Translating Research into Practice Intervention Improves Management of Acute Pain in Older Hip Fracture Patients

Objective. To test an interdisciplinary, multifaceted, translating research into practice (TRIP) intervention to (a) promote adoption, by physicians and nurses, of evidence-based (EB) acute pain management practices in hospitalized older adults, (b) decrease barriers to use of EB acute pain management practices, and (c) decrease pain intensity of older hospitalized adults.
Study Design. Experimental design with the hospital as the unit of randomization.
Study Setting. Twelve acute care hospitals in the Midwest.
Data Sources. (a) Medical records (MRs) of patients ≥65 years or older with a hip fracture admitted before and following implementation of the TRIP intervention and (b) physicians and nurses who care for those patients.
Data Collection. Data were abstracted from MRs and questions distributed to nurses and physicians.
Principal Findings. The Summative Index for Quality of Acute Pain Care (0–18 scale) was significantly higher for the experimental (10.1) than comparison group (8.4) at the end of the TRIP implementation phase. At the end of the TRIP implementation phase, patients in the experimental group had a lower mean pain intensity rating than those in the comparison group (  p <.0001).
Conclusion. The TRIP intervention improved quality of acute pain management of older adults hospitalized with a hip fracture.     

Comparing Methodologies for the Allocation of Overhead and Capital Costs to Hospital Services

Background:  Typically, little consideration is given to the allocation of indirect costs (overheads and capital) to hospital services, compared to the allocation of direct costs. Weighted service allocation is believed to provide the most accurate indirect cost estimation, but the method is time consuming.
Objective:  To determine whether hourly rate, inpatient day, and marginal mark-up allocation are reliable alternatives for weighted service allocation.
Methods:  The cost approaches were compared independently for appendectomy, hip replacement, cataract, and stroke in representative general hospitals in The Netherlands for 2005.
Results:  Hourly rate allocation and inpatient day allocation produce estimates that are not significantly different from weighted service allocation.
Conclusions:  Hourly rate allocation may be a strong alternative to weighted service allocation for hospital services with a relatively short inpatient stay. The use of inpatient day allocation would likely most closely reflect the indirect cost estimates obtained by the weighted service method.     

ID4 Evaluation of the Cost-Effectiveness of Management Strategies in Cytomegalovirus Infection and Disease

OBJECTIVE: To develop a decision analytical model for current and anticipated management of cytomegalovirus infection and disease in renal transplant patients.
METHODS: We developed a decision analytical model for the US and UK, containing currently recognised management strategies for cytomegealovirus infection and disease in renal transplant patient. The model enables comparison of current management strategies, assessment of anticipated strategies, and the impact of country-specific practice. Outcomes are expressed as "number of cases avoided" and "quality-adjusted time without symptoms or toxicity" (Q-TWIST).
RESULTS: The model indicates that in the UK, for donor seropositive/recipient seronegative (D+/R−) patients, prophylaxis with IV ganciclovir cost an additional 27,000 GBP, whereas testing for virus and preemptive therapy with IV ganciclovir costs an additional 18,000 GBP per case of CMV avoided compared with a "wait and treat" strategy. Modeling indicates that prophlaxis with an efficacious oral drug could reduce these figures to 800 GBP per avoided case. In the US, preemptive therapy with IV ganciclovir is currently a dominant strategy compared with a "wait and treat" option with IV ganciclovir ($500 less expensive and avoids 18 CMV cases per 100). This reflects the trend to provide preemptive therapy in ambulatory settings. There is potential for new oral prophylactic therapies, of similar efficacy to existing therapies, that could result in further cost savings.
CONCLUSIONS: The model demonstrates the costeffectiveness of preemptive therapy in ambulatory settings compared with inpatient treatment of CMV disease (US), suggesting a potential cost-effectiveness of new oral prophylactic therapies.     

