How do inpatients' costs, length of stay, and quality of care vary across age groups after a new case-based payment reform in China? An interrupted time series analysis

CONTEXT

A patient classification-based payment system called diagnosis-intervention packet (DIP) was piloted in a large city in southeast China in 2018.

OBJECTIVE

This study evaluates the impact of DIP payment reform on total costs, out-of-pocket (OOP) payments, length of stay (LOS), and quality of care in hospitalised patients of different age.

METHODS

An interrupted time series model was employed to examine the monthly trend changes of outcome variables before and after the DIP reform in adult patients, who were stratified into a younger (18-64 years) and an older group (≥ 65 years), further stratified into young-old (65-79 years) and oldest-old (≥ 80 years) groups.

RESULTS

The adjusted monthly trend of costs per case significantly increased in the older adults (0.5%, P = 0.002) and oldest-old group (0.6%, P = 0.015). The adjusted monthly trend of average LOS decreased in the younger and young-old groups (monthly slope change: -0.058 days, P = 0.035; -0.025 days, P = 0.024, respectively), and increased in the oldest-old group (monthly slope change: 0.107 days, P = 0.030) significantly. The changes of adjusted monthly trends of in-hospital mortality rate were not significant in all age groups.

CONCLUSION

Implementation of the DIP payment reform associated with increase in total costs per case in the older and oldest-old groups, and reduction in LOS in the younger and young-old groups without deteriorating quality of care.

Tackling Extended Hospital Stays in Patients with Acute Bacterial Skin and Skin Structure Infections

Hospitalisation rates for acute bacterial skin and skin structure infection (ABSSSI) are rising and represent a large pharmacoeconomic burden as treatment may involve an extended number of days of antibiotic therapy. This article first aims to provide a review of treatment challenges associated with ABSSSIs in both hospital and outpatient settings, and shows that while more traditionally treatment has been conducted in a hospital setting, for a number of patients, a variety of considerations, including pharmacoeconomics, infection control, and patient preference, has led to the development of recommendations to assess the eligibility of patients for early discharge from hospital to complete their antibiotic regimen in the outpatient setting. However, such patients require monitoring for drug adherence to oral regimens or complications associated with daily intravenous administration, such as injection site reactions and infection. This review also focuses on one of a number of new antibiotics for ABSSSI, dalbavancin, as the long-acting glycopeptide with the most clinical experience to date. This antibiotic has been shown to be as effective as a daily/twice daily regimen with similar safety profiles. Health economic analysis of dalbavancin is also presented. It has shown that in some, though not all, clinical settings a reduction in the overall treatment cost is evident as, despite a higher medication cost, the lower hospitalisation time can lead to greater cost savings. In conclusion, while the burden of ABSSSI is rising, new treatment options provide additional therapeutic choice, although pharmacoeconomic considerations might limit use in some cases.

Failure of sterilization in a dental outpatient facility: Investigation, risk assessment, and management

In 2017, an incident of failed sterilization of dental instruments occurred at a large dental outpatient facility in Singapore. We aim to describe findings of the investigation of the sterilization breach incident, factors related to risk of viral transmission to the potentially affected patients, and the contact tracing process, patient management, and blood test results at a 6-month follow-up. A full assessment of the incident was immediately carried out. The factors related to risk of viral transmission due to affected instruments were analyzed using 3 keys points: breached step(s) and scale of the incident, prevalence of underlying bloodborne diseases and immunity in the Singapore population, health status of potential source patients, and type of dental procedure performed, and health status of affected patients and type of dental procedure received. Up to 72 affected instrument sets were used in 714 potentially affected patients who underwent noninvasive dental procedures. The investigation revealed that there was a lapse in the final step of steam sterilization, resulting in the use of incompletely sterilized items. The assessment determined that there was an extremely low risk of bloodborne virus transmission of diseases to the patients. At the 6-month follow-up, there were no infected/colonized cases found related to the incident. Lapses in the sterilization process for medical and dental instruments can happen, but a risk assessment approach is useful to manage similar incidents. Quick response and proper documentation of the sterilization process can prevent similar incidents.

Medication Compliance Aids Unpackaged: A National Survey

Aims

Sixty‐four million pharmacy‐filled multicompartment medication compliance aids (MCAs) are dispensed by pharmacies in England each year. Despite the widespread use of MCAs and evidence that their use may be associated with harm there is no national consensus regarding MCA provision by acute hospital Trusts in England. The aim was to determine current practice for initiation and supply of MCAs in acute hospital Trusts in England and the potential consequences for patients and hospitals.

Methods

A 26‐item survey was distributed to all acute hospital Trusts in England. The questionnaire covered: policy, initiation, supply and review of MCAs; alternatives offered; and pharmacy staffing and capacity related to MCAs.

Results

Seventy‐two out of 138 (52%) Trusts responded to the survey: 70 Trusts responded regarding policy for MCA provision, with 60 (86%) having a policy regarding this; 33/55 (60%) that supplied MCAs on discharge supplied a different prescription length for MCA vs. non‐MCA prescriptions; 49/55 (89%) Trusts provided only 1 brand of MCA; 47/55 (85%) MCA‐supplying Trusts identified frequent difficulties with MCAs and 13/55 (24%) reported employing staff specifically to complete MCAs; and 30/35 (86%) MCA‐initiating Trusts had an assessment process for initiation, with care agency request reportedly the most common reason for initiation.

Conclusion

There is a lack of a national approach to MCA provision and initiation by acute hospital Trusts in England. This leads to significant variation in care and has the potential to put MCA users at an increased risk of medication‐related harm.

