Graduate Medical Education Should Not Be A Commodity.

The demise of Hahnemann University Hospital demonstrates the need for health care and graduate medical education policy reform.

Factors Influencing Seeking and Reaching Care in Patients With Peritonitis in Rwanda.

BACKGROUND: Peritonitis is an emergency which frequently requires surgical intervention. The aim of this study was to describe factors influencing seeking and reaching care for patients with peritonitis presenting to a tertiary referral hospital in Rwanda. METHODS: This was a cross-sectional study of patients with peritonitis admitted to University Teaching Hospital of Kigali. Data were collected on demographics, prehospital course, and in-hospital management. Delays were classified according to the Three Delays Model as delays in seeking or reaching care. Chi square test and logistic regression were used to determine associations between delayed presentation and various factors. RESULTS: Over a 9-month period, 54 patients with peritonitis were admitted. Twenty (37%) patients attended only primary school and 15 (28%) never went to school. A large number (n = 26, 48%) of patients were unemployed and most (n = 45, 83%) used a community-based health insurance. For most patients (n = 44, 81%), the monthly income was less than 10,000 Rwandan francs (RWF) (11.90 U.S. Dollars [USD]). Most (n = 51, 94%) patients presented to the referral hospital with more than 24 h of symptoms. More than half (n = 31, 60%) of patients had more than 4 d of symptoms on presentation. Most (n = 37, 69%) patients consulted a traditional healer before presentation at the health care system. Consultation with a traditional healer was associated with delayed presentation at the referral hospital (P < 0.001). Most (n = 29, 53%) patients traveled more than 2 h to reach a health facility and this was associated with delayed presentation (P = 0.019). The cost of transportation ranged between 5000 and 1000 RWF (5.95-11.90 USD) for most patients and was not associated with delayed presentation (P = 0.449). CONCLUSIONS: In this study, most patients with peritonitis present in a delayed fashion to the referral hospital. Factors associated with seeking and reaching care included sociodemographic characteristics, health-seeking behaviors, cost of care, and travel time. These findings highlight factors associated with delays in seeking and reaching care for patients with peritonitis.

First-line trastuzumab plus taxane-based chemotherapy for metastatic breast cancer: cost-minimization analysis.

AIM: To carry out a cost-minimization analysis including a comparison of the costs arising from first-line treatment by trastuzumab plus docetaxel versus trastuzumab plus paclitaxel in patients with metastatic breast cancer. METHODS: All consecutive patients with human epidermal growth receptor 2-postive metastatic breast cancer who were treated at Besançon University Hospital and Saint Vincent private hospital between 2001 and 2010 by first-line therapy containing trastuzumab plus taxane were retrospectively studied. Economic analysis took into account costs related to drugs, hospitalization, and healthcare travel. RESULTS: Progression-free survival difference between the two treatments was not significant (p = 0.65). First-line treatment by trastuzumab plus taxane was estimated at approximately €68,000 (p = 0.74). The drug costs represented around 70-75% of the total cost, mainly related to the use of trastuzumab. CONCLUSION: Our economic analysis shows that although the costs of the two trastuzumab plus taxane regimens are similar, they may contribute to the on-going debate about the availability and use of innovative chemotherapy drugs, in particular in human epidermal growth factor receptor 2-positive metastatic breast cancer with new therapies such as trastuzumab-DM1 and pertuzumab.

[Dermatology day-care: between official rules and reality]. / Hôpital de jour de dermatologie : entre circulaire frontière et réalité

