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.     

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.     

The future burden of cancer in Canada: Long-term cancer incidence projections 2013–2042

BackgroundCancer is the leading cause of death in Canada and the estimated annual spending associated with cancer is approximately $7.5 billion. Projecting the future burden of cancer in Canada is essential for health planning and evaluation. We aimed to estimate the future incidence of cancer in Canada to 2042.MethodsAge-sex-region-specific cancer incidence data were obtained for the years 1983-2012 and cancer incidence was projected from 2013 to 2042 for the top five cancer sites. The modelling algorithm combined a mixture of cancer projection methods to select the best-fitted model. When the chosen model produced by the modelling algorithm resulted in estimates that were not consistent with expert opinion, an alternate model was selected that took into consideration historical changes in policy, screening and lifestyle behaviours. Incidence projections were made for Canada and its provinces.ResultsLung cancer incidence is estimated to rise to 14,866 cases in men and 19,162 in women in 2042. Colorectal cancer incidence is estimated to rise to 28,146 in men and 21,102 in women. Cases of bladder cancer are projected to rise to 10,708 and 3,364 in men and women, respectively. Breast cancer incidence is predicted to rise to 40,712 and prostate cancer incidence is projected to rise to 92,949.ConclusionThese cancer incidence projections up to 2042 can be used for planning cancer control strategies and prevention programs. Given the ongoing changes in the prevalence of risk factors and in cancer prevention policies, these estimates should be interpreted with caution.     

Comparison of the deep inferior epigastric perforator flap and free transverse rectus abdominis myocutaneous flap in postmastectomy reconstruction: a cost-effectiveness analysis

This study compared the deep inferior epigastric perforator (DIEP) flap and the free transverse rectus abdominis myocutaneous (TRAM) flap in postmastectomy reconstruction using a cost-effectiveness analysis. A decision analytic model was used. Medical costs associated with the two techniques were estimated from the Ontario Ministry of Health Schedule of Benefits for 2002. Hospital costs were obtained from St. Joseph's Healthcare, a university teaching hospital in Hamilton, Ontario, Canada. The utilities of clinically important health states related to breast reconstruction were obtained from 32 "experts" across Canada and converted into quality-adjusted life years. The probabilities of these various clinically important health states being associated with the DIEP and free TRAM flaps were obtained after a thorough review of the literature. The DIEP flap was more costly than the free TRAM flap ($7026.47 versus $6508.29), but it provided more quality-adjusted life years than the free TRAM flap (28.88 years versus 28.53 years). The baseline incremental cost-utility ratio was $1464.30 per quality-adjusted life year, favoring adoption of the DIEP flap. Sensitivity analyses were performed by assuming that the probabilities of occurrence of hernia, abdominal bulging, total flap loss, operating room time, and hospital stay were identical with the DIEP and free TRAM techniques. By assuming that the probability of postoperative hernia for the DIEP flap increased from 0.008 to 0.054 (same as for TRAM flap), the incremental cost-utility ratio changed to $1435.00 per quality-adjusted life year. A sensitivity analysis was performed for the complication of hernia because the DIEP flap allegedly diminishes this complication. Increasing the probability of abdominal bulge from 0.041 to 0.103 for the DIEP flap changed the ratio to $2731.78 per quality-adjusted life year. When the probability of total flap failure was increased from 0.014 to 0.016, the ratio changed to $1384.01 per quality-adjusted life year. When the time in the operating room was assumed to be the same for both flaps, the ratio changed to $4026.57 per quality-adjusted life year. If the hospital stay was assumed to be the same for both flaps, the ratio changed to $1944.30 per quality-adjusted life year. On the basis of the baseline calculation and sensitivity analyses, the DIEP flap remained a cost-effective procedure. Thus, adoption of this new technique for postmastectomy reconstruction is warranted in the Canadian health care system.     

