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Busse R, Schreyogg J, Smith PC. Variability in healthcare treatment costs amongst nine EU countries - results from the HealthBASKET project. Health Econ 2008;17: S1–8.
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Skeie B, Mishra V, Vaaler S, et al. A comparison of actual cost, DRG-based cost, and hospital reimbursement for liver transplant patients. Transpl Int 2002;15:439–45.
10 Tan SS, Oppe M, Zoet-Nugteren SK, et al. A microcosting study of diagnostic tests for the detection of coronary artery disease in The Netherlands. Eur J Radiol 2009; 72:98–103. 11 Dormont B, Milcent C. The sources of hospital cost variability. Health Econ 2004;13: 927–39. 12 Lotter O, Jaminet P, Amr A, et al. Reimbursement of burns by DRG in four European countries: an analysis. Burns 2011;37:1109–16. 13 Pirson M, Schenker L, Martins D, et al. What can we learn from international comparisons of costs by DRG? Eur J Health Econ 2013;14:67–73.
15 Scheller-Kreinsen D, Quentin W, Busse R. DRG-based hospital payment systems and technological innovation in 12 European countries. Value Health 2011;14: 1166–72. 16 St-Hilaire C, Crepeau PK. Hospital and unit cost allocation methods. Healthc Manage Forum 2000;13:12–32.
19 Clement Nee Shrive FM, Ghali WA, Donaldson C, et al. The impact of using different costing methods on the results of an economic evaluation of cardiac care: microcosting vs gross-costing approaches. Health Econ 2009;18:377–88. 20 Tan SS, Rutten FF, van Ineveld BM, et al. Comparing methodologies for the cost estimation of hospital services. Eur J Health Econ 2009;10:39–45. 21 Wordsworth S, Ludbrook A, Caskey F, et al. Collecting unit cost data in multicentre studies. Creating comparable methods. Eur J Health Econ 2005;6:38–44. 22 Swindle R, Lukas CV, Meyer DA, et al. Cost analysis in the Department of Veterans Affairs: consensus and future directions. Med Care 1999;37:AS3–8. 23 Jackson T. Cost estimates for hospital inpatient care in Australia: evaluation of alternative sources. Aust N Z J Public Health 2000;24:234–41. 24 Fattore G, Torbica A. Inpatient reimbursement system in Italy: how do tariffs relate to costs. Health Care Manag Sci 2006;9:251–8. 25 Forgione DA, Vermeer TE, Surysekar K, et al. The impact of DRG-based payment systems on quality of health care in OECD countries. J Health Care Finance 2004;31: 41–54. 26 Pongpirul K, Walker DG, Rahman H, et al. DRG coding practice: a nationwide hospital survey in Thailand. BMC Health Serv Res 2011;11:290. 27 Ghaffari S, Doran C, Wilson A, et al. Investigating DRG cost weights for hospitals in middle income countries. Int J Health Plann Manage 2009;24:251–64.
17 Tan SS, van Ineveld BM, Redekop WK, et al. Comparing methodologies for the allocation of overhead and capital costs to hospital services. Value Health 2009;12:530–5.
......................................................................................................... European Journal of Public Health, Vol. 24, No. 6, 1028–1033 ß The Author 2014. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/cku037 Advance Access published on 3 April 2014
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Direct health care costs of hospital admissions due to adverse events in the Netherlands Fabienne J. H. Magdelijns1, Patricia M. Stassen1,2,3, Coen D. A. Stehouwer1,4, Evelien Pijpers1,5 1 Division of General Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht University, Maastricht, The Netherlands 2 Division of Acute Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht University, Maastricht, The Netherlands 3 School of CAPHRI, Maastricht University Medical Centre, Maastricht University, Maastricht, The Netherlands 4 Cardiovascular Research Institute, Maastricht University Medical Centre, Maastricht University, Maastricht, The Netherlands 5 Section of Clinical Geriatric Medicine, Maastricht University Medical Centre, Maastricht University, Maastricht, The Netherlands Correspondence: Fabienne J. H. Magdelijns, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht University, 6202 AZ Maastricht, The Netherlands, Tel: +31 (0)43 3875100, Fax: +31 (0)43 3877822, e-mail: [email protected]
Background: Health care-related adverse events (AEs) are common, and the economic burden is substantial. Information on costs of health care-related AEs ‘leading’ to hospitalization is limited and has focused on adverse drug events. Aim: To provide insight into costs of admissions due to (preventable) health care-related AEs, not limited to adverse drug events. Methods: This study was conducted during a 5-month period (May–September 2010) in the Netherlands, in a 600-bed university medical centre. All patients who were admitted via the emergency department to an internal medicine department because of a health care-related AE were included. We retrospectively retrieved all data on medical information as well as health care resource utilization from the patient’s medical record. The cost of the admission was estimated (for each patient individually) by multiplying the number of resources by their specific unit cost and then summing all costs per patient. Results: In total, 324 admissions due to a health care-related AE were included (28.7% of all admissions). Total direct health care costs of these hospitalizations amounted to E1 404 070 in a 5-month period. Medication-related AEs were most common (43.5%) and contributed most to the costs (E587 550; 41.8%). Inpatient days were most expensive (E1 076 385; 77.3%). Preventable health care-related AEs accounted for E277 665 (19.8%). Conclusion: We found that health care-related AEs are expensive, with preventable health care-related AEs accounting for one-fifth of the costs. Awareness of possible health care-related AEs following medical actions is necessary to reduce already high health care costs.
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14 Busse R, Geissler A, Quentin W, et al. Diagnosis-Related Groups in Europe: moving towards transparency, efficiency and quality in hospitals, 1st edn. Buckingham: Open University Press and WHO Regional Office for Europe, 2011.
18 Williams SV, Finkler SA, Murphy CM, et al. Improved cost allocation in case-mix accounting. Med Care 1982;20:450–9.
Hospital admissions due to adverse events: a cost analysis
Introduction
Methods Patients and study design The study was conducted within another retrospective single-centre study of which the study design and results have been described previously.6 In summary, all patients 18 years of age who were admitted to the department of internal medicine via the ED because of a health care-related AE during the period May– September 2010 were included. Our hospital is a secondary and tertiary university medical care centre (Maastricht University Medical Centre; MUMC+). Most patients presenting to the ED are referred by general practitioners, except for high-urgency (ambulance) patients and some self-presenters. Internists specialized in acute care assess and treat these patients with general internal medicine, oncological, haematological, nephrological, gastrointestinal and rheumatological problems. A health care-related AE was defined according to the Dutch Internal Medicine Association as ‘any event or state during or following treatment by a specialist that influenced the health of the patient in such way that renewed treatment was necessary or that it led to damage’.18 All investigators had successfully completed an e-learning course concerning the registration of health carerelated AEs.18 Health care-related AEs were categorized into medication-, chemotherapy-, procedure- or diabetes mellitusrelated or other AEs.
Data collection From the admitted patient’s medical record, we retrieved the nature of all health care-related AEs. If a patient was admitted for more than one health care-related AE, the health care-related AE with (potentially) the most serious consequences was scored.
Two independent investigators evaluated the potential preventability of a health care-related AE. If there was no consensus, a third investigator decided on the issue. For assessing the preventable medication-related AEs, we used the algorithm by Schumock et al.19 The assessment of preventability of the other types of health carerelated AEs was based on the opinion of the investigators.
Health care system structure In the Netherlands, the health insurance company pays the hospital based on a diagnosis-based reimbursement system, which is thought to reflect average costs. This means that if a patient has, for example, acute myeloid leukaemia, this diagnosis will be reimbursed by the insurance company (so a standard amount will be reimbursed). This amount includes not only the treatment of the acute myeloid leukaemia but also the likelihood of a hospital admission due to a health care-related AE. Consequently, this amount is independent of the number of admissions. Analysing the costs reimbursed by the insurance company would not give us any insight into the costs of admissions due to a health care-related AE. Moreover, information on costs reimbursed by the insurance company is generally confidential, as publishing this information could lead to problems in the negotiations between hospitals and insurance companies. Therefore, we calculated with unit costs of all health care resources used by patients to give detailed information on costs of an admission due to a health care-related AE. In the Netherlands, all inhabitants are obliged to have a health insurance for monthly rates must be paid. The insurance company pays all costs incurred by hospital admissions.
