Making visible the cost of informal caregivers' time in Latin America: a case study for major cardiovascular, cancer and respiratory diseases in eight countries.

BACKGROUND: Informal care is a key element of health care and well-being for society, yet it is scarcely visible and rarely studied in health economic evaluations. This study aims to estimate the time use and cost associated with informal care for cardiovascular diseases, pneumonia and ten different cancers in eight Latin American countries (Argentina, Brazil, Chile, Colombia, Costa Rica, Ecuador, Mexico and Peru). METHODS: We carried out an exhaustive literature review on informal caregivers' time use, focusing on the selected diseases. We developed a survey for professional caregivers and conducted expert interviews to validate this data in the local context. We used an indirect estimate through the interpolation of the available data, for those cases in which we do not found reliable information. We used the proxy good method to estimate the monetary value of the use of time of informal care. National household surveys databases were processed to obtain the average wage per hour of a proxy of informal caregiver. Estimates were expressed in 2020 US dollars. RESULTS: The study estimated approximately 1,900 million hours of informal care annually and $ 4,300 million per year in average informal care time cost for these fifteen diseases and eight countries analyzed. Cardiovascular diseases accounted for an informal care burden that ranged from 374 to 555 h per year, while cancers varied from 512 to 1,825 h per year. The informal care time cost share on GDP varied from 0.26% (Mexico) to 1.38% (Brazil), with an average of 0.82% in the studied American countries. Informal care time cost represents between 16 and 44% of the total economic cost (direct medical and informal care cost) associated with health conditions. CONCLUSIONS: The study shows that there is a significant informal care economic burden -frequently overlooked- in different chronic and acute diseases in Latin American countries; and highlights the relevance of including the economic value of informal care in economic evaluations of healthcare.

Patient Experiences of Integrated Care in Medicare Accountable Care Organizations and Medicare Advantage Versus Traditional Fee-for-Service.

BACKGROUND: Health insurance design can influence the extent to which clinical care is well-coordinated. Through alternative payment models, Medicare Advantage (MA) and Accountable Care Organizations (ACOs) have the potential to improve integration relative to traditional fee-for-service (FFS) Medicare. OBJECTIVE: To characterize patient experiences of integrated care within Medicare and identify whether MA or ACO beneficiaries perceive greater integration than FFS beneficiaries. DESIGN: Retrospective cross-sectional analysis of the 2015 Medicare Current Beneficiary Survey. SUBJECTS: Nationally representative sample of 11,978 Medicare beneficiaries. MEASURES: Main outcomes included 8 previously derived domains of patient-perceived integrated care (PPIC), measured on a scale of 1-4. RESULTS: The final sample was 55% female with a mean (SD) age of 71.1 (11.3). In unadjusted analyses, we observed considerable variation across PPIC domains in the full sample, but little variation across subsamples defined by coverage type within a given PPIC domain. In linear models adjusting for a rich set of patient characteristics, we observe no significant benefits of ACOs nor MA relative to FFS, a finding which is robust to alternative specifications and adjustment for multiple comparisons. We similarly observed no benefits in subgroup analyses restricted to states with relatively high market penetration of ACOs or MA. CONCLUSIONS: Despite characteristics of ACOs and MA that theoretically promote integrated care, we find that PPIC is largely similar across coverage types in Medicare.

Conditional cash transfers, spillovers, and informal health care: Evidence from Peru.

Conditional cash transfer programs have become instrumental in encouraging the use of formal health services in developing countries, but little is known about their effect on the use of low-quality informal care. Using a large survey of Peruvian rural households and a regression discontinuity design, we find a sizeable reduction in the use of informal health care providers not only by targeted but also by nontargeted members of households that qualify for the program. This indicates the existence of spillover effects within the household. We also provide evidence that beyond the direct increase in income, the availability of better information about institutional services is a potential mechanism that drives these effects.

Cost-effectiveness of the utilization of "good practice" or the lack thereof according to a bronchiolitis evidence-based clinical practice guideline.

RATIONALE, AIMS, AND OBJECTIVES: The aim of the present study was to determine the cost-effectiveness of the utilization of "good practice" according to a bronchiolitis clinical practice guideline (CPG) in a population of infants hospitalized for acute bronchiolitis. METHOD: A decision-analysis model was developed in order to estimate the cost-effectiveness of the utilization of "good practice" compared with the lack of use of "good practice" according to a bronchiolitis evidence-based CPG. The effectiveness parameters and costs of the model were obtained from electronic medical records. The main outcome was the readmission of the patients within 10 days of post discharge. RESULTS: Compared with lack of "good practice," the utilization of "good practice" in the diagnosis and management of patients with bronchiolitis was associated with both fewer patients readmitted within 10 days of post discharge (0.88 vs 0.99 on average per patient) and lower costs (US$1529.3 versus $1709.1 average cost per patient), thus leading to dominance. Results were robust to deterministic and probabilistic sensitivity analyses. CONCLUSIONS: Compared with lack of "good practice," the utilization of "good practice" in the diagnosis and management of acute bronchiolitis according to a bronchiolitis CPG is a dominant strategy because it involves both fewer patients readmitted within 10 days of post discharge and lower costs.

