Challenges of Costing a Surgical Procedure in a Lower-Middle-Income Country.

BACKGROUND: It is vital to enquire into cost of health care to ensure that maximum value for money is obtained with available resources; however, there is a dearth of information on cost of health care in lower-middle-income countries (LMICs). Our aim was to develop a reproducible costing method for three routes of hysterectomy in benign uterine conditions: total abdominal (TAH), non-descent vaginal (NDVH) and total laparoscopic hysterectomy (TLH). METHODS: A societal perspective with a micro-costing approach was applied to find out direct and indirect costs. A total of 147 patients were recruited from a district general hospital (Mannar) and a tertiary care hospital (Ragama). Costs incurred from preoperative period to convalescence included direct costs of labour, equipment, investigations, medications and utilities, and indirect costs of out-of-pocket expenses, productivity losses, carer costs and travelling. Time-driven activity-based costing was used for labour, and top-down micro-costing was used for utilities. RESULTS: The total cost [(interquartile range), number] of TAH was USD 339 [(308-397), n = 24] versus USD 338 [(312-422), n = 25], NDVH was USD 315 [(316-541), n = 23] versus USD 357 [(282-739), n = 26] and TLH was USD 393 [(338-446), n = 24] versus USD 429 [(390-504), n = 25] at Mannar and Ragama, respectively. The direct cost of TAH, NDVH and TLH was similar between the two centres, whilst indirect cost was related to the setting rather than the route of hysterectomy. CONCLUSIONS: The costing method used in this study overcomes logistical difficulties in a LMIC and can serve as a guide for clinicians and policy makers in similar settings. TRIAL REGISTRATION: The study was registered in the Sri Lanka clinical trials registry (SLCTR/2016/020) and the International Clinical Trials Registry Platform (U1111-1194-8422) on 26 July 2016.

Postdischarge complications: what exactly happens when the patient goes home?

Economic implications favouring early discharge have led to an ever increasing demand to send patients home for recuperation. Patients are now routinely released on their fourth postoperative day, thereby making postdischarge complications harder to record and audit. We set about the use of a structured questionnaire to evaluate the incidence of all postdischarge complications requiring therapy within the first six weeks of convalescence. Over a 24-month period, 382 patients were questioned following cardiac surgery. Of these patients, 72% had an uneventful postoperative recovery, however, 17% needed treatment from their general practitioner, 6% were readmitted, 5% required district nurse treatment and 1% called the National Health Service advice line (NHS direct). Furthermore, despite the fact that 28% of discharges required further medical intervention in the majority of cases, cardiothoracic clinicians were not aware of complications requiring treatment. The auditing of these complications has resulted in changes in our surgical practice leading to a reduction in postoperative complications. Structured questionnaires are a useful tool in allowing improvement in surgical technique. They can be used by all members of the cardiothoracic team regardless of their grade and enable a methodical and reproducible assessment of all discharged patients.

[Convalescence, sick leave and health economics]. / Rekonvalescens, sygemelding og sundhedsøkonomi.

National health policies have been proposed to reduce long-term absenteeism in order to increase labour supply. Convalescence interventions have been developed and optimised and shown to reduce long-term absenteeism and as such they form an integral part of the national health policy. We describe absenteeism and convalescence within an economic perspective. In Denmark, the economic costs of absenteeism amounted to more than 37 billion Danish kroner in 2006, including sick leave benefits and non-productive wage expenditure. Optimising convalescence interventions, if efficacious, is highly cost-effective.

Convalescent phase outpatient parenteral antiinfective therapy for children with complicated appendicitis.

