Understanding Pathways into Care-homes using Data (UnPiCD study): a two-part model to estimate inpatient and care-home costs using national linked health and social care data.

BACKGROUND: Pathways into care-homes have been under-researched. Individuals who move-in to a care-home from hospital are clinically distinct from those moving-in from the community. However, it remains unclear whether the source of care-home admission has any implications in term of costs. Our aim was to quantify hospital and care-home costs for individuals newly moving-in to care homes to compare those moving-in from hospital to those moving-in from the community. METHODS: Using routinely-collected national social care and health data we constructed a cohort including people moving into care-homes from hospital and community settings between 01/04/2013-31/03/2015 based on records from the Scottish Care-Home Census (SCHC). Individual-level data were obtained from Scottish Morbidity Records (SMR01/04/50) and death records from National Records of Scotland (NRS). Unit costs were identified from NHS Scotland costs data and care-home costs from the SCHC. We used a two-part model to estimate costs conditional on having incurred positive costs. Additional analyses estimated differences in costs for the one-year period preceding and following care-home admission. RESULTS: We included 14,877 individuals moving-in to a care-home, 8,472 (57%) from hospital, and 6,405 (43%) from the community. Individuals moving-in to care-homes from the community incurred higher costs at £27,117 (95% CI £ 26,641 to £ 27,594) than those moving-in from hospital with £24,426 (95% CI £ 24,037 to £ 24,814). Hospital costs incurred during the year preceding care-home admission were substantially higher (£8,323 (95% CI£8,168 to £8,477) compared to those incurred after moving-in to care-home (£1,670 (95% CI£1,591 to £1,750). CONCLUSION: Individuals moving-in from hospital and community have different needs, and this is reflected in the difference in costs incurred. The reduction in hospital costs in the year after moving-in to a care-home indicates the positive contribution of care-home residency in supporting those with complex needs. These data provide an important contribution to inform capacity planning on care provision for adults with complex needs and the costs of care provision.

Costs of the COVID-19 vaccination programme: estimates from the West Rand district of South Africa, 2021/2022.

BACKGROUND: The COVID-19 vaccination programme in South Africa was rolled out in February 2021 via five delivery channels- hospitals, primary healthcare (PHC), fixed, temporary, and mobile outreach channels. In this study, we estimated the financial and economic costs of the COVID-19 vaccination programme in the first year of roll out from February 2021 to January 2022 and one month prior, in one district of South Africa, the West Rand district. METHODS: Financial and economic costs were estimated from a public payer's perspective using top-down and ingredient-based costing approaches. Data were collected on costs incurred at the national level and from the West Rand district. Total cost and cost per COVID-19 vaccine dose were estimated for each of the five delivery channels implemented in the district. In addition, we estimated vaccine delivery costs which we defined as total cost exclusive of vaccine procurement costs. RESULTS: Total financial and economic costs were estimated at US$8.5 million and US$12 million, respectively; with a corresponding cost per dose of US$15.31 (financial) and US$21.85 (economic). The two biggest total cost drivers were vaccine procurement which contributed 73% and 51% to total financial and economic costs respectively, and staff time which contributed 10% and 36% to total financial and economic costs, respectively. Total vaccine delivery costs were estimated at US$2.1 million (financial) and US$5.7 million (economic); and the corresponding cost per dose at US$3.84 (financial) and US$10.38 (economic). Vaccine delivery cost per dose (financial/economic) was estimated at US$2.93/12.84 and US$2.45/5.99 in hospitals and PHCs, respectively, and at US$7.34/20.29, US$3.96/11.89 and US$24.81/28.76 in fixed, temporary and mobile outreach sites, respectively. Staff time was the biggest economic cost driver for vaccine delivery in PHCs and hospitals while per diems and staff time were the biggest economic cost drivers for vaccine delivery in the three outreach delivery channels. CONCLUSION: This study offers insights for budgeting and planning of COVID-19 vaccine delivery in South Africa's public healthcare system. It also provides input for cost-effectiveness analyses to guide future strategies for maximizing vaccination coverage in the country.

