Estimates of patient costs related with population morbidity: can indirect costs affect the results?

[Primary Care frequentation determinants in Catalonia]

Objetivo

Determinar qué variables definen el tiempo de asistencia anual medio por paciente en Atención Primaria (AP) en Cataluña, para mejorar la adecuación de la asignación presupuestaria.

Diseño

Estudio ecológico transversal.

Emplazamiento

Los Equipos de Atención Primaria (EAP) del Institut Català de la Salut (ICS) en 2016.

Participantes

Los 285 EAP del ICS, que dan cobertura a un 75% de los ciudadanos mayores de 14 años en Cataluña.

Mediciones principales

Tiempo medio de visita anual en medicina familiar por paciente para cada EAP. Se estudió cómo este tiempo dependía de potenciales variables explicativas, a nivel de EAP, mediante modelos de regresión lineal.

Resultados

El tiempo medio de visita por paciente/año fue de 49 minutos, variando entre 23-87 minutos, según el EAP. Los EAP con población asignada de más edad, más comorbilidad, más atención domiciliaria, peor índice socioeconómico, mayor número de pensionistas jóvenes y mayor dispersión tuvieron más tiempo de visita, mientras que los EAP con más población y más mujeres tuvieron menos tiempo de visita. Estas variables explicaron un 64% de la variabilidad del tiempo de visita.

Conclusiones

La asignación presupuestaria en AP se puede basar en un modelo que incorpore las principales determinantes de la frecuentación de la población y se adecúe a las necesidades reales de ésta. Sería necesario profundizar en aquellos factores que dependen del profesional o de las organizaciones sanitarias para acabar de encontrar un modelo óptimo de asignación de recursos en la AP.

An 8-step framework for implementing time-driven activity-based costing in healthcare studies

Micro-costing studies still deserving for methods orientation that contribute to achieve a patient-specific resource use level of analysis. Time-driven activity-based costing (TDABC) is often employed by health organizations in micro-costing studies with that objective. However, the literature shows many deviations in the implementation of TDABC, which might compromise the accuracy of the results obtained. One reason for that can be attributed to the non-existence of a step-by-step orientation to conduct cost analytics with the TDABC specific for micro-costing studies in healthcare. This article aimed at exploring the literature and practical cases to propose an eight-step framework to apply TDABC in micro-costing studies for health care organizations. The 8-step TDABC framework is presented and detailed exploring online spreadsheets already coded to demonstrate data structure and math formula building. A list of analyses that can be performed is suggested, including an explanation about the information that each analysis can provide to increase the organization capability to orient decision making. The case study developed show that actual micro-costing of health care processes can be achieved with the 8-step TDABC framework and its use in future researches can contribute to increase the number of studies that achieve high-quality level in cost information, and consequently, in health resource evaluation.

Development of clinical value unit method for calculating patient costs

The objective of the study was to develop the clinical value unit method of allocating indirect costs to patient costs using clinical factors. The method was tested to determine whether it is a more reliable alternative to using the length of stay and marginal mark-up allocation method. The method developed used data from a Polish specialist hospital. The study involved 4,026 patients grouped into nine diagnosis-related groups (DRG). The study methodology involved a three stage approach: (a) identification of correlates of patient costs, (b) a comparison of the costs calculated using the clinical value unit method with the alternative methods: length of stay and marginal mark-up methods, and (c) an estimation of the cost homogeneity of the DRGs. The study showed that length of stay cost allocation method may underestimate the proportion of indirect costs in patient costs for a short in-patient stay and overestimate the cost for the patients with a long stay. The total costs estimated using the marginal mark-up method were higher than those estimated with length of stay method. For most surgical procedures, the mean indirect costs are higher using clinical value unit method than when using length of stay or marginal mark-up method. In all medical procedure cases, the mean indirect costs calculated using the clinical value unit method are in the range between marginal mark-up and length of stay method. We also show that in all DRGs except one, that the coefficient of homogeneity for clinical value unit is higher than for length of stay or marginal mark-up method. We conclude that the clinical value unit method of cost allocation is a more precise and reliable alternative than the other methods.

[Impact of cardiovascular risk factors on the consumption of resources in Primary Care according to Clinical Risk Groups]

Objetivo

Analizar en el contexto de una Zona Básica de Salud (ZBS) la prevalencia de los factores de riesgo cardiovascular (FRCV) y el impacto que generan en la morbilidad y el consumo de recursos sanitarios en la población estratificada según el sistema Clinical Risk Groups (CRG) en Atención Primaria (AP), con la finalidad de identificar la población con multimorbilidad para aplicar medidas preventivas, así como aquella que genera más carga asistencial y necesidades sociales.

