - Zachary Mills
- Department of Surgery and Perioperative Care. University of Texas at Austin, Dell Medical School. Austin, TX, USA
| | | | - Jamie Moxham
- Department of Analytics and Health Economics. Ascension Seton. Austin, TX, USA
| | - Todd Olmstead
- Lyndon B. Johnson School of Public Affairs, University of Texas at Austin, Austin, TX, USA
| | - Scott Wallace
- Value Institute for Health and Care. University of Texas at Austin, Austin, TX, USA
| | - Kevin Bozic
- Department of Surgery and Perioperative Care. University of Texas at Austin, Dell Medical School. Austin, TX, USA
| | - Karl Koenig
- Department of Surgery and Perioperative Care. University of Texas at Austin, Dell Medical School. Austin, TX, USA
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Levy DE, Singh D, Aschbrenner KA, Davies ME, Pelton-Cairns L, Kruse GR. Challenges and recommendations for measuring time devoted to implementation and intervention activities in health equity-focused, resource-constrained settings: a qualitative analysis. Implement Sci Commun 2023; 4:108. [PMID: 37658387 PMCID: PMC10474749 DOI: 10.1186/s43058-023-00491-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 08/24/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND There is little guidance for conducting health equity-focused economic evaluations of evidence-based practices in resource-constrained settings, particularly with respect to staff time use. Investigators must balance the need for low-touch, non-disruptive cost data collection with the need for data on providing services to priority subpopulations. METHODS This investigation took place within a pilot study examining the implementation of a bundled screening intervention combining screening for social determinants of health and colorectal cancer at four federally qualified health centers (FQHCs) in the Boston metropolitan area. Methods for collecting data on personnel costs for implementation and intervention activities, including passive (automatic) and active (non-automatic, requiring staff time and effort) data collection, as well as three alternate wordings for self-reporting time-use, were evaluated qualitatively using data collected through interviews with FQHC staff (including clinicians, population health staff, and community health workers) and assessments of data completeness. RESULTS Passive data collection methods were simple to execute and resulted in no missing data, but missed implementation and intervention activities that took place outside planned meetings. Active cost data collection using spreadsheets was simple for users when applied to care processes already tracked in this fashion and yielded accurate time use data. However, for tasks where this was not typical, and when tasks were broken up over multiple sessions, spreadsheets were more challenging to use. Questions asking about time use for a typical rather than specific time period, and for typical patients, yielded the most reliable and actionable data. Still, even the best-performing question had substantial variability in time use estimates. Participants noted that patient characteristics of interest for equity-focused research, including language spoken, adverse social determinants of health, and issues related to poverty or mental health, all contributed significantly to this variability. CONCLUSIONS Passively collected time use data are the least burdensome and should be pursued in research efforts when possible, but should be accompanied by qualitative assessments to ensure the data are an accurate reflection of effort. When workflows are already tracked by active data collection, these are also strong data collection methods. Self-reported time use will be most accurate when questions inquire about "typical" tasks and specific types of patients.
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Affiliation(s)
- Douglas E Levy
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital, 100 Cambridge St., Suite 1600, Boston, MA, 02114, USA.
- Harvard Medical School, Boston, MA, 02115, USA.
