Introduction: Clostridium difficile infection (CDI) is a common hospital-acquired infection and a financial burden on the healthcare system. There is a need to reduce its impact on patients and the entire health system. More accurate estimates of the financial impact of CDI will assist hospitals in creating better CDI reduction strategies with limited resources. Previous research has not sufficiently accounted for the skewed nature of hospital cost data, baseline patient mortality risk, and the time-varying nature of CDI. Objective: We conducted a retrospective cohort study to estimate the cost impact of hospital-acquired CDI from the hospital perspective, using a number of analytical approaches. Method: We used clinical and administrative data for inpatients treated at The Ottawa Hospital to construct an analytical data set. Our primary outcome was direct costs and our primary exposure was hospital-acquired CDI. We performed the following analyses: Ordinary least square regression and generalized linear regression as time-fixed methods, and Kaplan-Meier survival curve and Cox regression models as time-varying methods. Results: A total of 49,888 admissions were included in this study (mean (SD) age of 64.6 ± 17.8 years, median (IQR) baseline mortality risk of 0.04 (0.01-0.14)). 360 (0.73%) patients developed CDI. Estimates of incremental cost due to CDI were substantially higher when using time-fixed methods than time-varying methods. Using methods that appropriately account for the time-varying nature of the exposure, the estimated incremental cost due to CDI was $8,997 per patient. In contrast, estimates from time-fixed methods ranged from $49,150 to $55,962: about a six fold difference. Conclusion: Estimates of hospital costs are strongly influenced by the time-varying nature of CDI as well as baseline mortality risk. If studies do not account for these factors, it is likely that the impact of hospital-acquired CDI will be overestimated.

Introduction: Clostridium difficile infection (CDI) is a common hospital-acquired infection and a financial burden on the healthcare system. There is a need to reduce its impact on patients and the entire health system. More accurate estimates of the financial impact of CDI will assist hospitals in creating better CDI reduction strategies with limited resources. Previous research has not sufficiently accounted for the skewed nature of hospital cost data, baseline patient mortality risk, and the time-varying nature of CDI. Objective: We conducted a retrospective cohort study to estimate the cost impact of hospital-acquired CDI from the hospital perspective, using a number of analytical approaches. Method: We used clinical and administrative data for inpatients treated at The Ottawa Hospital to construct an analytical data set. Our primary outcome was direct costs and our primary exposure was hospital-acquired CDI. We performed the following analyses: Ordinary least square regression and generalized linear regression as time-fixed methods, and Kaplan-Meier survival curve and Cox regression models as time-varying methods. Results: A total of 49,888 admissions were included in this study (mean (SD) age of 64.6 ± 17.8 years, median (IQR) baseline mortality risk of 0.04 (0.01-0.14)). 360 (0.73%) patients developed CDI. Estimates of incremental cost due to CDI were substantially higher when using time-fixed methods than time-varying methods. Using methods that appropriately account for the time-varying nature of the exposure, the estimated incremental cost due to CDI was $8,997 per patient. In contrast, estimates from time-fixed methods ranged from $49,150 to $55,962: about a six fold difference. Conclusion: Estimates of hospital costs are strongly influenced by the time-varying nature of CDI as well as baseline mortality risk. If studies do not account for these factors, it is likely that the impact of hospital-acquired CDI will be overestimated.

