Workshop aims,outline of the program

This workshop on the Technology Assessment of PACS has been organized as a rounding off of the Technology Assessment Activities which were initiated within the Dutch PACS Project (1986–1989). It is made possible by a funding from the Dutch Ministry of Health Care (WVC). We hope it will be not only a rounding off, but will contribute to more intensive cooperations in this area. In the scope of the Dutch PACS project, the software package CAPACITY for cost analyses of PACS has been developed, to stimulate the dialogue and exchange of data. During the workshop, the data which were collected with CAPACITY are used as a framework for discussions. This paper presents the outline of the workshop, its background, its aims and the program.     

Evaluation of PACS-induced organizational change

Filmless digital imaging with a PACS will affect health care institutions by changing the handling of clinically relevant information, altering needed staffing levels, and possibly affecting both the quality and cost of care. Economic evaluation of PACS compares the costs and/or benefits of PACS with those of all other relevant alternatives. Other evaluations may focus on narrower research questions. This paper discusses methodological considerations in economic evaluation, methods of time measurement, and the methods and results of several applied assessments of PACS effects on the medical imaging department or the hospital.     

The impact of PACS on the information flow

It is likely that changes in hospital operational practices made possible by the introduction of a whole hospital PACS will require the present information and data patterns to be changed significantly. Some of the factors which will affect the flow of data and information are considered, and the implications of comparing the costs of installing ‘whole hospital’ PACS systems in different institutions are discussed.     

PACS的高级预防维护技术

目的 通过讨论PACS高级预防维护技术,供同他人在日常维护过程中有一定地借鉴作用.方法 从PACS数据库性能检测与优化,存储设备检测及PACS各应用软件模块三方面进行阐述.结果 经过医院一线安装维护人员和PACS厂家多年实践的总结,拥有一定的可参考依据.结论 PACS的高级预防维护是一个复杂的系统工程,包括一般维护和高级维护在内的实践理论才刚刚起步,科学的、规范化的预防维护需要不断地完善和发展.     

Current and projected annual direct costs of screening asymptomatic men for prostate cancer using prostate-specific antigen

BACKGROUND: Concern over the cost of screening for asymptomatic prostate cancer by means of prostate-specific antigen (PSA) testing has played an important role in PSA screening policy. However, little is known about the true costs of current PSA screening in Canada and how costs may change in the future. METHODS: The authors performed a cost identification study from the perspective of provincial ministries of health. They used data from published reports, hospital discharge data, claims data from several provinces, a laboratory survey, a national survey of knowledge, attitudes and beliefs about screening, a provincial cancer registry and expert opinion to estimate current first-year screening costs. Using demographic data from Statistics Canada and various scenarios regarding changes in screening patterns, the authors derived estimates of the future costs of PSA screening. RESULTS: In 1995 PSA screening cost an estimated $45 million (range $40 million to $84 million). Treatment accounted for over 61% of total costs, whereas screening, diagnosis and staging accounted for 35%. Screening all eligible men in Canada in 1995 would have cost $317 million (range $356 million to $691 million), more than the costs of all prostate cancer care in that year. Annual recurrent screening for all eligible men in 2005 would cost $219 million (range $208 million to $412 million). Projections from existing trends suggest that annual costs of PSA screening in 2000 are likely to increase from the estimated $45 million to approximately $66 million (range $59 million to $126 million). INTERPRETATION: PSA screening is costly, but even universal screening would consume a smaller share of national health expenditures than previous studies have suggested. Costs attributable to PSA screening may increase in the future owing to changes in utilization patterns and demographic shifts.     

基于PACS的影像学检查流程优化研究

为了推行惠民便民措施,优化就医流程、降低候诊时间,切实解决“看病难”问题,提出了优化整合PACS（医学影像存储和传输系统）,整合以放射线科、磁共振室、CT室为主要科室,以信息流代替患者流为主要改进方式,以预约登记、检查诊断、数字传输、信息存储为主要功能的一体化综合诊断管理平台。基于PACS的影像学检查流程优化对于提升临床诊断水平、降低患者候诊时间、降低科室运营成本、缓解“看病难、看病贵”有着重大意义。     

Incidence and costs of severe hypoglycaemia requiring attendance by the emergency medical services in South Central England

