Cost and clinical outcomes of postoperative intensive care unit versus general floor management in head and neck free flap reconstructive surgery patients.

PURPOSE: To compare clinical, surgical, and cost outcomes in patients undergoing head and neck free-flap reconstructive surgery in the setting of postoperative intensive care unit (ICU) against general floor management. METHODS: Retrospective analysis of head and neck free-flap reconstructive surgery patients at a single tertiary academic medical center. Clinical data was obtained from medical records. Cost data was obtained via the Mayo Clinic Rochester Cost Data Warehouse, which assigns Medicare reimbursement rates to all professional billed services. RESULTS: A total of 502 patients were included, with 82 managed postoperatively in the ICU and 420 on the general floor. Major postoperative outcomes did not differ significantly between groups (Odds Ratio[OR] 1.54; p = 0.41). After covariate adjustments, patients managed in the ICU had a 3.29 day increased average length of hospital stay (Standard Error 0.71; p < 0.0001) and increased need for take-back surgery (OR 2.35; p = 0.02) when compared to the general floor. No significant differences were noted between groups in terms of early free-flap complications (OR 1.38;p = 0.35) or late free-flap complications (Hazard Ratio 0.81; p = 0.61). Short-term cost was $8772 higher in the ICU (range = $5640-$11,903; p < 0.01). Long-term cost did not differ significantly. CONCLUSION: Postoperative management of head and neck oncologic free-flap patients in the ICU does not significantly improve major postoperative outcomes or free-flap complications when compared to general floor care, but does increase short-term costs. General floor management may be appropriate when cardiopulmonary compromise is not present.

Exploring differences between private and public prices in the English care homes market.

This work quantitatively assesses the potential reasons behind the difference in prices paid by care home residents in England. Evidence suggests that the price paid by private payers is higher than that paid for publicly supported residents, and this is often attributed to the market power wielded by local authorities as the dominant purchaser in local markets. Estimations of private prices at the local authority level are used to assess the difference in price paid between private and public prices, the fees gap, using data from 2008 to 2010. Controlling for local area and average care home characteristics, the results indicate that both care home and local authority market power play a role in the price determination of the market.

Room Costs for Common Pediatric Hospitalizations and Cost-Reducing Quality Initiatives.

BACKGROUND: Improvement initiatives promote safe and efficient care for hospitalized children. However, these may be associated with limited cost savings. In this article, we sought to understand the potential financial benefit yielded by improvement initiatives by describing the inpatient allocation of costs for common pediatric diagnoses. METHODS: This study is a retrospective cross-sectional analysis of pediatric patients aged 0 to 21 years from 48 children's hospitals included in the Pediatric Health Information System database from January 1, 2017, to December 31, 2017. We included hospitalizations for 8 common inpatient pediatric diagnoses (seizure, bronchiolitis, asthma, pneumonia, acute gastroenteritis, upper respiratory tract infection, other gastrointestinal diagnoses, and skin and soft tissue infection) and categorized the distribution of hospitalization costs (room, clinical, laboratory, imaging, pharmacy, supplies, and other). We summarized our findings with mean percentages and percent of total costs and used mixed-effects models to account for disease severity and to describe hospital-level variation. RESULTS: For 195 436 hospitalizations, room costs accounted for 52.5% to 70.3% of total hospitalization costs. We observed wide hospital-level variation in nonroom costs for the same diagnoses (25%-81% for seizure, 12%-51% for bronchiolitis, 19%-63% for asthma, 19%-62% for pneumonia, 21%-78% for acute gastroenteritis, 21%-63% for upper respiratory tract infection, 28%-69% for other gastrointestinal diagnoses, and 21%-71% for skin and soft tissue infection). However, to achieve a cost reduction equal to 10% of room costs, large, often unattainable reductions (>100%) in nonroom cost categories are needed. CONCLUSIONS: Inconsistencies in nonroom costs for similar diagnoses suggest hospital-level treatment variation and improvement opportunities. However, individual improvement initiatives may not result in significant cost savings without specifically addressing room costs.

