Delayed cervical palsy following cervical spine fusion leads to an increase in hospital-related costs.

OBJECT: Delayed cervical palsy (DCP) is a known complication following cervical spine surgery. While most DCPs eventually improve, they can result in significant temporary disability. Postoperative complications affect hospital length of stay (LOS) as well as overall hospital cost. The authors sought to determine the hospital cost of DCP after cervical spine fusion operations. METHODS: A retrospective review of patients undergoing cervical fusion for degenerative disease at the Mayo Clinic from 2008 to 2012 was performed. Patients who developed DCPs not attributable to intraoperative trauma were included. All nonoperative-related costs were compared with similar costs in a control group matched according to age, sex, and surgical approach. All costs and services were reflective of the standard costs for the current year. Raw cost data were presented using ratios due to institutional policy against publishing cost data. RESULTS: There were 27 patients (18 men, 9 women) who underwent fusion and developed a DCP over the study period. These patients were compared with 24 controls (15 men, 9 women) undergoing fusion in the same time period. There was no difference between patients and controls in mean age (62.4 ± 3.1 years vs. 63.8 ± 2.5 years, respectively; p = 0.74), LOS (4.2 ± 3.3 days vs 3.8 ± 4.5 days, respectively; p = 0.43), or operating room-related costs (1.08 ± 0.09 vs. 1.0 ± 0.07, respectively; p = 0.58). There was a significant difference in nonoperative hospital-related costs between patients and controls (1.67 ± 0.15 vs 1.0 ± 0.09, respectively; p = 0.04). There was a significantly higher utilization of postoperative imaging (CT or MRI) in the DCP group (14/27, 52%) when compared with the matched cohort (4/24, 17%; p = 0.018), and a significantly higher utilization of physiatry services (24/27 [89%] vs 15/24 [63%], respectively; p = 0.046). CONCLUSIONS: While DCPs did not significantly prolong the length of hospitalization, they did increase hospital-related costs. This method could be further extrapolated to model costs of other complications as well.

[HEALTH INSURANCE ASPECTS OF PHYSIOTHERAPEUTIC CARE OF NEUROLOGY DISORDERS IN OUTPATIENT CARE]. / A NEUROLÓGIAI KÓRKÉPEK FIZIOTERÁPIÁS ELLÁTÁSÁNAK EGÉSZSÉGBIZTOSÍTÁSI VONATKOZÁSAI A JÁRÓBETEG-SZAKELLÁTÁSBAN.

BACKGROUND AND PURPOSE: The aim of our study is to analyse the ambulatory rehabilitation care of patients with neurological disorders in the field of physiotherapy. METHODS: Data derive from the database of the Hungarian National Health Insurance Fund Administration (year 2009). The analyses covered patients with diagnosis "G00-G99 Diseases of the nervous system" according to the International Classification of Diseases and underwent physiotherapy treatment. RESULTS: In 2009 altogether 190986 patients with neurological disorders received physiotherapy treatment in outpatient care, representing 1331675 cases and got 388.215 million Hungarian Forint health insurance reimbursement. The number of patients with nerve, nerve root and plexus disorders was 39 patients/10 000 population for males and 66 patients/10000 population for females. The number of patients with cerebral palsy and other paralytic syndromes was 49 patients/10000 population for males and 35 patients/10000 population for females. The number of patients with episodic and paroxysmal disorders was 33 patients/10000 population for males and 52 patients/10000 population for females. CONCLUSION: In the outpatient physiotherapy care the utilization indicators for female patients were higher in nerve, nerve root and plexus disorders and episodic and paroxysmal disorders, while in cerebral palsy and other paralytic syndromes the utilization by male patients was higher. There are important age and gender inequalities in the utilization of physiotherapy care of patients with neurological disorders.

Evaluation of the acute flacid paralysis (AFP) surveillance system in Bikita district Masvingo province 2010.

BACKGROUND: AFP is a rare syndrome and serves as a proxy for poliomyelitis. The main objective of AFP surveillance is to detect circulating wild polio virus and provide data for developing effective prevention and control strategies as well planning and decision making. Bikita district failed to detect a case for the past two years. FINDINGS: A total of 31 health workers from 14 health centres were interviewed. Health worker knowledge on AFP was low in Bikita. The system was acceptable, flexible, and representative but not stable and not sensitive since it missed1 AFP case. The system was not useful to the district since data collected was not locally used in anyway. The cost of running the system was high. The district had no adequate resources to run the system. Reasons for not reporting cases was that the mothers were not bringing children with AFP and ignorance of health workers on syndromes captured under AFP. CONCLUSION: Health worker's knowledge on AFP was low and all interviewed workers needed training surveillance. The system was found to be flexible but unacceptable. Reasons for failure to detect AFP cases could be, no cases reporting to the centres, lack of knowledge on health workers hence failure to recognise symptoms, high staff turnover.

