Teleophthalmology at a primary and tertiary eye care network from India: environmental and economic impact.

OBJECTIVE: To evaluate the environmental and economic impact of teleophthalmological services provided by a primary (rural) and tertiary (urban) eyecare network in India. METHODS: This prospective study utilised a random sampling method, and administered an environmental and economic impact assessment questionnaire. The study included 324 (primary: 173; tertiary: 151) patients who received teleconsultations from July to September 2022. The primary network (rural) used a colour-coded triage system (Green: eye conditions managed by teleconsult alone; yellow: semi-urgent referral within 1 week to a month, red: urgent referral within a day to a week). The tertiary network (urban) included new and follow-up patients. The environmental impact was assessed by estimating the potential CO2 emissions saved by avoiding travel for various transport modes. Economic impact measured by the potential cost savings from direct (travel) and indirect (food and wages lost) expenses spent by yellow and red referrals (primary) and the first-visit expenses of follow-up (tertiary) patients. RESULTS: The primary rural network saved 2.89 kg CO2/person and 80 km/person. The tertiary urban network saved 176.6 kg CO2/person and 1666 km/person. The potential cost savings on travel expenses were INR 19,970 (USD 250) for the primary (average: INR 370 (USD 4.6) per patient) and INR 758,870 (USD 9486) for the tertiary network (average: INR 8339 (USD 104) per patient). Indirect cost savings (food and wages) were of INR 29,100 (USD 364) for the primary and INR 347,800 (USD 4347) for the tertiary network. CONCLUSION: Teleophthalmology offers substantial environmental and economic benefits in rural and urban eyecare systems.

Costos médicos directos de la atención médica de pacientes con cáncer de mama / Direct medical costs in a cohort of patients with breast cancer

Introducción: el costo económico del tratamiento de cáncer de mama (CM) y el aumento en su incidencia y prevalencia desafía la estabilidad financiera de cualquier sistema de salud. Objetivo: determinar los costos médicos directos (CMD) del tratamiento de CM y los factores asociados a estos costos. Material y métodos: evaluación económica parcial en una cohorte retrospectiva de 160 pacientes con diagnóstico conf irmado de CM. Se consideraron CMD desde la perspectiva del IMSS. Se utilizó análisis de bootstrapping para tratar incertidumbre y el modelo lineal generalizado para identificar factores asociados a costos. Resultados: el costo promedio anual (CPA) del tratamiento de CM fue de $ 251,018 pesos. En estadio 1, $ 116,123; estadio II, $ 242,132; estadio III, $ 287,946, y estadio IV, $ 358,792 pesos. El CPA fue mayor en progresión del CM ($ 380,117 frente a no progresión $ 172,897), y en pacientes que fallecieron durante el seguimiento ($ 357,579) frente a aquellas que sobrevivieron ($ 218,699). Conclusiones: el CPA del tratamiento de CM fue de $ 251,018 pesos. Los CMD aumentan significativamente conforme las pacientes presentan estadios más avanzados de la enfermedad. Los factores asociados al CMD fueron edad, estadios II, III y la progresión del CM.

Background: The economic cost of breast cancer (BC) treatment and the increase in incidence and prevalence challenges the financial stability of any healthcare system. Objective: To determine direct medical costs (DMC) of BC treatment and factors associated with DMC. Material and methods: Partial economic evaluation in a retrospective cohort of 160 patients with a confirmed diagnosis of BC. DMC was considered from the IMSS perspective. Bootstrapping analysis was used to deal with uncertainty and generalized linear model to identify factors associated with DCM Results: The total average annual cost of BC treatment was $251,018 mexican pesos. In clinical stage I was $116,123, stage II $242,132, stage III $287,946, and stage IV $358,792 pesos. In progression disease, DMC were more elevate ($380,117) vs. without progression ($172,897), (p < 0.0001). In patients who died, DMC were $357,579 mexican pesos compared to those who survived ($218,699) (p < 0.0001). Conclusions: The average annual cost of CM treatment was $251,018 pesos. DMCs increase significantly as patients present more advanced stages of the disease. Factors associated with costs were age, stages II, III and the progression of BC.