Probabilistic Return-on-Investment Analysis of Single-Family Versus Open-Bay Rooms in Neonatal Intensive Care Units-Synthesis and Evaluation of Early Evidence on Nosocomial Infections, Length of Stay, and Direct Cost of Care.

BACKGROUND:: There is increasing evidence that the physical environment of neonatal intensive care units (NICUs), including single-family rooms (SFRs) versus open-bay rooms (OPBYs), has tangible effects on vulnerable patients. The objective of this study was to illustrate the financial implications of SFR versus OPBY units by synthesizing and evaluating the evidence regarding the benefits and costs of each unit from a hospital perspective. METHODS:: We assumed a hypothetical NICU with 40 beds in OPBY rooms, to be replaced with a new NICU with 32 SFRs and 8 OPBYs. We synthesized evidence regarding the comparative benefit of each option on 3 outcomes-nosocomial infections, length of stay, and direct costs. We calculated incremental benefit-cost ratio separately considering each outcome over an analysis period of 5 years. A ratio of more than 1 indicates that the investment is worthwhile. Input parameters were assigned probability distributions representing the degree of uncertainty around their true values. Monte Carlo simulation with 5000 iterations was used to quantify the distribution of benefits and costs. RESULTS:: The mean value of the incremental benefit-cost ratio was 0.730 (95% credible interval: 0.724-0.735) when nosocomial infections were considered, 1.298 (1.282-1.315) when reduced length of stay was considered, and 1.794 (1.783-1.804) when direct costs of care were compared. The probability of a benefit-cost ratio of lower than 1 was about 91%, 31%, and 2% in each case, respectively. CONCLUSION:: Cost savings associated with SFR units would justify additional construction and operation costs compared to OPBY units only when evidence on inclusive outcomes such as length of stay or direct costs of care is considered. A specific outcome such as infection rate potentially fails to capture all benefits of SFRs. As more evidence becomes available on full benefits and hazards of SFRs versus OPBYs, future studies should investigate the broader return-on-investment outcomes.

Models of care for non-invasive ventilation in the Acute COPD Comparison of three Tertiary hospitals (ACT3) study.

BACKGROUND AND OBJECTIVE: Non-invasive ventilation (NIV) improves clinical outcomes in hypercapnic acute exacerbations of COPD (AECOPD), but the optimal model of care remains unknown. METHODS: We conducted a prospective observational non-inferiority study comparing three models of NIV care: general ward (Ward) (1:4 nurse to patient ratio, thrice weekly consultant ward round), a high dependency unit (HDU) (1:2 ratio, twice daily ward round) and an intensive care unit (ICU) (1:1 ratio, twice daily ward round) model in three similar teaching tertiary hospitals. Changes in arterial blood gases (ABG) and clinical outcomes were compared and corrected for differences in AECOPD severity (Blood urea > 9 mmol/L, Altered mental status (Glasgow coma scale (GCS) < 14), Pulse > 109 bpm, age > 65 (BAP-65)) and co-morbidities. An economic analysis was also undertaken. RESULTS: There was no significant difference in age (70 ± 10 years), forced expiratory volume in 1 s (FEV1 ) (0.84 ± 0.35 L), initial pH (7.29 ± 0.08), partial pressure of CO2 in arterial blood (PaCO2 ) (72 ± 22 mm Hg) or BAP-65 scores (2.9 ± 1.01) across the three models. The Ward achieved an increase in pH (0.12 ± 0.07) and a decrease in PaCO2 (12 ± 18 mm Hg) that was equivalent to HDU and ICU. However, the Ward treated more patients (38 vs 28 vs 15, P < 0.001), for a longer duration in the first 24 h (12.3 ± 4.8 vs 7.9 ± 4.1 vs 8.4 ± 5.3 h, P < 0.05) and was more cost-effective per treatment day ($AUD 1231 ± 382 vs 1745 ± 2673 vs 2386 ± 1120, P < 0.05) than HDU and ICU. ICU had a longer hospital stay (9 ± 11 vs 7 ± 7 vs 13 ± 28 days, P < 0.002) compared with the Ward and HDU. There was no significant difference in intubation rate or survival. CONCLUSION: In acute hypercapnic Chronic obstructive pulmonary disease (COPD) patients, the Ward model of NIV care achieved equivalent clinical outcomes, whilst being more cost-effective than HDU or ICU models.