O aumento dos gastos e custos na saúde é acompanhado com preocupação pelos gestores. O conhecimento dos custos é passo fundamental para a gestão dos hospitais. Na composição dos custos hospitalares, o item material de consumo representa parcela significativa. Nos hospitais de ensino, organizações complexas, a gestão dos custos de materiais de consumo vem assumindo grande importância. Este trabalho foi desenvolvido no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo. Os objetivos foram: caracterizar os gerentes dos centros de custos auxiliares e produtivos; verificar o gerenciamento de custos de material de consumo, nas dimensões direção, planejamento e controle; verificar a utilização das informações disponibilizadas pela instituição sobre custos de material de consumo; identificar o conhecimento dos gerentes sobre conceitos elementares de custos e acerca dos materiais de consumo com maior impacto financeiro na programação dos centros de custos. A população do estudo constituiu-se dos gerentes dos centros de custos auxiliares e produtivos. Participaram da pesquisa 40 responsáveis aos quais foi aplicado um questionário que incluía uma escala tipo Likert com 29 afirmativas. Dos gerentes participantes há predominância do sexo feminino (70%); 65% são profissionais da área da saúde; 80% têm mais de 15 anos de formado; 87,5% atuam no Hospital há mais de 10 anos denotando experiência no setor; 82,5% assumiram o cargo há menos de 19 anos; 70% sem especialização em administração, gestão em saúde ou gestão de serviços, porém, 57,5% informaram possuir outra titulação técnica. Das afirmativas, 55% apresentaram, em média, repostas dos gerentes coerentes com uma gestão adequada de custos com materiais de consumo. Pela importância do tema entende-se que este índice é baixo, sem possibilidade de comparação com outro parâmetro na literatura disponível. O planejamento e controle são as funções do gerencia mento dos custos com materiais de consumo mais desenvolvidas pelos gerentes, enquanto que a função direção apontou práticas pouco rigorosas. Os gerentes apresentaram baixo conhecimento sobre os conceitos elementares de custos hospitalares. Demonstraram conhecer os materiais de consumo com maior impacto financeiro na programação dos centros de custos sob sua responsabilidade. As informações disponibilizadas pela Instituição são pouco aproveitadas, não sendo bem compreendidas e, segundo os respondentes, não representam a realidade da área. A melhoria desse resultado requer maior capacitação e conscientização dos gerentes dos centros de custos e também aprimoramento do sistema de gestão institucional, de forma a propiciar maior autonomia e responsabilização dos gerentes. / Health costs and expenses increase are observed with concern by their managers. Costs knowledge is a fundamental step to hospital management. On hospitals costs composition, consumption material item represents a meaningful parcel. At teaching hospitals, complex organizations, the consumption material costs management has been getting great importance. This work has been developed at Hospital das clínicas da faculdade de medicina de ribeirão Preto da Universidade de SÃO PAULO. The targets were: to characterize the managers from auxiliary and productive costs centers; to verify the consumption material costs on direction dimension, planning and controlling; to verify the information use available by the institution about consumption material costs; to identify the managers\' knowledge about elementary cost concepts and about consumption material with greater financial impact on cost center program. The studied group was formed by managers from auxiliary and productive costs centers. Forty responsible people participated of the research. A questionnaire which included LIKERT scale was applied having 29 affirmatives. There was female sex prevalence among the participant managers (70%); 65% were health professionals; 80% has been graduated for more than 15 years; 87,5% has been actuating for more than 10 years at the hospital, showing experience in the sector;82,5% has been in the function for less than 15 years; 70% without administration expertise, health management or service management, nevertheless ,57,5% said they had another technical title. From the affirmatives, in average, 55% presented manager\'s answer coherently with adequate management consumption material cost. According to the theme importance, we understand that this index is low, without possibility of comparing with other parameters on available literature. Planning and controlling are the costs management functions with consumption materials more developed by the managers, while the direction function pointed to less rigorous practices. The managers presented little knowledge about elementary hospital costs concepts. They demonstrate to know the consumption material with greater financial impact on costs programming centers on their responsibility. The available institution information is not well used, not being well understood and, according to the answers, they don\'t represent the area reality. This result improvement requires better managers\' qualification and awareness from costs centers and also institutional management system improving, in a way that a greater autonomy and managers\' responsibility are provided.