A shorter post-exposure prophylaxis regimen for rabies, Pakistan.

OBJECTIVE: To assess the cost and effectiveness of the two-site, 1-week, intradermal rabies post-exposure prophylaxis regimen recommended by the World Health Organization (WHO) in 2018. METHODS: We compared the number of rabies vaccine and rabies immunoglobulin ampoules consumed at The Indus Hospital in Karachi, Pakistan and their cost before and after implementing WHO's 2018 recommendations. In 2017, patients with suspected rabies-infected bites were treated using the two-site, 4-week, Thai Red Cross regimen, which involved administering four rabies vaccine doses intradermally over 4 weeks and infiltrating immunoglobulin into serious wounds, with the remainder injected into a distant muscle. In 2018, patients received three vaccine doses intradermally over 1 week, with a calculated amount of immunoglobulin infiltrated into wounds only. Remaining immunoglobulin was saved for other patients. The survival of patients bitten by apparently rabid dogs was used as a surrogate for effectiveness. FINDINGS: Despite treating 8.5% more patients in 2018 (5370 patients) than 2017 (4948 patients), 140 fewer ampoules of rabies vaccine and 436 fewer ampoules of rabies immunoglobulin were used, at a cost saving of 4202 United States dollars. Of 56 patients bitten by apparently rabid dogs, 50 were alive at 6-month follow-up. The remaining six patients could not be contacted but did not present to any hospital with rabies. CONCLUSION: The new regimen was more economical than the two-site, 4-week regimen and was equally effective. This regimen is recommended for preventing rabies in countries where the disease is endemic and rabies vaccine and immunoglobulin are in short supply.

[Establishment of Hematopoietic cell transplantation program in developing countries : Guidelines from the francophone Society of bone marrow transplantation and cellular therapy (SFGM-TC)]. / Mise en place d'un programme de greffe de cellules souches hématopoïétiques dans les pays en voie de développement. Recommandations de la Société francophone de greffe de moelle et de thérapie cellulaire (SFGM-TC).

Hematopoietic cell transplantation (HCT) is the curative treatment for many malignant and non-malignant blood disorders and some solid cancers. However, transplant procedures are considered tertiary level care requiring a high degree of technicality and expertise and generating very high costs for hospital structures in developing countries as well as for patients without health insurance. During the 11th annual harmonization workshops of the francophone Society of bone marrow transplantation and cellular therapy (SFGM-TC), a designated working group reviewed the literature in order to elaborate unified guidelines, for developing the transplant activity in emerging countries. Access to infrastructure must comply with international standards and therefore requires a hospital system already in place, capable of accommodating and supporting the HCT activity. In addition, the commitment of the state and the establishment for the financing of the project seems essential.

Simple Nephrectomy in a Tertiary Care Safety Net Hospital-Patient Characteristics, Causes, Cost, and Renal Function Implications.

OBJECTIVE: To evaluate factors associated with simple nephrectomy at a safety net hospital with a diverse patient population and large catchment area. Simple nephrectomy is an underreported surgery. Performance of simple nephrectomy may represent a failure of management of underlying causes. METHODS: We performed a retrospective review of simple nephrectomies performed at a major urban safety net hospital from 2014 to 2019. Detailed demographic, surgical, and renal functional outcomes were abstracted. We assessed the medical and social factors leading to performance of simple nephrectomy and report contemporaneous perception of preventability of the simple nephrectomy by the surgeon. RESULTS: Eighty-five patients underwent simple nephrectomy during the study period; 55% were non-white, 77% were women, and the median age at time of surgery was 46 years. The most common medical factors contributing to simple nephrectomy were stone disease in 55.3%, followed by retained ureteral stent (30.6%) and stricture (30.6%). The most common social factors were lack of insurance (58.5%), substance abuse issues (32.3%), mental health issues (24.6%), and immigration status (18.5%). In 38.8% of cases, the provider felt the surgery was preventable if medical factors leading to simple nephrectomy were properly addressed. CONCLUSIONS: Simple nephrectomy is a common surgery in the safety net hospital setting. Both medical and sociologic factors can lead to simple nephrectomy, and awareness of these factors can lead efforts to mitigate them. This review has led to the implementation of strategies to minimize occurrences of retained stents in our patients.