| | - Deepinder Singh
- Kraft Center for Community Health, Massachusetts General Hospital, 125 Nashua St, Boston, MA, 02114, USA
| | - Kelly A Aschbrenner
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, 46 Centerra Parkway, Lebanon, NH, 03766, USA
| | - Madeline E Davies
- Kraft Center for Community Health, Massachusetts General Hospital, 125 Nashua St, Boston, MA, 02114, USA
| | - Leslie Pelton-Cairns
- Massachusetts League of Community Health Centers, 40 Court St, Boston, MA, 02108, USA
| | - Gina R Kruse
- Harvard Medical School, Boston, MA, 02115, USA
- Division of General Internal Medicine, Massachusetts General Hospital, 100 Cambridge St., Suite 1600, Boston, MA, 02114, USA
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Koster F, Kok MR, van der Kooij J, Waverijn G, Weel-Koenders AEAM, Barreto DL. Dealing with Time Estimates in Hospital Cost Accounting: Integrating Fuzzy Logic into Time-Driven Activity-Based Costing. PHARMACOECONOMICS - OPEN 2023; 7:593-603. [PMID: 37129793 PMCID: PMC10152001 DOI: 10.1007/s41669-023-00413-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Time-driven activity-based costing (TDABC) can support value-based healthcare (VBHC) programs by providing insights into the actual relationships between time spent by the medical staff and the costs associated with specific care cycles. However, the robustness of time estimates (time variation) as well as the effort required to obtain these estimates are major challenges of the TDABC methodology, given the heterogeneity in patients' needs and the presence of (multi)morbidity. To allow for the variation in time estimates in an efficient manner, this study uses fuzzy logic (FL) to estimate the TDABC model parameters (FL-TDABC). METHODS A standardized care path was used to calculate the annual costs (per patient) and cost drivers of the Rheumatoid arthritis (RA) care cycle following the FL-TDABC methodology. Cost information (2018) was derived from hospital reports concerning financial, human resource and business intelligence data from a Dutch top clinical research hospital, Maasstad Hospital. Time estimates of procedures were obtained by interviewing the medical staff and relevant care activities were extracted from electronic health records. For analytical and validation purposes, FL-TDABC estimates were compared with TDABC and ABC cost estimates. RESULTS The RA care cycle annual costs totaled €1497 per patient (2018 prices) based on the FL-TDABC methodology. Maximum RA cycle costs (€1684) were some 22% higher than minimum costs (€1317) observed from FL-TDABC. Cost drivers explaining the cost variation are predominantly the number of consultations with rheumatologists and pharmacy costs related to RA. Based on TDABC and ABC, annual costs per patient were €1609 and €1604, respectively. CONCLUSIONS The FL-TDABC methodology offers a more precise and efficient estimate of care cycle costs, allowing for the subjective (fuzzy) nature of healthcare time estimates made by the medical staff. As a result, the FL-TDABC provides insight into the practice variation, and hence it can promote the transition from a volume-based system to a VBHC system.
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Affiliation(s)
- Fiona Koster
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Maasstadweg 21, 3079 DZ, Rotterdam, The Netherlands.
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands.
| | - Marc R Kok
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Maasstadweg 21, 3079 DZ, Rotterdam, The Netherlands
| | - Jaco van der Kooij
- Department of Finance and Control, Maasstad Hospital, Rotterdam, The Netherlands
| | - Geeke Waverijn
- Department of Business Intelligence, Maasstad Hospital, Rotterdam, The Netherlands
| | - Angelique E A M Weel-Koenders
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Maasstadweg 21, 3079 DZ, Rotterdam, The Netherlands
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Deirisa Lopes Barreto
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Maasstadweg 21, 3079 DZ, Rotterdam, The Netherlands
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Schneider NB, Roos EC, Staub ALP, Bevilacqua IP, de Almeida AC, de Camargo Martins T, Ramos NB, Loze P, Saute JAM, Etges APBDS, Polanczyk CA. Estimated costs for Duchenne muscular dystrophy care in Brazil. Orphanet J Rare Dis 2023; 18:159. [PMID: 37349725 DOI: 10.1186/s13023-023-02767-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 06/04/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND The economic burden of rare diseases on health systems is still not widely measured, with the generation of accurate information about the costs with medical care for subjects with rare diseases being crucial when defining health policies. Duchenne Muscular Dystrophy (DMD) is the most common form of muscular dystrophy, with new technologies recently being studied for its management. Information about the costs related to the disease in Latin America is scarce, and the objective of this study is to evaluate the annual hospital, home care and transportation costs per patient with DMD treatment in Brazil. RESULTS Data from 27 patients were included, the median annual cost per patient was R$ 17,121 (IQR R$ 6,786; 25,621). Home care expenditures accounted for 92% of the total costs, followed by hospital costs (6%) and transportation costs (2%). Medications and loss of family, and patient's productivity are among the most representative consumption items. When disease worsening due to loss of the ability to walk was incorporated to the analysis, it was shown that wheelchair users account for an incremental cost of 23% compared with non-wheelchair users. CONCLUSIONS This is an original study in Latin America to measure DMD costs using the micro-costing technique. Generating accurate information about costs is crucial to provide health managers with information that could help establish more sustainable policies when deciding upon rare diseases in emerging countries.