Dans la première partie, une méthode mixte combinant le top-down micro-costing et le bottom-up micro-costing a été développée afin d’évaluer le coût du prélèvement d’organes au sein d’un groupement hospitalier français. Cette méthode mixte a été comparée à une méthode utilisant exclusivement le top-down micro-costing, afin de mesurer les écarts entre les deux approches. Dans la seconde partie, la valorisation de la procédure de greffe des îlots de Langerhans a illustré l’usage pouvant être fait du coût du prélèvement d’organes. Au cours de la troisième partie, l’évaluation du coût du prélèvement a été étendue à l’ensemble des organes pouvant être prélevés sur une période de 8 années consécutives. Cette évaluation a été réalisée à partir d’une base de donnée médico-administrative nationale et de l’Etude Nationale de Coût. Les résultats des deux premières publications, chacune fondée sur une base de données spécifique, semblent fortement diverger. La dernière partie s’évertue à comparer le coût du prélèvement d’organes à partir de deux bases de données distinctes : la Comptabilité Analytique Hospitalière et l’Etude Nationale de Coût. Cette analyse a souligné les différences de coût existant entre deux bases de données pourtant intimement liées, l’une incrémentant l’autre. Les différences ont conduit à relativiser et à interpréter avec davantage de précaution les coûts du prélèvement d’organes évalués à partir des bases nationales. L’utilisation de différentes méthodes d’évaluation des coûts, de même que l’utilisation de différentes bases de données aboutissent à des écarts de coûts importants. Il est fondamental que les lecteurs, les directeurs d’hôpitaux, et les décideurs, gardent à l’esprit les forces et faiblesses de chaque approche méthodologique et de chaque base de données afin d’interpréter les résultats dans un contexte éclairé / In a first part, we developed a mixed method combining top-down micro-costing and bottom-up micro-costing to accurately assess the costs of organ recovery in a French hospital group. We compared this mixed method versus full top-down micro-costing to assess potential differences. In view of illustration, we applied in a second part the results of pancreas recovery cost to value the islet transplantation procedure. During a third part, we assessed organ recovery costs based on the national hospital discharge database and a national cost study from 8 consecutive years. Results of the first and the second publication, each based on specific database, appear to be widely different. We compared, in a last part, the hospital cost accounting system in a French hospital group with the national cost study in terms of the cost of organ recovery procedures. This study highlights the cost differences existing between hospital cost accounting and the national cost study. These differences relativize and lend caution to the interpretation of the results of our previous study assessing organ recovery cost from national data. Given these differences, it is fundamental for readers, hospital managers and decision-makers to know the strengths and weaknesses of each methodological approach and the strengths and weaknesses of each database used to be able to interpret the results in an informed context

O aumento dos gastos e custos na saúde é acompanhado com preocupação pelos gestores. O conhecimento dos custos é passo fundamental para a gestão dos hospitais. Na composição dos custos hospitalares, o item material de consumo representa parcela significativa. Nos hospitais de ensino, organizações complexas, a gestão dos custos de materiais de consumo vem assumindo grande importância. Este trabalho foi desenvolvido no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo. Os objetivos foram: caracterizar os gerentes dos centros de custos auxiliares e produtivos; verificar o gerenciamento de custos de material de consumo, nas dimensões direção, planejamento e controle; verificar a utilização das informações disponibilizadas pela instituição sobre custos de material de consumo; identificar o conhecimento dos gerentes sobre conceitos elementares de custos e acerca dos materiais de consumo com maior impacto financeiro na programação dos centros de custos. A população do estudo constituiu-se dos gerentes dos centros de custos auxiliares e produtivos. Participaram da pesquisa 40 responsáveis aos quais foi aplicado um questionário que incluía uma escala tipo Likert com 29 afirmativas. Dos gerentes participantes há predominância do sexo feminino (70%); 65% são profissionais da área da saúde; 80% têm mais de 15 anos de formado; 87,5% atuam no Hospital há mais de 10 anos denotando experiência no setor; 82,5% assumiram o cargo há menos de 19 anos; 70% sem especialização em administração, gestão em saúde ou gestão de serviços, porém, 57,5% informaram possuir outra titulação técnica. Das afirmativas, 55% apresentaram, em média, repostas dos gerentes coerentes com uma gestão adequada de custos com materiais de consumo. Pela importância do tema entende-se que este índice é baixo, sem possibilidade de comparação com outro parâmetro na literatura disponível. O planejamento e controle são as funções do gerencia mento dos custos com materiais de consumo mais desenvolvidas pelos gerentes, enquanto que a função direção apontou práticas pouco rigorosas. Os gerentes apresentaram baixo conhecimento sobre os conceitos elementares de custos hospitalares. Demonstraram conhecer os materiais de consumo com maior impacto financeiro na programação dos centros de custos sob sua responsabilidade. As informações disponibilizadas pela Instituição são pouco aproveitadas, não sendo bem compreendidas e, segundo os respondentes, não representam a realidade da área. A melhoria desse resultado requer maior capacitação e conscientização dos gerentes dos centros de custos e também aprimoramento do sistema de gestão institucional, de forma a propiciar maior autonomia e responsabilização dos gerentes. / Health costs and expenses increase are observed with concern by their managers. Costs knowledge is a fundamental step to hospital management. On hospitals costs composition, consumption material item represents a meaningful parcel. At teaching hospitals, complex organizations, the consumption material costs management has been getting great importance. This work has been developed at Hospital das clínicas da faculdade de medicina de ribeirão Preto da Universidade de SÃO PAULO. The targets were: to characterize the managers from auxiliary and productive costs centers; to verify the consumption material costs on direction dimension, planning and controlling; to verify the information use available by the institution about consumption material costs; to identify the managers\' knowledge about elementary cost concepts and about consumption material with greater financial impact on cost center program. The studied group was formed by managers from auxiliary and productive costs centers. Forty responsible people participated of the research. A questionnaire which included LIKERT scale was applied having 29 affirmatives. There was female sex prevalence among the participant managers (70%); 65% were health professionals; 80% has been graduated for more than 15 years; 87,5% has been actuating for more than 10 years at the hospital, showing experience in the sector;82,5% has been in the function for less than 15 years; 70% without administration expertise, health management or service management, nevertheless ,57,5% said they had another technical title. From the affirmatives, in average, 55% presented manager\'s answer coherently with adequate management consumption material cost. According to the theme importance, we understand that this index is low, without possibility of comparing with other parameters on available literature. Planning and controlling are the costs management functions with consumption materials more developed by the managers, while the direction function pointed to less rigorous practices. The managers presented little knowledge about elementary hospital costs concepts. They demonstrate to know the consumption material with greater financial impact on costs programming centers on their responsibility. The available institution information is not well used, not being well understood and, according to the answers, they don\'t represent the area reality. This result improvement requires better managers\' qualification and awareness from costs centers and also institutional management system improving, in a way that a greater autonomy and managers\' responsibility are provided.

