A cost analysis of training expenses versus the value of medical care provided during West Africa Training Cruise 2004: Senegal

A medical civic assistance program (MEDCAP) visit was conducted by naval reservists in eight villages in Senegal, West Africa. More than 6,000 patients were treated by MEDCAP team members. Medical and dental care, eyeglasses, vitamins, medications, educational material, and mass casualty training were provided. Major challenges confronting the mission were to provide care in makeshift clinics in remote villages in an arduous sub-Saharan climate, where more than one-half of the population lacks adequate public health funding to address basic medical and dental needs. To estimate the economic costs and benefits of the mission, as a guide to future planning, we calculated the total costs of the mission and its economic benefits. Total costs were found to be $502,500. We estimated that the monetary value of the medical services provided was $730,090. Additional nonquantifiable value was created through training and development of military and professional partnerships. In a post-September 11 world, the MEDCAP is an important and cost-effective vehicle to advance U.S. foreign policy in a nonthreatening manner. Countless lasting friendships can be won with bandages and medicines.     

脑电双频谱指数指导下监测麻醉在老年患者ERCP中应用

目的探讨脑电双频谱指数(BIS)指导下的监测麻醉在老年患者内镜下逆行胰胆造影(ERCP)手术中的应用效果。方法选择2015年1月至2016年7月在沈阳军区总医院拟行ERCP患者80例为研究对象。将患者随机分为监测麻醉组(MAC组)和局部麻醉强化组(LA组),每组各40例。观察并记录两组患者的心率(HR)、平均动脉压(MAP)、呼吸频率(RR)、呼气末二氧化碳分压(P_(ET)CO_2)、脉搏氧饱和度(SpO_2),以及术中肢体躁动情况,呕吐呛咳等不良反应,患者、术者舒适满意度。结果 MAC组患者的出室时间明显长于LA组(P<0.05);在T_3、T_4、T_5时点,MAC组的MAP和HR变化幅度明显小于LA组(P<0.05);MAC组的肢体躁动情况和呕吐呛咳反应明显少于LA组(P<0.05);呼吸抑制次数明显多于LA组(P<0.05);呼吸道梗阻次数两组比较,差异无统计学意义(P>0.05)。两组患者均无反流误吸发生。MAC组的医患镇静/镇痛满意度明显高于LA组(P<0.05)。结论 BIS指导下的监测麻醉能更安全、有效、舒适的完成手术,是一种满意度高的麻醉方法,更适合高龄行ERCP术患者。     

集束化干预策略在口腔科儿童全麻患者治疗中的应用价值分析

目的 探讨集束化干预策略在口腔科全麻患儿治疗中的应用价值。方法 选取2020年11月1日-2021年7月31日在首都医科大学附属北京朝阳医院就诊,需接受全身麻醉下口腔综合治疗的3～6岁患儿共60例患者为研究对象。随机分为干预组30例和对照组30例。两组患儿均在全身麻醉状态下行口腔综合治疗,干预组采用集束化干预策略,对照组采用常规干预策略。比较两组患儿儿科畏惧症、口腔健康知识、治疗情况、治疗效果、患者满意度。结果 干预组患儿术后改良中文版儿童牙科畏惧调查表(CFSS-DS)评分较对照组明显降低（P<0.001）;干预组术前准备时间较对照组减少,差异有统计学意义（P<0.001）;干预组术后口腔健康知识、信念改善较对照组显著（P<0.001）,干预组儿童刷牙及饮食习惯改善较对照组明显,且菌斑指数（plaque index,PLI）下降较对照组有统计学差异（P=0.01）;干预组护理满意度显著高于对照组（P<0.05）。结论 集束化干预策略能够有效缩短术前准备时间,提高全麻治疗效率;增加患儿舒适感,培养患儿口腔健康习惯及观念,提高患儿及监护人就诊满意度。     

64-Slice CT coronary angiography versus conventional coronary angiography: activity-based cost analysis

Purpose

This study was done to analyse the costs of 64-slice computed tomography (CT) coronary angiography and conventional coronary angiography and determine the costeffectiveness of the two modalities.

Materials and methods

Detailed activity-based cost analyses of the two modalities were carried out at the departments of radiology and cardiology of a teaching hospital. The differential costs (equipment, variable, personnel), common costs and external costs were estimated. Finally, the full costs of the two procedures were obtained; the full cost of conventional coronary angiography also considered the cost of 1 day in hospital. The cost-effectiveness of the two procedures at different levels of pretest likelihood of coronary artery disease (CAD) was estimated.