Costing analysis of an information & communications technology-enabled primary healthcare facility in India.

BACKGROUND & OBJECTIVES: Information and communications technology (ICT) has often been endorsed as an effective tool to improve primary healthcare. However, evidence on the cost of ICT-enabled primary health centre (PHC) is lacking. The present study aimed at estimating the costs for customization and implementation of an integrated health information system for primary healthcare at a public sector urban primary healthcare facility in Chandigarh. METHODS: We undertook economic costing of an ICT-enabled PHC based on health system perspective and bottom-up costing. All the resources used for the provision of ICT-enabled PHC, capital and recurrent, were identified, measured and valued. The capital items were annualized over their estimated life using a discount rate of 3 per cent. A sensitivity analysis was undertaken to assess the effect of parameter uncertainties. Finally, we assessed the cost of scaling up ICT-enabled PHC at the state level. RESULTS: The estimated overall annual cost of delivering health services through PHC in the public sector was ₹ 7.88 million. The additional economic cost of ICT was ₹ 1.39 million i.e. 17.7 per cent over and above a non-ICT PHC cost. In a PHC with ICT, the cost per capita increased by ₹ 56. On scaling up to the state level (with 400 PHCs), the economic cost of ICT was estimated to be ₹ 0.47 million per year per PHC, which equates to approximately six per cent expenditure over and above the economic cost of a regular PHC. INTERPRETATION & CONCLUSIONS: Implementing a model of information technology-PHC in a state of India would require an augmentation of cost by about six per cent, which seems fiscally sustainable. However, contextual factors related to the availability of infrastructure, human resources and medical supplies for delivering quality PHC services will also need to be considered.

COVID-19 and hospital management costs: the Italian experience.

BACKGROUND: This article investigates the hospital costs related to the management of COVID-19 positive patients, requiring a hospitalization (from the positivity confirmation to discharge, including rehabilitation activities). METHODS: A time-driven activity-based costing analysis, grounding on administrative and accounting flows provided by the management control, was implemented to define costs related to the hospital management of COVID-19 positive patients, according to real-word data, derived from six public Italian Hospitals, in 2020. RESULTS: Results reported that the higher the complexity of care, the higher the hospitalization cost per day (low-complexity = €475.86; medium-complexity = €700.20; high-complexity = €1,401.65). Focusing on the entire clinical pathway, the overall resources absorption, with the inclusion of rehabilitation costs, ranged from 6,198.02€ to 32,141.20€, dependent from the patient's clinical condition. CONCLUSIONS: Data could represent the baseline cost for COVID-19 hospital management, thus being useful for the further development of proper reimbursement tariffs devoted to hospitalized infected patients.

A costing analysis of B-GAP: index-linked HIV testing for children and adolescents in Zimbabwe.

BACKGROUND: By testing children and adolescents of HIV positive caretakers, index-linked HIV testing, a targeted HIV testing strategy, has the ability to identify high risk children and adolescents earlier and more efficiently, compared to blanket testing. We evaluated the incremental cost of integrating index-linked HIV testing via three modalities into HIV services in Zimbabwe. METHODS: A mixture of bottom-up and top-down costing was employed to estimate the provider cost per test and per HIV diagnosis for 2-18 year olds, through standard of care testing, and the incremental cost of index-linked HIV testing via three modalities: facility-based testing, home-based testing by a healthcare worker, and testing at home by the caregiver using an oral mucosal transudate test. In addition to interviews, direct observation and study process data, facility registries were abstracted to extract outcome data and resource use. Costs were converted to 2019 constant US$. RESULTS: The average cost per standard of care test in urban facilities was US$5.91 and US$7.15 at the rural facility. Incremental cost of an index-linked HIV test was driven by the uptake and number of participants tested. The lowest cost approach in the urban setting was home-based testing (US$6.69) and facility-based testing at the rural clinic (US$5.36). Testing by caregivers was almost always the most expensive option (rural US$62.49, urban US$17.49). CONCLUSIONS: This is the first costing analysis of index-linked HIV testing strategies. Unit costs varied across sites and with uptake. When scaling up, alternative testing solutions that increase efficiency such as index-linked HIV testing of the entire household, as opposed to solely targeting children/adolescents, need to be explored.