Diabetes in Canada: Direct Medical Costs of Major Macrovascular Complications

Objectives: To estimate direct medical costs of managing major macrovascular complications in diabetic patients.
Methods: Costs were estimated for acute myocardial infarction (AMI) and ischemic stroke by applying unit costs to typical resource use profiles. Data were obtained from many Canadian sources, including the Ontario Case Cost Project, provincial physician and laboratory fee schedules, provincial formularies, government reports, and peer-reviewed literature. For each complication, the event costs per patient are those associated with resource use specific to the acute episode and any subsequent care occurring in the first year. State costs are the annual costs per patient of continued management. All costs are expressed in 1996 Canadian dollars.
Results: Acute hospital care accounts for approximately half of the first year management costs ($15,125) of AMI. Given the greater need for postacute care, acute hospital care has less impact (28%) on event costs for stroke ($31,076). The state costs for AMI and stroke are $1544 and $8141 per patient, respectively.
Conclusions: Macrovascular complications of diabetes potentially represent a substantial burden to Canada's health care system. As new therapies emerge that may reduce the incidence of some diabetic complications, decision makers will need information to make critical decisions regarding how to spend limited health care dollars. Published literature lacks Canadian-specific cost estimates that may be readily translated into patient-level cost inputs for an economic model. This paper provides two key pieces of the many needed to understand the scope of the economic burden of diabetes and its complications for Canada.     

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.     

广州市1998-2007年3449例骨质疏松髋部骨折患者住院医疗资源分析

目的 了解骨质疏松性髋部骨折的基本趋势及其所需要的医疗资源情况.方法 3449例患者的基本情况来源于医院病案信息管理系统.统计分析年龄50岁以上因髋部骨折住院患者的一般情况、住院时间、住院费用及其结构等.结果 髋部骨折的住院人数逐年呈曲线增长,女性患者人数显著多于男性,男女总人数比为1:1.95(男性33.86%,女性66.14%).患者平均年龄(76.32±9.52)岁,最大年龄116岁.平均住院时间(23.59±13.48)d,各年龄组住院时间的差异无统计学意义.70～79岁与80～89岁年龄组人数最多,分别占总人数的38.45%和33.08%.股骨颈骨折与粗隆问骨折的比例为1.33:1.患者住院总费用平均(2.35±1.70)万元(RMB),其中粗隆问骨折(2.14± 1.59)万元,股骨颈骨折(2.51±1.76)万元.住院总费用中包括治疗费(含内置物费用,52%)、药费(25%)、手术费(6%)、床位费(5%)、放射及其他检查费(5%)、化验费(4%).近10年米总住院费用逐年递增,平均年增加6.18%,总费用与住院时间密切相关.结论 随着社会老龄化,骨质疏松髋部骨折逐年增多,医疗费用逐年递增;有效控制治疗费及药费是减少髋部骨折占用医疗资源,减轻患者与社会经济负担的有效途径.     

Coding Response to a Case-Mix Measurement System Based on Multiple Diagnoses

Objective. To examine the hospital coding response to a payment model using a case-mix measurement system based on multiple diagnoses and the resulting impact on a hospital cost model.
Data Sources. Financial, clinical, and supplementary data for all Ontario short stay hospitals from years 1997 to 2002.
Study Design. Disaggregated trends in hospital case-mix growth are examined for five years following the adoption of an inpatient classification system making extensive use of combinations of secondary diagnoses. Hospital case mix is decomposed into base and complexity components. The longitudinal effects of coding variation on a standard hospital payment model are examined in terms of payment accuracy and impact on adjustment factors.
Principal Findings. Introduction of the refined case-mix system provided incentives for hospitals to increase reporting of secondary diagnoses and resulted in growth in highest complexity cases that were not matched by increased resource use over time. Despite a pronounced coding response on the part of hospitals, the increase in measured complexity and case mix did not reduce the unexplained variation in hospital unit cost nor did it reduce the reliance on the teaching adjustment factor, a potential proxy for case mix. The main implication was changes in the size and distribution of predicted hospital operating costs.
Conclusions. Jurisdictions introducing extensive refinements to standard diagnostic related group (DRG)-type payment systems should consider the effects of induced changes to hospital coding practices. Assessing model performance should include analysis of the robustness of classification systems to hospital-level variation in coding practices. Unanticipated coding effects imply that case-mix models hypothesized to perform well ex ante may not meet expectations ex post.     