Cost analysis All health care resources used by the patients during admission were collected retrospectively from the patients’ medical record and analysed per individual patient. For the cost analysis, unit costs for each of the used resources (ED visit, admission days, imaging studies, interventions and some treatments) were retrieved from the central accounting system of the hospital. These are standardized real cost calculations based on true activities involved and taking into account the person-hours and resources involved to perform the activity, as well as the estimated hospital overhead.20 These costs are used for internal payments of the departments that perform the different activities and are not the actual costs that are reimbursed by the insurance company. The unit costs correspond to reference costs based on Dutch guidelines for pharmacoeconomic evaluations21 but are specific to our own hospital. The Dutch reference costs of admission days in general wards or intensive care units (ICUs) of academic hospitals are calculated from data of cost evaluations combined with statistical data from general hospitals acquired in 2008 (Supplementary table S1). Reference costs of hospital days and the ED visit include costs of medical and nursing staff, material and equipment and housing and overhead.21,22 The following six resources were included in the cost analysis (Supplementary figure S1), which are all direct costs: (1) Cost of the visit to the ED. A fixed tariff is used for every visit of a patient to the ED, which includes person-hours, housing, all necessary blood tests and treatments (antibiotics, infusion and other medication). (2) Cost of subsequent inpatient days. In this analysis, costs per first day and per subsequent days were calculated separately, as the first day is more expensive than subsequent inpatient days. For the same reason, costs for admission to general wards and ICUs were calculated separately. (3) Cost of blood tests. We calculated the mean costs of the most relevant analyses per day, i.e. electrolytes (sodium and potassium), renal function, haemoglobin, leucocytes, platelets and C-reactive proteins.
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ealth care-related adverse events (AEs) are common and may 1–6 Apart from the loss of quality of life and life expectancy, health care-related AEs lead to considerable costs.2,7–11 In Europe and the United States, costs of (preventable) health care-related AEs, including adverse drug events (ADEs), occurring ‘during’ hospitalization are found to be substantial.2,9,10,12 However, costs of health care-related AEs ‘leading’ to hospitalization have not been studied extensively. In 2000, a study performed in the United States showed that ADEs leading to hospitalization exceeded $3066 [in July 2000 $1 = E1.0513] per admission.11 In the United Kingdom, the annual cost of ADEs directly leading to admission amounted to E11.9 million/1 million inhabitants.8,14 In Germany, ADEs leading to admission to an internal medicine department cost E5.2 million/1 million inhabitants.7,15 In the Netherlands, preventable medication-related admissions amounted to E5.7 million/ 1 million inhabitants.16,17 To reduce costs caused by health care-related AEs, gaining insight into the extent and nature of these costs is necessary. To our knowledge, costs of a hospital admission due to all health carerelated AEs, not just ADEs, have not yet been investigated. The objective of this study is to investigate total direct health care costs of hospitalization of patients admitted through the emergency department (ED) due to a health care-related AE. We investigated direct costs of several types of health care-related AEs, evaluated which health care-related AEs are most expensive and to what extent each separate item (inpatient days, imaging studies, interventions and provided treatments) contributes to total costs. Finally, we investigated direct costs of ‘potentially preventable’ health carerelated AEs.
Hlead to disability, morbidity and even mortality.
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cases. The mean age of our patients was 66 years (range: 21–96, SD: 16 years), and 49.4% were female. The median number of inpatient days was 5 (range: 1–92 days). Table 1 shows the different health care-related AEs in more detail. Almost half (43.5%) of the health care-related AEs were medication related. In all, 27% (n = 90) of these AEs were judged preventable (table 2). Table 1 Study population and prevalence of health care-related AEs in a 5-month study period Study population
N (%)
Sex, female Median age in years (Q1, Q3) Mean age in years (range) Mean duration of admission in days (range) Median duration of admission in days (Q1, Q3)
160 67 66 8 5
(49.4) (57,77) (21–96) (1–92) (3,10)
AEs
N (%)
Results
Medication-related Bleeding using anticoagulants Coumarines Other anticoagulants Fever/infections using immunosuppressive drugs Electrolyte problems Constipation Anaphylaxis Other Chemotherapy-related Non-neutropenic fever Neutropenic fever Gastrointestinal complaints Electrolyte problems Other Procedure-related Dialysis-related Cholangitis after ERCP GvHD after SCT Bleeding Perforation Contrast-associated renal dysfunction Other Diabetes mellitus-related Hypoglycaemia Hyperglycaemia Ketoacidosis Other (renal dysfunction) Other While on a waiting lista
141 (43.5) 46 (14.2) 19 (5.9) 27 (8.3) 44 (13.6) 11 (3.4) 9 (2.8) 2 (0.6) 29 (9.0) 87 (26.9) 34 (10.5) 17 (5.2) 14 (4.3) 5 (1.5) 17 (5.2) 56 (17.3) 9 (2.8) 8 (2.5) 6 (1.9) 4 (1.2) 2 (0.6) 1 (0.3) 26 (8.0) 36 (11.1) 17 (5.2) 18 (5.6) 2 (0.6) 1 (0.3) 4 (1.2) 3 (0.9)
In the period May–September 2010, 284 patients were admitted 324 times because of a health care-related AE, accounting for 28.7% of all admissions to the department of internal medicine through the ED. Multiple health care-related AEs occurred in 4% (n = 13) of the
Abbreviations: Q, quartile; GvHD, graft versus host disease; SCT, stem cell transplantation; ERCP = endoscopic retrograde cholangiopancreatography. a These patients are counted twice in the table.
To calculate the costs per patient, each resource used was multiplied by the unit cost of that resource, and the cost was summed thereafter. In addition, we calculated direct costs per type of health care-related AE and calculated to what extent each of the cost categories (inpatient days, imaging studies, interventions, medication, transfusions and blood tests) contributed to total costs. Furthermore, direct costs of potentially preventable health care-related AEs were analysed separately. No statistical analyses were performed, except for descriptive analyses for which SPSS Statistics version 18 (SPSS Inc, Chicago, IL, USA) was used. Categorical data were reported as absolute counts with percentages; continuous data were reported as mean with standard deviations (SD) and as medians with interquartiles (Q1 and Q3). The medical ethics committee of the institution (MedischEthische Toetsing Onderzoek, Maastricht, the Netherlands) approved this study.
Table 2 Costs of admissions due to a (preventable) health care-related AE in a 5-month study period Health care-related AEs n
Total cost in E
Preventable health care-related AEs
Percentage of total costs
Mean cost in E per patient
SD in E of mean cost per patient
n
Total cost in E
Percentage of total costs
Mean cost in E per patient
SD in E of mean cost per patient
Medication-related Chemotherapy-related Procedure-related Diabetes mellitus-related Other
141 34 56 36 4
587 550 412 626 291 841 105 537 6515
41.8 29.4 20.8 7.5 0.5
4167 4743 5211 2932 1629
5065 4010 5005 2762 448
43 1 19 25 2
136 339 2005 69 523 67 294 2 503
49.1 0.7 25.0 24.3 0.9
3171 2005 3659 2692 1252
2311 0 3128 1899 0
Total
324
1 404 070
100
4334
4582
90
277 665
100
3085
2383
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(4) Cost of all imaging studies. (5) Cost of all performed interventions. (6) Cost of specific treatments including all required transfusions (packed cells, platelets and fresh frozen plasma), infusion fluids and antibiotics. For this analysis, we made two assumptions. First, to calculate the amount of infusion fluids administered during hospitalization, we estimated how many units of 500-ml infusion fluids each patient admitted to a general ward of the department of internal medicine received. For this estimation, we counted the number of units of infusion fluids that were administered per patient per day on four different days during two consecutive weeks and assumed that this sample could be extrapolated to the entire cohort of patients. On average, each of the 370 patients received 500 ml of infusion fluids per 24 h. Second, regarding the antibiotics prescribed on admission, we assumed that patients could be divided into three groups— haematology, oncology and general internal medicine—as these groups are treated according to different treatment protocols. We assumed that all haematology patients were treated with piperacillin/tazobactam intravenously for 7 days, all oncology patients with amoxicillin/clavulanic acid and ciprofloxacin for 7 days (5 days intravenously) and general internal medicine patients with amoxicillin/clavulanic acid for 7 days (3 days intravenously) and one dose of gentamicin. Costs of these antibiotics were based on pharmacy prices in the Netherlands.23
Hospital admissions due to adverse events: a cost analysis
Direct costs of health care-related AEs The total direct costs of the 324 admissions due to a health care-related AE in the 5-month period amounted to E1 404 070. Medicationrelated AEs (43.5%) contributed most to the costs (E587 550; 41.8%) (table 2). Per patient, procedure-related admissions were most expensive (E5211, SD: E5005), with chemotherapy-related AEs being second most expensive (E4743, SD: E4010).
