Economic burden of cardiovascular diseases in the European Union: a population-based cost study

BACKGROUND AND AIMS

Cardiovascular disease (CVD) impacts significantly health and social care systems as well as society through premature mortality and disability, with patients requiring care from relatives. Previous pan-European estimates of the economic burden of CVD are now outdated. This study aims to provide novel, up-to-date evidence on the economic burden across the 27 European Union (EU) countries in 2021.

METHODS

Aggregate country-specific resource use data on morbidity, mortality, and health, social and informal care were obtained from international sources, such as the Statistical Office of the European Communities, enhanced by data from the European Society of Cardiology Atlas programme and patient-level data from the Survey of Health, Ageing and Retirement in Europe. Country-specific unit costs were used, with cost estimates reported on a per capita basis, after adjustment for price differentials.

RESULTS

CVD is estimated to cost the EU €282 billion annually, with health and long-term care accounting for €155 billion (55%), equalling 11% of EU-health expenditure. Productivity losses accounted for 17% (€48 billion), whereas informal care costs were €79 billion (28%). CVD represented a cost of €630 per person, ranging from €381 in Cyprus to €903 in Germany. Coronary heart disease accounted for 27% (€77 billion) and cerebrovascular diseases for 27% (€76 billion) of CVD costs.

CONCLUSIONS

This study provides contemporary estimates of the wide-ranging impact of CVD on all aspects of the economy. The data help inform evidence-based policies to reduce the impact of CVD, promoting care access and better health outcomes and economic sustainability.

Cost-effectiveness of WEB Embolization, Coiling and Stent-assisted Coiling for the Treatment of Unruptured Intracranial Aneurysms

PURPOSE

Information about the cost-effectiveness of a certain treatment is relevant for decision-making and healthcare providers. This study compares the cost-effectiveness of the novel Woven Endobridge (WEB) for intracranial aneurysm treatment with conventional coiling and stent-assisted coiling (SAC) from the perspective of the German Statutory Health Insurance.

METHODS

A patient-level simulation was constructed to simulate 55-year-old patients with an unruptured middle cerebral artery aneurysm (size: 3-11 mm) considering WEB treatment, coiling or SAC in terms of morbidity, angiographic outcome, retreatment, procedural and rehabilitation costs and rupture rates. Incremental cost-effectiveness ratios (ICERs) were calculated as costs per quality-adjusted life years (QALYs) and costs per year with neurologic morbidity avoided. Uncertainty was explored with deterministic and probabilistic sensitivity analyses. The majority of data were obtained from prospective multi-center studies and meta-analyses of non-randomized studies.

RESULTS

In the base case, lifetime QALYs were 13.24 for the WEB, 12.92 for SAC and 12.68 for coiling. Lifetime costs were 20,440 € for the WEB, 23,167 € for SAC, and 8200 € for coiling. Compared to coiling, the ICER for the WEB was 21,826 €/QALY, while SAC was absolutely dominated by WEB. Probabilistic sensitivity analysis revealed that at a willingness-to-pay of ≥ 30,000 €/QALY, WEB was the preferred treatment. Deterministic sampling showed that the discount rate, material costs and retreatment rates had the largest impact on the ICERs.

CONCLUSION

The novel WEB showed at least comparable cost-effectiveness to SAC for treatment of broad-based unruptured aneurysms. Considering all three modalities, coiling had the least costs; however this modality is often not appropriate for the treatment of wide-necked aneurysms.

Refining the provider payment system of India's government-funded health insurance programme: an econometric analysis

OBJECTIVES

Reimbursement rates in national health insurance schemes are frequently weighted to account for differences in the costs of service provision. To determine weights for a differential case-based payment system under India's publicly financed national health insurance scheme, the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), by exploring and quantifying the influence of supply-side factors on the costs of inpatient admissions and surgical procedures.

DESIGN

Exploratory analysis using regression-based cost function on data from a multisite health facility costing study-the Cost of Health Services in India (CHSI) Study.

SETTING

The CHSI Study sample included 11 public sector tertiary care hospitals, 27 public sector district hospitals providing secondary care and 16 private hospitals, from 11 Indian states.

PARTICIPANTS

521 sites from 57 healthcare facilities in 11 states of India.

INTERVENTIONS

Medical and surgical packages of PM-JAY.

PRIMARY AND SECONDARY OUTCOME MEASURES

The cost per bed-day and cost per surgical procedure were regressed against a range of factors to be considered as weights including hospital location, presence of a teaching function and ownership. In addition, capacity utilisation, number of beds, specialist mix, state gross domestic product, State Health Index ranking and volume of patients across the sample were included as variables in the models. Given the skewed data, cost variables were log-transformed for some models.

RESULTS

The estimated mean costs per inpatient bed-day and per procedure were 2307 and 10 686 Indian rupees, respectively. Teaching status, annual hospitalisation, bed size, location of hospital and average length of hospitalisation significantly determine the inpatient bed-day cost, while location of hospital and teaching status determine the procedure costs. Cost per bed-day of teaching hospitals was 38-143.4% higher than in non-teaching hospitals. Similarly, cost per bed-day was 1.3-89.7% higher in tier 1 cities, and 19.5-77.3% higher in tier 2 cities relative to tier 3 cities, respectively. Finally, cost per surgical procedure was higher by 10.6-144.6% in teaching hospitals than non-teaching hospitals; 12.9-171.7% higher in tier 1 cities; and 33.4-140.9% higher in tier 2 cities compared with tier 3 cities, respectively.