Single-use versus reusable medical devices in spinal fusion surgery: a hospital micro-costing analysis.

PURPOSE: Healthcare facilities could minimize the cost of surgical instrument and implant processing by using single-use devices. The main objective was to prospectively compare the total cost of a single-use and reusable device used in short lumbar spine fusion. METHODS: A 1-year, single-centre, prospective study was performed on patients requiring a one- or two-level lumbar arthrodesis. Patients were randomized in two groups treated with either reusable or single-use device. A cost minimization analysis was performed using a micro-costing approach from a hospital perspective. Every step of the preparation process was timed and costed based on hourly wages of hospital employees, cleaning supplies and hospital waste costs. RESULTS: Forty cases were evaluated. No significant difference in operation time was noted (reusable 176.1 ± 68.4 min; single use 190.4 ± 71.7 min; p = 0.569). Mean processing time for single-use devices was lower than for reusable devices (33 min vs. 176 min) representing a cost of 14€ versus 58€ (p < 0.05). Pre-/post-sterilization and spinal set recomposing steps were the most time-consuming in reusable device group. A total cost saving of 181€ per intervention resulted from the use and processing of the single-use device considering an additional sterilization cost of 137€ with the reusable device. The weight of the reusable device was 42 kg for three containers and 1.2 kg for the single-use device. CONCLUSIONS: Owing to the absence of re-sterilization, single-use devices in one- and two-level lumbar fusion allow significant money and time savings. They may also avoid delaying surgery in case of reusable device unavailability.

Manchester-Fothergill procedure versus vaginal hysterectomy with uterosacral ligament suspension: an activity-based costing analysis.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) is a common diagnosis that imposes high and ever-growing costs to the healthcare economy. Numerous surgical techniques for the treatment of POP exist, but there is no consensus about which is the ideal technique for treating apical prolapse. The aim of this study was to estimate hospital costs for the most frequently performed operation, vaginal hysterectomy with uterosacral ligament suspension (VH) and the uterus-preserving Manchester-Fothergill procedure (MP), when including costs of postoperative activities. METHODS: The study was based on a historical matched cohort including 590 patients (295 pairs) who underwent VH or MP during 2010-2014 owing to apical prolapse. The patients were matched according to age and preoperative prolapse stage and followed for a minimum of 20 months. Data were collected from four national registries and electronic medical records. Unit costs were obtained from relevant departments, hospital administration, calculated, or estimated by experts. The hospital perspective was applied for costing the resource use. RESULTS: Total costs for the first 20 months after operation were 3,514 € per VH patient versus 2,318 € per MP patient. The cost difference between the techniques was 898 € (95% confidence interval [CI]: 818-982) per patient when analyzing the primary operation only and 1,196 € (CI: 927-1,465) when including subsequent activities within 20 months (p < 0.0001). CONCLUSIONS: The MP is substantially less expensive than the commonly used VH from a 20-month time perspective. Healthcare costs can be reduced by one third if MP is preferred over VH in the treatment of apical prolapse.

Cost analysis of implementing mHealth intervention for maternal, newborn & child health care through community health workers: assessment of ReMIND program in Uttar Pradesh, India.

