Hospitalization costs and their determining factors among patients undergoing kidney transplantation: a cross-sectional descriptive study

ABSTRACT BACKGROUND: Cost evaluation is a key tool in monitoring expenditure for budget management. It increases the efficiency of possible changes through identifying potential savings and estimating the resources required to make such changes. However, there is a lack of knowledge of the total cost of hospitalization up to the clinical outcome, regarding patients admitted for kidney transplantation. Likewise, there is a lack of data on the factors that influence the amounts spent by hospital institutions and healthcare systems. OBJECTIVES: To describe the costs and determining factors relating to hospitalization of patients undergoing kidney transplantation. DESIGN AND SETTING: Cross-sectional descriptive study with a quantitative approach based on secondary data from 81 patients who were admitted for kidney transplantation at a leading transplantation center in southern Brazil. METHODS: The direct costs of healthcare for patients who underwent kidney transplantation were the dependent variable, and included personnel, expenses, third-party services, materials and medicines. The factors that interfered in the cost of the procedure were indirect variables. The items that made up these variables were gathered from the records of the internal transplantation committee and from the electronic medical records. The billing sector provided information on the direct costs per patient. RESULTS: The estimated total cost of patients' hospitalization was R$ 1,257,639.11 (US$ 571,010.44). Out of this amount, R$ 1,237,338.31 (US$ 561,793.20) was paid by the Brazilian National Health System and R$ 20,300.80 (US$ 9,217.24) by the transplantation center's own resources. The highest costs related to the length of hospital stay and clinical complications such as sepsis and pneumonia. CONCLUSIONS: The costs of hospitalization for kidney transplantation relate to the length of hospital stay and clinical complications.

Hospitalization costs and their determining factors among patients undergoing kidney transplantation: a cross-sectional descriptive study.

BACKGROUND: Cost evaluation is a key tool in monitoring expenditure for budget management. It increases the efficiency of possible changes through identifying potential savings and estimating the resources required to make such changes. However, there is a lack of knowledge of the total cost of hospitalization up to the clinical outcome, regarding patients admitted for kidney transplantation. Likewise, there is a lack of data on the factors that influence the amounts spent by hospital institutions and healthcare systems. OBJECTIVES: To describe the costs and determining factors relating to hospitalization of patients undergoing kidney transplantation. DESIGN AND SETTING: Cross-sectional descriptive study with a quantitative approach based on secondary data from 81 patients who were admitted for kidney transplantation at a leading transplantation center in southern Brazil. METHODS: The direct costs of healthcare for patients who underwent kidney transplantation were the dependent variable, and included personnel, expenses, third-party services, materials and medicines. The factors that interfered in the cost of the procedure were indirect variables. The items that made up these variables were gathered from the records of the internal transplantation committee and from the electronic medical records. The billing sector provided information on the direct costs per patient. RESULTS: The estimated total cost of patients' hospitalization was R$ 1,257,639.11 (US$ 571,010.44). Out of this amount, R$ 1,237,338.31 (US$ 561,793.20) was paid by the Brazilian National Health System and R$ 20,300.80 (US$ 9,217.24) by the transplantation center's own resources. The highest costs related to the length of hospital stay and clinical complications such as sepsis and pneumonia. CONCLUSIONS: The costs of hospitalization for kidney transplantation relate to the length of hospital stay and clinical complications.

Tendência temporal das internações por pneumonia em adultos e idosos na cidade do Salvador-Bahia, no período de 2003 a 2016 / Temporal trend of hospitalizations for pneumonia in adults and elderly in the city of Salvador-Bahia, from 2003 to 2016

Introdução: a pneumonia é uma doença infecciosa aguda do sistema respiratório que representa um grave problema de saúde pública no Brasil e no mundo. Objetivo: descrever a distribuição das internações por pneumonia em indivíduos residentes no município de Salvador, Estado da Bahia, no período de 2003 a 2016, conforme custo, sexo e faixa etária. Metodologia: estudo observacional descritivo e exploratório sobre internações por pneumonia (CID: J12-18) na cidade do Salvador, Bahia. Os dados foram obtidos no Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH-SUS), disponibilizados pelo Departamento de Informação do Sistema Único de Saúde (DATASUS), tabulados e tratados no Microsoft Excel 2016. Resultados: o número de internações por pneumonia totalizou 224.173. O sexo feminino correspondeu a 51,25% das internações. Em contrapartida, o sexo masculino apresentou os maiores custos médios de internação, tendo sido o mais elevado o de R$2.416,40 em 2016. Para ambos os sexos, as faixas etárias de maior ocorrência de internação foram as de 70-79 e a igual ou superior a 80 anos. O ano de 2015 apresentou a mais alta taxa de internação (97,1/100 mil hab.) e o mais alto custo médio (R$2.309,61). Conclusão: os dados revelam declínios pontuais das internações e elevação dos custos em termos nominais. Acompanhar a evolução da morbidade em série temporal contribui para questionar mudanças de gestão pública e avaliar o impacto da doença na coletividade.

