How palliative care can reduce healthcare costs &improve quality of care

The sustainability of the healthcare system has been in question for several years. With rising healthcare costs, limited resources and an aging population, society needs to come up with innovative ideas to reduce healthcare spending. This paper attempts to illustrate how addressing goals of care can have a significant impact on healthcare costs.

An Integrated Rehabilitation Model: An Ideal Framework for Limiting Health Care Costs

The financial crisis has caused a severe limitation of resources for the public health service and rehabilitation. The proposal of integrated diagnosis and treatment in rehabilitation, involving the introduction of new therapeutic models alongside orthodox models, could lead to a reduction in health care costs through better patient compliance. In rehabilitative assistance in health care, the limiting of financial resources can be simplified, given its multifaceted nature and the need to integrate clinical experience with research. In addition, the phases of rehabilitative recovery do not focus on organ damage, but improved participation and the reduction of disability. For this reason, we have considered incorporating narrative based medicine (NBM) and Psycho-Neuro-Immuno-Endocrinology (PNEI) in the rehabilitation process through an empathetic approach, taking evidence based medicine (EBM) into account, thus creating a “framework” of reference. Managing patients through this “framework” would be a move towards an integrated model of care that could lead to a reduction in health care costs, given the aging population and the rise in patients with chronic pain. The decision to modify health care in rehabilitative assistance through a new “framework” will require time, organizational capacity and experimentation, but may represent the appropriate response for an improved quality of life for patients and a better allocation of resources.

Cost-effectiveness of Crohn's disease post-operative care

AIM: To define the cost-effectiveness of strategies, including endoscopy and immunosuppression, to prevent endoscopic recurrence of Crohn’s disease following intestinal resection.METHODS: In the “POCER” study patients undergoing intestinal resection were treated with post-operative drug therapy. Two thirds were randomized to active care (6 mo colonoscopy and drug intensification for endoscopic recurrence) and one third to drug therapy without early endoscopy. Colonoscopy at 18 mo and faecal calprotectin (FC) measurement were used to assess disease recurrence. Administrative data, chart review and patient questionnaires were collected prospectively over 18 mo.RESULTS: Sixty patients (active care n = 43, standard care n = 17) were included from one health service. Median total health care cost was $6440 per patient. Active care cost $4824 more than standard care over 18 mo. Medication accounted for 78% of total cost, of which 90% was for adalimumab. Median health care cost was higher for those with endoscopic recurrence compared to those in remission [$26347 (IQR 25045-27485) vs $2729 (IQR 1182-5215), P < 0.001]. FC to select patients for colonoscopy could reduce cost by $1010 per patient over 18 mo. Active care was associated with 18% decreased endoscopic recurrence, costing $861 for each recurrence prevented.CONCLUSION: Post-operative management strategies are associated with high cost, primarily medication related. Calprotectin use reduces costs. The long term cost-benefit of these strategies remains to be evaluated.

Downsizing Health Care in the Community

This study reviewed recent changes in health care utilization in the health care providers of Syracuse, New York. The data indicated the largest decline in the numbers of inpatient volumes involved adult surgery and orthopedics. Numbers of inpatient discharges for this service declined by more than 2900 discharges for the combined Syracuse hospitals. The data also indicated that adult medicine discharges declined by more than 2600 during this time. For Diagnosis Related Groups with discharge differences of 30 or more, adult medicine discharges declined by 451 in neurology, 943 in respiratory medicine, and 625 in circulatory medicine. It was estimated that the value of the inpatient discharges amounted to approximately $1,740,000 in adult surgery and more than $1,560,000 for adult medicine. The savings that were achieved in this process related to staffing, pharmaceuticals, and testing.

Estimating the Future of Health Care at the Community Level

Developments in health care in the United States are changing the delivery of services for providers and payors. This study focused on inpatient hospital discharges in the Syracuse hospitals and other services. It demonstrated that, during the past five years, numbers of inpatient adult medicine discharges had increased while adult surgery discharges had declined. This information suggested that adult medicine discharges could be expected to increase and approach levels of five years ago. It also suggested adult surgery discharges could be expected to remain at previous levels or decline. This information indicated that the combined emergency department visits declined from 238,000 to 202,000 between 2019 and 2020, then increased from 218,000 to 228,000 visits between 2021 and 2023. These developments will probably result in greater efficiency at the community level. With a decline in numbers of inpatient beds, providers will be able to focus on the more efficient management by reducing numbers of staff as well as fewer pharmaceuticals and testing.