Cost-effectiveness analysis of epilepsy surgery in children and adolescents with drug resistant focal epilepsy at three years in a tertiary care epilepsy center in Thailand.

Epilepsy surgery is proven as a cost-effective treatment in developed countries, especially in adults with drug resistant epilepsy (DRE). This study is aimed to demonstrate the cost-effectiveness of epilepsy surgery in children and adolescents with DRE at three years compared with those who were eligible for surgery but received medical treatment. This study was conducted from January 2014 to December 2018. Clinical data were obtained from a retrospective chart review. Direct medical costs, including epilepsy surgery, inpatient and outpatient treatment were retrieved from the finance department. Direct non-medical costs were collected from the family interview. The effectiveness was determined by percent seizure reduction and quality of life assessed by EQ-5D scores. Decision tree analysis using TreeAge Pro® 2018 was deployed to determine the cost-effectiveness. Seventeen patients had epilepsy surgery and 19 were in the medical group. Seizure freedom was noted in 52% and 16% in the surgical and medical groups, respectively. Incremental cost-effectiveness ratio (ICER) was 743,040 THB (22,793 USD) per 1 QALY and 3302 THB (101 USD) per 1% seizure reduction. The study did not demonstrate cost-effectiveness of epilepsy surgery in the short term compared with Thailand's threshold (160,000 THB (4908 USD) per 1 QALY). Epilepsy surgery may be cost-effective if evaluated beyond three years.

A Tertiary Care-based Complex Care Program: Improving Care for Children With Medical Complexity.

OBJECTIVE: Children with medical complexity (CMC) have significant health care costs, but they also experience substantial unmet health care needs, hospitalizations, and medical errors. Their parents often report psychosocial stressors and poor care satisfaction. Complex care programs can improve the care for CMC. At our tertiary care institution, we developed a consultative complex care program to improve the quality and cost of care for CMC and to improve the experience of care for patients and families. METHODS: To address the needs of CMC at our institution, we developed the Compass Care Program, a consultative complex care program across inpatient and outpatient settings. Utilization data [hospital admissions per patient month; length of stay per admission; hospital days per patient month; emergency department (ED) visits per patient month; and institutional charges per patient month] and caregiver satisfaction data (obtained via paper survey at outpatient visits) were tracked over the period of participation in the program and compared preenrollment and postenrollment for program participants. RESULTS: Participants had significant decreases in hospital admissions per patient month, length of stay per admission, hospital days per patient month, and charges per patient month following enrollment (P<0.01) without a tandem increase in readmissions within 7 days of discharge. There was no statistically significant difference in ED visits. Caregiver satisfaction scores improved in all domains. CONCLUSION: Participation in a consultative complex care program can improve utilization patterns and cost of care for CMC, as well as experience of care for patients and families.

Cost implication of inpatient care of chronic kidney disease patients in a tertiary hospital in Southwest Nigeria.

The financial cost of inpatient care of chronic kidney disease (CKD) patients has not been well described in Nigeria; even though, the majority of these patients require inpatient care at the time of diagnosis due to late presentation. This study determined the cost implication of inpatient care among CKD patients in a Kidney Care Center in South-west Nigeria. This was an 18-month descriptive retrospective study. The financial records of the ward, laboratory, dialysis, pharmacy, and dietary services were obtained for each patient during their hospital stay and the sum of these costs was taken as the total direct cost of care. One hundred and twenty- three CKD patients with a male:female ratio of 2.3:1 and mean age of 50 ± 17 years were studied. One hundred and six (86.2%) patients had Stage 5 CKD, 105 (85.4%) had emergency hemodialysis (HD) at presentation and all patients paid out of pocket. The median number of HD sessions and days spent on admission was 4 and 14 days, respectively. The major contributors to the cost of care were total dialysis, ward, and pharmacy expenses with a median total cost of ₦70,000 (US $200), ₦28,000 ($80), and ₦22,230 ($66), respectively. The median total direct cost of inpatient care of CKD was ₦150,770 ($431). The cost of care was higher in those with Stage 5 CKD and diabetic nephropathy. The cost of inpatient care of CKD is beyond the reach of most Nigerians. There is a definite need for the government to include CKD care under the national insurance scheme.