Introduction: pneumonia is an acute infectious disease of the respiratory system that represents a serious public health problem in Brazil and in the world. Objective: describe the distribution of hospitalizations for pneumonia in individuals residents in the municipality of Salvador, State of Bahia, in the period from 2003 to 2016, as cost, sex and age group. Methodology: descriptive and exploratory observational study on hospitalizations for pneumonia (CID: J12-18) in the city of Salvador, Bahia. The data were obtained from the Hospital Information System of the Unified Health System (SIH-SUS), provided by the Department of Information of the Unified Health System (DATASUS), tabulated and treated in Microsoft Excel 2016. Results: the number of hospitalizations for pneumonia totaled 224,173. Females accounted for 51.25% of hospitalizations. On the other hand, the male sex showed the highest average costs of hospitalization, and the highest was of R$2.416,40 in 2016. For both sexes, the age groups of greater occurrence of hospitalization were those of 70-79 and the same or over 80 years of age. The year 2015 showed the highest rate of hospitalization (97.1/100 000 inhab.) and the highest average cost (R$2.309,61). Conclusion: the data reveal individual declines of hospitalizations and raise of costs in nominal terms. Follow the evolution of morbidity in temporal series contributes to question public management changes and assess the impact of the disease in the community.

Descriptive study on the evolution of hospitalization costs for ambulatory care sensitive conditions in Brazil, 2000-2013. / Estudo descritivo da evolução dos gastos com internações hospitalares por condições sensíveis à atenção primária no Brasil, 2000-2013.

OBJECTIVE: to analyze the proportions of costs of hospitalizations for ambulatory care sensitive conditions (ACSC) in relation to total hospitalization costs funded by the Brazilian National Health System (SUS) in Brazil, in 2000, 2005, 2010 and 2013, according to sex, age and group of causes. METHODS: this is a descriptive study, with data from SUS Hospital Information System (SIH/SUS); the proportion of hospitalization costs for ACSC was estimated in relation to total hospitalization costs. RESULTS: proportions decreased from 23.6% (2000) to 17.4% (2013); higher rates occurred among women (29.8%), children (42.3%) and the elderly (31.7%); on the other hand, there was a significant increase in the proportion of hospitalization costs for angina (237.5%) and pneumonia (84.3%). CONCLUSION: there were greater reductions in costs among children, elderly and women; however, the persistence of high proportion of costs attributed to cardiovascular diseases stands out, especially hospitalizations for angina.

Operative Treatment of Rib Fractures in Flail Chest Injuries: A Meta-analysis and Cost-Effectiveness Analysis.

OBJECTIVES: Flail chest is a common injury sustained by patients who experience high-energy blunt chest trauma and results in severe respiratory compromise because of altered mechanics of respiration. There has been increased interest in operative fixation of these injuries with the intention of restoring the mechanical integrity of the chest wall, and several studies have shown that ventilation requirements and pulmonary complications may be decreased with operative intervention. The purpose of this study was to evaluate fixation of rib fractures in flail chest injuries using cost-effectiveness analysis, supported by systematic review and meta-analysis. METHODS: This was a 2-part study in which we initially conducted a systematic literature review and meta-analysis on outcomes after operative fixation of flail chest injuries, evaluating intensive care unit (ICU) stay, hospital length of stay (LOS), mortality, pneumonia, and need for tracheostomy. The results were then applied to a decision-analysis model comparing the costs and outcomes of operative fixation versus nonoperative treatment. The validity of the results was tested using probabilistic sensitivity analysis. RESULTS: Operative treatment decreased mortality, pneumonia, and tracheotomy (risk ratios of 0.44, 0.59, and 0.52, respectively), as well as time in ICU and total LOS (3.3 and 4.8 days, respectively). Operative fixation was associated with higher costs than nonoperative treatment ($23,682 vs. $8629 per case, respectively) and superior outcomes (32.60 quality-adjusted life year (QALY) vs. 30.84 QALY), giving it an incremental cost-effectiveness ratio of $8577/QALY. CONCLUSIONS: Surgical fixation of rib fractures sustained from flail chest injuries decreased ICU time, mortality, pulmonary complications, and hospital LOS and resulted in improved health care-related outcomes and was a cost-effective intervention. These results were sensitive to overall complication rates, and operations should be conducted by surgeons or combined surgical teams comfortable with both thoracic anatomy and exposures as well as with the principles and techniques of internal fixation. LEVEL OF EVIDENCE: Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

[Estimation of economic costs for the care of patients with nosocomial pneumonia in a regional peruvian hospital, 2009-2011]. / Estimación de costos económicos en la atención de la neumonía nosocomial en un hospital regional peruano, 2009 al 2011.

OBJECTIVES: To estimate and compare the economic costs for the care of patients with and without nosocomial pneumonia at Hospital II Huánuco EsSalud during 2009-2011, in Peru. MATERIALS AND METHODS: This was a partial economic evaluation of paired cases and controls. A collection sheet was used. DEPENDENT VARIABLE: nosocomial pneumonia. INDEPENDENT VARIABLES: direct health costs, direct non-health costs, indirect costs, occupation, age, comorbidities, sex, origin, and education level. A bivariate analysis was performed. RESULTS: Forty pairs of cases and controls were identified. These patients were hospitalized for >2 weeks and prescribed more than two antibiotics. The associated direct health costs included those for hospitalization, antibiotics, auxiliary examinations, specialized assessments, and other medications. The direct non-health costs and associated indirect costs included those for transportation, food, housing, foregone payroll revenue, foregone professional fee revenue, extra-institutional expenses, and payment to caregivers during hospitalization and by telephone. CONCLUSIONS: The direct health costs for nosocomial pneumonia patients were more than three times and the indirect costs were more than two times higher than those for the controls. Variables with the greatest impact on costs were identified.