A single unit transfusion policy reduces red cell transfusions in general medical in-patients.

BACKGROUND: The NICE guidelines for blood transfusion and the patient blood management recommendations state that a single unit of red cells should be the standard dose for patients with stable anaemia who are not bleeding. Studies have shown that changing clinical transfusion practice can be difficult and that many clinicians' order two units of blood as standard for patients needing a transfusion. AIM: A collaborative project between NHS Blood and Transplant and Kings College Hospital started in September 2014 to evaluate the impact of a single unit policy on blood usage. DESIGN METHODS: Training and education was undertaken for clinical staff on eight general medical wards and all staff working in the blood transfusion laboratory. We collected transfusion data for 12 months, (6 months before and after implementation). RESULTS: There was a decrease of 50% red cell unit usage between the two periods, equating to a unit cost saving of £28 670. The number of single unit transfusions, increased from 30 to 53% whilst the number of two units decreased from 65 to 43% (P < 0.001). DISCUSSION/CONCLUSION: This project has shown that transfusion practice can be changed and savings in blood usage can be achieved through the successful implementation of the single unit transfusions policy. Key to the implementation was engagement from key medical staff within the medical department in which the policy was implemented and support from the hospital transfusion team. Continued attention and training shall be needed to support these, and implement other, patient blood management recommendations.

Costs and expected gain in lifetime health from intensive care versus general ward care of 30,712 individual patients: a distribution-weighted cost-effectiveness analysis.

BACKGROUND: Clinicians, hospital managers, policy makers, and researchers are concerned about high costs, increased demand, and variation in priorities in the intensive care unit (ICU). The objectives of this modelling study are to describe the extra costs and expected health gains associated with admission to the ICU versus the general ward for 30,712 patients and the variation in cost-effectiveness estimates among subgroups and individuals, and to perform a distribution-weighted economic evaluation incorporating extra weighting to patients with high severity of disease. METHODS: We used a decision-analytic model that estimates the incremental cost per quality-adjusted life year (QALY) gained (ICER) from ICU admission compared with general ward care using Norwegian registry data from 2008 to 2010. We assigned increasing weights to health gains for those with higher severity of disease, defined as less expected lifetime health if not admitted. The study has inherent uncertainty of findings because a randomized clinical trial comparing patients admitted or rejected to the ICU has never been performed. Uncertainty is explored in probabilistic sensitivity analysis. RESULTS: The mean cost-effectiveness of ICU admission versus ward care was €11,600/QALY, with 1.6 QALYs gained and an incremental cost of €18,700 per patient. The probability (p) of cost-effectiveness was 95% at a threshold of €22,000/QALY. The mean ICER for medical admissions was €10,700/QALY (p = 97%), €12,300/QALY (p = 93%) for admissions after acute surgery, and €14,700/QALY (p = 84%) after planned surgery. For individualized ICERs, there was a 50% probability that ICU admission was cost-effective for 85% of the patients at a threshold of €64,000/QALY, leaving 15% of the admissions not cost-effective. In the distributional evaluation, 8% of all patients had distribution-weighted ICERs (higher weights to gains for more severe conditions) above €64,000/QALY. High-severity admissions gained the most, and were more cost-effective. CONCLUSIONS: On average, ICU admission versus general ward care was cost-effective at a threshold of €22,000/QALY (p = 95%). According to the individualized cost-effectiveness information, one in six ICU admissions was not cost-effective at a threshold of €64,000/QALY. Almost half of these admissions that were not cost-effective can be regarded as acceptable when weighted by severity of disease in terms of expected lifetime health. Overall, existing ICU services represent reasonable resource use, but considerable uncertainty becomes evident when disaggregating into individualized results.

