Utilizing Time-Driven Activity-Based Costing to Increase Efficiency in Ultrasound-Guided Breast Biopsy Practice

PURPOSE

In this study, we used time-driven activity-based costing to increase efficiency in our ultrasound-guided breast biopsy practice by understanding costs associated with this procedure.

METHODS

We assembled a multidisciplinary team of all relevant stakeholders involved in ultrasound-guided breast biopsies, including a radiologist, a lead technologist, a clinical assistant, a licensed practical nurse, and a procedural support assistant. The team mapped each step in an ultrasound-guided breast biopsy from the time of scheduling a biopsy to patient checkout. We completed on average 20 time observations of each step involved in these biopsies from a provider's perspective. Using capacity cost rate, we calculated the cost of all resources including personnel, supply, room, and equipment costs. Several costly steps were identified in the process, which led to the intervention of changing our overlapping biopsy times to staggered biopsy times. Time observations for each step and cost calculations were repeated postintervention.

RESULTS

Our postintervention data showed that the total time spent by the radiologist in an ultrasound breast biopsy decreased by 28%, accounting for 56% of the total cost in comparison with 63% pre-intervention. The radiologist's wait time decreased by 38%, accounting for 28% of the total cost in comparison with 35% pre-intervention. Our total cost of the procedure decreased by 20%, and the personnel cost decreased by 25%.

CONCLUSIONS

Time-driven activity-based costing is a practical way to calculate costs and identify non-value-added steps, which can foster strategies to improve efficiency and minimize waste.

The productivity development of total hip arthroplasty in Sweden: a multiple registry-based longitudinal study using the Malmquist Productivity Index

OBJECTIVE

The increasing demand for total hip arthroplasty (THA) combined with limited resources in healthcare puts pressure on decision-makers in orthopaedics to provide the procedure at minimum costs and with good outcomes while maintaining or increasing access. The objective of this study was to analyse the development in productivity between 2005 and 2012 in the provision of THA.

DESIGN

The study was a multiple registry-based longitudinal study.

SETTING AND PARTICIPANTS

The study was conducted among 65 orthopaedic departments providing THA in Sweden from 2005 to 2012.

OUTCOME MEASURES

The development in productivity was measured by Malmquist Productivity Index by relating department level total costs of THA to the number of non-cemented, hybrid and cemented THAs. We also break down the productivity change into changes in efficiency and technology.

RESULTS

Productivity increased significantly in three periods (between 1.6% and 27.0%) and declined significantly in four periods (between 0.8% and 12.1%). Technology improved significantly in three periods (between 3.2% and 16.9%) and deteriorated significantly in two periods (between 10.2% and 12.6%). Significant progress in efficiency was achieved in two periods (ranging from 2.6% to 8.7%), whereas a significant regress was attained in one period (3.9%). For the time span as a whole, an average increase in productivity of 1.4% per year was found, where changes in efficiency contributed more to the improvement (1.1%) than did technical change (0.2%).

CONCLUSIONS

We found a slight improvement of productivity over time in the provision of THA, which was mainly driven by changes in efficiency. Further research is, however, needed where differences in quality of care and patient case mix between departments are taken into account.

Managing the Economic Challenges in the Treatment of Heart Failure

The economics of heart failure (HF) touches all patients with HF, their families, and the physicians and health systems that care for them. HF is specifically targeted by cost-reduction and care quality initiatives from the Centers for Medicare and Medicaid Services (CMS). The changing quality assessment and payment landscape is, and will continue to be, challenging for hospitals and HF specialists as they provide care for patients with this debilitating disease. Quality-based payment systems with evolving performance metrics are replacing traditional volume-based fee-for-service models. A critical objective of quality-based models is to improve care and reduce cost, but there are few data to support decision-making on how to improve. CMS payment programs and their implications for health systems treating HF were reviewed at a symposium at the Heart Failure Society of America conference in Nashville, Tennessee on September 15, 2018. This article constitutes the proceedings from that symposium.

Claims Variability in Charges and Payments for Common Open and Endovascular Procedures

BACKGROUND

Cost-effectiveness in healthcare is being increasingly scrutinized. Data regarding claims variability for vascular operations are lacking. Herein, we aim to describe variability in charges and payments for aortoiliac (AI) and infrainguinal (II) revascularizations.

METHODS

We analyzed 2012-2014 claims data from a statewide claims database for procedures grouped by Current Procedural Terminology codes into II-open (II-O), II-endovascular (II-E), AI-open (AI-O), and AI-endovascular interventions (AI-E). We compared charges and payments in urban (≥50,000 people, UAs) versus rural areas (<50,000 people, RAs). Amounts are reported in $US as median with interquartile range. Cost-to-charge ratios (CCRs) as a measure of reimbursement were calculated as the percentage of the charges covered by the payments. Wilcoxon rank-sum tests were performed to determine significant differences.

RESULTS

A total of 5,239 persons had complete claims data. There were 7,239 UA and 6,891 RA claims, and 1,057 AI claims (AI-E = 879, AI-O = 178) and 4,182 II claims (II-E = 3,012, II-0 = 1,170). Median charges were $5,357 for AI [$1,846-$27,107] and $2,955 for II [$1,484-$9,338.5] (P < 0.0001). Median plan payment was $454 for AI [$0-$1,380] and $454 for II [$54-$1,060] (P = 0.67). For AI and II, charges were significantly higher for UA than RA (AI: UA $9,875 [$2,489-$34,427], RA $3,732 [$1,450-$20,595], P < 0.0001; II: UA $3,596 [$1,700-$21,664], RA $2,534 [$1,298-$6,169], P < 0.0001). AI-E charges were higher than AI-O (AI-E $7,960 [$1,699-$32,507], AI-O $4,774 [$2,636-$7,147], P < 0.0001), but AI-O payments were higher (AI-E $424 [$0-$1,270], AI-O $869 [$164-$1,435], P = 0.0067). II-E charges were higher (II-E $2,994 [$1,552-$22,164], II-O $2,873 [$1,108-$5,345], P < 0.0001), but II-O payments were higher (II-E $427 [$50-$907], II-O $596 [$73-$1,299], P < 0.0001). CCRs were highest for II operations and UAs.

CONCLUSIONS

Wide variability in claim charges and payments exists for vascular operations. AI procedures had higher charges than II, without any difference in payments. UA charged more than RA for both AI and II operations, but RA had higher payments and CCRs. Endovascular procedures had higher charges, while open procedures had higher payments. Charge differences may be related to endovascular device costs, and further research is necessary to determine the reasons behind consistent claims variability between UA and RA.

Comparing 15D Valuation Studies in Norway and Finland-Challenges When Combining Information from Several Valuation Tasks

BACKGROUND

The 15D is a generic preference-based health-related quality-of-life instrument developed in Finland. Values for the 15D instrument are estimated by combining responses to three distinct valuation tasks. The impact of how these tasks are combined is relatively unexplored.

OBJECTIVES

To compare 15D valuation studies conducted in Norway and Finland in terms of scores assigned in the valuation tasks and resulting value algorithms, and to discuss the contributions of each task and the algorithm estimation procedure to observed differences.