Estimación de costos económicos en la atención de la neumonía nosocomial en un hospital regional peruano, 2009 al 2011 / Estimation of economic costs for the care of patients with nosocomial pneumonia in a regional peruvian hospital, 2009-2011

RESUMEN Objetivos. Estimar los costos económicos en la atención de la neumonía nosocomial al compararlo con el grupo sin neumonía nosocomial en Hospital II Huánuco EsSalud, 2009 -2011. Materiales y métodos. Evaluación económica parcial. Diseño de casos y controles pareado. Se empleó una ficha de recolección. Variable dependiente: neumonía nosocomial. Variables independientes: costos directos sanitarios, costos directos no sanitarios, costos indirectos, ocupación, comorbilidad, procedencia y grado de instrucción. Se realizó análisis bivariado. Resultados. Se identificaron 40 pares de casos y controles. Los casos estuvieron hospitalizados más de dos semanas y emplearon más de dos antibióticos. Los costos directos sanitarios asociados fueron por hospitalización, antibióticos, exámenes auxiliares, evaluaciones especializadas y otras medicaciones. Los costos directos no sanitarios y los costos indirectos asociados fueron por transporte, alimentación, alojamiento, ingresos por planilla dejados de percibir, ingresos por honorarios profesionales dejados de percibir, gastos extrainstitucionales, pago a cuidadores durante hospitalización y por telefonía. Conclusiones. Los costos directos sanitarios en neumonía nosocomial fueron más del triple, mientras los costos directos no sanitarios y costos indirectos fueron más del doble al compararlo con el grupo sin infección. Se identificaron variables con mayor impacto en los costos.

ABSTRACT Objectives. To estimate and compare the economic costs for the care of patients with and without nosocomial pneumonia at Hospital II Huánuco EsSalud during 2009-2011, in Peru. Materials and Methods. This was a partial economic evaluation of paired cases and controls. A collection sheet was used. Dependent variable: nosocomial pneumonia. Independent variables: direct health costs, direct non-health costs, indirect costs, occupation, age, comorbidities, sex, origin, and education level. A bivariate analysis was performed. Results. Forty pairs of cases and controls were identified. These patients were hospitalized for >2 weeks and prescribed more than two antibiotics. The associated direct health costs included those for hospitalization, antibiotics, auxiliary examinations, specialized assessments, and other medications. The direct non-health costs and associated indirect costs included those for transportation, food, housing, foregone payroll revenue, foregone professional fee revenue, extra-institutional expenses, and payment to caregivers during hospitalization and by telephone. Conclusions. The direct health costs for nosocomial pneumonia patients were more than three times and the indirect costs were more than two times higher than those for the controls. Variables with the greatest impact on costs were identified.

Air pollutants and hospitalization due to pneumonia among children. An ecological time series study.

CONTEXT AND OBJECTIVE: Exposure to air pollutants is one of the factors responsible for hospitalizations due to pneumonia among children. This has considerable financial cost, along with social cost. A study to identify the role of this exposure in relation to hospital admissions due to pneumonia among children up to 10 years of age was conducted. DESIGN AND SETTING: Ecological time series study using data from São José dos Campos, Brazil. METHODS: Daily data on hospitalizations due to pneumonia and on the pollutants CO, O3, PM10 and SO2, temperature and humidity in São José dos Campos, in 2012, were analyzed. A generalized additive model of Poisson's regression was used. Relative risks for hospitalizations due to pneumonia, according to lags of 0-5 days, were estimated. The population-attributable fraction, number of avoidable hospitalizations and cost savings from avoidable hospitalizations were calculated. RESULTS: There were 539 admissions. Exposure to CO and O3 was seen to be associated with hospitalizations, with risks of 1.10 and 1.15 on the third day after exposure to increased CO concentration of 200 ppb and ozone concentration of 20 µg/m3. Exposure to the pollutants of particulate matter and sulfur dioxide were not shown to be associated with hospitalizations. Decreases in CO and ozone concentrations could lead to 49 fewer hospitalizations and cost reductions of R$ 39,000.00. CONCLUSION: Exposure to certain air pollutants produces harmful effects on children's health, even in a medium-sized city. Public policies to reduce emissions of these pollutants need to be implemented.

A Cost-Effectiveness Analysis of Obtaining Blood Cultures in Children Hospitalized for Community-Acquired Pneumonia.

OBJECTIVE: To determine the clinical utility and cost-effectiveness of universal vs targeted approach to obtaining blood cultures in children hospitalized with community-acquired pneumonia (CAP). STUDY DESIGN: We conducted a cost-effectiveness analysis using a decision tree to compare 2 approaches to ordering blood cultures in children hospitalized with CAP: obtaining blood cultures in all children admitted with CAP (universal approach) and obtaining blood cultures in patients identified as high risk for bacteremia (targeted approach). We searched the literature to determine expected proportions of high-risk patients, positive culture rates, and predicted bacteria and susceptibility patterns. Our primary clinical outcome was projected rate of missed bacteremia with associated treatment failure in the targeted approach. Costs per 100 patients and annualized costs on the national level were calculated for each approach. RESULTS: The model predicts that in the targeted approach, there will be 0.07 cases of missed bacteremia with treatment failure per 100 patients, or 133 annually. In the universal approach, 118 blood cultures would need to be drawn to identify 1 patient with bacteremia, in which the result would lead to a meaningful antibiotic change compared with 42 cultures in the targeted approach. The universal approach would cost $5178 per 100 patients or $9,214,238 annually. The targeted approach would cost $1992 per 100 patients or $3,545,460 annually. The laboratory-related cost savings attributed to the targeted approach would be projected to be $5,668,778 annually. CONCLUSIONS: This decision analysis model suggests that a targeted approach to obtaining blood cultures in children hospitalized with CAP may be clinically effective, cost-saving, and reduce unnecessary testing.

