Is convenience really king?Comparative evaluation of catastrophic costs due to tuberculosis in the public and private healthcare sectors of Viet Nam:a longitudinal patient cost study

Background In Viet Nam,tuberculosis(TB)represents a devastating life-event with an exorbitant price tag,partly due to lost income from daily directly observed therapy in public sector care.Thus,persons with TB may seek care in the private sector for its flexibility,convenience,and privacy.Our study aimed to measure income changes,costs and catastrophic cost incurrence among TB-affected households in the public and private sector.Methods Between October 2020 and March 2022,we conducted 110 longitudinal patient cost interviews,among 50 patients privately treated for TB and 60 TB patients treated by the National TB Program(NTP)in Ha Noi,Hai Phong and Ho Chi Minh City,Viet Nam.Using a local adaptation of the WHO TB patient cost survey tool,participants were interviewed during the intensive phase,continuation phase and post-treatment.We compared income levels,direct and indirect treatment costs,catastrophic costs using Wilcoxon rank-sum and chi-squared tests and associated risk factors between the two cohorts using multivariate regression.Results The pre-treatment median monthly household income was significantly higher in the private sector versus NTP cohort(USD 868 vs USD 578;P=0.010).However,private sector treatment was also significantly costlier(USD 2075 vs USD 1313;P=0.005),driven by direct medical costs which were 4.6 times higher than costs reported by NTP participants(USD 754 vs USD 164;P<0.001).This resulted in no significant difference in catastrophic costs between the two cohorts(Private:55%vs NTP:52%;P=0.675).Factors associated with catastrophic cost included being a single-person household[adjusted odds ratio[(a OR=13.71;95%confidence interval(CI):1.36-138.14;P=0.026)],unemployment during treatment(a OR=10.86;95%CI:2.64-44.60;P<0.001)and experiencing TB-related stigma(a OR=37.90;95%CI:1.72-831.73;P=0.021)].Conclusions Persons with TB in Viet Nam face similarly high risk of catastrophic costs whether treated in the public or private sector.Patient costs could be reduced through expanded insurance reimbursement to minimize direct medical costs in the private sector,use of remote monitoring and multi-week/month dosing strategies to avert economic costs in the public sector and greater access to social protection mechanism in general.

Direct medical cost of radiation therapy for cancer patients in Taiwan

Background and purpose: The rising cost of health care is of concern worldwide, in particular, for cancer care. The costs of treatment, including chemotherapeutic drugs and radiotherapy, are no exceptions. The purpose of this study is to explore the direct medical cost of radiotherapy and the annual increasing trend of expenditures in Taiwan. Methods: This study utilized data retrieving from the original claim data of the reimbursement of the Health Insurance Research Database (HIRD) derived from Taiwan’s Health Insurance (HI) program. Detailed data on the direct medical cost within the radiotherapy process for beneficences were extracted from inpatient expenditures by admissions (DD) and ambulatory care expenditures by visits (CD) database according to the reimbursed expenditure code of radiotherapy from January 1, 2000 to December 31, 2005. Prescriptions for radiotherapy were retrieved and the direct medical costs for radiotherapy were collected based on the NHI reimbursement price list of 2005. The annual increasing trend of expenditures was also explored according to the perspective of Bureau Health Insurance of Taiwan. Results: The total direct medical costs of radiotherapy for cancer patients were increasing from 2000 to 2005, which were estimated to US $7.80 million, US $8.09 million, US $7.58 million, US $10.7 million, US $12.2 million and US $15.9 million in 2000, 2001, 2002, 2003, 2004 and 2005, respectively. The increased percentage corresponded to the total healthcare expenditures claimed was increased substantially from 0.82% in 2000 to 1.22% in 2005. The total direct medical costs within the radiotherapy process were also increased gradually if identified by different types of radiotherapy and teaching hospital levels. The direct medical costs attribute to radiotherapy, compared to total health care expenditures in Taiwan, were similar to the costs of anticancer drugs for cancer patients annually. Conclusions: The direct medical costs of radiation therapy increased substantially each year. Further cost analysis on radiation therapy is needed in years beyond 2005.