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inpatient days contributed most to the overall costs of the category. Costs related to the use of medication were highest in the chemotherapy-related AE category. Interventions or re-interventions contributed considerably to the total direct costs of procedure-related AEs compared with other categories of health care-related AEs.
Discussion Direct costs of potentially preventable health care-related AEs The 90 preventable health care-related AEs (27.8% of all health carerelated AEs) that resulted in an admission amounted to E277 665 (19.8% of total direct costs) (table 2). Medication-related AEs contributed most to these costs (E136 339; 49.1%), but procedurerelated admissions were most expensive per patient in this subgroup.
The degree to which costs of each of the six cost categories contributed to total direct costs is shown in more detail in figure 1. Inpatient days (mean: 8; range: 1–92) contributed most to the total direct costs (E1 076 385; 76.7%). Four patients were admitted to the ICU, which amounted to E41 515 of total direct costs (3.6% of costs of all inpatient days). The mean direct cost per patient for inpatient days amounted to E3322 (SD: E3909). On average per patient, E211 (SD: E342) was spent on imaging studies, E279 (SD: E227) on blood testing. If antibiotics were necessary, this amounted to a mean of E202 (SD: E160). If a patient needed transfusions, this amounted to a mean of E935 (range: E131–E8835, SD: E1420). Table 3 shows the contribution of each cost category to the total direct cost per health care-related AE category. In all categories, 3.1%
1.8% 0.5%
4.9% 1.6%
5.0%
6.4% Emergency department visit (€70,995) Inpatient days (€1,076,385) Blood testing (€90,307) Imaging studies (€68,221) Interventions (€21,811) Transfusions (€43,944) Antibiotics (€25,055) Infusions (€7,352)
76.7%
Figure 1 Contribution of each cost category presented in percentage of total costs. Treatment is divided into transfusions, antibiotics started at admission and infusions
Table 3 Contribution of each cost category to total costs per health care-related AE category Medication-related (%)
Chemotherapy-related (%)
Procedure-related (%)
ED visit Inpatient days Blood testing Imaging studies Interventions Transfusions Antibiotics Infusions
30 896 456 851 38 906 28 167 10 600 14 399 4581 3151
19 063 310 238 25 034 20 328 1706 15 178 19 009 2071
12 271 221 914 17 675 14 354 9505 13 483 1113 1526
Total costs
587 551 (100)
(5.3) (77.7) (6.6) (4.8) (1.8) (2.5) (0.8) (0.5)
(4.6) (75.2) (6.1) (4.9) (0.4) (3.7) (4.6) (0.5)
412 627 (100)
Diabetes mellitus-related (%)
Other (%)
(4.2) (76.0) (6.1) (4.9) (3.3) (4.6) (0.4) (0.5)
7888 (7.5) 83 468 (79.1) 8117 (7.7) 5132 (4.9) 0 0 352 (0.3) 581 (0.5)
877 (13.5) 3915 (60.1) 576 (8.8) 240 (3.6) 0 885 (13.6) 0 24 (0.4)
291 841 (100)
105 538 (100)
6517 (100)
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Contribution of each cost category to total direct costs of health care-related AEs
Health care-related AEs are not only a common reason for hospitalization, but they are also expensive, amounting to E1 404 070 in a 5-month period in one university hospital (E3 369 768 per year). In Europe, some studies have been performed on costs of ADEs leading to hospital admissions (as studies cited are performed in different years, we added Supplementary table S2 with annual average consumer price indices as a measure of inflation to compare the mentioned costs with present data). In the United Kingdom, ADEs leading to hospitalization are estimated to amount to E706 million per year, i.e. E11.9 million/1 million inhabitants (2001–2002).8,14 A German study found that the mean treatment costs of a single ADE regarding admission to departments of internal medicine amounted to E2250 (range: E733–E17 482) (2006–2007).7 In that study, total direct costs of treatment of these ADEs amounted to E5.2 million/1 million inhabitants.15 Our study shows that medication-related AEs are the most common AEs leading to hospitalization (43.5%). They cost E4167 (range: E867–E38 422) per hospital admission. The costs of medicationrelated admissions in our study are higher than in the German study. First, this may be explained by differences in health care systems between the Netherlands and Germany. Second, in the German study, a lump sum per case system based on diagnosisrelated groups was used for the cost analysis,7 which is less detailed than our cost analysis in which we present real costs. Reducing costs resulting from hospitalizations due to health carerelated AEs may be achieved—above all from improving a patient’s health by modification or change of therapy and thereby preventing health care-related AEs—by decreasing the number of inpatient days, as inpatient days explain the bulk of costs (E1 076 385; 76.7% of total direct costs). This was also found in the multicentre Hospital Admissions Related to Medication (HARM) study that was performed in the Netherlands.16 In confirmation of the impact of health care-related AEs on inpatient days, 4% of the hospital bed capacity was found to be occupied by patients admitted to the hospital due to an ADE in the United Kingdom.8 The median length of hospital stay in the HARM study was 8 days,16 which is comparable with the study conducted in the United Kingdom8 and our findings (mean: 8 days, median: 5 days). In all, 27% of health care-related AEs leading to hospitalization were judged preventable in our study. This is comparable with the German study on ADE-related hospital admissions, in which 20.1% were judged preventable.7 By preventing AEs, E87 million could be saved per year in Germany. The HARM study showed that each
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effective this shortening is in reducing the direct costs of health carerelated AEs. These items could be subject for further study. In conclusion, this study demonstrates that direct costs of health care-related AEs leading to hospital admissions are high, with medication-related admission being most expensive and inpatient days contributing most to these costs. Moreover, preventable health care-related AEs leading to hospitalization amount to nearly 20% of these costs. As all treatments are inevitably associated with the risk of health care-related AEs, awareness of health care-related AEs is necessary to reduce direct health care costs.
Supplementary data Supplementary data are available at EURPUB online.
Acknowledgements F.J.H.M. acquired data and drafted the manuscript; P.M.S., C.D.A.S., E.P. and A.B. contributed substantially to its revision; E.P. takes responsibility for the article as a whole. Conflicts of interest: None declared.
Key points In the Netherlands, health care-related AEs leading to hospitalization in an internal medicine department are expensive (almost E1.5 million in a 5-month period in one university hospital). One-fifth of the health care-related AEs are potentially preventable, corresponding to almost E300 000 (in a 5-month period in one university hospital). The largest contributing factor is the inpatient days (76.7% of total direct costs). Awareness of (preventable) health care-related AEs is desirable to reduce direct health care costs.