Variation in Emergency Department vs Internal Medicine Excess Charges in the United States.

Importance: Uninsured and insured but out-of-network emergency department (ED) patients are often billed hospital chargemaster prices, which exceed amounts typically paid by insurers. Objective: To examine the variation in excess charges for services provided by emergency medicine and internal medicine physicians. Design, Setting, and Participants: Retrospective analysis was conducted of professional fee payment claims made by the Centers for Medicare & Medicaid Services for all services provided to Medicare Part B fee-for-service beneficiaries in calendar year 2013. Data analysis was conducted from January 1 to July 31, 2016. Main Outcomes and Measures: Markup ratios for ED and internal medicine professional services, defined as the charges submitted by the hospital divided by the Medicare allowable amount. Results: Our analysis included 12 337 emergency medicine physicians from 2707 hospitals and 57 607 internal medicine physicians from 3669 hospitals in all 50 states. Services provided by emergency medicine physicians had an overall markup ratio of 4.4 (340% excess charges), which was greater than the markup ratio of 2.1 (110% excess charges) for all services performed by internal medicine physicians. Markup ratios for all ED services ranged by hospital from 1.0 to 12.6 (median, 4.2; interquartile range [IQR], 3.3-5.8); markup ratios for all internal medicine services ranged by hospital from 1.0 to 14.1 (median, 2.0; IQR, 1.7-2.5). The median markup ratio by hospital for ED evaluation and management procedure codes varied between 4.0 and 5.0. Among the most common ED services, laceration repair had the highest median markup ratio (7.0); emergency medicine physician review of a head computed tomographic scan had the greatest interhospital variation (range, 1.6-27.7). Across hospitals, markups in the ED were often substantially higher than those in the internal medicine department for the same services. Higher ED markup ratios were associated with hospital for-profit ownership (median, 5.7; IQR, 4.0-7.1), a greater percentage of uninsured patients seen (median, 5.0; IQR, 3.5-6.7 for ≥20% uninsured), and location (median, 5.3; IQR, 3.8-6.8 for the southeastern United States). Conclusions and Relevance: Across hospitals, there is wide variation in excess charges on ED services, which are often priced higher than internal medicine services. Our results inform policy efforts to protect uninsured and out-of-network patients from highly variable pricing.

Examining Invasive Bedside Procedure Performance at an Academic Medical Center.

OBJECTIVES: Explore the performance patterns of invasive bedside procedures at an academic medical center, evaluate whether patient characteristics predict referral, and examine procedure outcomes. METHODS: This was a prospective, observational, and retrospective chart review of adults admitted to a general medicine service who had a paracentesis, thoracentesis, or lumbar puncture between February 22, 2013 and February 21, 2014. RESULTS: Of a total of 399 procedures, 335 (84%) were referred to a service other than the primary team for completion. Patient characteristics did not predict referral status. Complication rates were low overall and did not differ, either by referral status or location of procedure. Model-based results showed a 41% increase in the average length of time until procedure completion for those referred to the hospital procedure service or radiology (7.9 vs 5.8 hours; P < 0.05) or done in radiology instead of at the bedside (9.0 vs 5.8 hours; P < 0.001). The average procedure cost increased 38% ($1489.70 vs $1023.30; P < 0.001) for referred procedures and 56% ($1625.77 vs $1150.98; P < 0.001) for radiology-performed procedures. CONCLUSIONS: Although referral often is the easier option, our study shows its shortcomings, specifically pertaining to cost and time until completion. Procedure performance remains an important skill for residents and hospitalists to learn and use as a part of patient care.

Study protocol for the Flooring for Injury Prevention (FLIP) Study: a randomised controlled trial in long-term care.

