Francesc Cots

Diagnosis related groups in Europe : moving towards transparency, efficiency, and quality in hospitals?

Hospitals in most European countries are paid on the basis of diagnosis related groups. Reinhard Busse and colleagues find much variation within and between systems and argue that they could be improved if countries learnt from each other

Perfil de la casuística hospitalaria de la población inmigrante en Barcelona

Objetivo: A pesar de que en los ultimos 5 anos la poblacion inmigrante se ha triplicado en ciudades como Barcelona, hasta el momento no se ha evaluado de forma rigurosa el impacto de este colectivo en el sistema sanitario. El objetivo del presente estudio ha sido comparar el perfil de la hospitalizacion de la poblacion inmigrante con la autoctona, desde el punto de vista de la casuistica, gravedad, caracteristicas demograficas y consumo de estancias. Material y metodos: Se han analizado las 15.057 altas del Hospital del Mar de Barcelona en el ano 2000. Este hospital asiste el 60% de los ingresos hospitalarios del distrito de Ciutat Vella, distrito que presentaba en el ano 2000 un porcentaje de inmigrantes residentes del 21%. Se han comparado las caracteristicas sociodemograficas y de casuistica de los pacientes en razon de ser o no inmigrantes. Tambien se ha comparado el consumo de recursos hospitalarios teniendo en cuenta la edad, la casuistica (grupos relacionados por el diagnostico) y la gravedad (severidad, complicaciones y comorbilidades) de la patologia atendida. Resultados: La poblacion inmigrante ha presentado una casuistica distinta de la autoctona por la marcada diferencia en la edad y por su mayor tasa de fecundidad. El 33% de los ingresos de inmigrantes han sido partos. El coste medio de las altas de inmigrantes de paises de renta baja valorado en consumo de estancias hospitalarias, ha sido un 30% menor que el del resto de las altas. Una vez ajustadas la edad, la casuistica y la severidad, el consumo de estancias hospitalarias en la poblacion inmigrante ha sido significativamente menor. La diferencia se ha cifrado en un 5% cuando solo se ha ajustado por patologia y en un 10% cuando han sido considerados todos los factores. Conclusiones: Las diferencias en la casuistica vienen marcadas por la edad y por las diferencias socioculturales. La piramide de edad de la poblacion hospitalaria inmigrante recompone la envejecida estructura de edad de los pacientes autoctonos y plantea la necesidad de recuperar el mayor peso de los servicios de ginecologia-obstetricia y pediatria. El hecho de que exista menor consumo de recursos por alta hospitalaria en la poblacion inmigrante de paises de renta baja contradice la relacion esperada de inmigrante-peor situacion socioeconomica-mayor intensidad de consumo de recursos por alta hospitalaria. Deben proponerse nuevas hipotesis de trabajo y analisis que permitan explicar esta realidad.

Outcomes and costs of outpatient and inpatient cataract surgery: a randomised clinical trial

The aim of this study was to compare clinical and perceived health outcomes and cost between ambulatory and inpatient cataract surgery. An unmasked randomised clinical trial was undertaken. Cataract surgery patients of three public hospitals in Barcelona (Spain) who met inclusion criteria for ambulatory surgery were randomly assigned to two groups: outpatient hospital and inpatient hospital. Primary outcome measures were early and late postoperative surgical complications and visual acuity. Secondary outcome measures were perceived visual function, overall perceived health status, and costs. A total of 464 outpatients and 471 inpatients were analysed. No statistically significant differences were observed between the two groups in visual acuity (P =.48), nor for the other clinical and perceived health outcome measures, except for early postoperative complications. Outpatients presented at least one complication in the first 24 h after surgery more frequently than inpatients (64 vs. 43; RR 1.6, 95% CI 1.1, 2.4), but 4 months after surgery the differences in complications rates between groups disappeared. The cost of surgery was lower for outpatients than for inpatients (1001 vs. 1218 Euros; P <.001). Ambulatory cataract surgery was more cost-effective than inpatient surgery. Despite the higher risk of early complications in the outpatient hospital group, these differences may not be clinically relevant because the 4-month postoperative outcomes were not affected.

