Centralising acute stroke care within clinical practice in the Netherlands: lower bounds of the causal impact.

BACKGROUND: Authors in previous studies demonstrated that centralising acute stroke care is associated with an increased chance of timely Intra-Venous Thrombolysis (IVT) and lower costs compared to care at community hospitals. In this study we estimated the lower bound of the causal impact of centralising IVT on health and cost outcomes within clinical practice in the Northern Netherlands. METHODS: We used observational data from 267 and 780 patients in a centralised and decentralised system, respectively. The original dataset was linked to the hospital information systems. Literature on healthcare costs and Quality of Life (QoL) values up to 3 months post-stroke was searched to complete the input. We used Synthetic Control Methods (SCM) to counter selection bias. Differences in SCM outcomes included 95% Confidence Intervals (CI). To deal with unobserved heterogeneity we focused on recently developed methods to obtain the lower bounds of the causal impact. RESULTS: Using SCM to assess centralising acute stroke 3 months post-stroke revealed healthcare savings of $US 1735 (CI, 505 to 2966) while gaining 0.03 (CI, - 0.01 to 0.73) QoL per patient. The corresponding lower bounds of the causal impact are $US 1581 and 0.01. The dominant effect remained stable in the deterministic sensitivity analyses with $US 1360 (CI, 476 to 2244) as the most conservative estimate. CONCLUSIONS: In this study we showed that a centralised system for acute stroke care appeared both cost-saving and yielded better health outcomes. The results are highly relevant for policy makers, as this is the first study to address the issues of selection and unobserved heterogeneity in the evaluation of centralising acute stroke care, hence presenting causal estimates for budget decisions.

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.

Building a New Transfusion Service.

OBJECTIVES: For over 60 years, Harborview Medical Center (HMC) in Seattle has received its blood components and pretransfusion testing from a centralized transfusion service operated by the regional blood supplier. In 2011, a hospital-based transfusion service (HBTS) was activated. METHODS: After 5 years of operation, we evaluated the effects of the HBTS by reviewing records of hospital blood use, quality system events, blood product delivery times, and costs. Furthermore, the effects of in-house expertise on laboratory medicine resident and medical laboratory scientist student training, as well as regulatory and accrediting agency concerns, were reviewed. RESULTS: Blood use records from 2003 to 2015 demonstrated large reductions in blood component procurement, allocation, transfusion, and wastage with decreases in costs temporally related to the change in service. The turnaround time for thawed plasma for trauma patients decreased from 90 to 3 minutes. Transfusion medicine education metrics for residents and laboratory technology students improved significantly. HMC researchers brought in $2 million in transfusion research funding. CONCLUSIONS: HMC successfully transitioned to an HBTS, providing world-class primary transfusion support to a level 1 trauma center. Near-term benefits in patient care, education, and research resulted. Blood support became faster, safer, and cheaper.

Postoperative pancreatic fistula-impact on outcome, hospital cost and effects of centralization.

BACKGROUND: One of the most serious complications after pancreaticoduodenectomy (PD) is postoperative pancreatic fistula (POPF). This study investigated the incidence of POPF before and after centralization of pancreatic surgery in Southern Sweden and its impact on outcome and health care costs. METHODS: The local registry comprising all pancreatic resections at Skåne University Hospital, Lund, Sweden, was searched for PDs from 2005 to 2015. The patients were analysed in three groups: low-volume, high-volume and after introduction of an enhanced recovery program. Only the clinically relevant POPF grades B and C (CR-POPF) were investigated. RESULTS: 322 consecutive patients were identified. The annual operation volume increased almost threefold and the postoperative length of stay and total hospital cost decreased concurrently. The incidence of CR-POPF did not decrease over time. The group with CR-POPF had more complications and prolonged length of stay. The cost was 1.5 times higher for patients with CR-POPF and the cost did not decline despite the increase of hospital volume. CONCLUSION: Centralization of pancreatic surgery did not decrease the rate of CR-POPF nor its subsequent impact on LOS and costs. Further efforts must be made to reduce the incidence of CR-POPF.

