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1.
J Surg Res ; 246: 123-130, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31569034

RESUMO

BACKGROUND: National changes in health care disparities within the setting of trauma care have not been examined within Accountable Care Organizations (ACOs) or non-ACOs. We sought to examine the impact of ACOs on post-treatment outcomes (in-hospital mortality, 90-day complications, and readmissions), as well as surgical intervention among whites and nonwhites treated for spinal fractures. MATERIALS AND METHODS: We identified all beneficiaries treated for spinal fractures between 2009 and 2014 using national Medicare fee for service claims data. Claims were used to identify sociodemographic and clinical criteria, receipt of surgery and in-hospital mortality, 90-day complications, and readmissions. Multivariable logistic regression analysis accounting for all confounders was used to determine the effect of race/ethnicity on outcomes. Nonwhites were compared with whites treated in non-ACOs between 2009 and 2011 as the referent. RESULTS: We identified 245,704 patients who were treated for spinal fractures. Two percent of the cohort received care in an ACO, whereas 7% were nonwhite. We found that disparities in the use of surgical fixation for spinal fractures were present in non-ACOs over the period 2009-2014 but did not exist in the context of care provided through ACOs (odds ratio [OR] 0.75; 95% confidence interval [CI] 0.44, 1.28). A disparity in the development of complications existed for nonwhites in non-ACOs (OR 1.09; 95% CI 1.01, 1.17) that was not encountered among nonwhites receiving care in ACOs (OR 1.32; 95% CI 0.90, 1.95). An existing disparity in readmission rates for nonwhites in ACOs over 2009-2011 (OR 1.34; 95% CI 1.01, 1.80) was eliminated in the period 2012-2014 (OR 0.85; 95% CI 0.65, 1.09). CONCLUSIONS: Our work reinforces the idea that ACOs could improve health care disparities among nonwhites. There is also the potential that as ACOs become more familiar with care integration and streamlined delivery of services, further improvements in disparities could be realized.


Assuntos
Organizações de Assistência Responsáveis/estatística & dados numéricos , Fixação de Fratura/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Fraturas da Coluna Vertebral/cirurgia , Organizações de Assistência Responsáveis/economia , Idoso , Idoso de 80 Anos ou mais , Grupos de Populações Continentais/estatística & dados numéricos , Redução de Custos/economia , Redução de Custos/estatística & dados numéricos , Grupos Étnicos , Feminino , Fixação de Fratura/efeitos adversos , Fixação de Fratura/economia , Gastos em Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/organização & administração , Mortalidade Hospitalar , Humanos , Masculino , Medicare/economia , Medicare/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade/estatística & dados numéricos , Fatores Socioeconômicos , Fraturas da Coluna Vertebral/economia , Estados Unidos/epidemiologia
2.
Int J Equity Health ; 18(1): 154, 2019 10 15.
Artigo em Inglês | MEDLINE | ID: mdl-31615526

RESUMO

INTRODUCTION: In Africa, a majority of women bring their infant to health services for immunization, but few are checked in the postpartum (PP) period. The Missed opportunities for maternal and infant health (MOMI) EU-funded project has implemented a package of interventions at community and facility levels to uptake maternal and infant postpartum care (PPC). One of these interventions is the integration of maternal PPC in child clinics and infant immunization services, which proved to be successful for improving maternal and infant PPC. AIM: Taking stock of the progress achieved in terms of PPC with the implementation of the interventions, this paper assesses the economic cost of maternal PPC services, for health services and households, before and after the project start in Kaya health district (Burkina Faso). METHODS: PPC costs to health services are estimated using secondary data on personnel and infrastructure and primary data on time allocation. Data from two household surveys collected before and after one year intervention among mothers within one year PP are used to estimate the household cost of maternal PPC visits. We also compare PPC costs for households and health services with or without integration. We focus on the costs of the PPC intervention at days 6-10 that was most successful. RESULTS: The average unit cost of health services for days 6-10 maternal PPC decreased from 4.6 USD before the intervention in 2013 (Jan-June) to 3.5 USD after the intervention implementation in 2014. Maternal PPC utilization increased with the implementation of the interventions but so did days 6-10 household mean costs. Similarly, the household costs increased with the integration of maternal PPC to BCG immunization. CONCLUSION: In the context of growing reproductive health expenditures from many funding sources in Burkina Faso, the uptake of maternal PPC led to a cost reduction, as shown for days 6-10, at health services level. Further research should determine whether the increase in costs for households would be deterrent to the use of integrated maternal and infant PPC.


