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.     

A cost study of a general practitioner hospital in the Netherlands

Objective: To perform a cost study of the first general practitioner (GP) hospital in the Netherlands.

Methods: We conducted a cost study in a GP hospital in the Netherlands. Data on healthcare utilisation from 218 patients were collected for a period of one year. The costs of admission to the GP hospital were compared with the expected costs of the alternative mode of care. In the GP hospital three types of bed categories were distinguished: GP beds (admission and discharge by GPs, n=131), rehabilitation beds (recovery from hospital surgery, n=62) and nursing home beds (hospital patients awaiting a vacancy in a nursing home, n=25). GPs were interviewed to indicate the best alternative form of healthcare for the GP bed patients in the absence of a GP hospital (dichotomised for this study into ‘hospital’ or ‘home care’). For the ‘rehabilitation’ and ‘nursing home’ patients the alternative care mode was admission to a hospital.

Results: The mean length of stay was 15 days for the GP beds, 31 days for the rehabilitation beds and 90 days for the nursing home beds. For the GP bed patients the costs were ?2533 per admission compared with ?3792 for hospital stay. For the group of GP bed patients for whom ‘home care’ was the best alternative, the costs were ?2494 for GP hospital days compared with ?2814, the average cost for home care of patients of 65 years and older. For rehabilitation patients the costs per patient were ?4744 compared with ?8041 in a hospital. For patients waiting for admission to a nursing home, these costs were ?13,143 and ?22,670, respectively.

Conclusion: The GP hospital might be a cost-saving alternative for elderly patients in need of intermediate medical and nursing care between hospital and home care. Further research on the cost-effectiveness of the GP hospital compared with home care and nursing home care is needed.     

Predicting length of stay for Medicare patients at a teaching hospital.

This research examines how the patients' characteristics and clinical indicators affect length of stay for the top five Diagnosis-Related-Groups (DRGs) for Medicare patients at a teaching hospital in the United States. The top DRGs were selected on the basis of volume per year. Teaching hospitals in the United States devote a significant amount of their resources to research and teaching, while providing treatment for patients. The ability to predict length of stay can substantially improve a teaching hospital's capacity utilization, while ensuring that resources are available to meet the health care needs of the Medicare population. Multiple regression models are developed to predict the length of stay using the patients' characteristics and clinical indicators as independent variables. The results indicate that approximately 60 percent (R(2)) of the variance in the length of stay is explained by the patients' characteristics and clinical indicators for these DRGs. The Mortality and Severity indices are found to be the strongest predictors for length of stay in all DRGs. Other patients' characteristics and clinical indicators such as age, gender, race/ethnicity, marital status, admission type and admission source are also significant predictors for some DRGs. In addition, most of these variables affect the length of stay in the same manner as shown in previous studies, even though the previous studies do not have the DRG specificity of this study.     

Investigating DRG cost weights for hospitals in middle income countries

Identifying the cost of hospital outputs, particularly acute inpatients measured by Diagnosis Related Groups (DRGs), is an important component of casemix implementation. Measuring the relative costliness of specific DRGs is useful for a wide range of policy and planning applications. Estimating the relative use of resources per DRG can be done through different costing approaches depending on availability of information and time and budget. This study aims to guide costing efforts in Iran and other countries in the region that are pursuing casemix funding, through identifying the main issues facing cost finding approaches and introducing the costing models compatible with their hospitals accounting and management structures. The results show that inadequate financial and utilisation information at the patient's level, poorly computerized 'feeder systems'; and low quality data make it impossible to estimate reliable DRGs costs through clinical costing. A cost modelling approach estimates the average cost of 2.723 million Rials (Iranian Currency) per DRG. Using standard linear regression, a coefficient of 0.14 (CI = 0.12-0.16) suggests that the average cost weight increases by 14% for every one-day increase in average length of stay (LOS).We concluded that calculation of DRG cost weights (CWs) using Australian service weights provides a sensible starting place for DRG-based hospital management; but restructuring hospital accounting systems, designing computerized feeder systems, using appropriate software, and development of national service weights that reflect local practice patterns will enhance the accuracy of DRG CWs.     