Safety monitoring of treatment in bipolar disorder in a tertiary care setting in Sri Lanka and recommendations for improved monitoring in resource limited settings.

BACKGROUND: Safety monitoring of medicines is essential during therapy for bipolar disorder (BD). We determined the extent of safety monitoring performed according to the International Society for Bipolar Disorders (ISBD) guidelines in patients with BD attending the main tertiary care psychiatry clinics in Sri Lanka to give realistic recommendations for safety monitoring in resource limited settings. METHODS: Patients diagnosed with BD on mood stabilizer medications for more than 1 year were recruited. Data were collected retrospectively from clinic and patient held records and compared with the standards of care recommended by ISBD guidelines for safety monitoring of medicines. RESULTS: Out of 256 patients diagnosed with BD, 164 (64.1%) were on lithium. Only 75 (45.7%) had serum lithium measurements done in the past 6 months and 96 (58.5%) had concentrations recorded at least once in the past year. Blood urea or creatinine was measured in the last 6 months only in 30 (18.3%). Serum electrolytes and thyroid-stimulating hormone (TSH) concentrations were measured in the last year only in 34 (20.7%) and 30 (18.3%) respectively. Calcium concentrations were not recorded in any patient. None of the patients on sodium valproate (n = 119) or carbamazepine (n = 6) had blood levels recorded to establish therapeutic concentrations. Atypical antipsychotics were prescribed for 151 (59%), but only 13 (8.6%) had lipid profiles and only 31 (20.5%) had blood glucose concentration measured annually. Comorbidities experienced by patients influenced monitoring more than the medicines used. Patients with diabetes, hypothyroidism and hypercholesterolemia were more likely to get monitored for fasting blood glucose and (p < 0.001), TSH (p < 0.001) and lipid profiles (p < 0.001). Lithium therapy was associated with TSH monitoring (p < 0.05). Therapy with atypical antipsychotics was not associated with fasting blood glucose or lipid profile monitoring (p > 0.05). A limitation of the study is that although some tests were performed, the results may not have been recorded. CONCLUSIONS: Safety monitoring in BD was suboptimal compared to the ISBD guidelines. ISBD standards are difficult to achieve in resource limited settings due to a multitude of reasons. Realistic monitoring benchmarks and recommendations are proposed for methods to improve monitoring in resource limited settings based on our experience.

Defining and Optimizing Value in Total Joint Arthroplasty From the Patient, Payer, and Provider Perspectives.

BACKGROUND: The purpose of this study is to define value in bundled total joint arthroplasty (TJA) from the differing perspectives of the patient, payer/employer, and hospital/provider. METHODS: Demographic, psychosocial, clinical, financial, and patient-reported outcomes (PROs) data from 2017 to 2018 elective TJA cases at a multihospital academic health system were queried. Value was defined as improvement in PROs (preoperatively to 1 year postoperatively) for patients, improvement in PROs per $1000 of bundle cost for payers, and the normalized sum of improvement in PROs and hospital bundle margin for providers. Bivariate analysis was used to compare high value vs low value (>50th percentile vs <50th percentile). Multivariate analysis was performed to identify predictors. RESULTS: A total of 280 patients had PRO data, of which 71 had Medicare claims data. Diabetes (odds ratio [OR], 0.45; P = .02) predicted low value for patients; female gender (OR, 0.25), hypertension (OR, 0.17), pulmonary disease (OR, 0.12), and skilled nursing facility discharge (OR, 0.17) for payers (P ≤ .03 for all); and pulmonary disease (OR, 0.16) and skilled nursing facility discharge (OR, 0.19) for providers (P ≤ .04 for all). CONCLUSION: This is the first article to define value in TJA under a bundle payment model from multiple perspectives, providing a foundation for future studies analyzing value-based TJA.

