A cost comparison of balloon angioplasty and stenting versus endarterectomy for the treatment of carotid artery stenosis

PURPOSE: Percutaneous transluminal angioplasty with stenting (PTAS) of the carotid artery has been advocated as an alternative treatment for high-grade stenosis. Rationale for this approach includes less morbidity, shorter recovery, and lower cost when compared with carotid endarterectomy (CEA). METHODS: The clinical results and hospital charges of patients who underwent elective treatment for carotid stenosis were reviewed. During a concurrent 14-month period, 218 patients were admitted 229 times for 234 procedures for the treatment of 239 carotid bifurcation stenoses, 109 by PTAS and 130 by CEA. Hospital charges were reviewed for each hospitalization and were categorized according to radiology, operating room, cardiac catheterization laboratory, and all other hospital charges. RESULTS: The combined incidence of postprocedure strokes and deaths were: PTAS, eight strokes (7.7%) and one death (0.9%); CEA, two strokes (1.5%) and two deaths (1.5%). Total hospital charges per admission for the two groups were $30,140 for PTAS and $21,670 for CEA. The average postprocedure length of stay for PTAS was 2.9 days (median, 2 days) and for CEA was 3.1 days (median, 3 days). Cardiac catheterization laboratory charges for the PTAS group were $12,968, whereas the operating room charges for the CEA group were $4263. When hospitalizations that were extended by complications were excluded, the average total charges for the PTAS group (n = 84) dropped to $24,848 (mean length of stay, 1.9 days) and for the CEA group (n = 111) to $19,247 (mean length of stay, 2.6 days). CONCLUSIONS: After evaluating hospital charges, PTAS for the treatment of carotid stenosis cannot currently be justified on the basis of reduced costs alone. With future cost-containing measures, total hospital charges can be reduced in both groups.     

Cost of comprehensive pharmaceutical services in a 45-bed rural hospital

The financial impact of a comprehensive pharmacy program on patient charges and hospital operating costs in a 45-bed community hospital was studied. Data were collected retrospectively for the fiscal year prior to initiating pharmacy services (FY73), the fiscal year during program development (FY74) and the fiscal year following full operations (FY75). The total cost of pharmacy services increased 75% from FY73 to FY75, with the largest dollar increase being in pharmacy salaries. Large increases among other cost items also were noted. The average total cost for pharmacy services increased from $3.28 per patient day in FY73 to $6.04 in FY75 (84%). Total hospital cost per patient day increased by approximately $35 from FY73 to FY75 (5%). The pharmaceutical services fee per dose of medication administered did not change from FY73 to FY75. Patient charges per day for medications and pharmaceutical services increased $0.55 (9.8%) from FY73 to FY75. There was a 55% reduction in the number of items carried in pharmacy inventory from FY73 to FY74 following the initiation of a formulary and a unit dose drug distribution system.     

Use of outpatient preoperative evaluation to decrease length of stay for vascular surgery

Interventions that decrease perioperative length of stay can result in considerable cost-savings. This study assesses the impact of same-day admission using outpatient preoperative evaluation on the lengths of stay and hospital costs for patients who underwent carotid end-arterectomy (CEA) or lower extremity revascularization (LER). Patient characteristics and length of stay were compared for two 1-yr periods before and after outpatient preoperative evaluation had been implemented. There were no significant differences before and after the initiation of outpatient preoperative evaluation in the CEA and LER groups in mean age and ASA physical status distributions. The average preoperative length of stay decreased significantly from 7.0 to 1.9 days in the CEA group and from 9.0 to 2.8 days in the LER group. This reduction in the length of stay was associated with a cost-savings of $900 per patient and did not have an adverse effect on patient outcome. We conclude that outpatient preoperative evaluation clinics reduce the cost and length of stay in vascular surgery patients. Implications: We found that outpatient preoperative evaluation and same-day admission were associated with a decrease of 4.5 days in the preoperative length of stay for carotid endarterectomy and lower-extremity revascularization. This was not accompanied by increased mortality and led to hospital cost-savings of approximately $900 per patient.     