Assuntos
Serviços de Saúde Comunitária/economia , Redução de Custos/economia , Acesso aos Serviços de Saúde/economia , Serviços de Saúde Materna/economia , Adulto , Burkina Faso , Assistência à Saúde/economia , Eficiência Organizacional , Feminino , Humanos , Imunização/economia , Lactente , Cuidado Pós-Natal/economia , Período Pós-Parto , Gravidez
3.
Am J Health Syst Pharm ; 76(18): 1413-1419, 2019 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-31372630

RESUMO

PURPOSE: Inhaled epoprostenol and inhaled nitric oxide are pulmonary vasodilators commonly used in the management of acute respiratory distress syndrome and right ventricular failure; however, they have vastly different cost profiles. The purpose of the project was to transition from nitric oxide to epoprostenol as the inhaled pulmonary vasodilator (IPV) of choice in adult critically ill patients and evaluate the effect of the transition on associated usage and costs. METHODS: A single-center, prospective, before and after quality improvement project including adult patients receiving inhaled nitric oxide, inhaled epoprostenol, or both was conducted in 7 adult intensive care units, operating rooms, and postanesthesia care units of a tertiary care academic medical center. The total number of patients, hours of therapy, and costs for each agent were compared between stages of protocol implementation and annually. RESULTS: Seven hundred twenty-nine patients received inhaled nitric oxide, inhaled epoprostenol, or both during the study period. The monthly inhaled nitric oxide use in number of patients, hours, and cost decreased during all stages of the project (p < 0.01). The monthly inhaled epoprostenol use in number of patients, hours, and cost increased during all stages (p < 0.01). Overall, total IPV use increased during the study. However, despite this increase in usage, there was a 47% reduction in total IPV cost. CONCLUSION: Implementation of a staged protocol to introduce and expand inhaled epoprostenol use in adult critically ill patients resulted in decreased use and cost of inhaled nitric oxide. The total cost of all IPV was decreased by 47% despite increased IPV use.


Assuntos
Epoprostenol/administração & dosagem , Óxido Nítrico/administração & dosagem , Melhoria de Qualidade/organização & administração , Síndrome do Desconforto Respiratório do Adulto/tratamento farmacológico , Vasodilatadores/administração & dosagem , Administração por Inalação , Adulto , Redução de Custos/economia , Redução de Custos/estatística & dados numéricos , Estado Terminal/terapia , Custos de Medicamentos/estatística & dados numéricos , Uso de Medicamentos/economia , Uso de Medicamentos/estatística & dados numéricos , Epoprostenol/economia , Implementação de Plano de Saúde , Humanos , Pulmão/irrigação sanguínea , Pulmão/efeitos dos fármacos , Óxido Nítrico/economia , Avaliação de Programas e Projetos de Saúde , Estudos Prospectivos , Melhoria de Qualidade/economia , Melhoria de Qualidade/estatística & dados numéricos , Síndrome do Desconforto Respiratório do Adulto/economia
4.
J Manag Care Spec Pharm ; 25(9): 984-988, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31456492

RESUMO

BACKGROUND: This study summarizes the potential financial impact of a 3-year collaboration focused on delivering disease management services through pharmacies in 12 rural Colorado communities. OBJECTIVES: To (a) identify components within the disease management program that would be billable and generate revenue to each pharmacy and (b) estimate the revenue amount that could be generated based on these services across the 3-year project. METHODS: Reimbursable services included diabetes self-management education; medication therapy management services, including the comprehensive medication review; and improvements in Medicare star ratings through pharmacy interventions. RESULTS: An estimated total of $117,800 could have been generated by services provided to patients across the 12 pharmacy sites. After subtracting the estimated cost of labor for a pharmacist to provide these services, an estimated net profit of $60,023 resulted over 3 years. Star rating impacts were discussed but were not able to be included as specific revenue based on the complex contracting between pharmacies and third-party insurers. CONCLUSIONS: Based on these estimates, delivery of chronic disease management could represent a financially feasible option for community pharmacists. Some credentialing and changes to the mode of delivery would be required to meet billing requirements. Further research is needed to better estimate the cost savings resulting from these services to possibly expand pharmacists' reimbursement opportunities. DISCLOSURES: This publication was supported by Cooperative Agreement Number DP004796-05, funded by the Centers for Disease Control and Prevention. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services. None of the authors have any conflicts of interest to disclose regarding this work.


Assuntos
Serviços Comunitários de Farmácia/economia , Conduta do Tratamento Medicamentoso/economia , Farmácias/economia , Farmacêuticos/economia , Colorado , Redução de Custos/economia , Gerenciamento Clínico , Humanos , Medicare/economia , Adesão à Medicação , Estados Unidos
5.
Plast Reconstr Surg ; 144(5): 1182-1195, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31441805

RESUMO

BACKGROUND: Several studies have demonstrated a reduced wound complication rate when immediate soft-tissue reconstruction is performed after complex spine instrumentations in high-risk patients; however, the cost-effectiveness of this technique is not known. The authors hypothesized that immediate soft-tissue reconstruction of oncologic spine wounds would be a cost-effective strategy compared with the standard of care (i.e., oncologic spine surgery with conventional primary wound closure). METHODS: The authors used a decision tree model to evaluate the cost-utility, from the perspective of a hospital/insurer, of immediate reconstruction relative to the standard of care after oncologic spine surgery. A systematic review of the literature on oncologic spine surgery and immediate and delayed spinal wound reconstruction was performed to estimate health state probabilities. Overall expected cost and quality-adjusted life-years were assessed using a Monte Carlo simulation and sensitivity analyses. RESULTS: Immediate soft-tissue reconstruction after oncologic spine surgery had an expected cost of $81,458.90 and an expected average of 24.19 quality-adjusted life-years, whereas primary wound closure (no reconstruction) had an expected cost of $83,434.34 and an expected average of 24.17 quality-adjusted life-years, making immediate reconstruction the dominant, most cost-effective strategy. Monte Carlo sensitivity analysis demonstrated that immediate reconstruction was the preferred and most cost-effective option in the majority of simulations. Even when the willingness-to-pay threshold varied from $0 to $100,000 per quality-adjusted life-year, immediate reconstruction remained the dominant strategy across all iterations. CONCLUSION: This cost-utility analysis suggests that immediate soft-tissue reconstruction after oncologic spine surgery is more cost-effective than primary closure alone.