BACKGROUND: Official rules published in 2006 and 2010 concerning ambulatory care rates in France led to artificial redistribution of this activity from day-care hospitalization to consultations. In our dermatological day-care establishment, we compared the financial costs engendered for patients admitted for day-care hospitalization and those seen at consultations. PATIENTS AND METHODS: From 2011/01/10 to 2011/02/04, for each patient, we prospectively analyzed the following data: day-care hospitalization or consultation, age, sex, diagnosis, laboratory and radiological examination, non-dermatological consultations, time spent with the patient by doctors (interns, senior doctors) and nurses, with timing by a stop-watch. The hospital cost was the total for medical examinations (official nomenclature), non-dermatological consultations, physicians' and nurses' salaries and establishment overheads (216 €). The hospital revenue regarding the consultation group consisted of the sum of reimbursement for medical examination, dermatological and non-dermatological consultations, and regarding the day-care hospitalization group, the dermatology rate (670 €) or chemotherapy sessions (380 €). Results were compared using a Chi(2) test and a Student's t-test (P ≤ 0.05). RESULTS: One hundred and twenty-seven patients were included: 67 in the day-care hospitalization group and 60 in the consultation group. Patients in the day-care hospitalization group were older and had significantly more radiological examinations and non-dermatological consultations, but the number of laboratory examinations and skin biopsies did not differ between the two groups. The mean time spent by doctors was similar in both groups but the time spent by senior doctors without the help of interns was significantly greater and longer than the time for a standard consultation. Nurses spent a mean 72 minutes with each hospitalized patient and 35 minutes with consultation patients (P = 0.007). Hospital costs were identical in both groups at around 415 €. The hospital showed a profit for day-care hospitalization patients (252 €) and a loss (244 €) for consultation patients. DISCUSSION: Half of the patients studied were in day-care hospitalization and half were seen in consultations. The high number of bed-ridden patients with bullous pemphigoid accounts for the fact that day-care patients were older. The reasons for the significantly longer time spent by nurses with day-care hospitalized patients were administration and supervision of chemotherapy, skin care and nursing of bed-ridden patients. However, nurses spent 35 min with each consultation patient, justifying the need to maintain the posts of these staff in such day-care units. The availability of physicians for patients with severe dermatoses and the organization of medical examinations in the same place in the same day underscore the need for medical structures like day-care hospitalization. At present, time spent on intellectual work involving reflection is regrettably not taken into account, which is detrimental to this specialty. The hospital was in profit for day hospitalizations while consultations resulted in losses, in particular because of the absence of social security reimbursement of the establishment's overheads. CONCLUSION: Rules are in need of modification in order to allow the treatment of patients with more complicated conditions.

[Cost of anaesthesia at the university hospital]. / Ocena kosztów zwiazanych z dzialalnoscia anestezjologiczna w akademivkim szpitalu klinikcznym.

BACKGROUND: The costs of anaesthesia in Polish hospitals are usually calculated as a percentage of the cost of the surgical procedure, or as a percentage of the total cost of the operating theatre. These methods cannot be accurate, since they do not take into consideration, the specifics of anaesthesia. Therefore, a new method of calculation, based of the actual use of materials and manpower, has been introduced in our institution. METHODS: Anaesthesia procedures were divided into nine categories, according to risk of anaesthesia, type of surgery, type of anaesthesia, and working hours of the anaesthetic personnel. Each category was priced in points which expressed the actual value of the service provided, and the resulting totals were allocated to surgical specialties. RESULTS: The costs of anaesthesia calculated by the new method differed markedly from previous calculations. The number of anaesthetics between 2008 and 2010 increased by 20%, while the cumulative costs of anaesthesia rose by only 13%, when compared to the previous method of calculation. Changes in anaesthesia costs, in various surgical specialties, varied from -49% to +65%, and were not related to the number of procedures. CONCLUSION: The new scoring system made it possible to calculate actual anaesthesia costs in various surgical specialties. It is logical and practical and merits recommendation.

[Referrals to dermatology: proportion of banal disorders]. / Demanda derivada a Dermatología: peso de la patología banal.

BACKGROUND AND OBJECTIVE: Skin diseases account for a large number of consultations in primary care. The objective of this study was to determine the characteristics and cost of referrals from primary care to a dermatology clinic. MATERIAL AND METHODS: Descriptive cross-sectional study of referrals from a primary care health center to a dermatology clinic. The dermatology clinic was situated in the same health center and was attended by a dermatologist from Complejo Hospitalario Universitario in Albacete, Spain. The study was performed on 10 days selected at random between April 21, 2009, and June 26, 2009. The data gathered included age, sex, use of cryotherapy, and diagnostic group. Patients were divided into 4 diagnostic groups: A) benign degenerative disease or trivial disorders whose treatment may not merit involvement of the national health service, B) diseases resolved with a single dermatology consultation at the health center, C) diseases requiring evaluation in hospital-based dermatology outpatients, and D) diseases referred for surgical treatment. RESULTS: Data were gathered on 257 patients with a mean age was 41.18 years and there was a slight female predominance. The majority of patients were in diagnostic group B (53.7%), followed by groups A (19.1%), C (19.1%), and D (8.2%). The total estimated cost of these 257 visits was €29 750.32, of which €5672.24 was for trivial disorders. CONCLUSIONS: The current high prevalence of trivial disorders in the caseload of dermatology clinics by trivial disorders makes it necessary to control referrals from primary care more strictly.