METHODS

Norwegian and Finnish scores from the three valuation tasks were compared using independent samples t tests and Lin concordance correlation coefficients. Covariance between tasks was assessed using Pearson product-moment correlations. Norwegian and Finnish value algorithms were compared using concordance correlation coefficients, total ranges, and ranges for individual dimensions. Observed differences were assessed using minimal important difference.

RESULTS

Mean scores in the main valuation task were strikingly similar between the two countries, whereas the final value algorithms were less similar. The largest differences between Norway and Finland were observed for depression, vision, and mental function.

CONCLUSIONS

15D algorithms are a product of combining scores from three valuation tasks by use of methods involving multiplication. This procedure used to combine scores from the three tasks by multiplication serves to amplify variance from each task. From relatively similar responses in Norway and Finland, diverging value algorithms are created. We propose to simplify the 15D algorithm estimation procedure by using only one of the valuation tasks.

Improving Value for Patients with Eczema

OBJECTIVE

Chronic diseases now represent a cost majority in the United States health care system. Contributing factors to rising costs include expensive novel and emerging therapies, under-treatment of disease, under-management of comorbidities, and patient dissatisfaction with care results. Critical to identifying replicable improvement methods is a reliable model to measure value.

STUDY DESIGN

If we understand value within healthcare consumerism to be equal to a patient's health outcome improvement over costs associated with care (Value=Outcomes/Costs), we can use this equation to measure the improvement of value.

METHODS

Research and literature show that patient activation-the skills and confidence that equip patients to become actively engaged in their health care-impact health outcomes, costs, and patient experience. Reaching patient activation through engagement methods including shared decision-making (SDM) lead to improved value of care received. The National Eczema Association (NEA) Shared Decision-Making Resource Center can be a transformative strategy to measure and evaluate value of health care interventions for eczema patients to advance a value-driven health care system in the United States.

RESULTS

Through this Resource Center, NEA will measure patient value through their own perceptions using validated PRO instruments and other patient-generated health data.

CONCLUSIONS

Assessment of this data will reveal findings that can assist researchers in evaluating the impact this care framework on patient-perceived value across other chronic diseases.

Early Treatment at a Referral Center Improves Outcomes for Patients with Acute Vascular Disease

BACKGROUND

Patients with acute vascular disease frequently need specialized management that may require transfer to a vascular referral center. Although transfer may be medically necessary, it can delay definitive care and is an indicator of incorrect triage to the initial hospital. Regionalization of acute vascular care could improve patient triage and subsequent outcomes. To evaluate the potential benefit from regionalization, we analyzed outcomes of patients treated for acute vascular disease at vascular referral centers.

METHODS

Using a statewide database capturing all inpatient admissions in Maryland during 2013-2015, patients undergoing noncardiac vascular procedures on an acute basis were identified. Patients admitted to a vascular referral center were stratified by admission status as direct or transfer. The primary outcome was inpatient mortality, and the secondary outcome was resource use. Patient groups were compared by univariable analyses, and the effect of admission status on mortality was assessed by multivariable logistic regression.

RESULTS

Of 4,873 patients with acute vascular disease managed at vascular referral centers, 2,713 (56%) were admitted directly, whereas 2,160 (44%) were transferred. Transfers to referral centers accounted for 71% of all interhospital transfers. The transfer-group patients were older, had more comorbidities, and higher illness severities. Patients who were transferred had higher mortality (14% vs. 9%, P < 0.0001), longer hospital lengths of stay, greater critical care-resource utilization, and higher costs. After adjusting for demographics, comorbidities, and illness severity, transfer status was independently associated with higher inpatient mortality.

CONCLUSIONS

Primary treatment at a referral center is independently associated with improved outcomes for patients with acute vascular disease. Direct admission or earlier triage to a specialty center may improve patient and system outcomes and could be facilitated by standardization and regionalization of complex acute vascular care.

Biting the Hands that Feed "the Alligators": A Case Study in Morbid Obesity Extremes, End-of-Life Care, and Prohibitions on Harming and Accelerating the End of Life

Obesity, recognized as a disease in the U.S. and at times as a terminal illness due to associated medical complications, is an American epidemic according to the Centers for Disease Control and Prevention ("CDC"), American Heart Association ("AHA"), and other authorities. More than one third of Americans (39.8% of adults and 18.5% of children) are medically obese. This article focuses on cases of "extreme morbid obesity" ("EMO")-situations in which death is imminent without aggressive medical interventions, and bariatric surgery is the only treatment option with a realistic possibility of success. Bariatric surgeries themselves are very high risk for EMO patients. Individuals in this state have impeded mobility and are partially, if not entirely, bedridden, highly vulnerable, and dependent upon caregivers who often are enablers feeding their food addictions. The article draws from existing Centers for Medicare and Medicaid Services ("CMS") and Social Security Administration ("SSA") policies and procedures for severe obesity treatment and disability benefits. The discussion also encompasses myriad areas in which the law imposes a duty to report on professionals to protect vulnerable individuals from harm from others, and constraints and prohibitions on accelerating the end of life. The article proposes, among other law and policy measures, to introduce an obligation on medical professionals to investigate and report instances of enablement when food addiction has put the lives of individuals at risk of imminent death. The objectives of the proposals are to give providers more leverage to prevent food addiction enablers from impeding treatment and to enable EMO patients to comply with treatment protocols, to save lives and, ironically, to empower enablers to stand firm against the demands of individuals whose lives have been consumed by their food addictions.

Subsidies for Oral Chemotherapy and Use of Immunomodulatory Drugs Among Medicare Beneficiaries With Myeloma

Purpose The low-income subsidy (LIS) substantially lowers out-of-pocket costs for qualifying Medicare Part D beneficiaries who receive orally administered chemotherapy. We examined the association of LIS with the use of novel oral immunomodulatory drugs (IMiDs; lenalidomide and thalidomide) among beneficiaries with myeloma, who can receive either orally administered or parenteral (bortezomib-based) therapy. Methods Using SEER-Medicare data, we identified Part D beneficiaries diagnosed with myeloma in 2007 to 2011. In multivariable models adjusted for sociodemographic and clinical characteristics, we analyzed associations between the LIS and use of IMiD-based therapy, delays between IMiD refills, and select health outcomes during the first year of therapy. Results Among 3,038 beneficiaries, 41% received first-line IMiDs. Median out-of-pocket cost for the first IMiD prescription was $3,178 for LIS nonrecipients and $3 for LIS recipients, whereas the respective median costs for the first year of therapy were $5,623 and $6, respectively. Receipt of the LIS was associated with a 32% higher (95% CI, 16% to 47%) probability of receiving IMiDs among beneficiaries age 75 to 84 years and a significantly lower risk of delays between refills in all age groups (adjusted relative risk, 0.54; 95% CI, 0.32 to 0.92). Duration of therapy did not significantly differ between LIS recipients and nonrecipients (median, 7.6 months). Patients treated with IMiDs had significantly fewer emergency department visits and hospitalizations compared with patients receiving bortezomib (without IMiDs), but 1-year overall survival and cumulative Medicare costs were similar. Conclusion Medicare beneficiaries with myeloma who do not receive LISs face a substantial financial barrier to accessing orally administered anticancer therapy, warranting urgent attention from policymakers. Limiting out-of-pocket costs for expensive anticancer drugs like the IMiDs may improve access to oral therapy for patients with myeloma.