Changing practice and costs of carotid endarterectomy in Toronto, Canada

BACKGROUND and PURPOSE: During our annual audits of carotid endarterectomy (CEA) in Toronto metropolitan hospitals, we have been aware of major changes in the practice of this operation in recent years. To evaluate the effect of changing practice on costs of carotid endarterectomy, we have therefore compared the effects of changes in length of stay, complication rates, and other variables on cost during the last 3 years for which we have complete data. METHODS: We evaluated 757 consecutive patients, of whom 600 had CEA procedures in 3 teaching hospitals, and 190 procedures in 2 community hospitals in metropolitan Toronto. We estimated costs using a specially designed computer program, Transitional System Incorporated, including surgical complications, in patients admitted between January 1994 and December 1996. RESULTS: There was a significant decrease in length of stay in both groups of hospitals, mainly due to preoperative outpatient evaluation but also due to lower complication rates, which probably reflect an increase in asymptomatic surgery in both hospital groups. Costs fell from approximately $8000 per procedure to $5000 in asymptomatic patients and from approximately $10,000 to $7000 in symptomatic patients (Can $). CONCLUSIONS: Major changes in the management of patients undergoing CEA have resulted in a significant decrease in both length of hospital stay and utilization of postoperative intensive care. At the same time, complication rates have significantly fallen, although our mortality and morbidity figures remain slightly higher than those from published multicenter trials. Future changes in surgical practice in Canada, including noninvasive carotid imaging, should produce even lower costs within the next few years.     

Operative outcome and hospital cost

INTRODUCTION: Because of concern about increasing health care costs, we undertook a study to find patient risk factors associated with increased hospital costs and to evaluate the relationship between increased cost and in-hospital mortality and serious morbidity. METHODS: More than 100 patient variables were screened in 1221 patients undergoing cardiac procedures. Simultaneously, patient hospital costs were computed from the cost-to-charge ratio. Univariate and multivariate statistics were used to explore the relationship between hospital cost and patient outcomes, including operative death, in-hospital morbidity, and length of stay. RESULTS: The greatest costs were for 31 patients who did not survive operation ($74,466, 95% confidence interval $27,102 to $198,025), greater than the costs for 120 patients who had serious, nonfatal morbidity ($60,335, 95% confidence interval $28,381 to $130,897, p = 0.02) and those for 1070 patients who survived operation without complication ($31,459, 95% confidence interval $21,944 to $49,849, p = 0.001). Breakdown of the components of hospital costs in fatalities and in cases with nonfatal complications revealed that the greatest contributions were in anesthesia and operating room costs. Significant (by stepwise linear regression analysis) independent risks for increased hospital cost were as follows (in order of decreasing importance): (1) preoperative congestive heart failure, (2) serum creatinine level greater than 2.5 mg/dl, (3) New York state predicted mortality risk, (4), type of operation (coronary artery bypass grafting, valve, valve plus coronary artery bypass grafting, or other), (5) preoperative hematocrit, (6) need for reoperative procedure, (7) operative priority, and (8) sex. These risks were different than those for in-hospitality death or increased length of stay. Hospital cost correlated with length of stay (r = 0.63, p < 0.001), but there were many outliers at the high end of the hospital cost spectrum. CONCLUSIONS: We conclude that operative death is the most costly outcome; length of stay is an unreliable indicator of hospital cost, especially at the high end of the cost spectrum; risks of increased hospital cost are different than those for perioperative mortality or increased length of stay; and ventricular dysfunction in elderly patients undergoing urgent operations for other than coronary disease is associated with increased cost. Certain patient factors, such as preoperative anemia and congestive heart failure, are amenable to preoperative intervention to reduce costs, and a high-risk patient profile can serve as a target for cost-reduction strategies.     