Diagnosis related groups (DRGs): efficiency and/or quality producing? Some evidence from surgical patients.

Hospital charges and length of stay for inguinal hernia and acute appendicitis patients were examined in a university hospital to determine the degree of variation with DRGs. Evidence presented here suggests that DRGs may lead to a reduction in medical care costs without a reduction in patient outcomes. Mode/year DRGs to take account of source of admission and maintaining outliers payments may be desirable to avoid patient selectivity and incentives for lowering quality of care of the most severely ill patients.     

Costs of nosocomial Clostridium difficile-associated diarrhoea

Nosocomial Clostridium difficile-associated disease (CDAD) is a common infection in hospitals. A matched case-control study was carried out to determine hospital-wide excess costs due to CDAD. Cases were assessed by prospective hospital-wide surveillance in a tertiary care university hospital in 2006. Nosocomial cases of CDAD (>72h after admission) were matched to control patients without CDAD in a ratio 1:3 using the same diagnosis-related group in the same year, for a hospital stay at least as long as the time of risk of the CDAD cases before infection and a Charlson comorbidity index +/-1. Data on overall costs per case were provided by the finance department. Matching was possible for 45 nosocomial CDAD cases. The difference in the length of stay showed that CDAD cases stayed significantly longer (median 7 days; P=0.006) than their matched controls. The average cost per CDAD patient was euro33,840. The difference in the cost per patient showed that the cost for CDAD patients was significantly more than for their matched controls (median euro7,147; 95% confidence interval: 4,067-9,276). Nosocomial CDAD is associated with high costs for healthcare systems. Clinicians should be aware of the financial impact of this disease and the application of appropriate infection control measures is recommended to reduce spread.     

DRGs IE15组在临床路径管理前后的费用影响分析

目的 探讨临床路径对DRGs付费IE15组费用的影响.方法 对某三级甲等医院骨关节科2012年DRGs试点IE15组146例病历实行临床路径管理,分析其平均住院费用和平均住院日的情况,并与2011年166例病历未实行临床路径管理的结果进行比较.结果 某三级甲等医院骨关节科IE15组实行临床路径管理后的平均住院费用（10 463.65元）和平均住院日（4.03天）明显低于实行临床路径管理前的平均住院费用（11 373.27元）和平均住院日（4.90天） （分别有P＜0.05和P＜0.000 l）.结论 临床路径可以降低DRGs的费用和住院日.     

495例肝脓肿患者疾病经济负担及其影响因素

目的分析2010-2019年住院治疗的肝脓肿患者基本情况、住院费用及其结构变化和影响因素,评估肝脓肿直接经济负担,探寻有效减轻肝脓肿疾病经济负担的方法。方法回顾性收集中南大学湘雅医院2010年1月-2019年12月收治的495例肝脓肿住院患者资料,分析逐年住院费用变化、各项住院费用变化、各临床特征与住院费用的相关关系,多元逐步回归分析住院费用影响因素。结果 495例病例中,平均住院日为15.93 d,人均住院费用34 548.02元,所有项目费用中西药类占比最高;既往有肝胆手术史、肿瘤病史、治疗过程中合并胸腔积液、肺部感染、采用手术治疗患者住院费用显著升高(P<0.05);多因素回归分析提示住院天数越长、治疗手段越复杂、合并肿瘤史、出现胸腔积液患者住院费用更高。结论 2010-2019年住院治疗肝脓肿人均费用34 548.02元,其中西药费用占比最高,诊断类费用逐年增长,不同特征患者住院费用有差异。住院日、治疗手段、肿瘤史、合并胸腔积液均会对住院费用产生影响。     

国考背景下咸宁市某三甲医院控费提质的探索与实践

为有效控制医院医疗费用不合理增长,减轻人民群众就医负担,咸宁市某三甲综合医院以2018年度国考"费用控制"考核指标为突破口,结合医院学科发展、功能定位、质量安全、优化流程等全方位、多角度的进行精细化控费管理.通过采取关键绩效指标(KPI)管理、疾病诊断相关分组(DRGs)费用监控、开展日间手术、药占比和耗占比目标值管理...     