Assuntos
Análise Custo-Benefício , Árvores de Decisões , Procedimentos Cirúrgicos Reconstrutivos/economia , Neoplasias da Coluna Vertebral/cirurgia , Técnicas de Fechamento de Ferimentos/economia , Cicatrização/fisiologia , Redução de Custos/economia , Feminino , Humanos , Masculino , Cuidados Pós-Operatórios/métodos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Lesões dos Tecidos Moles/cirurgia , Fatores de Tempo
6.
Eur Addict Res ; 25(5): 224-228, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31216535

RESUMO

IMPORTANCE: According to recent studies, only a small proportion of alcoholics in the system for addiction treatment receive expedited treatment [Rehm et al.: Sucht 2014;60:93-105] and that those who are untreated are at risk of harmful and dependent alcohol consumption. This is associated with significantly negative effects on morbidity, mortality, and quality of life [Kraus et al.: Sucht 2010;56:337-347]. As a result, not only individuals and their environment suffer but there is also a health economic impact. OBJECTIVE: How often do patients with a primary or secondary diagnosis of alcohol dependence who have been discharged from inpatient treatment receive anticraving medication in the follow-up period of 6 months? DESIGN, SETTING, AND PARTICIPANTS: Based on data from a statutory health insurance in Germany, 12,958 patients were investigated regarding alcohol dependence, rates for readmission to hospital, and prescription of anticraving drugs. In addition, outpatient and inpatient treatment costs were calculated. Main Outcomes and Measures: There will be an examination of how often anticraving medications are prescribed and what the economic consequences are. RESULTS: Two hundred and eighty-eight (2.22%) patients received anticraving medication, 98 (0.76%) in the first 6 months after inpatient treatment. Fifty-nine of the 288 patients were monitored with a pre- and postcomparison over a 90-day period. Inpatient treatment fell from 0.83 times (±1.10) during the 3 months afterward to 0.79 (±1.01). On average, the duration of an inpatient stay before anticraving treatment (n = 29) was 17.34 days (±14.37), with an average cost of EUR 4,142.70 (±2,721.28). Among the anticraving treatment group, this fell to 14.03 days (±9.96) with an average cost of EUR 3,685.43 (±2,307.67). Overall, the average outpatient and inpatient treatment costs dropped from EUR 1,533.88 before treatment to EUR 1,462.76 after treatment. If this is extrapolated to the whole group, it leads to between EUR 921,500 and EUR 6.6 million saving for a health insurance company. CONCLUSION: Anticraving medications are hardly ever prescribed. Their routine use could reduce hospital readmission rates and save on health-care costs.


Assuntos
Dissuasores de Álcool/uso terapêutico , Alcoolismo , Redução de Custos/economia , Naltrexona/uso terapêutico , Padrões de Prática Médica , Alcoolismo/tratamento farmacológico , Alcoolismo/economia , Feminino , Alemanha , Hospitalização , Humanos , Pacientes Internados , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos
7.
Integr Cancer Ther ; 18: 1534735419839466, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30938212

RESUMO

BACKGROUND: The physical and economic toll of cancer make it a high health priority. The rising cost of cancer care is now a primary focus for patients, payers, and providers. Escalating costs of clinical trials and national drug regulations have led the median monthly costs of cancer drugs to rise from less than $100 in 1965 to 1969, to more than $5000 in 2005 to 2009, stressing the importance of finding innovative ways to reduce cost burden. In the present study, we report the economic evaluation of an individualized exercise oncology program beginning early after diagnosis. METHODS: An independent research group, ASCEND Innovations, retrospectively analyzed patient records to statistically demonstrate the impact of exercise oncology during cancer treatment. All patients completed 12 weeks of prescribed, individualized exercise that included cardiovascular, strength training, and flexibility components. The 3 primary hospital measures leveraged for statistical comparison before and after supportive care enrollment were number of encounters, number of readmissions, and average total charges, as well as emergency room visits and length of hospital stay ( P < .05). RESULTS: The resulting dataset consisted of 1493 total hospital encounters for 147 unique patients. The results statistically demonstrate a positive effect of exercise oncology during cancer care, in terms of reductions in overall cost per patient pre- to post-intervention. CONCLUSIONS: Individualized exercise oncology programs should be employed as part of the national standard of care for individuals battling cancer, in order to improve patient outcome and reduce cost burden.


