Book Summary: Provides the information and tools neccessary for nurses to express themselves more effectively using financial principles and data while interfacing with financial personnel.

Successful treatment of chronic hepatitis C virus (HCV) leads to significant benefits in both hepatic and extrahepatic morbidity and mortality. However, treatment is costly and onerous. The purpose of this study was to evaluate the resource utilization and healthcare costs of chronic HCV patients who are treated versus those who are not treated. Patients eligible for this study were Texas Medicaid patients ≥18 and ≤63 years who had evidence of chronic HCV during the identification period (1/1/07-9/30/11) and continuous enrollment throughout the analysis period. High dimensional propensity scoring techniques were used to match treated vs. untreated patients (1:2 ratio). Unadjusted and adjusted analyses compared the healthcare costs and utilization between patient cohorts at 6 and 18 months. For those treated, adherence was measured by proportion of days covered and persistence was evaluated as a gap in medication (of one fill) as determined by refill records. There were a total of 24,032 patients identified with chronic HCV. After high dimensional propensity scoring, there were no significant differences in key clinical and demographic characteristics between treated (n=939) and untreated (n=1878) cohorts. Over 97% of patients had evidence of end stage liver disease at baseline. Based on adjusted analyses of total costs using a generalized linear regression model, the mean difference in costs between the treated vs. untreated patients was $13,960 (SE $458, p<0.001). At 18 months of follow-up, the adjusted mean all-cause costs were $20,834 higher for treated patients (n=456) compared to those untreated (n=849) (p<0.001); however, mean outpatient costs were $1,894 (SE $274) less in treated vs. untreated patients. For those treated, the average HCV medication PDC was 71%, and by the end of 24 weeks, only 42.3% of patients remained on HCV therapy. This study did not show short-term cost offsets, but the sub-analysis following patients for 18 months showed trends in downstream cost offsets. Most patients had advanced liver disease, reducing the chances of successful treatment and averting liver disease sequelae. Earlier identification and treatment could bend the cost curve before these patients reached the more advanced stages seen in this costly cohort. / text

A blood transfusion is one of the most common hospital procedures, yet there is a lack of reliable information on the costs of administering blood. This thesis aims to fill this information gap, and considers the impact on total costs of alternative transfusion management strategies in the National Health Service (NHS) in the United Kingdom. A high user of blood transfusion, cardiac surgery, acts as a clinical exemplar. Comprehensive estimates of the costs of administering blood are first produced. The costs of administering blood add substantially to the costs of the blood products themselves, costs for red blood cells are 40% higher when the costs of administration are added to red blood cell costs. These cost estimates were used to more accurately cost blood products transfused (compared to the costs of blood products only) in two economic evaluations assessing firstly, the cost-effectiveness of a restrictive versus a liberal red blood cell transfusion threshold after cardiac surgery, and secondly, the cost-effectiveness of introducing bedside tests of haemostatic function in cardiac surgery. Both economic evaluations showed little difference in costs or outcomes between the groups and uncertainty around the cost-effectiveness results. While a restrictive threshold reduces costs associated with transfusion compared to a liberal threshold, there is no evidence based on detailed and comprehensive costings, to suggest that a restrictive threshold saves the NHS money overall. Reliable resource use data are vital for economic evaluations, and a subgroup of patients in both economic evaluations enabled resource use data collected from alternative sources to be compared. There was strong agreement between primary (clinical trial) data and routine datasets for data available from both sources, however, primary data captured post-operative complications more comprehensively than routine datasets. This thesis provides hospital managers and health economists with accurate information on the costs of administering blood for budget impact assessments and economic evaluations.

