Inpatient costs and predictors of costs in the psychosomatic treatment of anorexia nervosa.

OBJECTIVE: In German inpatient psychosomatics per diem lump sums will be introduced as reimbursement rates by 2013. It was the aim to calculate total inpatient costs per case for the psychosomatic treatment of patients with anorexia nervosa and to identify cost predictors. METHOD: The sample comprised of 127 inpatients. Cost calculation was executed from the hospital's perspective, mainly using microcosting. Medical records provided data on patient characteristics and individual resource use. Two generalized linear models with gamma distribution and log link function were estimated to determine cost predictors by means of demographic data, comorbidities, and body-mass-index at admission. RESULTS: Inpatient costs amounted to 4,647 €/6,831 US$ per case (standard deviation 3,714 €/5,460 US$).The admission BMI and "Disorders of Adult Personality and Behavior" were significant cost predictors (p < 0.05). DISCUSSION: The formation of patient groups within the diagnosis anorexia nervosa should be oriented towards the determined cost predictors.

The relationship between nurse staffing levels and nursing-sensitive outcomes in hospitals: Assessing heterogeneity among unit and outcome types.

OBJECTIVE: To identify which unit types are most sensitive to nurse staffing levels. DATA SOURCES/STUDY SETTING: Collection of secondary data took place from March to July 2016. For our study, we analyzed administrative hospital claims data and self-reported structural data from hospitals in Germany. We used 26,502,579 admissions nested in 13,089 units in 3,680 hospitals from 2012 to 2014. STUDY DESIGN: We used regression analysis to examine the relationship between 11 established nursing-sensitive outcomes (NSOs) and nurse-to-patient ratios on a unit level. Nurse-to-patient ratios were our key explanatory variable. We conducted separate OLS regressions for each NSO in each unit type using linear and non-linear terms. DATA COLLECTION/EXTRACTION METHODS: We linked hospital claims data with self-reported structural data from hospitals from 2012 to 2014. PRINCIPAL FINDINGS: We identified 15 unit types with at least one significant NSO. The effect of potential understaffing on NSOs depends on the unit type. CONCLUSIONS: Our study indicates that the relationship between nurse staffing levels and NSOs varies greatly depending on the unit type concerning both significance and magnitude. Future research might consider performing analyses on unit level instead of hospital level.

Pay for performance in the inpatient sector: A review of 34 P4P programs in 14 OECD countries.

Across the member countries of the Organisation for Economic Co-operation and Development (OECD), pay-for-performance (P4P) programs have been implemented in the inpatient sector to improve the quality of care provided by hospitals. This paper provides an overview of 34 existing P4P programs in the inpatient sector in 14 OECD countries based on a structured literature search in five databases to identify relevant sources in Danish, English, French, German, Hebrew, Italian, Japanese, Korean, Norwegian, Spanish, Swedish and Turkish. It assembles information on the design and effects of these P4P systems and discusses whether evaluations of such programs allow preliminary conclusions to be drawn about the effects of P4P. The programs are very heterogeneous in their aim, the selection of indicators and the design of financial rewards. The impact of P4P is unclear and it may be that the moderately positive effects seen for some programs can be attributed to side effects, such as public reporting and increased awareness of data recording. Policy makers must decide whether the potential benefits of introducing a P4P program outweigh the potential risks within their particular national or regional context, and should be aware that P4P programs have yet not lived up to expectations.

The trade-off between costs and quality of care in the treatment of psychosomatic patients with somatoform pain disorder.