Results

The costs of multidetector CT (MDCT) coronary angiography were as follows: differential cost 222.23 €, common cost 5.50 €, external cost 2.30 € and full cost 230.03 €. The costs of conventional coronary angiography were: differential cost 366.18 €, common cost 0.50 €, external cost 9.20 €, hospitalisation cost 1,652 € and full cost 2,027.88 €. Cost-effectiveness analysis showed that the cost per correctly identified CAD patient decreased exponentially with increasing pretest likelihoods of CAD. MDCT coronary angiography was more cost effective than conventional coronary angiography up to a pretest likelihood of 86%.

Conclusions

MDCT coronary angiography has far lower costs than conventional coronary angiography, and its costeffectiveness is better in the large majority of patients.     

Functional MR imaging versus Wada test for evaluation of language lateralization: cost analysis

PURPOSE: To compare the total direct costs (fixed and variable costs) of functional magnetic resonance (MR) imaging and of the Wada test for evaluation of language lateralization. MATERIALS AND METHODS: The direct fixed and variable costs of functional MR imaging (performed in 21 patients with mean age +/- SD of 15.5 years +/- 8.9) and of the Wada test (performed in 18 patients aged 19.2 years +/- 5.4) were determined prospectively with time and motion analyses. The labor of all personnel involved in evaluations of language lateralization was tracked, and involvement times were recorded to the nearest minute. All material items used in the studies were recorded. Costs of labor and of materials were determined from personnel reimbursement data and from vendor pricing, respectively. Direct fixed costs were determined from hospital accounting department records. Means (+/- SDs) were calculated for all direct fixed and variable costs. Total direct costs were determined for each procedure and compared by using the Student t test. RESULTS: The total direct costs of the Wada test (US dollars 1130.01 +/- US dollars 138.40) and of functional MR imaging (US dollars 301.82 +/- US dollars 10.65) were significantly different (P <.001). The cost of the Wada test was 3.7 times higher than that of functional MR imaging. CONCLUSION: Substantial savings are achievable with the use of functional MR imaging instead of the Wada test to evaluate language lateralization.     

MR angiography versus intra-arterial digital subtraction angiography of the lower extremities: activity-based cost analysis

PURPOSE: The aim of this study was to analyse the costs pertaining to the radiology department of magnetic resonance angiography (MRA) and intra-arterial digital subtraction angiography (DSA) in the evaluation of arterial disease of the lower limbs. MATERIALS AND METHODS: The differential cost of the two procedures, i.e. the sum of equipment costs (amortisation and service contract), variable costs (supplies and related services) and personnel costs (radiologist, radiographer and nurse) was determined. The common cost (auxiliary personnel and indirect internal costs) was also calculated. Finally, the full cost of the two procedures was obtained (sum of differential and common costs). RESULTS: The differential cost of MRA was 186.14 euro (equipment costs: 50.80 euro, variable costs: 75.04 euro, personnel costs: 60.30 euro) while the differential cost of intra-arterial DSA was 238.18 euro (equipment costs: 57.60 euro, variable costs: 90.13 euro, staff costs: 90.45 euro). The estimated common cost was 5.62 euro. Therefore, the full cost of MRA was 191.76 euro and the full cost of intra-arterial DSA was 243.80 euro (27.1% higher). DISCUSSION AND CONCLUSIONS: Intra-arterial DSA costs more than MRA, mainly because of the higher costs of supplies used during the procedure and higher personnel costs (as a result of the longer duration of intra-arterial DSA). It should be noted that our evaluation considers costs pertaining to the radiology department only. It is evident that an economic analysis considering hospital costs as well would result in much higher costs for DSA if post-procedure hospitalisation is required. Our results cannot be simply exported to other radiology departments since they refer to the technology and organisation adopted in our department. However, our cost analysis model can be easily applied to other environments. MRA provides good diagnostic accuracy in the evaluation of arteries of the lower extremities, and its biological cost is far lower than that of intra-arterial DSA (MRA is noninvasive, it does not use ionising radiation, and the contrast medium is safe). Its lower cost is another argument in favour of the use of MRA instead of intra-arterial DSA in the evaluation of lower-extremity arterial disease.     

The role of cost effectiveness analysis in health care evaluation.

This paper provides an overview of the key elements of cost effectiveness analysis (CEA). CEA is a method for evaluating the relative costs and benefits of treatments and procedures. Typically, CEA compares a proposed intervention with (at least) one alternative intervention, yielding an incremental cost effectiveness ratio. This ratio reflects both the longevity and health status of the differing interventions and permits the researcher to more completely compare and evaluate the "payoff" of the interventions. This paper discusses different perspectives CEA studies might adopt, and reviews the major methods for measuring both outcomes and costs.     