Effect of the Asymptomatic Carotid Atherosclerosis Study on carotid endarterectomy in Florida

BACKGROUND AND PURPOSE: The value of carotid endarterectomy (CEA) has been defined by several recent multicenter trials. The clinical effect of these trials remains undetermined since the Asymptomatic Carotid Atherosclerosis Study (ACAS) Clinical Advisory (dated September 28, 1994). METHODS: Patients undergoing CEA (ICD-9-CM 38.12) in nonfederal Florida hospitals were identified from the discharge database. Data were analyzed by federal fiscal year (FY, October 1 through September 30), comparing the years following the Advisory (FY95-FY96) to the preceding 3 years (FY92-FY94). RESULTS: There was a 68.3% increase in the number of CEAs during FY95-FY96 (mean FY92-FY94, 7,343; mean FY95-FY96, 12,356). This exceeded increases in total hospital discharges (4.5%), surgical discharges (2.2%), and the state's population (4.7%). The increase in CEAs spanned all patient demographic groups (gender, race, and age), although the magnitude was not consistent (range, 57.8% increase for 55 to 64 age group; 92.9% increase for > 84 age group). Concomitantly, there was a significant decrease in mortality (1.2% versus 0.8%), cardiac complication rate (ICD-9-CM 997.1, 4.1% versus 3.0%) and percentage of patients discharged > 7 days postoperatively (8.9% versus 4.9%). Mean length of stay declined 28% (5.8 versus 4.1 days), and mean adjusted charges declined 7% ($19,456 versus $18,055). Although the average case was less costly, the increased volume resulted in an estimated $56 million increase in annual hospital payments. CONCLUSIONS: The dramatic increase in the number of CEAs performed in the state of Florida after release of the ACAS Clinical Advisory suggests a causal relationship and mandates further cost-effectiveness analyses.     

The effect on costs of the use of half-dose aprotinin for first-time reoperative coronary artery bypass patients

Half-dose aprotinin previously has been shown to reduce bleeding and the need for blood transfusions, but the results of cost-reduction studies have been variable. The purpose of the present retrospective study was to compare, from the perspective of the acute care hospital as health care provider, the costs associated with first-time reoperative coronary artery bypass graft (CABG) surgery in patients who received half-dose aprotinin with the costs in those who did not. Medical records from 46 historical controls (first-time reoperative CABG patients receiving no aprotinin) and 51 half-dose aprotinin-treated patients were reviewed. A total of 36 variables were abstracted from the medical records for analysis. It was found that more aprotinin-treated patients did not require transfusion compared with nontreated patients (47% vs 26%). Twenty-one percent fewer aprotinin-treated patients received red blood cell transfusions, 21% fewer received plateletpheresis packs, and 19% fewer received fresh frozen plasma. Cost savings per patient receiving half-dose aprotinin compared with no aprotinin were approximately $878 in blood products and $1088 in total length of stay (including critical care), for total savings of $1966. When the cost of aprotinin ($450) was subtracted, the approximate net mean savings per patient were $1516. This did not include additional cost savings with aprotinin resulting from a median 19.5-minute shorter pump time. The authors conclude that the use of half-dose aprotinin results in reductions in surgical and associated hospitalization costs because of decreases in the length of hospital stay, including length of stay in critical care, and in the use of blood products.     

Opportunities for control of hospital cost for total knee arthroplasty

The hospital financial records of 120 consecutive patients who underwent unilateral knee replacement surgery at one hospital during 1995 were reviewed to determine opportunities for control of hospital cost for total knee arthroplasty. The average hospital length of stay for these patients was 4.27 days (range, 3-10 days). The average hospital cost was $10,231. All 120 patients were classified under Diagnosis Related Group 209, principle procedure 81.54 primary total knee arthroplasty. Medicare paid for 70% of the patients. All payers were profitable except Medicaid and one managed care organization. When hospital cost for total knee arthroplasty was allocated to hospital service centers, 78% of the cost was attributed to the operating room, nursing units, recovery room, and pharmacy. When hospital cost for total knee arthroplasty was allocated to hospital days, 80% of the hospital cost occurred during the first 48 hours of hospitalization. Hospital reimbursement for total knee arthroplasty is primarily a prospective case price payment system. After initial cost containment efforts reduce the hospital length of stay for total knee arthroplasty to 4 to 6 days, additional control of hospital cost should focus on these areas of opportunity.     