Aims The aim was to estimate the incidence of severe hypoglycaemia requiring emergency ambulance assistance, its management and associated costs. Methods A retrospective observational study used routinely collected data for a 1-year period from December 2009 to November 2010 from the South Central Ambulance Service National Health Service Trust, UK. The main outcome was episodes reported by ambulance personnel and costs were estimated from published data. Results During the 1-year study period, 398?409 emergency calls were received, of which 4081 (1.02%) were coded as hypoglycaemia. The overall numbers (and annual rate) of hypoglycaemia recorded among people ≥?15?years with presumed diabetes was 3962 (2.1%), but for those aged 15-35?years was 516 (7.5%) and for those aged ≥?65?years was 1886 (1.9%). Of those attended, 1441 (35.3%) were taken to hospital. The estimated total cost of initial ambulance attendance and treatment at scene was ￡553?000; if transport to hospital was necessary, the additional ambulance costs were ￡223?000 plus emergency department costs of ￡140?000; and the cost of primary care follow-up was estimated as ￡61?000. The average cost per emergency call was ￡263. The estimated annual cost of emergency calls for severe hypoglycaemia is ￡13.6m for England. Conclusions Our estimates suggest prevalence of severe hypoglycaemia attended by the emergency services is high in younger age groups and lower for older age groups, although the absolute numbers of severe events in older age groups contribute substantially to the overall costs of providing emergency assistance for hypoglycaemia.     

Treatment costs of acute myocardial infarction in the Netherlands

Background

This study aimed to calculate the treatment costs of acute myocardial infarction (AMI) in the Netherlands for 2012. Also, the degree of association between treatment costs of AMI and some patient and hospital characteristics was examined.

Methods

For this retrospective cost analysis, patients were drawn from the database of the Diagnosis Treatment Combination (Diagnose Behandeling Combinatie, DBC) casemix system, which contains data on the resource use of all hospitalisations in the Netherlands. All costs were based on Euro 2012 cost data.

Results

The analysis was based on data of 25,657 patients. Mean treatment costs were estimated at € 5021, with significant cost increases for patients with percutaneous coronary intervention (PCI) treatment. ST-segment elevation myocardial infarction (STEMI) patients receiving thrombolysis incurred the lowest (€ 4286), while non-STEMI patients receiving PCI the highest costs (€ 6060). Length of stay and hospital type were strong predictors of treatment costs.

Conclusions

This study is the most extensive cost assessment of the treatment costs of AMI in the Netherlands thus far. Our results may be used as input for health-economic models and economic evaluations to support the decision making of registration, reimbursement and pricing of interventions in healthcare.     

The role of pirfenidone in the treatment of idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a progressive disease, with a median survival time of 2–5 years. The search for effective treatment has involved numerous clinical trials of investigational agents without significant success. However, in 2011, pirfenidone was the first drug to be approved for the treatment of IPF in Europe. Four key clinical trials supported the efficacy and tolerability of pirfenidone.In the two recently published Phase III CAPACITY trials evaluating pirfenidone (studies 004 and 006), patients with mild-to-moderate IPF were treated with pirfenidone or placebo. Study 004 and pooled analysis of primary endpoint data from both studies showed that pirfenidone significantly reduced decline in percent-predicted forced vital capacity (FVC) compared with placebo (p<0.005). Evidence of beneficial effects of pirfenidone treatment was also observed with regard to several secondary endpoints. Pirfenidone was generally well tolerated, with the most common side effects being gastrointestinal and photosensitivity. Data from the RECAP extension phase of the CAPACITY studies, where patients were treated with pirfenidone for up to three years, further support the manageable tolerability profile of pirfenidone. The efficacy data, coupled with long-term safety data, provide further evidence of a clinically-meaningful treatment effect with pirfenidone in patients with IPF.     

Domiciliary care for the elderly sick--economy or neglect?

This paper reports an investigation of the costs of domiciliary care for 139 elderly sick patients under the care of the home nursing service. The data suggest that there may be little economic advantage in home care for seriously disabled elderly people. The revenue cost of domiciliary care was equal to or greater than the average associated with residential or hospital custodial care in such patients. Even so, the cost of services received at home did not disclose the real need for domiciliary care, since at present this is obscured by compulsory rationing and the separation of responsibility between health and social services. It is suggested that the supposed economic advantage of domiciliary care will depend increasingly on restricting such services, thus increasing the degree of neglect to some patients.     