Clinical and cost impact of intravenous proton pump inhibitor use in non-ICU patients

AIM:To assess the appropriateness of the indication and route of administration of proton-pump-inhibitors (PPIs) and their associated cost impact. METHODS:Data collection was performed prospec-tively during a 6-mo period on 340 patients who re-ceived omeprazole intravenously during their hospital stay in non-intensive care floors. Updated guidelines were used to assess the appropriateness of the indication and route of administration. RESULTS:Complete data collection was available for 286 patients which were used to assess intravenous (IV) PPIs utilization. Around 88% of patients were receiving PPIs for claimed stress ulcer prophylaxis (SUP) indication; of which,only 17% met the guideline criteria for SUP indication,14% met the criteria for non-steroidal-anti-inflammatory drugs-induced ulcer prophylaxis,while the remaining 69% were identifi ed as having an unjustified indication for PPI use. Theinitiation of IV PPIs was appropriate in 55% of pa-tients. Half of these patients were candidates for switching to the oral dosage form during their hos-pitalization,while only 36.7% of these patients were actually switched. The inappropriate initiation of PPIs via the IV route was more likely to take place on the medical floor than the surgical floor (53% vs 36%,P = 0.003). The cost analysis associated with the appro-priateness of the indication for PPI use as well as the route of administration of PPI revealed a possible saving of up to $17 732.5 and $14 571,respectively. CONCLUSION:This study highlights the over-utili-zation of IV PPIs in non-intensive care unit patients. Restriction of IV PPI use for justified indications and route of administration is recommended.

Evaluation of Length of Hospital Stay Joining Educational Programs for Type 2 Diabetes Mellitus Patients: Can We Control Medical Costs in Japan?

Diabetes has become a growing concern in Japan, both medically and financially. The medical cost of diabetes was estimated at 1215 billion yen for fiscal year 2011. We analyzed the length of stay (LOS) in a hospital for type 2 diabetes mellitus patients who participated in educational programs to determine factors affecting LOS. Data on 991 patients obtained from 28 Red Cross hospitals in 2008 were used. For the analysis, we used the Box-Cox transformation model and Hausman test. The results revealed that patients aged 75 years and above and those with comorbidities and complications were prone to longer LOS. The analysis also revealed significant differences in LOS across the hospitals, even after controlling for patient characteristics. Finally, we applied the least squares method to determine the effects of hospital and regional factors and revealed that patients’ LOS was affected by the region’s average LOS. Regional corporations and networks appeared to be important in improving educational programs.

广州市某医院脑梗死患者疾病经济负担研究

目的分析脑梗死患者次均住院费用,特别是次均住院自负费用的结构以及影响因素,为缓解患者疾病经济负担提供参考依据。方法运用描述性统计分析对广州市某三甲医院2015—2022年脑梗死出院患者的次均费用及费用结构进行比较分析,并采用多重线性分析法研究影响患者次均住院自负费用的因素。结果脑梗死患者次均住院费用增长放缓,年均增长率为2.86%;费用结构逐步优化,2022年次均技术劳务费占比47.41%;脑梗死患者次均住院自负费用呈增长趋势,年均增长率5.96%,且受住院时间、病例分型、付费方式以及患者来源等因素共同影响。结论脑梗死患者的疾病经济负担仍然较重,医疗机构应不断规范诊疗行为,加强临床路径管理,政府应该不断完善社会保障体系,降低患者的疾病经济负担。

DRG支付制度改革对老年患者就诊费用的影响与政策建议

目的:分析南京市某老年病医院DRG付费改革前后医疗数据的变化,通过优化老年病医院的管理策略,可科学利用医保基金、促进医院高质量发展。方法:收集南京市某老年病医院支付制度改革前后住院患者医疗数据,分析制度对老年病医院运营的影响,并对支付制度改革政策优化提出建议。结果:老年病医院患者医疗服务需求与资源消耗随年龄同步增长;DRG支付制度改革推动医院注重绩效进步,CMI提升,住院费用结构发生改变,次均住院费用降低,平均住院日减少(P<0.05)。结论:DRG支付可以合理地控制医院住院费用不合理增长;医院通过科学有效的管理对策可提高医保基金使用效能;DRG政策设计应考虑高龄患者对医疗资源的刚性需求特点进行改革与调整。