Prevalence of asymptomatic carotid stenosis in patients undergoing infrainguinal bypass surgery

BACKGROUND: The prevalence of asymptomatic carotid stenosis in patients with lower-extremity ischemia is unknown. This report represents the largest carotid screening program to date of patients undergoing leg bypass. DESIGN: Patients undergoing infrainguinal bypass from 1987 through 1993 on the vascular surgery service at Oregon Health Sciences University, Portland, underwent routine carotid duplex examinations to detect the presence of asymptomatic carotid stenosis. PATIENTS: During the study period, 352 patients underwent infrainguinal revascularization for ischemia, of whom 225 (64%) had no prior carotid surgery, carotid arteriography, or cerebrovascular symptoms. There were 117 men and 108 women, with a mean age of 67 years. The indication for surgery was limb salvage in 67% and claudication in 33% of patients. RESULTS: Sixty-four patients (28.4%) who required lower-extremity revascularization had hemodynamically significant asymptomatic carotid artery stenosis or occlusion; 12.4% had stenosis of 60% or greater, the qualifying level for randomization in the Asymptomatic Carotid Atherosclerosis Study. Based on these findings, eight patients with carotid stenosis of 80% or greater underwent elective carotid endarterectomy. There were no postoperative neurologic events in the 225 leg bypass patients. By multivariate logistic regression analysis, the presence of carotid bruit (P < .001) and the presence of rest pain (P = .006) were associated with carotid stenosis of 50% or greater. Limiting screening to patients with carotid bruit, limb salvage indications for surgery, and/or advanced age excluded significant numbers of patients with stenosis; thus, these were not effective screening strategies. CONCLUSION: Screening carotid duplex scanning is indicated in patients who require lower-extremity revascularization.     

Pronounced differences between the native K+ channels and KAT1 and KST1 alpha-subunit homomers of guard cells

BACKGROUND: Stroke occurs concurrently with myocardial infarction (MI) in approximately 30 000 US patients each year. This number is expected to rise with the increasing use of thrombolytic therapy for MI. However, no data exist for the economic effect of stroke in the setting of acute MI (AMI). The purpose of this prospective study was to assess the effect of stroke on medical resource use and costs in AMI patients in the United States. METHODS AND RESULTS: Medical resource use and cost data were prospectively collected for 2566 randomly selected US GUSTO I patients (from 23 105 patients) and for the 321 US GUSTO I patients who developed non-bypass surgery-related stroke during the baseline hospitalization. Follow-up was for 1 year. All costs are expressed in 1993 US dollars. During the baseline hospitalization, stroke was associated with a reduction in cardiac procedure rates and an increase in length of stay, despite a hospital mortality rate of 37%. Together with stroke-related procedural costs of $2220 per patient, the baseline medical costs increased by 44% ($29 242 versus $20 301, P<0.0001). Follow-up medical costs were substantially higher for stroke survivors ($22 400 versus $5282, P<0.0001), dominated by the cost of institutional care. The main determinant for institutional care was discharge disability status. The cumulative 1-year medical costs for stroke patients were $15 092 higher than for no-stroke patients. Hemorrhagic stroke patients had a much higher hospital mortality rate than non-hemorrhagic stroke patients (53% versus 15%, P<0.001), which was associated with approximately $7200 lower mean baseline hospitalization cost. At discharge, hemorrhagic stroke patients were more likely to be disabled (68% versus 46%, P=0.002). CONCLUSIONS: In this first large prospective economic study of stroke in AMI patients, we found that strokes were associated with a 60% ($15 092) increase in cumulative 1-year medical costs. Baseline hospitalization costs were 44% higher because of longer mean lengths of stay. Stroke type was a key determinant of baseline cost. Follow-up costs were more than quadrupled for stroke survivors because of the need for institutional care. Disability level was the main determinant of institutional care and thus of follow-up costs.     