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preventable medication-related hospital admission amounted to E6009, taking production losses into account. Therefore, total costs of preventable medication-related admissions would amount to >E94 million per year in the Netherlands, of which E86 million would be due to medical costs alone.16 In our study, preventable medication-related admission cost E3170 per patient, which is less than in the HARM study. However, in the HARM study, production losses were taken into account, which could explain this difference. Of the preventable health care-related AEs in our study, diabetes mellitus-related hospitalizations were most prevalent. Nearly 70% of diabetes-related AEs were judged preventable. However, in the HARM study, admissions related to the endocrine system (including hypoglycaemia or hyperglycaemia) were only the fourth most prevalent preventable AE.16 This difference can be explained by the fact that we judged non-compliance as a preventable health carerelated AE. This assumption is of course open for debate. Our study has some limitations. First, this study was based on one department, internal medicine, of one university hospital and is a rather small study. Thereby, only patients admitted through the ED were included. Patients admitted through an outpatient department were not included. Thus, the health care-related AEs included in the present study are likely to be severe and therefore costly. Moreover, patients with a health care-related AE leading to hospitalization to departments of other medical specialties not treated by internists were not taken into account. Therefore, our study must be seen as a first step in the analysis of all health care-related AEs of all specialties leading to hospitalization. Moreover, our study was performed in the Netherlands, which makes confirmation in other countries with different health care systems necessary. However, this limitation exists for every national study. To correct for international differences, each country might perform its own calculations and report these in a standard manner. Second, the judgement of health care-related AEs being potentially preventable was based on the opinion of two or (in case of disagreement) three investigators. This could be a source of bias. However, a standardized method is, as far as we know, not available for AEs in general except for ADEs. For the ADEs, we used the method by Schumock et al., as in other studies (e.g. HARM study).16,19 Third, charges are not the actual costs reimbursed by the insurance company. Therefore, the economic burden of health care-related AEs to society is not exactly clear. Fourth, pre-existing comorbidity that is independent of the health care-related AE may to some extent have contributed to the hospital admission due to a health care-related AE. This could have led to overestimation of direct costs. In future study, this must be investigated and taken into account. Further, information on sociodemographic differences in the study population was not available. Therefore, it is unknown whether sociodemographic differences influenced the costs of some health care-related AEs. However, as every inhabitant in the Netherlands is obliged to have health care insurance, access to complete health care is not limited to socioeconomic class. For future perspectives, more information on sociodemographic differences should be gathered. Moreover, in future study, non-health care direct costs, as well as indirect costs such as loss of productivity and outpatient health care after discharge, may be included to make a broader cost estimation. Even if our study underestimates direct costs of health carerelated AEs leading to hospitalization, our study still shows that health care-related AEs occur frequently and add up to the already high health care costs. Further, we believe that this study gives broad insight into the direct costs of health care-related AEs leading to hospitalization, including the contribution of the inpatient days, antibiotic use, blood tests, interventions and transfusions to total direct costs. However, in our study, no distinction has been made between mild, moderate or severe AEs. In addition, as our study provides clues to reduce direct health care costs, it would be interesting to find out what actions can be taken to shorten the number of inpatient days (as this is the main cost driver) and to explore how
Change in breastfeeding patterns in Scotland
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12 Rottenkolber D, Hasford J, Stausberg J. Costs of adverse drug events in German hospitals–a microcosting study. Value Health 2012;15:868–75.
17 Statline Centraal Bureau voor de Statistiek. . Bevolking; generatie, geslacht, leeftijd en herkomstgroepering, 1 januari, 2012. Available at: http://statline.cbs.nl/ StatWeb/publication/?DM=SLNL&PA=37325&D1=0&D2=a&D3=0&D4=0& D5=0&D6=10&VW=T (4 October 2013, date last accessed).
13 European Central Bank, Eurosystem. . Available at: https://http://www.ecb.europa. eu/stats/exchange/eurofxref/html/eurofxref-graph-usd.en.html (11 January 2013, date last accessed).
18 Nederlandse Internisten Vereniging (NIV); Complicatieregistratie (E-learning). . The Netherlands, 2012. Available at: http://www.internisten.nl/home/kwaliteit/ complicatieregistratie/complicatieregistratie.
14 Office for National Statistics. . Mid-1971 to Mid-2010 Population Estimates: United Kingdom; estimated resident population for constituent countries and regions in England. Population Demography Division, Fareham, 2011. Available at: http://www.ons.gov.uk/ons/taxonomy/search/index.html?nscl=Population+ Change&nscl-orig=Population+Change&content-type=Dataset&content-type= Reference+table&sortDirection=DESCENDING&sortBy=pubdate (4 October 2013, date last accessed).
19 Schumock GT, Thornton JP. Focusing on the preventability of adverse drug reactions. Hosp Pharm 1992;27:538.
16 Leendertse AJ, Van Den Bemt PM, Poolman JB, et al. Preventable hospital admissions related to medication (HARM): cost analysis of the HARM study. Value Health 2011;14:34–40.
21 Hakkaart-van Roijen L, Tan SS, Bouwmans CAM. Handleiding voor kostenonderzoek. Methoden en Standaard Kostprijzen voor Economische Evaluatie in de Gezondheidszorg. Diemen, The Netherlands: College Voor Zorgverzekeringen Geactualiseerde versie, 2010. 22 Tan SS, Bouwmans CA, Rutten FF, Hakkaart-van Roijen L. Update of the Dutch Manual for Costing in Economic Evaluations. Int J Technol Assess Health Care 2012; 28:152–8. 23 Medicijnkosten. College voor Zorgverzekeringen, 2013. Available at: http://www. medicijnkosten.nl.
......................................................................................................... European Journal of Public Health, Vol. 24, No. 6, 1033–1041 ß The Author 2014. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/cku029 Advance Access published on 18 March 2014
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Change in breastfeeding patterns in Scotland between 2004 and 2011 and the role of health policy Valeria Skafida Centre for Population Health Sciences & Centre for Research on Families and Relationships, University of Edinburgh, Edinburgh Correspondence: Valeria Skafida, Centre for Population Health Sciences & Centre for Research on Families and Relationships, University of Edinburgh, 23 Buccleuch Place, EH8 9LN, Edinburgh. Tel: +44 (0)131 651 3215, Fax: +44 (0)131 651 1833, e-mail: [email protected]
Background: Substantial investments in promoting breastfeeding have taken place in the past 10 years in Scotland. This study assesses whether there were significant changes in breastfeeding initiation and mixed breastfeeding duration between 2004–2005 and 2010–2011. Methods: This study uses data from two nationally representative cohorts of babies in Scotland born between June 2004–May 2005 (N = 5030) and March 2010– February 2011 (N = 5838). Multivariate logistic regression for breastfeeding initiation and multivariate survival analysis for breastfeeding duration using cross-sectional data based on maternal recall were performed. Results: An increase in breastfeeding initiation from 60 to 63% was not significant (P = 0.125), and controlling for covariates, there was no significant cohort effect when comparing breastfeeding initiation between cohorts [odds ratio (OR) 1.02, 95% confidence interval (CI) 0.91–1.13]. For breastfeeding duration of up to 1 month, the 2010–11 cohort was more likely to give up breastfeeding sooner (HR 1.23, 95%CI 1.12–1.34). However, for breastfeeding durations of >1–6 months, or 6 months, the 2010–11 cohort was significantly less likely to give up breastfeeding sooner (HR 0.79, 95%CI 0.70–0.88 and HR 0.79, 95%CI 0.68–0.92, respectively). Breastfeeding duration increased the most among mothers with fewer educational qualifications, and mothers with no qualifications in 2010–11 were far less likely to stop breastfeeding early compared with their counterparts in 2004–05 (HR 0.32, 95%CI 0.17–0.58). Conclusion: After the 1 month mark, babies born in 2010–11 were more likely to be breastfed for longer compared with those born in 2004–05, and this effect was particularly pronounced among more disadvantaged families. The potential causal role of health policy is discussed.
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Introduction Evidence on breastfeeding benefits A wealth of research has focused on the positive health outcomes of breastfeeding for mother and child.1–5 Public health policy at
international level has, since the 80s and 90s, endorsed higher breastfeeding initiation and longer duration rates, and regulation of breast milk substitutes through a series of policy initiatives, including the International Code of Marketing of Breastmilk Substitutes,6 the Innocenti Declaration that also announced the launch of the Baby
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15 Statistisches Bundesamt. Yearbook Germany Extract j Chapter 2 Population, Families, Living Arrangements 2012 Federal Statistical Office of Germany. Federal Statistical Office, Wiesbaden, 2012. Available at: https://http://www.destatis.de/EN/ Publications/Specialized/Population/StatYearbook_Chapter2_5011001129004. pdf?__blob=publicationFile (4 October 2013, date last accessed).