一站式预住院服务模式在肿瘤化疗患者中的应用实践

目的探讨一站式预住院服务模式在肿瘤化疗患者中的应用实践。方法选取江西省人民医院肿瘤科2023年1月至6月收治的180例恶性肿瘤化疗患者作为研究对象,按照随机数字表法将患者分为对照组(90例)和观察组(90例)。对照组采用常规方法办理住院手续,观察组采用一站式预住院方法办理住院手续。比较两组患者办理入院手续耗时、治疗前的完成检查时间、住院天数、住院费用、病区护士接待新入院患者的护理耗时、患者在病区和检查科室之间的往返次数和患者满意度情况。结果观察组患者办理入院手续的耗时、治疗前的完成检查时间、住院天数短于对照组,差异有统计学意义(P<0.05)。观察组患者住院费用低于对照组,差异有统计学意义(P<0.05)。病区护士接待新入院观察组患者的护理耗时短于对照组,差异有统计学意义(P<0.05)。观察组患者在病区和检查科室之间的往返次数少于对照组,差异有统计学意义(P<0.05)。观察组患者住院治疗后的满意率为95.56%,高于对照组的87.78%,差异有统计学意义(P<0.05)。结论一站式预住院服务模式能有效缩短患者办理入院手续耗时,缩短治疗前的完成检查时间和住院天数,降低住院费用,缩短病区护士接待新入院患者的护理耗时,减少患者在病区和检查科室之间的往返次数,提高患者满意度,值得在临床进一步推广。

PDCA循环法在提高日间手术占比中的应用研究

目的探讨计划-实施-检查-处理(plan-do-check-act,PDCA)循环法在提高日间手术占比中的应用效果。方法于2019年1—11月开展PDCA活动,通过基线调研2019年1—3月济宁医学院附属医院开展日间手术例数,统计日间手术占比。针对日间手术占比低通过原因分析,设定活动目标并拟定对策,于2019年4—8月实施拟定对策并确认效果,2019年9—11月将有效对策标准化并持续实施。对2019年1—3月(改善前)与2019年9—11月(改善后)的日间手术占比情况进行比较。结果开展PDCA活动后日间手术占比由改善前的8.50%提高至改善后的21.50%,差异有统计学意义(P<0.001)。日间手术患者住院时间短于非日间手术,均次费用、均次药费、均次抗菌药物药费、药占比、抗菌药物费用占比均低于非日间手术(P<0.001)。以腹腔镜胆囊切除术为观察对象,日间手术患者住院时间短于非日间手术,均次费用、均次药费、均次抗菌药物药费、药占比、抗菌药物费用占比均低于非日间手术(P<0.001)。结论PDCA循环法可显著提高日间手术占比;同时日间手术的模式缩短了住院时间,提高了患者满意度,降低了经济成本,社会效益显著。

糖尿病患者生产力损失的研究进展

糖尿病产生的成本分为直接成本和间接成本,直接成本指住院、检查和药物费用等直接产生的成本,间接成本指缺勤、工作效率降低和过早死亡造成的生产力损失。如果糖尿病患者血糖控制不佳,产生相关并发症,会增加糖尿病成本,除增加相关治疗费用外,也会对雇主和国家造成经济损失。本文通过系统检索国内外相关文献,对国内外老年糖尿病患者生产力损失的概念、研究现状、评估工具、影响因素、干预措施和对个人、雇主、经济产生的影响进行阐述,建议今后应更加关注糖尿病患者的健康教育和生活方式干预,以提高糖尿病患者自我管理水平,减少糖尿病导致的生产力损失。

福建省某三甲医院2016—2023年子宫内膜癌患者的住院费用比较

目的探讨子宫内膜癌(endometrial cancer,EC)患者的住院费用情况。方法选取福建省立医院2016年1月—2023年12月收治的100例EC患者进行回顾性分析,研究EC患者的基本情况与住院费用构成和变化趋势。结果100例EC患者各变量占比最高的分别为:年龄>45~60岁(51%)、住院天数>10~20 d(69%)、医保支付(84%)、手术(79%)、一般病例类型(67%)、有合并症/并发症(63%)。与2016—2019年的患者住院费用相比,2020—2023年患者的抗菌药费(728.54±32.13)元、西药费(4654.23±243.53)元更低,且患者的手术治疗费(7178.24±359.46)元、非手术治疗项目费(555.28±13.64)元、护理费(1226.37±33.61)元、麻醉费(1921.35±185.42)元、诊断费(3542.35±254.63)元、其他医疗费(4857.42±166.28)元、总费用(32147.59±1324.28)元均更高,差异有统计学意义(P<0.05)。结论EC患者的住院总费用存在上涨趋势,患者的经济负担较重。