Relevance of Outlier Cases in Case Mix Systems and Evaluation of Trimming Methods

Objectives: To determine the most appropriate outlier trimming method when the main source of information for case mix classification is length of stay (LOS) because cost information is unavailable. Methods: Discharges (35,262) from two public hospitals were analysed. LOS and cost outliers were calculated using different trimming methods. The agreement between cost and LOS trimming was analysed. Results: The trimming method using the geometric mean with two standard deviations (GM2) showed the highest level of agreement between cost and LOS and revealed the greatest proportion of extreme costs. Nearly 5% of cases were outliers, containing 16% of total LOS. This was the best approximation to 18% of extreme cost because when GM2 was applied to LOS, 88% of outlier cost was revealed. Conclusions: The methods were analysed because they are the most frequently used but the same methodology could be employed to compare other outlier determination methods. Outliers should be calculated because they ought to be valued differently from inlier cases.

Cost-effectiveness of early detection of breast cancer in Catalonia (Spain)

BackgroundBreast cancer (BC) causes more deaths than any other cancer among women in Catalonia. Early detection has contributed to the observed decline in BC mortality. However, there is debate on the optimal screening strategy. We performed an economic evaluation of 20 screening strategies taking into account the cost over time of screening and subsequent medical costs, including diagnostic confirmation, initial treatment, follow-up and advanced care.MethodsWe used a probabilistic model to estimate the effect and costs over time of each scenario. The effect was measured as years of life (YL), quality-adjusted life years (QALY), and lives extended (LE). Costs of screening and treatment were obtained from the Early Detection Program and hospital databases of the IMAS-Hospital del Mar in Barcelona. The incremental cost-effectiveness ratio (ICER) was used to compare the relative costs and outcomes of different scenarios.ResultsStrategies that start at ages 40 or 45 and end at 69 predominate when the effect is measured as YL or QALYs. Biennial strategies 50-69, 45-69 or annual 45-69, 40-69 and 40-74 were selected as cost-effective for both effect measures (YL or QALYs). The ICER increases considerably when moving from biennial to annual scenarios. Moving from no screening to biennial 50-69 years represented an ICER of 4,469€ per QALY.ConclusionsA reduced number of screening strategies have been selected for consideration by researchers, decision makers and policy planners. Mathematical models are useful to assess the impact and costs of BC screening in a specific geographical area.

Medicare's DRG-weights in a European environment: the Spanish experience

Hospital payment systems are being changed to mixed systems, composed of case-mix categories and structure indicators. The Health Care Financing Administrations Diagnosis-Related-Groups (HCFAs DRG-weights are used in Catalonia as Prospective Payment System (PPS)-instruments for hospital inpatient reimbursement. The Catalonian and Spanish health systems, however, are very different from the US health environment. The aim of this study is to determine whether the HCFAs DRG-weights fit the special characteristics of a European environment. To do this, cost-based weights, determined from information from the cost accounting system of two public hospitals in Barcelona, are compared with Medicare-weights. A total of 35 262 discharges representing 12 794 million pesetas are analyzed. Medicare-weights do not differ globally from cost-based-weights and the adjusted correlation weighted least squares regression between the two weight-scales is 95%. There are, however, systematic deviations in six DRG-groupings. The most important deviations are concentrated in Ambulatory Surgery categories, in DRGs in which prostheses are used, and in specialties excluded from several PPSs because of extreme variables in treatment intensity. In conclusion, Medicare-weights can be used to pay hospital output in European environment but they should be adjusted to avoid systematic deviations.

Clinical outcomes and costs of cataract surgery performed by planned ECCE and phacoemulsification

AbstractPurpose: To compare clinical outcomes and costs of cataract surgery between patients operated with standard extracapsular extraction (ECCE) and those undergoing phacoemulsification. Setting: Patients from the Ophthalmology Department of a teaching hospital in Barcelona (Spain) scheduled for cataract surgery, not combined with any other ophthalmic procedure. Methods: A retrospective analysis has been performed on a database of 1046 patients undergoing ECCE and phacoemulsification. The outcome measures used were: surgical complications, visual acuity and costs of surgery and of follow-up. Overall rate of all complications and postoperative visual acuity were compared between the two groups, adjusting for age, preoperative visual acuity, medical and ocular comorbidity. Results: 31.9% of the patients (334) underwent phacoemulsification, and 68.1% (712) underwent ECCE. Patients undergoing phacoemulsification presented a frequency of intra- and postoperative complications lower than those undergoing ECCE (odds ratio 0.57, 95%Cl 0.37–0.87 and 0.66, 95%Cl 0.46–0.96, respectively), specifically for intraoperative iris trauma (3.1% vs 0.3%, p = 0.004), residual posterior capsular opacity (2% vs 0.3%, p = 0.035) and postoperative corneal edema (7.4% vs 3.6%, p = 0.016). Costs of intervention and follow-up were lower for phacoemulsification compared with ECCE (23.9% and 14%, respectively). But global costs were slightly higher for phacoemulsification (4.87%), due to supply costs, which were more than twice those ofECCE. Conclusions: Phacoemulsification, when performed by an experienced surgeon, has better clinical outcomes than planned extracapsular extraction, and costs may be lower since supply costs are expected to decrease as the phacoemulsification technique becomes more widespread.

