Potential reduction of hospital stay length with outpatient management of low-risk febrile neutropenia in a regional cancer center.

BACKGROUND: Febrile neutropenia is a serious complication of chemotherapy. The Multinational Association for Supportive Care in Cancer (MASCC) risk index score identifies patients at low risk of serious complications. Outpatient management programs have been successfully piloted in other Australian metropolitan cancer centers. AIM: To assess current management of febrile neutropenia at our regional cancer center and determine potential impacts of an outpatient management program. METHOD: We performed a retrospective review of medical records for all patients admitted at our regional institution with febrile neutropenia between 1 January 2016, and 31 December 2018. We collected information regarding patient characteristics, determined the MASCC risk index score, and if low risk, we determined the eligibility for outpatient care and potential reduction in length of stay and cost benefit. RESULTS: A total of 98 hospital admissions were identified. Of these, 66 had a MASCC low-risk index score. Fifty-eight patients met the eligibility criteria for outpatient management. Seventy-one percent were female. The most common tumor type was breast cancer. Forty-eight percent were treated with curative intent. The median length of stay was 3 days. The median potential reduction in length of stay for each admission was 2 days. The total potential reduction in length of stay was 198 days. No admission resulted in serious complications. CONCLUSION: This review demonstrates a significant number of hospital admission days can be avoided. We intend to conduct a prospective pilot study at our center to institute an outpatient management program for such low-risk patients with potential reduction in hospital length of stay. This will have significant implications on health resource usage, service provision planning, and patient quality of life.

Impact of pediatric cardiac surgery regionalization on health care utilization and mortality.

OBJECTIVE: Regionalization directs patients to high-volume hospitals for specialized care. We investigated regionalization trends and outcomes in pediatric cardiac surgery. DATA SOURCES/STUDY SETTING: Statewide inpatient data from eleven states between 2000 and 2012. STUDY DESIGN: Mortality, length of stay (LOS), and cost were assessed using multivariable hierarchical regression with state and year fixed effects. Primary predictor was hospital case-volume, categorized into low-, medium-, and high-volume tertiles. DATA COLLECTION/EXTRACTION METHODS: We used Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) to select pediatric cardiac surgery discharges. PRINCIPAL FINDINGS: In total, 2841 (8.5 percent), 8348 (25.1 percent), and 22 099 (66.4 percent) patients underwent heart surgeries in low-, medium-, and high-volume hospitals. Mortality decreased over time, but remained higher in low- and medium-volume hospitals. High-volume hospitals had lower odds of mortality and cost than low-volume hospitals (odds ratio [OR] 0.59, P < 0.01, and relative risk [RR] 0.91, P < 0.01, respectively). LOS was longer for high- and medium-volume hospitals, compared to low-volume hospitals (high-volume: RR 1.18, P < 0.01; medium-volume: RR 1.05, P < 0.01). CONCLUSIONS: Regionalization reduced mortality and cost, indicating fewer complications, but paradoxically increased LOS. Further research is needed to explore the full impact on health care utilization.

Factors influencing regional variability in the rate of total knee arthroplasty.

BACKGROUND AND PURPOSE: Geographic variations in knee arthroplasty have been detected through international surveys. We aim to investigate in this study the influence of aging index, health budget, and number of orthopedic surgeons in the regional variations of the primary and revision TKA rate in a single European country, Spain. MATERIAL AND METHODS: Inpatient database of knee arthroplasty procedures for years 1997 to 2010 was obtained from the Spanish Ministry of Health, including 393,714 primaries and 37,037 revisions, segregated for each of the 17 regional health services in Spain. Crude and adjusted rates (direct method with total Spanish population per year) were calculated and used as dependent variables. Aging index, regional health budget, and number of orthopedic surgeons per region were used as independent variables in a Kruskal-Wallis test and a negative binomial regression analysis model. RESULTS AND CONCLUSIONS: With a mean crude rate for Spain of 76 primary TKA and 7 revision surgeries per 10(5) population and year, the mean adjusted rate per region oscillated between 702 and 27 primary TKA and 87 and 3 revisions per 10(5). A model was adjusted confirming the influence of aging index, health budget, and number of surgeons, but regional variations remained partly unexplained by these factors.

[Quality parameters in the treatment of acute stroke: comparison of various regional treatment concepts]. / Qualitätsparameter der akuten Schlaganfallversorgung: Gegenüberstellung unterschiedlicher regionaler Versorgungskonzepte.