[Cost analysis of contrast-enhanced cranial MRI at a German university hospital]. / Kostenanalyse einer kontrastgestützten MRT des Schädels an einem Universitätsklinikum.

PURPOSE: Detailed evaluation and cost analysis of a cranial contrast-enhanced MRI (c-ceMRI) in outpatients, inpatients, patients in an intensive care unit and children under anesthesia. MATERIALS AND METHODS: Based on a detailed process-oriented model, we calculated the cost of a cranial MRI for the four situations mentioned above. A comprehensive evaluation of the overhead and personnel costs was performed. RESULTS: We performed 5108 MRI examinations on 2 scanners in the year 2008. 2150 examinations (42 %) were identified as c-ceMRI. For inpatients we calculated a total cost of € 242.46 per examination with a personnel cost of € 81.71 for the radiological department. In outpatients we calculated total costs of € 181.97 with radiological personnel costs of € 68.67. Patients coming from an intensive care unit were treated by an intensive care team, which resulted in total costs of € 416.58 with € 283 in costs for radiological personnel (32.8 %). MRI examinations of children under anesthesia resulted in costs of € 616.79 for the hospital, of which € 285.78 were radiological personnel costs (34.5 %). CONCLUSION: In this study we evaluated for the first time different radiological scenarios of a c-ceMRI at a university hospital. Considering the present reimbursement situation, all outpatients covered by statutory health insurance resulted in a deficit for the hospital. Particularly high costs for patients in intensive care units as well as for children under anesthesia have to be taken into account and are currently not adequately covered by care providers.

[Ambulatory aftercare of forensic patients after release]. / Ambulante Sicherungsnachsorge.

OBJECTIVE: The efficacy of specific forensic outpatient treatment should be investigated. METHODS: In 2000 the Ministry of Social Affairs of the State of Bavaria, Germany, implemented a model for forensic outpatient treatment. Three forensic hospitals established forensic outpatient clinics. The Department of Forensic Psychiatry of the Psychiatric Hospital of the Ludwig Maximilian University of Munich evaluated the treatment and management programs with financial support from the Ministry. RESULTS: 111 mentally ill offenders were included after release from forensic hospitals. 65 % suffered from schizophrenia. In 4.5 years time of observation a recidivism rate of 0.9 % of severe offences could be found (3.6 % including cases of suspicion). 17 % of the patients needed a rehospitalisation and 12 % a legal intervention. At the end of the observation period 42 patients still needed treatment, but 44 patients continued therapy in the forensic outpatient setting out of own interests. CONCLUSIONS: In accordance to literature very low rates of criminal recidivism under specific forensic outpatient aftercare could be found, and in addition a relatively high compliance with the treatment.

[The German University Medicine Map]. / Landkarte Hochschulmedizin.

The University Medicine Map is a major step towards the realization of more transparency regarding the overall services of the medical schools in research, teaching, and patient care within the German university system. It includes comparative information about all 36 medical schools in Germany for the following areas: legal framework, finance, personnel, medical research, teaching and medical education, as well as patient care. The complete set of data for this map is accessible online under www.landkarte-hochschulmedizin.de and a selection of data is also available in print. Advantages and possible political implications for the higher education sector as well as the public domain are illustrated. Finally, the perspectives for future developments are indicated.

[Anesthesiological co-diagnosis "difficult intubation": effects on the reimbursement situation of a university hospital]. / Anästhesiologische Nebendiagnose "schwierige Intubation" : Auswirkung auf die Erlössituation eines Universitätsklinikums.