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Affiliation(s)
- Nayê Balzan Schneider
- National Institute of Science and Technology for Health Technology Assessment (IATS)- CNPq/Brazil (project: 465518/2014-1), Porto Alegre, Brazil
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Erica Caetano Roos
- Programa de Pós-Graduação em Engenharia de Produção, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Ana Lúcia Portella Staub
- Centro de Pesquisa Clínica, Hospital de Clínicas de Porto Alegre, Neurogenética, Porto Alegre, Brazil
| | | | | | | | | | - Priscilla Loze
- Produtos Roche Químicos e Farmacêuticos S/A, São Paulo, SP, Brazil
| | - Jonas Alex Morales Saute
- Centro de Pesquisa Clínica, Hospital de Clínicas de Porto Alegre, Neurogenética, Porto Alegre, Brazil
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Programa de Pós-Graduação em Medicina: Ciências Médicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Departamento de Medicina Interna, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Serviço de Neurologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Ana Paula Beck da Silva Etges
- National Institute of Science and Technology for Health Technology Assessment (IATS)- CNPq/Brazil (project: 465518/2014-1), Porto Alegre, Brazil.
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
- School of Technology, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil.
| | - Carisi Anne Polanczyk
- National Institute of Science and Technology for Health Technology Assessment (IATS)- CNPq/Brazil (project: 465518/2014-1), Porto Alegre, Brazil
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Departamento de Medicina Interna, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
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Leusder M, van Elten HJ, Ahaus K, Hilders CGJM, van Santbrink EJP. Protocol for improving the costs and outcomes of assistive reproductive technology fertility care pathways: a study using cost measurement and process mining. BMJ Open 2023; 13:e067792. [PMID: 37280027 PMCID: PMC10254617 DOI: 10.1136/bmjopen-2022-067792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 05/21/2023] [Indexed: 06/08/2023] Open
Abstract
INTRODUCTION Value-based healthcare suggests that care outcomes should be evaluated in relation to the costs of delivering that care from the perspective of the provider. However, few providers achieve this because measuring cost is considered complex and elaborate and, further, studies routinely omit cost estimates from 'value' assessments due to lacking data. Consequently, providers are currently unable to steer towards increased value despite financial and performance pressures. This protocol describes the design, methodology and data collection process of a value measurement and process improvement study in fertility care featuring complex care paths with both long and non-linear patient journeys. METHODS AND ANALYSIS We employ a sequential study design to calculate total costs of care for patients undergoing non-surgical fertility care treatments. In doing so, we identify process improvement opportunities and cost predictors and will reflect on the benefits of the information generated for medical leaders. Time-to-pregnancy will be viewed in relation to total costs to determine value. By combining time-driven, activity-based costing with observations and process mining, we trial a method for measuring care costs for large cohorts using electronic health record data. To support this method, we create activity and process maps for all relevant treatments: ovulation induction, intrauterine insemination, in vitro fertilisation (IVF), IVF with intracytoplasmic sperm injection and frozen embryo transfer after IVF. Our study design, by showing how different sources of data can be combined to enable cost and outcome measurements, can be of value to researchers and practitioners looking to measure costs for care paths or entire patient journeys in complex care settings. ETHICS AND DISSEMINATION This study was approved by the ESHPM Research Ethics Review Committee (ETH122-0355) and the Reinier de Graaf Hospital (2022-032). Results will be disseminated through seminars, conferences and peer-reviewed publications.
