Costs of stroke and stroke services: Determinants of patient costs and a comparison of costs of regular care and care organised in stroke services

Background  

Stroke is a major cause of death and long-term disability in Western societies and constitutes a major claim on health care budgets. Organising stroke care in a stroke service has recently been demonstrated to result in better health effects for patients. This paper discusses patient costs after stroke and compares costs between regular and stroke service care.     

A model for costs of stroke services

In industrialised countries, stroke is one of the most common causes of death and handicap, and the costs for stroke services are high. However, rational planning of stroke services and estimation of the costs of their provision are complex, even when generic pathways for stroke diagnosis and treatment are well understood. The reason is the chronic nature of cerebro-vascular disease and the cumulative effect of disabling brain injury. In this paper we describe development of a computer model for estimating the costs of stroke services, intended for use by planners and purchasers of stroke care services. The model operates by incrementing patients' experience of stroke events and their outcomes in annual steps, and is calibrated using Swedish data. We demonstrate the cost consequences by simulating three different policy changes. The model facilitates comparisons between stroke prevention, treatment and rehabilitation, and we conclude that by combining the three policy options it is possible to reduce the costs for stroke services markedly.     

Obstetric care in the Netherlands: Manpower substitution and differential costs

Trends in the Netherlands show an expanded role for obstetricians in hospital-based prenatal and natal care, as well as a shift in postnatal care away from hospitals to domiciliary care. While general practitioners attend a steadily declining share of total births, midwives continue to play a central role in supporting over 40 per cent of all births and in attending nearly two thirds of all home births, which, in the Netherlands, is the preferred option for more than a third of childbearing women. As shown in the figures, shifts of births into hospitals and of postnatal care out of hospitals produce opposite effects on obstetric expenditures. Cost differences are primarily associated with variation in location of care, and only secondarily with variation in provider of care, underscoring the importance of contrasting styles of obstetric management and their influence on costs. In the context of these observed transitions, the increasing popularity of policlinical deliveries constitutes a pivotal force whose impact to date appears to have been neglected by planners and health care decision makers.     

Hospital budgeting in the Netherlands: Effects upon hospital services

This article analyses the impact of the transition from outputreimbursement to prospective budgeting upon hospital services.In the period immediately after the adoption of budgeting importantchanges in hospital services can be observed, such as a dropin admissions and the occupancy rate and falling treatment Intensityratios (number of treatments per admission/outpatient visit).Hospital services prove sensitive to incentives built into thepayment system. The specific impact upon services depends uponthe design of the budgeting system. Changes in hospital healthservices can be seen as the result of cost containment strategiesof hospital management. Some instruments for cost containmentwere: a reduction of staff; a more selective use of beds; andmore stringent procedures for investments in medical technology.The common characteristic of these instruments is that theyall reduce the volume of resources for the treatment of patients.Hospital management lacks effective instruments for more directlyinfluencing the medical treatment process.     

Organisation of services for acute stroke in Scotland--report of the Scottish stroke services audit

An audit was undertaken of hospital service provision for acute strokes in Scotland, using as a template key recommendations in the four SIGN guidelines on management of stroke. A questionnaire and structured interview was undertaken of key personnel in the 43 Trusts and three directly managed units providing in-patient stroke care in Scotland, and the 15 Health Boards commissioning stroke care. All Trusts and Health Boards participated and a complete set of information for each was recorded on a data-base and analysed. This report gives an overview for 14 key components of an integrated stroke service with results presented in four bands according to Trust type determined by the number of strokes admitted. No Trust provided all key components and for a few components a lack of provision was widespread, e.g. fast-track assessment clinics for TIA and minor stroke, access to CT scanning within 48 hours. Variation occurred between Trusts of similar size, between Trusts of different sizes. Overall the Health Boards were at a preliminary stage in the development of stroke specific service specifications. The results of the audit are a view of stroke services around April 1998, and should enable commissioners and providers to consider how to progress implementation of the clinical guidelines on stroke care.     

Incidence and costs of injuries in The Netherlands

BACKGROUND: Injuries are a major and persistent public health problem, but a comprehensive and detailed overview of the economic burden is missing. We therefore estimated the number of emergency department (ED) attendances and health care costs as a result of injury. METHODS: We estimated lifetime health care costs of injuries occurring in The Netherlands in the year 1999. Patient groups were defined that are homogeneous in terms of health service use. Health service use and costs per patient group was estimated with data from national databases and a prospective study among 5755 injury patients. RESULTS: Total health care costs due to injury in 1999 were euro 1.15 billion, or 3.7% of the total health care budget. Major cost peaks were observed among males between ages 15 and 44 due to a high incidence, and among females from age 65 onwards due to a high incidence and high costs per patient. For the age groups 0-14, 15-44, 45-64, and 65+ ED attendances per 1000 person years were 85, 85, 43, and 49, respectively, and costs per capita were euro 38, euro 59, euro 43, and euro 210, respectively. Costs per patient rise about linearly up to age 60 and about exponentially thereafter. From age 25 onwards, females have higher costs per patient than males. Hip fracture (20%), superficial injury (13%), open wounds (7%), and skull-brain injury (6%) had the highest total costs. Most costs were attributable to falls (44%) and traffic injuries (19%). CONCLUSION: Young adult males, elderly females, falls, hip fractures, and minor injuries without medical need for hospitalization account for a substantial share of health care costs.     

Future costs in cost-effectiveness analysis: an empirical assessment

Aim  

The aim of this study was to assess the impact on the cost-effectiveness ratio of including measures of production and consumption following a health care or health promotion intervention that improves survival.     