OBJECTIVE: Within the German diagnosis related groups (G-DRG) system, the accurate coding of the co-morbidity "failed or difficult intubation (T88.4)" may be relevant with respect to reimbursement. In this study, the impact of this typical anesthesia co-morbidity on revenues of an university hospital was investigated. METHODS: The computerized records of 21,204 anesthesia procedures from the year 2005 were scanned for failed or difficult intubations. The results were checked for accordance with the coding recommendation of the Medical Service of the Health Insurance Funds (MDK) with respect to the co-morbidity T88.4. For all valid cases, the DRG, the diagnosis code and the co-morbidity codes were retrieved from the hospital information system. Subsequently all cases were regrouped with the GetDRG grouper (Fa. GEOS), taking the co-morbidity T88.4 in account. RESULTS: Out of the 21,204 patients, 12,261 were intubated for general anesthesia. A failed or difficult intubation according to the definition of the expert group of social medicine was documented in 276 anesthesia cases (2.3%). In 31 cases the coding of the co-morbidity T88.4 led to an increase in revenue by grouping the case in a different DRG. Using the base rate of the year 2005 (EUR 3,379.66), the surplus in basic points of 17.093 resulted in an additional reimbursement of EUR 57,768.53. CONCLUSION: With this study it was shown that the consequent coding of the co-morbidity T88.4 during anesthesia can lead to increased reimbursement. A prerequisite is the accurate documentation and coding by the attending anesthetist.

Understanding the economic and social effects of academic clinical partnerships.

Partnerships between medical schools and their clinical associates, which we describe in this article as academic clinical partnerships (ACPs), are powerful economic and social actors through their roles as major employers and procurers of goods and services. A broad spectrum of effects extending beyond the tripartite mission shapes the social contract between ACPs and the communities they serve. The authors present a model for identifying and measuring effects across this spectrum and illustrate the model's application with reference to specific case studies set in the United Kingdom. This model categorizes effects into five different domains: economic, human capital, social capital, knowledge, and place. These different effects express themselves along a spatial scale that varies from the very local to the global. The authors describe the theoretical background for each domain, as well as the methods required to identify and measure effects. These methods range from a quantitative economic impact analysis using extended input-output models to qualitative methods to capture social capital and place effects. The authors demonstrate how leaders in academic medicine can use the model to build a holistic picture of the societal effects of ACPs. Evidence of impact is of value to ACP leaders in engaging with both national and local stakeholders, and the approach is likely transferable to different countries.

[Cost calculations for treating penetrating eye injuries within the DRG C01Z at a university eye hospital]. / Kostenkalkulation für die Behandlung von offenen Augenverletzungen in der DRG C01Z an einer Universitäts-Augenklinik.

BACKGROUND: Since 2004, inpatient health care for penetrating eye injuries in Germany had been paid according to the calculated DRG C01Z. Because the extent of treatment mainly derives from the extent of eye damage, this DRG economically summarises very heterogeneous cases. It was the aim to check the cost recovery for the surgical treatment of penetrating eye injuries at a university eye hospital. MATERIAL AND METHODS: Performance data for the DRG C01Z were collected for the years 2005 and 2006 using the E1 sheets according to section sign21 KHEntG. Costs for single operations were calculated from fixed and variable costs for the operating theatre and the ward, including costs for personnel and supplies. RESULTS: In the 2-year period, out of 4,721 inpatient procedures, 180 perforating eye injuries were surgically treated. In 80 cases, a pure corneal/scleral suture (plus cataract surgery, n=10; mean operating time 67.81 min) was performed. In the other 100 cases, a pars plana vitrectomy (ppV) with adjuvant measures (mean operating time 124.69 min) was needed. Each operation had fixed surgical costs of EUR 130.60; variable costs, including personnel and supplies, varied between EUR 570 for corneal/scleral suture (+/-EUR 250 for combined cataract surgery (n=10) and EUR 1230 (mean) for a ppV. Cost-effective additional adjuncts such as cerclage, perfluorocarbon, gas, silicone oil, or cataract surgery led to extra costs of between EUR 51 and EUR 250 per adjunct (mean EUR 182). At least two of these adjuncts were used in 50% of ppVs, and at least one was used in 90% of ppVs. Hospitalisation costs were about EUR 2184 (EUR 273 per day), with a mean stay of 8 days. The overall costs of an operation for penetrating eye injuries differed significantly in terms of the procedure (corneal/scleral suture: EUR 2662, mean length of stay 7.06 days; ppV: EUR 3712, mean length of stay 8.62 days). Additional costs for multiple surgeries, as occurred in 11.1% of all cases, were not compensated by the DRG system. CONCLUSION: In consideration of a relative DRG weight of 1,177 and a base rate of EUR 2723.79 in Bavaria for 2005 and 2006, perforating eye injuries were compensated within the C01Z DRG at EUR 3205,96. Thus, for ppVs no costs are recovered, whereas "pure suture" procedures are overweighted. Due to this inhomogeneity, a split in the C01Z DRG is necessary.