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Affiliation(s)
- Maura Leusder
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - Kees Ahaus
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Carina G J M Hilders
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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van Elten HJ, Howard SW, De Loo I, Schaepkens F. Reflections on Managing the Performance of Value-Based Healthcare: A Scoping Review. Int J Health Policy Manag 2023; 12:7366. [PMID: 37579381 PMCID: PMC10461846 DOI: 10.34172/ijhpm.2023.7366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 04/07/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Value-based healthcare (VBHC), which can be viewed as a strategy to organize and improve healthcare services, has far-reaching organizational and managerial consequences. It is common managerial practice to support the execution of a strategy by monitoring the ensuing activities. Such monitoring provides feedback and guidance on the execution of these activities to the management of an organization and helps to realize organizational strategies. Monitoring of activities is commonly done by performance management systems. Given the rising attention in the literature and in practice for VBHC, we ask to what extent VBHC is supported by performance management systems in practice, and how we can explain what we find to support further successful implementation of VBHC. METHODS In our scoping review of financial and performance management at the organization or unit-level of healthcare organizations that apply value-based approaches, we identified 1267 unique papers in Embase, Medline, OVID, and Web of Science. After the (double-blinded) title and abstract screening, 398 full-text articles were assessed for further analysis. RESULTS Our review reveals only eleven original papers discussing specifically the integration of VBHC and performance management systems. Almost all the featured applications in these papers focus on a specific project or medical specialty. Only one paper exemplifies how VBHC has been integrated with the performance management systems of a medical institution, and no paper provides a clear link with strategy execution. We ask why this is the case and propose several explanations by studying the extant performance management literature. We see these explanations as issues for further reflection for VBHC practitioners and researchers. CONCLUSION We conclude that one of the reasons for the absence of papers integrating VBHC and performance management systems is formed by the tensions that exist between striving for "the best care" or even for providing "all care that is viably possible" and pursuing greater (financial) efficiency. Implementing VBHC as an important organizational strategy and explicating this strategy in the performance management systems requires that these tensions need to be brought into the fore. When this is not done, we believe that VBHC adoptions that are fully integrated with performance management systems will remain limited in practice.
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Affiliation(s)
| | - Steven W. Howard
- Health Services Administration Department, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ivo De Loo
- Nyenrode Business Universiteit, Breukelen, The Netherlands
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Hilhorst N, Roman E, Borzée J, Deprez E, Hoorens I, Cardoen B, Roodhooft F, Lambert J. Value in psoriasis (IRIS) trial: implementing value-based healthcare in psoriasis management - a 1-year prospective clinical study to evaluate feasibility and value creation. BMJ Open 2023; 13:e067504. [PMID: 37221023 PMCID: PMC10230887 DOI: 10.1136/bmjopen-2022-067504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 05/02/2023] [Indexed: 05/25/2023] Open
Abstract
INTRODUCTION Currently, the healthcare sector is under tremendous financial pressure, and many acknowledge that a dramatic shift is required as the current system is not sustainable. Furthermore, the quality of care that is delivered varies strongly. Several solutions have been proposed of which the conceptual framework known as value-based healthcare (VBHC) is further explored in this study for psoriasis. Psoriasis is a chronic inflammatory skin disease, which is associated with a high disease burden and high treatment costs. The objective of this study is to investigate the feasibility of using the VBHC framework for the management of psoriasis. METHODS AND ANALYSIS This is a prospective clinical study in which new patients attending the psoriasis clinic (PsoPlus) of the Ghent University Hospital will be followed up during a period of 1 year. The main outcome is to determine the value created for psoriasis patients. The created value will be considered as a reflection of the evolution of the value score (ie, the weighted outputs (outcomes) divided by weighted inputs (costs)) obtained using data envelopment analysis. Secondary outcomes are related to comorbidity control, outcome evolution and treatment costs. In addition, a bundled payment scheme will be determined as well as potential improvements in the treatment process. A total of 350 patients will be included in this trial and the study initiation is foreseen on 1 March 2023. ETHICS AND DISSEMINATION This study has been approved by the Ethics Committee of the Ghent University Hospital. The findings of this study will be disseminated by various means: (1) publication in one or more peer-reviewed dermatology and/or management journals, (2) (inter)national congresses, (3) via the psoriasis patient community and (4) through the research team's social media channels. TRIAL REGISTRATION NUMBER NCT05480917.
