Risk adjusted resource utilization for AMI patients treated in Japanese hospitals

Impact of reimbursement rates on the length of stay in tertiary public hospitals: a retrospective cohort study in Shenzhen, China

OBJECTIVE

To examine the association between reimbursement rates and the length of stay (LOS).

DESIGN

A retrospective cohort study.

SETTING

The study was conducted in Shenzhen, China by using health administrative database from 1 January 2015 to 31 December 2017.

PARTICIPANTS

6583 patients with acute myocardial infarction (AMI), 12 395 patients with pneumonia and 10 485 patients who received percutaneous coronary intervention (PCI) surgery.

MEASURES

The reimbursement rate was defined as one minus the ratio of out-of-pocket to the total expenditure, multiplied by 100%. The outcome of interest was the LOS. Multilevel negative binomial regression models were constructed to control for patient-level and hospital-level characteristics, and the marginal effect was reported when non-linear terms were available.

RESULTS

Each additional unit of the reimbursement rate was associated with an average of an additional increase of 0.019 (95% CI, 0.015 to 0.023), 0.011 (95% CI, 0.009 to 0.014) and 0.013 (95% CI, 0.010 to 0.016) in the LOS for inpatients with AMI, pneumonia and PCI surgery, respectively. Adding the interaction term between the reimbursement rate and in-hospital survival, the average marginal effects for the deceased inpatients with AMI and PCI surgery were 0.044 (95% CI, 0.031 to 0.058) and 0.034 (95% CI, 0.017 to 0.051), respectively. However, there was no evidence that higher reimbursement rates prolonged the LOS of the patients who died of pneumonia (95% CI, -0.013 to 0.016).

CONCLUSIONS

The findings indicate that the higher the reimbursement rate, the longer the LOS; and implementing dynamic supervision and improving the service capabilities of primary healthcare providers may be an important strategy for reducing moral hazard in low-income and middle-income countries including China.

Cost-effectiveness of rivaroxaban versus warfarin for stroke prevention in non-valvular atrial fibrillation in the Japanese healthcare setting

Aims: This article aimed to examine the cost-effectiveness of rivaroxaban in comparison to warfarin for stroke prevention in Japanese patients with non-valvular atrial fibrillation (NVAF), from a public healthcare payer's perspective.Materials and methods: Baseline event risks were obtained from the J-ROCKET AF trial and the treatment effect data were taken from a network meta-analysis. The other model inputs were extracted from the literature and official Japanese sources. The outcomes included the number of ischaemic strokes, myocardial infarctions, systemic embolisms and bleedings avoided, life-years, quality-adjusted life-years (QALYs), incremental costs and incremental cost-effectiveness ratio (ICER). The scenario analysis considered treatment effect data from the same network meta-analysis.Results: In comparison with warfarin, rivaroxaban was estimated to avoid 0.284 ischaemic strokes per patient, to increase the number of QALYs by 0.535 per patient and to decrease the total costs by ¥118,892 (€1,011.11) per patient (1 JPY = 0.00850638 EUR; XE.com, 7 October 2019). Consequently, rivaroxaban treatment was found to be dominant compared to warfarin. In the scenario analysis, the ICER of rivaroxaban versus warfarin was ¥2,873,499 (€24,446.42) per QALY.Limitations: The various sources of data used resulted in the heterogeneity of the cost-effectiveness analysis results. Although, rivaroxaban was cost-effective in the majority of cases.Conclusion: Rivaroxaban is cost-effective against warfarin for stroke prevention in Japanese patients with NVAF, giving the payer WTP of 5,000,000 JPY.

The cost-effectiveness of dulaglutide versus insulin glargine for the treatment of type 2 diabetes mellitus in Japan

AIMS

Dulaglutide is a new once weekly glucagon-like peptide-1 (GLP-1) receptor agonist administered via a disposable auto-injection pen for the management of type 2 diabetes mellitus (T2DM). The objective of this study was to estimate the cost-effectiveness of dulaglutide vs insulin glargine for the management of T2DM from a Japanese healthcare perspective, in accordance with recently approved Japanese Cost-Effectiveness Guidelines.