CONCLUSION

Our study findings support and validate the recently introduced differential provider payment system under the PM-JAY. While our results are indicative of heterogeneity in hospital costs, other considerations of how these weights will affect coverage, quality, cost containment, as well as create incentives and disincentives for provider and consumer behaviour, and integrate with existing price mark-ups for other factors, should be considered to determine the future revisions in the differential pricing scheme.

Original Article: The impacts of DRG payment system on financial balance of multiple trauma: Experiences of three trauma centers in Taiwan

INTRODUCTION

There are concerns regarding the adequacy of applying the diagnosis-related groups (DRG) payment system for multiple traumas (i.e., major diagnostic category 24, MDC-24) patients in Taiwan. Therefore, this study used a multi-center dataset to assess the influence of the DRG payment system on the cost and outcome of multiple trauma care.

MATERIALS AND METHODS

We collected data of all multiple trauma patients from the Trauma Registry of three hospitals from 2014 - 2017. Next, we selected patients who met the criteria of MDC-24 and calculated the corresponding DRG payment. Subsequently, we combined the clinical care information with health insurance information to analyze the problems of applying the DRG payment system to multiple trauma care.

RESULTS

Overall, of 465 cases, 367 met the criteria of MDC-24, and the mean injury severity score (ISS) was high (average 20.1). The total deficit of the polytrauma DRG cases amounted to 131,445 USD, and the average deficit in each case was 397 USD. In the multivariable analysis, higher revised trauma score and specific lower abbreviated Injury Scale (AIS) scores in certain body regions resulted in profits, while increased length of stay in intensive care units, longer operative time, and higher AIS score in the thorax were significantly correlated with deficits in medical costs.

CONCLUSION

Our study revealed that the current DRG payment system results in financial losses for hospitals. Further, the payment grouping of MDC-24 should consider adding more disease severity factors to reduce the financial constraints faced by trauma centers.

Commodification and healthcare in the third sector in England: from gift to commodity-and back?

IMPACT

This article suggests why a different approach may be required for commissioning services from third sector providers than from, say, corporate or public providers. English systems for commissioning third sector providers contain both commodified elements (for example formal procurement, provider competition, commissioner-provider separation) and collaborative, relational elements (for example long-term collaboration, reliance on inter-organizational networks). When the two elements conflicted, commissioners and third sector organizations tended to try to work around the commodified elements in order to preserve and develop the collaborative aspects, which suggests that, in practice, they find de-commodified, collaborative methods better adapted to the commissioning of third sector organizations.

ABSTRACT

When publicly-funded services are outsourced, governments still use multiple governance structures to retain some control over the services provided. Using realist methods the authors systematically compared this aspect of community health activities provided by third sector organizations in six English localities during 2020-2022. Two modes of commissioning coexisted. Commodified commissioning largely embodied Washington consensus models of formal, competitive procurement. A contrasting, collaborative mode of commissioning relied more upon relational, long-term co-operation and networking among organizations. When the two modes conflicted, commissioners often favoured the collaborative mode and sought to adjust their commissioning to make it less commodified.

Challenges of implementing diagnostic-related groups and healthcare promotion in Iran: A strategic applied research

Background and Aim

Implementing the diagnostic-related groups (DRGs) promotes the efficiency of healthcare. Therefore, the present study aimed to identify the challenges facing implementing the DRGs in Iran.

Methods

The present study is a strategic applied research conducted in two phases. In the first phase, the challenges facing DRGs were extracted through a literature review. Then the collected data is entered into a checklist consisting of five sections including technological, cultural, organizational, strategic, and natural challenges. In the second phase, data were collected by purposive sampling and semistructured interviews with 10 managers of the Medical Services Organization of Tehran, Iran. Data analysis was performed by conventional content analysis using MAXQDA software and descriptive using SPSS software version 19.

Results

The challenges facing the implementing DGRs from the experts' perspective included technological, organizational, nature, strategic, and cultural in order of priority. The three main fundamental challenges were reported; lack of integrating the DGRs with health information system (70%), frequent changes of management (70%), reducing the quality of care following early patient discharge (60%).

Conclusion

The results of the present study showed that the DRG system faced with challenges and healthcare officials should apply policies and guidelines to reform the system before changing the reimbursement system in Iran. By considering the leading countries experiences in the nationalizing the DRG system field, the problems and solutions of the system can be identified and aid in the more successful implementation of these systems.

