Remdesivir and dexamethasone as tools to relieve hospital care systems stressed by COVID-19: A modelling study on bed resources and budget impact.

Remdesivir and dexamethasone are the only drugs providing reductions in the lengths of hospital stays for COVID-19 patients. We assessed the impacts of remdesivir on hospital-bed resources and budgets affected by the COVID-19 outbreak. A stochastic agent-based model was combined with epidemiological data available on the COVID-19 outbreak in France and data from two randomized control trials. Strategies involving treating with remdesivir only patients with low-flow oxygen and patients with low-flow and high-flow oxygen were examined. Treating all eligible low-flow oxygen patients during the entirety of the second wave would have decreased hospital-bed occupancy in conventional wards by 4% [2%; 7%] and intensive care unit (ICU)-bed occupancy by 9% [6%; 13%]. Extending remdesivir use to high-flow-oxygen patients would have amplified reductions in ICU-bed occupancy by up to 14% [18%; 11%]. A minimum remdesivir uptake of 20% was required to observe decreases in bed occupancy. Dexamethasone had effects of similar amplitude. Depending on the treatment strategy, using remdesivir would, in most cases, generate savings (up to 722€) or at least be cost neutral (an extra cost of 34€). Treating eligible patients could significantly limit the saturation of hospital capacities, particularly in ICUs. The generated savings would exceed the costs of medications.

How Many Intensive Care Beds are Justifiable for Hospital Pandemic Preparedness? A Cost-effectiveness Analysis for COVID-19 in Germany.

INTRODUCTION: Germany is experiencing the second COVID-19 pandemic wave. The intensive care unit (ICU) bed capacity is an important consideration in the response to the pandemic. The purpose of this study was to determine the costs and benefits of maintaining or expanding a staffed ICU bed reserve capacity in Germany. METHODS: This study compared the provision of additional capacity to no intervention from a societal perspective. A decision model was developed using, e.g. information on age-specific fatality rates, ICU costs and outcomes, and the herd protection threshold. The net monetary benefit (NMB) was calculated based upon the willingness to pay for new medicines for the treatment of cancer, a condition with a similar disease burden in the near term. RESULTS: The marginal cost-effectiveness ratio (MCER) of the last bed added to the existing ICU capacity is €21,958 per life-year gained assuming full bed utilization. The NMB decreases with an additional expansion but remains positive for utilization rates as low as 2%. In a sensitivity analysis, the variables with the highest impact on the MCER were the mortality rates in the ICU and after discharge. CONCLUSIONS: This article demonstrates the applicability of cost-effectiveness analysis to policies of hospital pandemic preparedness and response capacity strengthening. In Germany, the provision of a staffed ICU bed reserve capacity appears to be cost-effective even for a low probability of bed utilization.

Peripherally Inserted Central Catheters (PICCs) and Potential Cost Savings and Shortened Bed Stays In an Acute Hospital Setting.

Peripheral inserted central catheters (PICCs) have increasingly become the mainstay of patients requiring prolonged treatment with antibiotics, transfusions, oncologic IV therapy and total parental nutrition. They may also be used in delivering a number of other medications to patients. In recent years, bed occupancy rates have become hugely pressurized in many hospitals and any potential solutions to free up beds is welcome. Recent introductions of doctor or nurse led intravenous (IV) outpatient based treatment teams has been having a direct effect on early discharge of patients and in some cases avoiding admission completely. The ability to deliver outpatient intravenous treatment is facilitated by the placement of PICCs allowing safe and targeted treatment of patients over a prolonged period of time. We carried out a retrospective study of 2,404 patients referred for PICCs from 2009 to 2015 in a university teaching hospital. There was an exponential increase in the number of PICCs requested from 2011 to 2015 with a 64% increase from 2012 to 2013. The clear increase in demand for PICCs in our institution is directly linked to the advent of outpatient intravenous antibiotic services. In this paper, we assess the impact that the use of PICCs combined with intravenous outpatient treatment may have on cost and hospital bed demand. We advocate that a more widespread implementation of this service throughout Ireland may result in significant cost savings as well as decreasing the number of patients on hospital trollies.

An evaluation of the costs and consequences of Children Community Nursing teams.