METHODS

The IQVIA CORE Diabetes Model (version 9) was used to estimate the long-term costs and effects of treatment with dulaglutide and insulin glargine. Direct comparative data from the Araki 2015 trial (NCT01584232) was used to inform the analysis. Costs associated with treatment and complications were derived from Japanese sources wherever possible and inflated to 2015 Japanese Yen (JPY). Utilities were based upon a European systematic review of diabetes utilities and adjusted for use in a Japanese population. One-way and probabilistic sensitivity analyses (OWSA and PSA) were conducted on all inputs and key modeling assumptions.

RESULTS

Dulaglutide 0.75 mg was associated with higher quality-adjusted life years (QALYs), life years (LYs), and total costs, compared to insulin glargine, resulting in an incremental cost-effectiveness ratio (ICER) of 416,280 JPY/QALY gained. Treatment with dulaglutide increased the time alive and free from diabetes-related complications by 4 months. OWSA and PSA indicated that results were robust to plausible variations in input parameters and modeling assumptions.

LIMITATIONS

Key limitations of this study are similar to other cost-utility analyses of diabetes, including the extrapolation of short-term clinical trial data into lifelong durations. In addition, due to the lack of robust published Japanese data, some values were derived from non-Japanese sources.

CONCLUSIONS

This analysis suggests that dulaglutide 0.75 mg may be a cost-effective treatment alternative to insulin glargine for patients with T2DM in Japan.

Comparison of the treatment practice and hospitalization cost of percutaneous coronary intervention between a teaching hospital and a general hospital in Malaysia: A cross sectional study

Introduction

The increasing disease burden of coronary artery disease (CAD) calls for sustainable cardiac service. Teaching hospitals and general hospitals in Malaysia are main providers of percutaneous coronary intervention (PCI), a common treatment for CAD. Few studies have analyzed the contemporary data on local cardiac facilities. Service expansion and budget allocation require cost evidence from various providers. We aim to compare the patient characteristics, procedural outcomes, and cost profile between a teaching hospital (TH) and a general hospital (GH).

Methods

This cross-sectional study was conducted from the healthcare providers’ perspective from January 1^st to June 30^th 2014. TH is a university teaching hospital in the capital city, while GH is a state-level general hospital. Both are government-funded cardiac referral centers. Clinical data was extracted from a national cardiac registry. Cost data was collected using mixed method of top-down and bottom-up approaches. Total hospitalization cost per PCI patient was summed up from the costs of ward admission and cardiac catheterization laboratory utilization. Clinical characteristics were compared with chi-square and independent t-test, while hospitalization length and cost were analyzed using Mann-Whitney test.

Results

The mean hospitalization cost was RM 12,117 (USD 3,366) at GH and RM 16,289 (USD 4,525) at TH. The higher cost at TH can be attributed to worse patients’ comorbidities and cardiac status. In contrast, GH recorded a lower mean length of stay as more patients had same-day discharge, resulting in 29% reduction in mean cost of admission compared to TH. For both hospitals, PCI consumables accounted for the biggest proportion of total cost.

Conclusions

The high PCI consumables cost highlighted the importance of cost-effective purchasing mechanism. Findings on the heterogeneity of the patients, treatment practice and hospitalization cost between TH and GH are vital for formulation of cost-saving strategies to ensure sustainable and equitable cardiac service in Malaysia.

Cost of elective percutaneous coronary intervention in Malaysia: a multicentre cross-sectional costing study

OBJECTIVES

Limitations in the quality and access of cost data from low-income and middle-income countries constrain the implementation of economic evaluations. With the increasing prevalence of coronary artery disease in Malaysia, cost information is vital for cardiac service expansion. We aim to calculate the hospitalisation cost of percutaneous coronary intervention (PCI), using a data collection method customised to local setting of limited data availability.

DESIGN

This is a cross-sectional costing study from the perspective of healthcare providers, using top-down approach, from January to June 2014. Cost items under each unit of analysis involved in the provision of PCI service were identified, valuated and calculated to produce unit cost estimates.