[Economic aspects of oncological esophageal surgery : Centralization is essential]. / Ökonomische Aspekte der onkologischen Ösophaguschirurgie : Zentralisierung ist essenziell.

The incidence of esophageal carcinoma has increased in recent years in Germany. The aim of this article is a discussion of the economic aspects of oncological esophageal surgery within the German diagnosis-related groups (DRG) system focusing on the association between minimum caseload requirements and outcome quality as well as costs. The margins for the DRG classification G03A are low and quickly exhausted if complications determine the postoperative course. A current study using nationwide German hospital discharge data proved a significant difference in hospital mortality between clinics with and without achieving the minimum caseload requirements for esophagectomy. Data from the USA clearly showed that besides patient-relevant parameters, the caseload of a surgeon is relevant for the cost of treatment. Such cost-related analyses do not exist in Germany at present. Scientific validation of reliable minimum caseload numbers for oncological esophagectomy is desirable in the future.

Options for tele-intensive care unit design: centralized versus decentralized and other considerations: it is not just a "another black sedan".

This article seeks assist physicians or administrators considering establishing a Tele-ICU. Owing to an apparent domination of the Tele-ICU field by a single vendor, some may believe that there is only one design option. In fact, there are many alternative design formats that do not require the consumer to possess high-level technical expertise. As when purchasing any major item, if the consumer can formulate basic concepts of design and research the various vendors, then the consumer can develop the Tele-ICU system best for their facility, finances, availability of staff, coverage model, and quality metric goals.

Delivery system characteristics and their association with quality and costs of care: implications for accountable care organizations.

BACKGROUND: Implementation of accountable care organizations (ACOs) is currently underway, but there is limited empirical evidence on the merits of the ACO model. PURPOSE: The aim was to study the associations between delivery system characteristics and ACO competencies, including centralization strategies to manage organizations, hospital integration with physicians and outpatient facilities, health information technology, infrastructure to monitor community health and report quality, and risk-adjusted 30-day all-cause mortality and case-mixed-adjusted inpatient costs for the Medicare population. METHODOLOGY: Panel data (2006-2009) were assembled from Florida and multiple sources: inpatient hospital discharge, vital statistics, the American Hospital Association, the Healthcare Information and Management Systems Society, and other databases. We applied a panel study design, controlling for hospital and market characteristics. PRINCIPAL FINDINGS: Hospitals that were in centralized health systems or became more centralized over the study period had significantly larger reductions in mortality compared with hospitals that remained freestanding. Surprisingly, tightly integrated hospital-physician arrangements were associated with increased mortality; as such, hospitals may wish to proceed cautiously when developing specific types of alignment with local physician organizations. We observed no statistically significant differences in the growth rate of costs across hospitals in any of the health systems studied relative to freestanding hospitals. Although we observed quality improvement in some organizational types, these outcome improvements were not coupled with the additional desired objective of lower cost growth. This implies that additional changes not present during our study period, potentially changes in provider payment approaches, are essential for achieving the ACO objectives of higher quality of care at lower costs. PRACTICE IMPLICATIONS: Provider organizations implementing ACOs should consider centralizing service delivery as a viable strategy to improve quality of care, although the strategy did not result in lower cost growth.

[Concept of an interdisciplinary emergency department at the Schwarzwald-Baar Hospital]. / Konzept einer interdisziplinären Notaufnahmeklinik am Schwarzwald-Baar Klinikum.

BACKGROUND: Numerous hospitals were combined years ago into a new Central Hospital for cost reasons in the Schwarzwald-Baar region. This also suggested the idea of a large central emergency department. The concept of a central emergency department is an organizational challenge, since they are directly engaged in the organizational structure of all medical departments that are involved in emergency treatment. Such a concept can only be enforced if it is supported by hospital management and all parties are willing to accept interdisciplinary and interprofessional work. OBJECTIVE: In this paper, the concept of a central emergency department in a tertiary care hospital which was rebuilt as an organizationally independent unit is described. Collaborations with various departments, emergency services, and local physicians are highlighted. The processes of a central emergency department with an integrated admission department and personnel structures are described. CONCLUSION: The analysis of the concept after almost a year has shown that the integration into the clinic has been successful, the central emergency department has proven itself as a central hub and has been accepted as a unit within the hospital.