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Affiliation(s)
- Niels Hilhorst
- Dermatology Research Unit (DRU), Ghent University, Ghent, Belgium
- Department of Dermatology, University Hospital Ghent, Ghent, Belgium
| | - Erin Roman
- Health Care Management Centre, Vlerick Business School, Ghent, Belgium
- Faculty of Economics and Business, Catholic University of Leuven, Leuven, Belgium
| | - Joke Borzée
- Health Care Management Centre, Vlerick Business School, Ghent, Belgium
- Faculty of Economics and Business, Catholic University of Leuven, Leuven, Belgium
| | - Elfie Deprez
- Dermatology Research Unit (DRU), Ghent University, Ghent, Belgium
- Department of Dermatology, University Hospital Ghent, Ghent, Belgium
| | - Isabelle Hoorens
- Dermatology Research Unit (DRU), Ghent University, Ghent, Belgium
- Department of Dermatology, University Hospital Ghent, Ghent, Belgium
| | - Brecht Cardoen
- Health Care Management Centre, Vlerick Business School, Ghent, Belgium
- Faculty of Economics and Business, Catholic University of Leuven, Leuven, Belgium
| | - Filip Roodhooft
- Faculty of Economics and Business, Catholic University of Leuven, Leuven, Belgium
- Accounting and Finance, Vlerick Business School, Ghent, Belgium
| | - Jo Lambert
- Dermatology Research Unit (DRU), Ghent University, Ghent, Belgium
- Department of Dermatology, University Hospital Ghent, Ghent, Belgium
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Rognoni C, Furnari A, Lugli M, Maleti O, Greco A, Tarricone R. Time-Driven Activity-Based Costing for Capturing the Complexity of Healthcare Processes: The Case of Deep Vein Thrombosis and Leg Ulcers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20105817. [PMID: 37239543 DOI: 10.3390/ijerph20105817] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/17/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023]
Abstract
Time-driven activity-based costing (TDABC) is suggested to assess costs within the value-based healthcare approach, but there is a paucity of applications in chronic diseases such as deep vein thrombosis (DVT) and leg ulcers. In this context, we applied TDABC in a cost-effectiveness analysis comparing venous stenting to compression ± anticoagulation (standard of care-SOC) from both hospital and societal perspectives in Italy. TDABC was applied to both treatments to assess costs that were included in a cost-effectiveness model. Clinical inputs were retrieved from the literature and integrated with real-world data. The Incremental Cost Utility Ratio (ICUR) of stenting compared to SOC was EUR 10,270/QALY and EUR 8962/QALY for hospital and societal perspectives, respectively. The mean cost per patient for venous stenting of EUR 5082 was higher than the Diagnosis-Related Group (DRG) reimbursement (EUR 4742). For SOC, an ulcer healing in 3 months costs EUR 1892, of which EUR 302 (16%) is borne by the patient versus a reimbursement of EUR 1132. TDABC showed that venous stenting may be cost-effective compared with SOC but that reimbursement rates may not completely cover the real costs, which are partially sustained by the patients. A more efficient policy for covering the real costs may be beneficial for both clinical centers and patients.