The 22-Modifier in Reimbursement for Orthopedic Procedures: Hip Arthroplasty and Obesity Are Worth the Effort.

BACKGROUND: Orthopedic surgeons utilize the 22-modifier when billing for complex procedures under the American Medical Association's Current Procedural Terminology (CPT) for reasons such as excessive blood loss, anatomic abnormality, and morbid obesity, cases that would ideally be reimbursed at a higher rate to compensate for additional physician work and time. We investigated how the 22-modifier affects physician reimbursement in knee and hip arthroplasty. METHODS: We queried hospital billing data from 2009 to 2016, identifying all cases performed at our urban tertiary care orthopedic center for knee arthroplasty (CPT codes 27438, 27447, 27487, and 27488) and hip arthroplasty (CPT codes 27130, 27132, 27134, 27236). We extracted patient insurance status and reimbursement data to compare the average reimbursement between cases with and without the 22-modifier. RESULTS: We analyzed data from 2605 procedures performed by 10 providers. There were 136 cases with 22-modifiers. For knee arthroplasty (n = 1323), the 22-modifier did not significantly increase reimbursement after adjusting for insurer, provider, and fiscal year (4.2% dollars higher on average, P = .159). For hip arthroplasty (n = 1282), cases with a 22-modifier had significantly higher reimbursement than those without the 22-modifier (6.2% dollars more, P = .049). For hip arthroplasty cases with a 22-modifier, those noting morbid obesity were reimbursed 29% higher than those cases with other etiology. CONCLUSIONS: The effect of the 22-modifier on reimbursement amount is differential between knee and hip arthroplasty. Hip arthroplasty procedures coded as 22-modifier are reimbursed more than those without the 22-modifier. Providers should consider these potential returns when considering submitting a 22-modifier.

Direct costs for nonsurgical management of Chronic Pancreatitis in a tertiary care teaching hospital.

BACKGROUND: Chronic pancreatitis (CP) is a leading cause of hospitalization among gastrointestinal diseases resulting in considerable financial burden to patients. However the direct costs for nonsurgical management in CP remains unexplored. METHODS: A cross sectional study was carried out (2011-14) in the Department of Gastroenterology, Kasturba Hospital, Manipal, India. Demographic and clinical data on laboratory investigations, interventions and follow up were obtained from the medical records department. Item costs were derived from the hospital electronic billing section. Cost was expressed as median annual cost per patient. RESULTS: 65 (male 48; 73.8%) patients were included. Their median age was 31 (range 12-68) years. The annual median (IQR) total cost per patient was INR 88,892 (70,550.5-116,004); [USD 1410(1119-1841); € 1155(916-1507)], comprising of INR 61,089 (39,102.5-90,360.5) [USD 970 (621-1434); € 793(508-1174)] for outpatient management and INR 32,450 (11,016-46,958) [USD 515 (175-745); €421(143-610)] for hospitalization. 69.5% of the treatment cost was attributed to outpatient treatment. Drugs contributed to 54%, hospitalization incurred 30.5%, investigations 12% and professional fees (3.5%) of the total cost. Pancreatic enzyme replacement therapy (PERT) cost contributed to three-quarters of drug therapy. Use of rabeprazole as against pantoprazole reduced the overall annual cost of therapy by 4%. CONCLUSIONS: This study depicts the first nonsurgical management of accrued direct costs associated with CP due to expensive medications. Due to the high cost for PERT, its usefulness needs proper validation by cost benefit analysis.

Hospital-acquired lower respiratory tract infections among high risk hospitalized patients in a tertiary care teaching hospital in China: An economic burden analysis.