Advance directives and do-not-resuscitate orders on general medical wards versus the intensive care unit

The records of 335 patients admitted to the general medicine wards and to the medical intensive and coronary care unit (MICCU) at Brooke Army Medical Center were retrospectively reviewed to assess the frequency of advance directives and "do not resuscitate" (DNR) designations. Two hundred sixty-seven (79.7%) were admitted to the ward and 68 (20.3%) were admitted to the MICCU. Advance directives were executed in 14.9% of patients. DNR designations were made for 21 (7.9%) patients on the ward and 11 (16.2%) patients in the MICCU (p = 0.064). There were no statistical differences in mean length of stay, presence of advance directives, or documentation of advance directives in ward versus MICCU patients. However, there was a statistical difference in the number of deaths in the MICCU as compared with that on the ward (9.7 vs. 2.7%, p < 0.05). The frequency of advance directives and DNR designations did not differ between ward and MICCU patients in this population, although there was a trend for greater DNR designations in the MICCU environment.     

Pleural block: technique for regional anesthesia during percutaneous hepatobiliary drainage

A new technique was used to achieve safe regional anesthesia in seven patients undergoing percutaneous hepatobiliary drainage. The pleural block was administered, and pain was assessed during and after the procedure by means of sensitivity to pin prick, verbal response, electrocardiographic tracings, and blood pressure measurements. In all patients the technique produced relief of somatic pain and did not alter hemodynamic or respiratory status.     

全身麻醉与硬腰联合麻醉在髋关节置换术中应用效果分析

目的探讨髋关节置换术中应用全身麻醉与硬腰联合麻醉的术中及术后治疗效果。方法选取2011年1月至2015年9月在中国医科大学附属第四医院行髋关节置换术的患者68例为研究对象。将患者分为全身麻醉组(n=36)与硬腰联合麻醉组(n=32),观察并比较两组患者的手术时间、术中失血量、住院时间、输血情况、深静脉血栓发生率及术后恶心呕吐发生率。结果两组患者的手术时间、术中失血量、住院时间比较,差异均无统计学意义(P>0.05)。而硬腰联合麻醉组患者的需要输血的人数、深静脉血栓发生率及术后恶心呕吐发生率均明显低于全身麻醉组,两组比较,差异均有统计学意义(P<0.05)。结论与全身麻醉相比,硬腰联合麻醉在不延长手术时间及住院时间的基础上可明显降低一些并发症的发生率。     

CEUS versus CT Angiography in the follow-up of abdominal aortic endoprostheses: diagnostic accuracy and activity-based cost analysis

Purpose

To evaluate diagnostic accuracy and to perform an activity-based cost analysis of contrast-enhanced ultrasonography (CEUS) compared to computed tomography (CT) during annual surveillance after abdominal aortic aneurysm repair with endovascular procedure (EVAR).

Materials and methods

This retrospective study included 137 patients in post-EVAR follow-up over a 6-year period (average post-operatory follow-up without aneurysm sac volumetric reduction). Sensitivity, specificity, positive predictive values, negative predictive values and accuracy were considered for CEUS using CT angiography (CTA) as reference standard. An activity-based cost analysis was performed to evaluate potential savings due to the introduction of CEUS as an alternative to CT, after the first year of postoperative negative controls.

Results

CEUS reported accuracy, sensitivity, specificity, positive predictive values, negative predictive values of 97.4, 96, 100, 100 and 93.1% in the detection and characterization of endoleaks. CEUS cost was € 84.7, and CTA cost was € 157.77, with a differential cost of € 73.07; using CEUS as an alternative to CT allowed a potential saving of 50.052,95 € during follow-up.

Conclusions

CEUS is an accurate and cheap imaging method in post-EVAR follow-up patients, and it could be considered as a valid alternative to CTA, after the first year of negative controls, reducing the number of unnecessary CT examinations.

     

Knee arthroscopy with different anesthesia methods: a comparison of efficacy and cost

To evaluate the cost and time effectiveness for different anesthesia methods when performing knee arthroscopy, this study compared three different anesthesia methods. Four hundred healthy patients scheduled for knee arthroscopy were randomized to either local anesthesia (LA) (n=200), spinal anesthesia (SA) (n=100) or general anesthesia (GA) (n=100). The LA arthroscopies were performed in a facility set up in our outpatient department without anesthesia service. The SA and GA arthroscopies were performed in our central operating department with full anesthesia service. Comparisons were made between total hospital stay, anesthesia time, surgery time, recovery time, pharmaceutical and total cost. The total hospital time was 130.4 min (SD 35.14, range 63–383) in the LA group compared to 280.4 min (SD 79.29, range 155–589) in the GA group (p<0.001). The total hospital time in the GA group was also shorter than that of 350.3 min (SD 65.37, range 198–502) in the SA group (p<0.001). The time from start of anesthesia to start of surgery was significantly longer in the LA group, 39.2 min (SD 13.13, range 17–87), compared to 20.1 min (SD 4.93, range 11–35) in the SA group and to 17.6 min (SD 4.64, range 9–44) in the GA group. There were no differences in the surgery time for the three groups. The use of LA was shown to save SEK 1011 (Swedish Crowns) per patient compared to SA and GA.     