Effects of Payment Changes on Trends in Post-Acute Care

Objective. To test how the implementation of new Medicare post-acute payment systems affected the use of inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies.
Data Sources. Medicare acute hospital, IRF, and SNF claims; provider of services file; enrollment file; and Area Resource File data.
Study Design. We used multinomial logit models to measure realized access to post-acute care and to predict how access to alternative sites of care changed in response to prospective payment systems.
Data Extraction Methods. A file was constructed linking data for elderly Medicare patients discharged from acute care facilities between 1996 and 2003 with a diagnosis of hip fracture, stroke, or lower extremity joint replacement.
Principal Findings. Although the effects of the payment systems on the use of post-acute care varied, most reduced the use of the site of care they directly affected and boosted the use of alternative sites of care. Payment system changes do not appear to have differentially affected the severely ill.
Conclusions. Payment system incentives play a significant role in determining where Medicare beneficiaries receive their post-acute care. Changing these incentives results in shifting of patients between post-acute sites.     

PMH15 Development of a Self-Administered Outcome Measure for use in an Outpatient Population of Individuals with Schizophrenia

Insurers' influence on patterns of care and disease management continues to be questioned in the U.S.
OBJECTIVE: To determine the effect managed care has on length of stay (LOS) and costs of inpatient management of schizophrenia in acute general hospitals.
METHODS: LOS and cost estimates were developed based on patient-level data from the 1996 Massachusetts discharge database. Analyses were limited to patients with a principal diagnosis of schizophrenia (based on ICD9 codes). Three populations were examined: an all payer group, a standard Medicaid coverage group, and those with a Medicaid-funded managed care plan (MMC). Unique patient identifiers enabled examination of annual admission frequency. All costs are reported in 1996 US$, adjusted appropriately for cost-to-charge ratios.
RESULTS: Of the 3,500 patients admitted for schizophrenia, 582 (17%) were covered by Medicaid and 419 (12%) by MMC. Overall, patients were admitted an average of 1.7 times in the year, with 67% having only one admission. The mean admission rate was 1.8 among Medicaid patients and 1.6 with MMC; a single admission occurred in 73% of the Medicaid group and 67% for MMC. The mean LOS was 14 days for the Medicaid group compared to 13.5 days for the all payer group and 12.3 days for those with MMC. Among those with only one admission, the differences increases: 16.4 days for the Medicaid group, 14.7 days for the all payer group, and 12.9 for the MMC group. Costs for this admission were correspondingly highest for standard Medicaid ($10,864) and lowest for MMC ($7,911).
CONCLUSION: The managed care approach decreases the length of stay and cost of inpatient management of schizophrenia. The appropriateness of these reductions remains unclear.     

Time to Send the Preemie Home? Additional Maturity at Discharge and Subsequent Health Care Costs and Outcomes

Objective. To determine whether longer stays of premature infants allowing for increased physical maturity result in subsequent postdischarge cost savings that help counterbalance increased inpatient costs.
Data Sources. One thousand four hundred and two premature infants born in the Northern California Kaiser Permanente Medical Care Program between 1998 and 2002.
Study Design/Methods. Using multivariate matching with a time-dependent propensity score we matched 701 "Early" babies to 701 "Late" babies (developmentally similar at the time the earlier baby was sent home but who were discharged on average 3 days later) and assessed subsequent costs and clinical outcomes.
Principal Findings. Late babies accrued inpatient costs after the Early baby was already home, yet costs after discharge through 6 months were virtually identical across groups, as were clinical outcomes. Overall, after the Early baby went home, the Late–Early cost difference was $5,016 ( p <.0001). A sensitivity analysis suggests our conclusions would not easily be altered by failure to match on some unmeasured covariate.
Conclusions. In a large integrated health care system, if a baby is ready for discharge (as defined by the typical criteria), staying longer increased inpatient costs but did not reduce postdischarge costs nor improve postdischarge clinical outcomes.     