新形势下药品集采利伐沙班与华法林治疗卒中的成本-效果评价

目的:研究分析新形势下药品集中带量采购新型抗凝药物利伐沙班的成本效果,并比较评价其与传统抗凝药物华法林优劣。方法:收集2022年5月至2023年5月本院收治的房颤卒中患者134例,对需要抗凝药物治疗者,随机分为华法林片(甲组)、利伐沙班片(乙组)进行治疗观察,运用成本-效果分析及差异法对两种药物进行药物经济学评价。结果:国家实行药品集中带量采购后,新型抗凝药物利伐沙班价格降低,华法林与利伐沙班的增量成本效果比(ICER)参数值都大于我国2021年人均GDP的3倍。结论:新形势下我国大部分地区使用利伐沙班预防治疗房颤患卒中的患者比使用华法林更具有成本优势。

Computerised tomography vs magnetic resonance imaging for modeling of patient-specific instrumentation in total knee arthroplasty

AIM: To summarise and compare currently available evidence regarding accuracy of pre-operative imaging, which is one of the key choices for surgeons contemplating patient-specific instrumentation(PSI) surgery.METHODS: The MEDLINE and EMBASE medical literature databases were searched, from January 1990 to December 2013, to identify relevant studies. The data from several clinical studies was assimilated to allow appreciation and comparison of the accuracy of each modality. The overall accuracy of each modality was calculated as proportion of outliers > 3% in the coronal plane of both computerised tomography(CT) or magnetic resonance imaging(MRI). RESULTS: Seven clinical studies matched our inclusion criteria for comparison and were included in our study for statistical analysis. Three of these reported series using MRI and four with CT. Overall percentage of outliers > 3% in patients with CT-based PSI systems was 12.5% vs 16.9% for MRI-based systems. These results were not statistically significant. CONCLUSION: Although many studies have been undertaken to determine the ideal pre-operative imaging modality, conclusions remain speculative in the absence of long term data. Ultimately, information regarding accuracy of CT and MRI will be the main determining factor. Increased accuracy of pre-operative imaging could result in longer-term savings, and reduced accumulated dose of radiation by eliminating the need for post-operative imaging and revision surgery.

Sugammadex: Role in current anaesthetic practice and its safety benefits for patients

Sugammadex has revolutionized anaesthetic management of reversal of neuromuscular block(NMB) by way of its unique mechanism of action encapsulating the amino steroid neuromuscular blocking drugs rocuroniumand vecuronium. The cholinesterase inhibitors have significant pharmacological and clinical limitations whereas sugammadex allows predictable, safe and rapid reversal from any depth of blockade. The financial cost of sugammadex is significant. Many hospitals in the United Kingdom use clinical guidelines to direct best use of sugammadex in their institutions. Auditing the use of sugammadex provides useful information on which patients are benefiting from sugammadex. The clinical benefits of sugammadex are well understood. No patient should now be subjected to the danger of post-operative residual curarization. Versatility in the ability to reverse NMB has brought opportunities to the anaesthetist in the management of rapid sequence induction using high dose rocuronium with the knowledge that safe reversal of NMB is now possible in the unlikely event of a "can't intubate can't ventilate" situation. Do we still need suxamethonium to be available? The nature of surgery continues to evolve with ever-increasing enthusiasm for minimally invasive laparoscopic techniques. There is evidence to support using a deeper level of NMB to improve the working space and operating conditions in laparoscopic surgery. It is now possible to maintain a deep level of NMB right up until the end of surgery with no concerns about the ability to effect safe reversal of NMB. Vigilance about the possibility of allergic sensitivity to sugammadex needs to be maintained. The increased usage of rocuronium has the potential for rocuroniuminduced anaphylaxis. Conversely, there is a potential role for sugammadex in the treatment of rocuronium anaphylaxis. Clinicians who have used sugammadex are struck with the quality of recovery seen in their patients. It is important that the economic implications of the use of sugammadex are fully understood. This article considers the current role of sugammadex in clinical practice outside of routine reversal of NMB and discusses how the addition of sugammadex to the anaesthetic armamentarium brings safety benefits for patients.