The impact of teaching and research on hospital costs

This study assessed the impact of teaching and research on the average adjusted cost per stay of French public hospitals. Stepwise regression analyses were conducted using a 1994 database covering 144 public and private nonprofit hospitals. The dependent variable was the average cost per stay adjusted for the casemix. Various cost predictors were used, among which variables describing the intensity of teaching and research. On the entire sample, selected predictors explained 48% of the variance of adjusted average cost per stay. We found a positive very significant relationship between cost and research intensity, teaching intensity, the proportion of patients over 80 years, the proportion of admissions coming from another acute care hospital. There was a negative relationship with the proportion of 1-day surgical activity. Research had a higher impact on costs than teaching. Results suggest a nonlinear relationship between research intensity and costs, a threshold effect occurring for the 25% most active hospitals. On the subsample of 97 nonteaching nonresearch hospitals, the best model explained 39% of the variance of adjusted average cost per stay. Research had a positive significant impact, only for the 50% most active hospitals. We found no significant variation with training. On the subsample of 47 teaching and research hospitals, we found a positive relationship for teaching, but results were contradictory for research, according to what measure was used. Research and teaching have an impact on the differential of costs between university hospitals and others. This suggests a necessary adjustment of financing.     

Hospital costs of,and factors contributing to,a pertussis epidemic

Pertussis (whooping cough), a vaccine-preventable and highly infectious respiratory tract disease, caused a major epidemic in Australia during 1997, resulting in large numbers of babies and children being hospitalised. This retrospective study was designed to calculate the costs of this epidemic to a 250-bed paediatric teaching hospital in Western Australia (WA) and discuss the factors contributing to the epidemic.In all, 92 babies and children required 115 hospital admissions for pertussis. Thirteen were admitted to the paediatric or neonatal intensive care unit (P/NICU) at a cost of $229,500 and the 113 ward admissions cost $504,500. In addition, the microbiology diagnostic testing was estimated to cost $200,000. Thus, the real cost to the hospital over the 12-month period was $934,000. The majority of the patients were aged between 2 and 6 months, while all those requiring P/NICU admission were less than 6 months old. The younger the patient the greater the length of stay (average 6.6 days). A comparison was made between patient age, incidence of hospital admission, length of stay and P/NICU admission.When the immunisation compliance rate of inpatienls with pertussis was assessed, only 45 per cent of all those aged more than 2 months were up to date with their pertussis immunisation regime and, for 17 per cent, their immunisation status in the medical records was either lacking or poorly written.This study highlighted the need to improve pertussis immunisation compliance by educating both parents and health professionals regarding expected reactions to, and true contraindications for, pertussis vaccination, as well as for health-care professionals to improve immunisation documentation in the hospital's medical records. (AIC Aust Infect Control 1999; 4(1):15-22.)     

Variation in Hospital Length of Stay: Do Physicians Adapt Their Length of Stay Decisions to What Is Usual in the Hospital Where They Work?

OBJECTIVE: To test the hypothesis that physicians who work in different hospitals adapt their length of stay decisions to what is usual in the hospital under consideration. DATA SOURCES: Secondary data were used, originating from the Statewide Planning and Research Cooperative System (SPARCS). SPARCS is a major management tool for assisting hospitals, agencies, and health care organizations with decision making in relation to financial planning and monitoring of inpatient and ambulatory surgery services and costs in New York state. STUDY DESIGN: Data on length of stay for surgical interventions and medical conditions (a total of seven diagnosis-related groups [DRGs]) were studied, to find out whether there is more variation between than within hospitals. Data (1999, 2000, and 2001) from all hospitals in New York state were used. The study examined physicians practicing in one hospital and physicians practicing in more than one hospital, to determine whether average length of stay differs according to the hospital of practice. Multilevel models were used to determine variation between and within hospitals. A t-test was used to test whether length of stay for patients of each multihospital physician differed from the average length of stay in each of the two hospitals. PRINCIPAL FINDINGS: There is significantly (p<.05) more variation between than within hospitals in most of the study populations. Physicians working in two hospitals had patient lengths of stay comparable with the usual practice in the hospital where the procedure was performed. The proportion of physicians working in one hospital did not have a consistent effect for all DRGs on the variation within hospitals. CONCLUSION: Physicians adapt to their colleagues or to the managerial demands of the particular hospital in which they work. The hospital and broader work environment should be taken into account when developing effective interventions to reduce variation in medical practice.     