Assuntos
Redução de Custos/economia , Exercício Físico/fisiologia , Neoplasias/economia , Neoplasias/fisiopatologia , Feminino , Humanos , Tempo de Internação/economia , Masculino , Oncologia/economia , Pessoa de Meia-Idade , Estudos Retrospectivos
8.
Am J Health Syst Pharm ; 76(Supplement_1): S15-S20, 2019 Feb 08.
Artigo em Inglês | MEDLINE | ID: mdl-30753317

RESUMO

Purpose: The accuracy of cost savings and reimbursement predictions for medications added to an academic medical center formulary was assessed. Methods: Formulary changes over a 5-year period were reviewed by the investigators. Medications were included if the medication was added to formulary and the monograph included cost savings or reimbursement data that indicated a positive net margin. The primary endpoints were percent predicted cost savings and net margin per medication based on medication cost only. Secondary endpoints included the percent of medications with at least 100% predicted cost savings or net margin and evaluation of median percent predicted savings or net margin individually. Results: The pharmacy and therapeutics committee reviewed 558 formulary agenda items, 184 of which were selected for further analysis. In total, 19 medications were identified as having a predicted monetary advantage. The endpoints of percent predicted cost savings and net margin yielded a median of 76.5% (range 72.9-188.71%) (n = 3) and 148.2% (IQR 108.9-543.3%) (n = 16), respectively. For 13 (68%) of 19 medications, the percent predicted cost savings or net margin was at least 100%. Conclusion: Economic predictions utilized for formulary management at an academic medical center generated net positive monetary value for medications where predicted cost savings or reimbursement factored into the decision to add a medication to the formulary.


Assuntos
Centros Médicos Acadêmicos/organização & administração , Redução de Custos , Tomada de Decisões Gerenciais , Formulários de Hospitais como Assunto , Reembolso de Seguro de Saúde/economia , Centros Médicos Acadêmicos/economia , Redução de Custos/economia , Redução de Custos/métodos , Custos de Medicamentos , Humanos , Mecanismo de Reembolso/economia
9.
Med Care ; 57(3): 218-224, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30676355

RESUMO

BACKGROUND: Medication adherence is associated with lower health care utilization and savings in specific patient populations; however, few empirical estimates exist at the population level. OBJECTIVE: The main objective of this study was to apply a data-driven approach to obtain population-level estimates of the impact of medication nonadherence among Medicare beneficiaries with chronic conditions. RESEARCH DESIGN: Medicare fee-for-service (FFS) claims data were used to calculate the prevalence of medication nonadherence among individuals with diabetes, heart failure, hypertension, and hyperlipidemia. Per person estimates of avoidable health care utilization and spending associated with medication adherence, adjusted for healthy adherer effects, from prior literature were applied to the number of nonadherent Medicare beneficiaries. SUBJECTS: A 20% random sample of community-dwelling, continuously enrolled Medicare FFS beneficiaries aged 65 years or older with Part D (N=14,657,735) in 2013. MEASURES: Avoidable health care costs and hospital use from medication nonadherence. RESULTS: Medication nonadherence for diabetes, heart failure, hyperlipidemia, and hypertension resulted in billions of Medicare FFS expenditures, millions in hospital days, and thousands of emergency department visits that could have been avoided. If the 25% of beneficiaries with hypertension who were nonadherent became adherent, Medicare could save $13.7 billion annually, with over 100,000 emergency department visits and 7 million inpatient hospital days that could be averted. CONCLUSION: Medication nonadherence places a large resource burden on the Medicare FFS program. Study results provide actionable information for policymakers considering programs to manage chronic conditions. Caution should be used in summing estimates across disease groups, assuming all nonadherent beneficiaries could become adherent, and applying estimates beyond the Medicare FFS population.


Assuntos
Doença Crônica/economia , Planos de Pagamento por Serviço Prestado/economia , Gastos em Saúde/estatística & dados numéricos , Medicare Part D/economia , Adesão à Medicação/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Doença Crônica/terapia , Redução de Custos/economia , Serviço Hospitalar de Emergência , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Humanos , Medicare Part D/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos
10.
J Surg Res ; 236: 110-118, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30694743

RESUMO

BACKGROUND: Surgical supplies occupy a large portion of health care expenditures but is often under the surgeon's control. We sought to assess whether an automated, surgeon-directed, cost feedback system can decrease supply expenditures for five common general surgery procedures. MATERIALS AND METHODS: An automated "surgical receipt" detailing intraoperative supply costs was generated and emailed to surgeons after each case. We compared the median cost per case for 18 mo before and after implementation of the surgical receipt. We controlled for price fluctuations by applying common per-unit prices in both periods. We also compared the incision time, case length booking accuracy, length of stay, and postoperative occurrences. RESULTS: Median costs decreased significantly for open inguinal hernia ($433.45 to $385.49, P < 0.001), laparoscopic cholecystectomy ($886.77 to $816.13, P = 0.002), and thyroidectomy ($861.21 to $825.90, P = 0.034). Median costs were unchanged for laparoscopic appendectomy and increased significantly for lumpectomy ($325.67 to $420.53, P < 0.001). There was an increase in incision-to-closure minutes for open inguinal hernia (71 to 75 min, P < 0.001) and laparoscopic cholecystectomy (75 to 96 min, P < 0.001), but a decrease in thyroidectomy (79 to 73 min, P < 0.001). There was an increase in booking accuracy for laparoscopic appendectomy (38.6% to 55.0%, P = 0.001) and thyroidectomy (32.5% to 48.1%, P = 0.001). There were no differences in postoperative occurrence rates and length of stay duration. CONCLUSIONS: An automated surgeon-directed surgical receipt may be a useful tool to decrease supply costs for certain procedures. However, curtailing surgical supply costs with surgeon-directed cost feedback alone is challenging and a multimodal approach may be necessary.