Diseño

Estudio observacional, de corte transversal y ámbito poblacional para una ZBS durante el año 2013.

Emplazamiento

Departamento de salud de Castellón, Comunidad Valenciana (CV). Incluye asistencia ambulatoria en AP y especializada.

Participantes

Todos los ciudadanos dados de alta en el Sistema de Información Poblacional (SIP), N = 32.667.

Mediciones

Del sistema informatizado Abucasis obtuvimos las variables demográficas, clínicas y de consumo de recursos sanitarios. Consideramos la prevalencia de los FRCV a partir de la presencia o ausencia de los códigos diagnósticos CIE.9.MC. Se analizó la relación de los FRCV con los 9 estados de salud CRG, y se realizó un análisis predictivo con el modelo de regresión logística para evaluar la capacidad explicativa de cada variable. Además se obtuvo mediante regresión multivariante un modelo explicativo del gasto farmaceútico ambulatorio.

Resultados

La población del estado de salud CRG 4 en adelante tenía multimorbilidad. Los estados de salud CRG 7 y CRG 6 tienen mayor prevalencia de FRCV. Fue predictivo que a mayor morbilidad, mayor consumo de recursos, mediante OR superiores a la media, p < 0,05 e intervalos de confianza del 95%. Se observó que un 59,8% del gasto farmacéutico ambulatorio quedaba explicado por el sistema CRG y todos los FRCV (p < 0,05 y R² corregido = 0,598). En cuanto al efecto de los FRCV sobre los estados de salud CRG, hubo asociación significativa (p < 0,05) para la alteración de la glucemia, dislipidemia e HTA en todos los estados CRG.

Conclusiones

El estudio de los FRCV en una población estratificada mediante el sistema CRG identifica y predice dónde se genera mayor impacto en la morbilidad y consumo de recursos sanitarios. Nos permite conocer los grupos de pacientes en quienes desarrollar estrategias de prevención y cronicidad. A nivel de la práctica clínica se aporta un nuevo concepto de multimorbilidad, definido a partir del estado de salud CRG 4 en adelante.

Standardised mortality rate for cerebrovascular diseases in the Slovak Republic from 1996 to 2013 in the context of income inequalities and its international comparison

Non-communicable diseases represent one of the greatest challenges for health policymakers. The main objective of this study is to analyse the development of standardised mortality rates for cerebrovascular disease, which is one of the most common causes of deaths, in relation to income inequality in individual regions of the Slovak Republic. Direct standardisation was applied using data from the Slovak mortality database, covering the time period from 1996 to 2013. The standardised mortality rate declined by 4.23% in the Slovak Republic. However, since 1996, the rate has been higher by almost 33% in men than in women. Standardised mortality rates were lower in the northern part of the Slovak Republic than in the southern part. The regression models demonstrated an impact of the observed income-related dimensions on these rates. The income quintile ratio and Gini coefficient appeared to be the most influencing variables. The results of the analysis highlight valuable baseline information for creating new support programmes aimed at eliminating health inequalities in relation to health and social policy.

Hospital Costs of Foreign Non-Resident Patients: A Comparative Analysis in Catalonia, Spain

Although patient mobility has increased over the world, in Europe there is a lack of empirical studies. The aim of the study was to compare foreign non-resident patients versus domestic patients for the particular Catalan case, focusing on patient characteristics, hospitalisation costs and differences in costs depending on the typology of the hospital they are treated. We used data from the 2012 Minimum Basic Data Set-Acute Care hospitals (CMBD-HA) in Catalonia. We matched two case-control groups: first, foreign non-resident patients versus domestic patients and, second, foreign non-resident patients treated by Regional Public Hospitals versus other type of hospitals. Hospitalisation costs were modelled using a GLM Gamma with a log-link. Our results show that foreign non-resident patients were significantly less costly than domestic patients (12% cheaper). Our findings also suggested differences in the characteristics of foreign non-resident patients using Regional Public Hospitals or other kinds of hospitals although we did not observe significant differences in the healthcare costs. Nevertheless, women, 15-24 and 35-44 years old patients and the days of stay were less costly in Regional Public Hospitals. In general, acute hospitalizations of foreign non-resident patients while they are on holiday cost substantially less than domestic patients. The typology of hospital is not found to be a relevant factor influencing costs.

