利用1＋3模式改进医院成本核算

针对全成本核算过程中收入数据统计存在的问题，运用1＋3质量管理模式进行持续改进，通过分析查找根本原因，完善服务流程，建立相关制度，提高执行科室归并的准确性，以此更加准确反映各科室的收入情况，保证全成本核算的质量。     

The budgetary impact of genetic testing for hereditary breast cancer for the statutory health insurance

Abstract

Objectives: Potential opportunities and challenges of predictive genetic risk classification of healthy persons are currently discussed. However, the budgetary impact of rising demand is uncertain. This project aims to evaluate budgetary consequences of predictive genetic risk classification for statutory health insurance in Germany.

Methods: A Markov model was developed in the form of a cohort simulation. It analyzes a population of female relatives of hereditary breast cancer patients. Mutation carriers are offered intensified screening, women with a BRCA1 or BRCA2 mutation can decide on prophylactic mastectomy and/or ovarectomy. The model considers the following scenarios: (a) steady demand for predictive genetic testing, and (b) rising demand. Most input parameters are based on data of the German Consortium for Hereditary Breast and Ovarian Cancer. The model contains 49 health states, starts in 2015, and runs for 10 years. Prices were evaluated from the perspective of statutory health insurance.

Results: Steady demand leads to an expenditure of €49.8 million during the 10-year period. Rising demands lead to additional expenses of €125.5 million. The model reveals the genetic analysis to be the main cost driver while cost savings in treatment costs of breast and ovarian cancer are indicated.

Conclusions: The results contribute to close the knowledge gap concerning the budgetary consequences due to genetic risk classification. A rising demand leads to additional costs especially due to costs for genetic analysis. The model indicates budget shifts with cost savings due to breast and ovarian cancer treatment in the scenario of rising demands.     

Modifiable Factors to Decrease the Cost of Robotic-Assisted Procedures

In 2000, the US Food and Drug Administration approved the da Vinci Surgical System® for use in the United States. Since that time, the number of surgical robotic systems throughout the United States has continued to grow. The costs for using the system include the initial purchase ($1 million to $2.3 million) plus annual maintenance fees ($100,000 to $150,000) and the cost of limited-use or disposable instruments. Increasing the number of procedures that are performed using the robotic system can decrease the per-procedure costs. Two modifiable factors that contribute to increasing the annual caseload are increasing the number of surgeons capable of using the system and having a properly educated perioperative nursing team. An educated surgical team decreases turnover time, facilitates proper flow of each surgical procedure, and is able to actively and passively solve intraoperative problems.     

Exoskeleton plantarflexion assistance for elderly

Elderly are confronted with reduced physical capabilities and increased metabolic energy cost of walking. Exoskeletons that assist walking have the potential to restore walking capacity by reducing the metabolic cost of walking. However, it is unclear if current exoskeletons can reduce energy cost in elderly. Our goal was to study the effect of an exoskeleton that assists plantarflexion during push-off on the metabolic energy cost of walking in physically active and healthy elderly. Seven elderly (age 69.3 ± 3.5 y) walked on treadmill (1.11 m s²) with normal shoes and with the exoskeleton both powered (with assistance) and powered-off (without assistance). After 20 min of habituation on a prior day and 5 min on the test day, subjects were able to walk with the exoskeleton and assistance of the exoskeleton resulted in a reduction in metabolic cost of 12% versus walking with the exoskeleton powered-off. Walking with the exoskeleton was perceived less fatiguing for the muscles compared to normal walking. Assistance resulted in a statistically nonsignificant reduction in metabolic cost of 4% versus walking with normal shoes, likely due to the penalty of wearing the exoskeleton powered-off. Also, exoskeleton mechanical power was relatively low compared to previously identified optimal assistance magnitude in young adults. Future exoskeleton research should focus on further optimizing exoskeleton assistance for specific populations and on considerate integration of exoskeletons in rehabilitation or in daily life. As such, exoskeletons should allow people to walk longer or faster than without assistance and could result in an increase in physical activity and resulting health benefits.     

The Continuing Story of the Cost-Effectiveness of Photoselective Vaporization of the Prostate versus Transuretheral Resection of the Prostate for the Treatment of Symptomatic Benign Prostatic Obstruction

BackgroundIn 2008, a UK assessment of technologies for benign prostatic obstruction concluded negatively about photoselective vaporization of the prostate (PVP), and the 2010 National Institute for Health and Care Excellence guidance caused several UK institutions to abandon PVP.ObjectiveTo reassess the costs and effects of PVP versus transurethral resection of the prostate (TURP) on the basis of most recent data.MethodsThe same model was used as in 2008. Transition probabilities were estimated using a Bayesian approach updating the 2008 estimates with data from two meta-analyses and data from GOLIATH, the latest and largest trial comparing PVP with TURP. Utility estimates were from the 2008 assessment, and estimates of resource utilization and costs were updated. Effectiveness was measured in quality-adjusted life-years gained, and costs are in UK pounds. The balance between costs and effects was addressed by multivariate sensitivity analysis.ResultsIf the 2010 National Institute for Health and Care Excellence analysis would have updated the cost-effectiveness analysis with figures from its own meta-analysis, it would have estimated the change in quality-adjusted life-years at −0.01 (95% confidence interval [CI] −0.05 to 0.01) instead of at −0.11 (95% CI −0.31 to −0.01) as in the 2008 analysis. The GOLIATH estimate of −0.01 (95% CI −0.07 to 0.02) strengthens the conclusion of near equivalence. Estimates of additional costs vary from £491 (£21−£1286) in 2008 to £111 (−£315 to £595) for 2010 and to £109 (−£204 to £504) for GOLIATH. PVP becomes cost saving if more than 32% can be carried out as a day case in the United Kingdom.ConclusionsThe available evidence indicates that PVP can be a cost-effective alternative for TURP in a potentially broad group of patients.     