Air pollutants and hospitalization due to pneumonia among children. An ecological time series study / Poluentes atmosféricos e internações por pneumonia em crianças. Estudo ecológico de série temporal

ABSTRACT CONTEXT AND OBJECTIVE: Exposure to air pollutants is one of the factors responsible for hospitalizations due to pneumonia among children. This has considerable financial cost, along with social cost. A study to identify the role of this exposure in relation to hospital admissions due to pneumonia among children up to 10 years of age was conducted. DESIGN AND SETTING: Ecological time series study using data from São José dos Campos, Brazil. METHODS: Daily data on hospitalizations due to pneumonia and on the pollutants CO, O3, PM10 and SO2, temperature and humidity in São José dos Campos, in 2012, were analyzed. A generalized additive model of Poisson's regression was used. Relative risks for hospitalizations due to pneumonia, according to lags of 0-5 days, were estimated. The population-attributable fraction, number of avoidable hospitalizations and cost savings from avoidable hospitalizations were calculated. RESULTS: There were 539 admissions. Exposure to CO and O3 was seen to be associated with hospitalizations, with risks of 1.10 and 1.15 on the third day after exposure to increased CO concentration of 200 ppb and ozone concentration of 20 µg/m3. Exposure to the pollutants of particulate matter and sulfur dioxide were not shown to be associated with hospitalizations. Decreases in CO and ozone concentrations could lead to 49 fewer hospitalizations and cost reductions of R$ 39,000.00. CONCLUSION: Exposure to certain air pollutants produces harmful effects on children's health, even in a medium-sized city. Public policies to reduce emissions of these pollutants need to be implemented.

RESUMO CONTEXTO E OBJETIVOS: A exposição a poluentes do ar é um dos fatores responsáveis pelas internações por pneumonias em crianças. Esse desfecho tem custo financeiro considerável, além do custo social. Estudo para identificar o papel dessa exposição nas internações em crianças com até 10 anos de idade foi desenvolvido. TIPO DE ESTUDO E LOCAL: Estudo ecológico de séries temporais com dados de São José dos Campos, Brasil. MÉTODOS: Dados diários de internações por pneumonia, dos poluentes CO, O3, PM10, SO2 além de temperatura e umidade de São José dos Campos, em 2012, foram analisados. Utilizou-se modelo aditivo generalizado da regressão de Poisson e foram estimados os riscos relativos para internações por pneumonia segundo defasagens de 0 a 5 dias. Foram calculadas a fração atribuível populacional, as internações evitáveis e a economia nos custos das internações evitáveis. RESULTADOS: Foram 539 internações. Exposição ao CO e O3 se mostraram associadas às internações, com riscos de 1,10 e 1,15 no terceiro dia após a exposição decorrentes de aumento nas concentrações do CO em 200 ppb e nas concentrações de ozônio em 20 µg/m3. Exposições aos poluentes material particulado e dióxido de enxofre não se mostraram associados às internações. Diminuição nas concentrações de CO e O3 poderiam reduzir em 49 internações e de R$ 39 mil nos custos. CONCLUSÃO: Mesmo em uma cidade de médio porte, exposição a determinados poluentes do ar causa efeito danoso à saúde da criança, sendo necessária a implantação de políticas públicas para redução da emissão desses poluentes.

Community-acquired pneumonia: economics of inpatient medical care vis-à-vis clinical severity.

OBJECTIVE: To assess the direct and indirect costs of diagnosing and treating community-acquired pneumonia (CAP), correlating those costs with CAP severity at diagnosis and identifying the major cost drivers. METHODS: This was a prospective cost analysis study using bottom-up costing. Clinical severity and mortality risk were assessed with the pneumonia severity index (PSI) and the mental Confusion-Urea-Respiratory rate-Blood pressure-age ≥ 65 years (CURB-65) scale, respectively. The sample comprised 95 inpatients hospitalized for newly diagnosed CAP. The analysis was run from a societal perspective with a time horizon of one year. RESULTS: Expressed as mean ± standard deviation, in Euros, the direct and indirect medical costs per CAP patient were 696 ± 531 and 410 ± 283, respectively, the total per-patient cost therefore being 1,106 ± 657. The combined budget impact of our patient cohort, in Euros, was 105,087 (66,109 and 38,979 in direct and indirect costs, respectively). The major cost drivers, in descending order, were the opportunity cost (lost productivity); diagnosis and treatment of comorbidities; and administration of medications, oxygen, and blood derivatives. The CURB-65 and PSI scores both correlated with the indirect costs of CAP treatment. The PSI score correlated positively with the overall frequency of use of health care services. Neither score showed any clear relationship with the direct costs of CAP treatment. CONCLUSIONS: Clinical severity at admission appears to be unrelated to the costs of CAP treatment. This is mostly attributable to unwarranted hospital admission (or unnecessarily long hospital stays) in cases of mild pneumonia, as well as to over-prescription of antibiotics. Authorities should strive to improve adherence to guidelines and promote cost-effective prescribing practices among physicians in southeastern Europe.