Assuntos
Equipamentos e Provisões Hospitalares/economia , Custos Hospitalares/organização & administração , Salas Cirúrgicas/economia , Cirurgiões/organização & administração , Procedimentos Cirúrgicos Operatórios/economia , Redução de Custos/economia , Redução de Custos/estatística & dados numéricos , Análise Custo-Benefício , Correio Eletrônico , Equipamentos e Provisões Hospitalares/estatística & dados numéricos , Estudos de Viabilidade , Retroalimentação , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Salas Cirúrgicas/organização & administração , Duração da Cirurgia , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Cirurgiões/economia , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos
11.
Eur J Health Econ ; 20(4): 625-632, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30600467

RESUMO

Aortic stenosis (AS) is the most common valvular heart disease, with a dismal prognosis when untreated. Recommended therapy is surgical (SAVR) or transcatheter (TAVR) aortic valve replacement. Based on a retrospective cohort of isolated SAVR and TAVR procedures performed in Germany in 2015 (N = 17,826), we examine the impact of treatment selection on in-hospital mortality and total in-hospital costs for a variety of at-risk populations. Since patients were not randomized to the two treatment options, the two endpoints in-hospital mortality and reimbursement are analyzed using logistic and linear regression models with 20 predefined patient characteristics as potential confounders. Incremental cost-effectiveness ratios were calculated as a ratio of the risk-adjusted reimbursement and mortality differences with 95% confidence intervals obtained by Fieller's theorem. Our study shows that TF-TAVR is more costly that SAVR and that cost differences between the procedures vary little between patient groups. Results regarding in-hospital mortality are mixed. SAVR is the predominant procedure among younger patients. For patients older than 85 years or at intermediate and higher pre-operative risk TF-TAVR seems to be the treatment of choice. Incremental cost-effectiveness ratios (ICER) are most favorable for patients older than 85 years (ICER €154,839, 95% CI €89,163-€302,862), followed by patients at higher pre-operative risk (ICER €413,745, 95% CI €258,027-€952,273). A hypothetical shift from SAVR towards TF-TAVR among patients at intermediate pre-operative risk is associated with a less favorable ICER (€1,486,118, 95% CI €764,732-€23,692,323), as the risk-adjusted mortality benefit is relatively small (- 0.97% point), while the additional reimbursement is still eminent (+€14,464). From a German healthcare system payer's perspective, the additional costs per life saved due to TAVR are most favorable for patients older than 85 and/or at higher pre-operative risk.


Assuntos
Redução de Custos/estatística & dados numéricos , Substituição da Valva Aórtica Transcateter/economia , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/economia , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/cirurgia , Redução de Custos/economia , Registros Eletrônicos de Saúde/estatística & dados numéricos , Feminino , Alemanha/epidemiologia , Implante de Prótese de Valva Cardíaca/economia , Implante de Prótese de Valva Cardíaca/mortalidade , Implante de Prótese de Valva Cardíaca/estatística & dados numéricos , Custos Hospitalares/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Modelos Lineares , Modelos Logísticos , Masculino , Substituição da Valva Aórtica Transcateter/mortalidade , Substituição da Valva Aórtica Transcateter/estatística & dados numéricos
12.
BMC Geriatr ; 19(1): 1, 2019 01 03.
Artigo em Inglês | MEDLINE | ID: mdl-30606112

RESUMO

BACKGROUND: Accidental falls, especially for the elderly, are a major health issue. Balance disorders are one of their main causes. Vestibular rehabilitation (VR) has proven to be useful in improving balance of elderly patients with instability. Its major handicap is probably its cost, which has prevented its generalisation. So, we have designed a clinical trial with posturographic VR, to assess the optimum number of sessions necessary for a substantial improvement and to compare computerised dynamic posturography (CDP) (visual feedback) and mobile posturography (vibrotactile feedback). METHODS: Design: randomized controlled trial. It is an experimental study, single-center, open, randomized (balanced blocks of patients) in four branches in parallel, in 220 elderly patients with high risk of falls; follow-up period: twelve months. SETTING: Department of Otorhinolaryngology of a tertiary referral hospital. PARTICIPANTS: people over 65 years, fulfilling two or more of the following requirements: a) at least one fall in the last twelve months. b) take at least 16 s or require some support in perform the "timed up and go" test. c) a percentage of average balance in the sensory organization test (SOT) of the CDP < 68%. d) at least one fall in any of the conditions in SOT-CDP. e) a score in Vertiguard's gSBDT > 60%. INTERVENTION: Four differents protocols of vestibular rehabilitation (randomization of the patients). MAIN OUTCOME MEASURE: The percentage of average balance in the SOT-CDP. Secondary measures: time and supports in the "timed up and go" test, scores of the CDP and Vertiguard, and rate of falls. DISCUSSION: Posturographic VR has been proven to be useful for improving balance and reducing the number of falls among the aged. However, its elevated cost has limited its use. It is possible to implement two strategies that improve the cost-benefit of posturography. The first involves optimising the number of rehabilitation sessions; the second is based on the use of cheaper posturography systems. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03034655. Registered on 25 January 2017.