The effect of activity-based financing on hospital length of stay for elderly patients suffering from heart diseases in Norway.

BACKGROUND: Whether activity-based financing of hospitals creates incentives to treat more patients and to reduce the length of each hospital stay is an empirical question that needs investigation. This paper examines how the level of the activity-based component in the financing system of Norwegian hospitals influences the average length of hospital stays for elderly patients suffering from ischemic heart diseases. During the study period, the activity-based component changed several times due to political decisions at the national level. METHODS: The repeated cross-section data were extracted from the Norwegian Patient Register in the period from 2000 to 2007, and included patients with angina pectoris, congestive heart failure, and myocardial infarction. Data were analysed with a log-linear regression model at the individual level. RESULTS: The results show a significant, negative association between the level of activity-based financing and length of hospital stays for elderly patients who were suffering from ischemic heart diseases. The effect is small, but an increase of 10 percentage points in the activity-based component reduced the average length of each hospital stay by 1.28%. CONCLUSIONS: In a combined financing system such as the one prevailing in Norway, hospitals appear to respond to economic incentives, but the effect of their responses on inpatient cost is relatively meagre. Our results indicate that hospitals still need to discuss guidelines for reducing hospitalisation costs and for increasing hospital activity in terms of number of patients and efficiency.

[Cost of functioning of a centralised pharmaceutical unit: evaluation of mean costs of chemotherapy preparations according to the level of production of the unit]. / Coût de fonctionnement d'une unité de reconstitution des cytotoxiques : estimation des besoins en personnel et équipements et estimation du coût moyen d'une préparation selon le niveau de production et d'exigences.

The interest of centralization of preparations of chemotherapy drugs is in addition to its economic aspect, to secure drugs circuit. The aims of this study are to determine needs in employees and equipments of 11 theoretical levels of production from 1,000 to 50,000 preparations per year and to determine the cost of chemotherapy's preparation for each theoretical unit. The operating cost was divided in four areas of expenditure: employees (66-78%), investment (5-15%), maintenance (3-15%) and consumables (4-16%). If we consider the 11 units, the theoretical cost varies between 27.4 € for a unit with 50,000 preparations per year and 114.1 € for a unit with 1,000 preparations per year. This study shows the importance of setting up an optimal unit of preparations according to its activity and highlights the high cost's variation in relation to the activity of the unit.

[Organizational forms of emergency medicine from the viewpoint of hospital management. Discipline-specific or interdisciplinary?]. / Organisationsformen der Notfallmedizin aus Sicht des Krankenhausmanagement. Fachspezifisch oder interdisziplinär?

Almost 16 million Germans are treated annually in an emergency room (ER). Most patients are seen in a specialty ER and only 10-20% of all hospitals have a centralized ER facility. Clinical emergency medicine is currently not adequately reimbursed, but represents a major patient entry point for most hospitals. It remains unclear whether the implementation of specialized ER physicians is more cost-effective than centralized specialization. However, it appears reasonable to centralize all ER resources, to optimize the workflow using electronic patient charts and order entry sets and to incorporate the general practitioner into the treatment of simple medical problems.

Reusing cytostatics in a centralised pharmacy preparation unit.

OBJECTIVE: To measure and provide an economic assessment of the preparations returned to a centralised cytostatic drug preparation unit, analyse reasons for their return, propose measures for minimising returns and assess their impact on the Medical Oncology division's outpatient services. METHODS: This prospective study contained two phases. During the first, we registered all returns, motives, cases of reuse and costs. In the second phase, we analysed returns at the Oncology outpatient division after having adopted measures to minimise the returns. RESULTS: During the first phase, 218 preparations (worth € 51,131) were returned. The Oncology Day Hospital returned 1% of the preparations worth 1% of the total value; during the second phase, these figures were 0.56% of the preparations and 0.14% of the total value. CONCLUSIONS: Favouring reporting on and identifying expensive treatments with little stability and using returned preparations as a quality indicator for Oncology has improved management of the central cystostatic preparation unit.