[Third level centers in Integrated Health Care: no room, no interest, no needs?]. / Maximalversorger und Integrierte Versorgung: Kein Raum, kein Interesse, kein Bedarf?

Third level health care providers are often highly integrated in the sense that they provide a broad variety of medical specialties. They mostly lack cooperative structures with physicians who are running private practices. By this "isolation", they realize disadvantages in the race for more patients. This is one reason why more university teaching hospitals are growingly interested in contracts for Integrated Health Care. Another field of growing needs for cooperative structures is rehabilitation to ensure achieved therapeutic success especially in highly specialized centers. The paper outlines these growing interests but also formulates preconditions for contracts which should be regarded if university hospitals are to become involved in Integrated Health Care.

Palliative care inpatient service in a comprehensive cancer center: clinical and financial outcomes.

PURPOSE: Inpatient palliative care units are unavailable in most cancer centers and tertiary hospitals. The purpose of this article is to review the outcomes of the first 344 admissions to the Palliative Care Inpatient Service (PCIS) at our comprehensive cancer center. PATIENTS AND METHODS: We retrospectively reviewed our computerized database for clinical and demographic information, length of stay, and hospital billing during the first year of the service's operation. RESULTS: Three hundred twenty patients were admitted during the study period. Their median age was 57 years. The main cancer diagnoses were thoracic or head and neck (44%), gastrointestinal (25%), and hematologic malignancy (8%). The main referral symptoms were pain (44%), nausea (41%), fatigue (39%), and dyspnea (38%). The median length of stay in the PCIS was 7 days (range, 1 to 58 days). Fifty-nine patients died while in the PCIS. However, the overall hospital mortality rate was not increased compared with that in the year before the establishment of the PCIS (3.58% v 3.59%). The mean reimbursement rate for all palliative care charges was approximately 57%, and the mean daily charges in the PCIS were 38% lower than the mean daily charges for the rest of the hospital. Symptom intensity data showed severe distress on admission and significant improvement in the main target symptoms. Most patients were discharged to a hospice. CONCLUSION: The PCIS has been accepted in our tertiary cancer center on the basis of its clinical utility and financial viability.

Analysis of direct hospital costs before and 18 months after treatment with vagus nerve stimulation therapy in 43 patients.

Vagus nerve stimulation (VNS) therapy is an established method for treating patients with refractory seizures. Although the initial cost of the device is about 10,000 US dollars, the battery life of the model 100 implanted in the patients in this analysis can exceed 5 years at standard settings. It is important to understand what type of cost-benefit can be expected after implantation. Our aim was to assess unplanned hospital costs 18 months before and 18 months after VNS implantation in 43 patients. The VNS therapy system was implanted according to standard procedures and stimulation of 0.75 to 2.0 mA was delivered either as 30 seconds on and 5 minutes off or 7 seconds on and 14 seconds off. Seizure frequency was calculated before and after 18 months of treatment. During this time no changes were made with other therapies for epilepsy. Hospitalization for emergency room (ER) visits, ward stays, and intensive care days were calculated according to the costs at Sahlgrenska University Hospital in Sweden. Therapy response was defined as 25% or greater reduction in seizure frequency. For all patients, intensive care unit (ICU) costs were reduced from 46,875 to 0 US dollars, ER visits from 13,000 to 9,000 US dollars, and ward stays from 151,125 to 21,375 US dollars. Total hospital costs for the 43 patients studied before VNS therapy were 211,000 US dollars and after 18 months of treatment were reduced to 30,375 US dollars, an average annual cost savings of approximately 3,000 US dollars per patient. The cost savings applied to all patients, irrespective of whether they responded to VNS therapy. VNS therapy resulted in annual reductions of approximately 3000 US dollars in unplanned hospital costs per study patient. Such direct savings sustained over the battery life of the VNS therapy system can equal or exceed the purchase price of the device.