Regional differences of standardised mortality rates for ischemic heart diseases in the Slovak Republic for the period 1996-2013 in the context of income inequality

BACKGROUND

The aim of paper is to analyse the development of standardised mortality rates for ischemic heart diseases in relation to the income inequality in the regions of Slovakia. This paper assesses different types of income indicators, such as mean equivalised net income per household, Gini coefficient, unemployment rate, at risk of poverty threshold (60 % of national median), S80/S20 and their effect on mortality.

METHODS

Using data from the Slovak mortality database 1996-2013, the method of direct standardisation was applied to eliminate variances resulted from differences in age structures of the population across regions and over time. To examine the relationships between income indicators and standardised mortality rates, we used the tools of descriptive statistics and methods of correlation and regression analysis.

RESULTS

At first, we show that Slovakia has the worst values of standardised mortality rates for ischemic heart diseases in EU countries. Secondly, mortality rates are significantly higher for males compared with females. Thirdly, mortality rates are improving from Eastern Slovakia to Western Slovakia; additionally, high differences in the results of variability are seen among Slovak regions. Finally, the unemployment rate, the poverty rate and equivalent disposable income were statistically significant income indicators.

CONCLUSIONS

Main contribution of paper is to demonstrate regional differences between mortality and income inequality, and to point out the long-term unsatisfactory health outcomes.

Analysing the Costs of Integrated Care: A Case on Model Selection for Chronic Care Purposes

BACKGROUND

The objective of this study is to investigate whether the algorithm proposed by Manning and Mullahy, a consolidated health economics procedure, can also be used to estimate individual costs for different groups of healthcare services in the context of integrated care.

METHODS

A cross-sectional study focused on the population of the Baix Empordà (Catalonia-Spain) for the year 2012 (N = 92,498 individuals). A set of individual cost models as a function of sex, age and morbidity burden were adjusted and individual healthcare costs were calculated using a retrospective full-costing system. The individual morbidity burden was inferred using the Clinical Risk Groups (CRG) patient classification system.

RESULTS

Depending on the characteristics of the data, and according to the algorithm criteria, the choice of model was a linear model on the log of costs or a generalized linear model with a log link. We checked for goodness of fit, accuracy, linear structure and heteroscedasticity for the models obtained.

CONCLUSION

The proposed algorithm identified a set of suitable cost models for the distinct groups of services integrated care entails. The individual morbidity burden was found to be indispensable when allocating appropriate resources to targeted individuals.

Indirect costs associated with glioblastoma: Experience at one hospital

INTRODUCTION

Glioblastoma is the most common primary brain tumour. Despite advances in treatment, its prognosis remains dismal, with a mean survival time of about 14 months. Many articles have addressed direct costs, those associated with the diagnosis and treatment of the disease. Indirect costs, those associated with loss of productivity due to the disease, have seldom been described.

MATERIAL AND METHOD

We conducted a retrospective study in patients diagnosed with glioblastoma at Hospital Universitario Donostia between January 1, 2010 and December 31, 2013. We collected demographics, data regarding the treatment received, and survival times. We calculated the indirect costs with the human capital approach, adjusting the mean salaries of comparable individuals by sex and age and obtaining mortality data for the general population from the Spanish National Statistics Institute. Past salaries were updated to 2015 euros according to the annual inflation rate and we applied a discount of 3.5% compounded yearly to future salaries.

RESULTS

We reviewed the records of 99 patients: 46 women (mean age 63.53) and 53 men (mean age 59.94); 29 patients underwent a biopsy and the remaining 70 underwent excisional surgery. Mean survival was 18.092 months for the whole series. The total indirect cost for the series was €11 080 762 (2015). Mean indirect cost per patient was €111 926 (2015).

DISCUSSION

Although glioblastoma is a relatively uncommon type of tumour, accounting for only 4% of all cancers, its poor prognosis and potential sequelae generate disproportionately large morbidity and mortality rates which translate to high indirect costs. Clinicians should be aware of the societal impact of glioblastoma and indirect costs should be taken into account when cost effectiveness studies are performed to better illustrate the overall consequences of this disease.

Cost-effectiveness of asthma therapy: a comprehensive review

BACKGROUND

Asthma has an important impact in terms of both direct and indirect costs. In Europe, the disease costs € 19 000 million a year. Moreover, the cost is greater among patients with severe uncontrolled asthma and is even higher when the work productivity is also taken into account. Improved control of the disease results in cost savings. In this context, cost-effectiveness and cost-utility studies offer important information for clinicians in deciding the best treatment options for asthmatic patients and contribute to ensure an efficient use of the available healthcare resources.