BACKGROUND: Children with a perforated or gangrenous appendix become clinically stable after medical and/or surgical therapy but often remain in the hospital solely to complete parenteral antibiotic therapy. This prospective study investigates the outcomes when children who meet specified criteria are discharged to complete parenteral antibiotic therapy at home. METHODS: Children age 1 to 17 years with appendicitis complicated by generalized peritonitis or intraabdominal abscess were eligible to participate. Subjects whose fever was decreasing, who were able to tolerate oral liquids and for whom further parenteral antibiotic therapy was deemed necessary were discharged from the hospital to receive outpatient parenteral antiinfective therapy (OPAT) with meropenem. Therapy was administered by a family member and supervised by home care nurses. Study personnel visited the home daily to collect data on adverse events, compliance and resource utilization. Pa tients served as their own controls in models of reduced hospitalization and net cost savings. RESULTS: Discharged on average on the fourth postoperative day, 87 children received 4.5 +/- 2.1 days of OPAT. Six (7%) children were subsequently readmitted for complications including bowel obstruction (4 children), intraabdominal abscess (1 child) and pleural effusion (1 child). Another child developed a viral syndrome during OPAT. All other patients recovered uneventfully. Six (7%) children discontinued meropenem prematurely because of rash (4 patients) or diarrhea (2 patients). According to models in which each day of OPAT replaced a day of inpatient care, discharge to OPAT reduced hospitalization by 42 +/- 15% and saved a median of $2908 (10th to 90th percentile range, $1,077 to $4,707) per patient. CONCLUSION: Convalescent phase OPAT is a cost-effective alternative to continued hospitalization for children with complicated appendicitis who are clinically stable yet require further parenteral antibiotic therapy.

Cost analysis of early discharge after hip fracture.

OBJECTIVE: To ascertain the economic impact of an early discharge scheme for hip fracture patients. DESIGN: Population based study comparing costs of care for patients who had "hospital at home" as an option for rehabilitation and those who had no early discharge service available in their area of residence. SETTING: District hospital orthopaedic and rehabilitation wards and community hospital at home scheme. PATIENTS: 1104 consecutively admitted patients with fractured neck of femur. 24 patients from outside the district were excluded. MAIN OUTCOME MEASURES: Cost per patient episode and number of bed days spent in hospital. RESULTS: Patients with the hospital at home option spent significantly less time as inpatients (mean of 32.5 v 41.7 days; p < 0.001). Those patients who were discharged early spent a mean of 11.5 days under hospital at home care. The total direct cost to the health service was significantly less for those patients with access to early discharge than those with no early discharge option (4884 pounds v 5606 pounds; p = 0.048). CONCLUSIONS: About 40% of patients with fractured neck of femur are suitable for early discharge to a scheme such as hospital at home. The availability of such a scheme leads to lower direct costs of rehabilitative care despite higher readmission costs. These savings accrue largely from shorter stays in orthopaedic and geriatric wards.

Back transporting infants from neonatal intensive care units to community hospitals for recovery care: effect on total hospital charges.

Many neonates are referred to neonatal intensive care units (NICUs) for specialized care far from their parents' residence. This distance can add to the stress of the parents and reduce the contact of the parents with their newborn. Small studies have found that back transporting these neonates to hospitals closer to their homes is safe and cost-effective. Despite these findings, the reluctance of many insurers to pay for back transports prevents or delays many back transports. Insurers may not consider the findings of the previous studies to be conclusive, given that the comparisons were between small numbers of neonates back transported and neonates who remained in tertiary care, and the potential for differences in severity of illness between the groups is significant. In this study the effect on hospital charges of back transports was examined by comparing the charges for care in community hospitals with what these charges would have been in a tertiary care center. The advantage of this method is that it avoids case-mix differences between the groups and thus minimizes the potential for small-sample bias. Data were collected for all back transports from a NICU to non-tertiary care centers (n = 90) for a 9-month period. We were able to obtain the itemized bills for the care at community hospitals for 42 of these patients. Each bill was recalculated using the charges for the NICU to determine potential for savings. The average charges for recovery care were about $6200 lower at the community hospital than they would have been at the NICU.(ABSTRACT TRUNCATED AT 250 WORDS)

[Admission to health resorts/sanatoriums. The public health office between requirements and reality exemplified by sections 7 and 8 of the public assistance regulations]. / Heilkuren/Sanatoriumsaufenthalt. Das Gesundheitsamt zwischen Anspruch und Wirklichkeit an Beispiel der Beihilfevorschriften Sections 7 und 8.

The state (FRG) provides public assistance to its civil servants and their families by granting a state subsidy for diseases, births and deaths. Preventive measures such as stay and treatment in sanatoria and reconvalescent homes have also been subject to regulations. The variance in their specific definitions is discussed critically and compared with the concept "hospital". The official assistance rendered by the public health officer is explained. The applications forms and their handling by the attending family doctors and others are adversely criticised. The ambiguity between sanatorium and reconvalescent homes, the choice of the location and the medical efficacy of this preventive measure are discussed.