OBJETIVO: Avaliar os custos médicos diretos e indiretos de diagnóstico e tratamento para pacientes com pneumonia adquirida na comunidade (PAC), correlacionando-os com a gravidade da PAC ao diagnóstico e identificando os principais fatores de custo. MÉTODOS: Análise de custos prospectiva utilizando custo bottom-up. A gravidade clínica e o risco de mortalidade foram determinados através de pneumonia severity index (PSI) e a escala mentalConfusion-Urea-Respiratory rate-Blood pressure-age ≥ 65 years (CURB-65), respectivamente. A amostra foi composta por 95 pacientes hospitalizados devido a PAC recém-diagnosticada. A análise foi realizada em uma perspectiva social com um horizonte de tempo de um ano. RESULTADOS: Expressos em média ± desvio-padrão em euros, os custos médicos diretos e indiretos por paciente com PAC foram de 696 ± 531 e 410 ± 283, respectivamente, sendo, portanto, o custo total por paciente de 1.106 ± 657. O impacto orçamentário combinado deste grupo de pacientes em euros foi de 105.087 (66.109 e 38.979 nos custos diretos e indiretos, respectivamente). Os principais fatores de custo, em ordem descendente, foram custo de oportunidade (perda de produtividade); diagnóstico e tratamento de comorbidades; e administração de medicamentos, oxigênio e derivados do sangue. Os escores CURB-65 e PSI correlacionaram-se com os custos indiretos do tratamento da PAC. O escore PSI correlacionou-se positivamente com a frequência global no uso de serviços médicos. Nenhum dos escores mostrou uma relação clara com os custos diretos do tratamento da PAC. CONCLUSÕES: A gravidade clínica na admissão parece não se correlacionar com os custos do tratamento da PAC. Esses custos são principalmente causados por internações hospitalares desnecessárias (ou por internação desnecessariamente prolongada) em casos de pneumonia leve, assim como pela prescrição exagerada de antibióticos. As autoridades devem se esforçar para melhorar a adesão às diretrizes e promover práticas de prescrição custo-efetivas entre os médicos do sudeste da Europa.

Treatment costs of diarrheal disease and all-cause pneumonia among children under-5 years of age in Colombia.

OBJECTIVE: We estimate treatment costs associated with diarrheal disease and all-cause pneumonia among children under-5 years of age in Colombia and assess similarities or differences with previous cost estimations in developing countries of the Americas. METHODS: Macro-costing methods were used to carry out an analysis of diarrhea and all-cause pneumonia costs in Colombia in 2010. The perspective of the health care system was taken. Data were extracted from a health insurer database that includes information on health service utilization among 130,800 children from low-income households. Lengths of stay for hospital admissions and frequencies of cases at all levels of care registered in the database were estimated. RESULTS: There were 1456 diarrheal disease cases among the 130,800 children (aged ≥ 60 months) included in the study. The median cost per case was $27.10 (interquartile range [IQR]: $15.60-77.40). A total of 1545 all-cause pneumonia cases were reported to the insurer in 2010, resulting in a frequency of 1181 cases per 100,000 children (95% confidence interval [CI]=1122, 1240). The overall cost of all-cause pneumonia cases was $858,791, and the median cost per case treated was $263 (IQR: $27-546). Comparisons by level of care showed that costs were significantly different for the two diseases (p<.05). Costs for the diseases did not differ by age group (p>.05). CONCLUSIONS: Diarrhea and all-cause pneumonia constitute a significant economic and health burden in Colombia. The relatively large size of our sample allowed us to provide reliable national estimates of the costs associated with these diseases. Our results for Colombia are similar to previous estimates from developing countries in the Americas. These data provide valid estimates that may be used decision makers in other countries to make appropriate recommendations on the introduction of rotavirus and pneumococcal vaccines.

Estimating health service utilization for treatment of pneumococcal disease: the case of Brazil.

BACKGROUND: Health service utilization (HSU) is an essential component of economic evaluations of health initiatives. Defining HSU for cases of pneumococcal disease (PD) is particularly complex considering the varying clinical manifestations and diverse severity. OBJECTIVE: We describe the process of developing estimates of HSU for PD as part of an economic evaluation of the introduction of pneumococcal conjugate vaccine in Brazil. METHODS: Nationwide inpatient and outpatient HSU by children under-5 years with meningitis (PM), sepsis (PS), non-meningitis non-sepsis invasive PD (NMNS), pneumonia, and acute otitis media (AOM) was estimated. We assumed that all cases of invasive PD (PM, PS, and NMNS) required hospitalization. The study perspective was the health system, including both the public and private sectors. Data sources were obtained from national health information systems, including the Hospital Information System (SIH/SUS) and the Notifiable Diseases Information System (SINAN); surveys; and community-based and health care facility-based studies. RESULTS: We estimated hospitalization rates of 7.69 per 100,000 children under-5 years for PM (21.4 for children <1 years of age and 4.3 for children aged 1-4 years), 5.89 for PS (20.94 and 2.17), and 4.01 for NMNS (5.5 and 3.64) in 2004, with an overall hospitalization rate of 17.59 for all invasive PD (47.27 and 10.11). The estimated incidence rate of all-cause pneumonia was 93.4 per 1000 children under-5 (142.8 for children <1 years of age and 81.2 for children aged 1-4 years), considering both hospital and outpatient care. DISCUSSION: Secondary data derived from health information systems and the available literature enabled the development of national HSU estimates for PD in Brazil. Estimating HSU for noninvasive disease was challenging, particularly in the case of outpatient care, for which secondary data are scarce. Information for the private sector is lacking in Brazil, but estimates were possible with data from the public sector and national population surveys.