BACKGROUND: Data on the economic burden of hospital-acquired lower respiratory tract infection (LRTI) among high risk hospitalized patients are lacking in China. This study aims to fill this knowledge gap. METHODS: We used a prospective matched cohort design, comparing patients with LRTIs and 1:1 matched patients without LRTIs. Study period was from January 2013 to December 2015 analyzing inpatients from high risk wards - intensive care unit (ICU), dialysis, hematology, etc. - in a tertiary hospital. Hospital information system and hospital infection surveillance system were applied to extract necessary information. The primary outcome was incidence of hospital-acquired LRTIs, and the secondary was economic burden outcomes, including incremental medical costs and prolonged length of stay (LOS). Wilcoxon's signed rank test was used to explore the differences in the economic burden. RESULTS: Among 5990 hospital visitors over the period of time, 895 (14.94%) had hospital-acquired LRTIs. We analyzed 340 patients with LRTIs and 340 respective controls without infections. The median hospital costs for patients with ICU-acquired LRTIs were significantly higher than those without LRTIs in other wards ($12,301.17 vs. $4674.64, P<0.01). The average attributable cost per patient was $2853.93 ($6916.48 vs. $4062.55, P<0.01). Patients from hematology department had the longest LOS, at 15days (25days vs. 10 days, P<0.01). An LRTI led to an attributable increase in LOS by 8days on average (P<0.01). Western medicine, treatment and laboratory test were the dominant contributors to the growth in overall medical costs in hospital-acquired LRTIs. CONCLUSIONS: Hospital-acquired LRTI imposed considerable economic burden on patients hospitalized in high risk wards in China. This study provides the first data for economic evaluation of LRTI, highlighting the urgent need to establish targeted preventive strategies to minimize the occurrence of this complication to reduce economic burden.

Government health insurance and spatial peer effects: New evidence from India.

What is the role of spatial peers in diffusion of information about health care? We use the implementation of a health insurance program in Karnataka, India that provided free tertiary care to poor households to explore this issue. We use administrative data on location of patient, condition for which the patient was hospitalized and date of hospitalization (10,507 observations) from this program starting November 2009 to June 2011 for 19 months to analyze spatial and temporal clustering of tertiary care. We find that the use of healthcare today is associated with an increase in healthcare use in the same local area (group of villages) in future time periods and this association persists even after we control for (1) local area fixed effects to account for time invariant factors related to disease prevalence and (2) local area specific time fixed effects to control for differential trends in health and insurance related outreach activities. In particular, we find that 1 new hospitalization today results in 0.35 additional future hospitalizations for the same condition in the same local area. We also document that these effects are stronger in densely populated areas and become pronounced as the insurance program becomes more mature suggesting that word of mouth diffusion of information might be an explanation for our findings. We conclude by discussing implications of our results for healthcare policy in developing economies.

Big data modeling to predict platelet usage and minimize wastage in a tertiary care system.

Maintaining a robust blood product supply is an essential requirement to guarantee optimal patient care in modern health care systems. However, daily blood product use is difficult to anticipate. Platelet products are the most variable in daily usage, have short shelf lives, and are also the most expensive to produce, test, and store. Due to the combination of absolute need, uncertain daily demand, and short shelf life, platelet products are frequently wasted due to expiration. Our aim is to build and validate a statistical model to forecast future platelet demand and thereby reduce wastage. We have investigated platelet usage patterns at our institution, and specifically interrogated the relationship between platelet usage and aggregated hospital-wide patient data over a recent consecutive 29-mo period. Using a convex statistical formulation, we have found that platelet usage is highly dependent on weekday/weekend pattern, number of patients with various abnormal complete blood count measurements, and location-specific hospital census data. We incorporated these relationships in a mathematical model to guide collection and ordering strategy. This model minimizes waste due to expiration while avoiding shortages; the number of remaining platelet units at the end of any day stays above 10 in our model during the same period. Compared with historical expiration rates during the same period, our model reduces the expiration rate from 10.5 to 3.2%. Extrapolating our results to the ∼2 million units of platelets transfused annually within the United States, if implemented successfully, our model can potentially save ∼80 million dollars in health care costs.

Do Capitation-based Reimbursement Systems Underfund Tertiary Healthcare Providers? Evidence from New Zealand.