A Study Protocol on the Evaluation of Referral Strategies for Inflammatory Arthritis in Primary Care Patients at the Level of Healthcare Organization, Patient Relevant Outcomes and Costs

Background: Considering the importance of getting the right patient at the right location to maintain and optimize quality of life of inflammatory arthritis patients, appropriate referral by general practitioners is essential. This study aims to assess the effect and cost effectiveness of different referral strategies for inflammatory arthritis in primary care patients. Methods: This study follows a cluster randomized controlled trial design. General practitioners from primary care centers in Southwest-The Netherlands are randomly assigned to either one of the two strategic interventions for referring adult patients who are in the opinion of the general practitioner suspected of inflammatory arthritis: 1) Standardized digital referral algorithm based on existing referral models PEST, CaFaSpA and CARE;2) Triage by a rheumatologist in the local primary care center. These interventions will be compared to a control group, e.g. usual care. The primary outcome is the percentage of patients diagnosed with inflammatory arthritis by the rheumatologist. Secondary outcomes are quality of life as a patient reported outcome, work participation and healthcare costs. These data, including demographic and clinical parameters, are prospectively collected at baseline, three, six, and twelve months. Discussion: If this study can demonstrate improvements in appropriate referrals to the rheumatologist, thereby improving cost-effectiveness, there is sufficient supporting evidence to implement one of the referral strategies as a standard of care. Finally, with these optimization strategies a higher quality of care can be achieved, that might be of value for all patients with arthralgia. Trial Registration: NCT03454438, date of registration: March 5, 2018. Retrospectively registered: https://clinicaltrials.gov/ct2/show/NCT03454438?term=NCT03454438&draw=1&rank=1.

Attributable cost of a nosocomial infection in the intensive care unit: A prospective cohort study

AIM To study the impact of hospital-acquired infections(HAIs) on cost and outcome from intensive care units(ICU) in India. METHODS Adult patients(> 18 years) admitted over 1-year, to a 24-bed medical critical care unit in India, were enrolled prospectively. Treatment cost and outcome data were collected. This cost data was merged with HAI data collected prospectively by the Hospital Infection Control Committee. Only infections occurring during ICU stay were included. The impact of HAI on treatment cost and mortality was assessed. RESULTS The mean(± SD) age of the cohort(n = 499) was42.3 ± 16.5 years. Acute physiology and chronic health evaluation-Ⅱ score was 13.9(95%CI: 13.3-14.5); 86% were ventilated. ICU and hospital length of stay were 7.8 ± 5.5 and 13.9 ± 10 d respectively. Hospital mortality was 27.9%. During ICU stay, 76(15.3%) patients developed an infection(ventilator-associated pneumonia 50; bloodstream infection 35; urinary tract infections 3), translating to 19.7 infections/1000 ICU days. When compared with those who did not develop an infection, an infection occurring during ICU stay was associated with significantly higher treatment cost [median(inter-quartile range, IQR) INR 92893(USD 1523)(IQR 57168-140286) vs INR 180469(USD 2958)(IQR 140030-237525); P < 0.001 and longer duration of ICU(6.7 ± 4.5 d vs 13.4 ± 7.0 d; P < 0.01) and hospital stay(12.4 ± 8.2 d vs 21.8 ± 13.9 d; P < 0.001)]. However ICU acquired infections did not impact hospital mortality(31.6% vs 27.2%; P = 0.49).CONCLUSION An infection acquired during ICU stay was associated with doubling of treatment cost and prolonged hospitalization but did not significantly increase mortality.

Discharging patients home from the intensive care unit:A new trend

Discharging patients directly to home from the intensive care unit(ICU)is becoming a new trend.This review examines the feasibility,benefits,challenges,and considerations of directly discharging ICU patients.By analyzing available evidence and healthcare professionals'experiences,the review explores the potential impacts on patient outcomes and healthcare systems.The practice of direct discharge from the ICU presents both opportunities and complexities.While it can potentially reduce costs,enhance patient comfort,and mitigate complications linked to extended hospitalization,it necessitates meticulous patient selection and robust post-discharge support mechanisms.Implementing this strategy successfully mandates the availability of home-based care services and a careful assessment of the patient's readiness for the transition.Through critical evaluation of existing literature,this review underscores the significance of tailored patient selection criteria and comprehensive post-discharge support systems to ensure patient safety and optimal recovery.The insights provided contribute evidence-based recommendations for refining the direct discharge approach,fostering improved patient outcomes,heightened satisfaction,and streamlined healthcare processes.Ultimately,the review seeks to balance patientcentered care and effective resource utilization within ICU discharge strategies.