20 Oostenbrink JB, Koopmanschap MA, Rutten FF. Standardisation of costs: the Dutch Manual for Costing in economic evaluations. Pharmacoeconomics 2002;20:443–54.
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Busse R, Schreyogg J, Smith PC. Variability in healthcare treatment costs amongst nine EU countries - results from the HealthBASKET project. Health Econ 2008;17: S1–8.
9
Skeie B, Mishra V, Vaaler S, et al. A comparison of actual cost, DRG-based cost, and hospital reimbursement for liver transplant patients. Transpl Int 2002;15:439–45.
10 Tan SS, Oppe M, Zoet-Nugteren SK, et al. A microcosting study of diagnostic tests for the detection of coronary artery disease in The Netherlands. Eur J Radiol 2009; 72:98–103. 11 Dormont B, Milcent C. The sources of hospital cost variability. Health Econ 2004;13: 927–39. 12 Lotter O, Jaminet P, Amr A, et al. Reimbursement of burns by DRG in four European countries: an analysis. Burns 2011;37:1109–16. 13 Pirson M, Schenker L, Martins D, et al. What can we learn from international comparisons of costs by DRG? Eur J Health Econ 2013;14:67–73.
15 Scheller-Kreinsen D, Quentin W, Busse R. DRG-based hospital payment systems and technological innovation in 12 European countries. Value Health 2011;14: 1166–72. 16 St-Hilaire C, Crepeau PK. Hospital and unit cost allocation methods. Healthc Manage Forum 2000;13:12–32.
19 Clement Nee Shrive FM, Ghali WA, Donaldson C, et al. The impact of using different costing methods on the results of an economic evaluation of cardiac care: microcosting vs gross-costing approaches. Health Econ 2009;18:377–88. 20 Tan SS, Rutten FF, van Ineveld BM, et al. Comparing methodologies for the cost estimation of hospital services. Eur J Health Econ 2009;10:39–45. 21 Wordsworth S, Ludbrook A, Caskey F, et al. Collecting unit cost data in multicentre studies. Creating comparable methods. Eur J Health Econ 2005;6:38–44. 22 Swindle R, Lukas CV, Meyer DA, et al. Cost analysis in the Department of Veterans Affairs: consensus and future directions. Med Care 1999;37:AS3–8. 23 Jackson T. Cost estimates for hospital inpatient care in Australia: evaluation of alternative sources. Aust N Z J Public Health 2000;24:234–41. 24 Fattore G, Torbica A. Inpatient reimbursement system in Italy: how do tariffs relate to costs. Health Care Manag Sci 2006;9:251–8. 25 Forgione DA, Vermeer TE, Surysekar K, et al. The impact of DRG-based payment systems on quality of health care in OECD countries. J Health Care Finance 2004;31: 41–54. 26 Pongpirul K, Walker DG, Rahman H, et al. DRG coding practice: a nationwide hospital survey in Thailand. BMC Health Serv Res 2011;11:290. 27 Ghaffari S, Doran C, Wilson A, et al. Investigating DRG cost weights for hospitals in middle income countries. Int J Health Plann Manage 2009;24:251–64.
17 Tan SS, van Ineveld BM, Redekop WK, et al. Comparing methodologies for the allocation of overhead and capital costs to hospital services. Value Health 2009;12:530–5.
......................................................................................................... European Journal of Public Health, Vol. 24, No. 6, 1028–1033 ß The Author 2014. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/cku037 Advance Access published on 3 April 2014
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Direct health care costs of hospital admissions due to adverse events in the Netherlands Fabienne J. H. Magdelijns1, Patricia M. Stassen1,2,3, Coen D. A. Stehouwer1,4, Evelien Pijpers1,5 1 Division of General Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht University, Maastricht, The Netherlands 2 Division of Acute Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht University, Maastricht, The Netherlands 3 School of CAPHRI, Maastricht University Medical Centre, Maastricht University, Maastricht, The Netherlands 4 Cardiovascular Research Institute, Maastricht University Medical Centre, Maastricht University, Maastricht, The Netherlands 5 Section of Clinical Geriatric Medicine, Maastricht University Medical Centre, Maastricht University, Maastricht, The Netherlands Correspondence: Fabienne J. H. Magdelijns, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht University, 6202 AZ Maastricht, The Netherlands, Tel: +31 (0)43 3875100, Fax: +31 (0)43 3877822, e-mail: [email protected]
Background: Health care-related adverse events (AEs) are common, and the economic burden is substantial. Information on costs of health care-related AEs ‘leading’ to hospitalization is limited and has focused on adverse drug events. Aim: To provide insight into costs of admissions due to (preventable) health care-related AEs, not limited to adverse drug events. Methods: This study was conducted during a 5-month period (May–September 2010) in the Netherlands, in a 600-bed university medical centre. All patients who were admitted via the emergency department to an internal medicine department because of a health care-related AE were included. We retrospectively retrieved all data on medical information as well as health care resource utilization from the patient’s medical record. The cost of the admission was estimated (for each patient individually) by multiplying the number of resources by their specific unit cost and then summing all costs per patient. Results: In total, 324 admissions due to a health care-related AE were included (28.7% of all admissions). Total direct health care costs of these hospitalizations amounted to E1 404 070 in a 5-month period. Medication-related AEs were most common (43.5%) and contributed most to the costs (E587 550; 41.8%). Inpatient days were most expensive (E1 076 385; 77.3%). Preventable health care-related AEs accounted for E277 665 (19.8%). Conclusion: We found that health care-related AEs are expensive, with preventable health care-related AEs accounting for one-fifth of the costs. Awareness of possible health care-related AEs following medical actions is necessary to reduce already high health care costs.
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14 Busse R, Geissler A, Quentin W, et al. Diagnosis-Related Groups in Europe: moving towards transparency, efficiency and quality in hospitals, 1st edn. Buckingham: Open University Press and WHO Regional Office for Europe, 2011.
18 Williams SV, Finkler SA, Murphy CM, et al. Improved cost allocation in case-mix accounting. Med Care 1982;20:450–9.
Hospital admissions due to adverse events: a cost analysis
Introduction
Methods Patients and study design The study was conducted within another retrospective single-centre study of which the study design and results have been described previously.6 In summary, all patients 18 years of age who were admitted to the department of internal medicine via the ED because of a health care-related AE during the period May– September 2010 were included. Our hospital is a secondary and tertiary university medical care centre (Maastricht University Medical Centre; MUMC+). Most patients presenting to the ED are referred by general practitioners, except for high-urgency (ambulance) patients and some self-presenters. Internists specialized in acute care assess and treat these patients with general internal medicine, oncological, haematological, nephrological, gastrointestinal and rheumatological problems. A health care-related AE was defined according to the Dutch Internal Medicine Association as ‘any event or state during or following treatment by a specialist that influenced the health of the patient in such way that renewed treatment was necessary or that it led to damage’.18 All investigators had successfully completed an e-learning course concerning the registration of health carerelated AEs.18 Health care-related AEs were categorized into medication-, chemotherapy-, procedure- or diabetes mellitusrelated or other AEs.
Data collection From the admitted patient’s medical record, we retrieved the nature of all health care-related AEs. If a patient was admitted for more than one health care-related AE, the health care-related AE with (potentially) the most serious consequences was scored.
Two independent investigators evaluated the potential preventability of a health care-related AE. If there was no consensus, a third investigator decided on the issue. For assessing the preventable medication-related AEs, we used the algorithm by Schumock et al.19 The assessment of preventability of the other types of health carerelated AEs was based on the opinion of the investigators.