Echinococcosis: An Economic Evaluation of a Veterinary Public Health Intervention in Rural Canada

Echinococcosis is a rare but endemic condition in people in Canada, caused by a zoonotic cestode for which the source of human infection is ingestion of parasite eggs shed by canids. The objectives of this study were to identify risk factors associated with infection and to measure the cost-utility of introducing an echinococcosis prevention program in a rural area. We analyzed human case reports submitted to the Canadian Institutes for Health Information between 2002 and 2011. Over this 10 year period, there were 48 cases associated with E. granulosus/E. canadensis, 16 with E. multilocularis, and 251 cases of echinococcosis for which species was not identified (total 315 cases). Nationally, annual incidence of echinococcosis was 0.14 cases per 100 000 people, which is likely an underestimate due to under-diagnosis and under-reporting. Risk factors for echinococcosis included female gender, age (>65 years), and residing in one of the northern territories (Nunavut, Yukon, or Northwest Territories). The average cost of treating a case of cystic echinococcosis in Canada was $8,842 CAD. Cost-utility analysis revealed that dosing dogs with praziquantel (a cestocide) at six week intervals to control cystic echinococcosis is not currently cost-effective at a threshold of $20,000-100,000 per Quality Adjusted Life Year (QALY) gained, even in a health region with the highest incidence rate in Canada ($666,978 -755,051 per QALY gained). However, threshold analysis demonstrated that the program may become cost-saving at an echinococcosis incidence of 13-85 cases per 100,000 people and therefore, even one additional CE case in a community of 9000 people could result in the monetary benefits of the program outweighing costs.     

The reuse of hemodialyzers: an assessment of safety and potential savings.

OBJECTIVE: To evaluate the safety and potential cost savings of hemodialyzer reuse. DATA SOURCES: All English and French articles published from 1960 to 1991 related to hemodialyzer reuse (retrieved through an Index Medicus and MEDLINE search [corrected]), the indexes of eight North American journals from 1960 onward, conference proceedings, association guidelines, and US and Canadian laws and regulations. RESULTS: For health care personnel the reuse of hemodialyzers did not entail any increased risk of infection or exposure to toxic substances if proper control measures were taken. For patients there was no evidence to suggest any excess risk of complications or death as long as precise and appropriate procedures are observed. The "first-use syndrome" can be prevented and should no longer be considered as a reason to favour reuse. A cost-minimization analysis indicated that five uses might save up to $3629 per patient yearly. Thus, the adoption of a policy of reuse in Canada for all eligible patients undergoing long-term hemodialysis could result in direct savings of about $5.8 to $8.9 million per year. CONCLUSION: The health risks associated with hemodialyzer reuse can be reduced to acceptable levels through the rigorous observance of proper quality-assurance and quality-control measures and the use of automated reconditioning equipment. Such a policy could achieve modest savings for the health care system. A decision to reuse should be formally adopted by the institution and accompanied by a precise definition of the standards of quality assurance and control.     

A pressure-operated drop net for capturing Greater Sage-Grouse

ABSTRACT.   A pressure-operated drop net was developed to capture endangered Greater Sage-Grouse ( Centrocercus urophasianus ) in Alberta, Canada. A drop net was developed because other capture methods, such as night lighting and walk-in traps, have largely been unsuccessful in Alberta, and rocket netting was too dangerous to be used with an endangered population. Nets (one black and one gray) were used to capture 13 birds (12 males and 1 female) in six attempts. Nets dropped quickly (about 1 s) and quietly and captured all birds under the net. More birds ( N = 12) were captured using a gray net than a black net, probably because it was less conspicuous. The presence of a drop net on the lek did not alter the behavior of the birds at the lek or influence lek attendance. The cost of a net, including all supplies, tools, and equipment needed, was $790 US ($900 CAN). This pressure-operated drop net system should prove effective for capturing other lekking species and other ground-dwelling birds that will respond to baiting.     

Life Course Impact of School-Based Promotion of Healthy Eating and Active Living to Prevent Childhood Obesity

Background

The Alberta Project Promoting active Living and healthy Eating in Schools (APPLE Schools) is a comprehensive school health program that is proven feasible and effective in preventing obesity among school aged children. To support decision making on expanding this program, evidence on its long-term health and economic impacts is particularly critical. In the present study we estimate the life course impact of the APPLE Schools programs in terms of future body weights and avoided health care costs.