BACKGROUND: The main intervention under ReMiND program consisted of a mobile health application which was used by community health volunteers, called ASHAs, for counselling pregnant women and nursing mothers. This program was implemented in two rural blocks in Uttar Pradesh state of India with an overall aim to increase quality of health care, thereby increasing utilization of maternal & child health services. The aim of the study was to assess annual & unit cost of ReMiND program and its scale up in UP state. METHOD AND MATERIALS: Economic costing was done from the health system and patient's perspectives. All resources used during designing & planning phase i.e., development of application; and implementation of the intervention, were quantified and valued. Capital costs were annualised, after assessing their average number of years for which a product could be used and accounting for its depreciation. Shared or joint costs were apportioned for the time value a resource was utilized under intervention. Annual cost of implementing ReMiND in two blocks of UP along and unit cost per pregnant woman were estimated. Scale-up cost for implementing the intervention in entire state was calculated under two scenarios - first, if no extra human resource were employed; and second, if the state government adopted the same pattern of human resource as employed under this program. RESULTS: The annual cost for rolling out ReMiND in two blocks of district Kaushambi was INR 12.1 million (US $ 191,894). The annualised start-up cost constituted 9% of overall cost while rest of cost was attributed to implementation of the intervention. The health system program costs in ReMiND were estimated to be INR 31.4 (US $ 0.49) per capita per year and INR 1294 (US $ 20.5) per registered women. The per capita incremental cost of scale up of intervention in UP state was estimated to be INR 4.39 (US $ 0.07) when no additional supervisory staffs were added. CONCLUSION: The cost of scale up of ReMiND in Uttar Pradesh is 6% of annual budget for 'reproductive and child health' line item under state budget, and hence appears to be financially sustainable.

Healthcare utilization and costs associated with autologous haematopoietic stem cell transplantation in Norwegian patients with relapsing remitting multiple sclerosis.

Multiple sclerosis (MS) patients experience long-term deterioration of neurological function, reduced quality of life, long-lasting treatment cycles, and an increased risk of early workability loss imposing an economic burden to society. Autologous haematopoietic stem cell transplantation (AHSCT) has shown promising treatment effects for relapsing remitting MS (RRMS). This study employs a micro-costing approach to estimate healthcare utilization and costs associated with AHSCT in Norwegian RRMS patients. Patient-level data were extracted from medical journals of 30 RRMS patients receiving AHSCT treatment at Haukeland University Hospital in the period from January 2015 to January 2018. The time horizon for the analysis was from the pretransplant screening until one year after AHSCT. A correlation was found between patient body weight and total healthcare cost. The average total healthcare cost of AHSCT for RRMS patients was estimated to EUR 66 304 (95% CI: EUR 63 598 - EUR 69 010) including costs associated with the pre-AHSCT period, AHSCT treatment phases and one-year follow-up. The majority of the costs, EUR 64 329, occurred during the treatment phase and within the first 100 days after AHSCT. The results indicate that long-term healthcare cost savings may be achieved using AHSCT in selected patients with aggressive RRMS. This is due to the high costs of most used disease modifying treatments. Further research including long-term clinical data is needed to determine the cost-effectiveness of this treatment.

Costs of Newly Funded Proton Therapy Using Time-Driven Activity-Based Costing in The Netherlands.

BACKGROUND: Proton therapy (PT) has characteristics that enable the sparing of healthy, non-cancerous tissue surrounding the radiotherapy target volume better from radiation doses than conventional radiotherapy for patients with cancer. While this innovation entails investment costs, the information about the treatment costs per patient, especially during the start-up phase, is limited. This study aims to calculate the costs of PT at a single center during the start-up phase in the Netherlands. METHODS: The cost of PT per patient was estimated for the treatment indications, head and neck cancer, breast cancer, brain cancer, thorax cancer, chordoma and eye melanoma. A time-driven activity-based costing analysis (TDABC), a methodology that calculates the costs of consumed healthcare resources by a patient, was conducted in a newly established PT center in the Netherlands (HPTC). Both direct (e.g., the human resource costs for medical staff) and indirect costs (e.g., the operating/interest costs, indirect human resource costs and depreciation costs) were included. A scenario analysis was conducted for short-term (2021), middle-term (till 2024) and long-term (after 2024) predicted patient numbers in the PT center. RESULTS: The total cost of PT in 2020 at the center varied between EUR 12,062 for an eye melanoma course and EUR 89,716 for a head and neck course. Overall, indirect costs were the largest cost component. The high indirect costs implied the potential of the scale of economics; according to our estimation, the treatment cost could be reduced to 35% of the current cost when maximum treatment capacity is achieved. CONCLUSION: This study estimated the PT cost delivered in a newly operated treatment center. Scenario analysis for increased patient numbers revealed the potential for cost reductions. Nevertheless, to have an estimation that reflects the matured cost of PT which could be used in cost-effectiveness analysis, a follow-up study assessing the full-fledged situation is recommended.