SETTING

Five public cardiac centres participated. All the centres provide full-fledged cardiology services. They are also the tertiary referral centres of their respective regions.

PARTICIPANTS

The cost was calculated for elective PCI procedure in each centre. PCI conducted for urgent/emergent indication or for patients with shock and haemodynamic instability were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome measures of interest were the unit costs at the two units of analysis, namely cardiac ward admission and cardiac catheterisation utilisation, which made up the total hospitalisation cost.

RESULTS

The average hospitalisation cost ranged between RM11 471 (US$3186) and RM14 465 (US$4018). PCI consumables were the dominant cost item at all centres. The centre with daycare establishment recorded the lowest admission cost and total hospitalisation cost.

CONCLUSIONS

Comprehensive results from all centres enable comparison at the levels of cost items, unit of analysis and total costs. This generates important information on cost variations between centres, thus providing valuable guidance for service planning. Alternative procurement practices for PCI consumables may deliver cost reduction. For countries with limited data availability, costing method tailored based on country setting can be used for the purpose of economic evaluations.

REGISTRATION

Malaysian MOH Medical Research and Ethics Committee (ID: NMRR-13-1403-18234 IIR).

Impact of the Local Public Hospital Reform on the Efficiency of Medium-Sized Hospitals in Japan: An Improved Slacks-Based Measure Data Envelopment Analysis Approach

OBJECTIVE

To assess the change in efficiency and total factor productivity (TFP) of the local public hospitals in Japan after the local public hospital reform launched in late 2007, which was aimed at improving the financial capability and operational efficiency of hospitals.

DATA SOURCES AND DATA COLLECTION

Secondary data were collected from the Ministry of Internal Affairs and Communications on 213 eligible medium-sized hospitals, each operating 100-400 beds from FY2006 to FY2011.

STUDY DESIGN

The improved slacks-based measure nonoriented data envelopment analysis models (Quasi-Max SBM nonoriented DEA models) were used to estimate dynamic efficiency score and Malmquist Index.

PRINCIPAL FINDINGS

The dynamic efficiency measure indicated an efficiency gain in the first several years of the reform and then was followed by a decrease. Malmquist Index analysis showed a significant decline in the TFP between 2006 and 2011. The financial improvement of medium-sized hospitals was not associated with enhancement of efficiency. Hospital efficiency was not significantly different among ownership structure and law-application system groups, but it was significantly affected by hospital location.

CONCLUSIONS

The results indicate a need for region-tailored health care policies and for a more comprehensive reform to overcome the systemic constraints that might contribute to the decline of the TFP.

Systematic review of factors influencing length of stay in ICU after adult cardiac surgery

BACKGROUND

Intensive care unit (ICU) care is associated with costly and often scarce resources. In many parts of the world, ICUs are being perceived as major bottlenecks limiting downstream services such as operating theatres. There are many clinical, surgical and contextual factors that influence length of stay. Knowing these factors can facilitate resource planning. However, the extent at which this knowledge is put into practice remains unclear. The aim of this systematic review was to identify factors that impact the duration of ICU stay after cardiac surgery and to explore evidence on the link between understanding these factors and patient and resource management.

METHODS

We conducted electronic searches of Embase, PubMed, ISI Web of Knowledge, Medline and Google Scholar, and reference lists for eligible studies.

RESULTS

Twenty-nine papers fulfilled inclusion criteria. We recognised two types of objectives for identifying influential factors of ICU length of stay (LOS) among the reviewed studies. These were general descriptions of predictors and prediction of prolonged ICU stay through statistical models. Among studies with prediction models, only two studies have reported their implementation. Factors most commonly associated with increased ICU LOS included increased age, atrial fibrillation/ arrhythmia, chronic obstructive pulmonary disease (COPD), low ejection fraction, renal failure/ dysfunction and non-elective surgery status.

CONCLUSION

Cardiac ICUs are major bottlenecks in many hospitals around the world. Efforts to optimise resources should be linked to patient and surgical characteristics. More research is needed to integrate patient and surgical factors into ICU resource planning.