METHODS

An English and Spanish literature search using electronic search engines (PubMed and EMBASE) was conducted in peer-review journals, from 2009 to June 2014. In order to perform the search for the most suitable and representative articles, key words were selected ("asthma", "cost-effectiveness", "cost-utility", "QALY", "cost-benefit", "economic impact of asthma" "healthcare cost", "asthma treatment" and "work productivity with asthma").

RESULTS

Two-hundred forty-three titles and abstracts were identified by the primary literature search. The full text of the potentially 76 eligible papers was reviewed, and 22 articles were qualified to be finally included.

CONCLUSIONS

This article provides a comprehensive review on the evidence of cost-effectiveness of asthma treatments derived from the published literature and offers an overall summary of the socioeconomic burden of asthma and its relationship with the degree of disease control. Management alternatives, such as the use of combination therapy with ICS/LABA or omalizumab, when administered according to their current therapeutic indications, have been shown to be cost-effective.

[Morbidity observed in a health area: Impact on professionals and funding]

Objetivo

Analizar, en el contexto de un área sanitaria, la morbilidad desagregada por centro de salud de los pacientes que entran en contacto con los servicios asistenciales para proponer un ajuste a la financiación en el pago per cápita.

Diseño

Estudio descriptivo, retrospectivo, de la morbilidad observada en los ciudadanos asignados a un área de salud durante el año 2010.

Emplazamiento

Área 9 de salud de la Comunidad Autónoma de Madrid, que comprende los municipios de Fuenlabrada, Humanes y Moraleja de Enmedio. Incluyendo todos los niveles de atención sanitaria.

Participantes

La totalidad de ciudadanos con tarjeta sanitaria asignada a un centro de salud del área que haya mantenido contacto con los servicios públicos de salud del propio área.

Mediciones

Se obtienen y agrupan los contactos codificados de los pacientes mediante el agrupador poblacional 3MTM Clinical Risk Grouping Software (CRG) cada paciente resulta incluido en un grupo homogéneo y excluyente con una morbilidad numérica y sentido clínico. A través de la tarjeta sanitaria se conoce centro de salud, médico de atención primaria, edad y sexo.

Resultados

Se estratifica la morbilidad por centro de salud, médico de atención primaria, edad y sexo y analizando las diferencias entre cada una de ellas y sus diferentes combinaciones.

Conclusiones

Se comprueba cómo los valores promedio de morbilidad de la población presentan valores distintos en cada zona básica de salud. Para mantener el principio de equidad sería necesario ajustar pago per cápita y número de tarjetas asignadas en función de la morbilidad observada de la población.

Estimating lifetime healthcare costs with morbidity data

BACKGROUND

In many developed countries, the economic crisis started in 2008 producing a serious contraction of the financial resources spent on healthcare. Identifying which individuals will require more resources and the moment in their lives these resources have to be allocated becomes essential. It is well known that a small number of individuals with complex healthcare needs consume a high percentage of health expenditures. Conversely, little is known on how morbidity evolves throughout life. The aim of this study is to introduce a longitudinal perspective to chronic disease management.

METHODS

Data used relate to the population of the county of Baix Empordà in Catalonia for the period 2004-2007 (average population was N = 88,858). The database included individual information on morbidity, resource consumption, costs and activity records. The population was classified using the Clinical Risk Groups (CRG) model. Future morbidity evolution was simulated under different assumptions using a stationary Markov chain. We obtained morbidity patterns for the lifetime and the distribution function of the random variable lifetime costs. Individual information on acute episodes, chronic conditions and multimorbidity patterns were included in the model.

RESULTS

The probability of having a specific health status in the future (healthy, acute process or different combinations of chronic illness) and the distribution function of healthcare costs for the individual lifetime were obtained for the sample population. The mean lifetime cost for women was €111,936, a third higher than for men, at €81,566 (all amounts calculated in 2007 Euros). Healthy life expectancy at birth for females was 46.99, lower than for males (50.22). Females also spent 28.41 years of life suffering from some type of chronic disease, a longer period than men (21.9).

CONCLUSIONS

Future morbidity and whole population costs can be reasonably predicted, combining stochastic microsimulation with a morbidity classification system. Potential ways of efficiency arose by introducing a time perspective to chronic disease management.