C5 palsy after posterior cervical decompression and fusion: cost and quality-of-life implications.

BACKGROUND CONTEXT: C5 palsy is a debilitating postoperative complication of cervical decompression surgery. Although the prognosis is typically good, patients may be unable to perform basic activities of daily living, resulting in a decreased quality of life. No studies have investigated the quality-of-life and financial implications. PURPOSE: The aim of the study was to determine the impact on quality-of-life and costs of C5 palsy after posterior cervical decompression and fusion (PCDF). STUDY DESIGN/SETTING: A 2:1 matched retrospective cohort study was conducted at a single tertiary-care institution between 2007 and 2012. PATIENT SAMPLE: Individuals who had undergone PCDF were included. OUTCOME MEASURES: Self-reported: Euroqol-5 Dimensions quality-of-life survey. Physiologic: postoperative change in deltoid and biceps strength via manual muscle testing. Functional: cost of interventions and missed workdays postoperatively. METHODS: Individuals with postoperative C5 palsy were matched to controls based on age, gender, body mass index, and diagnosis. Demographic, operative, postoperative, quality-of-life, and cost data were collected for both the C5 palsy and control groups, with 1-year follow-up. RESULTS: We reviewed 245 patients who underwent PCDF and 17 were identified (6.9%) with C5 palsy and matched to 34 controls. No significant differences in demographic or operative characteristics were observed between groups. The C5 palsy group had a significantly reduced capacity for self-care in the immediate postoperative (2.0±0.71 vs. 1.2±0.4, p<.001) and long-term (1.6±0.6 vs. 1.2±0.4, p=.004) periods and a significantly reduced capacity for completion of usual activities (2.4±0.7 vs. 1.9±0.6, p=.014) compared with controls. Furthermore, the C5 group had a significantly greater cost of physical/occupational therapy, an increase of $2,078 ($4,386±$2,801 vs. $2,307±$1,907, p=.013). There were no significant differences between groups in the cost of hospital stay, surgery, or other direct or indirect costs. Overall, there was a significantly greater cost ($1,918) for the C5 palsy group compared with the control group ($7,584±$3,992 vs. $5,666±$2,359, respectively, p=.038). CONCLUSIONS: This study represents the first quantification of the impact of C5 palsy on patients' quality of life and the associated costs for care. We found that C5 palsy adds a significant burden on patients' quality of life and presents a financial burden to the health-care system.

Disability and marginal utility of income: evidence from hypothetical choices.

It is often assumed that disability reduces the marginal utility of income. In this article, individuals' marginal utility of income in two states-(i) paralyzed in both legs from birth and (ii) not mobility impaired at all-is measured through hypothetical choices between imagined lotteries behind a so-called veil of ignorance. The outcomes of the lotteries include both income and disability status. It is found that most people have higher marginal utility when paralyzed than when not mobility impaired at all. The two marginal utilities are evaluated at the same levels of income. Having personal experience of mobility impairment and supporting the Left Party, the Social Democratic Party, the Green Party, or the Liberal Party are associated with having a higher marginal utility when paralyzed. The results suggest that more than full insurance of income losses connected to being disabled is optimal. The results further suggest that, given a utilitarian social welfare function, resources should be transferred to rather than from disabled people. Finally, if the transfers are not large enough to smooth out the marginal utilities of the disabled and the nondisabled, distributional weights based on disability status should be used in cost-benefit analysis.

Surveillance of acute flaccid paralysis in Hong Kong: 1997 to 2002.