Centralization of care for patients with advanced-stage ovarian cancer: a cost-effectiveness analysis.

BACKGROUND: The objective of this study was to evaluate the cost-effectiveness of centralized referral of patients with advanced-stage epithelial ovarian cancer who underwent primary cytoreductive surgery and adjuvant chemotherapy. METHODS: A decision-analysis model was used to compare 2 referral strategies for patients with advanced-stage ovarian cancer: 1) referral to an expert center, with a rate of optimal primary cytoreduction of 75% and utilization of combined intraperitoneal and intravenous adjuvant chemotherapy, and 2) referral to a less experienced center, with a rate of optimal primary cytoreduction of 25% and adjuvant treatment that consisted predominantly of intravenous chemotherapy alone. The cost-effectiveness of each strategy was evaluated from the perspective of society. RESULTS: A cost-effectiveness analysis revealed that the strategy of expert center referral had an overall cost per patient of $50,652 and had an effectiveness of 5.12 quality-adjusted life years (QALYs). The strategy of referral to a less experienced center carried an overall cost of $39,957 and had an effectiveness of 2.33 QALYs. The expert center strategy was associated with an additional 2.78 QALYs at an incremental cost of $10,695 but was more cost-effective, with a cost-effective ratio of $9893 per QALY compared with $17,149 per QALY for the less experienced center referral strategy. Sensitivity analyses and a Monte Carlo simulation confirmed the robustness of the model. CONCLUSIONS: According to results from the decision-analysis model, centralized referral of patients with ovarian cancer to an expert center was a cost-effective healthcare strategy and represents a paradigm for quality cancer care, delivering superior patient outcomes at an economically affordable cost. Increased efforts to align current patterns of care with a universal strategy of centralized expert referral are warranted.

[Centralised diagnostic]. / Centraliseret diagnostik.

Diagnostic examinations with complicated and expensive equipment should be centralised in departments of radiology, clinical physiology and nuclear medicine, clinical biochemistry etc. For the future reorganisation of hospitals in Denmark, focus on centralisation in larger university hospitals is recommended with close collaboration between diagnostic specialities and clinical specialities, and with research and advanced competence as main assets.

[Economical assessment of intravenous mixture centralization]. / Evaluación económica de la centralización de mezclas intravenosas.

OBJECTIVE: To evaluate the cost of preparing intravenous mixtures in the centralized pharmacy service of the hospital as compared to the cost of their preparation by nurses on wards, assuming that the results are clinically analogous for the patients. METHOD: A cost-minimization analysis has been carried out. Data concerning types of mixtures and quantities has been analyzed retrospectively. The fixed and variable costs in both drug preparation options have been assessed using the real costs of the hospital in 2003. This study considered the productive time of nurses in our hospital as well as time described in bibliography. The materials used and their cost has been quantified, along with the cost of recycled mixtures. A sensitivity analysis was conducted considering the most influential variables. RESULTS: The preparation times of nurses in pharmacy are equal or shorter. The material costs/100 intravenous mixtures represent a fifth part in pharmacy (1.10 euro compared to 5.69-12.37 euro). The minimum ratio of cost between pharmacy and ward was 1:2.94 (10,619:31,265 euro) and the maximum was 1:3.77 (37,075:139,633 euro). The savings due to recycling of intravenous mixtures (36,168 to 118,110 euro) always favours the pharmacy. The sensibility analysis indicates that centralization maintains the usefulness level (ratio total annual cost 1:3.23), with a ratio of minimum annual productive time between pharmacy and ward nurses of 1:3.5. CONCLUSIONS: In our hospital the preparation of intravenous mixtures at the pharmacy department minimizes costs compared to preparation on wards, allowing nurses to devote more time to patient care, and thus improving the efficiency of management.

Consignment trays and the hidden costs of sterilization.