A systematic review of economic evaluation in pancreatic ductal adenocarcinoma

OBJECTIVES

The economic evaluation (EE) of healthcare interventions has become a necessity. However, high quality needs to be ensured in order to achieve validated results and help making informed decisions. Thus, the objective of the present study was to systematically identify and review published pancreatic ductal adenocarcinoma-related EEs and to assess their quality.

METHODS

Systematic literature research was conducted in PubMed and Cochrane to identify published EEs between 2000 and 2015. The quality of each selected EE was assessed by two independent reviewers, using the Drummond's checklist.

RESULTS

Our systematic review was based on 32 EEs and showed a wide variety of methodological approaches, including different perspectives, time horizon, and cost effectiveness analyses. Nearly two-thirds of EEs are full EEs (n = 21), and about one-third of EEs had a Drummond score ≥7, synonymous with 'high quality'. Close to 50% of full EEs had a Drummond score ≥7, whereas all of partial EEs had a Drummond score <7 (n = 11).

CONCLUSIONS

Over the past 15 years, a lot of interest has been evinced over the EE of pancreatic ductal adenocarcinoma (PDAC) and its direct impact on therapeutic advances in PDAC. To provide a framework for health care decision-making, to facilitate transferability and to lend credibility to health EEs, their quality must be improved. For the last 4 years, a tendency towards a quality improvement of these studies has been observed, probably coupled with a context of rational decision-making in health care, a better and wider spread of recommendations and thus, medical practitioners' full endorsement.

Treating Peripheral Artery Disease in the Wake of Rising Costs and Protracted Length of Stay

BACKGROUND

There has been growing scrutiny in the treatment of patients with peripheral artery disease due to the utilization of resources to manage this complex patient population. The purpose of this study was to determine the factors associated with prolonged length of stay (LOS > 7 days) following lower extremity bypass using data from the Vascular Quality Initiative as well as to define the additional costs incurred due to prolonged LOS in our health system.

METHODS

Summary statistics were performed of patients undergoing lower extremity bypass from 2010 to 2015. Student's t-tests and χ² tests were performed to compare those with and without prolonged LOS. Multivariable logistic regression was then performed to determine the independent predictors for increased LOS. We then compared our institutional LOS with that of representative institutions from the University Health System Consortium and evaluated the impact of prolonged LOS on limb salvage and survival.

RESULTS

This study included 334 patients with a mean age of 66.4 ± 12.4 years, 64.7% males, 58.5% of white race, 11.1% on dialysis, 80.5% smokers, and 53.6% with diabetes. The mean LOS was 15.7 ± 12.2 days. Prolonged LOS was associated with transfer (15.4% vs. 2.3%, P = 0.001), diabetes (58.3% vs. 40.2%, P = 0.004), critical limb ischemia (71.3% vs. 49.4%, P < 0.001), preoperative need for ambulatory assistance (44.5% vs. 16.1%, P < 0.001), prior ipsilateral bypass (6.9% vs. 1.1%, P = 0.042), urgent surgery (39.7% vs. 9.8%, P < 0.001), tibial or distal target vessel (52.7% vs. 28.0%, P < 0.001), use of vein (65.4% vs. 46.3%, P = 0.002), return to operating room (42.6% vs. 1.2%, P < 0.001), ambulatory assistance (65.0% vs. 34.1%, P < 0.001) as well as discharge anticoagulant (22.8% vs. 9.8%, P = 0.010). Multivariable logistic regression identified urgency (odds ratio [OR] = 5.09, 95% confidence interval [CI] 2.16-12.02, P < 0.001), critical limb ischemia (OR = 3.12, 95% CI 1.65-5.90, P < 0.001), return to OR (OR = 40.30, 95% CI 5.36-303.20, P < 0.001), use of vein (OR = 2.19, 95% CI 1.18-4.07, P = 0.013), and the need for anticoagulation at discharge (OR = 2.56, 95% CI 1.03-6.33, P = 0.043) as independent predictors of LOS > 7 days. Prolonged hospital stays accounted for an additional $40,561.64 in total cost and $26,028 in direct costs incurred. Despite these increased costs, limb salvage and overall survival were not adversely impacted in the prolonged LOS group in follow-up.

CONCLUSIONS

Lower extremity bypass is associated with a longer than expected LOS in our health system, much of which can be attributed to return to the OR for minor amputations and wound issues. This led to added total and direct costs, where the majority of this increase was attributable to prolonged LOS. Limb salvage and overall survival were preserved, however, in this subset of patients in follow-up. These findings suggest that lower extremity bypass patients are a resource-intensive population of patients, but that these costs are worthwhile in the setting of preserved limb salvage and overall survival.

Cost-utility analysis comparing laparoscopic vs open aortobifemoral bypass surgery

OBJECTIVES

Laparoscopic aortobifemoral bypass has become an established treatment option for symptomatic aortoiliac obstructive disease at dedicated centers. Minimally invasive surgical techniques like laparoscopic surgery have often been shown to reduce expenses and increase patients' health-related quality of life. The main objective of our study was to measure quality-adjusted life years (QALYs) and costs after totally laparoscopic and open aortobifemoral bypass.

PATIENTS AND METHODS

This was a within trial analysis in a larger ongoing randomized controlled prospective multicenter trial, Norwegian Laparoscopic Aortic Surgery Trial. Fifty consecutive patients suffering from symptomatic aortoiliac occlusive disease suitable for aortobifemoral bypass surgery were randomized to either totally laparoscopic (n=25) or open surgical procedure (n=25). One patient dropped out of the study before surgery. We measured health-related quality of life using the EuroQol (EQ-5D-5L) questionnaire at 4 different time points, before surgery and for 6 months during follow-up. We calculated the QALYs gained by using the area under the curve for both groups. Costs were calculated based on prices for surgical equipment, vascular prosthesis and hospital stay.

RESULTS

We found a significantly higher increase in QALYs after laparoscopic vs open aortobifemoral bypass surgery, with a difference of 0.07 QALYs, (p=0.001) in favor of laparoscopic aortobifemoral bypass. The total cost of surgery, equipment and hospital stay after laparoscopic surgery (9,953 €) was less than open surgery (17,260 €), (p=0.001).

CONCLUSION

Laparoscopic aortobifemoral bypass seems to be cost-effective compared with open surgery, due to an increase in QALYs and lower procedure-related costs.

Possible consequences of regionally based bundled payments for diabetic amputations for safety net hospitals in Texas

OBJECTIVE

Ongoing health reform in the United States encourages quality-based reimbursement methods such as bundled payments for surgery. The effect of such changes on high-risk procedures is unknown, especially at safety net hospitals. This study quantified the burden of diabetes-related amputation and the potential financial effect of bundled payments at safety net hospitals in Texas.

METHODS

We performed a cross-sectional analysis of diabetic amputation burden and charges using publically available data from Centers for Medicare and Medicaid and the Texas Department of Health from 2008 to 2012. Using hospital referral region (HRR)-level analysis, we categorized the proportion of safety net hospitals within each region as very low (0%-9%), low (10%-20%), average (20%-33%), and high (>33%) and compared amputation rates across regions using nonparametric tests of trend. We then used charge data to create reimbursement rates based on HRR to estimate financial losses.