Out-of-pocket expenditures and care time for children with Down Syndrome: A single-hospital study in Mexico City.

AIM: To examine the burden of out-of-pocket household expenditures and time spent on care by families responsible for children with Down Syndrome (DS). METHODS: A cross-sectional analysis was performed after surveying families of children with DS. The children all received medical care at the Hospital Infantil de México Federico Gomez (HIMFG), a National Institute of Health. Data were collected on out-of-pocket household expenditures for the medical care of these children. The percentage of such expenditure was calculated in relation to available household expenditure (after subtracting the cost of food/housing), and the percentage of households with catastrophic expenditure. Finally, the time spent on the care of the child was assessed. RESULTS: The socioeconomic analysis showed that 67% of the households with children with DS who received medical care in the HIMFG were within the lower four deciles (I-IV) of expenses, indicating a limited ability to pay for medical services. Yearly out-of-pocket expenditures for a child with DS represented 27% of the available household expenditure, which is equivalent to $464 for the United States dollars (USD). On average, 33% of families with DS children had catastrophic expenses, and 46% of the families had to borrow money to pay for medical expenses. The percentage of catastrophic expenditure was greater for a household with children aged five or older compared with households with younger children. The regression analysis revealed that the age of the child is the most significant factor determining the time spent on care. CONCLUSIONS: Some Mexican families of children with DS incur substantial out-of-pocket expenditures, which constitute an economic burden for families of children who received medical care at the HIMFG.

Utilizing big data to provide better health at lower cost.

PURPOSE: The efficient use of big data in order to provide better health at a lower cost is described. SUMMARY: As data become more usable and accessible in healthcare, organizations need to be prepared to use this information to positively impact patient care. In order to be successful, organizations need teams with expertise in informatics and data management that can build new infrastructure and restructure existing infrastructure to support quality and process improvements in real time, such as creating discrete data fields that can be easily retrieved and used to analyze and monitor care delivery. Organizations should use data to monitor performance (e.g., process metrics) as well as the health of their populations (e.g., clinical parameters and health outcomes). Data can be used to prevent hospitalizations, combat opioid abuse and misuse, improve antimicrobial stewardship, and reduce pharmaceutical spending. These examples also serve to highlight lessons learned to better use data to improve health. For example, data can inform and create efficiencies in care and engage and communicate with stakeholders early and often, and collaboration is necessary to have complete data. To truly transform care so that it is delivered in a way that is sustainable, responsible, and patient-centered, health systems need to act on these opportunities, invest in big data, and routinely use big data in the delivery of care. CONCLUSION: Using data efficiently has the potential to improve the care of our patients and lower cost. Despite early successes, barriers to implementation remain including data acquisition, integration, and usability.

Understanding Time-driven Activity-based Costing.

Transitioning to a value-based health care system will require providers to increasingly scrutinize their outcomes and costs. Although there has been a great deal of effort to understand outcomes, cost accounting in health care has been a greater challenge. Currently the cost accounting methods used by hospitals and providers are based off a fee-for-service system. As resources become increasingly scarce and the health care system attempts to understand which services provide the greatest value, it will be critically important to understand the true costs of delivering a service. An understanding of the true costs of a particular service will help providers make smarter decisions on how to allocate and utilize resources as well as determine which activities are nonvalue added. Achieving value will require providers to have a greater focus on accurate outcome data as well as better methods of cost accounting.

Modern wound care for the poor: a randomized clinical trial comparing the vacuum system with conventional saline-soaked gauze dressings.

BACKGROUND: A clinical randomized trial was performed to determine whether a simple homemade wound vacuum-dressing system (HM-VAC) is a feasible alternative to the use of conventional saline-soaked gauze dressings (WET) for the treatment of complex wounds in a resource-poor hospital. METHODS: Forty patients were analyzed to compare the HM-VAC and the WET dressings. The HM-VAC was assembled with tools available in most operating room worldwide. The primary outcome measure was the time of complete wound healing. Additionally, the costs of both methods were calculated. RESULTS: The time required to achieve complete healing was 16 days in the HM-VAC group compared with 25 days in the WET group (P = .013). The HM-VAC costs US $360 per case, and the WET technique costs US $271 per case (P = .008). CONCLUSIONS: The HM-VAC should be considered in underdeveloped countries to provide modern management for complex wounds because healing is significantly faster compared with conventional wound care. Although the HM-VAC is more costly than the conventional approach, it is probably affordable for most resource-poor hospitals.