Healthcare costs and effects of post-COVID-19 condition in Canada.

Background: As evidence of the long-term health impacts of coronavirus disease 2019 (COVID-19) continues to grow across Canada, a key concern is the costs and health impacts of post-COVID-19 condition (PCC), especially while the healthcare system remains under substantial strain. The objective of this study is to estimate healthcare costs and quality-adjusted life year (QALY) decrements per PCC case and per acute COVID-19 case by vaccination status. Methods: First, we conducted a rapid review of the literature to estimate 1) the probability of developing PCC following COVID-19 infection by vaccination status, 2) the probability of each condition commonly associated with PCC, 3) healthcare costs and QALY decrements associated with each condition and 4) the number of PCC cases currently in Canada. Second, using the data gathered from the literature, we built a tool to estimate the cost and QALY decrements per PCC and COVID-19 case. Results: Post-COVID-19 condition costs per COVID-19 case ranged from CAD 1,675 to CAD 7,340, and QALY decrements ranged between 0.047 to 0.206, in the first year following COVID-19 infection. Overall, individuals who were unvaccinated when they were infected had higher costs and QALY decrements. We estimated the total burden of PCC to the Canadian healthcare system based on PCC estimates up until spring 2023 would be between CAD 7.8 and CAD 50.6 billion. Conclusion: This article demonstrates the large potential health and economic burden of PCC for Canadians, and the importance of vaccination and other infection control strategies in reducing the longer-term costs and effects.

Resource utilization and disaggregated cost analysis of bariatric surgery in the Australian public healthcare system.

OBJECTIVES: To present a comprehensive real-world micro-costing analysis of bariatric surgery. METHODS: Patients were included if they underwent primary bariatric surgery (gastric banding [GB], gastric bypass [GBP] and sleeve gastrectomy [SG]) between 2013 and 2019. Costs were disaggregated into cost items and average-per-patient costs from the Australian healthcare systems perspective were expressed in constant 2019 Australian dollars for the entire cohort and subgroup analysis. Annual population-based costs were calculated to capture longitudinal trends. A generalized linear model (GLM) predicted the overall bariatric-related costs. RESULTS: N = 240 publicly funded patients were included, with the waitlist times of ≤ 10.7 years. The mean direct costs were $11,269. The operating theatre constituted the largest component of bariatric-related costs, followed by medical supplies, salaries, critical care use, and labour on-costs. Average cost for SG ($12,632) and GBP ($15,041) was higher than that for GB ($10,049). Operating theatre accounted for the largest component for SG/GBP costs, whilst medical supplies were the largest for GB. We observed an increase in SG and a decrease in GB procedures over time. Correspondingly, the main cost driver changed from medical supplies in 2014-2015 for GB procedures to operating theatre for SG thereafter. GLM model estimates of bariatric average cost ranged from $7,580 to $36,633. CONCLUSIONS: We presented the first detailed characterization of the scale, disaggregated profile and determinants of bariatric-related costs, and examined the evolution of resource utilization patterns and costs, reflecting the shift in the Australian bariatric landscape over time. Understanding these patterns and forecasting of future changes are critical for efficient resource allocation.

Direct medical costs of breast cancer in Jordan: cost drivers and predictors.