Patient Classification And Hospital Costs Of Care For Acute Myocardial Infarction In Nine European Countries

This study contributes to the literature on the performance of diagnosis-related groups (DRGs) for acute myocardial infarction (AMI) patients by evaluating in nine countries the factors--in addition to DRGs--that affect costs or length of stay and comparing the variation that can be explained with or without DRGs. We evaluate whether the existing DRGs for AMI patients would benefit from additional patient-related and treatment-related factors that are found in administrative data across countries. In most countries, the set of patient and quality variables performed better than the DRG variables. Our results suggest that DRG systems in all countries could be improved by including additional explanatory factors or by refining the existing DRGs. Our results suggest that for AMI and possibly for other related episodes, a refinement of DRGs to include information on patient severity, procedures and levels of complications could improve the ability of DRGs to explain resource use. It seems possible to improve DRG-like hospital payment systems through the inclusion of episode-specific variables.

Impacto económico de los eventos adversos en los hospitales españoles a partir del Conjunto Mínimo Básico de Datos

OBJECTIVE To evaluate the incidence and costs of adverse events registered in an administrative dataset in Spanish hospitals from 2008 to 2010. METHODS A retrospective study was carried out that estimated the incremental cost per episode, depending on the presence of adverse events. Costs were obtained from the database of the Spanish Network of Hospital Costs. This database contains data from 12 hospitals that have costs per patient records based on activities and clinical records. Adverse events were identified through the Patient Safety Indicators (validated in the Spanish Health System) created by the Agency for Healthcare Research and Quality together with indicators of the EuroDRG European project. RESULTS This study included 245,320 episodes with a total cost of 1,308,791,871€. Approximately 17,000 patients (6.8%) experienced an adverse event, representing 16.2% of the total cost. Adverse events, adjusted by diagnosis-related groups, added a mean incremental cost of between €5,260 and €11,905. Six of the 10 adverse events with the highest incremental cost were related to surgical interventions. The total incremental cost of adverse events was € 88,268,906, amounting to an additional 6.7% of total health expenditure. CONCLUSIONS Assessment of the impact of adverse events revealed that these episodes represent significant costs that could be reduced by improving the quality and safety of the Spanish Health System.

Estimation of lung cancer diagnosis and treatment costs based on a patient-level analysis in Catalonia (Spain)

BackgroundAssessing of the costs of treating disease is necessary to demonstrate cost-effectiveness and to estimate the budget impact of new interventions and therapeutic innovations. However, there are few comprehensive studies on resource use and costs associated with lung cancer patients in clinical practice in Spain or internationally. The aim of this paper was to assess the hospital cost associated with lung cancer diagnosis and treatment by histology, type of cost and stage at diagnosis in the Spanish National Health Service.MethodsA retrospective, descriptive analysis on resource use and a direct medical cost analysis were performed. Resource utilisation data were collected by means of patient files from nine teaching hospitals. From a hospital budget impact perspective, the aggregate and mean costs per patient were calculated over the first three years following diagnosis or up to death. Both aggregate and mean costs per patient were analysed by histology, stage at diagnosis and cost type.ResultsA total of 232 cases of lung cancer were analysed, of which 74.1% corresponded to non-small cell lung cancer (NSCLC) and 11.2% to small cell lung cancer (SCLC); 14.7% had no cytohistologic confirmation. The mean cost per patient in NSCLC ranged from 13,218 Euros in Stage III to 16,120 Euros in Stage II. The main cost components were chemotherapy (29.5%) and surgery (22.8%). Advanced disease stages were associated with a decrease in the relative weight of surgical and inpatient care costs but an increase in chemotherapy costs. In SCLC patients, the mean cost per patient was 15,418 Euros for limited disease and 12,482 Euros for extensive disease. The main cost components were chemotherapy (36.1%) and other inpatient costs (28.7%). In both groups, the Kruskall-Wallis test did not show statistically significant differences in mean cost per patient between stages.ConclusionsThis study provides the costs of lung cancer treatment based on patient file reviews, with chemotherapy and surgery accounting for the major components of costs. This cost analysis is a baseline study that will provide a useful source of information for future studies on cost-effectiveness and on the budget impact of different therapeutic innovations in Spain.