Costs for a hospital stay: another lesson learned from the COVID-19 pandemic

Background and aim: After two years of pandemic, planning and budgeting for use of healthcare resources and services is very important. Inpatient COVID-19 hospitalizations costs, regardless of ICD-10 procedure codes, in a Covid-19 support military hospital were analyzed. Methods: The national protocol for the treatment of Covid-19 infection was applied. The costs for laboratory tests, drugs, protection equipment and radiological investigations (imaging techniques such as computed-tomography or radiography), hospitalization days and food were assessed. Results: In our hospital, from August 2020 through June 2021, 241 patients were hospitalized with COVID-19: mean age 59.92±7.8 years, 46% men, 26% military personnel, 11.57±3 days of hospitalization; two third of patients had moderate and severe forms of COVID-19. The main manifestations were: 69% respiratory (18% with severe pneumonia), 3.3% cardiac (2.9% with pulmonary embolism, diagnosed by computed tomography angiography), 28% digestive and 33% psychiatric (most commonly anxiety). The average estimated costs were about 3000€/patient, without significant differences based on disease severity. Equipment costs were 2 times higher than for drugs and 3 times than for laboratory tests. Conclusions: In a Covid-19 support military hospital that cared for patients with predominantly moderate forms of COVID-19, the costs for equipment were much higher than those for treatment. New criteria for hospitalization of these forms of COVID-19 deserve to be analyzed in order to avoid useless costs

Contact patterns and costs of multiple sclerosis in the Swedish healthcare system-A population-based quantitative study

BACKGROUND

The burden of disease for persons with multiple sclerosis (MS) and society is changing due to new treatments. Knowledge about the total need for care is necessary in relation to changing needs and new service models.

OBJECTIVE

The aim of this study was to describe the contact patterns for MS patients, calculate costs in health care, and create meaningful subgroups to analyze contact patterns.

METHODS

All patients diagnosed with MS at Ryhov Hospital were included. All contacts in the region from January 1, 2018, until September 30, 2019, were retrieved from the hospital administrative system. Data about age, sex, contacts, and diagnosis were registered. The cost was calculated using case costing, and costs for prescriptions were calculated from medical files.

RESULTS

During the 21-month period, patients (n = 305) had 9628 contacts and 7471 physical visits, with a total cost of $7,766,109. Seventeen percent of the patients accounted for 48% of the visits. The median annual cost was $7386 in the group with 10 or fewer visits, compared to $22,491 in patients with more than 50 visits.

CONCLUSION

There are considerable differences in the utilization of care and cost between patients with MS in an unselected population, meaning that the care needs to be better customized to each patient's demands.

In Search for Comparability: The PECUNIA Reference Unit Costs for Health and Social Care Services in Europe

Improving the efficiency of mental healthcare service delivery by learning from international best-practice examples requires valid data, including robust unit costs, which currently often lack cross-country comparability. The European ProgrammE in Costing, resource use measurement and outcome valuation for Use in multi-sectoral National and International health economic evaluAtions (PECUNIA) aimed to harmonize the international unit cost development. This article presents the methodology and set of 36 externally validated, standardized reference unit costs (RUCs) for five health and social care services (general practitioner, dentist, help-line, day-care center, nursing home) in Austria, England, Germany, Hungary, The Netherlands, and Spain based on unambiguous service definitions using the extended DESDE PECUNIA coding framework. The resulting PECUNIA RUCs are largely comparable across countries, with any causes for deviations (e.g., country-specific scope of services) transparently documented. Even under standardized methods, notable limitations due to data-driven divergences in key costing parameters remain. Increased cross-country comparability by adopting a uniform methodology and definitions can advance the quality of evidence-based policy guidance derived from health economic evaluations. The PECUNIA RUCs are available free of charge and aim to significantly improve the quality and feasibility of future economic evaluations and their transferability across mental health systems.

The process of estimating the cost of surgery: Providing a practical framework for surgeons

Over the last decades, health care costs have been increasing at an alarming, exponential rate which is considered unsustainable. Surgical care utilizes one-third of health care costs. Estimating, evaluating, and understanding the cost of surgery is a vital step towards cost management and reduction. Current cost estimation studies and cost-effectiveness studies have vast disparities in their methodology, with published costs of Operating Room varying from as low as $7 and as high as $113 per minute. Costs in surgery are distinguished as direct and indirect. Allocation of direct costs involves identification, measurement, and valuation processes. Allocation of indirect costs involves the allocation of capital and overhead costs and of indirect department costs. Annualised capital costs and overhead hospital costs are then allocated to surgery by either the cost-centre allocation or the activity-based allocation frameworks. Indirect department costs are allocated to a specific surgery by weighted service allocation or hourly rate allocation or inpatient day allocation, or marginal markup allocation. The growing societal, financial and political pressure for cost reduction has brought cost analysis to the forefront of healthcare discussions. Thus, we believe that almost every single surgeon will eventually enter the field of healthcare economics by necessity. This review aims to provide surgeons with a practical framework for engaging in cost estimation studies.

Establishing a comprehensive list of mental health-related services and resource use items in Austria: A national-level, cross-sectoral country report for the PECUNIA project

BACKGROUND

A comprehensive, comparable assessment of the economic disease burden and the value of relevant care forms a major challenge in the case of mental diseases. This study aimed to inform the development of a resource use measurement (RUM) instrument and harmonized reference unit costs valid for multi-sectoral and multi-national cost assessments for mental health diseases as part of the European PECUNIA project.

METHODS

An iterative, multi-methods approach was applied. Systematic literature reviews appended with national grey literature searches in six European countries were conducted to generate preliminary, literature-based, international, mental health-related service and resource use lists for all investigated sectors in 2018. As part of a multi-national expert survey, these lists were reviewed by 18 Austrian sector-specific experts regarding the clarity, relevance, comprehensiveness and availability in the Austrian context.