Introduction: Breast cancer is the most common cancer amongst females in Jordan. The study aimed to estimate the total direct medical cost of breast cancer from a healthcare provider's perspective.Methods: A retrospective cohort study was done to include all Jordanian females who were diagnosed with breast cancer at two leading public providers of cancer care in Jordan, Bashir Hospital and the University of Jordan Hospital. Data were extracted from the Jordan Cancer Registry (JCR) from 2011 to 2014 including demographic, clinical, and economic data of the patient.Results: A total of 877 and 665 patients were included in the first and second year after diagnosis, respectively. Costs increased in the advanced stages; costs for stages 0, I, II, III, and IV were Jordanian dinars)JD(6,749.94 ($9,517.42), JD 5,960.46 ($8,404.25), JD 8,003.58 ($11,285.05), JD 9,390.59 ($13,240.73), and JD 9,587.44 ($13,518.29), respectively. Treatment costs were the main cost driver across all stages.Conclusions: This analysis offers insight into costs, cost drivers, and resources utilization incurred by breast cancer patients in Jordan. Two major hospitals in Jordan can play a key informative role in future cost-effectiveness of breast cancer screening and therapeutic treatments in the different stages of cancer.

Hospital-acquired Clostridium difficile infection: an institutional costing analysis.

BACKGROUND: Healthcare-acquired Clostridium difficile infection (HA-CDI) is a common infection and a financial burden on the healthcare system. AIM: To estimate the hospital-based financial costs of HA-CDI by comparing time-fixed statistical models that attribute cost to the entire hospital stay to time-varying statistical models that adjust for the time between admission, diagnosis of HA-CDI, and discharge and that only attribute HA-CDI costs post diagnosis. METHODS: A retrospective cohort study was conducted (April 2008 to March 2011) using clinical and administrative costing data of inpatients (≥15 years) who were admitted to The Ottawa Hospital with stays >72 h. Two time-fixed analyses, ordinary least square regression and generalized linear regression, were contrasted with two time-dependent approaches using Kaplan-Meier survival curve. FINDINGS: A total of 49,888 admissions were included and 366 (0.73%) patients developed HA-CDI. Estimated total costs (Canadian dollars) from time-fixed models were as high as $74,928 per patient compared to $28,089 using a time-varying model, and these were 1.47-fold higher compared to a patient without HA-CDI (incremental cost $8,997 per patient). The overall annual institutional cost at The Ottawa Hospital associated with HA-CDI was as high as $10.07 million using time-fixed models and $1.62 million using time-varying models. CONCLUSION: When calculating costs associated with HA-CDI, accounting for the time between admission, diagnosis, and discharge can substantially reduce the estimated institutional costs associated with HA-CDI.

Pierre Robin Sequence: Cost-Analysis and Qualitative Assessment of 89 Patients at the Hospital for Sick Children.

INTRODUCTION: Children with Pierre Robin sequence (PRS) have a complex clinical presentation and requires many health-care providers. Thus, multiple clinical pathways have been proposed on how to manage this population, with some opting for conservative measures while others opting for a surgical approach. However, no consensus has been reached on the most appropriate protocol. OBJECTIVE: To present the treatment protocol for PRS at the Hospital for Sick Children. This will be evaluated through a qualitative examination of the approach from the patient's perspective, and a micro-costing analysis of the financial aspects of providing care. METHODS: A retrospective cohort study was conducted to evaluate infants who were admitted with PRS and failure to thrive from January 2004 to December 2015. This was followed by a micro-costing analysis to evaluate the cost of the management protocol. Finally, a qualitative evaluation of the parent's perspective was done. RESULTS: Eighty-nine patients were admitted with failure to thrive during the study period. Fourteen patients underwent surgical management. Fourteen patients required readmission for airway or feeding issues secondary to PRS. The average cost per patient was Can$105 996. With regard to the qualitative evaluation, key themes that were generated included stress upon hospital admission, variable methods of understanding PRS, good level of communication with the team, excellent hospital process, and challenging transition home. CONCLUSION: These results will aid in the continual evolution of a protocol and provide important information on PRS to both families and centers that manage these children.