Poisoning is frequently associated with psychological and physiological co-morbidities that can be assessed in order to improve patients' management and reduce cost. The primary objective of this study is to conduct a review of emergency department (ED) poisonings to characterize its demographics and assess associated co-morbidities. The second objective is to explore correlation between personal history of diseases and poisonings. Predictors for poisonings and its outcomes were investigated and risk factors for suicidal poisoning and how it relates to mental illnesses were explored. Six hundred and forty nine cases admitted to ED between 2004 and 2007 were studied. Results indicate that difference in ethnic background was substantial as poisoning cases were predominantly African Americans (79.9%) between 36-45 years old with a male to female ratio of 1.3. Intentional illicit drug overdose was the greatest risk factor for ED poisonings, and among the 649 cases, heroin overdose was the most common cause of poisoning at 35.4% (n=230), cocaine overdose at 31.7% (n=206), heroin and cocaine overdose at 4.3% (n=28), multiple drug poisoning at 5.5% (n=36), and antidepressant/antipsychotic poisoning at 6% (n=39). A significant correlation between heroin poisonings and asthma (F=20.29, DF=1, p= .0001) was found, as well as between cocaine poisoning and hypertension (F=33.34, DF=1, p=.0001), and cocaine poisoning and cardiovascular diseases (F=35.34, DF=1, p=.0001). Another significant finding is the change in the pattern of the route of illicit drug use from injection to inhalation; it is thought this may reduce the rate of HIV and Hepatitis transmission via hypodermic needles among illicit drug users. As well, inhalation and insufflation may be risk factors that aggravate preexisting asthma. Mental illnesses, chiefly depression, remain one of the greatest risk factors for suicidal poisoning beside age, Hispanic race, gender, ingestion route and unemployment. This study provides supporting evidence that poisoning, particularly deliberate poisoning with illicit drugs remains a serious issue that significantly aggravates co-morbidities and raises treatment cost by increasing both the rate of hospitalization and hospital length of stay (LOS). Pragmatic guidelines and innovations in reducing heroin and cocaine abuse in these patients may lessen the severity of diseases and reduce its burden on the healthcare system and on society.

Every year, 2 million patients in the United States suffer with at least 1 hospital-acquired infection resulting in an estimated 99,000 deaths annually. The purpose of this exploratory single case study was to explore strategies healthcare managers in U.S. hospitals used to reduce hospital-acquired infections. The study included face-to-face, semistructured interviews with 5 healthcare managers from a hospital in Maryland who were successful in reducing these infections. The conceptual framework was human capital theory. Field notes, hospital documents, and transcribed interviews were analyzed to identify themes regarding strategies used by healthcare managers. The data analysis and coding process resulted in 5 major themes: use of HAI-related data; implementation of detailed cleaning method; implementation of define, measure, analyze, implement, and control; education and training of staff; and implementation of the Antimicrobial Stewardship Program. The findings from this study might benefit healthcare managers in implementing and sustaining successful strategies to reduce hospital-acquired infections. The implications for positive social change included reducing hospital-acquired infections, thereby leading to fewer hospitalization days for patients and a faster recovery time to return to normal life. Reducing hospital acquired infections might reduce patient deaths related to the infections.