RESULTS

Out of 295 items included in the preliminary, international, sector-specific lists (health and social care-201 items, criminal justice-35 items, education-39 items; patient, family and informal care-20 items), a total of 261 items and descriptions (88%) were considered clear by all experts. 42 items (14%) were considered not existing in Austria, and 111 items (38%) were prioritized regarding their relevance in the national context. Thirteen additional items (4%) were suggested to be added to accommodate for Austria-specific features of the individual sectors. Major typological difficulties based on item names were observed.

CONCLUSIONS

The identified country-specific variations and general typological bias and their potential contributions to service and resource use cost variations across countries and sectors call for further systematic investigation. Next, PECUNIA will develop internationally harmonized and comparable definitions of the listed items and their units of analysis based on a new conceptual multi-sectoral costing framework. The developed lists will require consolidation and further prioritization for the development of a patient-reported RUM instrument and consequent reference unit cost valuation.

A time-driven activity-based costing approach of magnetic resonance-guided high-intensity focused ultrasound for cancer-induced bone pain

OBJECTIVE

To determine resource consumption and total costs for providing magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) treatment to a patient with cancer-induced bone pain (CIBP).

METHODS

We conducted a time-driven activity-based costing (TD-ABC) of MR-HIFU treatments for CIBP from a hospital perspective. A European care-pathway (including a macro-, meso-, and micro-level) was designed to incorporate the care-delivery value chain. Time estimates were obtained from medical records and from prospective direct observations. To calculate the capacity cost rate, data from the controlling department of a German university hospital were allocated to the modules of the care pathway. Best- and worst-case scenarios were calculated by applying lower and upper bounds of time measurements.

RESULTS

The macro-level care pathway consisted of eight modules (i.e., outpatient consultations, pretreatment imaging, preparation, optimization, sonication, post-treatment, recovery, and anesthesia). The total cost of an MR-HIFU treatment amounted to €5147 per patient. Best- and worst-case scenarios yielded a total cost of €4092 and to €5876. According to cost categories, costs due to equipment accounted for 41% of total costs, followed by costs with personnel (32%), overhead (16%) and materials (11%).

CONCLUSION

MR-HIFU is an emerging noninvasive treatment for alleviating CIBP, with increasing evidence on treatment efficacy. This costing study can support MR-HIFU reimbursement negotiations and facilitate the adoption of MR-HIFU as first-line treatment for CIBP. The present TD-ABC model creates the opportunity of benchmarking the provision of MR-HIFU to bone tumor.Key pointsMagnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) is an emerging noninvasive treatment modality for alleviating cancer-induced bone pain (CIBP).From a hospital perspective, the total cost of MR-HIFU amounted to €5147 per treatment.This time-driven activity-based costing model creates the opportunity of benchmarking the provision of MR-HIFU to bone tumor.

From centralized DRG costing to decentralized TDABC-assessing the feasibility of hospital cost accounting for decision-making in Denmark

BACKGROUND

The objective is to examine hospital cost accounts to understand the foundation upon which healthcare decisions are based. More specifically, the aim is to add insights to accounting practices and their applicability towards a newly establish value-based agenda with a focus on patient-level cost data.

METHODS

We apply a cost accounting framework developed to position and understand hospital cost practices in relation to government requirements. Allocated cost account data from 2015 from all Danish hospitals were collected and analyzed. These cost accounts lay the foundation for diagnosis related group (DRG) rate setting. We further compare the data's limitations and potential in a value-based healthcare (VBHC) agenda with the aim of implementing time-driven activity based costing (TDABC).

RESULTS

We find exceedingly aggregated department-level data that are not tied to patient information. We investigate these data and find large data skewness in the current system, mainly due to structural variances within hospitals. We further demonstrate the current costs data's lack of suitability for VBHC but with suggestions of how cost data can become applicable for such an approach, which will increase cost data transparency and, thus, provide a better foundation for both local and national decision-making.

CONCLUSIONS

The findings raise concerns about the cost accounts' ability to provide valid information in healthcare decision-making due to a lack of transparency and obvious variances that distort budgets and production-value estimates. The standardization of costs stemming from hospitals with large organizational differences has significant implications on the fairness of resource allocation and decision-making at large. Thus, for hospitals to become more cost efficient, a substantially more detailed clinically bottom-led cost account system is essential to provide better information for prioritization in health.

The Use of Diagnosis-Related Group-Based Reimbursement in the Czech Hospital Care System

(1) Background: Diagnosis-Related Groups (DRG), one possibility of a hospital payment system, are currently used in most European countries. Introduced to the Czech system in the 1990s, the DRGs are currently used mainly for care reporting and partly for reimbursement. According to most experts, the use of DRG remain controversial. The goal of this paper was to study the effects of the current Czech DRG system on hospitals financing and, on this basis, to propose possible changes to the reimbursement mechanism in the Czech Republic. (2) Methods: Qualitative research methods were used for evaluating DRG mechanisms of application in three selected healthcare establishments in the CR in the period of 2012–2018. (3) Results: Our study shows that the current implementation of the DRG system is set up in a way that is very similar to traditional flat rates and is unlikely to yield major positive effects of the DRG mechanism, such as predictability of payments for hospitalisation cases, care quality and efficiency and transparent financing. (4) Conclusions: Based on our results, deep systemic change of the reimbursement mechanism in the Czech Republic is necessary. We propose five partial measures leading to the cultivation of the Czech DRG.