Assuntos
Acidentes por Quedas/economia , Redução de Custos/economia , Exercício Físico/fisiologia , Equilíbrio Postural/fisiologia , Tato/fisiologia , Vibração/uso terapêutico , Acidentes por Quedas/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Dispositivos Eletrônicos Vestíveis/economia
13.
J Clin Microbiol ; 57(1)2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30355758

RESUMO

Blood culture contamination results in increased hospital costs and exposure to antimicrobials. We evaluated the potential clinical and economic benefits of an initial specimen diversion device (ISDD) when routinely utilized for blood culture collection in the emergency department (ED) of a quaternary care medical center. A decision analysis model was created to identify the cost benefit of the use of the ISDD device in the ED. Probabilistic costs were determined from the published literature and the direct observation of pharmacy/microbiology staff. The primary outcome was the expected per-patient cost savings (microbiology, pharmacy, and indirect hospital costs) with the routine use of an ISDD from a hospital perspective. The indirect costs included those related to an increased hospital length of stay, additional procedures, adverse drug reactions, and hospital-acquired infections. Models were created to represent hospitals that routinely or do not routinely use rapid diagnostic tests (RDT) on positive blood cultures. The routine implementation of ISDD for blood culture collection in the ED was cost beneficial compared to conventional blood culture collection methods. When implemented in a hospital utilizing RDT with a baseline contamination rate of 6%, ISDD use was associated with a cost savings of $272 (3%) per blood culture in terms of overall hospital costs and $28 (5.4%) in direct-only costs. The main drivers of cost were baseline contamination rates and the duration of antibiotics given to patients with negative blood cultures. These findings support the routine use of ISDD during blood culture collection in the ED as a cost-beneficial strategy to reduce the clinical and economic impact of blood culture contamination in terms of microbiology, pharmacy, and wider indirect hospital impacts.


Assuntos
Hemocultura/métodos , Coleta de Amostras Sanguíneas/instrumentação , Análise Custo-Benefício , Erros de Diagnóstico/prevenção & controle , Serviço Hospitalar de Emergência/economia , Contaminação de Equipamentos/prevenção & controle , Antibacterianos/economia , Antibacterianos/uso terapêutico , Redução de Custos/economia , Infecção Hospitalar/economia , Infecção Hospitalar/prevenção & controle , Técnicas de Apoio para a Decisão , Contaminação de Equipamentos/economia , Custos Hospitalares , Humanos
14.
Diagn Microbiol Infect Dis ; 93(2): 136-139, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30293678

RESUMO

OBJECTIVE: In an era of rising healthcare expenditures, it is critical to find ways to decrease cost. The objective of this study is to evaluate the number of repeated tests and the associated cost savings in a university-affiliated hospital. METHODS: The following 7 microbiology analysis were assessed for nonrepeat testing: HCV antibody, HBV core antibody, CMV IgG, rubella IgG, Treponema pallidum antibodies, Clostridioides difficile toxin detection, and vancomycin-resistant enterococci PCR. Presence of a prior positive result leads to the cancellation of subsequent orders. RESULTS: Percentages of not repeated test ranged from 0.1% to 21.4%. Rubella IgG had the highest proportion of unnecessary repeat testing. Total cost savings were estimated at $33,627 for 2016. CONCLUSION: Unnecessary repeated microbiologic test can account for a non-negligible part of total volume test. Use of an automated software to detect unnecessary repeated microbiologic test through laboratory information system can generate important savings.


Assuntos
Sistemas de Informação em Laboratório Clínico/economia , Técnicas de Laboratório Clínico/economia , Redução de Custos/economia , Procedimentos Desnecessários/economia , Sistemas de Informação em Laboratório Clínico/estatística & dados numéricos , Técnicas de Laboratório Clínico/estatística & dados numéricos , Redução de Custos/estatística & dados numéricos , Humanos , Procedimentos Desnecessários/estatística & dados numéricos
15.
Can J Surg ; 62(1): 20-24, 2019 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-30265646

RESUMO

BACKGROUND: A substantial portion of the cost of total knee arthroplasty (TKA) results from the postoperative inpatient length of stay (LOS). Considering the annual increase in TKAs, reducing LOS represents a potential for cost savings. We sought to compare in-hospital costs and patient-reported outcomes for an early discharge protocol compared with the standard LOS following TKA. METHODS: We conducted a retrospective matched cohort study, matching patients on age, sex, body mass index and preoperative Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC) score. We compared costs associated with time in the operating room, intraoperative pain control and inpatient stay as well as 1-year postoperative patient-reported outcomes between early discharge and standard LOS groups. RESULTS: We included 50 patients in our study (25 per group). The average LOS in the early discharge group was 26.5 hours, compared with 48.9 hours in the standard care group. The early discharge group had higher intraoperative costs associated with pain control (mean difference 26.98, 95% confidence interval 14.41-37.90, p < 0.01); however, this difference was offset by substantial savings associated with the reduced LOS. The mean total cost for the early discharge group was $649.62 ± $281.71 versus $1279.71 ± $515.98 for the standard care group. There were no significant differences in SF12 or WOMAC scores between groups at 1 year postoperative. CONCLUSION: In-hospital costs were significantly lower with a postoperative day 1 discharge protocol than with standard LOS following TKA, with no difference in patient-reported outcomes.