What causes international variations in length of stay: a comparative analysis for two inpatient conditions in Japanese and Canadian hospitals

Hospital average length of stay varies considerably between countries. However, there is limited patient-level research identifying or discounting possible reasons for these differences. This study compares the length of stay of patients in Japan, where it is the longest in the OECD, and Canada, where length of stay is closer to the OECD mean. Administrative patient-level data, including age, gender, co-morbidities, intervention, discharge plan, outcome and length of stay were collected from two Japanese and two Ontario, Canada hospitals for two diagnoses: colorectal cancer surgery and acute myocardial infarction. Analyses examined linkages between patient characteristics, hospitals and countries and length of stay. When controlling for patient demographic characteristics, the incidence of co-morbidities and discharge plan practices, Japanese length of stay tended to be significantly longer than that in Canada for both diagnoses. Mortality rates were not significantly different; however, the readmission rate (28 days or less) for acute myocardial infarction was higher in the Canadian hospitals. The findings indicate that non-clinical factors contribute to sustained international differences in length of stay. These factors may include professional or cultural norms, differing payment schemes and access to long-term care facilities. The study also introduces a protocol that can be used for international patient-level comparisons that can enable effective policy and management learning.

Increasing use of non-invasive ventilation in asthma: a long-term analysis of the Portuguese national hospitalization database

OBJECTIVES

To describe the use and outcomes of non-invasive positive pressure ventilation (NPPV) and invasive ventilation (IV) in adults hospitalized for acute asthma exacerbations in Portugal.

METHODS

We analyzed the hospitalizations of adults with a principal diagnosis of asthma in mainland Portugal between 2000 and 2010. The data source was the national hospitalizations database, which includes administrative and clinical data produced by physicians trained in coding.

RESULTS

Ventilation support was used in 5.1% (n = 747) of the 14,515 hospitalizations with a principal diagnosis of asthma: NPPV in 1.7% (n = 241) and IV in 3.5% (n = 506); NPPV use increased from 1% in 2000 to 3.3% in 2010. In patients with asthma, the ratio of NPPV use to IV use increased from 0.27 to 1.06. This increase was observed even after exclusion of secondary diagnoses in which NPPV is frequently used. The mortality rate was 1.5% for all asthma hospitalizations: 2.5% when NPPV was used and 15.8% for those requiring IV.

CONCLUSIONS

The use of ventilation support in asthma remained stable over time; however, the use of non-invasive ventilation has increased. Still, we do not have good data regarding the effectiveness of non-invasive ventilation when treating asthma exacerbations. Therefore, additional studies are much needed and should assess physiologic and clinical variables that might affect the effectiveness of non-invasive ventilation in patients with asthma exacerbations.

Measuring the relationship between costs and outcomes: the example of acute myocardial infarction in German hospitals

In this paper, we propose a methodological approach to measure the relationship between hospital costs and health outcomes. We propose to investigate the relationship for each condition or disease area by using patient-level data. We examine health outcomes as a function of costs and other patient-level variables by using the following: (1) two-stage residual inclusion with Murphy-Topel adjustment to address costs being endogenous to health outcomes, (2) random-effects models in both stages to correct for correlation between observation, and (3) Cox proportional hazard models in the second stage to ensure that the available information is exploited. To demonstrate its application, data on mortality following hospital treatment for acute myocardial infarction (AMI) from a large German sickness fund were used. Provider reimbursement was used as a proxy for treatment costs. We relied on the Ontario Acute Myocardial Infarction Mortality Prediction Rules as a disease-specific risk-adjustment instrument. A total of 12,284 patients with treatment for AMI in 2004-2006 were included. The results showed a reduction in hospital costs by €100 to increase the hazard of dying, that is, mortality, by 0.43%. The negative association between costs and mortality confirms that decreased resource input leads to worse outcomes for treatment after AMI.