BACKGROUND: The long-term prognosis of stroke patients is still dependent in particular on the timing of a correct diagnosis, immediate initiation of a suitable specific therapy and competent treatment in a stroke unit. Therefore, nationwide attempts are being made to establish a comprehensive coverage of the necessary specific competence and infrastructural requirements. Divergent regional circumstances and economic viewpoints determine the characteristics of the various healthcare concepts and the interplay between participating cooperation partners. This article compares the development with respect to three qualitative treatment parameters exemplified by four regional healthcare models during the time period 2008-2011. METHODS: The hospitalization rates for patients with transitory ischemic attacks, ischemic and hemorrhagic stroke, the case numbers for stoke unit treatment and the rates of systemic thrombolysis and mechanical thrombectomy in the regions of Berlin, the Ruhr Area, Ostwestfalen-Lippe and southeast Bayern (TEMPiS) are presented based on the data from the DRG statistical reports for the years 2008 and 2011. RESULTS: The average hospitalization rates for ischemic stroke patients (brain infarct ICD 163) in the time period from 2008 to 2011 were 294 per 100,000 inhabitants for the Ruhr Area, 257 per 100,000 inhabitants for Ostwestfalen-Lippe and 265 per 100,000 inhabitants each for Berlin and southeast Bayern. The complex stroke treatment quota for southeast Bayern in 2008 was 31 % and 47 % in 2011 and the respective quotas for the other regions studied were 42-44 % and 58-59 %. The rate of systemic thrombolysis in 2008 ranged between 4.2 % and 7.4 % and in 2011 the increase in the range for the 4 regions studied was between 41 % and 145 %. In 2011 the thrombectomy quota of 2 % in the Ruhr Area was the only one which was above the national average of 1.3 % of all brain infarcts. DISCUSSION: Stroke is a common disease in the four regions studied. For the established forms of therapy, complex treatment of stroke and systemic thrombolysis, the positive effect of structurally improved approaches in the four different regional treatment concepts could be confirmed during the course of the observational time period selected. Mechanical thrombectomy which is currently still considered to be an individual healing attempt, was used significantly more often in the Ruhr Area in 2011 than in the other three regions studied. A standardized referral procedure had previously been established in the metropolitan regions.

Workload and costs associated with providing a neonatal surgery service.

AIM: To identify the workload related to provision of a neonatal surgical service in a UK neonatal network in order to inform local and national service commissioning. METHOD: Data relating to neonatal surgical admissions to a level 3 perinatal centre serving a network with 36,000 births per year collected prospectively over a 5-year period were analysed to identify annual activity. Daily dependency was assessed prospectively over a 6-month period and service costs calculated using existing local tariffs. Admissions from outside the network were excluded from analysis, and allowance was made for refused network admissions. RESULTS: On average 140 admissions required 2137 cot-days per year. At 80% occupancy, the service requires seven neonatal cots suggesting that there is a national requirement for one neonatal surgical cot per 5000 births. Intensive care, high care (HC) and special care accounted for 37%, 46% and 17% of cot-days, respectively. This equates to an annual service cost of £2m, about £250,000 per 5000 births. CONCLUSIONS: This assessment of the facilities and costs required to provide a neonatal surgical service in a level 3 perinatal centre in the UK may be used to inform network and national commissioning.

Quasi-market and cost-containment in Beveridge systems: the Lombardy model of Italy.

In the very recent past, the Lombardy health care system - established in 1997 on the quasi market model - has caught the interest of researchers and politicians in different OECD countries(1). Its merits, compared to other Italian regional systems, are the control of health care spending and the balanced budget, in a frame of good quality of services and patient choice. From the theoretical point of view, an appealing aspect of the Lombardy model is its gradual shift from a quasi market (QM) to a "quasi administered" system, which maintains all the typical features of the QM orientation - separation between purchasers and providers, the co-presence of public, not for profit and public providers, and patient free choice - but has deliberately sacrificed competition in order to control health expenditure. Another aspect of the Lombardy model is the sharp presence of private providers: the evidence that private sector is mainly concentrated in the long term care, where risks of complications are lower and financial remuneration is higher, suggests that a closer control should be exerted on hospital activity. Furthermore, possible distortions such as cream skimming and cherry picking by the private providers need more consideration. Another concern is linked to health spending control: equity issues could arise when observing a still relatively high share of private (out of pocket) health care expenditure. The paper stems from a literature review and tries to analyse the evolution of this regional system, the institutional path that brought to the implementation of the model, its theoretical basis, its merits and criticism. The period considered ranges from 1997, when the reform was enacted, to 2010.