Health care system structure In the Netherlands, the health insurance company pays the hospital based on a diagnosis-based reimbursement system, which is thought to reflect average costs. This means that if a patient has, for example, acute myeloid leukaemia, this diagnosis will be reimbursed by the insurance company (so a standard amount will be reimbursed). This amount includes not only the treatment of the acute myeloid leukaemia but also the likelihood of a hospital admission due to a health care-related AE. Consequently, this amount is independent of the number of admissions. Analysing the costs reimbursed by the insurance company would not give us any insight into the costs of admissions due to a health care-related AE. Moreover, information on costs reimbursed by the insurance company is generally confidential, as publishing this information could lead to problems in the negotiations between hospitals and insurance companies. Therefore, we calculated with unit costs of all health care resources used by patients to give detailed information on costs of an admission due to a health care-related AE. In the Netherlands, all inhabitants are obliged to have a health insurance for monthly rates must be paid. The insurance company pays all costs incurred by hospital admissions.
Cost analysis All health care resources used by the patients during admission were collected retrospectively from the patients’ medical record and analysed per individual patient. For the cost analysis, unit costs for each of the used resources (ED visit, admission days, imaging studies, interventions and some treatments) were retrieved from the central accounting system of the hospital. These are standardized real cost calculations based on true activities involved and taking into account the person-hours and resources involved to perform the activity, as well as the estimated hospital overhead.20 These costs are used for internal payments of the departments that perform the different activities and are not the actual costs that are reimbursed by the insurance company. The unit costs correspond to reference costs based on Dutch guidelines for pharmacoeconomic evaluations21 but are specific to our own hospital. The Dutch reference costs of admission days in general wards or intensive care units (ICUs) of academic hospitals are calculated from data of cost evaluations combined with statistical data from general hospitals acquired in 2008 (Supplementary table S1). Reference costs of hospital days and the ED visit include costs of medical and nursing staff, material and equipment and housing and overhead.21,22 The following six resources were included in the cost analysis (Supplementary figure S1), which are all direct costs: (1) Cost of the visit to the ED. A fixed tariff is used for every visit of a patient to the ED, which includes person-hours, housing, all necessary blood tests and treatments (antibiotics, infusion and other medication). (2) Cost of subsequent inpatient days. In this analysis, costs per first day and per subsequent days were calculated separately, as the first day is more expensive than subsequent inpatient days. For the same reason, costs for admission to general wards and ICUs were calculated separately. (3) Cost of blood tests. We calculated the mean costs of the most relevant analyses per day, i.e. electrolytes (sodium and potassium), renal function, haemoglobin, leucocytes, platelets and C-reactive proteins.
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ealth care-related adverse events (AEs) are common and may 1–6 Apart from the loss of quality of life and life expectancy, health care-related AEs lead to considerable costs.2,7–11 In Europe and the United States, costs of (preventable) health care-related AEs, including adverse drug events (ADEs), occurring ‘during’ hospitalization are found to be substantial.2,9,10,12 However, costs of health care-related AEs ‘leading’ to hospitalization have not been studied extensively. In 2000, a study performed in the United States showed that ADEs leading to hospitalization exceeded $3066 [in July 2000 $1 = E1.0513] per admission.11 In the United Kingdom, the annual cost of ADEs directly leading to admission amounted to E11.9 million/1 million inhabitants.8,14 In Germany, ADEs leading to admission to an internal medicine department cost E5.2 million/1 million inhabitants.7,15 In the Netherlands, preventable medication-related admissions amounted to E5.7 million/ 1 million inhabitants.16,17 To reduce costs caused by health care-related AEs, gaining insight into the extent and nature of these costs is necessary. To our knowledge, costs of a hospital admission due to all health carerelated AEs, not just ADEs, have not yet been investigated. The objective of this study is to investigate total direct health care costs of hospitalization of patients admitted through the emergency department (ED) due to a health care-related AE. We investigated direct costs of several types of health care-related AEs, evaluated which health care-related AEs are most expensive and to what extent each separate item (inpatient days, imaging studies, interventions and provided treatments) contributes to total costs. Finally, we investigated direct costs of ‘potentially preventable’ health carerelated AEs.
Hlead to disability, morbidity and even mortality.
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cases. The mean age of our patients was 66 years (range: 21–96, SD: 16 years), and 49.4% were female. The median number of inpatient days was 5 (range: 1–92 days). Table 1 shows the different health care-related AEs in more detail. Almost half (43.5%) of the health care-related AEs were medication related. In all, 27% (n = 90) of these AEs were judged preventable (table 2). Table 1 Study population and prevalence of health care-related AEs in a 5-month study period Study population
N (%)
Sex, female Median age in years (Q1, Q3) Mean age in years (range) Mean duration of admission in days (range) Median duration of admission in days (Q1, Q3)
160 67 66 8 5
(49.4) (57,77) (21–96) (1–92) (3,10)
AEs
N (%)
Results
Medication-related Bleeding using anticoagulants Coumarines Other anticoagulants Fever/infections using immunosuppressive drugs Electrolyte problems Constipation Anaphylaxis Other Chemotherapy-related Non-neutropenic fever Neutropenic fever Gastrointestinal complaints Electrolyte problems Other Procedure-related Dialysis-related Cholangitis after ERCP GvHD after SCT Bleeding Perforation Contrast-associated renal dysfunction Other Diabetes mellitus-related Hypoglycaemia Hyperglycaemia Ketoacidosis Other (renal dysfunction) Other While on a waiting lista
141 (43.5) 46 (14.2) 19 (5.9) 27 (8.3) 44 (13.6) 11 (3.4) 9 (2.8) 2 (0.6) 29 (9.0) 87 (26.9) 34 (10.5) 17 (5.2) 14 (4.3) 5 (1.5) 17 (5.2) 56 (17.3) 9 (2.8) 8 (2.5) 6 (1.9) 4 (1.2) 2 (0.6) 1 (0.3) 26 (8.0) 36 (11.1) 17 (5.2) 18 (5.6) 2 (0.6) 1 (0.3) 4 (1.2) 3 (0.9)
In the period May–September 2010, 284 patients were admitted 324 times because of a health care-related AE, accounting for 28.7% of all admissions to the department of internal medicine through the ED. Multiple health care-related AEs occurred in 4% (n = 13) of the
Abbreviations: Q, quartile; GvHD, graft versus host disease; SCT, stem cell transplantation; ERCP = endoscopic retrograde cholangiopancreatography. a These patients are counted twice in the table.
To calculate the costs per patient, each resource used was multiplied by the unit cost of that resource, and the cost was summed thereafter. In addition, we calculated direct costs per type of health care-related AE and calculated to what extent each of the cost categories (inpatient days, imaging studies, interventions, medication, transfusions and blood tests) contributed to total costs. Furthermore, direct costs of potentially preventable health care-related AEs were analysed separately. No statistical analyses were performed, except for descriptive analyses for which SPSS Statistics version 18 (SPSS Inc, Chicago, IL, USA) was used. Categorical data were reported as absolute counts with percentages; continuous data were reported as mean with standard deviations (SD) and as medians with interquartiles (Q1 and Q3). The medical ethics committee of the institution (MedischEthische Toetsing Onderzoek, Maastricht, the Netherlands) approved this study.