Assuntos
Artroplastia do Joelho/economia , Redução de Custos/economia , Custos Hospitalares , Tempo de Internação/economia , Medidas de Resultados Relatados pelo Paciente , Idoso , Protocolos Clínicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente/economia , Estudos Retrospectivos , Resultado do Tratamento
16.
J Ultrasound Med ; 38(8): 2133-2140, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30593670

RESUMO

OBJECTIVES: Point-of-care ultrasonography (POCUS) is an increasingly integral part of emergency medicine. This study investigated community emergency department physicians' choices regarding ultrasonography as a branch point in clinical decision making. METHODS: During shifts covering all days of the week and all time-spans over a 3-month period, emergency department physicians were interviewed whenever POCUS was used. Questions focused on the role of POCUS in clinical management and on tests avoided because of ultrasonography use. Cost savings attributable to POCUS were calculated using Center for Medicare and Medicaid Services and FairHealth data. Anonymization of data precluded follow-up testing to account for misdiagnosis. RESULTS: On average, POCUS use eliminated $1134.31 of additional testing for privately insured patients, $2826.31 for out-of-network or uninsured patients, and $181.63 for Center for Medicare and Medicaid Services patients. Differences were significant when the total cost of eliminated additional testing was compared to a baseline of no savings (p < .001). Aggregate cost savings remained significant when analyses were broadened to include POCUS encounters that did not yield changes in management (p < .001). CONCLUSIONS: When physicians' clinical expertise suggests that POCUS may be indicated, its use results in significant cost savings, even in encounters in which management is not directly impacted. POCUS, when incorporated earlier and more frequently into community hospital emergency medicine diagnostic protocols, can lower direct and indirect costs associated with diagnostic workups. Community emergency departments, in particular, would benefit from additional investigation informing specific guidelines for the integration of POCUS into clinical management and the role that this has in cost savings.


Assuntos
Tomada de Decisão Clínica/métodos , Redução de Custos/economia , Serviço Hospitalar de Emergência , Sistemas Automatizados de Assistência Junto ao Leito/economia , Ultrassonografia/economia , Ultrassonografia/métodos , Humanos
17.
Spine (Phila Pa 1976) ; 44(4): 298-304, 2019 02 15.
Artigo em Inglês | MEDLINE | ID: mdl-30045344

RESUMO

STUDY DESIGN: Retrospective analysis of Medicare claims and procedure details from a single institution participation in the Bundled Payments for Care Improvement (BPCI) program. OBJECTIVE: To analyze the effects of the BPCI program on patient outcome metrics and cost data. SUMMARY OF BACKGROUND DATA: The BPCI program was designed to improve the value of care provided to patients, but the financial consequences of this system remain largely unknown. We present 2 years of data from participation in the lumbar spine fusion bundle at a large, urban, academic institution. METHODS: In 2013 and 2014, all Medicare patients undergoing lumbar spine fusions for DGR 459 (spinal fusion except cervical with major complication or comorbidity [MCC]) and 460 (without MCC) at our institution were enrolled in the BPCI program. We compared the BPCI cohort to a baseline cohort of patients under the same diagnosis related groups (DRGs) from 2009 to 2012 from which the target price was established. RESULTS: Three hundred fifty patients were enrolled into the BPCI program, while the baseline group contained 518 patients. When compared with the baseline cohort, length of stay decreased (4.58 ±â€Š2.51 vs. 5.13 ±â€Š3.75; P = 0.009), readmission rate was unchanged, and discharges with home health aid increased. Nonetheless, we were unable to effect an episode-based cost savings ($52,655 ±â€Š27,028 vs. $48,913 ±â€Š24,764). In the larger DRG 460 group, total payments increased in the BPCI group ($51,105 ±â€Š26,347 vs. $45,934 ±â€Š19,638, P = 0.001). Operative data demonstrated a more complex patient mix in the BPCI cohort. The use of interbody fusions increased from 2% to 16% (P < 0.001), and the percentage of complex spines increased from 23% to 45% (P < 0.001). CONCLUSION: Increased case complexity was responsible for increasing costs relative to the negotiated baseline target price. This payment system may discourage advancement in spine surgery due to the financial penalty associated with novel techniques and technologies. LEVEL OF EVIDENCE: 3.


Assuntos
Redução de Custos/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Medicare/economia , Pacotes de Assistência ao Paciente/economia , Doenças da Coluna Vertebral/economia , Fusão Vertebral/economia , Idoso , Grupos Diagnósticos Relacionados , Serviços de Assistência Domiciliar/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Medicare/estatística & dados numéricos , Alta do Paciente , Readmissão do Paciente/estatística & dados numéricos , Melhoria de Qualidade , Mecanismo de Reembolso , Estudos Retrospectivos , Doenças da Coluna Vertebral/cirurgia , Estados Unidos
18.
Am Surg ; 85(12): 1405-1408, 2019 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-31908227

