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1.
Economic evaluations must use appropriate costing methods. However, in multicentre cost‐effectiveness analyses (CEA) a fundamental issue of how best to measure and analyse unit costs has been neglected. Multicentre CEA commonly take the mean unit cost from a national database, such as NHS reference costs. This approach does not recognise that unit costs vary across centres and are unavailable in some centres. This paper proposes the use of multiple imputation (MI) to predict those centre‐specific unit costs that are not available, while recognising the statistical uncertainty surrounding this imputation. We illustrate MI with a CEA of a multicentre randomised trial (1014 patients, 60 centres), implemented using multilevel modelling. We use MI to derive centre‐specific unit costs, based on centre characteristics including average casemix, and compare this to using mean NHS reference costs. In this case study, using MI unit costs rather than mean reference costs led to less heterogeneity across centres, more precise estimates of incremental cost, but similar estimates of incremental cost‐effectiveness. We conclude that using MI to predict unit costs can preserve correlations, maximise the use of available data, and, when combined with multilevel modelling is an appropriate method for recognising the statistical uncertainty in multicentre CEA. Copyright © 2009 John Wiley & Sons, Ltd.  相似文献   

2.
This paper compares two quite different approaches to estimating costs: a ‘bottom‐up’ approach, represented by the US Department of Veterans Affairs' (VA) Decision Support System that uses local costs of specific inputs; and a ‘top‐down’ approach, represented by the costing system created by the VA Health Economics Resource Center, which assigns the VA national healthcare budget to specific products using various weighting systems. Total annual costs per patient plus the cost for specific services (e.g. clinic visit, radiograph, laboratory, inpatient admission) were compared using scatterplots, correlations, mean difference, and standard deviation of individual differences. Analysis are based upon 2001 costs for 14 915 patients at 72 facilities. Correlations ranged from 0.24 for the cost of outpatient encounters to 0.77 for the cost of inpatient admissions, and 0.85 for total annual cost. The mean difference between costing methods was $707 ($4168 versus $3461) for total annual cost. The standard deviation of the individual differences was $5934. Overall, the agreement between the two costing systems varied by the specific cost being measured and increased with aggregation. Administrators and researchers conducting cost analyses need to carefully consider the purpose, methods, characteristics, strengths, and weaknesses when selecting a method for assessing cost. Copyright © 2008 John Wiley & Sons, Ltd.  相似文献   

3.
International comparisons of health care systems and services have created increased interest in the comparability of cost results. This study compared top-down and bottom-up approaches to collecting unit cost data across centres in the context of examining the cost-effectiveness of dialysis therapy across Europe. The study tested whether health care technologies in different countries can be costed using consistent and transparent methods to increase the comparability of results. There was more agreement across the approaches for peritoneal dialysis than for than haemodialysis, with differences, respectively of Euro 91-1,687 vs. 333-7,314 per patient per year. Haemodialysis results showed greatest differences where dialysis units were integrated as part of larger hospitals. Deciding which approach to adopt depends largely on the technology. However, bottom-up costing should be considered for technologies with a large component of staff input or overheads, significant sharing of staff or facilities between technologies or patient groups and health care costing systems which do not routinely allocate costs to the intervention level. In these circumstances this costing approach could increase consistency and transparency and hence comparability of cost results.  相似文献   

4.
This paper demonstrates the basic properties in the systems most commonly considered for costing treatments in the Danish hospitals. The differences between the traditional charge system, the DRG system and the ABC system are analysed, and difficulties encountered in comparing these systems are discussed. A sample of patients diagnosed with stable angina pectoris (SAP) at Odense University Hospital was used to compare the three systems when costing an entire treatment path, costing single hospitalisations and studying the effects of length of stay. Furthermore, it is illustrated that the main idea behind each system is reflected in how the systems over- or underestimate costs. Implications when managing the hospitals, particularly reimbursement, are discussed.  相似文献   

5.
A core element in economic evaluation studies is the patient-based measurement of costs. As the University Hospital of Ulm is not endowed with a patient-based cost accounting system, it was necessary to develop a concept for the measurement of the cost of acute inpatient care for economic evaluation purposes. For accounting, a partial cost accounting system is available. The measurement concept aimed at was supposed to be consistent, to adequately attribute costs to resource consumption and to be precise enough in order to identify differences between health care alternatives in an incremental economic evaluation study. Both prospective and retrospective uses were aimed at, and it was hoped to be able to transfer the approach to other hospitals, for example in the context of multicentre studies. The cost accounting concept used specifies unit costs according to direct patient cost centres and uses a simple mark-up percentage to account for the overhead costs of infrastructure services. The collection of service data is based upon routine documentation. Monetary figures used for the pricing of services are derived from the cost accounting system of the hospital. Diagnostic and therapeutic services which are rendered by cost centres not directly caring for patients are priced using the fee-for-services schedule of the Deutsche Krankenhausgesellschaft (DKG-NT). In the basic approach, medical care is determined for each individual patient in the areas of diagnostic and therapeutic services, operations and standard care in a normal ward. In terms of lump sums, the cost of care is measured for drugs, for basic physician services in the ward, and for nursing care in intensive wards. The standard approach can be developed into a more detailed approach in which higher effort of calculation would render more precise cost measurement. In general, the measurement concept is believed to be precise and consistent, and to be transferable to other hospitals as well. In addition, the approach can be considered a contribution to the development of costing methods in acute inpatient care. The concept is suited for all economic evaluation studies which intend to measure costs from a societal perspective or from the perspective of a hospital.  相似文献   