Describing Serbian Hospital Activity Using Australian Refined Diagnosis Related Groups: A Case Study in Vojvodina Province

Introduction

AR-DRG system for classification hospital episodes was implemented in Serbia to improve efficiency and transparency in the health system.

Methods

L3H3, IQR, and 10th-95th percentile methods were used to identify outlier episodes in the classification. Classification efficiency and within-group homogeneity were measured by an adjusted reduction in variance (R2) and a coefficient of variation (CV).

Results

There were 246,131 hospital episodes with a total 1,651,913 bed days from 14 hospitals. All episodes were classified into 652 groups of which 441 had CV lower than 100%. "Medical groups" accounted for 51% of groups and for 72% of episodes. Chemotherapy and vaginal delivery were the highest volume groups, with 5% and 4% of total episodes. Major diagnostic category 6 (MDC 6, Diseases of the digestive system) was the highest volume MDC, accounting for 11% of episodes. "Day-cases" and "prolonged hospitalisation" accounted for 21% and 3% of episodes, respectively. The average length of stay varied from 5.6 to 8.2 days. Adjusted R2 was 0.3 for untrimmed data. Trimming by L3H3, IQR, and 10th-95th percentile method improved the value of adjusted R2 to 0.61, 0.49, and 0.51, identifying 24%, 7%, and 7% of total cases as outliers, respectively. Mental diseases (MDC 19) remained the lowest adjusted R2 in untrimmed and trimmed datasets.

Conclusion

A long length of stay and a small percentage of "day-cases" characterized hospital activity in Vojvodina. Trimming methods significantly improved DRG efficiency. Future studies should consider cost data.

Opening the black box of diagnosis-related groups (DRGs): unpacking the technical remuneration structure of the Dutch DRG system

While we know that upcoding of diagnosis-related groups (DRGs) regularly occurs, we have little knowledge of the role of the technical features of coding systems in inducing coding behaviour. This paper presents methods for investigating the financial structure of the Dutch DRG system, and more in particular the grouper software, to gain such insight. The paper describes a system for investigating the robustness of the reward structure, by simulating the response of the DRG system to small changes in individual coding. The results from these analyses are used to visualise some data on coding behaviour, and to investigate how this behaviour is affected by incentives in the technical features of the DRG system. A number of technical weaknesses in the system are also identified.

New approaches to formation of diagnosis-related groups for payment for radiotherapy and chemoradiotherapy based on clinical guidelines with the use of standardized modules of healthcare

The article presents a methodology and results of developing diagnosis related groups (DRGs) for the cases of healthcare provided with the use of radiotherapy and chemoradiotherapy for malignant neoplasms in Russian Federation. A key element of the methodology is the standardized module of healthcare (SM) which allows calculating the tariffs for medical care in accordance with clinical guidelines. As a result of the application of the new methodology, in 2019, changes were made to the DRG model in terms of payment for radiotherapy and chemoradiotherapy. The changes included developing 10 DRGs for in-patient radiotherapy and 10 DRGs in day hospital; 7 DRGs for in-patient chemoradiotherapy and 5 DRGs in day hospital. New classification criteria have been introduced into the DRG model for attributing the case to a certain DRG, in addition to the medical service used before. The number of fractions became a new criterion for radiotherapy, the number of fractions and the international non-proprietary name of the drug were proposed for chemoradiotherapy. A wider range of DRG’s weight coefficients was calculated, which allows more differentiated reimbursement of the costs of medical care provided by medical organizations depending on the method and the regimen used.

The Epidemiology of Acute Liver Failure

BACKGROUND

Acute liver failure (ALF) is a life-threatening event associated with high mortality. Currently, only estimates are available for its incidence. The aim of the study was to assess the incidence of ALF in Germany, using the accounting data of the largest statutory health insurance company, which represents 26.5 million people.

METHODS

The analysis included patients insured from 1 January 2014 to 31 December 2018. Coding with the International Statistical Classification of Diseases and Related Health Problems and the German operation and procedure codes were used to identify the patients, whose age, sex, liver transplantations (LT), and fatal outcomes were then recorded and extrapolated to the total population. As a validity check, the extrapolated LT results were compared with the LT that were actually performed.

RESULTS

The calculated incidence of ALF was 1.13/100 000 person-years, representing 4652 cases. Women were more often affected (52% versus 48%, p < 0.001). The overall rate of mortality within 3 months was 47%. A total of 203 LT were recorded in 176 patients. Men received 41% of the LT, women 59% (p < 0.137). The 1-year overall mortality rate after LT was 20%. The 203 calculated transplantations corresponded to 228 actually performed transplantations.

CONCLUSION

The incidence of ALF was higher than previously estimated for Germany, with only a very low rate of LT despite high mortality. When extrapolating ny, it must be borne in mind that those insured by the company concerned do not represent a valid sample.