BACKGROUND: The introduction of efficiency-oriented provider payment systems in inpatient mental healthcare in various Western countries may lead to the use of less healthcare resources in the treatment of patients. To avoid unintended effects on quality of care that may result from reductions in resource utilization, it is essential for decision and policy makers to know whether there is a trade-off between costs and quality of care. AIM OF THE STUDY: The aim of this study was to investigate and quantify the relationship between costs and outcomes in psychosomatic inpatients with somatoform pain disorder. METHODS: The inclusion criteria for patient selection (n = 101) were (i) a main diagnosis of somatoform pain disorder according to International Classification of Diseases-10 (ICD-10) [F45.4, F45.40, F45.41]; (ii) complete data on the mental component summary reflecting overall functioning of mental health (MCS-8) measured with the Short Form-8 Health Survey (SF-8) within 3 days of the admission and discharge dates; and (iii) treatment at Charité Universitaetsmedizin (Berlin, Germany) during the period January 2006-June 2010. The change in the MCS-8 score incurred over the treatment period was used as an indicator of quality of care. Treatment costs were calculated from the provider's perspective, mainly using bottom-up micro-costing. The year of valuation for cost calculation was 2008 (with no inflation adjustment); for costs provided by the accounting department for services consumed by the patient, the valuation year was based on the year of service provision. We hypothesized that the outcome 'change in MCS-8 score' was a function of the independent variable costs, patient characteristics, socio-demographic variables, pain-related variables, co-morbidities and subjective illness attribution, i.e. whether patients attributed the origin of pain mainly to a somatic cause or not. An interaction term between costs and illness attribution was included to control for the hypothesized differing effects of resource input or costs on the outcome variable conditional on patients' illness attribution. Hausman tests indicated that endogeneity was not present, thus, ordinary least squares regression (OLS) was conducted. We assessed whether the change in the MCS-8 score was clinically meaningful and perceptible by the patient, using the minimal clinical important difference (MCID). For Short Form Health Surveys, the MCID for changes in the mental component summary is typically around 3 points. RESULTS: We found a trade-off between costs and outcome for patients without or with only minor somatic illness attribution (77 % of the sample). This patient group improved 0.4 points in outcome after every 100 increase in total costs per case (F 1,77 = 13.836, t(77) = 3.72, p = 0.0004). For patients with mainly somatic illness beliefs (23 % of the sample), we did not find a trade-off between costs and outcome. CONCLUSION: For the majority of patients, we found a trade-off between costs and health outcome, thus, it seems advisable to carefully monitor outcome parameters when applying cost containment measures.

Cost-effectiveness of open versus laparoscopic appendectomy: a multilevel approach with propensity score matching.

OBJECTIVE: To compare postoperative complications and cost of treatment of laparoscopic (LA) versus open appendectomy (OA) and to identify the most cost-effective treatment method. METHODS: Patients treated for appendectomy in US veterans health administration (VHA) hospitals in 2005 were included into our study. Direct medical cost and postoperative complications during hospitalization were used as outcomes. Propensity score matching was employed to adjust for baseline imbalances between treatment groups. It was adjusted for the severity of appendicitis, comorbidities according to Charlson Comorbidity Index, and demographic variables. 1:1 optimal matching with replacement was performed. Based on the matched samples, we estimated generalized linear mixed regression models for costs (gamma model) and postoperative complications (logit model). Besides patients' covariates, predictors of hospital resource use and quality of care at the hospital level were considered as explanatory variables. RESULTS: The total study population comprised of 1,128 patients (370 LA, 758 OA) from 95 VHA hospitals. Type of appendectomy had a significant influence on total costs (P=0.005), with predicted costs for LA being 17.1% lower in comparison to OA (OA: 10,851 US$ [95%CI: 9,707 US$; 12,131 US$] vs. LA: 8,995 US$ [95%CI: 8,073 US$; 10,022 US$]). Differences in the predicted overall postoperative complication were not significant between LA and OA (P=0.6311). Severity of appendicitis had a significant impact on costs and postoperative complications. CONCLUSION: Predicted costs for LA were 1,856 US$ lower than for OA while the postoperative complication rate did not differ significantly. Thus, LA is the treatment of choice from a provider's perspective.

Introduction of DRG-based reimbursement in inpatient psychosomatics--an examination of cost homogeneity and cost predictors in the treatment of patients with eating disorders.

OBJECTIVE: Various western countries are focusing on the introduction of reimbursement based on diagnosis-related groups (DRG) in inpatient mental health. The aim of this study was to analyze if psychosomatic inpatients treated for eating disorders could be reimbursed by a common per diem rate. METHODS: Inclusion criteria for patient selection (n=256) were (1) a main diagnosis of anorexia nervosa (AN), bulimia nervosa (BN) or eating disorder-related obesity (OB), (2) minimum length of hospital stay of 2 days, (3) and treatment at Charité Universitaetsmedizin Berlin, Germany during the years 2006-2009. Cost calculation was executed from the hospital's perspective, mainly using micro-costing. Generalized linear models with Gamma error distribution and log link function were estimated with per diem costs as dependent variable, clinical and patient variables as well as treatment year as independent variables. RESULTS: Mean costs/case for AN amounted to 5,251€, 95% CI [4407-6095], for BN to 3,265€, 95% CI [2921-3610] and for OB to 3,722€, 95% CI [4407-6095]. Mean costs/day over all patients amounted to 208€, 95% CI [198-218]. The diagnosis AN predicted higher costs in comparison to OB (p=.0009). A co-morbid personality disorder (p=.0442), every one-unit increase in BMI in OB patients (p=.0256), every one-unit decrease in BMI in AN patients (p=.0002) and every additional life year in BN patients (p=.0455) predicted increased costs. CONCLUSION: We see a need for refinements to take into account considerable variations in treatment costs between patients with eating disorders due to diagnosis, BMI, co-morbid personality disorder and age.