Evaluating the impact and costs of deploying an electronic medical record system to support TB treatment in Peru.

The PIH-EMR is a Web based electronic medical record that has been in operation for over four years in Peru supporting the treatment of drug resistant TB. We describe here the types of evaluations that have been performed on the EMR to assess its impact on patient care, reporting, logistics and observational research. Formal studies have been performed on components for drug order entry, drug requirements prediction tools and the use of PDAs to collect bacteriology data. In addition less formal data on the use of the EMR for reporting and research are reviewed. Experience and insights from porting the PIH-EMR to the Philippines, and modifying it to support HIV treatment in Haiti and Rwanda are discussed. We propose that additional data of this sort is valuable in assessing medical information systems especially in resource poor areas.

Costo efectividad de la atención del recién nacido de bajo peso < 2500 gr de madres controladas y no controladas en el Hospital Arzobispo Loayza del 1 junio 1996 al 31 mayo 1997 / Cost effectiveness of the attention of new born of low weight < 2500gr of mothers controlled and not controlled in the Hospital Arzobispo Loayza of the 1 of 31 June 1996 to May 1997

Esta investigación se realizó en el Hospital Nacional Arzobispo Loayza, en los servicios de Neonatología y Gineco-obstetricia en el período de 01 de junio de 1996-31 de mayo de 1997, la población en estudio estuvo conformada por 58 recién nacidos con bajo peso (RNBP), que nacieron en este hospital y pertenecieron a madres controladas y no controladas, y cuyos controles fueron realizados en el hospital de estudio. El estudio tuvo por objetivo determinar los costos en que se incurren en la atención RNBP con el fin de proporcionar información relevante que permita esbozar acciones con miras a una mejor asignación de recursos los hallazgos podrían ofrecer información importante que posibilite la promoción de los beneficios del control prenatal. El costo-efectividad en el estudio se obtuvo comparándose el costo de la atención de los RNBP tanto de madres con y sin control prenatal encontrándose diferencias significativas entre los costos de atención de dichos recién nacidos. Esto debido a que los hijos de madres que no controlaron su embarazo, tuvieron mayor estancia hospitalaria, le correspondió extremo bajo peso, tuvieron mayores complicaciones o patologías agregadas, generándose para ello un mayor costo en su atención. Sin embargo; en el grupo de las madres que controlaron su embarazo sus hijos tuvieron menos estancia hospitalaria, el peso fue > 2,000 gr. tuvieron menor morbilidad, asociándose en este grupo un menor costo para su atención. Finalmente, se concluye que el control prenatal en el estudio resultó ser un factor protector debido a que los RNBP de las madres controladas, tuvieron un menor costo que los hijos de las madres que no se controlaron.

Costo-efectividad en la atención hospitalaria de algunas patológías / Cost-effectiveness in hospital care of some pathologies

Se presentan los resultados del estudio de costo-efectividad realizado en enfermos internados en hospitales públicos del sector norte de Santiago. Corresponden a 181 pacientes con colelitiasis, apendicitis aguda, hernias abdominales, úlceras duodenales, adenoma prostático, embarazo ectópico, IRA e ictericias del recién nacido. Para estimar el costo de la atención médica se emplearon los valores FONASA de Pago Asociado a Diagnóstico (PAD) para estas patologías. La efectividad fue medida por el porcentaje de recuperación completa observada en el seguimiento domiciliario realizado 30 días y 6 meses después del alta. En conjunto, los pacientes tuvieron un 70,2 por ciento de recuperación a 30 días y 84 por ciento a 6 meses plazo. Como el costo promedio de hospitalización alcanzó a $ 414.000, la relación costo-efectividad a 30 días fue de $ 5.900 y a 6 meses de $ 4.960, montos que indican el gasto necesario para mejorar en un punto poncentual el porcentaje de recuperación completa de los pacientes. El costo-efectividad resultó más alto para patologías de manejo quirúrgico, para el género femenino, para adultos de edad media y para beneficiarios de FONASA. Mientras en la atención primaria una buena ecuación de costo-efectividad depende más de la proporción de recuperación de los pacientes que de bajos costos de atención médica, en el caso de la atención hospitalaria el costo-efectividad está fundamentalmente ligado a los costos de operación