Sacrum magnetic resonance imaging for low back and tail bone pain: A quality initiative to evaluate and improve imaging utility

As quality and cost effectiveness become essential in clinical practice, an evidence-based evaluation of the utility of imaging orders becomes an important consideration for radiology’s value in patient care. We report an institutional quality improvement project including a retrospective review of utility of sacrum magnetic resonance (MR) imaging for low back pain at our institution over a four-year period and follow-up results after physician education intervention. Sacral MR imaging for low back pain and tailbone pain were only positive for major findings in 2/98 (2%) cases, and no major changes in patient management related to imaging findings occurred over this period, resulting in almost $500000 cost without significant patient benefit. We distributed these results to the Family Medicine department and clinics that frequently placed this order. An approximately 83% drop in ordering rate occurred over the ensuing 3 mo follow-up period. Sacrum MR imaging for low back pain and tail bone pain has not been a cost-effective diagnostic tool at our institution. Physician education was a useful tool in reducing overutilization of this study, with a remarkable drop in such studies after sharing these findings with primary care physicians at the institution. In conclusion, sacrum MR imaging rarely elucidates the cause of low back/tail pain diagnosed in a primary care setting and is even less likely to result in major changes in management. The practice can be adopted in other institutions for the benefit of their patients and improve cost efficiency.     

A Cost Analysis of the Iowa Medicaid Primary Care Case Management Program

Objective. To determine the cost savings attributable to the implementation and expansion of a primary care case management (PCCM) program on Medicaid costs per member in Iowa from 1989 to 1997.
Data Sources. Medicaid administrative data from Iowa aggregated at the county level.
Study Design. Longitudinal analysis of costs per member per month, analyzed by category of medical expense using weighted least squares. We compared the actual costs with the expected costs (in the absence of the PCCM program) to estimate cost savings attributable to the PCCM program.
Principal Findings. We estimated that the PCCM program was associated with a savings of $66 million to the state of Iowa over the study period. Medicaid expenses were 3.8 percent less than what they would have been in the absence of the PCCM program. Effects of the PCCM program appeared to grow stronger over time. Use of the PCCM program was associated with increases in outpatient care and pharmaceutical expenses, but a decrease in hospital and physician expenses.
Conclusions. Use of a Medicaid PCCM program was associated with substantial aggregate cost savings over an 8-year period, and this effect became stronger over time. Cost reductions appear to have been mediated by substituting outpatient care for inpatient care.     

Predischarge occupational therapy home assessment visits: towards an evidence base

Background/aim:  Predischarge home assessment visits are a commonly accepted, but little researched, aspect of occupational therapy practice. The aim of this research was to systematically investigate current predischarge occupational therapy home assessment visit practices in a rehabilitation ward of a regional Australian hospital.
Methods:  A retrospective chart audit was conducted over a 7-month time period and included 227 patients discharged from the inpatient rehabilitation ward at the study hospital.
Results:  Fifty-five per cent of patients in the study sample received home assessment visits. At least one recommendation for change was made as a result of the visit for 99% of those patients receiving visits. A total of 139 visits were completed and resulted in 1179 recommendations for change. The median number of recommendations made for the home assessment visits was 10 (range 0–33). The most common types of recommendations, timing of visits, persons present during the visit and documentation of visits were also investigated.
Conclusion:  Although occupational therapy home assessment visits are routinely completed, there is limited research available to provide evidence-based guidelines relating to predischarge occupational therapy home assessment visit practices. Recommendations for future practice and areas for further research into occupational therapy home assessment visits are discussed.     