RESULTS

We identified 51 adult hospitals as safety nets in Texas. Regions varied in the proportion of safety net hospitals from 0% in Victoria to 65% in Harlingen. Among beneficiaries aged >65, amputation rates correlated to the proportion of safety net hospitals in each region; for example, patients in the lowest quartile of safety net had a yearly rate of 300 amputations per 100,000 beneficiaries, whereas those in the highest quartile had a yearly rate of 472 per 100,000 (P = .007). Charges for diabetic amputation-related admissions varied almost 200-fold, from $5000 to $1.4 million. Using reimbursement based on HRR to estimate a bundled payment, we noted net losses would be higher at safety net vs nonsafety net hospitals ($180 million vs $163 million), representing a per-hospital loss of $1.6 million at safety nets vs $700,000 at nonsafety nets (P < .001).

CONCLUSIONS

Regions with a high proportion of safety net hospitals perform almost half of the diabetic amputations in Texas. Changes to traditional payment models should account for the disproportionate burden of high-risk procedures performed by these hospitals.

Increased healthcare utilization costs following initiation of insulin treatment in type 2 diabetes: A long-term follow-up in clinical practice

AIMS

To compare long-term changes in healthcare utilization and costs for type 2 diabetes patients before and after insulin initiation, as well as healthcare costs after insulin versus non-insulin anti-diabetic (NIAD) initiation.

METHODS

Patients newly initiated on insulin (n=2823) were identified in primary health care records from 84 Swedish primary care centers, between 1999 to 2009. First, healthcare costs per patient were evaluated for primary care, hospitalizations and secondary outpatient care, before and up to seven years after insulin initiation. Second, patients prescribed insulin in second line were matched to patients prescribed NIAD in second line, and the healthcare costs of the matched groups were compared.

RESULTS

The total mean annual healthcare cost increased from €1656 per patient 2 years before insulin initiation to €3814 seven years after insulin initiation. The total cumulative mean healthcare cost per patient at year 5 after second-line treatment was €13,823 in the insulin group compared to €9989 in the NIAD group.

CONCLUSIONS

Initiation of insulin in type 2 diabetes patients was followed by increased healthcare costs. The increases in costs were larger than those seen in a matched patient population initiated on NIAD treatment in second-line.

Favorable cardiovascular risk factor profile is associated with lower healthcare expenditure and resource utilization among adults with diabetes mellitus free of established cardiovascular disease: 2012 Medical Expenditure Panel Survey (MEPS)

BACKGROUND AND AIMS

Given the prevalence and economic burden of diabetes mellitus (DM), we studied the impact of a favorable cardiovascular risk factor (CRF) profile on healthcare expenditures and resource utilization among individuals without cardiovascular disease (CVD), by DM status.

METHODS

25,317 participants were categorized into 3 mutually-exclusive strata: "Poor", "Average" and "Optimal" CRF profiles (≥4, 2-3, 0-1 CRF, respectively). Two-part econometric models were utilized to study cost data.

RESULTS

Mean age was 45 (48% male), with 54% having optimal, 39% average, and 7% poor CRF profiles. Individuals with DM were more likely to have poor CRF profile vs. those without DM (OR 7.7, 95% CI 6.4, 9.2). Individuals with DM/poor CRF profile had a mean annual expenditure of $9,006, compared to $6,461 among those with DM/optimal CRF profile (p < 0.001).

CONCLUSIONS

A favorable CRF profile is associated with significantly lower healthcare expenditures and utilization in CVD-free individuals across DM status, suggesting that these individuals require aggressive individualized prescriptions targeting lifestyle modifications and therapeutic treatments.

Improving Efficiency Using Time-Driven Activity-Based Costing Methodology

PURPOSE

The aim of this study was to increase efficiency in MR enterography using a time-driven activity-based costing methodology.

METHODS

In February 2015, a multidisciplinary team was formed to identify the personnel, equipment, space, and supply costs of providing outpatient MR enterography. The team mapped the current state, completed observations, performed timings, and calculated costs associated with each element of the process. The team used Pareto charts to understand the highest cost and most time-consuming activities, brainstormed opportunities, and assessed impact. Plan-do-study-act cycles were developed to test the changes, and run charts were used to monitor progress. The process changes consisted of revising the workflow associated with the preparation and administration of glucagon, with completed implementation in November 2015.

RESULTS

The time-driven activity-based costing methodology allowed the radiology department to develop a process to more accurately identify the costs of providing MR enterography. The primary process modification was reassigning responsibility for the administration of glucagon from nurses to technologists. After implementation, the improvements demonstrated success by reducing non-value-added steps and cost by 13%, staff time by 16%, and patient process time by 17%. The saved process time was used to augment existing examination time slots to more accurately accommodate the entire enterographic examination. Anecdotal comments were captured to validate improved staff satisfaction within the multidisciplinary team.

CONCLUSIONS

This process provided a successful outcome to address daily workflow frustrations that could not previously be improved. A multidisciplinary team was necessary to achieve success, in addition to the use of a structured problem-solving approach.

Smallest worthwhile effect of exercise programs to prevent falls among older people: estimates from benefit-harm trade-off and discrete choice methods

BACKGROUND

the smallest worthwhile effect (SWE) of an intervention is the smallest treatment effect that justifies the costs, risks and inconveniences associated with that health intervention.

OBJECTIVE

to estimate the SWE of exercise programs designed to prevent falls among older people and to compare estimates derived by two methodological approaches.

STUDY DESIGN AND SETTING

discrete choice experiment (n = 220) and benefit-harm trade-off (subsample n = 66) methods were used.

PARTICIPANTS

community-dwelling older people who reported a past fall or a mobility limitation answered online or face-to-face questionnaires.

RESULTS

a substantial proportion of participants (82% in the discrete choice experiment and 50% in the benefit-harm trade-off study) did not consider that participation in the proposed exercise programs would be worthwhile, even if it reduced their risk of falling to 0%. Among remaining participants, the average SWE of participation in an exercise program was an absolute reduction in the risk of falling of 35% (standard deviation [SD] = 13) in the discrete choice experiment and 16% (SD = 11) in the benefit-harm trade-off study.

CONCLUSIONS

many participants did not consider the hypothetical falls' risk reduction of the proposed exercise programs to be worth the associated costs and inconveniences. Greater community awareness of the fall prevention effects of exercise for older people is required.

Multifaceted intervention including education, rounding checklist implementation, cost feedback, and financial incentives reduces inpatient laboratory costs

BACKGROUND

Inappropriate laboratory testing is a contributor to waste in healthcare.

OBJECTIVE

To evaluate the impact of a multifaceted laboratory reduction intervention on laboratory costs.

DESIGN

A retrospective, controlled, interrupted time series (ITS) study.

SETTING

University of Utah Health Care, a 500-bed academic medical center in Salt Lake City, Utah.

POPULATION

All patients 18 years or older admitted to the hospital to a service other than obstetrics, rehabilitation, or psychiatry.

INTERVENTION

Multifaceted quality-improvement initiative in a hospitalist service including education, process change, cost feedback, and financial incentive.