AIMS: Recent years have seen an increasing shift towards providing care in the community, epitomised by the role of Children's Community Nursing (CCN) teams. However, there have been few attempts to use robust evaluative methods to interrogate the impact of such services. This study sought to evaluate whether reduction in secondary care costs, resulting from the introduction of 2 CCN teams, was sufficient to offset the additional cost of commissioning. METHODS: Among the potential benefits of the CCN teams is a reduction in the burden placed on secondary care through the delivery of care at home; it is this potential reduction which is evaluated in this study via a 2-part analytical method. Firstly, an interrupted time series analysis used Hospital Episode Statistics data to interrogate any change in total paediatric bed days as a result of the introduction of 2 teams. Secondly, a costing analysis compared the cost savings from any reduction in total bed days with the cost of commissioning the teams. This study used a retrospective longitudinal study design as part of the transforming children's community services trial, which was conducted between June 2012 and June 2015. RESULTS: A reduction in hospital activity after introduction of the 2 nursing teams was found, (9634 and 8969 fewer bed days), but this did not reach statistical significance. The resultant cost saving to the National Health Service was less than the cost of employing the teams. CONCLUSION: The study represents an important first step in understanding the role of such teams as a means of providing a high quality of paediatric care in an era of limited resource. While the cost saving from released paediatric bed days was not sufficient to demonstrate cost-effectiveness, the analysis does not incorporate wider measures of health care utilisation and nonmonetary benefits resulting from the CCN teams.

Evaluating the attendance of medical staff and room occupancy during palliative radiotherapy.

INTRODUCTION: Attendance of staff and use of resources during treatment have an impact on costs. For palliative radiotherapy, no reliable data are available on the subject. Therefore, the measurement of selected variables (staff absorbance and room occupancy) based on daily palliative irradiation was the aim of our prospective study. The analysis is part of a larger study conducted by the German Society of Radiation Oncology (DEGRO). PATIENTS, MATERIAL, AND METHODS: A total of 172 palliative radiation treatments were followed up prospectively between October 2009 and March 2010. The study was performed at two experienced radiotherapy departments (Herne and Bielefeld) and evaluated the attendance of medical personnel and room occupancy related to the selected steps of the treatment procedure: treatment planning and daily application of radiation dose. RESULTS: Computed tomography for treatment planning engaged the unit for 19 min (range: 17-22 min). The localization of target volume required on average 28 min of a technician's working time. The mean attendance of the entire staff (radiation oncologist, physicist, technician) for treatment planning was 159 min, while the total room occupancy was 140 min. Depending on the type of treatment, the overall duration of a radiotherapy session varied on average between 8 and 18 min. The staff was absorbed by the first treatment session (including portal imaging) for 8-27 min. Mean room occupancy was 18 min (range: 6-65 min). The longest medical staff attendance was observed during an initial irradiation session (mean: 11 min). Radiotherapy sessions with weekly performed field verifications occupied the rooms slightly longer (mean: 10 min, range: 4-25 min) than daily radiotherapy sessions (mean: 9 min, range: 3-29 min). We observed that the patients' symptoms, their condition, and their social environment confounded the time schedule. CONCLUSIONS: Target localization, treatment planning, and performance of palliative radiotherapy absorb resources to an extent comparable to nonpalliative treatment. Because of unexpected events, the time schedule before and during radiotherapy may reveal strong interindividual variability.

[A proposal to improve nursing fee differentiation policy for general hospitals using profitability-analysis in the national health insurance].

PURPOSE: The purpose of this study was to propose optimal hospitalization fees for nurse staffing levels and to improve the current nursing fee policy. METHODS: A break-even analysis was used to evaluate the impact of a nursing fee policy on hospital's financial performance. Variables considered included the number of beds, bed occupancy rate, annual total patient days, hospitalization fees for nurse staffing levels, the initial annual nurses' salary, and the ratio of overhead costs to nursing labor costs. Data were collected as secondary data from annual reports of the Hospital Nursing Association and national health insurance. RESULTS: The hospitalization fees according to nurse staffing levels in general hospitals are required to sustain or decrease in grades 1, 2, 3, 4, and 7, and increase in grades 5 and 6. It is suggested that the range between grade 2 and 3 be sustained at the current level, the range between grade 4 and 5 be widen or merged into one, and the range between grade 6 and 7 be divided into several grades. CONCLUSION: Readjusting hospitalization fees for nurse staffing level will improve nurse-patient ratio and enhance the quality of nursing care in hospitals. Follow-up studies including tertiary hospitals and small hospitals are recommended.

Diabetes inpatients: a case of lose, lose, lose. Is it time to use a 'diabetes-attributable hospitalization cost' to assess the impact of diabetes?