Submitted by Luiz Eduardo Gapanowicz (lgapanowicz@rededor.com.br) on 2012-08-21T13:24:33Z No. of bitstreams: 1 Dissertação Mex 2a 12 corrigida Ricardo BIBLIOTECA ajust parte numerada_R02 08 2012.docx: 371539 bytes, checksum: 0623ddaae545be40dced1a298d937001 (MD5) / Approved for entry into archive by Janete de Oliveira Feitosa (janete.feitosa@fgv.br) on 2012-08-24T15:51:42Z (GMT) No. of bitstreams: 1 Dissertação Mex 2a 12 corrigida Ricardo BIBLIOTECA ajust parte numerada_R02 08 2012.docx: 371539 bytes, checksum: 0623ddaae545be40dced1a298d937001 (MD5) / Approved for entry into archive by Marcia Bacha (marcia.bacha@fgv.br) on 2012-08-28T14:21:51Z (GMT) No. of bitstreams: 1 Dissertação Mex 2a 12 corrigida Ricardo BIBLIOTECA ajust parte numerada_R02 08 2012.docx: 371539 bytes, checksum: 0623ddaae545be40dced1a298d937001 (MD5) / Made available in DSpace on 2012-08-28T14:22:09Z (GMT). No. of bitstreams: 1 Dissertação Mex 2a 12 corrigida Ricardo BIBLIOTECA ajust parte numerada_R02 08 2012.docx: 371539 bytes, checksum: 0623ddaae545be40dced1a298d937001 (MD5) Previous issue date: 2012-06-26 / The health practice in the country has been going through big and difficult challenges. Concerning funds, the public sector is still in need of a better sizing and strategy. The private sector has its crisis by the lack of more analysis of its costs and variations. The regulation of the supplementary sector is still crude. The immense health challenges and the searches for solution are a constant for better sizing and handling the process. Several factors are pressuring the model, increasing expenses in a vicious unforeseeable situation, without any foresight. There is an urgent need of understanding the outflow model involved and above all the factors that most interfere in the variation of these expenses. The followed work searches a better understanding of the variation costs of the problem of the services given, through the analysis of three medical cases of high relevancy: appendicectomy, hysterectomy, colecistectomy, observing the prices variation practiced in historical 05 years’ time, comparing with the economic and inflationary indexes as IPCA, variation of the Health Insurance Plans by ANS and the variation of hospital/ medical expenses. As results, we observed that for these classics and isolated events, there isn’t a clear pattern of prices linked to any of these indexes, neither a linear variation that allows a better and big analysis. At the same time when the volume of the attending increase, in the mix of these three events we observe a very close relation to the IPCA that is, by the way, very close do the readjustment of the index authorized by ANS in this period. There is a lot to do and study for better understanding of these prices and costs model, as well as its variations. / A prática de saúde no país passa por grandes e difíceis desafios. No que tange a financiamento o setor público ainda carece de um melhor dimensionamento e proposta estratégica. Já o setor privado tem sua crise pela falta de maios análise dos seus custos e suas variações. A regulação do setor suplementar ainda é muito jovem. Os grandes desafios da saúde e a busca de solução são uma constante para melhor dimensionar e gerir o processo. Vários são os fatores pressionam o modelo aumentando seus gastos e ainda em uma situação mais perversa sem nenhuma previsão. Há a necessidade urgente de se entender o modelo de gastos envolvidos e acima de tudo os fatores que mais interferem na variação desses gastos. O trabalho que segue busca entender melhor o problema de variação de custos destes serviços prestados, através da análise de três casos médicos de alta relevância: apendicectomia; histerectomia; e colecistectomia, observando a variação dos preços praticados em uma série histórica de 5 anos, comparando com índices econômicos e inflacionários como IPCA, variação dos preços dos planos de saúde pela ANS e variação dos custos médicos hospitalares. Como resultados observamos que para estes eventos clássicos e isolados eventos não há um padrão nítido de preços atrelados a qualquer destes índices, nem uma variação linear que permita uma maior e melhor análise. Ao mesmo tempo quando se aumenta o volume dos atendimentos, no mix dos três eventos passamos a observar uma relação bem próxima ao IPCA que por sua vez é muito próxima do índice de reajustes autorizado pela ANS no período. Muito há o que ser feito e estudado como forma de melhor entender este modelo de preços e custos, bem como suas variações.