Collecting direct non-health care and time cost data: application to screening and diagnosis of cervical cancer.

BACKGROUND: Data on direct non-health care and time costs are rarely collected, though the incorporation of such data is essential for performing cost-effectiveness analyses according to established guidelines. OBJECTIVES: To explore the challenges involved in collecting and analyzing these data from patients enrolled in a clinical trial. METHODS: Through the use of a pilot study, the authors designed a questionnaire to collect these costs. They used this questionnaire in a clinical trial conducted at a comprehensive cancer center and a public community hospital. Patients in the trial were undergoing screening or diagnostic procedures through a clinical protocol designed to measure the effectiveness of fluorescence and reflectance spectroscopy for detecting cervical precancers. Direct non-health care costs were adjusted to 2003 constant dollars. RESULTS: The authors successfully collected direct non-health care and time cost data, thus demonstrating the feasibility of acquiring such data. Compared to patients receiving diagnostic services for cervical cancer, those receiving screening services for the same condition in both settings incurred lower direct non-health care costs and time costs, as defined in the questionnaire. Compared to patients receiving either service at the comprehensive cancer center, those seeking either service at the public community hospital incurred lower direct non-health care costs and time costs. When outliers were removed, total direct non-health care costs and time costs substantially decreased for diagnostic patients in the comprehensive cancer center; total direct non-health care costs and time costs for other subgroups remained essentially unchanged. CONCLUSIONS: Direct non-health care and time cost data can be collected within a large-scale clinical trial. The setting (community v. specialty hospital) and population (patients receiving screening v. diagnostic examination) makes a difference regarding the cost totals. The order of magnitude of the final result depends on the context in which the non-health care and time cost data will be used.     

Clinical education in two-year colleges: cost-benefit issues

Allied health program directors and administrators need to be aware of the costs and benefits of their clinical training programs to assure continued availability of training facilities for students. In a pilot study, program directors and administrators who are members of the National Network of Health Career Programs in Two-year Colleges (NN2) were surveyed concerning items to include in a cost-benefit-analysis tool, intangible and tangible costs and benefits of clinical education programs, and evaluation of a tool to analyze costs and benefits. Surveys were sent to 138 NN2 members, with 58 responding. Clinical sites were primarily in independent hospitals or health care systems. Most programs had preceptor-to-student ratios of 1:1-1:2, with few students being paid for clinical work. The respondents identified costs as staff time, materials and supplies, equipment, and others. Benefits were orientation and recruitment savings; increased professionalism, job satisfaction, and work quality of staff; ability to maintain and upgrade staff skills and knowledge; and student assistance with clinical coverage. Few programs were required to perform cost analysis. Allied health clinical education programs continue to depend on the willingness of health care facilities to accept students for clinical training.     

Case study: cost/benefit analysis of clinical education--radiologic technology, College A-Hospital B.

The Clinical Allied Health Education Center, Grand Rapids, Michigan, supported by Ferris State College, Big Rapids, Michigan, under Contract No. 1-AH-44106 with the Department of Health, Education and Welfare, designed a model for the clinical education of allied health personnel. Research concerning the cost of clinical education was a necessary part of the model design process. The primary purpose of this case study was to determine, in dollar terms, the cost or benefit to Hospital B, using available data, or data which could be developed with little effort by the hospital. The study breaks down the component costs into determinable factors, and assigns a dollar value to each. A value is also assigned to that portion of the student's activities that produced revenue for the hospital. Expenses related to the production of revenue by students are calculated and applied against said revenue in accordance with the matching principle. The result when revenue and expense were matched was net benefit of $46, 186 to Hospital B.     

Implementation and evaluation of a new approach to clinical instruction

An approach to clinical instruction based on the Learning Vector model was introduced in a hospital laboratory during the 1985-86 academic year. Fifteen clinical instructors and nine medical technology students participated in the study. Clinical instructors attended an initial workshop on the model and met monthly during the academic year with the project directors to discuss their progress. The implementation of the model and the reactions of students and instructors to the model were evaluated using attitudinal questionnaires, interviews, and observations. Instructors were most successful using the model during the learning activities component of clinical instruction and were less consistent in implementing the model in the expectation-setting and evaluation components of instruction. According to instructors and students, advantages of this approach included improved communication, guidance and organization of instruction, and an increased emphasis on feedback and evaluation. The major constraint to implementation was a limited amount of time spent with students, due to scheduling or workload.     