Evaluating hospital costs in type 2 diabetes care: does the choice of the model matter?

ABSTRACT

Background: Awareness of the economic burden of diabetes has led to a number of studies on economic issues. However, comparison among cost-of-illness studies is problematic because different methods are used to arrive at a final cost estimate.

Objective: The aim of the study is to show how estimates of hospitalisation costs for diabetic patients can vary significantly in relation to the statistical method adopted in the analysis.

Research design and methods: The study analyses diabetic patients’ costs as a function of demographic and clinical covariates, by applying the following statistical survival models: the parametric survival model assuming Weibull distribution, the Cox proportional hazard (PH) model and the Aalen additive regression for modelling costs. The Aalen approach is robust both for the non proportionality in hazard and for departures from normality. In addition it is able to easily model the effect of covariates on the extreme costs. This cost analysis is based on data collected for a retrospective observational study analysing repeated hospitalisations (N = 4816) in a cohort of 3892 diabetic patients.

Results: There is agreement in all models with the effects of the considered covariates (age, sex, duration of disease and presence of other pathologies). An effect of over- or under-estimation, according to the chosen model due to arguably inappropriate model fitting, was observed, being more evident for some specific profiles of the patients, and overall accounting for as much as 20% of the estimated effect. The Aalen model was able to cope with all the other models in furnishing unbiased estimates with the advantage of a greater flexibility in representing the covariates’ effect on the cost process.

Conclusions: An appropriate choice of the model is crucial in avoiding misinterpretation of cost determinants of type 2 diabetes care. For our data set the Aalen model proved itself to be a realistic and informative way to characterise the effect of covariates on costs.     

Impact of gestational age at delivery on the economics of triplet pregnancy

Objective: To establish the charges associated with triplet pregnancies managed at a single tertiary center, over a 5-year time period, and to evaluate the impact of prematurity on these charges.

Methods: All triplet pregnancies that reached at least 20 weeks gestation and received prenatal and neonatal care at our center from 1992 to 1996 were included. Charges for these mothers and neonates were extracted from two separate hospital billing computer systems, encompassing all inpatient, outpatient, technical, and professional charges. Linear regression was used to evaluate the relationship between gestational age at delivery and total charges.

Results: Fifty-five triplet pregnancies were included, resulting in the admission of 149 liveborn neonates. The median gestational age at delivery was 32.1 weeks. The mean charges per triplet mother were: $6,899 (professional), $3,959 (hospital outpatient), and $32,686 (hospital inpatient). The mean charges per neonatal sibling set were: $20,107 (professional) and $124,163 (hospital inpatient). The mean charges per complete triplet pregnancy was $187,814 (maternal plus neonatal). There was a significant inverse relationship between gestational age at delivery and total charges per triplet family, with a decrease of $16,584 for each additional gestational week reached (P = 0.006).

Conclusions: Triplet pregnancy charges averaged almost $190,000 each, which does not include charges associated with assisted reproductive technologies. These charges are almost all related to the expense of prolonged neonatal intensive care, and are significantly related to the gestational age at delivery. Efforts at containing these costs should focus on reducing the incidence of multiple gestation and preventing prematurity.     

The Effects of γ-rays on Fecundity and Mutagenesis in Oregon-R Males of Drosophila

Summary

Oregon-R males were tested in day-by-day sperm samples for dominant visible and hemizygous sex-linked mutations, fecundity (number of offspring produced), and crossing-over after exposure to cobalt-60 γ in the 100 r to 10 kr range. Tests totalled 42 184 X-chromosomes and 210 111 flies. Mutations were most frequent after irradiation during meiosis and spermiogenesis in low doses. Only sperm and gonial cells subsequently produced adult flies after exposure to 5 kr and 10 kr. After 500 r fecundity was reduced chiefly in cells in late mitosis, and in earlier and later stages with increasing doses. Reduced fecundity may not be due to the kind of mutation detected here, but both effects may combine to influence the frequency of mutations recovered, particularly from irradiated meiotic and spermiogenic cells. Males receiving 500 r might contribute more mutations to a population's gene pool than competing males after a substantially higher dose.     

International differences in cost and consumption of ready-to-consume food and drink products: United Kingdom and Brazil, 2008–2009

This paper tests the hypothesis that one important factor determining household availability of ready-to-consume products is their cost relative to the rest of the diet. National food expenditure surveys in the UK (2008) and Brazil (2008–09) were used. Purchased food quantities were converted into dietary energy (calories) and classified into three groups: (1) foods that are unprocessed or minimally processed; (2) processed culinary ingredients; and (3) ready-to-consume products, either processed or ultra-processed. The contribution of these groups to diets in each country was calculated as a percentage of total energy. Relative cost of ready-to-consume products in each country was calculated by dividing their cost by the cost of the rest of the diet (foods plus culinary ingredients). Linear regression analysis was used to test the association between the UK to Brazil ratios of the caloric share of different ready-to-consume products, and of the relative cost of these products. The caloric share of ready-to-consume products in the UK (63.4%) was well over double that of Brazil (27.7%), whereas their cost relative to the rest of the diet was 43% lower. The lower the relative cost of ready-to-consume products in the UK (compared with Brazil), the higher their relative consumption (R²=0.38, p<0.01).