Table 2 Costs of admissions due to a (preventable) health care-related AE in a 5-month study period Health care-related AEs n
Total cost in E
Preventable health care-related AEs
Percentage of total costs
Mean cost in E per patient
SD in E of mean cost per patient
n
Total cost in E
Percentage of total costs
Mean cost in E per patient
SD in E of mean cost per patient
Medication-related Chemotherapy-related Procedure-related Diabetes mellitus-related Other
141 34 56 36 4
587 550 412 626 291 841 105 537 6515
41.8 29.4 20.8 7.5 0.5
4167 4743 5211 2932 1629
5065 4010 5005 2762 448
43 1 19 25 2
136 339 2005 69 523 67 294 2 503
49.1 0.7 25.0 24.3 0.9
3171 2005 3659 2692 1252
2311 0 3128 1899 0
Total
324
1 404 070
100
4334
4582
90
277 665
100
3085
2383
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(4) Cost of all imaging studies. (5) Cost of all performed interventions. (6) Cost of specific treatments including all required transfusions (packed cells, platelets and fresh frozen plasma), infusion fluids and antibiotics. For this analysis, we made two assumptions. First, to calculate the amount of infusion fluids administered during hospitalization, we estimated how many units of 500-ml infusion fluids each patient admitted to a general ward of the department of internal medicine received. For this estimation, we counted the number of units of infusion fluids that were administered per patient per day on four different days during two consecutive weeks and assumed that this sample could be extrapolated to the entire cohort of patients. On average, each of the 370 patients received 500 ml of infusion fluids per 24 h. Second, regarding the antibiotics prescribed on admission, we assumed that patients could be divided into three groups— haematology, oncology and general internal medicine—as these groups are treated according to different treatment protocols. We assumed that all haematology patients were treated with piperacillin/tazobactam intravenously for 7 days, all oncology patients with amoxicillin/clavulanic acid and ciprofloxacin for 7 days (5 days intravenously) and general internal medicine patients with amoxicillin/clavulanic acid for 7 days (3 days intravenously) and one dose of gentamicin. Costs of these antibiotics were based on pharmacy prices in the Netherlands.23
Hospital admissions due to adverse events: a cost analysis
Direct costs of health care-related AEs The total direct costs of the 324 admissions due to a health care-related AE in the 5-month period amounted to E1 404 070. Medicationrelated AEs (43.5%) contributed most to the costs (E587 550; 41.8%) (table 2). Per patient, procedure-related admissions were most expensive (E5211, SD: E5005), with chemotherapy-related AEs being second most expensive (E4743, SD: E4010).
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inpatient days contributed most to the overall costs of the category. Costs related to the use of medication were highest in the chemotherapy-related AE category. Interventions or re-interventions contributed considerably to the total direct costs of procedure-related AEs compared with other categories of health care-related AEs.
Discussion Direct costs of potentially preventable health care-related AEs The 90 preventable health care-related AEs (27.8% of all health carerelated AEs) that resulted in an admission amounted to E277 665 (19.8% of total direct costs) (table 2). Medication-related AEs contributed most to these costs (E136 339; 49.1%), but procedurerelated admissions were most expensive per patient in this subgroup.
The degree to which costs of each of the six cost categories contributed to total direct costs is shown in more detail in figure 1. Inpatient days (mean: 8; range: 1–92) contributed most to the total direct costs (E1 076 385; 76.7%). Four patients were admitted to the ICU, which amounted to E41 515 of total direct costs (3.6% of costs of all inpatient days). The mean direct cost per patient for inpatient days amounted to E3322 (SD: E3909). On average per patient, E211 (SD: E342) was spent on imaging studies, E279 (SD: E227) on blood testing. If antibiotics were necessary, this amounted to a mean of E202 (SD: E160). If a patient needed transfusions, this amounted to a mean of E935 (range: E131–E8835, SD: E1420). Table 3 shows the contribution of each cost category to the total direct cost per health care-related AE category. In all categories, 3.1%
1.8% 0.5%
4.9% 1.6%
5.0%
6.4% Emergency department visit (€70,995) Inpatient days (€1,076,385) Blood testing (€90,307) Imaging studies (€68,221) Interventions (€21,811) Transfusions (€43,944) Antibiotics (€25,055) Infusions (€7,352)
76.7%
Figure 1 Contribution of each cost category presented in percentage of total costs. Treatment is divided into transfusions, antibiotics started at admission and infusions
Table 3 Contribution of each cost category to total costs per health care-related AE category Medication-related (%)
Chemotherapy-related (%)
Procedure-related (%)
ED visit Inpatient days Blood testing Imaging studies Interventions Transfusions Antibiotics Infusions
30 896 456 851 38 906 28 167 10 600 14 399 4581 3151
19 063 310 238 25 034 20 328 1706 15 178 19 009 2071
12 271 221 914 17 675 14 354 9505 13 483 1113 1526
Total costs
587 551 (100)
(5.3) (77.7) (6.6) (4.8) (1.8) (2.5) (0.8) (0.5)
(4.6) (75.2) (6.1) (4.9) (0.4) (3.7) (4.6) (0.5)
412 627 (100)
Diabetes mellitus-related (%)
Other (%)
(4.2) (76.0) (6.1) (4.9) (3.3) (4.6) (0.4) (0.5)
7888 (7.5) 83 468 (79.1) 8117 (7.7) 5132 (4.9) 0 0 352 (0.3) 581 (0.5)
877 (13.5) 3915 (60.1) 576 (8.8) 240 (3.6) 0 885 (13.6) 0 24 (0.4)
291 841 (100)
105 538 (100)
6517 (100)
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Contribution of each cost category to total direct costs of health care-related AEs
Health care-related AEs are not only a common reason for hospitalization, but they are also expensive, amounting to E1 404 070 in a 5-month period in one university hospital (E3 369 768 per year). In Europe, some studies have been performed on costs of ADEs leading to hospital admissions (as studies cited are performed in different years, we added Supplementary table S2 with annual average consumer price indices as a measure of inflation to compare the mentioned costs with present data). In the United Kingdom, ADEs leading to hospitalization are estimated to amount to E706 million per year, i.e. E11.9 million/1 million inhabitants (2001–2002).8,14 A German study found that the mean treatment costs of a single ADE regarding admission to departments of internal medicine amounted to E2250 (range: E733–E17 482) (2006–2007).7 In that study, total direct costs of treatment of these ADEs amounted to E5.2 million/1 million inhabitants.15 Our study shows that medication-related AEs are the most common AEs leading to hospitalization (43.5%). They cost E4167 (range: E867–E38 422) per hospital admission. The costs of medicationrelated admissions in our study are higher than in the German study. First, this may be explained by differences in health care systems between the Netherlands and Germany. Second, in the German study, a lump sum per case system based on diagnosisrelated groups was used for the cost analysis,7 which is less detailed than our cost analysis in which we present real costs. Reducing costs resulting from hospitalizations due to health carerelated AEs may be achieved—above all from improving a patient’s health by modification or change of therapy and thereby preventing health care-related AEs—by decreasing the number of inpatient days, as inpatient days explain the bulk of costs (E1 076 385; 76.7% of total direct costs). This was also found in the multicentre Hospital Admissions Related to Medication (HARM) study that was performed in the Netherlands.16 In confirmation of the impact of health care-related AEs on inpatient days, 4% of the hospital bed capacity was found to be occupied by patients admitted to the hospital due to an ADE in the United Kingdom.8 The median length of hospital stay in the HARM study was 8 days,16 which is comparable with the study conducted in the United Kingdom8 and our findings (mean: 8 days, median: 5 days). In all, 27% of health care-related AEs leading to hospitalization were judged preventable in our study. This is comparable with the German study on ADE-related hospital admissions, in which 20.1% were judged preventable.7 By preventing AEs, E87 million could be saved per year in Germany. The HARM study showed that each
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effective this shortening is in reducing the direct costs of health carerelated AEs. These items could be subject for further study. In conclusion, this study demonstrates that direct costs of health care-related AEs leading to hospital admissions are high, with medication-related admission being most expensive and inpatient days contributing most to these costs. Moreover, preventable health care-related AEs leading to hospitalization amount to nearly 20% of these costs. As all treatments are inevitably associated with the risk of health care-related AEs, awareness of health care-related AEs is necessary to reduce direct health care costs.
Supplementary data Supplementary data are available at EURPUB online.
Acknowledgements F.J.H.M. acquired data and drafted the manuscript; P.M.S., C.D.A.S., E.P. and A.B. contributed substantially to its revision; E.P. takes responsibility for the article as a whole. Conflicts of interest: None declared.
Key points In the Netherlands, health care-related AEs leading to hospitalization in an internal medicine department are expensive (almost E1.5 million in a 5-month period in one university hospital). One-fifth of the health care-related AEs are potentially preventable, corresponding to almost E300 000 (in a 5-month period in one university hospital). The largest contributing factor is the inpatient days (76.7% of total direct costs). Awareness of (preventable) health care-related AEs is desirable to reduce direct health care costs.
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10 Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA 1997; 277:307–11.