OBJECTIVES: To describe the characteristics of patients reported with acute flaccid paralysis between 1997 and 2002, and to evaluate the performance of the acute flaccid paralysis surveillance system using indicators recommended by the World Health Organization. DESIGN: Retrospective study. SETTING: Department of Health, Hong Kong. PARTICIPANTS: Children aged younger than 15 years who were reported to the Department of Health between 1997 and 2002 with acute flaccid paralysis. RESULTS: Of 120 children with acute flaccid paralysis reported between 1997 and 2002, 42% were younger than 5 years of age. None of the cases were acute poliomyelitis or polio-compatible. A neurological cause was identified in 67.5% of cases, of which the most common was Guillain-Barre syndrome (42%), followed by transverse myelitis (15%). All except one of the performance indicators consistently met World Health Organization requirements and thus demonstrated the effectiveness of the acute flaccid paralysis surveillance programme. The acute flaccid paralysis notification rate consistently exceeded 1.0 per 100 000 population below 15 years of age. The requirement for adequate stool investigation was the single indicator that did not satisfy World Health Organization requirements. This highlighted the importance of maintaining physicians' awareness of acute flaccid paralysis surveillance. CONCLUSION: Hong Kong should remain vigilant for acute flaccid paralysis. The effective surveillance system and its evaluation may serve as a model for surveillance of other infectious diseases.

Cervical spine evaluation in urban trauma centers: lowering institutional costs and complications through helical CT scan.

BACKGROUND: In the evaluation of the cervical spine (c-spine), helical CT scan has higher sensitivity and specificity than plain radiographs in the moderate- and high-risk trauma population, but is more costly. We hypothesize that institutional costs associated with missed injuries make helical CT scan the least costly approach. STUDY DESIGN: A cost-minimization study was performed using decision analysis examining helical CT scan versus radiographic evaluation of the c-spine. Parameter estimates were obtained from the literature for probability of c-spine injury, probability of paralysis after missed injury, plain film sensitivity and specificity, CT scan sensitivity and specificity, and settlement cost of missed injuries resulting in paralysis. Institutional costs of CT scan and plain radiography were used. Sensitivity analyses tested robustness of strategy preference, accounted for parameter variability, and determined threshold values for individual parameters on strategy preference. RESULTS: C-spine evaluation with helical CT scan has an expected cost of US 554 dollars per patient compared with US 2,142 dollars for plain films. CT scan is the least costly alternative if threshold values exceed US 58,180 dollars for institutional settlement costs, 0.9% for probability of c-spine fracture, and 1.7% for probability of paralysis. Plain films are least costly if CT scan costs surpass US 1,918 dollars or plain film sensitivity exceeds 90%. CONCLUSIONS: Helical CT scan is the preferred initial screening test for detection of cervical spine fractures among moderate- to high-risk patients seen in urban trauma centers, reducing the incidence of paralysis resulting from false-negative imaging studies and institutional costs, when settlement costs are taken into account.

Cervical spine screening with CT in trauma patients: a cost-effectiveness analysis.

PURPOSE: To investigate the cost-effectiveness of computed tomography (CT) relative to radiography for cervical spine screening in trauma patients. MATERIALS AND METHODS: A decision analysis model was constructed to compare the incremental cost-effectiveness of radiography and CT as primary cervical spine screening modalities in trauma patients. Analyses were performed from a societal perspective, and probability and cost estimates from the literature and institutional experience were used. In separate cost-effectiveness analyses, hypothetical cohorts of trauma patients from three defined clinical scenarios were considered: high, moderate, and low risk for cervical spine fracture. Outcome measures included cases of paralysis prevented, total cost of screening strategies, and incremental cost-effectiveness ratios. RESULTS: In high-risk patients, screening with CT is a dominant strategy that prevents cases of paralysis and saves money for society. In moderate-risk patients, screening with CT is cost-effective with reference-case assumptions and within the range of most sensitivity analyses. In the low-risk group, CT screening helps prevent cases of paralysis, but the incremental cost-effectiveness ratio is high (> $80,000 per quality-adjusted life year). CONCLUSION: CT is the preferred cervical spine screening modality in trauma patients at high and moderate risk for cervical spine fracture.

A preliminary case-mix classification system for Medicare home health clients.

In this study, a hierarchical case-mix model was developed for grouping Medicare home health beneficiaries homogeneously, based on the allowed charges for their home care. Based on information from a two-page form from 2,830 clients from ten states and using the classification and regression trees method, a four-component model was developed that yielded 11 case-mix groups and explained 22% of the variance for the test sample of 1,929 clients. The four components are rehabilitation, special care, skilled-nurse monitoring, and paralysis; each are categorized as present or absent. The range of mean-allowed charges for the 11 groups in the total sample was $473 to $2,562 with a mean of $847. Of the six groups with mean charges above $1,000, none exceeded 5.2% of clients; thus, the high-cost groups are relatively rare.