RESUMO

Instrument choices are influenced primarily by a surgeon's training and individual preference. Cost is often of secondary interest, particularly in the absence of any contracted fiscal obligation to the hospital. The purpose of this study was to evaluate how a simple intervention involving dissemination of cost data among a surgeon peer group influenced behavior with respect to surgical instrument choice. Cost data for laparoscopic appendectomies between July-December 2016 were disseminated to surgeons belonging to the same department of a teaching hospital. Each surgeon was provided his or her own cost data along with blinded data for his or her peers for comparison. Cost for each disposable instrument used among the group was provided for reference. Costs of laparoscopic appendectomy performed after the intervention (June-December 2017) were compared with costs before the intervention, for both individual surgeons and the group as a whole. A random effects linear regression model clustered on surgeon was then used to assess the average cost saving of the intervention while accounting for the intracorrelation of surgeon costs. One outlier was removed from the analysis, resulting in a cohort of 89 cases before the intervention and 74 postintervention. After outlier removal, data were normally distributed. The mean cost per case decreased for 10 of the 11 surgeons analyzed (minimum decrease of $7 to maximum decrease of $725). The remaining surgeon increased from an average of $985 ± 235 pre-intervention to $1003 ± 227 postintervention. The average cost saving for the group was $238 ± 226 and was associated with an average reduction in cost of 21 per cent. A linear regression analysis clustered on surgeon suggested the intervention was associated with an average saving of $260 (ß = -260, SE = 39, P < 0.001). After dissemination of cost data among surgeon peers, a reduction in costs was observed. Most notably, significant savings occurred in the absence of any mandate or incentive to reduce costs. Providing cost data to surgeons to facilitate natural competition among peers is a simple and effective tool for reducing operating room costs.


Assuntos
Apendicectomia/economia , Redução de Custos/métodos , Custos de Cuidados de Saúde/estatística & dados numéricos , Laparoscopia/economia , Apendicectomia/métodos , Redução de Custos/economia , Custos e Análise de Custo/métodos , Humanos , Disseminação de Informação/métodos , Laparoscopia/métodos , Padrões de Prática Médica/economia , Padrões de Prática Médica/estatística & dados numéricos , Cirurgiões
19.
BMC Health Serv Res ; 18(1): 862, 2018 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-30442126

RESUMO

BACKGROUND: During the last decade, pathology services in England have undergone profound changes with an extensive consolidation of laboratories. This has been driven by some national reviews forecasting a national reduction of costs by £250-£500 million ($315-$630 million) a year as a result. The main aim of this paper is to describe the financial impact of such consolidation, with a specific focus on the forecasted savings. A secondary aim is to describe the development of private sector involvement in laboratory services in a traditionally publicly funded healthcare system and the development of pathology staff size. METHODS: In the English scenario, the majority of hospitals and laboratories are publicly funded and a survey was sent as Freedom of Information request to all directors of pathology. A descriptive comparison of savings among consolidated and non-consolidated pathology services was made by using the pathology budgets in two different periods (2015 versus 2010), adjusted by inflation and increased activity. RESULTS: The hub-and-spoke model has been implemented as part of the consolidation process of pathology services in England. Consolidated pathology networks have achieved higher savings compared to non-consolidated single laboratories. There has been an increased role of private providers and savings were achieved with negligible personnel redundancies. CONCLUSIONS: Consolidated units have on average achieved larger cost savings than non-consolidated units but further analysis with stronger research design is required to independently evaluate the impact of pathology consolidation on both savings and quality.


Assuntos
Laboratórios/economia , Patologia Clínica/economia , Orçamentos , Redução de Custos/economia , Economia Hospitalar , Inglaterra , Hospitais/estatística & dados numéricos , Humanos , Laboratórios/organização & administração , Patologia Clínica/organização & administração , Setor Privado/economia , Setor Privado/organização & administração , Setor Público/economia , Setor Público/organização & administração , Medicina Estatal/economia , Medicina Estatal/organização & administração
20.
J Gen Intern Med ; 33(12): 2106-2112, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30291604

RESUMO

BACKGROUND: Programs to improve quality of care and lower costs for the highest utilizers of health services are proliferating, yet such programs have difficulty demonstrating cost savings. OBJECTIVE: In this study, we explore the degree to which changes in Patient Activation Measure (PAM) levels predict health care costs among high-risk patients. PARTICIPANTS: De-identified claims, demographic data, and serial PAM scores were analyzed on 2155 patients from multiple medical groups engaged in an existing Center for Medicare and Medicaid Innovation-funded intervention over 3 years designed to activate and improve care coordination for high-risk patients. DESIGN: In this prospective cohort study, four levels of PAM (from low to high) were used as the main predictor variable. We fit mixed linear models for log10 of allowed charges in follow-up periods in relation to change in PAM, controlling for baseline PAM, baseline costs, age, sex, income, and baseline risk score. MAIN MEASURES: Total allowed charges were derived from claims data for the cohort. PAM scores were from a separate database managed by the local practices. KEY RESULTS: A single PAM level increase was associated with 8.3% lower follow-up costs (95% confidence interval 2.5-13.2%). CONCLUSIONS: These findings contribute to a growing evidence base that the change in PAM score could serve as an early signal indicating the impact of interventions designed for high-cost, high-needs patients.


Assuntos
Redução de Custos/economia , Redução de Custos/tendências , Custos de Cuidados de Saúde/tendências , Participação do Paciente/economia , Participação do Paciente/tendências , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Medicaid/economia , Medicaid/tendências , Medicare/economia , Medicare/tendências , Pessoa de Meia-Idade , Estudos Prospectivos , Estados Unidos/epidemiologia
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