Improving patient follow-up in developing regions.

BACKGROUND: Cleft surgery follow-up in developing regions is challenging. This study evaluated rates, costs, and satisfaction of 2 follow-up programs at the Guwahati Comprehensive Cleft Care Centre (GC4) in Assam, India. METHODS: For this study, 10,582 postoperative visits were analyzed from May 2011 to November 2013. A questionnaire was administered to subsets of follow-up patients at both locations. Costs were calculated. RESULTS: Eighty-five percent of patients had follow-up at GC4, and 15% were seen in the patients' local districts. One hundred ninety-five questionnaires were completed (122 at GC4, 73 in local districts). Patients with local follow-up had fewer accompanying family members (mean, 1.95 vs 0.99; P = 0.00), fewer days off work (mean, 1.84 vs 1.15; P = 0.19), less lost income (Indian rupees 367 vs 143, P = 0.00), and lower direct costs (mean Rs, 911 vs 299; P = 0.00). The financial burden of local follow-up was significantly lower (P = 0.003). No significant differences were seen for convenience, likelihood of attending follow-up, or satisfaction. Follow-ups increased after revising programs from a mean of 139 monthly visits (follow-up to surgery ratio of 0.722) to a mean of 363 visits (ratio of 1.57). The center's mean cost for local follow-up was Rs 303 per patient, whereas the estimated costs would have been Rs 1100 for follow-up at the center. CONCLUSIONS: This study demonstrates potential improvements in costs and outcomes by changing the model of care. Despite significant follow-up challenges, much progress can be achieved through process changes and outreach follow-up programs. The results have important applications across the developing world.

Reduced length of stay in hospital for burn patients following a change in practice guidelines: financial implications.

The objective of this study was to analyze the financial implications of the implementation of new institutional practice guidelines including greater outpatient care and earlier operative intervention in a provincial burn center. A retrospective review was performed including all patients admitted to the Burn Unit with burns up to 20% TBSA between August 2005 and July 2009, including 2 years before and after the new guidelines were introduced. Daily costs for the burn unit were used to calculate this portion of cost. Length of stay (LOS) was based on actual data and representative clinical scenarios. Two hundred sixty-four patients were included. Mean LOS decreased from 10.3 to 3.9 (P < .01) and 21.0 to 13.3 (P > .05) for nonoperative burns 0 to 10% and 10 to 20% TBSA, respectively. Mean LOS for operative burns decreased from 16.6 to 12.9 and 32.3 to 29.8 days for 0 to 10% and 10 to 20% TBSA, respectively (P > .05). Burn patient management requires significant financial resources, and LOS has a large impact on cost. Given per diem rates of Can$1,663, scenario analysis shows potential cost savings of Can$19,956 per patient for operative and nonoperative burns <20% TBSA. With an average of 66 such patients treated each year, potential annual cost savings are Can$1.3 million. If outcomes are not compromised, earlier operative management and greater outpatient care can translate into significant cost savings. A prospective analysis capturing all costs and patient quality of life is required for further assessment.

The use of AlloDerm in postmastectomy alloplastic breast reconstruction: part II. A cost analysis.

BACKGROUND: Increasingly, AlloDerm is being used in alloplastic breast reconstruction, and has been the subject of a recent systematic review. The authors' objective was to perform a cost analysis comparing direct-to-implant with AlloDerm reconstruction to two-stage non-AlloDerm reconstruction. METHODS: Seven clinically important health outcomes and their probabilities for both types of reconstruction were derived from the recent review. A decision analytic model from the Canadian provincial payer's perspective was constructed based on these health states. Direct medical costs were estimated from a university-based hospital, yielding expected costs for direct-to-implant reconstruction with AlloDerm and two-stage non-AlloDerm reconstruction. Sensitivity analyses were conducted. RESULTS: Baseline and expected costs were calculated for direct-to-implant AlloDerm and two-stage non-AlloDerm reconstruction. Direct-to-implant reconstruction with AlloDerm was found to be less expensive in the baseline ($10,240 versus $10,584) and expected cost ($10,734 versus $11,251) using a 6 × 16-cm AlloDerm sheet. With a 6 × 12-cm sheet, expected cost falls to $9673. By increasing direct-to-implant operative time from 2 hours to 2.5 hours, expected cost rises to $11,784. If capsular contracture rate requiring revision is set at 15 percent for both procedures, expected costs are $10,926 and $11,251 for direct-to-implant and two-stage procedures, respectively. If the capsular contracture rate is lowered for either procedure, this has minimal impact on expected cost. CONCLUSIONS: Although AlloDerm is expensive, it appears to be cost-effective if used for direct-to-implant breast reconstruction. The methods used here may be extrapolated to different centers incorporating local costs and complication rates. A formal randomized controlled trial, including costs, is recommended.