Overview of some methodological problems in assessment of PACS

The purpose of technology assessment of picture archiving and communications systems (PACS) is to establish the need for the technology, provide a measure of functionality and to establish the costs and benefits associated with the introduction of the system. Given concerns about the clinical acceptability of PACS, it is unlikely that radiologists will change from existing film based systems until a clear demonstration of costs and benefits has been performed. The major need at present is to quantify the benefits which may flow from the introduction of PACS system in a standard manner which can be accepted by all parties involved.     

Calculation of the Average Cost per Case of Dengue Fever in Mexico Using a Micro-Costing Approach

IntroductionThe increasing burden of dengue fever (DF) in the Americas, and the current epidemic in previously unaffected countries, generate major costs for national healthcare systems. There is a need to quantify the average cost per DF case. In Mexico, few data are available on costs, despite DF being endemic in some areas. Extrapolations from studies in other countries may prove unreliable and are complicated by the two main Mexican healthcare systems (the Secretariat of Health [SS] and the Mexican Social Security Institute [IMSS]). The present study aimed to generate specific average DF cost-per-case data for Mexico using a micro-costing approach.MethodsExpected medical costs associated with an ideal management protocol for DF (denoted ´ideal costs´) were compared with the medical costs of current treatment practice (denoted ´real costs´) in 2012. Real cost data were derived from chart review of DF cases and interviews with patients and key personnel from 64 selected hospitals and ambulatory care units in 16 states for IMSS and SS. In both institutions, ideal and real costs were estimated using the program, actions, activities, tasks, inputs (PAATI) approach, a micro-costing technique developed by us.ResultsClinical pathways were obtained for 1,168 patients following review of 1,293 charts. Ideal and real costs for SS patients were US$165.72 and US$32.60, respectively, in the outpatient setting, and US$587.77 and US$490.93, respectively, in the hospital setting. For IMSS patients, ideal and real costs were US$337.50 and US$92.03, respectively, in the outpatient setting, and US$2,042.54 and US$1,644.69 in the hospital setting.ConclusionsThe markedly higher ideal versus real costs may indicate deficiencies in the actual care of patients with DF. It may be necessary to derive better estimates with micro-costing techniques and compare the ideal protocol with current practice when calculating these costs, as patients do not always receive optimal care.     

Cost of urology: financial audit in a clinical department.

OBJECTIVES--To cost a clinical unit over one month in 1991, to cost treatment of individual patients from audit data, and to compare this costing method with the hospital charging system. DESIGN--A financial breakdown was obtained for one month''s work. Ward stay, operating time, investigations, and outpatient visits were costed and a formula (episode = days on ward+hours of operating+investigations+outpatient visits) was used to cost patient episodes from audit data. SETTING--The adult urology unit in a teaching hospital. MAIN OUTCOME MEASURES--Costs for each part of patients'' treatment. RESULTS--Total cost was 147,796 pounds for 159 admissions, 738 inpatient days, 131 operations in 29 operating lists, and 615 outpatient visits. An uncomplicated transurethral prostatectomy cost 1140 pounds but complications increased this to 1500 pounds in another patient. The costs of diagnostic cystoscopy were 130 pounds in outpatients, 240 pounds in day surgery, and 430 pounds in inpatients. Hospital charges do not reflect the individual costs of treatment, charges being greater than costs for some patients and lower than costs for others. CONCLUSIONS--Clinicians can produce a financial analysis of their work and cost their patients'' treatment. Audit is strongly advocated as a resource planning tool.     

Unit Cost of Medical Services at Different Hospitals in India

Institutional care is a growing component of health care costs in low- and middle-income countries, but local health planners in these countries have inadequate knowledge of the costs of different medical services. In India, greater utilisation of hospital services is driven both by rising incomes and by government insurance programmes that cover the cost of inpatient services; however, there is still a paucity of unit cost information from Indian hospitals. In this study, we estimated operating costs and cost per outpatient visit, cost per inpatient stay, cost per emergency room visit, and cost per surgery for five hospitals of different types across India: a 57-bed charitable hospital, a 200-bed private hospital, a 400-bed government district hospital, a 655-bed private teaching hospital, and a 778-bed government tertiary care hospital for the financial year 2010–11. The major cost component varied among human resources, capital costs, and material costs, by hospital type. The outpatient visit cost ranged from Rs. 94 (district hospital) to Rs. 2,213 (private hospital) (USD 1 = INR 52). The inpatient stay cost was Rs. 345 in the private teaching hospital, Rs. 394 in the district hospital, Rs. 614 in the tertiary care hospital, Rs. 1,959 in the charitable hospital, and Rs. 6,996 in the private hospital. Our study results can help hospital administrators understand their cost structures and run their facilities more efficiently, and we identify areas where improvements in efficiency might significantly lower unit costs. The study also demonstrates that detailed costing of Indian hospital operations is both feasible and essential, given the significant variation in the country’s hospital types. Because of the size and diversity of the country and variations across hospitals, a large-scale study should be undertaken to refine hospital costing for different types of hospitals so that the results can be used for policy purposes, such as revising payment rates under government-sponsored insurance schemes.     