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Affiliation(s)
- Carla Rognoni
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, 20136 Milan, Italy
| | - Alessandro Furnari
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, 20136 Milan, Italy
| | - Marzia Lugli
- National Reference Training Center in Phlebology (NRTCP), Vascular Surgery-Cardiovascular Department, Hesperia Hospital, 41125 Modena, Italy
| | - Oscar Maleti
- National Reference Training Center in Phlebology (NRTCP), Vascular Surgery-Cardiovascular Department, Hesperia Hospital, 41125 Modena, Italy
| | - Alessandro Greco
- Outpatient Wound Care Centre, Local Health Care System, 03100 Frosinone, Italy
| | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, 20136 Milan, Italy
- Department of Social and Political Science, Bocconi University, 20136 Milan, Italy
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Cidav Z, Mandell D, Ingersoll B, Pellecchia M. Programmatic Costs of Project ImPACT for Children with Autism: A Time-Driven Activity Based Costing Study. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2023; 50:402-416. [PMID: 36637638 PMCID: PMC9838366 DOI: 10.1007/s10488-022-01247-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2022] [Indexed: 01/14/2023]
Abstract
Programmatic cost assessment of clinical interventions can inform future dissemination and implementation efforts. We conducted a randomized trial of Project ImPACT (Improving Parents As Communication Teachers) in which community early intervention (EI) providers coached caregivers in techniques to improve young children's social communication skills. We estimated implementation and intervention costs while demonstrating an application of Time-Driven Activity-Based Costing (TDABC). We defined Project ImPACT implementation and intervention as processes that can be broken down successively into a set of procedures. We created process maps for both implementation and intervention delivery. We determined resource use and costs, per unit procedure in the first year of the program, from a payer perspective. We estimated total implementation cost per clinician and per site, intervention cost per child, and provided estimates of total hours spent and associated costs for implementation strategies, intervention activities and their detailed procedures. Total implementation cost was $43,509 per clinic and $14,503 per clinician. Clinician time (60%) and coach time (12%) were the most expensive personnel resources. Implementation coordination and monitoring (47%), ongoing consultation (26%) and clinician training (19%) comprised most of the implementation cost, followed by fidelity assessment (7%), and stakeholder engagement (1%). Per-child intervention costs were $2619 and $9650, respectively, at a dose of one hour per week and four hours per week Project ImPACT. Clinician and clinic leader time accounted for 98% of per child intervention costs. Highest cost intervention activity was ImPACT delivery to parents (89%) followed by assessment for child's ImPACT eligibility (10%). The findings can be used to inform funding and policy decision-making to enhance early intervention options for young children with autism. Uncompensated time costs of clinicians are large which raises practical and ethical concerns and should be considered in planning of implementation initiatives. In program budgeting, decisionmakers should anticipate resource needs for coordination and monitoring activities. TDABC may encourage researchers to assess costs more systematically, relying on process mapping and gathering prospective data on resource use and costs concurrently with their collection of other trial data.
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Affiliation(s)
- Zuleyha Cidav
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - David Mandell
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Brooke Ingersoll
- Department of Psychology, Michigan State University, East Lansing, MI, USA
| | - Melanie Pellecchia
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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47
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Subbe C, Hughes DA, Lewis S, Holmes EA, Kalkman C, So R, Tranka S, Welch J. Value of improving patient safety: health economic considerations for rapid response systems-a rapid review of the literature and expert round table. BMJ Open 2023; 13:e065819. [PMID: 37068893 PMCID: PMC10111929 DOI: 10.1136/bmjopen-2022-065819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 03/26/2023] [Indexed: 04/19/2023] Open
Abstract
OBJECTIVES Failure to rescue deteriorating patients in hospital is a well-researched topic. We aimed to explore the impact of safer care on health economic considerations for clinicians, providers and policymakers. DESIGN We undertook a rapid review of the available literature and convened a round table of international specialists in the field including experts on health economics and value-based healthcare to better understand health economics of clinical deterioration and impact of systems to reduce failure to rescue. RESULTS Only a limited number of publications have examined the health economic impact of failure to rescue. Literature examining this topic lacked detail and we identified no publications on long-term cost outside the hospital following a deterioration event. The recent pandemic has added limited literature on prevention of deterioration in the patients' home.Cost-effectiveness and cost-efficiency are dependent on broader system effects of adverse events. We suggest including the care needs beyond the hospital and loss of income of patients and/or their informal carers as well as sickness of healthcare staff exposed to serious adverse events in the analysis of adverse events. They are likely to have a larger health economic impact than the direct attributable cost of the hospital admission of the patient suffering the adverse event. Premorbid status of a patient is a major confounder for health economic considerations. CONCLUSION In order to optimise health at the population level, we must limit long-term effects of adverse events through improvement of our ability to rapidly recognise and respond to acute illness and worsening chronic illness both in the home and the hospital.