6.
We propose reimbursement schemes based on patient classification systems (PCSs) that include adjustments for length of stay (LOS) and exceptional costs and are designed to minimize undesirable effects of economic incentives. In addition, a statistical approach to compare the schemes and the underlying PCSs is proposed, where costs and LOSs for two successive years are used. The first year data provides estimates of the class cost means and the next year's reimbursements which are compared with the second year's costs. This method focuses on the predictive power of a PCS and differs from the usual retrospective analyses based on the proportion of explained variance for single year data. The approach is applied to discharge data of Swiss hospitals where stays are grouped according to five PCSs: All Patient Diagnosis-Related Groups (AP-DRGs), All Patient Refined Diagnosis-Related Groups (APR-DRGs), International Refined Diagnosis-Related Groups (IR-DRGs), Australian Refined Diagnosis-Related Groups (AR-DRGs), and SQLape. When adjusting for LOS and outliers, these systems do not differ substantially in their ability to predict cost of stay. Therefore, increasing the number of classes does not necessarily improve cost predictions. However, the payment of a fixed amount per diem (not exceeding the marginal cost) and correcting the reimbursements for exceptional costs substantially reduces the average discrepancy between costs and reimbursements.  相似文献   

7.
ABSTRACT: BACKGROUND: Allocating national resources to regions based on need is a key policy issue in most health systems. Many systems utilise proxy measures of need as the basis for allocation formulae. Increasingly these are underpinned by complex statistical methods to separate need from supplier induced utilisation. Assessment of need is then used to allocate existing global budgets to geographic areas. Many low and middle income countries are beginning to use formula methods for funding however these attempts are often hampered by a lack of information on utilisation, relative needs and whether the budgets allocated bear any relationship to cost. An alternative is to develop bottom-up estimates of the cost of providing for local need. This method is viable where public funding is focused on a relatively small number of targeted services. We describe a bottom-up approach to developing a formula for the allocation of resources. The method is illustrated in the context of the state minimum service package mandated to be provided by the Indonesian public health system. METHODS: A standardised costing methodology was developed that is sensitive to the main expected drivers of local cost variation including demographic structure, epidemiology and location. Essential package costing is often undertaken at a country level. It is less usual to utilise the methods across different parts of a country in a way that takes account of variation in population needs and location. Costing was based on best clinical practice in Indonesia and province specific data on distribution and costs of facilities. The resulting model was used to estimate essential package costs in a representative district in each province of the country. FINDINGS: Substantial differences in the costs of providing basic services ranging from USD 15 in urban Yogyakarta to USD 48 in sparsely populated North Maluku. These costs are driven largely by the structure of the population, particularly numbers of births, infants and children and also key diseases with high cost/prevalence and variation, most notably the level of malnutrition. The approach to resource allocation was implemented using existing data sources and permitted the rapid construction of a needs based formula that is highly specific to the package mandated across the country. Refinement could focus more on resources required to finance demand side costs and expansion of the service package to include priority non-communicable services.  相似文献   

8.
Resource-Based Relative Value Scale (RBRVS) costing has been promoted as an accurate cost allocation methodology and has gained popularity in recent years as a way to support many aspects of medical practice management. In this article, we demonstrate that RBRVS (also known as relative value unit (RVU) costing), is simply an overly complex form of revenue-based cost assignment and is identical to ratio of cost to charges (RCC) and percent revenue cost assignment approaches. However, this equivalence can be easily obfuscated by routine numerical manipulations used in financial analysis for many aspects of practice management. Further we show that since RBRVS cost systems assume all procedures and hence providers earn the same profit margin, the reported costs derived from this analysis in complex medical settings are highly inaccurate. Reported costs are highly inaccurate because the equal profit margin assumption is inappropriate in most, if not all, medical settings. Furthermore, the equal profit margin assumption is in direct contradiction to the conceptual design of the RVU system where value is increased according to complexity and skill of a procedure. Finally, we demonstrate, no fundamental improvement is achieved in the accuracy of reported costs through the adoption of the more complicated component RBRVS approach. With medical costs at the forefront of the national agenda it is important that costs reported to the Centers for Medicare & Medicaid Services (CMS) and subsequently used in setting RVUs are accurate.  相似文献   

9.
As a result of organizational changes in the National Health Service (NHS) there is a need for a coherent costing model for NHS libraries, particularly for the smaller libraries based in postgraduate medical centres. One possible model is functional cost analysis, whereby all costs are assigned to library functions representing services to users, such as loans from stock, interlibrary loans, enquiry services, etc. Using data from a 1991 survey of postgraduate centre-based libraries in the North West Thames (NWT) Region of the NHS, the feasibility and appropriateness of functional cost analysis is examined.  相似文献   

10.
In this paper, the principles of costing health care for economic evaluation are outlined. Hypothetical and published examples are used to illustrate these principles. First, the economic concept of opportunity cost is defined. Secondly, the techniques of economic evaluation which follow from this definition are introduced: they are cost-benefit analysis, cost-effectiveness analysis and cost-utility analysis. Thirdly, a list of costs which should be considered for inclusion in either of these types of evaluation is provided, this listing being based on the concept of opportunity cost. Problems of measurement and valuation of costs are then outlined, focusing in particular on inflation, discounting, marginal costing, patient-based versus per diem costing, allocating overheads, costing capital and equipment and adjusting distorted market valuations. An example of sensitivity analysis is provided and also a checklist of questions to ask when setting up any costing exercise within an economic evaluation.  相似文献   

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