AIMS: The UK National Health Service in England pays for inpatients using a formula ('tariff'). The appropriateness of the tariff for people with diabetes is unknown. We have compared the tariff paid and costs for inpatients with/without diabetes and tested the concept of a 'diabetes-attributable hospitalization cost'. METHODS: This was a cross-sectional, retrospective 12-month audit in a single teaching hospital assessing mortality, bed days per annum and 'diabetes-attributable hospitalization cost' (i.e. the proportion of costs for all patients with diabetes in excess of that paid for comparable patients without diabetes). RESULTS: There were 64 829 inpatient admissions, with 4864 of those coded as having diabetes; 12.9% was estimated to be the number of patients having diabetes but not coded. People with diabetes occupied 13.9% of all bed days and were 18.1% (1.3-37.8%) more likely to die (age adjusted). The mean bed days per annum were greatest among those with (vs. without) diabetes (men 10.9 ± 17.0 vs. 6.3 ± 12.8; women 11.4 ± 19.4 vs. 5.9 ± 11.6; P < 0.001). The greatest excess admission rates were among those aged 25-64 years. The annual mean tariff was greater for those with diabetes (5380 ± 8740) than those without diabetes (3706 ± 6221) (P < 0.001). The overall cost was even higher among those with diabetes: 5835 ± 11 246 vs. 3567 ± 7238 (P < 0.001). The diabetes-attributable hospitalization cost was 46.5% (9 125 085). An HbA(1c) > 10.0% (> 86 mmol/mol) was associated with excess hospitalization. CONCLUSIONS: Those with diabetes cost more and are more likely to die when inpatients. The tariff paid for diabetes is high, but in this centre less than the actual costs. Approaches known to reduce hospitalization are urgently required.

[Changes in mental health care by a regional budget: results of a pilot Project in Schleswig-Holstein (Germany)]. / Veränderung der psychiatrischen Versorgung durch ein Regionales Budget: Ergebnisse eines Modellprojektes in Schleswig-Holstein.

OBJECTIVES: In a region of Schleswig-Holstein, a regional budget was used to investigate which structural changes would be brought about by a financial plan which enables (clinical) treatment that defies rigid financial limits and makes flexible treatment in various settings possible. RESULTS: In 5 years, the number of inpatient treatment places in the care region was reduced considerably. The length of stay per patient and year decreased by 25 %. Day care and outpatient treatment offers were expanded substantially and new treatment concepts were established. The quality of treatment remained safeguarded. CONCLUSIONS: A regional budget is suitable for bringing about fundamental changes in terms of content and structure in psychiatric care. The result is clearly improved flexibility as compared to previous care structures; incentives for disorders are reduced. The principle "outpatient before inpatient" is strengthened. The financial plan can be transposed onto other regions, whereby modifications according to the structure of the care region seem necessary.

Incorporating efficiency in hospital-capacity planning in Germany.

Hospital occupancy is a key metric in hospital-capacity planning in Germany, even though this metric neglects important drivers of economic efficiency, for example treatment costs and case mix. We suggest an alternative metric, which incorporates economic efficiency explicitly, and illustrate how this metric can be used in the hospital-capacity planning cycle. The practical setting of this study is the hospital capacity planning process in the German federal state of Rheinland-Pfalz. The planning process involves all 92 acute-care hospitals of this federal state. The study is based on standard hospital data, including annual costs, number of cases--disaggregated by medical departments and ICD codes, respectively--length-of-stay, certified beds, and occupancy rates. Using the developed metric, we identified 18 of the 92 hospitals as inefficient and targets for over-proportional capacity cuts. On the upside, we identified 15 efficient hospitals. The developed model and analysis has affected the federal state's most recent medium term planning cycle.

Financial and operational impact of a direct-from-PACU discharge pathway for laparoscopic cholecystectomy patients.