MEASUREMENTS

Primary outcomes of lab cost per day and per visit. Secondary outcomes of number of basic metabolic panel (BMP), comprehensive metabolic panel (CMP), complete blood count (CBC), and prothrombin time/international normalized ratio tests per day; length of stay (LOS); and 30-day readmissions.

RESULTS

A total of 6310 hospitalist patient visits (intervention group) were compared to 25,586 nonhospitalist visits (control group). Among the intervention group, the unadjusted mean cost per day was reduced from $138 before the intervention to $123 after the intervention (P < 0.001), and the unadjusted mean cost per visit decreased from $618 to $558 (P = 0.005). The ITS analysis showed significant reductions in cost per day, cost per visit, and the number of BMP, CMP, and CBC tests per day (P = 0.034, 0.02, <0.001, 0.004, and <0.001). LOS was unchanged and 30-day readmissions decreased in the intervention group.

CONCLUSION

A multifaceted approach to laboratory reduction demonstrated a significant reduction in laboratory cost per day and per visit, as well as common tests per day at a major academic medical center. Journal of Hospital Medicine 2016;11:348-354. © 2016 Society of Hospital Medicine.

A decision model and cost analysis of intra-operative cell salvage during hepatic resection

BACKGROUND

Intraoperative cell salvage (ICS) can reduce allogeneic transfusions but with notable direct costs. This study assessed whether routine use of ICS is cost minimizing in hepatectomy and defines a subpopulation of patients where ICS is most cost minimizing based on patient transfusion risk.

METHODS

A decision model from a health systems perspective was developed to examine adoption and non-adoption of ICS use for hepatectomy. A prospectively maintained database of hepatectomy patients provided data to populate the model. Probabilistic sensitivity analysis was used to determine the probability of ICS being cost-minimizing at specified transfusion risks. One-way sensitivity analysis was used to identify factors most relevant to institutions considering adoption of ICS for hepatectomies.

RESULTS

In the base case analysis (transfusion risk of 28.8%) the probability that routine utilization of ICS is cost-minimizing is 64%. The probability that ICS is cost-minimizing exceeds 50% if the patient transfusion risk exceeds 25%. The model was most sensitive to patient transfusion risk, variation in costs of allogeneic blood, and number of appropriate cases the device could be used for.

CONCLUSIONS

ICS is cost-minimizing for routine use in liver resection, particularly when used for patients with a risk of transfusion of 25% or greater.

Vertical Sculpted Pillar Reduction Mammaplasty in 317 Patients: Technique, Complications, and BREAST-Q Outcomes

BACKGROUND

The senior author (JCG) has described the vertical sculpted pillar breast reduction.

OBJECTIVES

This manuscript aimed to compare this technique's safety profile to other established techniques via complication rate reporting. Few studies have utilized the BREAST-Q for long-term outcomes reporting in bilateral reduction mammaplasty patients. BREAST-Q outcome comparisons, between cosmetic and insurance-based breast reduction cohorts, have not been previously reported.

METHODS

A retrospective chart review was performed on patients who underwent reduction mammaplasty using the vertical sculpted pillar technique. The BREAST-Q postoperative reduction mammaplasty module was administered. Complication rates and outcomes data were compared among patient cohorts distinguished by pedicle, scar pattern, and payor population. Statistically significant differences were set at P < .05.

RESULTS

Compared to the superior pedicle, use of the superomedial pedicle statistically increased rates of postoperative fat necrosis in this series. Complication rates did not differ among scar patterns, but use of a J, L-shaped, or short-T scar decreased the need for secondary/revisional surgery. Cosmetic and insurance-based outcomes did not differ in any domain of the postoperative reduction mammaplasty BREAST-Q module.

CONCLUSIONS

Complications data for the vertical sculpted pillar reduction mammaplasty were comparable to published results for other techniques. Complication rates are unaffected by scar pattern. Superomedial pedicle selection and larger insurance-based reductions may predispose to statistically significant increases in fat necrosis compared to use of the superior pedicle. Payor source neither affects the majority of complication rates, nor BREAST-Q satisfaction and quality of life domains. This information can be used to improve management of expectations during the preoperative consultation process.

LEVEL OF EVIDENCE

4 Therapeutic.

Practice-Level Variation in Outpatient Cardiac Care and Association With Outcomes

BACKGROUND

Utilization of cardiac services varies across regions and hospitals, yet little is known regarding variation in the intensity of outpatient cardiac care across cardiology physician practices or the association with clinical endpoints, an area of potential importance to promote efficient care.

METHODS AND RESULTS

We included 7 160 732 Medicare beneficiaries who received services from 5635 cardiology practices in 2012. Beneficiaries were assigned to practices providing the plurality of office visits, and practices were ranked and assigned to quartiles using the ratio of observed to predicted annual payments per beneficiary for common cardiac services (outpatient intensity index). The median (interquartile range) outpatient intensity index was 1.00 (0.81-1.24). Mean payments for beneficiaries attributed to practices in the highest (Q4) and lowest (Q1) quartile of outpatient intensity were: all cardiac payments (Q4 $1272 vs Q1 $581; ratio, 2.2); cardiac catheterization (Q4 $215 vs Q1 $64; ratio, 3.4); myocardial perfusion imaging (Q4 $253 vs Q1 $83; ratio, 3.0); and electrophysiology device procedures (Q4 $353 vs Q1 $142; ratio, 2.5). The adjusted odds ratios (95% CI) for 1 incremental quartile of outpatient intensity for each outcome was: cardiac surgical/procedural hospitalization (1.09 [1.09, 1.10]); cardiac medical hospitalization (1.00 [0.99, 1.00]); noncardiac hospitalization (0.99 [0.99, 0.99]); and death at 1 year (1.00 [0.99, 1.00]).

CONCLUSION

Substantial variation in the intensity of outpatient care exists at the cardiology practice level, and higher intensity is not associated with reduced mortality or hospitalizations. Outpatient cardiac care is a potentially important target for efforts to improve efficiency in the Medicare population.

Evidence-based care pathway for cellulitis improves process, clinical, and cost outcomes

BACKGROUND

Cellulitis is a common infection with wide variation of clinical care.

OBJECTIVE

To implement an evidence-based care pathway and evaluate changes in process metrics, clinical outcomes, and cost for cellulitis.

DESIGN

A retrospective observational pre-/postintervention study was performed.

SETTING

University of Utah Health Care, a 500-bed academic medical center in Salt Lake City, Utah.

PATIENTS

All patients 18 years or older admitted to the emergency department observation unit or hospital with a primary diagnosis of cellulitis.

INTERVENTION

Development of an evidence-based care pathway for cellulitis embedded into the electronic medical record with education for all emergency and internal medicine physicians.

MEASUREMENTS

Primary outcome of broad-spectrum antibiotic use. Secondary outcomes of computed tomography/magnetic resonance imaging orders, length of stay (LOS), 30-day readmission, and pharmacy, lab, imaging, and total facility costs.