Factors Associated with Hepatitis B and C Co-Infection among HIV-Infected Patients in Singapore, 2006-2017

Co-infection of hepatitis B virus (HBV) and hepatitis C virus (HCV) with human immunodeficiency virus (HIV) is associated with increased risk of hepatic complications and mortality. A retrospective study to estimate the proportion of HBV and HCV co-infections in Singapore was conducted using a clinical database. We included 3065 patients who were seen under the Clinical HIV Programme at the largest referral centre for HIV care between 2006 and 2017 and were tested for both HBV and HCV. Factors associated with HIV-HBV and HIV-HCV co-infections were determined using logistic regressions. The majority (86.3%) of HIV-infected patients were mono-infected, while 7.2% were co-infected with HBV, 6.0% with HCV, and 0.5% were co-infected with both HBV and HCV. The most common HCV genotype was GT1 (63%). Factors significantly associated with HBV co-infection in the multivariable model were: Aged 30–49 years and 50–69 years at HIV diagnosis, male gender, and HIV transmission through intravenous drug use (IDU). Independent factors associated with HCV co-infection were: Malay ethnicity, HIV transmission through IDU, and HIV diagnosis between 2006 and 2008. Behavioural risk factors such as IDU, as well as epidemiologic differences associated with co-infection, should inform further studies and interventions aimed at reducing viral hepatitis infection among HIV-infected individuals.

Experts' perspectives on SwissDRG: Second class care for vulnerable patient groups?

On the 1st of January 2012, Switzerland introduced the diagnosis-related group hospital tariff structure (SwissDRG). It was recognised that healthcare provided to the most vulnerable patient groups would be a challenge for the new SwissDRG. Coincident with the implementation of SwissDRG, we explored hospital experts' perceptions of which patient groups are vulnerable under the SwissDRG system, what has changed for this group, as well as solutions to ensure adequate access to health care for them. We interviewed 43 experts from 40 Swiss hospitals. Participating experts named several vulnerable patient groups who share some common characteristics. These hospital experts were concerned about the patient groups that are not financially profitable and questioned the practicability of the current regulation. At the same time, they highlighted the complexity associated with caring for this group under the new SwissDRG and reported measures at the macro, meso, and micro levels to protect vulnerable patient groups from negative effects. To curb negative outcomes for vulnerable patient groups after the introduction of the SwissDRG, the Swiss legislation has introduced various instruments including the acute and transitional care (ATC) measures. We conclude that ATC measures do not produce the expected effect the legislators had hoped for. More health data is needed to identify situations where vulnerable patient groups are more susceptible to inadequate health care access in Switzerland.

Liver Disease in Singapore

Liver disease is a significant health issue in Singapore. In the Singapore Burden of Disease Survey, liver cancer and liver cirrhosis contributed 3.2 and 0.9% of years of life lost (YLL) out of 182,753 YLL respectively. Liver cancer was ranked 8th and liver cirrhosis was ranked 20th in YLL. Liver cancer is the 5th most common cancer in males, and has an age-adjusted rate of 17.6 per 100,000 population. The underlying etiology of liver cirrhosis is chronic hepatitis B (CHB) in 63.3%, alcohol in 11.2%, cryptogenic in 9%, and chronic hepatitis C (CHC) in 6.9%. The overall seroprevalence rate of CHB is 3.6%, while CHC is approximately 0.1%. The trend in prevalence of liver cancer is gradually reducing as is CHB. However, less is known about alcoholic liver disease and fatty liver disease and there is some evidence that the latter is increasing. Singapore has a multilayered health care system designed to provide basic health care needs to the population. There are various schemes available that provide subsidized and assisted health care for treatment of hepatitis B and C as well as liver transplantation. Health policy with regard to a national action plan has not yet been developed and there is room for health care specialists, government and nongovernment agencies to work together to tackle liver disease in Singapore. How to cite this article: Muthiah M, Chong CH, Lim SG. Liver Disease in Singapore. Euroasian J Hepato-Gastroenterol 2018;8(1):66-68.

Management of hepatitis C virus infection in the Asia-Pacific region: an update

The Asia-Pacific region has disparate hepatitis C virus (HCV) epidemiology, with prevalence ranging from 0·1% to 4·7%, and a unique genotype distribution. Genotype 1b dominates in east Asia, whereas in south Asia and southeast Asia genotype 3 dominates, and in Indochina (Vietnam, Cambodia, and Laos), genotype 6 is most common. Often, availability of all-oral direct-acting antivirals (DAAs) is delayed because of differing regulatory requirements. Ideally, for genotype 1 infections, sofosbuvir plus ledipasvir, sofosbuvir plus daclatasvir, or ombitasvir, paritaprevir, and ritonavir plus dasabuvir are suitable. Asunaprevir plus daclatasvir is appropriate for compensated genotype 1b HCV if baseline NS5A mutations are absent. For genotype 3 infections, sofosbuvir plus daclatasvir for 24 weeks or sofosbuvir, daclatasvir, and ribavirin for 12 weeks are the optimal oral therapies, particularly for patients with cirrhosis and those who are treatment experienced, whereas sofosbuvir, pegylated interferon, and ribavirin for 12 weeks is an alternative regimen. For genotype 6, sofosbuvir plus pegylated interferon and ribavirin, sofosbuvir plus ledipasvir, or sofosbuvir plus ribavirin for 12 weeks are all suitable. Pegylated interferon plus ribavirin has been replaced by sofosbuvir plus pegylated interferon and ribavirin, and all-oral therapies where available, but cost and affordability remain a major issue because of the absence of universal health coverage. Few patients have been treated because of multiple barriers to accessing care. HCV in the Asia-Pacific region is challenging because of the disparate epidemiology, poor access to all-oral therapy because of availability, cost, or regulatory licensing. Until these problems are addressed, the burden of disease is likely to remain high.