Contributions of public hospitals to regional health care: a population-based analysis of the county health care system serving metropolitan Chicago.

To determine the proportions of countywide expenditures and service delivery for the Cook County Health and Hospitals System (CCHHS), we obtained data from the CCHHS budget; CCHHS registration, program, and pharmacy databases; public health departments and organization reports; and federal agency estimates. The annual CCHHS budget of $1.2B represents 3.4% of total Cook County health care expenditures. Eight of the nine population-based proportions of health care services delivered by the CCHHS exceeded this proportion of health expenditures by factors of 1.3-8 times. These services include diagnosis of tuberculosis, sexually transmitted diseases, and cancers; care of very low birth weight babies; primary care for HIV and diabetes; and emergency room and ambulatory visits. This county health care system is a productive contributor to overall health service delivery in Cook County, and its contributions exceed its proportionate funding in eight of nine priority health areas.

[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.

The costs and savings of a regional public palliative care program: the Catalan experience at 18 years.

Conceived as a World Health Organization demonstration project for public health initiatives at the end of life, the palliative care program in Catalonia illustrates the impact that similar initiatives may have in terms of cost savings for a regional health system. In a publicly funded and freely accessible health system, decreasing the number of hospital admissions, shortening the lengths of hospital stay, diminishing the frequency of emergency room consultations, shifting the use of acute hospital beds to palliative care beds for treating advanced disease inpatients, and substantially improving the use of opioids in the community are major determinants of the palliative care program's success. These features add to the opportunity the discipline offers to improve the quality of health care at the end of life. In this article, the information gathered over an 18-year trajectory of the program is summarized. Key features of the existing financial models used while developing palliative care in Catalonia are described, and the mechanisms by which palliative care may have contributed to increase savings for the health care system in end-of-life care, from euro3,000,000 in 1995 to euro8,000,000 in 2005, are discussed.

Pharmaceuticals and the strategic national stockpile program.

This article discusses current stockpile practices after exploring a history of the use of biologic agents as weapons, the preventive measures that the federal government has used in the past, and the establishment of a Strategic National Stockpile Program in 2003. The article also describes the additional medical supplies from the managed inventory and the federal medical stations. The issues (financial burden, personnel, and materiel selection) for local asset development are also discussed. Critical is the cost to local communities of the development and maintenance of a therapeutic agent stockpile and the need for personnel to staff clinics and medical stations. Finally, the important role of the dental profession for dispensing medication and providing mass immunization in the event of a disaster is described.

Regional palliative care program in Extremadura: an effective public health care model in a sparsely populated region.

The Regional Palliative Care Program in Extremadura (RPCPEx) was created and fully integrated into the Public Health Care System in 2002. The local health care authorities of Extremadura (a large sparsely populated region in the west of Spain with 1,083,897 inhabitants) decided to guarantee palliative care as a basic right, offering maximum coverage, availability, and equity, functioning at all levels of assistance and based on the complexity of the case. The program provides full coverage of the region through a network of eight Palliative Care Teams under the direction of a regional coordinator. The mobile teams work in acute hospitals and in the community. This paper describes the program, using qualitative and quantitative indicators of structure, process, and outcome. Qualitative indicators assess, among others, the performance of the regional network, including the outcomes of the quality, training, registry, treatment, and research groups. Quantitative indicators applied consisted of the number of professionals (1/26,436 inhabitants), number of patients (1,635/million inhabitants/year), number of activities/million inhabitants/year (6,183 hospital and 3,869 home visits; 1,863 consultations; 14,748 advising services; 11,539 coordination meetings; and 483 educational meetings), cost of care (2,242,000 Euros per year), and opioid consumption (494,654 daily defined doses/year). Four years after the planning process and three years after becoming operational, the RPCPEx offers an effective and efficient model integrated into the public health care system and is able to offer comprehensive coverage, availability, equity and networking among all the structures and levels of the program. Several structural and organizational tools were developed, which may be adopted by other programs within the scope of public health. The provision of palliative care should not be conditioned by the patient's geographical location, his or her condition or disease or on the ability to pay, but on need alone. This model has successfully implemented palliative care in a region that offered many challenges, including limited resources and a disperse population in a geographically extensive region. These variables are also common in many rural areas in developing countries and the regional palliative care program offers a flexible approach that can be adapted to the needs and resources in different settings and countries in the world.