Pharmacist influence on economic and morbidity outcomes in a tertiary care teaching hospital

The influence of pharmacist participation on economic and morbidity outcomes at a tertiary care teaching hospital was studied. Patients admitted to internal medicine wards during a nine-month period were assigned to either a treatment team or a control team. Each team consisted of an attending physician, senior and junior medical residents, and medical students; the treatment team included a pharmacist who reviewed all patient charts, made rounds with the team, and recommended modifications of drug therapy. Pharmacy interaction with the control team was limited to contacting physicians about potentially dangerous orders, answering questions from the medical team, and handling orders for items not on the formulary or otherwise unavailable. After discharge, data from patient records were analyzed for pharmacy costs and total hospital costs and length of stay (as markers of the pharmacist's effect on economics and morbidity, respectively). Analysis of baseline characteristics showed that the two groups of patients were statistically comparable. Treatment team patients who were included in the data analysis (414) had significantly shorter stays (by a mean of 1.3 days) and lower pharmacy and total hospital costs (by a mean of $301 and $1654, respectively) than those included in the control team analysis (453). The direct participation of a pharmacist on a patient care team significantly decreased pharmacy and hospital costs, as well as length of stay, compared with minimal participation of a pharmacist.     

Open compared with laparoscopic approach to Burch colposuspension: a cost analysis

OBJECTIVE: To compare postoperative course and hospital charges of an open versus laparoscopic approach to Burch colposuspension for the treatment of genuine stress urinary incontinence. METHODS: A retrospective chart review was performed to identify all patients undergoing open or laparoscopic Burch colposuspension by the same surgeon over a 2-year period. Patients undergoing additional surgical procedures at the time of colposuspension were excluded from the study. Twenty-one patients underwent open Burch colposuspension and 17 patients underwent laparoscopic colposuspension. Demographic data including age, parity, height, and weight were collected for each group. Both groups also were compared with regard to operative time, operating room charges, estimated blood loss, intraoperative complications, change in postoperative hematocrit, time required to resume normal voiding, length of hospital stay, and total hospital charges. RESULTS: The laparoscopic colposuspension group had significantly longer operative times (110 versus 66 minutes, P < .01) and increased operating room charges ($3479 versus $2138, P < .001). There was no statistical difference in estimated blood loss or change in postoperative hematocrit between the two groups. No major intraoperative complications occurred in either group. Mean length of hospital stay was 1.3 days for the laparoscopic group and 2.1 days for the open group (P < .005). However, total hospital charges for the laparoscopic group were significantly higher ($4960 versus $4079, P < .01). CONCLUSION: Laparoscopic colposuspension has been described as a minimally invasive, cost-effective technique for the surgical correction of stress urinary incontinence. Although the laparoscopic approach was found to be associated with a reduction in length of hospital stay, it had significantly higher total hospital charges than the traditional open approach because of expenses associated with increased operative time and use of laparoscopic equipment.     

Cost analysis for thoracoscopy: thoracoscopic wedge resection

Video-assisted thoracic surgery (VATS) procedures are now being performed with increasing frequency. The instrumentation and video equipment continue to evolve and much of this new technology is expensive. We reviewed our experience with VATS in our most recent 150 cases for the purpose of cost analysis. The costs incurred in patients undergoing VATS wedge resection for nodules (n = 45) were compared with those in similar patients having wedge resection using open techniques (n = 31). We found that patients who undergo open resections were more likely to spend time in the intensive care unit after surgery. The anesthesia costs were similar in the two groups. Disposable instrument costs were $623 higher for VATS resection; however, the operative time was shorter (101.4 minutes for VATS versus 122.5 minutes for the open procedure), making the total operating room costs comparable. The length of hospital stay was shorter after VATS resection (4.4 days for VATS versus 6.5 days for the open procedure), resulting in lower total hospital charges in the VATS group; however, this difference was not statistically significant. The cost of a VATS wedge resection for removing peripheral nodules is competitive with that of open techniques. Additional benefits, such as reduced pain, shorter operating times, and decreased hospital stays, make thoracoscopy a valuable diagnostic tool. The length of hospital stay, operating room time, disposable instrument costs, complications, and patient acuity all have an impact on the total costs and vary for different procedures. The operative time has shortened and the use of disposable instrumentation has lessened as our experience with thoracoscopy has increased.(ABSTRACT TRUNCATED AT 250 WORDS)     