Cost effectiveness of intensive care in a low resource setting: A prospective cohort of medical critically ill patients

AIM: To calculate cost effectiveness of the treatment of critically ill patients in a medical intensive care unit(ICU) of a middle income country with limited access to ICU resources. METHODS: A prospective cohort study and economic evaluation of consecutive patients treated in a recently established medical ICU in Sarajevo, Bosnia and Herzegovina. A cost utility analysis of the intensive care of critically ill patients compared to the hospital ward treatment from the perspective of the health care system was subsequently performed. Incremental cost effectiveness was calculated using estimates of ICU vs non-ICU treatment effectiveness based on a formal systematic review of published studies. Decision analytic modeling was used to compare treatment alternatives. Sensitivity analyses of the key model parameters were performed.RESULTS: Out of 148 patients, seventy patients(47.2%) survived to one year after critical illness with a median quality of life index 0.64 [interquartile range(IQR)0.49-0.76]. Median number of life years gained per patient was 30(IQR 16-40) or 18 quality adjusted life years(QALYs)(IQR 7-28). The cost of treatment of critically ill patients varied between 1820 dollar and20109 dollar per hospital survivor and between 100 dollar and 2514 dollar per QALY saved. Mean factors that influenced costs were: Age, diagnostic category,ICU and hospital length of stay and number and type of diagnostic and therapeutic interventions. The incremental cost effectiveness ratio for ICU treatment was estimated at 3254 dollar per QALY corresponding to35% of per capita GDP or a Very Cost Effective category according to World Health Organization criteria.CONCLUSION: The ICU treatment of critically ill medica patients in a resource poor country is cost effective and compares favorably with other medical interventions.Public health authorities in low and middle income countries should encourage development of critical care services.

Outcomes and Cost Effectiveness of a Respiratory Coordinated Care Program in Patients with Severe or Very Severe COPD

Multidisciplinary community coordinated care programs are widely adopted to optimise care of chronic disease patients, but there is a need for further evaluation in the setting of COPD. This observational study evaluated 147 patients with severe or very severe COPD who were enrolled in a multidisciplinary community respiratory coordinated care program (RCCP) from 2007 to 2012. Comparison was made of hospitalisation rates and length of stay for 12 months prior to joining the program, and the first 12 months after joining the program. This data was used to inform a cost analysis. Enrolment into RCCP halved the annual hospital admission rate from 1.18 to 0.57 admissions per year (relative risk reduction 51.4%, p < 0.001), and annual total length of stay was reduced from 8.06 to 3.59 days per patient per year (p < 0.001). Hospital admissions were reduced from 5.05 days to 2.00 days (p < 0.001). Accounting for the program’s costs, these changes resulted in a $US 906.94 ($AUD 972.80) cost saving per patient per year. A RCCP program can reduce patient hospitalisation and overall costs in the COPD setting.

中国老年人口健康状况及其家庭照料需求预测

中国人口老龄化快速发展,失能、半失能老年人口规模迅速扩大,老年照料需求快速增加。科学预测不同失能状况老年人口规模及其照料服务需求是推动老年照护服务体系建设的重要基础。文章基于中国老年健康影响因素跟踪调查(CLHLS)数据,使用Markov模型测算中国分性别、分年龄段老年人口健康状况转移矩阵,运用队列要素预测法、多元回归法等预测得到2020—2035年中国不同失能状况老年人口规模及其照料服务人员需求规模、家庭照料经济成本。预测结果显示:中国失能老年人口规模呈现增长态势,从2020年的1946万人增至2035年的3424万人,失能老年人口的比例从2020年的7.4%小幅增至2035年的7.9%,且中重度失能老年人口增幅更快,2035年时轻度失能老年人口规模相比2020年增加66%,中重度失能老年人口规模相比2020年增加92%。女性失能老年人口规模增速快于男性,80岁及以上老年人口失能比例增长更快,2035年男性70~79岁、80~89岁、90+岁三个年龄组失能老年人口规模分别为2020年的1.53倍、1.92倍、1.94倍;2035年女性三个年龄组失能老年人口规模分别为2020年的1.72倍、2.29倍、2.52倍。老年家庭照料需求将呈现快速增长态势,家庭照料服务人员需求量从2020年的2795万人增至2035年的4863万人,增长74%。2020—2035年健康老年人口的照料服务人员需求量占总需求量的比例在57%左右,中重度失能老年人口需求量占比在24%左右,轻度失能老年人口需求量占比在19%左右。60~69岁老年人口所需的照料服务人员占比最高,90岁及以上年龄组对照料服务人员的需求量增长更快。老年人口家庭照料经济成本从2020年的3027亿元增至2035年的11676亿元,将增长近3倍。中重度失能老年人口所需的家庭照料现金成本相比2020年增长3.1倍,轻度失能老年人口所需的家庭照料现金成本相比2020年增长2.6倍。男性老年人口所需家庭照料现金成本低于女性老年人口,且增速也低于女性老年人口。本研究基于定量预测结果提出积极推进健康老龄化,加大促进生育的政策支持力度,尽快推广长期照护保险制度,以赋能家庭为着力点加强失能老年人口的支持体系建设,大力发展老年护理服务业,大力发展养老护理职业教育等政策建议。