Socioeconomic factors influencing hospitalized patients with pneumonia due to influenza A(H1N1)pdm09 in Mexico.

BACKGROUND: In addition to clinical aspects and pathogen characteristics, people's health-related behavior and socioeconomic conditions can affect the occurrence and severity of diseases including influenza A(H1N1)pdm09. METHODOLOGY AND PRINCIPAL FINDINGS: A face-to-face interview survey was conducted in a hospital in Mexico City at the time of follow-up consultation for hospitalized patients with pneumonia due to influenza virus infection. In all, 302 subjects were enrolled and divided into two groups based on the period of hospitalization. Among them, 211 tested positive for influenza A(H1N1)pdm09 virus by real-time reverse-transcriptase-polymerase-chain-reaction during the pandemic period (Group-pdm) and 91 tested positive for influenza A virus in the post-pandemic period (Group-post). All subjects were treated with oseltamivir. Data on the demographic characteristics, socioeconomic status, living environment, and information relating to A(H1N1)pdm09, and related clinical data were compared between subjects in Group-pdm and those in Group-post. The ability of household income to pay for utilities, food, and health care services as well as housing quality in terms of construction materials and number of rooms revealed a significant difference: Group-post had lower socioeconomic status than Group-pdm. Group-post had lower availability of information regarding H1N1 influenza than Group-pdm. These results indicate that subjects in Group-post had difficulty receiving necessary information relating to influenza and were more likely to be impoverished than those in Group-pdm. Possible factors influencing time to seeking health care were number of household rooms, having received information on the necessity of quick access to health care, and house construction materials. CONCLUSIONS: Health-care-seeking behavior, poverty level, and the distribution of information affect the occurrence and severity of pneumonia due to H1N1 virus from a socioeconomic point of view. These socioeconomic factors may explain the different patterns of morbidity and mortality for H1N1 influenza observed among different countries and regions.

Quality of care in the US territories.

BACKGROUND: Health care quality in the US territories is poorly characterized. We used process measures to compare the performance of hospitals in the US territories and in the US states. METHODS: Our sample included nonfederal hospitals located in the United States and its territories discharging Medicare fee-for-service (FFS) patients with a principal discharge diagnosis of acute myocardial infarction (AMI), heart failure (HF), or pneumonia (PNE) (July 2005-June 2008). We compared risk-standardized 30-day mortality and readmission rates between territorial and stateside hospitals, adjusting for performance on core process measures and hospital characteristics. RESULTS: In 57 territorial hospitals and 4799 stateside hospitals, hospital mean 30-day risk-standardized mortality rates were significantly higher in the US territories (P<.001) for AMI (18.8% vs 16.0%), HF (12.3% vs 10.8%), and PNE (14.9% vs 11.4%). Hospital mean 30-day risk-standardized readmission rates (RSRRs) were also significantly higher in the US territories for AMI (20.6% vs 19.8%; P=.04), and PNE (19.4% vs 18.4%; P=.01) but was not significant for HF (25.5% vs 24.5%; P=.07). The higher risk-standardized mortality rates in the US territories remained statistically significant after adjusting for hospital characteristics and core process measure performance. Hospitals in the US territories had lower performance on all core process measures (P<.05). CONCLUSIONS: Compared with hospitals in the US states, hospitals in the US territories have significantly higher 30-day mortality rates and lower performance on every core process measure for patients discharged after AMI, HF, and PNE. Eliminating the substantial quality gap in the US territories should be a national priority.

[Cost-effectiveness of chest x-rays in infants with clinically suspected viral bronchiolitis in Colombia]. / Costo-efectividad de la radiografía de tórax en lactantes con sospecha clínica de bronquiolitis viral en Colombia.

OBJECTIVE: Estimate the cost-effectiveness of not taking chest x-rays of any infant with clinically suspected viral bronchiolitis versus routinely taking them of all such patients, the most common practice today in Colombia. METHODS: A cost-effectiveness study was conducted, comparing strategies of taking chest x-rays of all infants with clinically suspected viral bronchiolitis and not x-raying any of these infants. The principal outcome was the proportion of correct diagnoses. The time horizon was the clinical course of the bronchiolitis. The perspective was that of the third-party payer, and the costs were obtained from the rates in effect in a clinic in Bogotá. Deterministic and probabilistic sensitivity analyses were performed. RESULTS: The strategy of not taking a chest x-ray of any patient prevailed over that of routinely taking one in all cases, with an average cost of US$ 111.00 and a correct diagnosis rate of 0.8020, versus the respective values of US$ 129.00 and 0.7873 for the strategy of routinely x-raying all of these patients. The most influential variable was pneumonia-related hospital costs. In the probabilistic sensitivity analysis, the strategy of not x-raying any infant prevailed in 61.1% of the simulations. CONCLUSIONS: The results suggest that not taking routine chest x-rays of infants with clinically suspected viral bronchiolitis is a cost-effective strategy compared with the common practice of taking them in all cases, since the former yields a greater proportion of correct diagnoses at a lower average cost per patient. Nevertheless, new studies will be needed that have more representative samples from all of the health facilities and include the strategy of taking chest x-rays only of patients with predictors of radiologic abnormalities.