A surgical approach to coexistent coronary and carotid artery disease

OBJECTIVE: To assess the early results of combined coronary artery bypass graft surgery and carotid endarterectomy. DESIGN: Retrospective and ongoing analysis of patients who underwent combined coronary artery bypass graft surgery and carotid endarterectomy. SETTING: Cardiothoracic unit in a London teaching hospital. PATIENTS: From June 1987 to March 1995, 64 patients were identified. They were patients who were scheduled to have coronary artery bypass graft surgery or required urgent coronary revascularisation and who were found to have significant coexistent carotid disease. (Unilateral carotid stenosis > 70%, bilateral carotid stenosis > 50%, or unilateral carotid stenosis > 50% with contralateral occlusion.) INTERVENTIONS: Both procedures were performed during one anaesthesia: the carotid endarterectomy was performed first without cardiopulmonary bypass. After completion of carotid endarterectomy, coronary artery bypass graft surgery was performed. MAIN OUTCOME MEASURES: The incidence of stroke, transient ischaemic attack, and myocardial infarction in the early postoperative period was analysed. RESULTS: Myocardial revascularisation was successful in all 64 patients. There were no perioperative infarcts. In three patients (4.7%) a new neurological deficit developed postoperatively: two recovered fully before hospital discharge. CONCLUSIONS: Combined coronary artery bypass graft surgery and carotid endarterectomy were performed safely and with good results.     

Glucose and lactate kinetics during a short exercise bout in pregnancy

Recent studies have shown that carotid endarterectomy for significant lesions lowers the risk of stroke and also reduces medical costs by averting the high costs of strokes. However, there has been no information on the cost effect of duplex ultrasound examination which has evolved as the prime means of discovering these carotid lesions. This study reviewed the findings and management of 100 consecutive new patients referred for duplex ultrasound management of the carotid arteries and the cost effects resulting. Seventy-three patients with < 70% stenosis were managed non-operatively; the remaining 27 with 33 lesions producing > 70% stenosis were treated by carotid endarterectomy. It was estimated that 6.5 patients would have had a stroke within 18 months if not operated on. While the medical costs of these strokes would have been $958,838, the cost of avoiding them was $300,494; the result was a significant medical costs saving of $658,344.     

Simultaneous coronary artery bypass grafting and abdominal aneurysm repair decreases stay and costs

BACKGROUND: Patients with large (> or = 5.0 cm) abdominal aortic aneurysms (AAA) frequently have marked associated coronary artery disease. We hypothesized that a single operation for coronary artery bypass grafting (CABG)/AAA would provide equivalent, if not improved, patient care while decreasing postoperative length of stay and hospital costs compared with staged procedures. METHODS: Eleven patients to date have undergone a combined procedure at our institution. Ten underwent CABG followed by AAA repair, whereas one patient received an aortic valve replacement before aneurysm repair. We performed a retrospective analysis comparing the postoperative length of stay and hospital costs for this single procedure to a combined cohort of 20 randomly selected patients who either received AAA repair (n = 10) or standard CABG (n = 10) during the same time period. RESULTS: No operative mortality has been reported. There were no episodes of neurologic deficit or cardiac complication after these procedures. The postoperative length of stay was significantly decreased for the CABG/AAA group compared with the combined postoperative length of stay for the AAA plus CABG group (7.44+/-0.88 days versus 14.10+/-2.00; p = 0.012). Total hospital costs were also significantly decreased for the CABG/AAA group compared with total hospital costs for the AAA plus CABG group ($22,941+/-$1,933 versus $34,076+/-$2,534; p = 0.003). CONCLUSIONS: A single operation for coronary revascularization and AAA repair is safe and effective. Simultaneous CABG and AAA repair substantially decreases postoperative length of stay and hospital costs while avoiding possible interim aneurysm rupture and repeat anesthesia.     