The economic burden of endoscopic treatment for anastomotic leaks following oncological Ivor Lewis esophagectomy

Background

Complications after surgery for esophageal cancer are associated with significant resource utilization. The aim of this study was to analyze the economic burden of two frequently used endoscopic treatments for anastomotic leak management after esophageal surgery: Treatment with a Self-expanding Metal Stent (SEMS) and Endoscopic Vacuum Therapy (EVT).

Materials and methods

Between January 2012 and December 2016, we identified 60 German-Diagnosis Related Group (G-DRG) cases of patients who received a SEMS and / or EVT for esophageal anastomotic leaks. Direct costs per case were analyzed according to the Institute for Remuneration System in Hospitals (InEK) cost-accounting approach by comparing DRG payments on the case level, including all extra fees per DRG catalogue.

Results

In total, 60 DRG cases were identified. Of these, 15 patients were excluded because they received a combination of SEMS and EVT. Another 6 cases could not be included due to incomplete DRG data. Finally, N = 39 DRG cases were analyzed from a profit-center perspective. A further analysis of the most frequent DRG code -G03- including InEK cost accounting, revealed almost twice the deficit for the EVT group (N = 13 cases, € - 9.282 per average case) compared to that for the SEMS group (N = 9 cases, € - 5.156 per average case).

Conclusion

Endoscopic treatments with SEMS and EVT for anastomotic leaks following oncological Ivor Lewis esophagectomies are not cost-efficient for German hospitals. Due to longer hospitalization and insufficient reimbursements, EVT is twice as costly as SEMS treatment. An adequate DRG cost compensation is needed for SEMS and EVT.

Influence of hospital adverse events and previous diagnoses on hospital care cost of patients with hip fracture

Previous diagnoses of patients with hip fracture influence the hospitalization cost of these patients, either directly or by increasing the risk of in-hospital adverse events associated with increased costs.

PURPOSE

To investigate how previous diagnoses influence the occurrence of in-hospital adverse events and how both factors impact on hospital costs.

METHODS

This is a retrospective analysis of the hospital Minimum Basic Data Set. Patients aged 70 years or older admitted for hip fracture (HF) at a single University Hospital between January 2012 and December 2016. Both, previous diagnoses and adverse events, were defined according to the International Classification of Diseases (ICD-9/ICD-10). The anticipated cost of each admission was calculated based on diagnosis-related groups and using the "all patients refined" method (APR-DRG). The occurrence of adverse events during hospital stay was assessed by excluding all diagnoses present on admission.

RESULTS

The record included 1571 patients with a mean (SD) age of 84 years. The most frequent previous diagnoses were diabetes (n = 432, 27.5%) and dementia (n = 251, 16.0%), and the most frequent adverse events were delirium (n = 238, 15.1%) and anemia (n = 188, 12.0%). The mean (SD) total acute care costs per patient were €8752.1 (1864.4). The presence of heart failure, COPD, and kidney disease at admission significantly increased the hospitalization cost. In-hospital adverse events of delirium, cardiac events, anemia, urinary tract infection, and digestive events significantly increased costs. The multivariate analyses identified kidney disease as a previous diagnosis significantly contributing to explain an increase in hospitalization costs, and delirium, cardiac disease, anemia, urinary infection, respiratory event, and respiratory infection as in-hospital adverse events significantly contributing to an increase of hospitalization costs.

CONCLUSIONS

Although few baseline comorbidities have a direct impact on hospitalization costs, most previous diagnoses increase the risk of in-hospital adverse events, which ultimately influence the hospitalization cost.

National cost study versus hospital cost accounting for organ recovery cost assessment in a French hospital group

Background

Methods

Results

Conclusions

Intraductal papillary mucinous neoplasms of the pancreas - a cost-effectiveness analysis of management strategies for the branch-duct subtype

BACKGROUND

Branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) presents a clinical conundrum. Rigorous long-term surveillance or surgical resection is recommended. The economic consequences of the management have not been fully investigated.

METHODS

A Markov decision model compared 4 strategies for low-risk BD-IPMN: I = upfront total pancreatectomy, II = upfront partial pancreatectomy, III = initial surveillance, IV = watchful waiting. Surveillance was based on the Swedish Guidelines for Pancreatic Cancer. Probabilities and costs were obtained from the participating unit and from the scientific literature. The incremental cost-effectiveness ratios (ICERs) were calculated and sensitivity analyses were performed by varying relevant parameters. Survival was reported in quality-adjusted life-years (QALYs).

RESULTS

Strategy III was the most cost-effective strategy with an ICER of €31 682 compared to strategy IV. Strategy I was the most expensive but yielded the best QALY (9.32). Total number of years, annual risk of pancreatic cancer and annual risk of a low-risk BD-IPMN turning into a high-risk lesion had the greatest impact in the model.

CONCLUSIONS

Initial surveillance seems to be the most cost-effective strategy in the management of low-risk asymptomatic BD-IPMN. However, the possibility of personalized approaches remains to be investigated.

[Data sources, the data used, and the modality for collection]

The hospital costing process implies access to various sources of data. Whether a micro-costing or a gross-costing approach is used, the choice of the methodology is based on a compromise between the cost of data collection, data accuracy, and data transferability. This work describes the data sources available in France and the access modalities that are used, as well as the main advantages and shortcomings of: (1) the local unit costs, (2) the hospital analytical accounting, (3) the Angers database, (4) the National Health Cost Studies, (5) the INTER CHR/U databases, (6) the Program for Medicalizing Information Systems, and (7) the public health insurance databases.