BACKGROUND: A promising strategy for reducing the incidence and severity of fall-related injuries in long-term care (LTC) is to decrease the ground surface stiffness, and the subsequent forces applied to the body parts at impact, through installation of compliant flooring that does not substantially affect balance or mobility. Definitive evidence of the effects of compliant flooring on fall-related injuries in LTC is lacking. The Flooring for Injury Prevention (FLIP) Study is designed to address this gap. METHODS: The FLIP Study is a 4-year, parallel-group, 2-arm, randomised controlled superiority trial of flooring in 150 resident rooms at a LTC site. The primary objective is to determine whether compliant flooring reduces serious fall-related injuries relative to control flooring. Intervention (2.54 cm SmartCells compliant; 74 rooms) and control (2.54 cm plywood; 76 rooms) floorings were installed over the top of existing concrete floors and covered with identical 2.00 mm vinyl. The primary outcome is serious fall-related injury, defined as any impact-related injury due to a fall in a study room that results in Emergency Department visit or hospital admission. Secondary outcomes include minor fall-related injury, any fall-related injury, falls, number of fallers, fractures, and healthcare utilisation and costs for serious fall-related injuries. Randomisation of study rooms, and residents in rooms, was stratified by residential unit, and flooring assignments were concealed. Outcome ascertainment began September 2013. DISCUSSION: Results from the FLIP Study will provide evidence about the effects of compliant flooring on fall-related injuries in LTC and will guide development of safer environments for vulnerable older adults. TRIAL REGISTRATION NUMBER: NCT01618786.

Hospital cost of pediatric patients with complicated acute sinusitis.

OBJECTIVE: Review costs for pediatric patients with complicated acute sinusitis. METHODS: A retrospective case series of patients in a pediatric hospital was created to determine hospital costs using a standardized activity-based accounting system for inpatient treatment between November 2010 and December 2014. Children less than 18 years of age who were admitted for complicated acute sinusitis were included in the study. Demographics, length of stay, type of complication and cost of care were determined for these patients. RESULTS: The study included 64 patients with a mean age of 10 years. Orbital cellulitis (orbital/preseptal/postseptal cellulitis) accounted for 32.8% of patients, intracranial complications (epidural/subdural abscess, cavernous sinus thrombosis) for 29.7%, orbital abscesses (subperiosteal/intraorbital abscesses) for 25.0%, potts puffy tumor for 7.8%, and other (including facial abscess and dacryocystitis) for 4.7%. The average length of stay was 5.7 days. The mean cost per patient was $20,748. Inpatient floor costs (31%) and operating room costs (18%) were the two greatest expenditures. The major drivers in variation of cost between types of complications included pediatric intensive care unit stays and pharmacy costs. CONCLUSION: Although complicated acute sinusitis in the pediatric population is rare, this study demonstrates a significant financial impact on the health care system. Identifying ways to reduce unnecessary costs for these visits would improve the value of care for these patients.

Do cost savings from reductions in nosocomial infections justify additional costs of single-bed rooms in intensive care units? A simulation case study.

PURPOSE: Evidence shows that single-patient rooms can play an important role in preventing cross-transmission and reducing nosocomial infections in intensive care units (ICUs). This case study investigated whether cost savings from reductions in nosocomial infections justify the additional construction and operation costs of single-bed rooms in ICUs. MATERIALS AND METHODS: We conducted deterministic and probabilistic return-on-investment analyses of converting the space occupied by open-bay rooms to single-bed rooms in an exemplary ICU. We used the findings of a study of an actual ICU in which the association between the locations of patients in single-bed vs open-bay rooms with infection risk was evaluated. RESULTS: Despite uncertainty in the estimates of costs, infection risks, and length of stay, the cost savings from the reduction of nosocomial infections in single-bed rooms in this case substantially outweighed additional construction and operation expenses. The mean value of internal rate of return over a 5-year analysis period was 56.18% (95% credible interval, 55.34%-57.02%). CONCLUSIONS: This case study shows that although single-patient rooms are more costly to build and operate, they can result in substantial savings compared with open-bay rooms by avoiding costs associated with nosocomial infections.

Evidence-Based and Value-Based Decision Making About Healthcare Design: An Economic Evaluation of the Safety and Quality Outcomes.