INTRODUCTION: Les enfants ayant un syndrome de Pierre-Robin (SPR) ont une présentation clinique complexe, qui exige l'apport de nombreux professionnels de la santé. Ainsi, de multiples trajectoires cliniques sont proposées pour prendre cette population en charge. Certains optent pour des mesures prudentes et d'autres pour une approche chirurgicale. Cependant, il n'y a pas de consensus quant au protocole le mieux adapté. OBJECTIF: Présenter le protocole de traitement du SPR utilisé au Hospital for Sick Children. Il sera évalué par un examen qualitatif de l'approche selon le point de vue des parents et une analyse des aspects financiers de la prestation des soins. MÉTHODOLOGIE: Les chercheurs ont mené une étude de cohorte rétrospective pour évaluer les nourrissons qui avaient été hospitalisés à cause d'un SPR et d'un retard staturopondéral entre janvier 2004 et décembre 2015. Ils ont ensuite effectué une analyse pour évaluer le coût du protocole de prise en charge et ont terminé par une évaluation qualitative du point de vue des parents. RÉSULTATS: Pendant la période de l'étude, 89 patients ont été hospitalisés à cause d'un retard staturopondéral, dont 14 ont subi une opération. De plus, 14 patients ont été réhospitalisés à cause de problèmes respiratoires ou alimentaires liés au SPR. Le coût moyen par patient s'élevait à 105 996 Can$. Dans le cadre de l'évaluation qualitative, les principaux thèmes soulevés étaient le stress à l'hospitalisation, la méthodologie variable pour comprendre le SPR, le bon niveau de communication avec l'équipe, l'excellent processus hospitalier et une transition difficile à la maison. CONCLUSION: Les présents résultats contribueront à l'évolution d'un protocole et fournissent de l'information importante sur le SPR, à la fois pour les familles et les centres qui prennent ces enfants en charge.

Benefits and Costs of Digital Consulting in Clinics Serving Young People With Long-Term Conditions: Mixed-Methods Approach.

BACKGROUND: Since the introduction of digital health technologies in National Health Service (NHS), health professionals are starting to use email, text, and other digital methods to consult with their patients in a timely manner. There is lack of evidence regarding the economic impact of digital consulting in the United Kingdom (UK) NHS. OBJECTIVE: This study aimed to estimate the direct costs associated with digital consulting as an adjunct to routine care at 18 clinics serving young people aged 16-24 years with long-term conditions. METHODS: This study uses both quantitative and qualitative approaches. Semistructured interviews were conducted with 173 clinical team members on the impacts of digital consulting. A structured questionnaire was developed and used for 115 health professionals across 12 health conditions at 18 sites in the United Kingdom to collect data on time and other resources used for digital consulting. A follow-up semistructured interview was conducted with a single senior clinician at each site to clarify the mechanisms through which digital consulting use might lead to outcomes relevant to economic evaluation. We used the two-part model to see the association between the time spent on digital consulting and the job role of staff, type of clinic, and the average length of the working hours using digital consulting. RESULTS: When estimated using the two-part model, consultants spent less time on digital consulting compared with nurses (95.48 minutes; P<.001), physiotherapists (55.3 minutes; P<.001), and psychologists (31.67 minutes; P<.001). Part-time staff spent less time using digital consulting than full-time staff despite insignificant result (P=.15). Time spent on digital consulting differed across sites, and no clear pattern in using digital consulting was found. Health professionals qualitatively identified the following 4 potential economic impacts for the NHS: decreasing adverse events, improving patient well-being, decreasing wait lists, and staff workload. We did not find evidence to suggest that the clinical condition was associated with digital consulting use. CONCLUSIONS: Nurses and physiotherapists were the greatest users of digital consulting. Teams appear to use an efficient triage system with the most expensive members digitally consulting less than lower-paid team members. Staff report showed concerns regarding time spent digitally consulting, which implies that direct costs increase. There remain considerable gaps in evidence related to cost-effectiveness of digital consulting, but this study has highlighted important cost-related outcomes for assessment in future cost-effectiveness trials of digital consulting.