Supersaturated Calcium Phosphate Rinse vs. Standard of Care for Mitigating Mucositis in Head and Neck Chemoradiation

Introduction: Oral mucositis (OM) can have a significant impact on patients’ quality of life, pain and treatment costs. Almost all patients receiving head and neck chemoradiation develop OM. Patients and Methods: Twenty patients were evaluated retrospectively for OM when undergoing head and neck chemoradiation. The control, soda/salt rinse, was compared to a powdered supersaturated calcium phosphate rinse (SSCPR), SalivaMAX. Results: The SSCPR group experienced a delay in the onset of OM, which was not statistically significant, and a marked reduction in peak OM that was statistically significant (p > 0.001). Conclusion: This retrospective study demonstrates that a powdered SSCPR is a safe and effective method of oral mucositis mitigation.

Newborn care practices: A case study of tribal women, Gujarat

Plateaued rate of decline in neonatal mortality rate is one of the major obstacles in achieving Millennium Development Goal 4 especially in developing countries. Even in India, nationwide interventions targeting safe mother and newborn care have not yielded the desired impact, indicating the necessity to combat neonatal mortality rate at population specific level. The objective of this study is to identify the newborn care practices and beliefs, analyze their harmful or beneficial characteristics, describe the deviations from the essential newborn care practices during hospital/home delivery, explain barriers to care seeking and identify areas of potential resistance for behavior change;and utilize study findings to tailor-make cost-effective essential newborn care package. The study uses qualitative data from in-depth interview of mothers who had experienced neonatal death and key-informant interviews with healthcare personnel and birth attendants. 33 cases were randomly selected from the registered neonatal deaths across Bharuch district of Gujarat, India. Key finding of this study is less prevalent practice of essential newborn care among all cases irrespective of place of delivery and the health-care personnel facilitating delivery. Habitual traditional/tribal newborn care methods challenge the practice of prescribed essential newborn care. Clustering of deaths in few households added significantly to the existing burden of neonatal deaths, attributed to superstition “Ratewa” by tribal. Study has concluded that the introduction and implementation of essential newborn care at hospital and community/ household level are the need of the hour. Quality home based neonatal care through cost effective interventions is deemed necessary where accessing institutional care is not possible in the immediate term. Community health workers can contribute to the eradication of harmful newborn care practices and the sustenance of essential practices through community education and behavior change communication.

A COST-BENEFIT EVALUATION OF NEONATAL SCREENING PROGRAM IN CHINA

Objective Phenylketonuria (PKU) and congenital hypothyroidism (CH) are common diseases thatare associated with mental retardation. In order to make the best use of health care resources to achieve themaximum social and economic benefits and to lay the foundation for the popularization of neonatal screening, acost- benefit analysis of neonatal screening program was undertaken. Methods Based on screening results,medical history and the data published by the national statistic departments. Results Our result shows that it islairly profitable to conduct neonatal screening in China: the cost - benejit ratio for PKU screenging is 1:3.7, andthe cost-benefit ratio for CH screening is 1:3.6. Conclusion This report therefore strongly suPPorts furtherpopularization of neonatal screening in China.

Frugal Innovations Health Care Programs at the Community Level

Recent experience in some countries has suggested that the use of frugal innovations can be valuable. These initiatives can reduce health care expenses by substituting less costly services for more expensive ones and by limiting the organizational costs of maintaining these programs. These approaches have been defined as doing more with less. This study described the use of frugal approaches to improve the efficiency of care by providers in the metropolitan area of Syracuse, New York. In these programs, numbers of hospital patient days were reduced by discharging patients to long term care services. Hospital emergency department utilization was also monitored and managed at the community wide level. The utilization of hospital admissions per population was also limited. The three programs described in this study were implemented with annual staff expenses of $127,000. This amounted to only about $42,000 annually per hospital. The development and use of these frugal innovations was made possible through cooperation among providers and use of a single organization, the Hospital Executive Council to coordinate the programs.