BACKGROUND: We assessed the operational and financial impact of discharging laparoscopic cholecystectomy (LC) patients directly from the postanesthetic care unit (PACU) in comparison with post-transfer discharge from a hospital bed in a busy academic hospital. METHODS: We retrospectively compared 6 months of performance (bed utilization; recovery room and hospital length of stay; complications; readmissions; hospital costs, revenue, and margin) after implementation of PACU discharges (case patients) to the corresponding 6 months in the prior year (control patients). RESULTS: After implementation, 66% of LC case patients were discharged on the day of surgery, compared with 29% in the control group (P < .05). Eighty percent of the day-of-surgery discharges were directly from the PACU. Shifting to PACU discharge saved 1 in-hospital bed transfer and 1 bed-day for each PACU discharge. Recovery room length of stay for PACU discharge patients was 26% longer than for hospital discharge patients (P = NS). Average hospital length of stay for all patients discharged on the day of surgery was 3.2 hours shorter (P < .05) for case patients (80% PACU discharge) than for control patients. There were no readmissions in the PACU discharge group and no difference in complications. While costs, revenue, and net margin for PACU discharge patients were reduced by 40% to 50% (P < .02) relative to floor discharge patients, the hospital's net margin for the combined case patient group was preserved relative to the control group. CONCLUSIONS: PACU discharge of LC patients significantly reduces bed utilization, decreases in-hospital transfers, and allows congested hospitals to better accommodate patient care needs and generate additional revenue.

Resource use and costs of elective surgery for asymptomatic abdominal aortic aneurysm.

OBJECTIVES: To determine the hospital costs of elective abdominal aortic aneurysm repair. DESIGN: Observational study of resource use. MATERIALS: Forty-six elective aneurysm surgery patients in a hospital; 116 vascular surgeons participating in the U.K. Small Aneurysm Trial. METHODS: Data on resource use and associated costs were obtained in 1993 for 46 patients who had undergone elective surgery in a teaching hospital. Comparability of resource use with other hospitals in the U.K. was obtained from data on surgical patients in the U.K. Small Aneurysm Trial, and by questionnaire on use of resources sent to surgeons participating in the trial. RESULTS: The total cost of an elective aneurysm repair calculated from patient data in the teaching hospital was Pounds 4592. One-third of costs were due to stay in a standard surgical ward, and 20% were attributable to the operation. Overall, the use of resources in U.K. hospitals was comparable to that for the teaching hospital. Based on the surgeons' estimates, however, considerable variation existed for typical elective aneurysm patients, with costs ranging from Pounds 2173 to Pounds 7024. CONCLUSIONS: In the U.K. the average cost of an elective aneurysm repair in 1993 was around Pounds 4600, which was equivalent to around Pounds 5000 (US$8000) in 1996. This estimate is sufficiently reliable to be used in cost effectiveness analyses.

[Ambulatory surgery in the hospital: decision between national health insurance responsibility and personal job security]. / Ambulante Chirurgie am Krankenhaus: Entscheidung zwischen Staatsbürgerpflicht und Selbsterhalt.

The aim of outpatient surgery is to reduce costs in the health service. However, the number of surgeons working in a surgical department is dependent upon the numbers of occupied beds. This creates an existential conflict in which, by reducing the occupancy of beds in order to take on more outpatient cases, surgeons are putting their own jobs on the line. Possible solutions are here discussed.

Optimizing the hospital management of leg ulcers.

BACKGROUND: Leg ulcers are common and are often the cause of a long hospital admission. However, little information is available on the efficacy and efficiency of inpatient leg ulcer management. The inpatient management of leg ulceration was examined and areas for improvement were sought. METHODS: The management of patients admitted to a teaching hospital with a primary diagnosis of leg ulceration was examined, the costs estimated and areas for improvement identified. A retrospective analysis of 174 admissions to Heidelberg Repatriation Hospital between 1 January 1991 and 31 December 1992 was performed. RESULTS: Of 119 patients, 61 had ulcers due to arterial disease and 34 due to venous disease. Over 2 years, leg ulcers accounted for 5259 inpatient bed days, a mean of 44.2 days per patient. The estimated cost exceeded $2,750,000, averaging over $12,000 per admission. Thirty-three percent of patients had no recorded investigations into the cause of their ulcer and fewer than 50% had documented improvement at discharge. CONCLUSIONS: Leg ulcers are costly due to their extended treatment on an inpatient basis. Unfortunately, hospital admission does not guarantee optimal wound healing rates. A leg ulcer protocol is proposed to minimize inpatient stay and improve investigation and management in an outpatient or community setting.

[Ambulatory surgery in the Netherlands]. / Ambulante Chirurgie in den Niederlanden.

Day care treatment is encouraged in the Netherlands on the one hand by the government and on the other hand by the request of the patients. There is a continuous shift from clinical to day care cases and through diversification, f.i. 24-hour admittance and short stay, one will be able to further reduce the number of expensive long stay hospital beds.