RESULTS

A total of 677 visits occurred, including 370 visits where order sets were used. Among all patients, there was a 59% decrease in the odds of ordering broad-spectrum antibiotics (P < 0.001), 23% decrease in pharmacy cost (P = 0.002), and 13% decrease in total facility cost (P = 0.006). Compared to patients for whom order sets were not used, patients for whom order sets were used had a 75%, 13%, and 25% greater decrease in the odds of ordering broad-spectrum antibiotics (P < 0.001), clinical LOS (P = 0.041), and pharmacy costs (P = 0.074), respectively.

CONCLUSION

The evidence-based care pathway for cellulitis improved care at an academic medical center by reducing broad-spectrum antibiotic use, pharmacy costs, and total facility costs without an adverse change in LOS or 30-day readmissions.

Minimally Invasive Aortic Valve Replacement: Cost-Benefit Analysis of Ministernotomy Versus Minithoracotomy Approach

BACKGROUND AND AIM OF THE STUDY

Minimally invasive aortic valve replacement via ministernotomy (ministernotomy-AVR) or minithoracotomy (minithoracotomy-AVR) is gaining popularity. To date, a direct comparison of ministernotomy-AVR versus minithoracotomy-AVR is lacking. The study aim was to compare these two procedures from a cost-benefit perspective.

METHODS

Eight reports from the United States were selected from amongst 33,494 literature citations based on sample size and data completeness. Perioperative variables were collected for each surgical approach. Fixed and variable costs were estimated as cost per case in excess of full sternotomy AVR procedures.

RESULTS

Ministernotomy-AVR patients were of a significantly lower mean age (59.8 years versus 67.9 years), ejection fraction (50.4-51.6% versus 56.1-57.8%), shorter cardiopulmonary bypass time (97.2 min versus 125.6 min) and cross-clamp time (69.9 min versus 87.9 min), a lower rate of blood transfusion (25.9% versus 64.4%), and a shorter length of hospital stay (5.7 versus 6.2 days). There were no significant inter-group differences in 30-day mortality, conversion to sternotomy, neurologic events, arrhythmia, wound infection, or postoperative bleeding. Assuming a volume of 50 cases per year, the added operative cost per case for a minithoracotomy-AVR was US$ 4,254 compared to US$ 290 for a ministernotomy-AVR. The added costs per case, assuming 200 cases per year, were US$ 4,209 and US$ 290, respectively. A minithoracotomy-AVR program performing 50 cases per year adds US$ 1,063,665 of operative costs over five years, compared to US$ 72,500 for a ministernotomy-AVR program.

CONCLUSION

The present analysis suggested that the clinical benefits of ministernotomy-AVR are comparable or better than those of minithoracotomy-AVR, and at lower costs. Healthcare delivery organizations should consider the results of cost-benefit examinations when developing surgical valve replacement programs.

Cost-Effectiveness of Reduced Waiting Time for Head and Neck Cancer Patients due to a Lean Process Redesign

BACKGROUND

Compared with new technologies, the redesign of care processes is generally considered less attractive to improve patient outcomes. Nevertheless, it might result in better patient outcomes, without further increasing costs. Because early initiation of treatment is of vital importance for patients with head and neck cancer (HNC), these care processes were redesigned.

OBJECTIVES

This study aimed to assess patient outcomes and cost-effectiveness of this redesign.

METHODS

An economic (Markov) model was constructed to evaluate the biopsy process of suspicious lesion under local instead of general anesthesia, and combining computed tomography and positron emission tomography for diagnostics and radiotherapy planning. Patients treated for HNC were included in the model stratified by disease location (larynx, oropharynx, hypopharynx, and oral cavity) and stage (I-II and III-IV). Probabilistic sensitivity analyses were performed.

RESULTS

Waiting time before treatment start reduced from 5 to 22 days for the included patient groups, resulting in 0.13 to 0.66 additional quality-adjusted life-years. The new workflow was cost-effective for all the included patient groups, using a ceiling ratio of €80,000 or €20,000. For patients treated for tumors located at the larynx and oral cavity, the new workflow resulted in additional quality-adjusted life-years, and costs decreased compared with the regular workflow. The health care payer benefited €14.1 million and €91.5 million, respectively, when individual net monetary benefits were extrapolated to an organizational level and a national level.

CONCLUSIONS

The redesigned care process reduced the waiting time for the treatment of patients with HNC and proved cost-effective. Because care improved, implementation on a wider scale should be considered.

Content, participants and outcomes of three diabetes care programmes in three low and middle income countries

AIMS

To improve access and quality of diabetes care for people in low-income countries, it is important to understand which elements of diabetes care are effective. This paper analyses three diabetes care programmes in the DR Congo, Cambodia and the Philippines.

METHODS

Three programmes offering diabetes care and self-management were selected. Programme information was collected through document review and interviews. Data about participants' characteristics, health outcomes, care utilisation, expenditures, care perception and self-management were extracted from a study database. Comparative univariate analyses were performed.

RESULTS

Kin-réseau (DR Congo) is an urban primary care network with 8000 patients. MoPoTsyo (Cambodia) is a community-based peer educator network, covering 7000 patients. FiLDCare (Philippines) is a programme in which 1000 patients receive care in a health facility and self-management support from a community health worker. Content of care of the programmes is comparable, the focus on self-management largest in MoPoTsyo. On average, Kin-réseau patients have a higher age, longer diabetes history and more overweight. MoPoTsyo includes most female, most illiterate and most lean patients. Health outcomes (HbA1C level, systolic blood pressure, diabetes foot lesions) were most favourable for MoPoTsyo patients. Diabetes-related health care expenditure was highest for FiLDCare patients.

CONCLUSIONS

This study shows it possible to maintain a diabetes programme with minimal external resources, offering care and self-management support. It also illustrates that health outcomes of persons with diabetes are determined by their bio-psycho-social characteristics and behaviour, which are each subject to the content of care and the approach to chronic illness and self-management of the programme, in turn influenced by the larger context.

Performing well in financial management and quality of care: evidence from hospital process measures for treatment of cardiovascular disease

BACKGROUND

Fiscal constraints faced by U.S. hospitals as a result of the recent economic downturn are leading to business practices that reduce costs and improve financial and operational efficiency in hospitals. There naturally arises the question of how this finance-driven management culture could affect the quality of care. This paper attempts to determine whether the process measures of treatment quality are correlated with hospital financial performance.

METHODS

Panel study of hospital care quality and financial condition between 2005 and 2010 for cardiovascular disease treatment at acute care hospitals in the United States. Process measures for condition-specific treatment of heart attack and heart failure and hospital-level financial condition ratios were collected from the CMS databases of Hospital Compare and Cost Reports.

RESULTS

There is a statistically significant relationship between hospital financial performance and quality of care. Hospital profitability, financial leverage, asset liquidity, operating efficiency, and costs appear to be important factors of health care quality. In general, public hospitals provide lower quality care than their nonprofit counterparts, and urban hospitals report better quality score than those located in rural areas. Specifically, the first-difference regression results indicate that the quality of treatment for cardiovascular patients rises in the year following an increase in hospital profitability, financial leverage, and labor costs.

CONCLUSIONS

The results suggest that, when a hospital made more profit, had the capacity to finance investment using debt, paid higher wages presumably to attract more skilled nurses, its quality of care would generally improve. While the pursuit of profit induces hospitals to enhance both quantity and quality of services they offer, the lack of financial strength may result in a lower standard of health care services, implying the importance of monitoring the quality of care among those hospitals with poor financial health.