Estimate of the Costs Caused by Adverse Effects in Hospitalised Patients Due to Hip Fracture: Design of the Study and Preliminary Results

Introduction: Hip fracture is a health problem that presents high morbidity and mortality, negatively influencing the patient’s quality of life and generating high costs. Structured analysis of quality indicators can facilitate decision-making, cost minimization, and improvement of the quality of care. Methods: We studied 1571 patients aged 70 years and over with the diagnosis of hip fracture at Hospital Universitario de la Ribera in the period between 1 January 2012 and 31 December 2016. Demographic, clinical, functional, and quality indicator variables were studied. An indirect analysis of the costs associated with adverse events arising during hospital admission was made. A tool based on the “Minimum Basic Data Set (CMBD)” was designed to monitor the influence of patient risk factors on the incidence of adverse effects (AE) and their associated costs. Results: The average age of the patients analysed was 84.15 years (SD 6.28), with a length of stay of 8.01 days (SD 3.32), a mean preoperative stay of 43.04 h (SD 30.81), and a mortality rate of 4.2%. Likewise, the percentage of patients with AE was 41.44%, and 11.01% of patients changed their cost as a consequence of these AEs suffered during hospital admission. The average cost of patients was €8752 (SD: 1,864) and the average cost increase in patients with adverse events was €2321 (SD: 3,164). Conclusions: Through the analysis of the main clinical characteristics and the indirect estimation of the complexity of the patients, a simple calculation of the average cost of the attention and its adverse events can be designed in patients who are admitted due to hip fracture. Additionally, this tool can fit the welfare quality indicators by severity and cost.

Undernutrition is associated with increased financial losses in hospitals

BACKGROUND & AIMS

Undernutrition is associated with increased hospital costs. Whether these increased costs are totally compensated by third payer systems has not been assessed. We aimed to assess the differences between actual and reimbursed hospital costs according to presence/absence of nutritional risk, defined by a Nutritional risk screening-2002 (NRS-2002) score ≥3.

METHODS

Retrospective study. Administrative data for years 2013 and 2014 of the department of internal medicine of the Lausanne university hospital. The data included total and specific costs (i.e. clinical biology, treatments, pathology). Reimbursed costs were based on the Swiss Diagnosis Related Group (DRG) system.

RESULTS

2200 admissions with NRS-2002 data were included (mean age 76 years, 53.9% women), 1398 (63.6%) of which were considered nutritionally 'at-risk'. After multivariate adjustment, patients nutritionally 'at-risk' had higher costs (multivariate-adjusted difference ± standard error: 34,206 ± 1246 vs. 22,214 ± 1666 CHF, p < 0.001) and higher reimbursements (26,376 ± 1105 vs. 17,783 ± 1477 CHF, p < 0.001). Still, the latter failed to cover the costs, leading to a deficit between costs and reimbursements of 7831 ± 660 CHF in patients 'at-risk' vs. 4431 ± 881 in patients 'not at-risk' (p < 0.003). Being nutritionally 'at-risk' also led to a lower likelihood of complete coverage of costs: multivariate-adjusted odds ratio and 95% confidence interval 0.77 (0.62-0.97). Patients 'at-risk' had lower percentage of total costs in medical interventions, food, imaging and "other", but the absolute differences were less than 2%.

CONCLUSION

Hospital costs of patients nutritionally 'at-risk' are less well reimbursed than of patients 'not at-risk'. Better reporting of undernutrition in medical records and better reimbursement of undernourished patients is needed.

Mixed method versus full top-down microcosting for organ recovery cost assessment in a French hospital group

BACKGROUND

The costing method used can change the results of economic evaluations. Choosing the appropriate method to assess the cost of organ recovery is an issue of considerable interest to health economists, hospitals, financial managers and policy makers in most developed countries.

OBJECTIVES

The main objective of this study was to compare a mixed method, combining top-down microcosting and bottom-up microcosting versus full top-down microcosting to assess the cost of organ recovery in a French hospital group. The secondary objective was to describe the cost of kidney, liver and pancreas recovery from French databases using the mixed method.

METHODS

The resources consumed for each donor were identified and valued using the proposed mixed method and compared to the full top-down microcosting approach. Data on kidney, liver and pancreas recovery were collected from a medico-administrative French database for the years 2010 and 2011. Related cost data were recovered from the hospital cost accounting system database for 2010 and 2011. Statistical significance was evaluated at P < 0.05.

RESULTS

All the median costs for organ recovery differ significantly between the two costing methods (non-parametric test method; P < 0.01). Using the mixed method, the median cost for recovering kidneys was found to be €5155, liver recovery was €2528 and pancreas recovery was €1911. Using the full top-down microcosting method, median costs were found to be 21-36% lower than with the mixed method.

CONCLUSION

The mixed method proposed appears to be a trade-off between feasibility and accuracy for the identification and valuation of cost components when calculating the cost of organ recovery in comparison to the full top-down microcosting approach.