Method

We modeled growth rates of body mass index (BMI) using longitudinal data from the National Population Health Survey collected between 1996–2008. These growth rate characteristics were used to project BMI trajectories for students that attended APPLE Schools and for students who attended control schools (141 randomly selected schools) in the Canadian province of Alberta.

Results

Throughout the life course, the prevalence of overweight (including obesity) was 1.2% to 2.8% (1.7 on average) less among students attending APPLE Schools relative to their peers attending control schools. The life course prevalence of obesity was 0.4% to 1.4% (0.8% on average) less among APPLE Schools students. If the APPLE Schools program were to be scaled up, the potential cost savings would be $33 to 82 million per year for the province of Alberta, or $150 to 330 million per year for Canada.

Conclusions

These projected health and economic benefits seem to support broader implementation of school-based health promotion programs.     

Newborn circumcision: an economic perspective.

The purpose of this study was to analyse the hypothesis that prophylactic circumcision of male newborns is economically beneficial to the health care system in Canada. The minimal dollar benefits that would justify this conclusion were determined. The cost of the procedure was calculated in three Hamilton, Ont. hospitals and found to average about $38. The health benefits of circumcision are uncertain, but a review of the literature suggested that penile carcinoma is the most serious (and costly) disease potentially prevented by circumcision. Published estimates of the incidence rates, age at onset and costs incurred as a result of this disease were used in calculations of the per-case cost of prevention: $13.6 million. The authors conclude that the monetary benefits of circumcising newborns will not exceed this cost. It is proposed that the procedure be regarded as cosmetic surgery and be paid for by parents who wish the procedure carried out rather than by taxpayer-funded health insurance plans.     

Cost-effectiveness of simvastatin in the secondary prevention of coronary artery disease in Canada

OBJECTIVE: To determine the cost-effectiveness of simvastatin in the secondary prevention of coronary artery disease (CAD) in Canada. DESIGN: Cost-effectiveness model based on results from the Scandinavian Simvastatin Survival Study (45 study) and cost and resource utilization data from Canadian sources to simulate the economic impact of long-term simvastatin treatment (15 years). PATIENTS: Subjects with mean age of 59.4 years at recruitment into 4S study. OUTCOME MEASURES: Overall death rate and incidence of 5 major nonfatal events associated with CAD: myocardial infarction, coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, stroke and transient ischemic attack. Direct medical costs associated with CAD were assessed from the perspective of provincial ministries of health (i.e., costs borne by the ministries); the impact of simvastatin treatment on these costs was determined. RESULTS: The 4S study, with a median follow-up of 5.4 years, showed significantly reduced mortality and morbidity among the patients given simvastatin compared with the control subjects. Three premises were designed to predict the consequences of simvastatin treatment of CAD in Canada over 15 years, 10 years beyond the end of the 4S study. The 2 most probable premises, which assumed that the clinical benefits of simvastatin would be cumulative for either the first 10 years or the full 15 years of the model, had incremental costs per year of life gained (cost-effectiveness ratio) of $9867 and $6108 respectively. CONCLUSION: This model suggests that simvastatin provides a cost-effective approach to the long-term prevention of secondary CAD in Canada.     