Embarking on performance improvement

Healthcare organizations should approach performance improvement as a program, not a project. The program should be led by a guidance team that identifies goals, prioritizes work, and removes barriers to enable clinical improvement teams and work groups to realize performance improvements. A healthcare enterprise data warehouse can provide the initial foundation for the program analytics. Evidence-based best practices can help achieve improved outcomes and reduced costs.

Making process improvement 'stick'

To sustain gains from a process improvement initiative, healthcare organizations should: Explain to staff why a process improvement initiative is needed. Encourage leaders within the organization to champion the process improvement, and tie their evaluations to its outcomes. Ensure that both leaders and employees have the skills to help sustain the sought-after process improvements.

The effect of accountable care organizations on oncology practice

Cancer care accounts for a significant portion of the rise in health care costs, and therefore, as national efforts escalate to control cost, cancer care will be a focus of concern. Cost increases in cancer care are related to many factors, including increasing cancer incidence in an aging population, the introduction of new high-cost therapeutics, and the high cost of end-of-life care. Accountable care organizations (ACOs) have been one of the major efforts directed at controlling health care costs. How cancer care will fit into the rubric of ACOs is not entirely clear but will certainly evolve over the coming years. The oncology profession has the opportunity to play a role in this evolution or could leave the evolution to others driving the process, such as the Centers for Medicare and Medicaid Services (CMS), private payers, and ACOs. Ideally all parties will work together to provide a construct for high-value, high-quality care for patients with cancer while contributing to cost control in overall health care.

Reducing inequalities in cancer outcomes: what works?

Despite efforts to reduce disparities in cancer outcomes among vulnerable populations, certain subgroups do not experience the gains made in the reduction of cancer incidence and mortality. In this article, we review recent trial data reporting on patient-, physician-, and system-centered interventions to improve quality and reduce disparities in cancer care spanning patient navigation to health reform. We conclude with data from a state that implemented a multitiered approach, targeting patient and systems barriers, that serves as a guide for future endeavors.

Cost-effectiveness models for dental caries prevention programmes among Chilean schoolchildren

AIM

This study aims to estimate the cost-effectiveness from a societal perspective of seven dental caries prevention programmes among schoolchildren in Chile: three community-based programmes: water-fluoridation, salt-fluoridation and dental sealants; and four school-based programmes: milk-fluoridation; fluoridated mouthrinses (FMR); APF-Gel, and supervised toothbrushing with fluoride toothpaste.

METHODS

Standard cost-effectiveness analysis methods were used. The costs associated with implementing and operating each programme, using a societal perspective, were identified and estimated. The comparator was non-intervention. Health outcomes were measured as dental caries averted over a 6-year period. Costs were estimated as direct treatment costs, programmes costs and costs of productivity losses as a result of each dental caries prevention programme. Incremental cost-effectiveness ratios were calculated for each programme. Sensitivity analyses were conducted over key parameters.

RESULTS

Primary cost-effectiveness analysis (discounted) indicated that four programmes showed net social savings by the DMFT averted. These savings encompassed a range of values per diseased tooth averted; US$16.21 (salt-fluoridation), US$14.89 (community water fluoridation); US$14.78 (milk fluoridation); and US$8.63 (FMR). Individual programmes using an APF-Gel application, dental sealants, and supervised tooth brushing using fluoridated toothpaste, represent costs for the society per diseased tooth averted of US$21.30, US$11.56 and US$8.55, respectively.

CONCLUSION

Based on cost required to prevent one carious tooth among schoolchildren, salt fluoridation was the most cost-effective, with APF-Gel ranking as least cost-effective. Findings confirm that most community/school-based dental caries interventions are cost-effective uses of society's financial resources. The models used are conservative and likely to underestimate the real benefits of each intervention.

Should compliance with the Surgical Care Improvement Project (SCIP) process measures determine Medicare and Medicaid reimbursement rates?

The Surgical Care Improvement Project (SCIP) is a project that focuses on improving surgical care by reducing surgical morbidity and mortality by 25 per cent by 2010. Starting in 2011, SCIP compliance affects Medicare and Medicaid reimbursement rates. Although SCIP reinforces better practices in surgical care, does compliance with SCIP measures actually result in a decrease in surgical morbidity and mortality? This study examined compliance with the SCIP surgical site infection (SSI) module (prophylactic antibiotic received within 1 hour before surgical incision) during 2009 to 2010 (n = 703) to determine whether patients compliant with SCIP data had a correlation with SSI rates as reported by National Surgery Quality Improvement Program (NSQIP) data for the same time period. We found no statistically significant association in patients that have failed SCIP INF1 in the years 2009 to 2010 (n = 43) and the rates of SSI (n = 0) for the same time period. These data suggest that SCIP compliance should not be used to determine Medicare and Medicaid reimbursement rates because there is no correlation between failure of SCIP INF1 and SSI. Instead, further effort should be placed on developing tools designed to acknowledge outcome measures that result in decreased morbidity/mortality and change practices accordingly such as NSQIP.

The cost-effectiveness of improving diabetes care in U.S. federally qualified community health centers

OBJECTIVE

To estimate the incremental cost-effectiveness of improving diabetes care with the Health Disparities Collaborative (HDC), a national collaborative quality improvement (QI) program conducted in community health centers (HCs).

DATA SOURCES/STUDY SETTING

Data regarding the impact of the Diabetes HDC program came from a serial cross-sectional follow-up study (1998, 2000, 2002) of the program in 17 Midwestern HCs. Data inputs for the simulation model of diabetes came from the latest clinical trials and epidemiological studies.

STUDY DESIGN

We conducted a societal cost-effectiveness analysis, incorporating data from QI program evaluation into a Monte Carlo simulation model of diabetes.

DATA COLLECTION/EXTRACTION METHODS

Data on diabetes care processes and risk factor levels were extracted from medical charts of randomly selected patients.

PRINCIPAL FINDINGS

From 1998 to 2002, multiple processes of care (e.g., glycosylated hemoglobin testing [HbA1C] [71-->92 percent] and ACE inhibitor prescribing [33-->55 percent]) and risk factor levels (e.g., 1998 mean HbA1C 8.53 percent, mean difference 0.45 percent [95 percent confidence intervals -0.72, -0.17]) improved significantly. With these improvements, the HDC was estimated to reduce the lifetime incidence of blindness (17-->15 percent), end-stage renal disease (18-->15 percent), and coronary artery disease (28-->24 percent). The average improvement in quality-adjusted life year (QALY) was 0.35 and the incremental cost-effectiveness ratio was $33,386/QALY.

CONCLUSIONS

During the first 4 years of the HDC, multiple improvements in diabetes care were observed. If these improvements are maintained or enhanced over the lifetime of patients, the HDC program will be cost-effective for society based on traditionally accepted thresholds.