Estimating the cost of cervical cancer screening in five developing countries

Background

Cost-effectiveness analyses (CEAs) can provide useful information to policymakers concerned with the broad allocation of resources as well as to local decision makers choosing between different options for reducing the burden from a single disease. For the latter, it is important to use country-specific data when possible and to represent cost differences between countries that might make one strategy more or less attractive than another strategy locally. As part of a CEA of cervical cancer screening in five developing countries, we supplemented limited primary cost data by developing other estimation techniques for direct medical and non-medical costs associated with alternative screening approaches using one of three initial screening tests: simple visual screening, HPV DNA testing, and cervical cytology. Here, we report estimation methods and results for three cost areas in which data were lacking.

Methods

To supplement direct medical costs, including staff, supplies, and equipment depreciation using country-specific data, we used alternative techniques to quantify cervical cytology and HPV DNA laboratory sample processing costs. We used a detailed quantity and price approach whose face validity was compared to an adaptation of a US laboratory estimation methodology. This methodology was also used to project annual sample processing capacities for each laboratory type. The cost of sample transport from the clinic to the laboratory was estimated using spatial models. A plausible range of the cost of patient time spent seeking and receiving screening was estimated using only formal sector employment and wages as well as using both formal and informal sector participation and country-specific minimum wages. Data sources included primary data from country-specific studies, international databases, international prices, and expert opinion. Costs were standardized to year 2000 international dollars using inflation adjustment and purchasing power parity.

Results

Cervical cytology laboratory processing costs were I$1.57–3.37 using the quantity and price method compared to I$1.58–3.02 from the face validation method. HPV DNA processing costs were I$6.07–6.59. Rural laboratory transport costs for cytology were I$0.12–0.64 and I$0.14–0.74 for HPV DNA laboratories. Under assumptions of lower resource efficiency, these estimates increased to I$0.42–0.83 and I$0.54–1.06. Estimates of the value of an hour of patient time using only formal sector participation were I$0.07–4.16, increasing to I$0.30–4.80 when informal and unpaid labor was also included. The value of patient time for traveling, waiting, and attending a screening visit was I$0.68–17.74. With the total cost of screening for cytology and HPV DNA testing ranging from I$4.85–40.54 and I$11.30–48.77 respectively, the cost of the laboratory transport, processing, and patient time accounted for 26–66% and 33–65% of the total costs. From a payer perspective, laboratory transport and processing accounted for 18–48% and 25–60% of total direct medical costs of I$4.11–19.96 and I$10.57–28.18 respectively.

Conclusion

Cost estimates of laboratory processing, sample transport, and patient time account for a significant proportion of total cervical cancer screening costs in five developing countries and provide important inputs for CEAs of alternative screening modalities.     

Cost of elective surgery and utilization of ancillary services in teaching hospitals.

Measures of surgical utilization studied are the number of elective tests performed preoperatively and the total cost per case. The unit of analysis is a matched pair of patients who underwent the same elective procedure, one a Veterans Administration patient, and the other a municipal or voluntary hospital patient. Federal ownership of the hospital ahd the strongest impact on tests and cost per case. On average, costs for the VA patients were 52 percent more per case. The foreign medical graduate variable had a large positive (inflationary) effect on the number of tests, but a slight downward influence in the cost regressions. The fraction of surgeons with faculty appointments had a strong negative (curtailing) impact on elective testing, but an upward influence on cost per case. Additional variables such as age, average laboratory turnaround time, and fraction of the medical school's students doing their surgical clerkship at the hospital ahd a slight upward influence on utilization. The three policy issues raised in the study involve changing the hospital reimbursement incentives, targeting continuing education programs to categories of staff that need it most, and redistributing faculty and students.     