Hepatitis C virus cure with direct acting antivirals: Clinical,economic, societal and patient value for China

About 10 million people in China are infected with hepatitis C virus(HCV),with the seroprevalence of anti-HCV in the general population estimated at 0.6%.Delaying effective treatment of chronic hepatitis C(CHC)is associated with liver disease progression,cirrhosis,hepatocellular carcinoma,and liver-related mortality.The extrahepatic manifestations of CHC further add to the disease burden of patients.Managing CHC-related advanced liver diseases and systemic manifestations are costly for both the healthcare system and society.Loss of work productivity due to reduced well-being and quality of life in CHC patients further compounds the economic burden of the disease.Traditionally,pegylatedinterferon plus ribavirin(PR)was the standard of care.However,a substantial number of patients are ineligible for PR treatment,and only 40%–75%achieved sustained virologic response.Furthermore,PR is associated with impairment of patient-reported outcomes(PROs),high rates of adverse events,and poor adherence.With the advent of direct acting antivirals(DAAs),the treatment of CHC patients has been revolutionized.DAAs have broader eligible patient populations,higher efficacy,better PRO profiles,fewer adverse events,and better adherence rates,thereby making it possible to cure a large proportion of all CHC patients.This article aims to provide a comprehensive evaluation on the value of effective,curative hepatitis C treatment from the clinical,economic,societal,and patient experience perspectives,with a focus on recent data from China,supplemented with other Asian and international experiences where China data are not available.

Clinical outcomes of Clutch Cutter endoscopic submucosal dissection for older patients with early gastric cancer

AIM To evaluate the clinical outcome of endoscopic submucosal dissection using the Clutch Cutter(ESDCC) in older patients. METHODS We reviewed 232 consecutive patients with early gastric cancer who underwent ESDCC between June 2010 and February 2014 at Aso Iizuka Hospital. We divided patients into two groups according to age: Older patients(> 80 years, n = 64) and non-older patients(≤ 80 years, n = 168). We retrospectively compared the prevalence rates of pre-existing comorbidities, anticoagulant therapy, en bloc resection, mean duration of hospitalization, incidence of ESDCC-related complications, change in performance status(PS) before and after ESDCC, and financial cost of admission. RESULTS The older group comprised 64 patients with a mean age of 84.1 years, and the non-older group comprised 168 patients with a mean age of 69.5 years. Older patients had significantly more pre-existing comorbidities than did non-older patients, specifically heart disease(P < 0.05). The en bloc resection rate in non-older patients was significantly higher than that in older patients(100% vs 95.3%, P = 0.02). There were no significant differences between the older and non-older groups in the incidence of ESDCC-related complications(i.e., postoperative bleeding and perforation) and the post-ESDCC change in PS. There were also no significant differences between the older and non-older groups in the mean duration of hospitalization(11.4 and 10.7 d, respectively) and financial cost of admission(657040 JPY and 574890 JPY, respectively).CONCLUSION ESDCC has a good clinical outcome in older patients.

罕见病患者的权利保障:论争与辨析

充分保障罕见病患者是国家文明程度的重要体现。尽管各国通过法律和制度,力促罕见病患者平等医疗权的实现,但由于发病率低导致治疗成本高,患者权利仍难获保障。学界围绕是否要保障及如何保障展开了激烈论争。当代西方学者的研究集中于:如何优先保障罕见病患者的平等医疗权,让社会接受罕用药低成本效益的正当性。他们提出以平等原则、营救原则取代成本效益原则进行资源分配,或跨越实体公正原则,遵循程序公正原则。这些辩护与尝试虽未让各国各界达成共识,但为罕见病患者权利保障研究提供了伦理指引与道德基础。