Trauma service cost: the real story.

OBJECTIVE: The objective was to define and characterize the costs associated with trauma care at a level I trauma center. Once the costs were identified, attending physician-led teams were designed to reduce costs within each cost center. SUMMARY BACKGROUND DATA: The location and magnitude of the costs on a trauma service remain largely unknown. Focused cost-containment strategies remain difficult to implement because the expected return on these interventions is unknown. METHODS: Cost center data were reviewed for the 40 major DRGs admitted for the first 6 months of the fiscal years 1996 and 1997. Data were obtained from the hospital finance department using the Transition Systems Inc. accounting system. We focused on variable direct costs, those that vary with patient volume (e.g., staff nursing expense and medical/surgical supplies). To address issues of inflation, pay raises, and changing costs, a proxy value was created for 1996 and costs were held constant for the 1997 calculation. The major services that constitute cost centers identified in the system were nursing, surgical, pharmacy, laboratory, radiology, and emergency services. Attendings were assigned to develop and oversee customized cost-reduction modalities specific to each cost center. The cost-reduction modalities used to achieve significant savings were as follows: nursing, case management approach focusing on early discharge; surgical, meeting with operating room (OR) purchasing to modify expensive behavior patterns; pharmacy, integrating clinical pharmacist with direct attending support; laboratory, enforcing protocol for lab draws; radiology, increasing the use of emergency room ultrasound and accepting outside x-rays; and emergency services, 24-hour in-house attending staff to reduce emergency room time. The surgical and emergency services cost centers predominately generate costs by the length of time care is delivered in that area. RESULTS: For each period, data from 363 patients were compared. Mean length of stay decreased between the study periods from 8.72 to 7.06 days, while the average injury severity score was unchanged. Together, these cost centers constituted 87.4% of the total cost of care delivered. Significant cost reduction was achieved in all six variable cost centers: nursing (24%), surgical (5%), pharmacy (57%), laboratory (27), radiology (7%), and emergency (36). The mean cost per case was reduced by 25%. CONCLUSIONS: Identification of the true cost centers and directed attending surgeon involvement are essential to the development and implementation of a successful cost-reduction process.

Decrease in expenditures and selected nosocomial infections following implementation of an antimicrobial-prescribing improvement program.

OBJECTIVE: To evaluate changes in antimicrobial use and expenditures and the rates of selected nosocomial infections due to resistant organisms associated with implementation of an antimicrobial-prescribing improvement program. DESIGN: Before-after trial comparing 1992 (pre-program), 1993 (a transition year), and 1994 (after full implementation of the program). SETTING AND PARTICIPANTS: Academic medical center, all patients and physicians. INTERVENTION: An antimicrobial-prescribing improvement program with prior approval requirement for use of restricted agents. MAIN OUTCOME MEASURES: Antimicrobial use and expenditures, rates of selected nosocomial infection marker events. RESULTS: Between 1992 and 1994, there were substantial decreases in antimicrobial use, from 158,107 to 137,364 defined daily doses, and in expenditures from $2,486,902 ($24.01 per patient day) to $1,701,522 ($18.49 per patient day). After adjusting for changes in purchase prices and census days, we estimated savings attributable to the program of $279,573 in 1993 and $389,814 in 1994. In addition, we found significant decreases between 1992 and 1994 in the rates of enterococcal bacteremia (.34 vs .16 events per 1,000 patient days; P = .016), selected gram-negative bacteremia (.26 vs .11; P = .015), methicillin-resistant Staphylococcus aureus colonization or infection (.66 vs .20; P < .0001), and Stenotrophomonas colonization or infection (.35 vs .17; P = .019). No significant change occurred in rates of nosocomial candidemia or Clostridium difficile toxin-positive diarrhea. Values for 1993 were intermediate between those of 1992 and 1994. CONCLUSION: Implementation of an antimicrobial-prescribing improvement program was associated with substantial savings in antimicrobial use and expenditures and significant decreases in rates of selected nosocomial infections due to resistant organisms.