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Affiliation(s)
- Christian Subbe
- Bangor University, School of Medical Sciences, Bangor, UK
- Department of Medicine, Ysbyty Gwynedd, Bangor, UK
| | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Sally Lewis
- National Clinical Director for Value-Based Healthcare & Honorary Professor Swansea University Medical School, Swansea University, Swansea, UK
- National Clinical Director for Value-Based Healthcare, Wales, UK
| | - Emily A Holmes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Cor Kalkman
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ralph So
- Intensive Care and Medical Manager Department Quality, Safety and Innovation, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | | | - John Welch
- Intensive Care, University College London Hospitals NHS Foundation Trust, London, UK
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48
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Morrow C, Woodbury M, Simpson AN, Almallouhi E, Simpson KN. Determining the Marginal Cost Differences of a Telehealth Versus an In-person Occupational Therapy Evaluation Session for Stroke Survivors Using Time-driven Activity-based Costing. Arch Phys Med Rehabil 2023; 104:547-553. [PMID: 36513124 PMCID: PMC10967225 DOI: 10.1016/j.apmr.2022.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 10/31/2022] [Accepted: 11/09/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To estimate the marginal cost differences and care delivery process of a telerehabilitation vs outpatient session. DESIGN This study used a time-driven activity-based costing approach including (1) observation of rehabilitation sessions and creation of manual time stamps, (2) structured and recorded interviews with 2 occupational therapists familiar with outpatient therapy and 2 therapists familiar with telerehabilitation, (3) collection of standard wages for providers, and (4) the creation of an iterative flowchart of both an outpatient and telerehabilitation session care delivery process. SETTING Telerehabilitation and outpatient therapy evaluation. PARTICIPANTS Three therapists familiar with care deliver for telerehabilitation or outpatient therapy (N=3). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Marginal cost difference between telerehabilitation and outpatient therapy evaluations. RESULTS Overall, telerehabilitation ($225.41) was more costly than outpatient therapy ($168.29) per session for a cost difference of $57.12. Primary time drivers of this finding were initial phone calls (0 minutes for OP therapists vs 35 minutes for TR) and post documentation (5 minutes for OP vs 30 minutes for TR) demands for telerehabilitation. CONCLUSIONS Telerehabilitation is an emerging platform with the potential to reduce costs, improve health care inequities, and facilitate better patient outcomes. Improvements in documentation practices, staffing, technology, and reimbursement structuring would allow for a more successful translation.
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Affiliation(s)
- Corey Morrow
- College of Health Professions, Medical University of South Carolina, Charleston, SC; Department of Occupational Therapy, Whitworth University, Spokane, WA.