A model for calculating costs of hospital‐acquired infections: an Italian experience

PURPOSE

Many approaches on the economic aspect of hospital acquired infections (HAIs) have two major limitations: first, the lack of distinction between resources attributable to the management of HAI and resources absorbed by the main clinical problem for which the patient was hospitalized, and second, the lack of an adequate method for calculating the relative costs. These assume that the resources used by HAI can be determined by measuring the extra days of length of days (LOS) of infected patients versus non-infected patients and attribute to extra-LOS a value to the mean total cost. The aim of the article is to test a cost-modelling method that could overcome these limitations by applying the appropriateness evaluation protocol to the medical charts of patients with hospital-acquired symptomatic urinary tract infection (UTI) or sepsis, and by using cost-centre accounting.

DESIGN/METHODOLOGY/APPROACH

The paper explains and tests a model for calculating costs of HAIs.

FINDINGS

The data analysis showed that it is not always true that infections protract LOS: five out of 25 sepsis cases have extra-LOS and eight out of 25 UTI cases have extra-LOS, while the cases of sepsis that arose in surgery ward and intensive care units and urinary tract infections in ICU are without prolongation of LOS. The data analysis also showed that, using the mean total cost, the three cases of sepsis in the general surgery and the six in the ICU did not incur costs, nor did the two cases of UTI in ICU, so that they appear to be infections at zero cost. Moreover, the weight of the cost for the bed, or for the diagnostic services, or for the pharmacological treatment, varied widely depending on the site of the HAI and the ward where the patient was hospitalized.

ORIGINALITY/VALUE

The method can be applied in any hospital.

Time-based management of patient processes

PURPOSE

The purpose of this paper is to present a conceptual framework that would enable the effective application of time based competition (TBC) and work in process (WIP) concepts in the design and management of effective and efficient patient processes.

DESIGN/METHODOLOGY/APPROACH

This paper discusses the applicability of time-based competition and work-in-progress concepts to the design and management of healthcare service production processes. A conceptual framework is derived from the analysis of both existing research and empirical case studies.

FINDINGS

The paper finds that a patient episode is analogous to a customer order-to-delivery chain in industry. The effective application of TBC and WIP can be achieved by focusing on through put time of a patient episode by reducing the non-value adding time components and by minimizing time categories that are main cost drivers for all stakeholders involved in the patient episode.

RESEARCH LIMITATIONS/IMPLICATIONS

The paper shows that an application of TBC in managing patient processes can be limited if there is no consensus about optimal care episode in the medical community.

PRACTICAL IMPLICATIONS

In the paper it is shown that managing patient processes based on time and cost analysis enables one to allocate the optimal amount of resources, which would allow a healthcare system to minimize the total cost of specific episodes of illness. Analysing the total cost of patient episodes can provide useful information in the allocation of limited resources among multiple patient processes.

ORIGINALITY/VALUE

This paper introduces a framework for health care managers and researchers to analyze the effect of reducing through put time to the total cost of patient episodes.

Primary care funding, contract status, and outcomes: an observational study

BACKGROUND

The introduction of the Quality and Outcomes Framework (QOF) provides a quantitative way of assessing quality of care in general practice. We explore the achievements of general practice in the first year of the QOF, with specific reference to practice funding and contract status.

AIM

To determine the extent to which differences in funding and contract status affect quality in primary care.

DESIGN OF STUDY

Cross-sectional observational study using practice data obtained under the Freedom of Information Act 2000.

SETTING

One hundred and sixty-four practices from six primary care trusts (PCTs) in England.

METHOD

Practice data for all 164 practices were collated for income and contract status. The outcome measure was QOF score for the year 2004-2005. All data were analysed statistically.

RESULTS

Contract status has an impact on practice funding, with Employed Medical Services (EMS) and Personal Medical Services (PMS) practices receiving higher levels of funding than General Medical Services (GMS) practices (P<0.001). QOF scores also vary according to contract status. Higher funding levels in EMS practices are associated with lower QOF scores (P=0.04); while GMS practices exhibited the opposite trend, with higher-funded practices achieving better quality scores (P<0.001).

CONCLUSION

GMS practices are the most efficient contract status, achieving high quality scores for an average of pound 62.51 per patient per year. By contrast, EMS practices are underperforming, achieving low quality scores for an average of pound 105.37 per patient per year. Funding and contract status are therefore important factors in determining achievement in the QOF.

St. Francis Health System overhauls heart attack care process

For scoring in the top 20% of hospitals for acute myocardial infarction (AMI), Bon Secours' St. Francis Hospital, in Greenville, SC, received a $54,000 bonus check last November from a Medicare pay-for-performance demonstration project. By implementing several process improvements, including improving its door to balloon time--the time it takes for a heart attack patient to enter the emergency department and then having an angioplasty in the cardiac cath lab--St. Francis' composite quality scores improved to 98% from 90% for AMI, or heart attack.

Importance of clinical and epidemiological research in defining the long-term clinical care of pediatric cancer survivors

With the increasing number of long-term survivors of childhood cancer, there continues to be a critical need for development and implementation of evidence-based recommendations for clinical follow-up. In order to establish and maintain health-related follow-up guidelines, it is important to recognize the attributes of research from which the recommendations may be formulated. Issues including study design and clinical research methodology, completeness of long-term follow-up for the applicable study population, approaches for assessment of treatment-related exposures, methods utilized for ascertainment and characterization of outcomes, and recognition of potential modifiers of risk (e.g., demographic or treatment-specific factors) are all important considerations when evaluating the results of available research. For the future, greater attention will not only need to be given to further development and maintenance of recommendations for follow-up, but to the scientific evaluation of the recommendations to determine the subsequent impact on health status and quality of life among pediatric cancer survivors.

QALYs and the capability approach

This explores the applicability of Sen's capability approach to the economic evaluation of health care programmes. An individual's 'capability set' describes his freedom to choose valuable activities and states of being ('functionings'). Direct estimation and valuation of capability sets is not feasible at present. Standard preference-based methods such as willingness to pay are feasible, but problematic due to the adaptive and constructed nature of individual preferences over time and under uncertainty. An alternative is to re-interpret the QALY as a cardinal and interpersonally comparable index of the value of the individual's capability set. This approach has limitations, since the link between QALYs and capabilities is not straightforward. Nevertheless, the QALY approach is recognisable as an application of the capability approach since it pays close attention to functionings, through the use of survey-based multi-attribute health state valuation instruments, and permits conceptions of value other than the traditional utilitarian ones of choice, desire-fulfilment and happiness. Furthermore, suitably re-interpreted, it can account for (i) non-separability between health and non-health components of value; and suitably modified it can also account for (ii) process attributes of care, which may have a direct effect on non-health functionings such as comfort and dignity, and (iii) sub-group diversity in the value of the same health functionings.

A Nursing Process Model

Comprehensive measurement of the effort associated with a procedure, treatment, or project involves a myriad of planned observations and analyses. When accurately synthesized, these measurements show the amount of resources or the level of effort required for the intervention. In an era of unprecedented healthcare cost scrutiny, it is imperative for clinicians to understand and apply these components and methods to program development, budget management, staffing, and cost-to-outcome analysis. Through a series of on-site observations and interviews at in-office infusion centers providing a nonchemotherapeutic biologic therapy, specifically infliximab (Remicade), the investigators were able to isolate and assign value to the multiple factors that contribute to the cost of this procedure. The investigators also were able to establish a process model for clinicians who are inevitably involved in the "business" of healthcare.