OBJECTIVE: This study describes a vision and framework that can facilitate the implementation of evidence-based design (EBD), scientific knowledge base into the process of the design, construction, and operation of healthcare facilities and clarify the related safety and quality outcomes for the stakeholders. The proposed framework pairs EBD with value-driven decision making and aims to improve communication among stakeholders by providing a common analytical language. BACKGROUND: Recent EBD research indicates that the design and operation of healthcare facilities contribute to an organization's operational success by improving safety, quality, and efficiency. However, because little information is available about the financial returns of evidence-based investments, such investments are readily eliminated during the capital-investment decision-making process. METHOD: To model the proposed framework, we used engineering economy tools to evaluate the return on investments in six successful cases, identified by a literature review, in which facility design and operation interventions resulted in reductions in hospital-acquired infections, patient falls, staff injuries, and patient anxiety. RESULTS: In the evidence-based cases, calculated net present values, internal rates of return, and payback periods indicated that the long-term benefits of interventions substantially outweighed the intervention costs. This article explained a framework to develop a research-based and value-based communication language on specific interventions along the planning, design and construction, operation, and evaluation stages. CONCLUSIONS: Evidence-based and value-based design frameworks can be applied to communicate the life-cycle costs and savings of EBD interventions to stakeholders, thereby contributing to more informed decision makings and the optimization of healthcare infrastructures.

Cost-effectiveness of hip protector use on a geriatric ward in Germany: a Markov model.

UNLABELLED: In this study, we determined the cost-effectiveness of hip protector use compared with no hip protector on a geriatric ward in Germany. From both the societal and the statutory health insurance (SHI) perspectives, the cost-effectiveness ratios for the provision of hip protectors were below 12,000/quality-adjusted life year (QALY) even if unrelated costs in added life years were included. INTRODUCTION: The aim of this study is to determine the cost-effectiveness of the provision of hip protectors compared with no hip protectors on a geriatric ward in Germany. METHODS: A lifetime decision-analytic Markov model was developed. Costs were measured from the societal and from the statutory health insurance (SHI) perspectives and comprised direct medical, non-medical and unrelated costs in additional life years gained. Health outcomes were measured in terms of quality-adjusted life years (QALYs). To reflect several levels of uncertainty, first- and second-order Monte Carlo simulation (MCS) approaches were applied. RESULTS: Hip protector use compared with no hip protector results in savings (costs, -5.1/QALYs, 0.003) for the societal perspective. For the SHI perspective, the incremental cost-effectiveness ratio was 4416 /QALY (costs, +13.4). If unrelated costs in life years gained were included, the cost-effectiveness ratio increases to 9794/QALY for the societal perspective and to 11,426/QALY for the SHI perspective. In the MCS, for the societal perspective without unrelated costs, 47 % of simulations indicated hip protectors to be cost saving (i.e. lower costs and higher effects). CONCLUSION: Although the gain in QALYs due to the provision of providing hip protectors to patients on geriatric wards is small, all scenarios showed acceptable cost-effectiveness ratios or even savings.

Dose rate in brachytherapy using after-loading machine: pulsed or high-dose rate?

Since February 2014, it is no longer possible to use low-dose rate 192 iridium wires due to the end of industrial production of IRF1 and IRF2 sources. The Brachytherapy Group of the French society of radiation oncology (GC-SFRO) has recommended switching from iridium wires to after-loading machines. Two types of after-loading machines are currently available, based on the dose rate used: pulsed-dose rate or high-dose rate. In this article, we propose a comparative analysis between pulsed-dose rate and high-dose rate brachytherapy, based on biological, technological, organizational and financial considerations.

Single-site laparoscopic colorectal surgery provides similar lengths of hospital stay and similar costs compared with standard laparoscopy: results of a retrospective cohort study.