Hospital costs estimation and prediction as a function of patient and admission characteristics

The present work analyzed the association between hospital costs and patient admission characteristics in a general public hospital in the city of Rio de Janeiro, Brazil. The unit costs method was used to estimate inpatient day costs associated to specific hospital clinics. With this aim, three "cost centers" were defined in order to group direct and indirect expenses pertaining to the clinics. After the costs were estimated, a standard linear regression model was developed for correlating cost units and their putative predictors (the patients gender and age, the admission type (urgency/elective), ICU admission (yes/no), blood transfusion (yes/no), the admission outcome (death/no death), the complexity of the medical procedures performed, and a risk-adjustment index). Data were collected for 3100 patients, January 2001-January 2003. Average inpatient costs across clinics ranged from (US$) 1135 [Orthopedics] to 3101 [Cardiology]. Costs increased according to increases in the risk-adjustment index in all clinics, and the index was statistically significant in all clinics except Urology, General surgery, and Clinical medicine. The occupation rate was inversely correlated to costs, and age had no association with costs. The (adjusted) per cent of explained variance varied between 36.3% [Clinical medicine] and 55.1% [Thoracic surgery clinic]. The estimates are an important step towards the standardization of hospital costs calculation, especially for countries that lack formal hospital accounting systems.     

What does hospice cost?

This paper presents the preliminary results of the economic analyses of the National Hospice Study (NHS), mandated by the United States Congress to investigate the implications of including hospice services in Medicare. Data were collected over an 18-month period from approximately 4,000 patients receiving hospice and conventional terminal care in 25 hospices and 12 conventional care sites. Subsequent analysis may lead to changes in the specific results, and some of the differences may be due to confounding variables that cannot be adjusted for. According to these data, hospital based (HB) hospice costs per day are 44 per cent higher than home care (HC) hospice costs per day ($95 versus $66, respectively). In addition, per patient hospice costs are 24 per cent more for patients enrolled in HB than in HC hospices ($5,890 versus $4,758, respectively). The proportional difference between HB and HC in cost per patient is smaller than the cost per day difference due to the shorter average HB length of stay, 62.3 days compared to 72.5 days for HC. Regarding the cost savings of hospice compared to conventional care, HC hospice costs are lower than conventional care costs regardless of length of stay. However, HB costs seem lower than conventional care costs only for patients with lengths of stay less than two months. Hospice and conventional care patients appear to differ with respect to predisposition toward intensive health care utilization. When this difference is explored more thoroughly in subsequent analyses, the estimated cost differential between hospice and conventional care may change.     

Hospital economics of the hospitalist

OBJECTIVE: To determine the economic impact on the hospital of a hospitalist program and to develop insights into the relative economic importance of variables such as reductions in mean length of stay and cost, improvements in throughput (patients discharged per unit time), payer methods of reimbursement, and the cost of the hospitalist program. DATA SOURCES: The primary data source was Tufts-New England Medical Center in Boston. Patient demographics, utilization, cost, and revenue data were obtained from the hospital's cost accounting system and medical records. STUDY DESIGN: The hospitalist admitted and managed all patients during a six-week period on the general medical unit of Tufts-New England Medical Center. Reimbursement, cost, length of stay, and throughput outcomes during this period were contrasted with patients admitted to the unit in the same period in the prior year, in the preceding period, and in the following period. PRINCIPAL FINDINGS: The hospitalist group compared with the control group demonstrated: length of stay reduced to 2.19 days from 3.45 days (p<.001); total hospital costs per admission reduced to 1,775 dollars from 2,332 dollars (p<.001); costs per day increased to 811 dollars from 679 dollars (p<.001); no differences for readmission within 30 days of discharge to extended care facilities. The hospital's expected incremental profitability with the hospitalist was -1.44 dollars per admission excluding incremental throughput effects, and it was most sensitive to changes in the ratio of per diem to case rate reimbursement. Incremental throughput with the hospitalist was estimated at 266 patients annually with an associated incremental profitability of 1.3 million dollars. CONCLUSION: Hospital interventions designed to reduce length of stay, such as the hospitalist, should be evaluated in terms of cost, throughput, and reimbursement effects. Excluding throughput effects, the hospitalist program was not economically viable due to the influence of per diem reimbursement. Throughput improvements occasioned by the hospitalist program with high baseline occupancy levels are substantial and tend to favor a hospitalist program.     