Locomotor energetics in primates: gait mechanics and their relationship to the energetics of vertical and horizontal locomotion

All primates regularly move within three-dimensional arboreal environments and must often climb, but little is known about the energetic costs of this critical activity. Limited previous work on the energetics of incline locomotion suggests that there may be differential selective pressures for large compared to small primates in choosing to exploit a complex arboreal environment. Necessary metabolic and gait data have never been collected to examine this possibility and biomechanical mechanisms that might explain size-based differences in the cost of arboreal movement. Energetics and kinematics were collected for five species of primate during climbing and horizontal locomotion. Subjects moved on a treadmill with a narrow vertical substrate and one with a narrow horizontal substrate at their maximum sustainable speed for 10–20 min while oxygen consumption was monitored. Data during climbing were compared to those during horizontal locomotion and across size. Results show that climbing energetic costs were similar to horizontal costs for small primates (<0.5 kg) but were nearly double for larger species. Spatio-temporal gait characteristics suggest that the relationship between the cost of locomotion and the rate of force production changes between the two locomotor modes. Thus, the main determinants of climbing costs are fundamentally different from those during horizontal locomotion. These new results combining spatiotemporal and energetic data confirm and expand on our previous argument (Hanna et al.: Science 320 (2008) 898) that similar costs of horizontal and vertical locomotion in small primates facilitated the successful occupation of a fine-branch arboreal milieu by the earliest primates.     

Rapid Syphilis Testing Is Cost-Effective Even in Low-Prevalence Settings: The CISNE-PERU Experience

Studies have addressed cost-effectiveness of syphilis testing of pregnant women in high-prevalence settings. This study compares costs of rapid syphilis testing (RST) with laboratory-based rapid plasma reagin (RPR) tests in low-prevalence settings in Peru. The RST was introduced in a tertiary-level maternity hospital and in the Ventanilla Network of primary health centers, where syphilis prevalence is approximately 1%. The costs per woman tested and treated with RST at the hospital were $2.70 and $369 respectively compared with $3.60 and $740 for RPR. For the Ventanilla Network the costs per woman tested and treated with RST were $3.19 and $295 respectively compared with $5.55 and $1454 for RPR. The cost per DALY averted using RST was $46 vs. $109 for RPR. RST showed lower costs compared to the WHO standard costs per DALY ($64). Findings suggest syphilis screening with RST is cost-effective in low-prevalence settings.     

Reducing the incidence of infection after caesarean section: implications of prophylaxis with antibiotics for hospital resources.

OBJECTIVES--To estimate the cost effectiveness of giving prophylactic antibiotics routinely to reduce the incidence of wound infection after caesarean section. DESIGN--Estimation of cost effectiveness was based, firstly, on a retrospective overview of 58 controlled trials and, secondly, on evidence about costs derived from data and observations of practice. SETTING--Trials included in the overview were from obstetric units in several different countries, including the United Kingdom. The costing study was based on data referring to the John Radcliffe Maternity Hospital, Oxford. SUBJECTS--A total of 7777 women were included in the 58 controlled trials comparing the effects of giving routine prophylactic antibiotics at caesarean section with either treatment with a placebo or no treatment. Cost estimates were based on data on 486 women who had caesarean sections between January and September 1987. MAIN OUTCOME MEASURE--Cost effectiveness of prophylaxis with antibiotics. RESULTS--The odds of wound infection are likely to be reduced by between about 50 and 70% by giving antibiotics routinely at caesarean section. Forty one (8.4%) women who had caesarean section were coded by the Oxford obstetric data system as having developed wound infection. The additional average cost of hospital postnatal care for women with wound infection (compared with women who had had caesarean section and no wound infection) was estimated to be 716 pounds; introducing routine prophylaxis with antibiotics would reduce average costs of postnatal care by between 1300 pounds and 3900/100 pounds caesarean sections (at 1988 prices), depending on the cost of the antibiotic used and its effectiveness. CONCLUSIONS--The results suggest that giving antibiotics routinely at caesarean section will not only reduce rates of infection after caesarean section but also reduce costs.     