The Economic Impact for Farm Injury in Minnesota, 2004–2010

Only 2% of Minnesota’s employed population worked in agriculture between the years 2005 and 2012. However, this small portion of the state’s employed population accounted for 31% of total work-related deaths in the state during that same time period. During a similar time period, 2007–2013, the contribution of agriculture to Minnesota’s gross domestic product increased from approximately 1.5% to about 2.3%. This article describes the economic impact of injuries related to farm work between the years 2004 and 2010. Using hospital discharge data and the Census of Fatal Occupational Injuries (CFOI), estimates of the number of injuries and fatalities related to agricultural work were compiled. A cost of illness model was applied to these injury and fatality estimates to calculate the related indirect and direct costs in 2010 dollars. Estimated total costs, in 2010 dollars, ranged between $21 and $31 million annually over the 7-year study period. The majority of the costs were attributable to indirect costs, such as lost productivity at work and home. Fatal injuries accrued the largest proportion of the estimated costs followed by hospitalized and nonhospitalized injuries. A sensitivity analysis was performed to evaluate the impact each selected data source had upon the cost estimate. The magnitude of the costs associated with these injuries argues for better surveillance of injury related to agriculture to prioritize resources and evaluate intervention and prevention programs.     

Health risk influence on medical care costs and utilization among 2,898 municipal employees

Introduction: Although worksite health promotion programs are credited with stabilizing medical benefits costs, research is needed to characterize the medical costs of cohorts with selected health risk factors. The purpose of this study was to compare medical cost outcomes in City of Birmingham, Alabama, employees who differ on selected health risk factors.Methods: Health risk appraisal and medical claims cost data were examined in 2,898 employees participating in health screening during 1992 and 1993. Probit analysis was employed to test the null hypotheses that there are no differences in (1) probability of medical service utilization and (2) probability of medical service cost quartile (high, moderate, and low) between groups characterized by risks. Age, gender, race, education, marital status, and diabetes were included as covariates in each model examined. In addition, smoking habits was included as a covariate in models involving risk taking behavior and psychosocial risk.Results: Significant differences in medical care utilization and costs were found between risk groups based on psychosocial risk, cardiovascular disease risk, and total risk. No association was found between risk-taking behavior and utilization and costs.Conclusion. Subjects reporting psychosocial, cardiovascular disease, and total risk factors were more likely to use medical services and to be in the high or high/moderate cost categories.     

Dialysis in Barbados: the cost of hemodialysis provision at the Queen Elizabeth Hospital.

OBJECTIVE: The purpose of this study was to assess the health service cost of hemodialysis delivered at the Queen Elizabeth Hospital in St. Michael, Barbados. METHODS: A cost analysis was performed from the viewpoint of the tertiary hospital studied here, using treatment protocols based on current practice for establishing vascular access sites (surgical set-up) and dialysis maintenance. Cost and patient data were collected for the period from 1 April 1998 to 31 March 1999. Sixty-four patients were studied and a total of 7 488 hemodialysis sessions were performed in the study period. The costs analyzed were personnel, drug expenditure, supplies (dialysis and nondialysis), inpatient costs, laboratory and other ancillary services, and indirect or overhead costs such as engineering, housekeeping, laundry and administration. RESULTS: The cost per hemodialysis treatment was calculated as US$ 156.64 in the first year and US$ 145.55 in subsequent years. The total cost per patient per year was US$ 18 327.22 in the first year of dialysis including surgical set-up, and US$ 17 029.54 thereafter. Direct costs (determined by patients' utilization of resources and labor costs for physicians and nurses) contributed to 80.7% of the total cost. The main expenditures were dialysis-related supplies, labor and overheads. CONCLUSION: These findings are important in the light of limited economic resources available to health services in Caribbean countries coupled with the spiraling prevalence of kidney failure in these countries. Further analyses are recommended to review the provision of renal replacement therapy services in Barbados and to develop plans to expand and optimize services.     

Cost-effectiveness of home telemedical cardiotocography compared with traditional outpatient monitoring

We compared the cost of passive sensor telemedical non-stress cardiotocography performed at home and the same test performed by traditional equipment in an outpatient clinic in the Budapest area. The costs were calculated using two years' registered budget data from the home monitoring service in Budapest and the outpatient clinic of the department of obstetrics and gynaecology at the Haynal Imre University of Health Sciences. The traditional test at the university outpatient clinic cost 3652 forint for the health-care and 1000 forint in additional expenses for the patient (travel and time off work). This means that the total cost for each test in the clinic was 4652 forint. The cost of home telemedical cardiotocography was 1500 forint per test, but each test took 2.1 times as long. For a more realistic comparison between the two methods, we adjusted the cost to take account of the extra length of time that home monitoring required. The adjusted cost for home care was 3150 forint, some 32% lower than in the clinic. Passive sensor telemedical non-stress cardiotocography at home was therefore less expensive than the same test performed in the traditional way in an outpatient clinic.     