Explaining length of stay variation of episodes of care in the Netherlands

OBJECTIVES

Diagnosis Related Group (DRG) systems aim to classify patients into mutually exclusive groups of patients, with the patients in each group having the same expected length of stay (LOS). We examined the ability of current classification variables to explain LOS variation between DRG-like Diagnosis Treatment Combination (DBC)s for ten episodes of care in the Netherlands, including breast cancer, stroke and inguinal hernia repair. Additionally, we assessed the predictive ability of some other classification variables.

METHODS

For each episode of care, the relevant DBC codes of all hospitalizations in 2008 were identified and all available determinants that may serve as classification variables were acquired from the national database. Ordinary least squares regression was used to examine the predictive ability of these classification variables.

RESULTS

The current classification variables are not sufficiently distinct to classify patients into mutually exclusive groups of patients. ICU admissions and hospital type may serve as valuable classification variables. Additionally, episode-specific variables may improve the Dutch grouping algorithm.

CONCLUSIONS

Although it may not be feasible in the short term, grouping algorithms would benefit greatly from the introduction of classification variables tailored to the needs of specific episodes of care. A first step would be to focus on 'general' classification variables meaningful for specific episodes of care.

Acute myocardial infarction and diagnosis-related groups: patient classification and hospital reimbursement in 11 European countries

AIMS

As part of the diagnosis related groups in Europe (EuroDRG) project, researchers from 11 countries (i.e. Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Spain, and Sweden) compared how their DRG systems deal with patients admitted to hospital for acute myocardial infarction (AMI). The study aims to assist cardiologists and national authorities to optimize their DRG systems.

METHODS AND RESULTS

National or regional databases were used to identify hospital cases with a primary diagnosis of AMI. Diagnosis-related group classification algorithms and indicators of resource consumption were compared for those DRGs that individually contained at least 1% of cases. Six standardized case vignettes were defined, and quasi prices according to national DRG-based hospital payment systems were ascertained. European DRG systems vary widely: they classify AMI patients according to different sets of variables into diverging numbers of DRGs (between 4 DRGs in Estonia and 16 DRGs in France). The most complex DRG is valued 11 times more resource intensive than an index case in Estonia but only 1.38 times more resource intensive than an index case in England. Comparisons of quasi prices for the case vignettes show that hypothetical payments for the index case amount to only €420 in Poland but to €7930 in Ireland.

CONCLUSIONS

Large variation exists in the classification of AMI patients across Europe. Cardiologists and national DRG authorities should consider how other countries' DRG systems classify AMI patients in order to identify potential scope for improvement and to ensure fair and appropriate reimbursement.

Treatment costs of acute myocardial infarction in the Netherlands

BACKGROUND

This study aimed to calculate the treatment costs of acute myocardial infarction (AMI) in the Netherlands for 2012. Also, the degree of association between treatment costs of AMI and some patient and hospital characteristics was examined.

METHODS

For this retrospective cost analysis, patients were drawn from the database of the Diagnosis Treatment Combination (Diagnose Behandeling Combinatie, DBC) casemix system, which contains data on the resource use of all hospitalisations in the Netherlands. All costs were based on Euro 2012 cost data.

RESULTS

The analysis was based on data of 25,657 patients. Mean treatment costs were estimated at <euro> 5021, with significant cost increases for patients with percutaneous coronary intervention (PCI) treatment. ST-segment elevation myocardial infarction (STEMI) patients receiving thrombolysis incurred the lowest (<euro> 4286), while non-STEMI patients receiving PCI the highest costs (<euro> 6060). Length of stay and hospital type were strong predictors of treatment costs.

CONCLUSIONS

This study is the most extensive cost assessment of the treatment costs of AMI in the Netherlands thus far. Our results may be used as input for health-economic models and economic evaluations to support the decision making of registration, reimbursement and pricing of interventions in healthcare.

Factors influencing hospital high length of stay outliers

Background

The study of length of stay (LOS) outliers is important for the management and financing of hospitals. Our aim was to study variables associated with high LOS outliers and their evolution over time.