Objective The goal of this dissertation was to identify evidence regarding potential means to reduce healthcare spending on youth injury while protecting and promoting the health of our youth. The first analysis estimated and analyzed both the financial costs and time lost from sports injuries among inpatient and ED youth patients to aid in identifying key populations, raising awareness to policy makers, and emphasizing the need of prevention programs for sports injury. The second analysis analyzed the effect of volume and trauma center (TC) ownership type on trauma alert response charges, which are billed to injured patients for a trauma team activation. The objectives of the third analysis were to evaluate associations of mechanism of injury in youth who have been misclassified as trauma alerts, and to analyze the effect of misclassified youth on healthcare costs. Methods The first study was a retrospective analysis of sports injuries identified in Florida’s Agency for Healthcare Administration (AHCA) 2010-2014 all-inclusive inpatient and ED datasets. The study population included all hospital patients, aged 5 to 18 years, with a recorded injury from sport. Fixed effects linear and negative binomial regression were used. In the second analysis, every inpatient who visited a TC in Florida and was billed a trauma response charge from 2012 to 2014 was included for a total of 45,993 observations. Multiple linear regression, controlling for patient and hospital factors, was used to find associations between volume and trauma response charges and hospital ownership type and charges. Severity elasticity of trauma response charges was calculated by ownership type. AHCA's 2012-2014 inpatient and financial data were used in the third analysis. The study population included patients, aged 5 to 18 years with no surgery, an ICISS score ≥ .90, a hospital stay less than 24 hours, discharged to home, with recorded mechanism and defined injury. Misclassified patients were those designated as a trauma alert in the field. Logistic and multivariable linear regression were used. Results Over the five year period, sports injuries in Florida youth cost $24,555,547 for inpatient care and $87,083,482 for ED care. Youth spent 10,397 days in the hospital and a total of 536,893 hours in the ED. Youth averaged $6,039 and 2.5 days for an inpatient visit and $439 and 2.3 hours for an ED visit in costs from sports injuries. Volume had a significant, inverse relationship with trauma response charges. For-profit TCs had statistically higher trauma response charges and government owned TCs had statistically lower trauma response charges than not-for-profits. For-profit TCs had an inelastic response to severity for trauma response charges. The mechanisms of injury of firearm, motor vehicle traffic, and transport were significantly, positively associated with misclassification as a trauma alert. Inpatient costs were associated with an 87% increase for patients who were misclassified as a trauma alert. Conclusion Older athletes and males consistently have high healthcare costs from sports. Baseball, basketball, bike riding, football, rollerskating/skateboarding, and soccer are sports with high costs for both ED patients and inpatients and would benefit from prevention programs. Injuries from noncontact sport participants are few but can have high costs. These athletes could benefit from prevention programs as well. Trauma response charges are higher when patient volume is reduced and at for-profit TCs. If injured youth had visited government or not-for-profit TCs, an estimated annual $6.5 to $8.3 million reduction in trauma response charges would have occurred. Reducing these charges are a potential way to reduce excessive healthcare spending without decreasing quality. Mechanism of injury is not a reliable predictor of trauma and was associated with misclassification of pediatric patients with minor injuries as trauma alerts. Costs were higher for mildly injured patients who were trauma alerted, in part due to the trauma alert charge.

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Introdução: Os benefícios do emprego do selante de fibrina no reforço de anastomoses pancreatico-jejunais, após ressecção duodenopancreática, visando a redução da incidência de fístula pancreática pós operatória (FPPO), ainda são questionáveis. Objetivo: Avaliar a influência do emprego do selante de fibrina na anastomose pancreatico-jejunal, após duodenopancreatectomia, na incidência de fístula, bem como suas consequências clínicas e os custos hospitalares. Metodologia: Estudo retrospectivo de 62 pacientes consecutivos submetidos a duodenopancreatectomia, divididos em dois grupos: 31 pacientes utilizando o selante de fibrina (GCS) e 31 pacientes sem o emprego de selante (GSS). As variáveis estudadas foram agrupadas em epidemiológicas, clínicas, laboratoriais, com destaque para a incidência de fístula pancreática, classificada segundo a definição do International Study Group on Pancreatic Fistula, suas complicações pós operatórias catalogadas segundo a classificação de Clavien e suas repercussões na assistência e nos seus custos avaliados pelo método de absorção com rateio simples de todas as despesas, exceto a despesa com medicamentos, tratada de forma separada. Resultados: Os grupos foram homogêneos para os parâmetros epidemiológicos, clínicos, e laboratoriais e não foram registradas diferenças significativas na comparação da evolução pós operatória e dos indicadores assistenciais hospitalares. Por outro lado, os custos hospitalares foram mais elevados no GCS, em relação ao GSS (p<0,0001). Conclusão: O emprego do selante de fibrina, no reforço da anastomose pancreatico-jejunal, em pacientes submetidos a duodenopancreatectomias, nas condições estudadas, não melhorou os resultados clínicos e assistenciais e ainda aumentou os custos hospitalares. / Introduction: The benefits of fibrin sealant employment in strengthening pancreatico-jejunal anastomosis after duodenopancreatic resection, reducing the incidence of pancreatic fistula postoperative (PFPO) are still questionable. Objective: To evaluate the influence of the use of fibrin sealant in pancreatico-jejunal anastomosis after pancreaticoduodenectomy in the incidence of fistula and its clinical consequences and hospital costs. Methodology: A retrospective study of 62 consecutive patients who underwent pancreaticoduodenectomy, divided into two groups: 31 patients using fibrin sealant (GCS) and 31 patients without the sealant employment (GSS). The variables were grouped into epidemiological, clinical, laboratory, especially the incidence of pancreatic fistula classified as defined by the International Study Group on Pancreatic Fistula, their postoperative complications cataloged according to Clavien rating and its repercussions on care and its costs assessed by the absorption method with simple apportionment of all expenses except the expenditure on medicines, treated separately. Results: The groups were homogeneous for clinical, epidemiological and laboratory parameters and no significant differences were recorded in the comparison given postoperative progress and hospital assistance indicators. Moreover, hospital costs were higher in GCS, with respect to GSS (p <0.0001). Conclusion: The use of fibrin sealant in pancreatojejunal anastomosis after pancreaticoduodenectomy, in the studied conditions, did not improve the results of care and also increased hospital costs