Future costs in cost effectiveness analysis

This paper resolves several controversies in CEA. Generalizing [Garber, A.M., Phelps, C.E., 1997. Economic foundations of cost-effectiveness analysis. Journal of Health Economics 16 (1), 1-31], the paper shows accounting for unrelated future costs distorts decision making. After replicating [Meltzer, D., 1997. Accounting for future costs in medical cost-effectiveness analysis. Journal of Health Economics 16 (1), 33-64] quite different conclusion that unrelated future costs should be included in CEA, the paper shows that Meltzer's findings result from modeling the budget constraint as an annuity, which is problematic. The paper also shows that related costs should be included in CEA. This holds for a variety of models, including a health maximization model. CEA should treat costs in the manner recommended by Garber and Phelps.     

The impact of the introduction of market incentives on occupational health services and occupational health professionals: experiences from The Netherlands

OBJECTIVES: This paper describes the reform of the regulations on safety and health in the Netherlands towards a more competitive market and its impact on occupational health services (OHSs) and the health professionals over the period 1994-2005. Aims are to identify the crucial factors that bring about the intended effects (such as lower disability rates) and to evaluate the outcomes from the perspective of the occupational health professional. The paper contributes to the discussion of how the professionals could define and contain their professional identity and credibility in competitive circumstances. METHODS: Open interviews were completed with 12 key persons and secondary analyses were made on documents and various monitors. RESULTS: The reform changed the OHS safety market fundamentally. OHSs were transformed from medium sized regional units into business organizations mostly operating on a national level. Private insurance companies became key players. Only after the development of an effective social infrastructure, however, intended effects (lower absenteeism and disability) occurred. Occupational health professionals were initially opposed but by redefining their professional domain and identity, they finally succeeded in gaining negotiating power in order to preserve and develop expertise and professional integrity. CONCLUSIONS: The effectiveness of the introduction of market incentives depends strongly on their social embeddedness. Health professionals should adapt their strategy to the conditions of the competitive market, in order to preserve a credible and professional identity.     

The daily practice in home help services in the Netherlands: instrument development

Many developments have taken place in home help services which have made further professionalization necessary. For this reason, a national study has been planned in the Netherlands to obtain a representative picture of the work of home helps and to examine overloading aspects of their workload. Five instruments were developed for this purpose and a pilot study was carried out to establish the reliability and content validity of the main instrument: a registration form to record the activities that home helps perform. Twenty-five home helps participated in the pilot study. An observer monitored them during their home visits for a period of 1 week. Both the observer and the home help recorded the activities that were carried out independently on the registration form. The reliability of the registration form was assessed by inter-rater-reliability. The validity of this instrument was estimated by the content validity. The results show that the registration form is, in general, a reliable instrument. There is a high level of agreement between home helps and observers in the four main categories: 94% for the household and the caring activities, 98% for the psycho-social or supporting activities and 96% for the reporting activities. The content validity of the form is adequate and only a few items will be added to the final version of the form.     

Future medical and non-medical costs and their impact on the cost-effectiveness of life-prolonging interventions: a comparison of five European countries

When healthcare interventions prolong life, people consume medical and non-medical goods during the years of life they gain. It has been argued that the costs for medical consumption should be included in cost-effectiveness analyses from both a healthcare and societal perspective, and the costs for non-medical consumption should additionally be included when a societal perspective is applied. Standardized estimates of these so-called future costs are available in only a few countries and the impact of inclusion of these costs is likely to differ between countries. In this paper we present and compare future costs for five European countries and estimate the impact of including these costs on the cost-effectiveness of life-prolonging interventions. As countries differ in the availability of data, we illustrate how both individual- and aggregate-level data sources can be used to construct standardized estimates of future costs. Results show a large variation in costs between countries. The medical costs for the Netherlands, Germany, and the United Kingdom are large compared to Spain and Greece. Non-medical costs are higher in Germany, Spain, and the United Kingdom than in Greece. The impact of including future costs on the ICER similarly varied between countries, ranging from €1000 to €35,000 per QALY gained. The variation between countries in impact on the ICER is largest when considering medical costs and indicate differences in both structure and level of healthcare financing in these countries. Case study analyses were performed in which we highlight the large impact of including future costs on ICER relative to willingness-to-pay thresholds.

     

Rebuilding health systems in post-conflict countries: estimating the costs of basic services

After the fall of the Taliban in 2001, the Afghan transitional government and international donors found the health system near collapse. Afghanistan had some of the worst health indicators ever recorded. To begin activities that would quickly improve the health situation, the Ministry of Health (MOH) needed both a national package of health services and reliable data on the costs of providing those services. This study details the process of determining national health priorities, creating a basic package of services, and estimating per capita and unit costs for providing those services, with an emphasis on the costing exercise. Strategies for obtaining a rapid yet reasonably accurate estimate of health service costs nationwide are discussed. In 2002 this costing exercise indicated that the basic package of services could be provided for US dollars 4.55 per person. In 2006, the findings were validated: the four major donors who contracted with non-governmental organizations (NGOs) to provide basic health services for nearly 80% of the population found per capita costs ranging from dollars 4.30 to dollars 5.12. This study is relevant for other post-conflict countries that are re-establishing health services and seeking to develop cost-effective and equitable health systems.     

Heart transplantation in the Netherlands; costs, effects and scenarios

The Dutch heart transplantation programme was subjected to a prospective economic evaluation and costs and effects with or without such programme were estimated. The no-programme estimates were derived from pretransplant patient data. Future projections of both options were based on micro-stimulation using additional data on severe heart disease prevalence and on multi-organ donation. Costs per life year gained are estimated at NLG 57,650 (quality adjusted: NLG 71,900). Sensitivity analysis showed these results to depend highly on long term incidence of costs and on quality of life after transplantation.