A comparative regional analysis of coronary atherosclerosis and calcium score on multislice CT versus myocardial perfusion on SPECT.

For the noninvasive evaluation of coronary artery disease (CAD), both multislice CT and gated SPECT are available. How these 2 modalities relate, however, is yet unclear. The purpose of this study was to perform a head-to-head comparison of the results of multislice CT and gated SPECT on a regional basis (per vessel distribution territory) in patients with known or suspected CAD. METHODS: One hundred forty patients underwent both multislice CT for coronary calcium scoring and coronary angiography and gated SPECT for myocardial perfusion imaging. The coronary calcium score was determined for each coronary artery. Coronary arteries on multislice CT angiography were classified as having no CAD, insignificant stenosis (<50% luminal narrowing), significant stenosis, or total or subtotal occlusion (>/=90% luminal narrowing). Gated SPECT findings were classified as normal or abnormal (reversible or fixed defects) and were allocated to the territory of one of the various coronary arteries. RESULTS: In coronary arteries with a calcium score of 10 or less, the corresponding myocardial perfusion was normal in 87% (n = 194/224). In coronary arteries with extensive calcifications (score > 400), the percentage of vascular territories with normal myocardial perfusion was lower, 54% (n = 13/24). Similarly, in most of the normal coronary arteries on multislice CT angiography, the corresponding myocardial perfusion was normal on SPECT (156/175, or 89%). In contrast, the percentage of normal SPECT findings was significantly lower in coronary arteries with obstructive lesions (59%) or with total or subtotal occlusions (8%) (P < 0.01). Nonetheless, only 48% of vascular territories with normal perfusion corresponded to normal coronary arteries on multislice CT angiography, whereas insignificant and significant stenoses were present in, respectively, 40% and 12% of corresponding coronary arteries. CONCLUSION: Although a relationship exists between the severity of CAD on multislice CT and myocardial perfusion abnormalities on SPECT, analysis on a regional basis showed only moderate agreement between observed atherosclerosis and abnormal perfusion. Accordingly, multislice CT and gated SPECT provide complementary rather than overlapping information, and further studies should address how these 2 modalities can be integrated to optimize patient management.     

A cost analysis of positron emission tomography.

OBJECTIVE: Changes in regulations and improvements in reimbursement have propelled positron emission tomography (PET) into clinical use, making it increasingly important to understand the costs of this emerging service. Cost analyses are important tools to do this. Data published previously on these topics reflect assumptions that are no longer valid. The aim of this study was to determine the cost of developing and operating a PET facility and to evaluate whether a regional cyclotron serving several scanners reduces costs. MATERIALS AND METHODS: Financial data were collected on capital expense and global operating costs through interviews with industry experts, evaluation of prior studies, and review of expenses incurred at the University of Southern California PET center. A data model and cost templates were developed. Expenses were allocated either to the production or purchase of radiopharmaceuticals or to the provision of the PET scan, and the cost per procedure was determined. A sensitivity analysis was performed on the net present value for key parameters. RESULTS: A cyclotron serving a single scanner is not financially viable. The radiopharmaceutical distribution configurations were financially sound. In these cases, the cost of the radiopharmaceutical was approximately $700 per dose with modest levels of production (12 doses per day). In addition, the average cost of PET scans (technical scan and professional charges) ranged from approximately $900 to $1400. The critical factor for profitability was shown to be throughput. CONCLUSION: This analysis provides significant insight into the cost of PET and the comparative costs of offering PET through four operating configurations. Reductions in equipment prices, increased availability of radiopharmaceuticals, growth in demand, and improvements in reimbursement have all contributed to the financial viability of this imaging technique.     

Inappropriateness of breast imaging: cost analysis

Purpose

The aim of this study was to assess how an incorrect indication for an examination may affect the diagnostic workup and diagnosis as well as healthcare expenditure.

Materials and methods

We considered all the requests for breast imaging (mammography, ultrasound and magnetic resonance imaging) received by our radiology department between October 2010 and December 2010, and assessed their appropriateness based on the patient’s age and the clinical question, if present. We then analysed the unnecessary costs resulting from inappropriate requests.

Results

Out of a total of 1500 requests for ultrasound examination, the request was appropriate in 855 (57%) cases; out of a total of 2350 requests for mammography, the request was appropriate in 493 (21%) cases; out of a total of 100 requests for magnetic resonance imaging, the request was appropriate in 83 (83%) cases. The cost deriving from inappropriate requests was 51,235.04 Euros.

Conclusions

Improving the timeliness of diagnosis is an important goal to be pursued by enhancing the available health services, improving communication and coordination of the different professionals involved and optimising diagnostic pathways in order to reduce healthcare spending.