Small rural hospitals and high-risk operations: how would regionalization affect surgical volume and hospital revenue?

BACKGROUND: Because higher hospital procedure volume is associated with better outcomes for many high-risk procedures, regionalization to higher-volume hospitals has been proposed as a way to improve quality of surgical care. The potential impact of such policies on small rural hospital volume and revenue is unknown. STUDY DESIGN: We identified all hospitalizations in small rural hospitals (less than 50 beds) in New York State from 1998 to 2001 that included an ICD-9 procedure code for 1 of 9 procedures for which there is a documented volume-outcomes association: abdominal aortic aneurysm repair, aortic-valve replacement, carotid endarterectomy, colectomy, coronary artery bypass, cystectomy, esophagectomy, pancreatectomy, or pulmonary resection. Revenue from these procedures was estimated using gross charges and payor-specific reimbursement rates. We then compared these estimates with total hospital inpatient revenue for each rural hospital. RESULTS: We identified 14 small rural hospitals where at least one of the nine procedures was performed. All included hospitalizations for colectomy. Aortic aneurysm repairs, cystectomies, and pancreatectomies were performed in three hospitals; carotid endarterectomy in two; and esophagectomy in one. In no hospitals were cardiac procedures or pulmonary resections performed. Estimated average contribution to hospital net revenue for all 9 procedures was approximately 2%, nearly all attributable to colectomy. CONCLUSIONS: If all aortic aneurysm repairs, major cardiothoracic procedures, carotid endarterectomies, cystectomies, and pancreatectomies in New York State were regionalized to higher-volume hospitals, no small rural hospitals would experience substantial impact in terms of rural hospital procedure volume and revenue. Even regionalization of colectomy would have a small impact on inpatient volume and revenue.

[The regional budget for mental health care: a new approach to combine inpatient and outpatient care]. / Das Regionale Psychiatriebudget: Ein neuer Ansatz zur effizienten Verknüpfung stationärer und ambulanter Versorgungsleistungen.

OBJECTIVE: Due to increasing health care expenditures the discussion about advantages and disadvantages of new methods for resource allocation in mental health care has been intensified. A promising model is the Regional Budget for Mental Health Care, which is currently being examined in Schleswig-Holstein. The present paper describes first experiences with the new resource allocation model. BASIC CONDITIONS: An annual budget, provided for the treatment of a fixed number of patients, makes it possible to reduce inpatient capacity in favour of improved community-integrated approaches for the treatment of acute psychiatric illness. RESULTS: In a first step inpatient capacity will be reduced by 8 percent. By the end of 2007 capacity for hospital day care shall be increased by 87 percent and a home treatment will be implemented. The previous working method, orientated to treatment setting, will be replaced by an approach specialized in diagnostic groups. CONCLUSIONS: The Regional Budget could improve the continuity and flexibility of patient care. Service providers become motivated to treat in a way, which with little resource consumption achieves a long lasting health status improvement. For health insurances the Regional Budget is an opportunity to limit cost increases.

Outcome and cost of craniotomy performed to treat tumors in regional academic referral centers.

OBJECTIVE: Improved clinical and economic outcomes for high-risk surgical procedures have been previously cited in support of regionalization. The goal of this study was to examine the effects of regionalization by analyzing the cost and outcome of craniotomy for tumors and to compare the findings in academic medical centers versus community-based hospitals. METHODS: Outcomes and charges were analyzed for all adult patients undergoing craniotomy for tumor in 33 nonfederal acute care hospitals in Maryland using the Maryland Health Service Cost Review Commission database for the years 1990 to 1996. A total of 4723 patients who underwent craniotomy for tumor were selected on the basis of Diagnostic Related Group 1 (craniotomy except for trauma, age 18 or older) and International Classification of Diseases-9th Revision diagnosis code for benign tumor, primary malignant neoplasm, or secondary malignant neoplasm (codes 191, 192, 194, 200, 225, 227, 228, 237, and 239). Hospitals were categorized as high-volume hospitals (>50 craniotomies/yr) or low-volume hospitals (

Implementation and integration of regional health care data networks in the Hellenic National Health Service.