Costo-efectividad de la radiografía de tórax en lactantes con sospecha clínica de bronquiolitis viral en Colombia / Cost-effectiveness of chest x-rays in infants with clinically suspected viral bronchiolitis in Colombia

OBJETIVO: Estimar el costo-efectividad de no realizar radiografía de tórax a ningún lactante con sospecha clínica de bronquiolitis viral versus realizarla en todos estos pacientes de manera rutinaria, que es la práctica más utilizada hoy en Colombia. MÉTODOS: Se realizó un estudio de costo-efectividad en el que se compararon las estrategias consistentes en tomar radiografía a todos y no tomar radiografía de tórax a ningún lactante con sospecha clínica de bronquiolitis viral. El desenlace principal fue la proporción de diagnósticos correctos. El horizonte temporal fue la evolución de la bronquiolitis. La perspectiva fue la del tercer pagador y los costos se obtuvieron de las tarifas vigentes en una clínica en la ciudad de Bogotá. Se realizaron análisis de sensibilidad determinísticos y probabilísticos. RESULTADOS: La estrategia de no realizar radiografía de tórax a ningún paciente fue dominante en relación con realizarla en todos los casos de manera rutinaria, con un costo promedio de US$ 111,0 y una tasa de diagnósticos correctos de 0,8020, comparados con los valores correspondientes de US$ 129,0 y 0,7873 para la estrategia de tomar radiografía rutinaria a todos estos pacientes. La variable más influyente fue el costo hospitalario de la neumonía. En el análisis de sensibilidad probabilístico, la estrategia de no radiografiar a ningún lactante fue dominante en 61,1 por ciento de las simulaciones. CONCLUSIONES: Los resultados sugieren que no realizar radiografía de tórax de rutina a lactantes con sospecha clínica de bronquiolitis viral es una estrategia costo-efectiva respecto a la práctica común de realizarla en todos estos casos, dado que arroja una mayor proporción de diagnósticos correctos a un menor costo promedio por paciente. No obstante, harán falta nuevos estudios con muestras más representativas de todos los establecimientos de salud e incluir la estrategia de tomar radiografía de tórax únicamente a pacientes que tengan predictores de anormalidades radiológicas.

OBJECTIVE: Estimate the cost-effectiveness of not taking chest x-rays of any infant with clinically suspected viral bronchiolitis versus routinely taking them of all such patients, the most common practice today in Colombia. METHODS: A cost-effectiveness study was conducted, comparing strategies of taking chest x-rays of all infants with clinically suspected viral bronchiolitis and not x-raying any of these infants. The principal outcome was the proportion of correct diagnoses. The time horizon was the clinical course of the bronchiolitis. The perspective was that of the third-party payer, and the costs were obtained from the rates in effect in a clinic in Bogotá. Deterministic and probabilistic sensitivity analyses were performed. RESULTS: The strategy of not taking a chest x-ray of any patient prevailed over that of routinely taking one in all cases, with an average cost of US$ 111.00 and a correct diagnosis rate of 0.8020, versus the respective values of US$ 129.00 and 0.7873 for the strategy of routinely x-raying all of these patients. The most influential variable was pneumonia-related hospital costs. In the probabilistic sensitivity analysis, the strategy of not x-raying any infant prevailed in 61.1 percent of the simulations. CONCLUSIONS: The results suggest that not taking routine chest x-rays of infants with clinically suspected viral bronchiolitis is a cost-effective strategy compared with the common practice of taking them in all cases, since the former yields a greater proportion of correct diagnoses at a lower average cost per patient. Nevertheless, new studies will be needed that have more representative samples from all of the health facilities and include the strategy of taking chest x-rays only of patients with predictors of radiologic abnormalities.

Clinical and economic burden of pneumonia among adults in Latin America.

The clinical and economic burden of adult community-acquired pneumonia (CAP) in Latin America is not well known. We conducted a literature review to describe the etiology, incidence, hospitalization, morbidity and mortality, antibiotic resistance, costs associated with care, and the potential benefits of pneumococcal vaccination in the reduction of adult CAP in Latin America. Data that were published during the period from January 1970 through August 2008 were identified via the Web sites and databases of the Pan American Health Organization, Latin American health agencies, and the US National Institutes of Health, National Library of Medicine (MEDLINE). Streptococcus pneumoniae was identified as the most common pathogen, accounting for up to 35% of CAP cases. The mean rate of CAP due to penicillin-resistant S. pneumoniae was 39%. The mortality in Latin America due to lower respiratory tract infections has been reported to be 6%, compared with 4% in developed regions, and CAP was the third most frequent cause of death in adults in 31 Latin American countries in 2001-2003. Although S. pneumoniae caused the majority of CAP, similar to other regions of the world, mortality due to CAP in Latin America was substantially greater than that in developed countries. This review demonstrates the need to facilitate standardized surveillance and reporting systems to monitor the burden of CAP and to implement prevention strategies to decrease the clinical and economic burden of CAP in Latin American adults.