Reconsidering the moral hazard-risk avoidance tradeoff

The received model for optimal demand-side cost sharing trades off moral hazard and risk avoidance. This model appears to lie behind recent increases in initial cost sharing, such as those embodied in Health Savings Accounts and Health Reimbursement Accounts. At the same time there is evidence that lower cost sharing for certain drugs can reduce future total health care costs and/or improve future health, and this may be true of other medical services as well. To the degree that individuals remain in the same common insurance pool, lower cost sharing that induces increases in certain services that reduce total costs, including future costs, represents a classic case for a subsidy and will minimize an employer's labor costs. Even if total costs increase, the value of a change in health could increase more. In that case such a subsidy is consistent with recent work in behavioral economics for those with self-control problems.     

The costs of implementing and operating an oral health service from the perspective of the service and society

The aim of this study was to assess the costs of setting up and maintaining dental care in the public sector. Costs were updated or depreciated according to the service's lifespan and were analyzed from the perspective of the service itself and society. According to the findings, for the service the total cost of setting up a dental care unit with seven rooms was BRL$860.643.67 in the first year, plus BRL$545,419.23 for maintenance, and clinical dental care was the most expensive specialty. For society, the total cost was BRL$990,065.06 (implementation) and BRL$668,369.55 (maintenance), and the most expensive specialty was prevention (US$1.00 = BRL$1.62). Capital costs represented a small percentage of total costs for a dental care unit, but they need to be considered, since they can modify the results. Due to the high costs, preventive and promotional interventions should not be performed in the clinical setting, but should be replaced by broader and less expansive population-based interventions, since considerable sums need to be spent by the low-income population to participate in free public programs.     

The revenue generated from clinical chemistry and hematology laboratory services as determined using activity-based costing (ABC) model

Background

The rapid and continuous growth of health care cost aggravates the frequently low priority and less attention given in financing laboratory services. The poorest countries have the highest out-of-pocket spending as a percentage of income. Higher charges might provide a greater potential for revenue. If fees raise quality sufficiently, it can enhance usage. Therefore, estimating the revenue generated from laboratory services could help in capacity building and improved quality service provision.

Methods

Panel study design was used to determine revenue generated from clinical chemistry and hematology services at Tikur Anbessa Specialized Teaching Hospital, Addis Ababa, Ethiopia. Activity-Based Costing (ABC) model was used to determine the true cost of tests performed from October 2011 to December 2011 in the hospital. The principle of Activity-based Costing is that activities consume resources and activities consumed by services which incur the costs and hence service takes the cost of resources. All resources with costs are aggregated with the established casual relationships. The process maps designed was restructured in consultation with the senior staffs working and/or supervising the laboratory and pretested checklists were used for observation. Moreover, office documents, receipts and service bills were used while collecting data. The amount of revenue collected from services was compared with the cost of each subsequent test and the profitability or return on investment (ROI) of services was calculated. Data were collected, entered, cleaned, and analyzed using Microsoft Excel 2007 software program and Statistical Software Package for Social Sciences version 19 (SPSS). Paired sample t test was used to compare the price and cost of each test. P-value less than 0.05 were considered as statistically significant.

Result

A total of 25,654 specimens were analyzed during 3 months of regular working hours. The total numbers of clinical chemistry and hematology tests performed during the study period were 45,959 (66.1 %) and 23,570 (33.9 %), respectively. Only 274, 386 (25.3 %) Ethiopian Birr (ETB) was recovered from the total cost of 1,086,008.09 ETB incurred on clinical chemistry and hematology laboratory tests. The result showed that, about 133,821 (12.32 %) ETB was revenue not collected from out-of-pocket payments that was paid for the services as a result of under pricing. The result showed that 18 out of 20 laboratory tests were under priced. The cost burden related to free Anti Retro-viral Therapy (ART) services was 285,979.82 (26.3 %) ETB.

Conclusion

The cost per test estimated was significantly different to the existing price. About 90 % of the tests were under priced. This information could warn the hospital to reconsider resetting prices of these tests profitability ration less than 1. The revenue collected could help to build capacity, upscale quality, and sustainable service delivery.