BACKGROUND: The present study sought to compare the length of stay (LOS) and hospital costs for elective single-site (SSL) and standard laparoscopic (SDL) colorectal resections performed at a tertiary referral center. METHODS: An IRB-approved, retrospective cohort study of all elective SDL and SSL colorectal resections performed from 2008 to 2012 was undertaken. Patient charges and inflation adjusted hospital costs (US dollars) were compared with costs subcategorized by operating room expense, room and board, and pharmacy and radiology utilization. RESULTS: A total of 149 SDL and 111 SSL cases were identified. Compared with SSL, SDL surgeries were associated with longer median operative times (SSL: 153 min vs. SDL: 189 min, p = 0.001); however, median operating room costs were similar (p > 0.05). Median postoperative LOS was similar for both groups (SSL: 3 days; SDL: 4 days; p > 0.05). There was no difference between SSL and SDL with respect to either total patient charges (SSL: $34,847 vs. SDL: $38,306; p > 0.05) or hospital costs (SSL: $13,051 vs. SDL: $12,703; p > 0.05). Median costs during readmission were lower for SSL patients (SSL: $3,625 vs. SDL: $6,203, p = 0.04). CONCLUSIONS: SSL provides similar LOS as well as similar costs to both patients and hospitals compared with SDL, making it a cost-feasible alternative.

Is it financially efficient to lose the ring-fenced elective orthopaedic ward?

BACKGROUND: In an effort to rationalize National Health Service (NHS) funds in the United Kingdom, some hospitals have used the orthopaedic elective ring-fenced ward to admit general acute emergencies, admitting elective arthroplasty patients to general wards. OBJECTIVE: The aim of this study was to analyse the financial effect and length of stay of elective arthroplasty patients admitted to general wards rather than 'ring-fenced' orthopaedic wards. STUDY DESIGN: Retrospective observational study SETTING: Hospital care PATIENTS: During the period between 01 November 2010 and 31 March 2011, 194 consecutive patients were admitted for elective total hip and total knee arthroplasties. Due to increased bed pressures, 35 (18.04 %) of the patients were admitted to general wards instead of our standard elective ring-fenced orthopaedic ward. Data was collected and analysed for type of surgery, age, sex, length of stay, and ward. RESULTS: The average length of stay in the general wards was 1.89 days longer (range 3-22 days; p < 0.001) than in the elective orthopaedic ward. CONCLUSIONS: We conclude that losing the ring-fenced ward and admitting elective arthroplasty patients to general wards results in longer length of stay and a financial loss of 6.82 % per hip and knee arthroplasty patient.

Cost-effectiveness analysis of stroke management under a universal health insurance system.

OBJECTIVE: Cost-effectiveness analysis (CEA) of stroke management was evaluated in three care models: Neurology/Rehabilitation wards (NW), Neurosurgery wards (NS), and General/miscellaneous wards (GW) under a universal health insurance system. METHODS: From 1997 to 2002, subjects with first-ever acute stroke were sampled from claims data of a nationally representative cohort in Taiwan, categorized as hemorrhage stroke (HS) including subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH); or, ischemic stroke (IS), including cerebral infarction (CI), transient ischemic attack/ unspecified stroke (TIA/unspecified); with mild-moderate and severe severity. All-cause readmissions or mortality (AE) and direct medical cost during first-year (FYMC) after stroke were explored. CEA was performed by incremental cost-effectiveness ratios. RESULTS: 2368 first-ever stroke subjects including SAH 3.3%, ICH 17.9%, CI 49.8%, and TIA/unspecified 29.0% were identified with AE 59.0%, 63.0%, 48.6%, 46.8%, respectively. There were 50.8%, 13.5%, 35.6% of stroke patients served by NW, NS and GW with AE 44.9%, 60.6%, 56.0%, and medical costs of US$ 5,031, US$ 8,235, US$ 4,350, respectively. NW was cost-effective for both mild-moderate and severe IS. NS was the dominant care model in mild-moderate HS, while NW appeared to be a cost-minimization model for severe HS. CONCLUSIONS: TIA/unspecified stroke carried substantial risk of AE. NS performed better in serving mild-moderate HS, whereas NW was the optimal care model in management of IS.