BACKGROUND: Modern health care is provided with close cooperation among many different institutions and professionals, using their specialized expertise in a common effort to deliver best-quality and, at the same time, cost-effective services. Within this context of the growing need for information exchange, the demand for realization of data networks interconnecting various health care institutions at a regional level, as well as a national level, has become a practical necessity. OBJECTIVES: To present the technical solution that is under consideration for implementing and interconnecting regional health care data networks in the Hellenic National Health System. METHODS: The most critical requirements for deploying such a regional health care data network were identified as: fast implementation, security, quality of service, availability, performance, and technical support. RESULTS: The solution proposed is the use of proper virtual private network technologies for implementing functionally-interconnected regional health care data networks. CONCLUSIONS: The regional health care data network is considered to be a critical infrastructure for further development and penetration of information and communication technologies in the Hellenic National Health System. Therefore, a technical approach was planned, in order to have a fast cost-effective implementation, conforming to certain specifications.

Allogeneic bone marrow transplantation in the developing world: experience from a center in India.

We describe our experience of setting up an allogeneic BMT program at the Christian Medical College Hospital, Vellore over a period of 13 years, from October 1986 to December 1999. Two hundred and twenty-one transplants were performed during this period in 214 patients, with seven patients undergoing second transplants. Indication for BMT were thalassemia major - 106 (48%), CML - 30, AML - 35, ALL - 10, SAA - 22, MDS - six and six for other miscellaneous disorders. The mean age of this patient cohort was 15.6 years (range 2-52). Graft-versus-host disease of grades III and IV was seen in 36 patients (17%) and this was the primary cause of death in 20 patients (9.2%). All patients and donors were CMV IgG positive. Sepsis was the primary cause of death in 16 patients (7.4%), 10 bacterial, four fungal and two viral. One hundred and ten of this series of patients are alive and disease free (50%) with a median follow-up of 24 months (range 2-116). These results are comparable to those achieved for patients with similar disease status in transplant units in the Western world and cost a mean of US$15 000.

Effects of modification of the allocation system on ischemia duration and costs of heart transplantation. Transplantation Cooperation UNI-NRW.

BACKGROUND: In order to optimize regional utilization of transplantable thoracic organs, the seven university hospitals in North-Rhine-Westfalia have formed a transplant cooperation meanwhile approved by Eurotransplant. METHODS: Heart transplant and organ donation activities of the cooperating hospitals in the year before the foundation of the cooperation (period A, 7/95 - 6/96) and in the year thereafter (period B, 7/96 - 6/97) were retrospectively analysed. RESULTS: In period A, a total of 39 heart transplants and 74 heart donations were performed, whereas in period B 67 heart transplantations and 78 heart donations could be achieved. The regional utilization of the donor organs increased from 4% to 30% with a significantly shorter ischemia time of regionally or locally allocated donor hearts than of nationally or internationally allocated ones. CONCLUSIONS: A high rate of regional or local heart transplant procedures with short ischemia times clearly demonstrate the benefits of a regionalization of heart transplant medicine for medical as well as economical reasons.

The cost of large-scale school health programmes which deliver anthelmintics to children in Ghana and Tanzania. The Partnership for Child Development.

It has been argued that the delivery of anthelmintics to school-children through existing education infrastructure can be one of the most cost-effective approaches to controlling parasitic worm infection. This paper examines the actual costs of a combination of mass and selective treatment for schistosomiasis using praziquantel and mass treatment for intestinal nematodes using albendazole, as an integral part of school health programmes reaching 80442 pupils in 577 schools in Volta Region, Ghana, and reaching 109099 pupils in 350 schools in Tanga Region, Tanzania. The analysis shows that financial delivery costs per child treated using praziquantel, which involved a dose related to body mass and a prior screening at the school level, were US$ 0.67 in Ghana and US$ 0.21 in Tanzania, while the delivery costs for albendazole, which was given as a fixed dose to all children, were US$ 0.04 in Ghana and US$ 0.03 in Tanzania. The higher unit costs in Ghana reflect the epidemiology of infection; overall, fixed costs were similar in both countries, but fewer children required treatment in Ghana. Analysis of economic costs-which includes the cost of unpaid days of labour--indicates that the financial costs are increased in Ghana by 78% and in Tanzania by 44%. It is these additional costs which are avoided by integration into an existing infrastructure. It is concluded that: the base cost of delivering a universal, standard, school-based health intervention can be as low as US$ 0.03 per child treated; that even a slight increase in the complexity of delivery can have a significant impact on the cost of intervention; and that the use of the education infrastructure does indeed offer significant savings in delivery costs.