Methods

We used hospital administrative data from inpatient episodes in public acute care hospitals in the Portuguese National Health Service (NHS), with discharges between years 2000 and 2009, together with some hospital characteristics. The dependent variable, LOS outliers, was calculated for each diagnosis related group (DRG) using a trim point defined for each year by the geometric mean plus two standard deviations. Hospitals were classified on the basis of administrative, economic and teaching characteristics. We also studied the influence of comorbidities and readmissions. Logistic regression models, including a multivariable logistic regression, were used in the analysis. All the logistic regressions were fitted using generalized estimating equations (GEE).

Results

In near nine million inpatient episodes analysed we found a proportion of 3.9% high LOS outliers, accounting for 19.2% of total inpatient days. The number of hospital patient discharges increased between years 2000 and 2005 and slightly decreased after that. The proportion of outliers ranged between the lowest value of 3.6% (in years 2001 and 2002) and the highest value of 4.3% in 2009. Teaching hospitals with over 1,000 beds have significantly more outliers than other hospitals, even after adjustment to readmissions and several patient characteristics.

Conclusions

In the last years both average LOS and high LOS outliers are increasing in Portuguese NHS hospitals. As high LOS outliers represent an important proportion in the total inpatient days, this should be seen as an important alert for the management of hospitals and for national health policies. As expected, age, type of admission, and hospital type were significantly associated with high LOS outliers. The proportion of high outliers does not seem to be related to their financial coverage; they should be studied in order to highlight areas for further investigation. The increasing complexity of both hospitals and patients may be the single most important determinant of high LOS outliers and must therefore be taken into account by health managers when considering hospital costs.

Cost effectiveness of drug-eluting stents in acute myocardial infarction patients in Germany: results from administrative data using a propensity score-matching approach

BACKGROUND

The high number of patients with acute myocardial infarction (AMI) has facilitated greater research, resulting in the development of innovative medical devices. So far, results from economic evaluations that compared drug-eluting stents (DES) and bare-metal stents (BMS) have not shown clear evidence that one intervention is more cost effective than the other.

OBJECTIVE

The aim of this study was to measure the cost effectiveness of DES compared with BMS in routine care.

METHODS

We used administrative data from a large German sickness fund to compare the costs and effectiveness of DES and BMS in patients with AMI. Patients with hospital admission after AMI in 2004 and 2005 were followed up for 1 year after hospital discharge. The cost of treatment and survival after 365 days were compared for patients treated with DES and BMS. We adjusted for covariates defined according to the Ontario Acute Myocardial Infarction Mortality Prediction Rules using propensity score matching. After matching, we calculated incremental cost-effectiveness ratios (ICERs) by (i) using sample means based on bootstrapping procedures and (ii) estimating generalized linear mixed models for costs and survival.

RESULTS

After propensity score matching, the sample included 719 patients treated with DES and 719 patients treated with BMS. A comparison of sample means resulted in average costs of € 12 714 and € 11 714 for DES and BMS, respectively, in 2005 German euros. Difference in 365-day survival was not statistically significant (700 patients with DES and 701 with BMS). The ICER of DES versus BMS was -€ 718 709 per life saved. Bootstrapping resulted in DES being dominated by BMS in 54.5% of replications and DES being a dominant strategy in 2.7% of replications. Results from regression models and sensitivity analyses confirm these results.

CONCLUSION

Treatment with DES after admission with AMI is less cost effective than treatment with BMS. Our results are in line with other cost-effectiveness analyses that used administrative data, i.e. under routine care conditions. However, our results do not preclude that DES may be cost effective in specific patient subgroups.

Managerial performance and cost efficiency of Japanese local public hospitals: a latent class stochastic frontier model

The paper explores the link between managerial performance and cost efficiency of 617 Japanese general local public hospitals in 1999-2007. Treating managerial performance as unobservable heterogeneity, the paper employs a panel data stochastic cost frontier model with latent classes. Financial parameters associated with better managerial performance are found to be positively significant in explaining the probability of belonging to the more efficient latent class. The analysis of latent class membership was consistent with the conjecture that unobservable technological heterogeneity reflected in the existence of the latent classes is related to managerial performance. The findings may support the cause for raising efficiency of Japanese local public hospitals by enhancing the quality of management.