Introdução: Os benefícios do emprego do selante de fibrina no reforço de anastomoses pancreatico-jejunais, após ressecção duodenopancreática, visando a redução da incidência de fístula pancreática pós operatória (FPPO), ainda são questionáveis. Objetivo: Avaliar a influência do emprego do selante de fibrina na anastomose pancreatico-jejunal, após duodenopancreatectomia, na incidência de fístula, bem como suas consequências clínicas e os custos hospitalares. Metodologia: Estudo retrospectivo de 62 pacientes consecutivos submetidos a duodenopancreatectomia, divididos em dois grupos: 31 pacientes utilizando o selante de fibrina (GCS) e 31 pacientes sem o emprego de selante (GSS). As variáveis estudadas foram agrupadas em epidemiológicas, clínicas, laboratoriais, com destaque para a incidência de fístula pancreática, classificada segundo a definição do International Study Group on Pancreatic Fistula, suas complicações pós operatórias catalogadas segundo a classificação de Clavien e suas repercussões na assistência e nos seus custos avaliados pelo método de absorção com rateio simples de todas as despesas, exceto a despesa com medicamentos, tratada de forma separada. Resultados: Os grupos foram homogêneos para os parâmetros epidemiológicos, clínicos, e laboratoriais e não foram registradas diferenças significativas na comparação da evolução pós operatória e dos indicadores assistenciais hospitalares. Por outro lado, os custos hospitalares foram mais elevados no GCS, em relação ao GSS (p<0,0001). Conclusão: O emprego do selante de fibrina, no reforço da anastomose pancreatico-jejunal, em pacientes submetidos a duodenopancreatectomias, nas condições estudadas, não melhorou os resultados clínicos e assistenciais e ainda aumentou os custos hospitalares. / Introduction: The benefits of fibrin sealant employment in strengthening pancreatico-jejunal anastomosis after duodenopancreatic resection, reducing the incidence of pancreatic fistula postoperative (PFPO) are still questionable. Objective: To evaluate the influence of the use of fibrin sealant in pancreatico-jejunal anastomosis after pancreaticoduodenectomy in the incidence of fistula and its clinical consequences and hospital costs. Methodology: A retrospective study of 62 consecutive patients who underwent pancreaticoduodenectomy, divided into two groups: 31 patients using fibrin sealant (GCS) and 31 patients without the sealant employment (GSS). The variables were grouped into epidemiological, clinical, laboratory, especially the incidence of pancreatic fistula classified as defined by the International Study Group on Pancreatic Fistula, their postoperative complications cataloged according to Clavien rating and its repercussions on care and its costs assessed by the absorption method with simple apportionment of all expenses except the expenditure on medicines, treated separately. Results: The groups were homogeneous for clinical, epidemiological and laboratory parameters and no significant differences were recorded in the comparison given postoperative progress and hospital assistance indicators. Moreover, hospital costs were higher in GCS, with respect to GSS (p <0.0001). Conclusion: The use of fibrin sealant in pancreatojejunal anastomosis after pancreaticoduodenectomy, in the studied conditions, did not improve the results of care and also increased hospital costs

Approved for public release, distribution unlimited / Approved for public release; distribution unlimited. / Healthcare costs throughout the United States are on the rise, drawing increased scrutiny from government officials and Congress. The cost of pharmacy operations and pharmaceuticals is growing at a rate that is alarmingly higher than that of the total cost of military healthcare itself. Recent congressional legislation has essentially given the Department of Defense the ultimatum to cut costs for beneficiaries wherever possible, or risk having benefits arbitrarily cut by Congress. In the face of this possibility, cutting costs through better business practices must be explored, particularly within the area of pharmacy operations. This project explores the potential cost savings that can be realized by implementing Lean Six Sigma (LSS) methodology in the pharmacy operations of the DoD Medical Treatment Facilities (MTF). This research proves that implementing Lean Six Sigma methodology will improve military pharmacy operations, often at little cost, while realizing significant savings and increased customer satisfaction.

Contaminated blood cultures constitute diagnostic challenges and place a burden on healthcare services. An observational retrospective study was undertaken to evaluate the effect of routine labelling of blood culture bottles with the initials of the healthcare worker who drew them, followed by individualized feedback, on blood culture contamination rates. The contamination rate of the entire facility was 2.6% before the procedural change, and this decreased significantly to 1.5% after the procedural change (P < 0.001) over the first 12 months of the intervention. Routine labelling of blood culture bottles with the initials of the healthcare worker who drew them, followed by individualized feedback, was effective in reducing blood culture contamination rates.

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