[Health impact and treatment costs of community-acquired pneumonia in children in the first level of public attention in Argentina]. / Neumonía de la comunidad en niños: impacto sanitario y costos del tratamiento en el primer nivel de atención público de la Argentina.

UNLABELLED: Community acquired pneumonia in children remains an important cause of childhood deaths throughout the world that can be prevented by the use of antibiotics and access to medical care. Both were reduced in 2001 when Argentina suffered a severe social crisis. Among the responses to the crisis, the Remediar Program provided free essential medicines to the socially vulnerable population. OBJECTIVES: Assess the health impact and costs of the provision of free medicines at the first level of public attention for childhood pneumonia. MATERIALS AND METHODS: Three designs: 1. Ecological study with cross comparisons of diagnoses, prescriptions, beneficiaries by individual provinces of Remediar forms. TARGET POPULATION: children under 15 years old attended at 6 thousand health centres in Argentina, encompassing 24 Argentine provinces from March 2005 until February 2006. 2. Counterfactual approach. 3. Calculation of drug costs per unit of outcome. RESULTS: Over 15 million prescriptions were identified, 2,420 children under 1 year, 19,205 of 1 to 4 years and 15,977 from 5 to 14 years old with pneumonia. 90% of beneficiaries received antibiotics, most often amoxicillin. In children's under 5 years of age, Remediar coverage was 27.8%, with greater impact in the poorest provinces. The likely impact was 4,322 lives saved or 310,325 years of life lost avoided if mortality without antibiotics was 20%. Indigents who had children with pneumonia saved by medicines 14.3% of their income. Each life saved could have cost US $ 6.46 and each year of life lost averted US $ 0.09. CONCLUSION: This work highlights the impact of a low-cost health program for the treatment of vulnerable populations with childhood pneumonia in Argentina.

Costo efectividad del gas natural domiciliario como tecnología sanitaria en localidades rurales del Caribe Colombiano / The cost-effectiveness of installing natural gas as a sanitary alternative for rural communities on the Colombian Caribbean coast burning biomass fuels

Objetivo Valorar el impacto económico del Gas Natural Domiciliario -GND- como tecnología sanitaria sobre la enfermedad respiratoria asociada al humo de biomasa en localidades del caribe colombiano. Métodos Tres estudios combinados: a) carga de enfermedad respiratoria asociada al uso de combustibles de biomasa; b) costos de la enfermedad (Infección Respiratoria Aguda -IRA- y Enfermedad Pulmonar Obstructiva Crónica-EPOC); y c) análisis de costo efectividad del GND para reducir morbilidad por enfermedades respiratorias. Resultados En las localidades se esperarían anualmente 498 (477-560) casos de IRA que generaría 149 (119-196) hospitalizaciones, 6 (4-10) muertes y 7 291 (5 746 -9 696) AVAD. También se esperarían 459 (372-684) casos de EPOC, 138 (93- 239) hospitalizaciones, 11 (5-26) muertes y 1 500 (973-2 711) AVAD. Los costos de esta carga de enfermedad en ausencia del GND son anualmente de 5,2 (3,8-8,3) millones de dólares. De éstos, la mayoría son costos de EPOC (cerca del 85 por ciento). Los costos por IRA y EPOC, luego de instalado el GND, ascienden a 3,5 (2,5-5,7) millones de dólares. Los costos evitados serían 1,6 (1,2-2,6) millones de dólares, (30 por ciento de los costos de la carga). El costo efectividad incremental de introducir el GND sería un poco más de 56 (22-74) mil dólares por muerte evitada y entre 43 y 66 dólares evitar un AVAD. Conclusiones Frente a la no intervención, la instalación del GND resulta ser una tecnología costo efectiva para la reducción de las enfermedades respiratorias asociadas al consumo de combustibles de biomasa.

Objective Evaluating the economic impact of natural gas as a sanitary technology regarding respiratory disease associated with indoor air pollution in rural localities on the Colombian Caribbean coast. Methods Three studies were carried out: the burden of respiratory disease was evaluated (acute lower respiratory infection-ALRI and chronic obstructive pulmonary disease - COPD), disease costs were studied and the cost effectiveness of natural gas was analysed in terms of reducing indoor air pollution. Results Without natural gas in these localities, it would be expected that 498 (477-560) cases of ALRI per year would lead to 149 (119-196) hospitalisations, 6 (4-10) deaths and 7 291 (5,746-9,696) disability adjusted life years (DALY) annually. Furthermore, it is expected that 459 (372-684) cases of COPD per year would lead to 138 (93-239), hospitalisations, 11 deaths (5-26) and 1 500 (973-2 711) DALY annually. Annual disease burden cost was 5,2 (3,8-8,3) million dollars before installing domiciliary natural gas (DNG); most of such cost arose from COPD (around 85 percent). ARI and COPD costs after installing DNG would rise to 3,5 (2,5-5,7) million dollars; avoided costs would be 1,6 (1,2-2,6) million dollars, (30 percent of disease burden cost without DNG). The incremental cost-effectiveness (ICER) of installing DNG would be 56 (22-74) thousand dollars per life saved and ICER per DALY saved would be 43-66 dollars. Conclusion DNG is a sanitary technology which reduces the burden of indoor air pollution-associated respiratory diseases arising from burning biomass fuel in rural localities in a cost-effective way.