Healthcare-Associated Infections in Acute Ischaemic Stroke Patients from 36 Japanese Hospitals: Risk-Adjusted Economic and Clinical Outcomes

Background

Healthcare-associated infections are a major cause for worsening in ischaemic stroke patients. In addition to increased morbidity and mortality, healthcare-associated infections also result in a potentially preventable increase in economic costs.

Aims

The aim of this study was to identify healthcare-associated infection incidence in ischaemic stroke patients in Japanese hospitals, and to conduct a risk-adjusted analysis of the associated economic and clinical outcomes.

Methods

Healthcare-associated infections were identified in 36 Japanese hospitals using an administrative database. Identification was carried out using a combination of International Classification of Diseases-10 codes and antibiotic utilisation patterns that indicated the presence of an infection. Risk-adjusted hospital charges and length of stay were calculated using multiple linear regression analyses correcting for patient and hospital factors. A logistic regression model was used to analyse the association between healthcare-associated infection infection and mortality.

Results

There was an overall healthcare-associated infection incidence of 16·4 %, with an interhospital range of 4·7–28·3%. After risk-adjustment, infected cases paid an additional US$3 067 per admission (interhospital range US$434–US$7 151) and were hospitalised for an additional 16·3-days (interhospital range: 5·1–25·1-days) when compared with uninfected patients. Healthcare-associated infections also had a strongly significant association with increased mortality (odds ratio=23·2, 95% confidence intervals: 12·5–43·2).

Conclusions

We observed a wide range of healthcare-associated infection incidence between the hospitals. Healthcare-associated infections were found to be significantly associated with increased hospital charges, length of stay, and mortality. Furthermore, the use of risk-adjusted multi-institutional comparisons allowed us to analyse individual performance levels in both infection and cost control.

Costs and quality of hospitals in different health care systems: a multi-level approach with propensity score matching

Cross-country comparisons of costs and quality between hospitals are often made at the macro level. The goal of this study was to explore methods to compare micro-level data from hospitals in different health care systems. To do so, we developed a multi-level framework in combination with a propensity score matching technique using similarly structured data for patients receiving treatment for acute myocardial infarction in German and US Veterans Health Administration hospitals. Our case study shows important differences in results between multi-level regressions based on matched and unmatched samples. We conclude that propensity score matching techniques are an appropriate way to deal with the usual baseline imbalances across the samples from different countries. Multi-level models are recommendable to consider the clustered structure of the data when patient-level data from different hospitals and health care systems are compared. The results provide an important justification for exploring new ways in performing health system comparisons.

The trade-off between costs and outcomes: the case of acute myocardial infarction

Objective

To investigate and to quantify the relationship between hospital costs and health outcomes for patients with acute myocardial infarction (AMI) in Veterans Health Administration (VHA) hospitals using individual-level data for costs and outcomes.

Data Sources

VHA administrative files for the fiscal years 2000–2006.

Study Design

Costs were defined as costs incurred during the index hospitalization for treatment of AMI. Mortality and readmission, assessed 1 year after the index hospitalization, were used as measures of clinical outcome. We examined health outcomes as a function of costs and other patient-level and hospital-level characteristics using a two-stage Cox proportional hazard model that accounted for competing risks within a multilevel framework. To control for patient comorbidities, we compiled a comprehensive list of comorbidities that have been found in other studies to affect mortality and readmissions.

Principal Findings

We found that costs were negatively associated with mortality and readmissions. Every U.S.$100 less spent is associated with a 0.63 percent increase in the hazard of dying and a 1.24 percent increase in the hazard to be readmitted conditional on not dying. This main finding remained unchanged after a number of sensitivity checks.

Conclusions

Our results suggest that there is a trade-off between costs and outcomes. The negative association between costs and mortality suggests that outcomes should be monitored closely when introducing cost-containment programs. Additional studies are needed to examine the cost–outcome relationship for conditions other than AMI to see whether our results are consistent.