Costs of coronary heart disease and mortality associated with near-roadway air pollution.

BACKGROUND: Emerging evidence indicates that the near-roadway air pollution (NRAP) mixture contributes to CHD, yet few studies have evaluated the associated costs. OBJECTIVE: We integrated an assessment of NRAP-attributable CHD in Southern California with new methods to value the associated mortality and hospitalizations. METHODS: Based on population-weighted residential exposure to NRAP (traffic density, proximity to a major roadway and elemental carbon), we estimated the inflation-adjusted value of NRAP-attributable mortality and costs of hospitalizations that occurred in 2008. We also estimated anticipated costs in 2035 based on projected changes in population and in NRAP exposure associated with California's plans to reduce greenhouse gas emissions. For comparison, we estimated the value of CHD mortality attributable to PM less than 2.5µm in diameter (PM2.5) in both 2008 and 2035. RESULTS: The value of CHD mortality attributable to NRAP in 2008 was between $3.8 and $11.5 billion, 23% (major roadway proximity) to 68% (traffic density) of the $16.8 billion attributable to regulated regional PM2.5. NRAP-attributable costs were projected to increase to $10.6 to $22 billion in 2035, depending on the NRAP metric. Cost of NRAP-attributable hospitalizations for CHD in 2008 was $48.6 million and was projected to increase to $51.4 million in 2035. CONCLUSIONS: We developed an economic framework that can be used to estimate the benefits of regulations to improve air quality. CHD attributable to NRAP has a large economic impact that is expected to increase by 2035, largely due to an aging population. PM2.5-attributable costs may underestimate total value of air pollution-attributable CHD.

Cost saving potential in cardiovascular hospital costs due to reduction in air pollution.

OBJECTIVE: We describe a methodological framework to estimate potential cost savings in Belgium for a decrease in cardiovascular emergency admissions (ischemic heart disease (IHD), heart rhythm disturbances (HRD), and heart failure) due to a reduction in air pollution. METHODS: Hospital discharge data on emergency admissions from an academic hospital were used to identify cases, derive risk functions, and estimate hospital costs. Risk functions were derived with case-crossover analyses with weekly average PM10, PM2.5, and NO2 exposures. The risk functions were subsequently used in a micro-costing analysis approach. Annual hospital cost savings for Belgium were estimated for two scenarios on the decrease of air pollution: 1) 10% reduction in each of the pollutants and 2) reduction towards annual WHO guidelines. RESULTS: Emergency admissions for IHD and HRD were significantly associated with PM10, PM2.5, and NO2 exposures the week before admission. The estimated risk reduction for IHD admissions was 2.44% [95% confidence interval (CI): 0.33%-4.50%], 2.34% [95% CI: 0.62%-4.03%], and 3.93% [95% CI: 1.14%-6.65%] for a 10% reduction in PM10, PM2.5, and NO2 respectively. For Belgium, the associated annual cost savings were estimated at € 5.2 million, € 5.0 million, and € 8.4 million respectively. For HRD, admission risk could be reduced by 2.16% [95% CI: 0.14%-4.15%], 2.08% [95% CI: 0.42%-3.70%], and 3.46% [95% CI: 0.84%-6.01%] for a 10% reduction in PM10, PM2.5, and NO2 respectively. This corresponds with a potential annual hospital cost saving in Belgium of € 3.7 million, € 3.6 million, and € 5.9 million respectively. If WHO annual guidelines for PM10 and PM2.5 are met, more than triple these amounts would be saved. DISCUSSION: This study demonstrates that a model chain of case-crossover and micro-costing analyses can be applied in order to obtain estimates on the impact of air pollution on hospital costs.