Costs Analysis of a Population Level Rabies Control Programme in Tamil Nadu,India

The study aimed to determine costs to the state government of implementing different interventions for controlling rabies among the entire human and animal populations of Tamil Nadu. This built upon an earlier assessment of Tamil Nadu''s efforts to control rabies. Anti-rabies vaccines were made available at all health facilities. Costs were estimated for five different combinations of animal and human interventions using an activity-based costing approach from the provider perspective. Disease and population data were sourced from the state surveillance data, human census and livestock census. Program costs were extrapolated from official documents. All capital costs were depreciated to estimate annualized costs. All costs were inflated to 2012 Rupees. Sensitivity analysis was conducted across all major cost centres to assess their relative impact on program costs. It was found that the annual costs of providing Anti-rabies vaccine alone and in combination with Immunoglobulins was $0.7 million (Rs 36 million) and $2.2 million (Rs 119 million), respectively. For animal sector interventions, the annualised costs of rolling out surgical sterilisation-immunization, injectable immunization and oral immunizations were estimated to be $ 44 million (Rs 2,350 million), $23 million (Rs 1,230 million) and $ 11 million (Rs 590 million), respectively. Dog bite incidence, health systems coverage and cost of rabies biologicals were found to be important drivers of costs for human interventions. For the animal sector interventions, the size of dog catching team, dog population and vaccine costs were found to be driving the costs. Rabies control in Tamil Nadu seems a costly proposition the way it is currently structured. Policy makers in Tamil Nadu and other similar settings should consider the long-term financial sustainability before embarking upon a state or nation-wide rabies control programme.     

Variation in prices charged to patients for specialty intraocular lenses inserted during universally covered cataract surgery

Background

Patients often pay for specialty intraocular lenses (IOLs) for cataract surgery covered by universal insurance. This practice creates the potential for inequitable pricing where the medical service provider is also the retailer. We measured the variation in prices between cataract surgeons for the same IOL and associated testing.

Methods

We telephoned every cataract surgeon in Ontario, Canada, and asked their price for the most common type of specialty IOL as a prospective patient. We measured the total prices quoted and variation between providers.

Results

We contacted 404 ophthalmologists. There were 256 that performed cataract surgery but 127 offered the most commonly employed specialty IOL and would provide a price to patients over the telephone. We obtained prices from all 127 ophthalmologists. Prices for the same lens and associated testing varied substantially between ophthalmologists from $358 to $2790 (median $615, interquartile range $528–$915). There was variation in all components of the total out-of-pocket price, including the price for the IOL itself, charges for uninsured eye measurements, and non-specific supplemental fees.

Conclusion

Although cataract surgery is covered by public health insurance, some ophthalmologists charge much more than others for the same specialty IOL and associated testing. Greater access to price information and better regulatory control could help ensure patients receive fair value for out-of-pocket health expenses.     

Health Disparities from Economic Burden of Diabetes in Middle-income Countries: Evidence from México

The rapid growth of diabetes in middle-income countries is generating disparities in global health. In this context we conducted a study to quantify the health disparities from the economic burden of diabetes in México. Evaluative research based on a longitudinal design, using cost methodology by instrumentation. For the estimation of epidemiological changes during the 2010–2012 period, several probabilistic models were developed using the Box-Jenkins technique. The financial requirements were obtained from expected case management costs by disease and the application of an econometric adjustment factor to control the effects of inflation. Comparing the economic impact in 2010 versus 2012 (p<0.05), there was a 33% increase in financial requirements. The total amount for diabetes in 2011 (US dollars) was $7.7 billion. It includes $3.4 billion in direct costs and $4.3 in indirect costs. The total direct costs were $.4 billion to the Ministry of Health (SSA), serving the uninsured population; $1.2 to the institutions serving the insured population (Mexican Institute for Social Security–IMSS-, and Institute for Social Security and Services for State Workers-ISSSTE-); $1.8 to users; and $.1 to Private Health Insurance (PHI). If the risk factors and the different health care models remain as they currently are in the analyzed institutions, health disparities in terms of financial implications will have the greatest impact on users’ pockets. In middle-income countries, health disparities generated by the economic burden of diabetes is one of the main reasons for catastrophic health expenditure. Health disparities generated by the economic burden of diabetes suggests the need to design and review the current organization of health systems and the relevance of moving from biomedical models and curative health care to preventive and socio-medical models to meet expected challenges from diseases like diabetes in middle-income countries.     

Cost of primary health care services in the emergency department and the family physician's office.