One of the main concerns about capitation-based reimbursement systems is that tertiary institutions may be underfunded due to insufficient reimbursements of more complicated cases. We test this hypothesis with a data set from New Zealand that, in 2003, introduced a capitation system where public healthcare provider funding is primarily based on the characteristics of the regional population. Investigating the funding for all cases from 2003 to 2011, we find evidence that tertiary providers are at a disadvantage compared with secondary providers. The reasons are that tertiary providers not only attract the most complicated, but also the highest number of cases. Our findings suggest that accurate risk adjustment is crucial to the success of a capitation-based reimbursement system. Copyright © 2017 John Wiley & Sons, Ltd.

Direct and indirect cost of myasthenia gravis: A prospective study from a tertiary care teaching hospital in India.

Myasthenia gravis (MG) requires lifelong treatment. The cost of management MG is very high in developed countries but there is no information on the cost of management of MG in the developing countries. This study reports the direct and indirect cost and predictors of cost of MG in a tertiary care teaching hospital in India. In a prospective hospital based study, from a tertiary hospital in India 66 consecutive patient during 2014-2015 were included. The age of the patients ranged between 6 and 75years. The severity of MG was assessed by myasthenia gravis foundation association (MGFA) class (MGFA) I-V. The patient data was collected s and their direct cost was calculated from the computerized Hospital information system. The indirect cost was calculated from patient's memory, checking the bills of transportation and wages loss by the patient or the care giver. Total annual cost of MG ranged between INR (4560-532227) with median INR 61390.5 (US$911.64). The median cost of outpatient department (OPD) consultation of 16 patients was INR 20439.9 (US$303.53), of 50 admitted patients was INR 44311.8 (US$658.03) and 21 intensive care unit (ICU) patients was INR 59574.3 (US$ 884.6) and the direct cost of thymectomy was INR 45000 (US$ 668.25). Direct cost was related to indirect cost (r=0.55; p=0.0001). Predictors of patient outcome were severity of MG, ICU admission, and thymectomy. The total median cost for management of myasthenia gravis was INR 61390.5 (4560-532227, US$911.64) per year, and the cost was mainly determined by the severity of MG.

Identification and Cost of Potentially Avoidable Transfers to a Tertiary Care Neurosurgery Service: A Pilot Study.

BACKGROUND: Thousands of neurosurgical emergencies are transferred yearly to tertiary care facilities to assume a higher level of care. Several studies have examined how neurosurgical transfers influence patient outcomes, but characteristics of potentially avoidable transfers have yet to be investigated. OBJECTIVE: To identify whether potentially avoidable transfers represent a significant portion of transfers to a tertiary neurosurgical facility. METHODS: In this cohort study, we evaluated 916 neurosurgical patients transferred to a tertiary care facility over a 2-year period. Transfers were classified as potentially avoidable when no neurosurgical diagnostic test, intervention, or intensive monitoring was deemed necessary (n = 180). The remaining transfers were classified as justifiable (n = 736). The main outcomes and measures were age, sex, diagnosis, insurance status, intervention, distance of transfer, length of hospital and intensive care unit stay, mortality, discharge disposition, and cost. RESULTS: Nearly 20% of transfers were identified as being potentially avoidable. Although some of these patients had suffered devastating, irrecoverable neurological insults, many had innocuous conditions that did not require transfer to a higher level of care. Justifiable transfers tend to involve patients with nontraumatic intracranial hemorrhage and cranial neoplasm. Both groups were admitted to the intensive care unit at the same rate (approximately 70% of patients). Finally, the direct transportation cost of potentially avoidable transfers was $1.46 million over 2 years. CONCLUSION: This study identified the frequency and expense of potentially avoidable transfers. There is a need for closer examination of the clinical and financial implications of potentially avoidable transfers. ABBREVIATIONS: CI, confidence intervalIQR, interquartile rangeJT, justifiable transferOR, odds ratioPAT, potentially avoidable transferUAB, University of Alabama at Birmingham.