The ethical allocation of scarce resources in surgery: implants and cost

This paper is a discussion of the factors involved in instituting a bulk purchasing program for surgical supplies. An improved understanding of the surgical procedure of joint arthroplasty must relate to the variability in surgical methods that achieve patient outcomes. An understanding of the outcomes in relation to the expected duration of the success of an implant and the high costs associated with a revision earlier than expected must be factored into the budget and costs of implants. The ethical implications of choosing one implant over another are considered. A more uniform outcome assessment with respect to surgical activities is needed and potential savings related to other operating-room costs must be examined. Optimizing the implant to patient requirements is the goal within the framework of current fiscal constraints.     

The cost of medical education

As the result of another study which identified the indirect costs at a large teaching hospital in which Monash University has established a clinical school, it has been possible to estimate the cost per annum for each medical student. This is the sum of direct university costs ($4,617), Tertiary Education Assistance Scheme ($1,200) and indirect costs ($44)--in aggregate therefore $5,900 (rounded). Thus the cost of the six-year course for each student is approximately $35,500.     

The cost of psychotherapy.

Examines the relationship between psychotherapy funding policies and concepts of mental health. Three levels of mental health (necessity, improvement, and potentiality) are proposed. Necessity represents basic adaptation, the current dominant level illustrated by brief psychotherapy funded through managed mental health care. Improvement is the phase beyond necessity aimed at prevention and heightened quality of life, and potentiality is the ideal. The latter 2 now receive limited funding and emphasis. At question are both economic and social policies that endorse a narrow rather than a broad conception of mental health. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The cost of quality assurance

The relative importance of endothelial derived relaxing factor (EDRF)/nitric oxide (NO) in maintaining kidney function in normal condition and in acute renal failure (ARF) were evaluated in inactin anesthetized rats. ARF was induced by unilateral occlusion of the left renal artery (40 min) followed by reperfusion, with the contralateral kidney serving as normal control. This protocol resulted in marked reductions in renal plasma flow (RPF), glomerular filtration rate (GFR) and increases in fractional sodium excretion (FENa) and urinary protein excretion in the post-ischemic kidney in comparison to the contralateral normal kidney. Administration of the nitric oxide (NO) synthase inhibitor NG--monomethyl-L-arginine (0.25 mg/kg per min, L-NMMA) exacerbated the ischemia-induced changes in renal functions as reflected by further reductions in urine flow (V), GFR, marked sodium wasting and renal edema. Pretreatment of the animals with NO precursor L-arginine (2.5 mg/kg per min, L-Arg) abolished the detrimental effects of L-NMMA in ARF. In contrast, D-Arginine (2.5 mg/kg per min, D-Arg) failed to reverse the detrimental effects of L-NMMA. Infusion of L-Arg alone also resulted in improvements in RPF and GFR in the ischemic kidney. The results of the present study suggest that the function of the ischemic kidney is sustained by EDRF/NO and is thus more sensitive to NO synthase inhibition.     

The cost of atopic eczema

Candida shehatae NCL-3501 utilized glucose and xylose efficiently in batch cultures. The specific rate of ethanol production was higher with mixtures of glucose and xylose (0.64-0.83 g g-1 cells d-1) compared to that with individual sugars (0.38-0.58 g g-1 cells d-1). Although the optimum temperature for growth was 30 degrees C, this strain grew and produced appreciable levels of ethanol at 45 degrees C. A stable ethanol yield (0.40-0.43 g g-1 substrate utilized) was obtained between 10 g L-1 and 80 g L-1 of initial xylose concentration. Conversion efficiency was further improved by immobilization of the cells in calcium alginate beads. Free or immobilized cells of C. shehatae NCL-3501 efficiently utilized sugars present in rice straw hemicellulose hydrolysate, prepared by two different methods, with 48 h. Ethanol yields of 0.45 g g-1 and 0.5 g g-1 from autohydrolysate, and 0.37 g g-1 from acid hydrolysate were produced by free and immobilized cells, respectively.     

The cost of antidepressant overdose

Ninety percent of suicide attempts referred to a general hospital are by self-poisoning. Among women, drug overdose is the commonest means of suicide. In a retrospective naturalistic review of 200 patients who were treated in the Critical Care Unit of a general hospital following medication overdose, 12% were antidepressant overdoses. The mean duration of hospital stay for overdose with tricyclic antidepressants (TCA) was more than double that for overdose with selective serotonin reuptake inhibitors (SSRI) (7 vs 3 days; z = 2.20, p < 0.05). The dollar cost of hospital treatment for patients who overdosed on TCAs was four times greater than that for patients who overdosed on SSRIs ($22,923 vs $5,379; z = 2.30, p < 0.05). The tricyclic compounds clearly have a price advantage over more recently introduced antidepressant agents fluoxetine, sertraline, paroxetine, venlafaxine, and bupropion. The apparent cost advantage of prescribing a less expensive drug may be nullified by the cost associated with adverse consequences.     

What is the marginal cost for marginal risk in cardiac surgery?

BACKGROUND: It has been shown that postoperative length of stay (LOS) correlates highly with mortality risk for cardiac surgical procedures. Similar correlations have been found for charges with LOS and costs with risk. METHODS: Postoperative LOS and risk scores were obtained, tabulated, and compiled into the five original Parsonnet risk groups for 2,589 patients who underwent cardiac operations from 1992 through 1996 at one hospital. The correlation of the group mean LOS with the group mean risk was tested. RESULTS: The correlation coefficient was 0.9827; 96.58% of the variance was removed using risk to predict LOS. A calculation of the difference in cost for difference in risk for cohorts of patients is developed. CONCLUSIONS: The high correlation of mean LOS with mean risk permits calculation of marginal cost for marginal risk based on clinical data. The marginal cost is equal to the difference in variable costs for cohorts.     

The public cost of expanding coverage

The 103d Congress considered several health care reform bills that would encourage voluntary expansions of coverage through insurance market reforms, new tax deductions for premiums, and direct premium subsidies for low-income persons. We found that insurance reforms alone will do little to expand coverage. We also found that most of the proposed tax deductions would go to persons who already have insurance and would have little impact on coverage. Premium subsidies for low-income persons would greatly increase coverage. However, coverage would change little for those who would have to pay all or part of the premium.     

The cost of auditing outpatient records

When patient records are to be auditied in a program designed to assess the quality of medical care rendered, careful consideration must be given to the cost of the system implemented. Structured data collection and a defined treatment plan are advantageous in facilitating the use of nonphysicians for the majority of the audit. A system using checklists to ensure adequate recording of subjective and objective data and a defined treatment plan for a common symptom complex were implemented by physicians and physician's assistants with a patient load averaging more than 1,000 patient contacts per week in a general medical clinic at Duke University Medical Center. Audit was subsequently accomplished at a cost of 96 cents per record. To reduce this cost, more efficient methods of selecting records for audit should be developed.