Risk-adjusted increases in medical resource utilization associated with health care-associated infections in gastrectomy patients

RATIONALE, AIMS AND OBJECTIVES

Quantifying the impact of health care-associated infections (HAIs) on medical resource utilization is necessary for payers and providers to appropriately allocate limited resources for interventions. However, previous studies tend to involve single institutions and do not take into account patient and practice variations between several hospitals. The objective of this study was to conduct a multi-institutional risk-adjusted comparison of HAI-associated impact on medical resources in gastrectomy patients in Japan.

METHODS

Health care-associated infections were identified using a combination of International Classification of Diseases-10 codes and antibiotic utilization patterns in 1058 gastrectomy patients from 10 Japanese hospitals. Multiple linear regression models and risk adjustment were used to analyse the impact of HAIs on: (1) total hospital costs; (2) antibiotic costs; and (3) post-surgical length of stay (LOS).

RESULTS

Overall HAI incidence for the database was 20.3%, with a range of 8.8-29.6% among the 10 hospitals. Regression models showed that HAIs were significantly associated with increases in all three indicators. Risk-adjusted comparisons revealed that HAIs were associated with an increase of US$2767 (range: US$1035-6513) in overall hospital cost, US$202 (US$98.8-764.6) antibiotic costs and 10.6 (4.7-24 days) post-surgical LOS days.

CONCLUSIONS

Even after adjusting for patient characteristics and other variables, there was still a high degree of variation observed in the impact of HAIs on total hospital costs and antibiotic costs from a third-party payer's perspective and post-surgical LOS among the 10 hospitals. This information can increase the efficiency of allocation of resources for interventions to reduce HAIs.

A micro-costing approach to estimating hospital costs for appendectomy in a cross-European context

This paper aims (a) to determine whether variations in the hospital costs of appendectomy in EU member states are larger within individual countries or between different countries and (b) to explore causes for variations in costs between hospitals and countries. To do so, hospitalisation costs and reimbursement rates for appendectomy were obtained from 54 hospitals in nine European member states based on 1786 cases using a standardised methodology. Regression analysis was performed using hospital characteristics, treatment characteristics, and purchasing power parities (PPP) as explanatory variables in a multilevel framework. The within-country standard error was estimated to 294 euros (27%), whereas the between-country standard error was 796 euros (73%). Excluding hospitals in Spain, Hungary, and Poland, which had significantly lower costs than hospitals in the other countries in our analysis, the within-country standard error was 331 euros (57%) and the between-country standard error dropped to 248 euros (43%). Regression results show that the treatment decision for open surgery was associated with significantly lower costs, whereas a greater number of beds and a higher staff per bed ratio were associated with significantly higher costs. PPP explained a major part of the between-country variance.

Variations in hospitalisation costs for acute myocardial infarction - a comparison across Europe

The aim of this study was to determine whether between-country variations in hospital costs are larger than within-country variations and, furthermore, to explore reasons for this variability. For this purpose, we chose the primary treatment of patients with acute myocardial infarction (AMI) as an episode of care. We obtained hospitalisation costs and reimbursement rates from 45 hospitals in nine different EU member states (i.e. Denmark, England, France, Germany, Hungary, Italy, Netherlands, Poland, and Spain) for the year 2005. To further analyse the variations in hospital costs, we employed a hierarchical random effects model based on treatment and hospital characteristics and using purchasing power parities (PPPs) as a proxy for country-specific price levels. The between-country standard error was estimated at 2473 euros, whereas the within-country standard error was estimated at 1242 euros. Our regression analysis showed that percutaneous coronary intervention was associated with significantly increased hospitals costs compared to other treatment strategies. We were able to distinguish between three groups of countries with different cost levels based on the number of hospitals that were able to provide these services (i.e. percutaneous transluminal coronary angioplasty (PTCA) with intracoronary stenting). Excluding Hungary, Poland, and Spain, where none of the participating hospitals were able to provide these procedures, the between-country standard error decreased to 1632 euros, whereas the within-country standard error increased to 1416 euros. Finally, we observed exogenous price-level effects between countries and within countries for hospitals located in urban areas.