Bayesian profiling for cost with zeros to decompose total cost into probability of cost and mean nonzero cost

Cost of health care can vary substantially across hospitals, centers, or providers. Data from electronic health records provide information for studying patterns of cost variation and identifying high or low cost centers. Cost data often include zero values when patients receive no care, and joint two-part models have been developed for clustered cost data with zeros. Standard methods for center comparisons, sometimes called profiling, can use these methods to incorporate zero values into total cost. However, zero costs also provide opportunities to further examine sources of cost variation and outliers. For example, a hospital may have high (or low) cost due to frequency of nonzero cost, amount of nonzero cost, or a combination of those. We give methods for decomposing hospital differences in total cost with zeros into components for probability of use (i.e., of nonzero cost) and for cost of use (mean of nonzero cost). The components multiply to total cost and quantify components on the same easily interpreted multiplicative scales. The methods are based on Bayesian hierarchical models and counterfactual arguments, with Markov chain Monte Carlo estimation. We used simulated data to illustrate use, interpretation, and visualization of the methods in diverse situations, and applied the methods to 30,024 patients at 57 US Veterans Administration hospitals to characterize outlier hospitals in one year cost of inpatient care following a cardiac procedure. Twenty eight percent of patients had zero cost. These methods are useful in providing insight into cost variation and outliers for planning future studies or interventions.     

Ecosystem Services and Opportunity Costs Shift Spatial Priorities for Conserving Forest Biodiversity

Inclusion of spatially explicit information on ecosystem services in conservation planning is a fairly new practice. This study analyses how the incorporation of ecosystem services as conservation features can affect conservation of forest biodiversity and how different opportunity cost constraints can change spatial priorities for conservation. We created spatially explicit cost-effective conservation scenarios for 59 forest biodiversity features and five ecosystem services in the county of Telemark (Norway) with the help of the heuristic optimisation planning software, Marxan with Zones. We combined a mix of conservation instruments where forestry is either completely (non-use zone) or partially restricted (partial use zone). Opportunity costs were measured in terms of foregone timber harvest, an important provisioning service in Telemark. Including a number of ecosystem services shifted priority conservation sites compared to a case where only biodiversity was considered, and increased the area of both the partial (+36.2%) and the non-use zone (+3.2%). Furthermore, opportunity costs increased (+6.6%), which suggests that ecosystem services may not be a side-benefit of biodiversity conservation in this area. Opportunity cost levels were systematically changed to analyse their effect on spatial conservation priorities. Conservation of biodiversity and ecosystem services trades off against timber harvest. Currently designated nature reserves and landscape protection areas achieve a very low proportion (9.1%) of the conservation targets we set in our scenario, which illustrates the high importance given to timber production at present. A trade-off curve indicated that large marginal increases in conservation target achievement are possible when the budget for conservation is increased. Forty percent of the maximum hypothetical opportunity costs would yield an average conservation target achievement of 79%.     

Costs associated with gunshot wounds in Canada in 1991.

OBJECTIVE: To estimate the costs (in 1993 dollars) associated with gunshot wounds in Canada in 1991. DESIGN: Cost analysis using separate estimates of gunshot incidence rates and costs per incident for victims who died, those who survived and were admitted to hospital and those who survived and were treated and released from emergency departments. Estimates were based on costs for medical care, mental health care, public services (i.e., police investigation), productivity losses, funeral expenses, and individual and family pain, suffering and lost quality of life. SETTING: Canada. OUTCOME MEASURES: Costs per case, costs by type of incident (e.g., assault, suicide or unintentional shooting) and costs per capita. RESULTS: The total estimated cost associated with gunshot wounds was $6.6 billion. Of this, approximately $63 million was spent on medical and mental health care and $10 million on public services. Productivity losses exceeded $1.5 billion. The remaining cost represented the value attributed to pain, suffering and lost quality of life. Suicides and attempted suicides accounted for the bulk of the costs ($4.7 billion); homicides and assaults were the next most costly ($1.1 billion). The cost per survivor admitted to hospital was approximately $300,000; this amount included just over $29,000 for medical and mental health care. CONCLUSION: Costs associated with gunshot wounds were $235 per capita in Canada in 1991, as compared with $595 in the United States in 1992. The differences in these costs may be due to differences in gun availability in the two countries. This suggests that increased gun control may reduce Canada''s costs, especially those related to suicide.