Integrating palliative care in oncologic emergency departments:Challenges and opportunities

Although visiting the emergency departments(EDs) is considered poor quality of cancer care,there are indications these visits are increasing.Similarly,there is growing interest in providing palliative care(PC) to cancer patients in EDs.However,this integration is not without major challenges.In this article,we review the literature on why cancer patients visit EDs,the rates of hospitalization and mortality for these patients,and the models for integrating PC in EDs.We discuss opportunities such integration will bring to the quality of cancer care,and resource utilization of resources.We also discuss barriers faced by this integration.We found that the most common reasons for ED visits by cancer patients are pain,fever,shortness of breath,and gastrointestinal symptoms.The majority of the patients are admitted to hospitals,about 13% of the admitted patients die during hospitalization,and some patients die in ED.Patients who receive PC at an ED have shorter hospitalization and lower resource utilization.Models based solely on increasing PC provision in EDs by PC specialists have had modest success,while very limited ED-based PC provision has had slightly higher impact.However,details of these programs are lacking,and coordination between ED based PC and hospitalwide PC is not clear.In some studies,the objectives were to improve care in the communities and reduce ED visits and hospitalizations.We conclude that as more patients receive cancer therapy late in their disease trajectory,more cancer patients will visit EDs.Integration of PC with emergency medicine will require active participation of ED physicians in providing PC to cancer patients.PC specialist should play an active role in educating ED physicians about PC,and provide timely consultations.The impact of integrating PC in EDs on quality and cost of cancer care should be studied.

儿童照料费用对女性劳动参与决策的影响研究

自我国开始市场化改革以来,我国女性劳动参与率呈现不断下降的趋势,且长期低于男性劳动参与率。受传统家庭劳动分工的影响,女性在家庭中承担着养育孩子的主要责任,因而与儿童照料相关的成本负担通常会对女性劳动供给产生一定的负面影响。在我国进行托育制度改革后,公共托育体系的瓦解抬高了儿童托育服务的价格。目前,我国女性劳动参与率的持续下降与儿童照料费用的不断增加有着密切联系。基于此观察,利用中国健康和营养调查(CHNS)1991~2015年九期调查数据,创新性地利用了社区0~6岁儿童托幼机构的托儿费支出这一指标,综合使用Probit模型和工具变量法实证分析了儿童照料费用对我国女性劳动参与决策的影响。研究结果发现:儿童照料费用的增加显著降低了女性的劳动参与率。异质性分析表明,儿童照料费用的增加对于城镇、受教育程度较低、30岁以下和中低收入水平家庭的女性劳动参与率的负面影响更为明显。稳健性分析表明,儿童照料费用的增加对男性劳动参与率没有显著的负面影响;在控制内生性后,儿童照料费用对女性劳动参与率的负向影响显著增强。在生育政策完全放开的背景下,完善普惠托幼服务体系、健全女性就业保障制度和倡导男性共同承担育儿责任是提升我国女性劳动参与率的重要措施。

Choices of health care financing schemes for resource poor country: An analysis of Nepal’s experiences

An appropriate health care financing scheme can improve the efficient, equitable, and effective use of health care resources;however, each popular health care financing scheme has some advantages and disadvantages. The designing of health care financing strategy to fit with the country specific features is not straightforward. In resource poor country, allocation of resources for health care services are always critical and frequently unstable due to nuances annual budget process, small fiscal space, uncertainties in contributions of external development partners. Considerable quantities of country specific researches require for the choice of an appropriate health care financing scheme. The paper illustrates possible better options for the government to pursue the goal of ensuring that the poor receive more benefits. The paper compares the benefit incidences and cost of services with different options purposed for primary health care services by utilizing recently collected data from different hospitals in Nepal. The paper offers an alternative policy such as a universal free care below the district level services;but in the district level which is top level of primary care, “extended targeted free health care” may be an efficient, fair, and relatively simple approach.

The Cost of Caring

SOUTH Africa＇s acute incidence of HIV/AI DS is well-known globally. According to the United Nations, about 6.1 million South Africans were living with HIV/ AIDS in 2012. This means that one in every six South Africans is infected and of these, 17.9 percent of indi- viduals between the ages of 15 and 49 - considered to be the most economically productive age group - are infected with HIV/AIDS. According to the World Bank, this high infection rate among the economically active population could, in the most undesirable of scenarios, result in South Africa＇s per-capita income halving by 2100. While still a few decades away, the projected adverse impact of HIV/AIDS on the South African economy has seen government embarking on the largest anti-retroviral treatment （ART） access cam- paign in the world.

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.