基于麻雀搜索算法考虑病患流的医院诊疗设备维护优化研究

针对医院诊疗设备出现故障后对病人的影响不可控、产生的维修费用高等问题,提出了一种基于病患流分布不均的预防性维护决策模型。首先,针对医院诊疗设备退化速度受病患流分布影响的特点,采用病患流因子反映其人流量变化规律,并基于设备衰退演化规则构建了设备退化过程模型。其次,通过将量化的诊疗设备故障风险成本以及延迟或提前维护带来的变动成本纳入成本计算体系,提出了病患流分布不均状况下以故障风险值为约束的设备维护策略。最后,采用麻雀搜索算法进行寻优获取关键初始变量,并对模型进行数值仿真分析,结果表明,新维护策略在保障诊疗设备可靠度的同时,也能保持较低的维护成本。

DRG支付下某院恶性增生性疾患分组效果与住院费用分析

目的分析某医院疾病诊断相关分组(DRG)支付下恶性增生性疾患的分组效果与住院费用构成及变动情况,为医疗机构改进DRG付费相关措施、控制药品费用以及有关部门制定相关决策提供依据。方法收集某“三甲”综合医院2021、2022年的恶性增生性疾患住院病例信息,使用变异系数(CV)对DRG分组效能进行评价,结合结构变动度与新灰色关联分析法研究住院费用的结构变动及其与各项费用间的关联程度。结果恶性增生性疾患DRG病组总体变异降低系数(RIV)为79.36%,除RW21病组CV为1.09外其他病组CV均小于1;相比于2021年,2022年恶性增生性疾患的次均住院费用下降了17.80%,管理费、药品费的降幅分别为32.15%、21.30%,医疗费的增幅为17.26%;药品费的新灰色关联度降低,但医疗费的新灰色关联度升高。结论DRG支付下样本医院恶性增生性疾患住院费用下降,但RW21等病组的分组效能有待提升,费用结构有待优化。

1995～1999年糖尿病住院费用分析

目的 分析近 5年糖尿病患者住院费用的增长及分布情况。方法 采用总后勤部信息统计中心制发的全军病案首页 ,按照国际疾病分类法 ,抽取 1995～ 1999年住院的糖尿病病案。结果 5年内我院共收住 948例、15 0 9例次糖尿病患者。年人均住院费用以及药费、检查费、床位护理费和住院天数分别由 1995年 2 382元、95 0元、6 2 1元、5 2 4元增至1999年的 485 0元、1734元、1198元、15 6 4元 ,分别增加了 10 3.7%、82 .5 %、92 .9%、198.5 % ,住院天数则减少 2天。糖尿病合并单纯性脑梗塞、单纯性高血压、胆囊炎和 /或胆结石、上呼吸道感染的人均医疗费用分别为无糖尿病的同类病变患者的 2 .0 2、1.89、1.32、3.70倍 ,住院日则分别延长 9.7日、2 .0日、10 .8日和 9.1日。同一年龄段糖尿病合并胆囊炎和 /或胆结石的患者与对照者比较 ,前者住院总费用、药费、检查费、床位护理费和其它费用均明显高于后者 ,统计学有非常显著性差异。结论 近 5年来 ,糖尿病的住院费用增加了一倍以上 ,其中床位护理费增加近 2倍 ;因其它疾病住院的糖尿病患者的医疗费用明显地高于无糖尿病的同类病变者。本文强调要加强糖尿病防治工作 。

造口袋对危重病人大便失禁肛周皮肤保护的效果观察

目的探讨造口袋对危重病人大便失禁肛周皮肤保护的效果。方法选择2006年1月-2007年12月本院146例危重合并大便失禁病人,随机分为实验组75例和对照组71例。实验组采用造口袋保护肛周皮肤,对照组采用油性保护剂保护肛周皮肤。比较两组病人皮肤损伤的治愈率、愈合时间、清洗次数、清洗时间和治疗费用。结果两组病人Ⅰ度、Ⅱ度及Ⅲ度皮肤损伤的治愈率高于对照组(均P<0.05);实验组伤口愈合时间及清洗时间短于对照组、清洗次数少于对照组、换药费用低于对照组(均P<0.05)。结论对大便失禁的危重病人应用造口袋能有效收集粪水,预防皮肤损伤,并能促进皮炎、损伤愈合,减轻护理工作量;且价格便宜,效果满意,特别适合于合并骶尾部压疮的大便失禁危重病人,有利于肛周皮肤的保护。