An attempt has been made to determine the true cost of providing primary health care for nontraumatic conditions in the emergency departments of two hospitals in Ontario and in the offices of family physicians. A total of 1117 patients presenting with 1 of 10 common symptom/sign complexes at the emergency departments or the offices of 15 participating family physicians were studies with regard to number of visits made, type of assessment by the physician, investigations undertaken, management, therapy and outcome of the illness. Costs were calculated from the charges that would be made against the provincial health services insurance plan and from the system of hospital financing in effect in the province. The average true cost per illness episode of this type of care was $14.63 in hospital A, $14.20 in hospital B and $15.90 in the family physician''s office.     

Emergency response to raccoon rabies introduction into Ontario

During 15 July to 4 October, 1999, rabies control programs were implemented with the objective being to contain the first three confirmed cases of raccoon rabies in Canada. The strategy, called point infection control (PIC) involved the use of three tactics: population reduction (PR), trap-vaccinate-release (TVR) and oral rabies vaccination with baits (ORV), to control the spread of raccoon rabies. A total of 1,202 raccoons (Procyon lotor) and 337 skunks (Mephitis mephitis) were captured and euthanized using 24,719 trap-nights in the three PR zones around the location of the three rabies cases, near Brockville, Ontario. That represented an 83% to 91% reduction in the raccoon populations in an approximate 225 km2 area around the three rabies cases. Raccoon density in the PR zones declined from 5.1-7.1/km2 to 0.6-1.1/km2 following control. All tested specimens were negative for rabies by the fluorescent antibody test (FAT). In addition, 1,759 raccoons and 377 skunks were intramuscularly vaccinated against rabies and released using 27,956 trap-nights in an approximate 485 km2 TVR zone implemented outside of the PR zones. A total of 856 cats from both PR and TVR areas were also captured, vaccinated and released. Cost for the three PIC operations was $363,000.00 Cdn or about $500.00 Cdn/km2. To further contain the outbreak, about 81,300 baits containing Raboral V-RG oral rabies vaccine were aerially distributed on 8 and 27 September 1999, to create an 8 to 15 km wide buffer zone (1,200 km2 area) of vaccinated raccoons immediately beyond the PR and TVR zones. This was the first time that V-RG was used in Canada to orally vaccinate free ranging raccoons against rabies. Baiting costs were $241,000.00 Cdn or about $200.00 Cdn/km2 including post baiting assessment costs. As of 31 August, 2000, thirty-five additional cases (38 in total) of raccoon rabies have occurred in the control and vaccination zones. This number is far below the level of rabies prevalence in USA jurisdictions where raccoon rabies was epizootic. In the future, PIC methodologies will continue to be used in Ontario to contain isolated cases of raccoon rabies.     

Cost of Fetal Alcohol Spectrum Disorder Diagnosis in Canada

Background

Fetal Alcohol Spectrum Disorder (FASD) is underdiagnosed in Canada. The diagnosis of FASD is not simple and currently, the recommendation is that a comprehensive, multidisciplinary assessment of the individual be done. The purpose of this study was to estimate the annual cost of FASD diagnosis on Canadian society.

Methods

The diagnostic process breakdown was based on recommendations from the Fetal Alcohol Spectrum Disorder Canadian Guidelines for Diagnosis. The per person cost of diagnosis was calculated based on the number of hours (estimated based on expert opinion) required by each specialist involved in the diagnostic process. The average rate per hour for each respective specialist was estimated based on hourly costs across Canada. Based on the existing clinical capacity of all FASD multidisciplinary clinics in Canada, obtained from the 2005 and 2011 surveys conducted by the Canada Northwest FASD Research Network, the number of FASD cases diagnosed per year in Canada was estimated. The per person cost of FASD diagnosis was then applied to the number of cases diagnosed per year in Canada in order to calculated the overall annual cost.

Results

Using the most conservative approach, it was estimated that an FASD evaluation requires 32 to 47 hours for one individual to be screened, referred, admitted, and diagnosed with an FASD diagnosis, which results in a total cost of $3,110 to $4,570 per person. The total cost of FASD diagnostic services in Canada ranges from $3.6 to $5.2 million (lower estimate), up to $5.0 to $7.3 million (upper estimate) per year.