PMH2 Assessment of Health-Related Quality of Life During Treatment of Opiate Dependence using the Short Form-36

In the U.S., acute general hospitals increasingly provide treatment for patients with schizophrenia.
OBJECTIVE: To estimate the average annual cost of inpatient schizophrenia care per patient in an acute general hospital setting.
METHODS: Using ICD9 codes to identify disease and procedure-level data in five state (CA, FL, MA, MD, NC) acute care, all payer, discharge databases, an average cost per admission was estimated and combined with the frequency of admission calculated from the MA database to derive a mean annual acute care inpatient cost. Physician costs were calculated by applying 1997 Medicare fees to a resource use profile derived from the databases and published treatment recommendations. All costs are reported in 1997 US$, appropriately adjusted for medical inflation and cost-to-charge ratios.
RESULTS: Of 7.5 millions discharges, 73,000 were identified as having been admitted primarily due to schizophrenia. The average length of stay was 13.5 days, with 90% of time spent in a designated psychiatric bed. Over 90% were discharged within one month, most (∼80%) to home without documentation of further services. The mean cost per stay (including physician fees) was $8,963. Most (68%) patients had only one admission, and 96% had less than five in one year, leading to annual hospitalization cost per schizophrenic patient of $13,854.
CONCLUSIONS: Of schizophrenic patients admitted to an acute general hospital, the majority are admitted only once per year, spend their stay in a designated psychiatric unit bed, and are discharged within two weeks. Although these patients may have subsequent admissions to another type of inpatient facility, the majority are not transferred to such a facility at the time of discharge.     

Hypercholesterolemia Dietary and Pharmacotherapy

ABSTRACT

Objectives: To estimate the cost difference associated with tolvaptan treatment vs. fluid restriction (FR) among hospitalized patients with heart failure (HF) and hyponatremia (HN) based on a real-world registry of HN patients.

Methods: An Excel-based economic model was developed to evaluate the cost impact of tolvaptan treatment vs. FR. Model input for hospital length of stay (LOS) was based on published data from the Hyponatremia Registry (HNR). Based on HNR data, tolvaptan-treated patients had a 2-day (median) shorter LOS compared to FR. Real-world effectiveness of tolvaptan treatment from the HNR was applied to a national sample of inpatients visits from the Premier Hospital database to estimate the potential LOS-related cost difference between tolvaptan treatment and FR. A one-way sensitivity and multivariable Monte Carlo sensitivity analysis were conducted.

Results: Economic modeling results of the base-case analysis indicated that among hospitalized patients with HF, the hospital cost per admission, not including HN drug cost, was $3453 lower among patients treated with tolvaptan vs. FR, due to the shorter LOS associated with tolvaptan treatment. At wholesale acquisition cost of $362 per day and an average treatment duration of 3.2 days, the pharmacy cost of tolvaptan treatment per admission was estimated at $1157. Thus, after factoring the decrease in hospital medical costs and increase in pharmacy costs associated with tolvaptan treatment, results indicated a cost-offset opportunity of –$2296 per admission for patients treated with tolvaptan versus FR. Results of the sensitivity analyses were consistent with the base-case analysis.

Limitations: The model derives inputs from real-world observational data. No causal relationship can be inferred from this analysis.

Conclusions: Based on this economic analysis, tolvaptan treatment vs. FR among hospitalized patients with HF and HN may be associated with lower hospital-related costs, which offset the increase in pharmacy costs associated with tolvaptan treatment.     