| | - Michelle Woodbury
- College of Health Professions, Medical University of South Carolina, Charleston, SC
| | - Annie N Simpson
- College of Health Professions, Medical University of South Carolina, Charleston, SC
| | - Eyad Almallouhi
- College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Kit N Simpson
- College of Health Professions, Medical University of South Carolina, Charleston, SC
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Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVES Allocating cost is challenging with traditional hospital accounting. Time-driven activity-based costing (TDABC) is an efficient method to accurately assign cost. We sought to characterize the variation in direct total hospital cost (THC) among both lumbar fusion approaches and surgeons. METHODS Patients were treated with single-level anterior interbody (ALIF), lateral interbody (LLIF), transforaminal interbody (TLIF), instrumented posterolateral (PLF) or in-situ fusion (ISF) for degenerative disease. Process maps were developed for preoperative, intraoperative and postoperative care. THC was composed of implant, medication, other supply, and personnel costs. Linear regression and descriptive statistics were used to analyze THC variation. RESULTS A total of 696 patients underwent surgery by 8 surgeons. Approximately 50% of THC variation was associated with procedure choice while patient characteristics explained 10%. Implants (including biologics) accounted for 45% of cost. With reference to PLF, THC ranged from 0.6x (ISF) to 1.7x (LLIF). Implant cost ranged from 2.5x reference (LLIF) to 0.1x (ISF). There was a 1.7x difference between the highest THC surgeon and the lowest. The fusion type with the highest THC variation was TLIF. The surgeon with the highest TLIF THC was 1.5x more expensive than the surgeon with the lowest. CONCLUSIONS Surgeon-based choices have the greatest effect on THC variation and represent the largest opportunities for cost savings. Primary single-level lumbar fusion THC is driven primarily by fusion type. Implants, including biologics, account for nearly half this cost. Future work should incorporate outcomes data to characterize the differential value conferred by higher THC fusions.
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Affiliation(s)
- Raymond W Hwang
- Department of Orthopaedic Surgery, Tufts University School of Medicine, Boston, MA, USA
- Department of Orthopaedic Surgery, 22313New England Baptist Hospital, Boston, MA, USA
| | - Samuel W Golenbock
- Department of Research, 22313New England Baptist Hospital, Boston, MA, USA
| | - David H Kim
- Department of Orthopaedic Surgery, Tufts University School of Medicine, Boston, MA, USA
- Department of Orthopaedic Surgery, 22313New England Baptist Hospital, Boston, MA, USA
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50
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Pediatric Outpatient Noncontrast Brain MRI: A Time-Driven Activity-Based Costing Analysis at Three U.S. Hospitals. AJR Am J Roentgenol 2023; 220:747-756. [PMID: 36541593 DOI: 10.2214/ajr.22.28490] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND. MRI utilization and the use of sedation or anesthesia for MRI have increased in children. Emerging alternative payment models (APMs) require a detailed understanding of the health system costs of performing these examinations. OBJECTIVE. The purpose of this study was to use time-driven activity-based costing (TDABC) to assess health system costs for outpatient noncontrast brain MRI examinations across three children's hospitals. METHODS. Direct costs for outpatient noncontrast brain MRI examinations at three academic free-standing pediatric hospitals were calculated using TDABC. Examinations were categorized as sedated MRI (i.e., sedation or anesthesia), nonsedated MRI, or limited MRI. Process maps were created to describe patient workflows based on input from key personnel and direct observation. Time durations for each process activity were determined; time stamps from retrospective EMR review were used when possible. Capacity cost rates were calculated for resource types within three cost categories (labor, equipment, and space); cost was calculated in a fourth category (supplies). Resources were allocated to each activity, and the cost of each process step was determined by multiplying step-specific capacity costs by the time required for each step. The costs of all steps were summed to yield a base-case total examination cost. Sensitivity analysis for sedated MRI was performed using minimum and maximum time duration inputs for each activity to yield minimum and maximum costs by hospital. RESULTS. The mean base-case cost for a sedated brain MRI examination was $842 (range, $775-924 across hospitals), for a nonsedated brain MRI examination was $262 (range, $240-285), and for a limited brain MRI examination was $135 (range, $127-141). For all examination types, the largest cost category as well as the largest source of difference in cost between hospitals was labor. Sensitivity analysis found that the greatest influence on overall cost at each hospital was the duration of the MRI acquisition. CONCLUSION. The health system cost of performing a sedated MRI examination was substantially greater than that of performing a nonsedated MRI examination. However, the cost of each individual examination type did not vary substantially among hospitals. CLINICAL IMPACT. Health systems operating within APMs can use this comparative cost information for purposes of cost reduction efforts and establishment of bundled prices.
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