     

How much quality control is enough? A cost-effectiveness model for clinical laboratory quality control procedures (illustrated by its application to a ligand-assay-based screening program)

Quality assurance testing represents a substantial proportion of the clinical laboratory budget, but current guidelines are based on criteria that pertain to analytic error rather than to optimization of the cost-effectiveness of patient care. A general Bayesian mathematical model for the cost-effectiveness of assay quality control has been developed, and is demonstrated using previously published data. The cost-effectiveness of quality assurance as defined here depends upon the prevalence of disease, the shapes of the distributions of test results observed in the non-diseased and diseased populations, the decision limit selected for labeling results positive or negative, the costs and benefits associated with each of the possible therapeutic outcomes, the magnitude of random and systematic analytical errors, the statistical power of the quality control test in use, the costs associated with delays due to re-assay, and the proportion of total test cost attributable to quality control procedures. Given current clinical laboratory practice, much of this information will not be routinely available. The model combines these factors into a simple equation with three terms: one for the cost of the original and any required repeat laboratory analyses, one for the cost of delay entailed by the rejection of an assay batch, and one for the change in total costs consequent to rejection of erroneous assay results.     

Cost analysis for decision support: the case of comparing centralized versus distributed methods for blood gas testing.

Distributed testing, performed in satellite laboratories or at the bedside, is proliferating within healthcare systems. Users prefer it, and it is fast and convenient. A quick look at marginal costs, however, suggests that cost differentials between distributed and centralized testing may be prohibitive. Sound decision making on the part of health system administrators requires a broader understanding of the costs and benefits of testing options. This study illustrates an approach to cost analysis for decision support where opportunity costs (the costs associated with the next best alternative) provide the basis for decision making. Health system administrators need to understand the opportunity costs involved in their decisions to avoid being misled by analyses that omit important cost elements from consideration. We describe approaches to determining the costs of "stat" laboratory testing options. The costs of various blood gas testing options are compared among a central blood gas laboratory, two satellite laboratories, and point-of-care analysis. Opportunity costs were determined by modeling the substitution of one testing process for another. The cost analysis finds that a judicious mix of alternate-site testing methods can generate annual savings of between $250,000 and $330,000, and at the same time reduce test reporting times. In other words, technology that superficially appears more costly can deliver better service with lower costs.     

The tangible cost implications of a hospital outbreak of multiply-resistant Salmonella

A hospital outbreak of multiply-resistant Salmonella heidelberg infection, which affected 17 patients and 2 staff, is described. The tangible cost of the outbreak was estimated at 21 pounds 151, 17 pounds 989 (85.1%) of which was borne by the hospital. The cost to the Microbiology Department was 3596 pounds (17.0% of the total). A detailed analysis of the costs and implications for staffing disruption is given and a comparison is made with the costs of preventive activities. Ways of containing expenses in the event of an outbreak and the economic implications for clinical budgeting and privatization of the laboratory service are considered.     

温州市首轮医疗服务价格调整效果分析——以某省属三甲医院甲状腺癌病种为例

目的:分析医院在执行医疗服务价格调整方案后,甲状腺癌根治(单侧)手术患者住院费用构成情况及变化原因,并提出建议。方法:选取价格调整前后共计1859例住院患者为研究对象,分析价格调整前后平均住院费用及其构成。结果:价格调整后,病人负担的住院费用并未明显增加,费用结构更趋合理,药占比降低;化验费、大型设备检查费不减反增;体现医护人员技术劳务价值的项目价格与成本仍然不匹配。结论:应确定合理的收入与成本比价关系,并以此分层分类动态调整价格,优化费用结构,腾出空间提高技术劳务项目收费水平。     

The value of measuring height and weight of schoolchildren

Summary. The measurements of height and weight in the Stockholm school health service was appraised in relation to the screening value, the costs and benefits. The concept of a doubtful screening value of growth surveillances at school age was supported. Investment costs and running expenses were very low. The measurement procedure used only 2% of the total time spent by the nurses in the school health service. The growth data were an appropriate prerequisite for the reassurance of adolescents about their developing identity and body image. The growth data also constituted an appropriate indicator for public health research. The benefits and low costs may justify maintenance of the measurements in the school health service despite a low screening value.