Discussion

As a result of using the most conservative approach, the cost of FASD diagnostic services presented in the current study is most likely underestimated. The reasons for this likelihood and the limitations of the study are discussed.     

Cost-Effectiveness Analysis of Six Strategies to Treat Recurrent Clostridium difficile Infection

Objective

To assess the cost-effectiveness of six treatment strategies for patients diagnosed with recurrent Clostridium difficile infection (CDI) in Canada: 1. oral metronidazole; 2. oral vancomycin; 3.oral fidaxomicin; 4. fecal transplantation by enema; 5. fecal transplantation by nasogastric tube; and 6. fecal transplantation by colonoscopy.

Perspective

Public insurer for all hospital and physician services.

Setting

Ontario, Canada.

Methods

A decision analytic model was used to model costs and lifetime health effects of each strategy for a typical patient experiencing up to three recurrences, over 18 weeks. Recurrence data and utilities were obtained from published sources. Cost data was obtained from published sources and hospitals in Toronto, Canada. The willingness-to-pay threshold was $50,000/QALY gained.

Results

Fecal transplantation by colonoscopy dominated all other strategies in the base case, as it was less costly and more effective than all alternatives. After accounting for uncertainty in all model parameters, there was an 87% probability that fecal transplantation by colonoscopy was the most beneficial strategy. If colonoscopy was not available, fecal transplantation by enema was cost-effective at $1,708 per QALY gained, compared to metronidazole. In addition, fecal transplantation by enema was the preferred strategy if the probability of recurrence following this strategy was below 8.7%. If fecal transplantation by any means was unavailable, fidaxomicin was cost-effective at an additional cost of $25,968 per QALY gained, compared to metronidazole.

Conclusion

Fecal transplantation by colonoscopy (or enema, if colonoscopy is unavailable) is cost-effective for treating recurrent CDI in Canada. Where fecal transplantation is not available, fidaxomicin is also cost-effective.     

Who Are the High-Cost Users? A Method for Person-Centred Attribution of Health Care Spending

Objective

To develop person-centered episodes of care (PCE) for community-dwelling individuals in the top fifth percentile of Ontario health care expenditures in order to: (1) describe the main clinical groupings for spending; and (2) identify patterns of spending by health sector (e.g. acute care, home care, physician billings) within and across PCE.

Data sources

Data were drawn from population-based administrative databases for all publicly funded health care in Ontario, Canada in 2010/11.

Study design

This study is a retrospective cohort study.

Data collection/extraction methods

A total of 587,982 community-dwelling individuals were identified among those accounting for the top 5% of provincial health care expenditures between April 1, 2010 and March 31, 2011. PCE were defined as starting with an acute care admission and persisting through subsequent care settings and providers until individuals were without health system contact for 30 days. PCE were classified according to the clinical grouping for the initial admission. PCE and non-PCE costs were calculated and compared to provide a comprehensive measurement of total health system costs for the year.

Principal findings

Among this community cohort, 697,059 PCE accounted for nearly 70% ($11,815.3 million (CAD)) of total annual publicly-funded expenditures on high-cost community-dwelling individuals. The most common clinical groupings to start a PCE were Acute Planned Surgical (35.2%), Acute Unplanned Medical (21.0%) and Post-Admission Events (10.8%). Median PCE costs ranged from $3,865 (IQR = $1,712-$10,919) for Acute Planned Surgical to $20,687 ($12,207-$39,579) for Post-Admission Events. Inpatient acute ($8,194.5 million) and inpatient rehabilitation ($434.6 million) health sectors accounted for the largest proportions of allocated PCE spending over the year.

Conclusions

Our study provides a novel methodological approach to categorize high-cost health system users into meaningful person-centered episodes. This approach helps to explain how costs are attributable within individuals across sectors and has applications in episode-based payment formulas and quality monitoring.