Results of peripheral endovascular procedures in the operating room

PURPOSE: This study presents the results of closed (percutaneous) and open endovascular procedures performed exclusively by vascular surgeons in the operating room and compares them with results from combined series from the literature, including primarily closed procedures in radiology or cardiology facilities. METHODS: Retrospective review of 607 consecutive peripheral arterial and venous angioplasties, stents, thrombolytic cases, and inferior vena caval filters in 446 patients was analyzed for immediate success rate, complication rate, and 1-year life table patency rate. RESULTS: The incidence of initial technical success was: aorta, 89%; iliac artery, 91%; superficial femoral artery, 90%; popliteal artery, 91%; tibial arteries, 79%; arm arteries and veins, 86%; renal arteries, 100%; IVC filters, 98%; and iliofemoral veins, 100%. The 1-year primary patency rates, including technical failures, were 70.3% in 113 femoropopliteal procedures and 83.7% in 194 iliac arteries. Advantages to the use of the operating room included: (1) simultaneous angioplasty during a bypass operation for abnormalities proximal or distal to the graft, (2) correction of lesions first discovered during thrombectomy, and (3) optimum patient monitoring and sedation in the operating room. CONCLUSIONS: Endovascular procedures performed by vascular surgeons in the operating room lead to results comparable with procedures performed in nonsurgical interventional suites, and the use of the operating room has advantages.     

Research without billing data. Econometric estimation of patient-specific costs

OBJECTIVES: This article describes a method for computing the cost of care provided to individual patients in health care systems that do not routinely generate billing data, but gather information on patient utilization and total facility costs. METHODS: Aggregate data on cost and utilization were used to estimate how costs vary with characteristics of patients and facilities of the US Department of Veterans Affairs. A set of cost functions was estimated, taking advantage of the department-level organization of the data. Casemix measures were used to determine the costs of acute hospital and long-term care. RESULTS: Hospitalization for medical conditions cost an average of $5,642 per US Health Care Financing Administration diagnosis-related group weight; surgical hospitalizations cost $11,836. Nursing home care cost $197.33 per day, intermediate care cost $280.66 per day, psychiatric care cost $307.33 per day, and domiciliary care cost $111.84 per day. Outpatient visits cost an average of $90.36. These estimates include the cost of physician services. CONCLUSIONS: The econometric method presented here accounts for variation in resource use caused by casemix that is not reflected in length of stay and for the effects of medical education, research, facility size, and wage rates. Data on non-Veteran's Affairs hospital stays suggest that the method accounts for 40% of the variation in acute hospital care costs and is superior to cost estimates based on length of stay or diagnosis-related group weight alone.     

Relation of direct hospitalization costs with length of stay

OBJECTIVE: Our main objective is to analyse to the relationship between the direct cost of a hospitalary discharge and the length of stay controlling for other care variables. METHODS: Analysis of the direct costs of pharmacy, laboratory, pathology and radiology tests of the 21,883 discharged patients in two Barcelona hospitals during 1993, in relationship to care variables contained in the basic minimum data set for discharged patient (BMDSDP). Using both hospital information systems in which are detailed the complete activity carried out and the assignment of unitary costs by means of different methods adapted to the available information, the direct cost is built up for patient and it is assembled by DRG. With the direct cost information and the care variables of the BMDSDP, a simple linear regression (least squared method) is carried out. RESULTS: The average direct cost is up to 31,533 pesetas. The regression by least squared method explains 70% of the variance (R2) and the variables with higher explanatory power are the length of stay and the relative weight of average DRG direct costs, that acts like variable of adjustment. CONCLUSIONS: The variability of the direct cost is explained principally by the length of stay. In addition, the length of stay is also very important on explaining the internal variability of DRG direct cost.