Cost Estimates for Operating a Primary Care Practice Facilitation Program

PURPOSE

Practice facilitation is widely recognized as a promising method for achieving large-scale practice redesign. Little is known, however, about the cost of providing practice facilitation to small primary practices from the prospective of an organization providing facilitation activities.

METHODS

We report practice facilitation costs on 19 practices in South Texas that were randomized to receive facilitation activities. The study design assured that each practice received at least 6 practice facilitation visits during the intervention year. We examined only the variable cost associated with practice facilitation activities. Fixed or administrative costs of providing facilitation actives were not captured. All facilitator activities (time, mileage, and materials) were self-reported by the practice facilitators and recorded in spreadsheets.

RESULTS

The median total variable cost of all practice facilitation activities from start-up through monitoring, including travel and food, was $9,670 per practice (ranging from $8,050 to $15,682). Median travel and food costs were an additional $2,054 but varied by clinic. Approximately 50% of the total cost is attributable to practice assessment and start-up activities, with another 31% attributable to practice facilitation visits. Sensitivity analysis suggests that a 24-visit practice facilitation protocol increased estimated median total variable costs of all practice facilitation activities only by $5,428, for a total of $15,098.

CONCLUSIONS

We found that, depending on the facilitators wages and the intensity of the intervention, the cost of practice facilitation ranges between $9,670 and $15,098 per practice per year and have the potential to be cost-neutral from a societal prospective if practice facilitation results in 2 fewer hospitalizations per practice per year.     

Benefits and costs of a free community-based primary care clinic

This study estimates the benefits and costs of a free clinic providing primary care services. Using matched data from a free clinic and its corresponding regional hospital on a sample of newly enrolled clinic patients, patients' non-urgent emergency department (ED) and inpatient hospital costs in the year prior to clinic enrollment were compared to those in the year following enrollment to obtain financial benefits. We compare these to annual estimates of the costs associated with the delivery of primary care to these patients. For our sample (n = 207), the annual non-urgent ED and inpatient costs at the hospital fell by $170 per patient after clinic enrollment. However, the cost associated with delivering primary care in the first year after clinic enrollment cost $505 per patient. The presence of a free primary care clinic reduces hospital costs associated with non-urgent ED use and inpatient care. These reductions in costs need to be sustained for at least 3 years to offset the costs associated with the initially high diagnostic and treatment costs involved in the delivery of primary care to an uninsured population.     

An alternative approach to reducing the costs of patient care? A controlled trial of the multi-disciplinary doctor-nurse practitioner (MDNP) model.

OBJECTIVE: Hospitals adapt to changing market conditions by exploring new care models that allow them to maintain high quality while containing costs. The authors examined the net cost savings associated with care management by teams of physicians and nurse practitioners, along with daily multidisciplinary rounds and postdischarge patient follow-up. METHODS: One thousand two hundred and seven general medicine inpatients in an academic medical center were randomized to the intervention versus usual care. Intervention costs were compared to the difference in nonintervention costs, estimated by comparing changes between preadmission and postadmission in regression-adjusted costs for intervention versus usual care patients. Intervention costs were calculated by assigning hourly costs to the time spent by different providers on the intervention. Patient costs during the index hospital stay were estimated from administrative records and during the 4-month follow-up by weighting self-reported utilization by unit costs. RESULTS: Intervention costs were $1187 per patient and associated with a significant $3331 reduction in nonintervention costs. About $1947 of the savings were realized during the initial hospital stay, with the remainder attributable to reductions in postdischarge service use. After adjustment for possible attrition bias, a reasonable estimate of the cost offset was $2165, for a net cost savings of $978 per patient. Because health outcomes were comparable for the 2 groups, the intervention was cost-effective. CONCLUSIONS: Wider adoption of multidisciplinary interventions in similar settings might be considered. The savings previously reported with hospitalist models may also be achievable with other models that focus on efficient inpatient care and appropriate postdischarge care.