广东省1997～2001年住院患者伤害发生与死亡特征分析

目的 探索伤害发生、死亡的分布特征及变化规律。方法 对所有因伤害就诊并住院于广东省县级以上的322家综合医院的患者资料进行收集分析，了解伤害发生的外部原因、死亡情况、医疗结局、经济花费等情况。结果 在1997～2001年期间，广东省伤害住院率呈逐年上升趋势，医院伤害患者的住院死亡比例呈逐年下降趋势，5年的伤害总住院死亡比例为1．64％。同期医院住院伤害患者人数以机动车交通事故、意外跌伤、机器穿刺和切割、他伤／他杀较多，其中机动车交通事故死亡人数占总死亡人数的56．13％，居首位。5年期间伤害住院患者平均住院日以3．58％速度逐年下降；治愈伤害患者平均住院日以2．20％速度逐年下降。广东省同期伤害住院患者平均费用以3．89％速度逐年上升，治愈患者平均费用以4．71％速度逐年上升；平均每人每日费用以7．33％速度逐年上升。结论 广东省伤害的发生呈增长趋势，但伤害住院死亡比例呈下降趋势，同时伤害的直接医疗花费呈增加趋势。     

HMO growth and hospital expenses and use: a simultaneous-equation approach.

A principal problem with previous studies that have estimated the effects of prepaid group practices (PGPs) on hospital costs and use is the treatment of PGP growth rates as an exogenous variable. To the extent that the entry and subsequent growth of PGPs may be affected by high hospital costs and low use, the observed association between hospital costs and use and PGP market shares is confounded. To separate the effects of PGP growth on hospital expenses and use from the effects of hospital expenses and use on PGP growth, a simultaneous-equation model is estimated using data for 25 standard metropolitan statistical areas (SMSAs) from 1972 to 1982. The results indicate that PGP growth has a significant positive effect on average hospital expenses per day and per admission in an SMSA, but no statistically significant effect on average hospital expenses per capita. PGP growth also has a significant negative effect on both admission rates and average length of stay. In contrast to results from single-equation specifications, neither higher hospital expenses per day nor per admission are found to result in higher levels of PGP market shares in an SMSA and, in fact, both lower hospital expenses per capita and lower admission rates lead to significantly higher PGP market share levels.     

Case mix measurement in English hospitals: an evaluation of five methods for predicting resource use

OBJECTIVES: The introduction of an internal market in the British National Health Service (NHS) has highlighted the importance of developing appropriate, valid and timely measures of hospital activity, both for the purposes of specifying and monitoring contracts and for evaluating the success of the NHS reforms in general. This paper compares the validity of five case mix methods (Diagnosis Related Groups (DRGs); Healthcare Resource Groups (HRGs) versions 1 and 2; specialty classification; a simple age categorization) in predicting resource use. METHODS: Two data sets were used to compare different case mix methods. A 3% random sample (n approximately equal to 300,000) of the 1992/3 Hospital Episodes Statistics was used to test their ability to predict variation in length of stay, and a second set of individually costed patient episodes from two hospitals (n approximately equal to 40,000) was used to test their ability to explain cost variation. Analysis of variance models were used to assess the fit of each of the case mix systems to test data and a simple significance test of differences in mean squared error between models was applied. RESULTS: All case mix methods performed poorly on untrimmed data. When lengths of stay greater than 29 days were excluded, version 2 of HRGs explained 31% of total variance in length of stay and 25% of cost variation. DRGs explained less variance but performed better than HRGs version 1. For a typical hospital patient population consisting of a range of specialties, the difference in explanatory power between HRGs V2 and DRGs was statistically significant at the 5% level for sample sizes of approximately 2000 or greater. For individual specialties, the minimum sample size required for the difference between the groupers to be significant ranged from around 300 to over 2000. CONCLUSIONS: The locally developed HRGs version 2 system appears to offer superior performance in terms of resource homogeneity to other currently available approaches. It is also more adaptable and cheaper than imported alternatives and has been formally endorsed by the UK medical Royal Colleges.