Consignment implant trays are often an overlooked facet of the supply chain. If not handled properly, they can cost a hospital thousands of dollars in delivery charges as well as potentially decreasing the level of patient safety. It is critical that value analysis committees have input from central service and that time is taken to consider logistics before signing agreements, especially with regard to proper sterilization instructions and delivery method. If trays arrive too late, it is more likely that corners will be cut with the sterilization process.

[Medical monopolies--a choice between quality and equality?]. / Medisinske monopoler--et valg mellom kvalitet eller likhet?

BACKGROUND: The highly specialised medical services in Norway consist of 33 monopolies and 8 bipolies, involving both a duty of referral and a duty of admittance for defined patient groups. All the specialised services are located to large hospitals in southern Norway. MATERIAL: In conjunction with a thorough review of the specialised services, the geographical distribution of the 2711 patients treated in 2001 was analysed. RESULTS: The geographical distribution was highly skewed, with a decreasing coverage with increasing distances from the monopoly centres. The ratio between the county with the most and the one with the least use of the services was 2.3. Northern Norway had a significantly lower usage. INTERPRETATION: Monopolies seem to have an inherent tendency to give poor distribution of health care. Medical monopolies seem to have many of the negative effects associated with economic monopolies. A cautious attitude towards new and a rigid control of old monopolies is recommended. Equality of access to services should be maintained as a primary goal in public health care systems.

Equity of access to tertiary hospitals in Wales: a travel time analysis.

BACKGROUND: The objective of the study was to investigate the implications for equity of geographical access for population subgroups arising from hypothetical scenarios of change in configuration of National Health Service tertiary hospital service provision located in Wales. METHODS: For each of three scenarios, the status quo and centralization of services to one of two locations, we used a travel time road length matrix in geographical information software to calculate the proportion of the population living within 30, 60, 90 and 120 min travel of each hospital site and the associated mean, median and 90th percentile travel times. We analysed data for the total resident population of Wales, for residents aged 75 or more years, for residents of the most deprived 10 per cent of enumeration districts, and for residents of rural areas. RESULTS: Centralization of services reduces geographical access for all population subgroups. Access varies between population subgroups, both between and within different scenarios of service configuration. A change in service configuration may improve access for one subgroup but reduce access for another. The interpretation may also vary according to whether the defined cut point for comparing access is based on short or long travel times. Measurements of absolute and relative access are sensitive to the assumed travel speeds. CONCLUSION: Access for the total population does not imply equity of access for subgroups of the population. Comparisons of access between scenarios are dependent on which measure of access is the indicator of choice. Results are sensitive to the road network travel speeds and further local validation may be necessary. This method can provide explicit information to health service planners on the effects on equity of access from a change in service configuration.

Transformation of a pharmacy department: impact on pharmacist interventions, error prevention, and cost.

BACKGROUND: Current medical literature supports the unit-based (UB) pharmacy concept as a best practice. In an effort to determine its feasibility, Huntsville Hospital (Huntsville, Alabama) conducted a pilot study to compare the central-based (CB) model with the UB model and then implemented the new model. IMPLEMENTING THE PILOT STUDY: Data were collected for two high-volume nursing units for 10 days for each model. Pharmacists practicing in the UB setting documented more interventions than the CB pharmacist by a factor of three to one, resulting in an 85% increase in cost avoidance. IMPLEMENTING THE UB MODEL: Converting the pharmacy services to a UB model entailed creating 16 new pharmacist positions. Extrapolation of the savings for the UB model ($520 per day) and the CB model ($280) for 1 year suggested that adoption of the UB model would generate an additional $87,600 in cost avoidance for these two nursing units. Each new pharmacist was trained for at least 3 months before being scheduled to work independently as a UB pharmacist. Clinical interventions by pharmacists greatly increased after implementation of the UB model. The baseline monthly average of interventions for the 6 months before implementation was 239, and the monthly cost avoidance was $21,300. In October 2001, the first full month of implementation, there were 1,315 interventions and a monthly cost avoidance of $130,192. SUMMARY: Converting to the UB model has required a considerable increase in the number of pharmacist positions, yet there has been a dramatic increase in clinical pharmacy interventions, with a corresponding decrease in drug expenditures.