Economic evaluation of chronic lymphocytic leukemia from a hospital management perspective

OBJECTIVES

Treatment of chronic lymphocytic leukemia (CLL) is currently undergoing dramatic changes. We analyzed economic risks in hospitalized patients with CLL from a management perspective.

METHODS

One hundred and twelve patients with CLL hospitalized in 2013 and 2014 at the University Hospital of Cologne were analyzed. To assess profit margins (PMs) per case, diagnosis-related group (DRG) reimbursement data were merged with an internal cost accounting scheme depending on age, prognostic factors, and DRG key performance indicators.

RESULTS

In 112 patients, 284 cases coded by 19 different DRG with strongly fluctuating cost revenue ratios were found with an overall negative PM of €137 147. The DRG R61H was identified as the one most commonly coded (174 cases, 61.3%) with a deficit per case of €814. Subanalysis demonstrated that the payments were not cost covering due to excessive length of stay and staff costs. Significant differences in PM per case concerning age, length of stay and number of operation and procedure key (OPS) codes (P < 0.05) were found.

CONCLUSION

In our research-driven tertiary care hospital, inpatient treatment of patients with CLL is not cost covering. This analysis demonstrates the need for novel care/reimbursement structures in CLL. From a hospital management perspective, cost revenue controlling is crucial to avoid major economic risks.

Is it time to rebalance the case mix? A portfolio analysis of direct catheterization laboratory costs over a 5-year period

Background

Cardiac catheterization laboratories (CLL) have continued to function as profit centers for hospitals. Due to a high percentage of material and labor costs, they are natural targets for process improvement. Our study applied a contribution margin (CBM) concept to evaluate costs and cost dynamics over a 5-year period.

Methods

We retrospectively analyzed all procedures performed at a tertiary heart center between 2007 and 2011. Total variable costs, including labor time, material, and maintenance-expenses, were allocated at a global as well as a procedural level. CBM and CBM ratios were calculated by integration of individual DRG revenues.

Results

Annual case volume increased from 1288 to 1545. In parallel, overall profitability improved as indicated by a 2% increase in CBM ratio and a higher CBM generated per hour of CLL working time (4325 vs. 5892 €, p < 0.001). Coronary angiography generated higher average CBMs per hour than coronary or electrophysiological interventions (5831 vs. 3458 vs. 1495 €; p < 0.001). The latter are characterized by relatively high per case material expenditures. On a procedural level, DRG-specific trends as a steady improvement of examination time or an increase in material costs were detectable.

Conclusions

The CBM concept allows a comprehensive analysis of CLL costs and cost dynamics. From a health service providers view, its range of application includes global profitability analysis, portfolio evaluation, and a detailed cost analysis of specific service lines. From a healthcare payers perspective, it may help to monitor hospital activities and to provide a solid data basis in cases where inappropriate developments are suspected. The calculation principle is simple which may increase user acceptance and thus the motivation of team members.

Electronic supplementary material

The online version of this article (doi:10.1186/s40001-016-0238-5) contains supplementary material, which is available to authorized users.

Quantifying the incidence and cost of acute gastrointestinal illness in Sweden, 2013-2014

In Sweden, acute gastrointestinal illness (AGI) incidence, severity, impact on productivity, related healthcare usage and associated costs are not ascertained. We measured these in 2013-2014 using a population-based cohort reporting weekly. We defined AGI as ⩾3 episodes of loose stools or vomiting/24 h; or loose stools or vomiting with ⩾2 other gastrointestinal symptoms. After each AGI episode, we collected information about perceived severity, healthcare use and absenteeism. We calculated incidence rates, AGI absenteeism and costs comprising direct healthcare costs and productivity loss due to work/school absenteeism. A total of 3241 participants reported 1696 AGI episodes [incidence 360/1000 person-years, 95% confidence interval (CI) 326-395; highest in the <5 years age group]. In the <5 years age group, 31% of episodes were perceived as mild, 61% as moderate and 8% as severe; 9·4% led to primary-care consultations, and 1·4% to hospital admissions. In the ⩾5 years age group, 18% of episodes were perceived as mild, 64% as moderate and 18% as severe; 6·4% led to primary-care consultations, and 1·9% to hospital admissions. AGI caused 8 891 000 days of absenteeism (95% CI 6 009 000-12 780 000). AGI cost €1 005 885 000 (95% CI 754 309 000-1 257 195 000) nationally for the year. In Sweden, a minority of cases perceive AGI as a mild illness. AGI is a burden on the healthcare system and causes productivity loss, with high costs. Countries may consider these estimates when prioritizing health interventions.

Heterogeneity of European DRG systems and potentials for a common EuroDRG system Comment on "Cholecystectomy and Diagnosis-Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries"

Diagnosis-Related Group (DRG) systems across Europe are very heterogeneous, in particular because of different classification variables and algorithms as well as costing methodologies. But, given the challenge of increasing patient mobility within Europe, health systems are forced to incorporate a common patient classification language in order to compare and identify similar patients e.g. for reimbursement purposes. Beside the national adoption of DRGs for a wide range of purposes (measuring hospital activity vs. paying hospitals), a common DRG system can serve as an international communication basis among health administrators and can reduce the national development efforts as it is demonstrated by the NordDRG consortium.