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preventable medication-related hospital admission amounted to E6009, taking production losses into account. Therefore, total costs of preventable medication-related admissions would amount to >E94 million per year in the Netherlands, of which E86 million would be due to medical costs alone.16 In our study, preventable medication-related admission cost E3170 per patient, which is less than in the HARM study. However, in the HARM study, production losses were taken into account, which could explain this difference. Of the preventable health care-related AEs in our study, diabetes mellitus-related hospitalizations were most prevalent. Nearly 70% of diabetes-related AEs were judged preventable. However, in the HARM study, admissions related to the endocrine system (including hypoglycaemia or hyperglycaemia) were only the fourth most prevalent preventable AE.16 This difference can be explained by the fact that we judged non-compliance as a preventable health carerelated AE. This assumption is of course open for debate. Our study has some limitations. First, this study was based on one department, internal medicine, of one university hospital and is a rather small study. Thereby, only patients admitted through the ED were included. Patients admitted through an outpatient department were not included. Thus, the health care-related AEs included in the present study are likely to be severe and therefore costly. Moreover, patients with a health care-related AE leading to hospitalization to departments of other medical specialties not treated by internists were not taken into account. Therefore, our study must be seen as a first step in the analysis of all health care-related AEs of all specialties leading to hospitalization. Moreover, our study was performed in the Netherlands, which makes confirmation in other countries with different health care systems necessary. However, this limitation exists for every national study. To correct for international differences, each country might perform its own calculations and report these in a standard manner. Second, the judgement of health care-related AEs being potentially preventable was based on the opinion of two or (in case of disagreement) three investigators. This could be a source of bias. However, a standardized method is, as far as we know, not available for AEs in general except for ADEs. For the ADEs, we used the method by Schumock et al., as in other studies (e.g. HARM study).16,19 Third, charges are not the actual costs reimbursed by the insurance company. Therefore, the economic burden of health care-related AEs to society is not exactly clear. Fourth, pre-existing comorbidity that is independent of the health care-related AE may to some extent have contributed to the hospital admission due to a health care-related AE. This could have led to overestimation of direct costs. In future study, this must be investigated and taken into account. Further, information on sociodemographic differences in the study population was not available. Therefore, it is unknown whether sociodemographic differences influenced the costs of some health care-related AEs. However, as every inhabitant in the Netherlands is obliged to have health care insurance, access to complete health care is not limited to socioeconomic class. For future perspectives, more information on sociodemographic differences should be gathered. Moreover, in future study, non-health care direct costs, as well as indirect costs such as loss of productivity and outpatient health care after discharge, may be included to make a broader cost estimation. Even if our study underestimates direct costs of health carerelated AEs leading to hospitalization, our study still shows that health care-related AEs occur frequently and add up to the already high health care costs. Further, we believe that this study gives broad insight into the direct costs of health care-related AEs leading to hospitalization, including the contribution of the inpatient days, antibiotic use, blood tests, interventions and transfusions to total direct costs. However, in our study, no distinction has been made between mild, moderate or severe AEs. In addition, as our study provides clues to reduce direct health care costs, it would be interesting to find out what actions can be taken to shorten the number of inpatient days (as this is the main cost driver) and to explore how
Change in breastfeeding patterns in Scotland
11 Rodriguez-Monguio R, Otero MJ, Rovira J. Assessing the economic impact of adverse drug effects. Pharmacoeconomics 2003;21:623–50.
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12 Rottenkolber D, Hasford J, Stausberg J. Costs of adverse drug events in German hospitals–a microcosting study. Value Health 2012;15:868–75.
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14 Office for National Statistics. . Mid-1971 to Mid-2010 Population Estimates: United Kingdom; estimated resident population for constituent countries and regions in England. Population Demography Division, Fareham, 2011. Available at: http://www.ons.gov.uk/ons/taxonomy/search/index.html?nscl=Population+ Change&nscl-orig=Population+Change&content-type=Dataset&content-type= Reference+table&sortDirection=DESCENDING&sortBy=pubdate (4 October 2013, date last accessed).
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16 Leendertse AJ, Van Den Bemt PM, Poolman JB, et al. Preventable hospital admissions related to medication (HARM): cost analysis of the HARM study. Value Health 2011;14:34–40.
21 Hakkaart-van Roijen L, Tan SS, Bouwmans CAM. Handleiding voor kostenonderzoek. Methoden en Standaard Kostprijzen voor Economische Evaluatie in de Gezondheidszorg. Diemen, The Netherlands: College Voor Zorgverzekeringen Geactualiseerde versie, 2010. 22 Tan SS, Bouwmans CA, Rutten FF, Hakkaart-van Roijen L. Update of the Dutch Manual for Costing in Economic Evaluations. Int J Technol Assess Health Care 2012; 28:152–8. 23 Medicijnkosten. College voor Zorgverzekeringen, 2013. Available at: http://www. medicijnkosten.nl.
......................................................................................................... European Journal of Public Health, Vol. 24, No. 6, 1033–1041 ß The Author 2014. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/cku029 Advance Access published on 18 March 2014
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Change in breastfeeding patterns in Scotland between 2004 and 2011 and the role of health policy Valeria Skafida Centre for Population Health Sciences & Centre for Research on Families and Relationships, University of Edinburgh, Edinburgh Correspondence: Valeria Skafida, Centre for Population Health Sciences & Centre for Research on Families and Relationships, University of Edinburgh, 23 Buccleuch Place, EH8 9LN, Edinburgh. Tel: +44 (0)131 651 3215, Fax: +44 (0)131 651 1833, e-mail: [email protected]
Background: Substantial investments in promoting breastfeeding have taken place in the past 10 years in Scotland. This study assesses whether there were significant changes in breastfeeding initiation and mixed breastfeeding duration between 2004–2005 and 2010–2011. Methods: This study uses data from two nationally representative cohorts of babies in Scotland born between June 2004–May 2005 (N = 5030) and March 2010– February 2011 (N = 5838). Multivariate logistic regression for breastfeeding initiation and multivariate survival analysis for breastfeeding duration using cross-sectional data based on maternal recall were performed. Results: An increase in breastfeeding initiation from 60 to 63% was not significant (P = 0.125), and controlling for covariates, there was no significant cohort effect when comparing breastfeeding initiation between cohorts [odds ratio (OR) 1.02, 95% confidence interval (CI) 0.91–1.13]. For breastfeeding duration of up to 1 month, the 2010–11 cohort was more likely to give up breastfeeding sooner (HR 1.23, 95%CI 1.12–1.34). However, for breastfeeding durations of >1–6 months, or 6 months, the 2010–11 cohort was significantly less likely to give up breastfeeding sooner (HR 0.79, 95%CI 0.70–0.88 and HR 0.79, 95%CI 0.68–0.92, respectively). Breastfeeding duration increased the most among mothers with fewer educational qualifications, and mothers with no qualifications in 2010–11 were far less likely to stop breastfeeding early compared with their counterparts in 2004–05 (HR 0.32, 95%CI 0.17–0.58). Conclusion: After the 1 month mark, babies born in 2010–11 were more likely to be breastfed for longer compared with those born in 2004–05, and this effect was particularly pronounced among more disadvantaged families. The potential causal role of health policy is discussed.
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Introduction Evidence on breastfeeding benefits A wealth of research has focused on the positive health outcomes of breastfeeding for mother and child.1–5 Public health policy at
international level has, since the 80s and 90s, endorsed higher breastfeeding initiation and longer duration rates, and regulation of breast milk substitutes through a series of policy initiatives, including the International Code of Marketing of Breastmilk Substitutes,6 the Innocenti Declaration that also announced the launch of the Baby
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15 Statistisches Bundesamt. Yearbook Germany Extract j Chapter 2 Population, Families, Living Arrangements 2012 Federal Statistical Office of Germany. Federal Statistical Office, Wiesbaden, 2012. Available at: https://http://www.destatis.de/EN/ Publications/Specialized/Population/StatYearbook_Chapter2_5011001129004. pdf?__blob=publicationFile (4 October 2013, date last accessed).
20 Oostenbrink JB, Koopmanschap MA, Rutten FF. Standardisation of costs: the Dutch Manual for Costing in economic evaluations. Pharmacoeconomics 2002;20:443–54.
