Cost-effectiveness analysis of different treatment modalities in BCG-unresponsive NMIBC.

OBJECTIVE: Radical cystectomy (RC) is the standard of care (SOC) in BCG-unresponsive NMIBC and is associated with a significant health-related quality-of-life burden. Recently, promising results have been published on Gemcitabine/Docetaxel, Pembrolizumab, and Hyperthermic Intravesical Chemotherapy (HIVEC) as salvage therapy options trying to increase the rate of bladder preservation. Here, we performed a Cost-Effectiveness-Analysis of those treatment modalities. PATIENTS AND METHODS: We developed a Markov model from a payer's perspective drawing on clinical data of single-arm trials testing intravesical gemcitabine/docetaxel and pembrolizumab in BCG-unresponsive NMIBC, as well as clinical data from patients receiving hyperthermic intravesical chemotherapy HIVEC (n = 29) as intravesical salvage chemotherapy at our uro-oncological centre in Cologne. Costs were simulated utilising a non-commercial diagnosis-related groups grouper, utilities were derived from comparable cost-effectiveness studies. We used a Monte Carlo simulation to identify the optimal treatment, comparing the incremental cost effectiveness ratios (ICERs) at a willingness-to-pay threshold of €50 000 (euro)/quality-adjusted life year (QALY). RESULTS: Over a horizon of 10 years, gemcitabine/docetaxel, HIVEC, and pembrolizumab were associated with costs of €48 353, €64 438, and €204 580, as well as a gain of QALYs of 6.16, 6.48, and 6.00, resulting in an ICER of €26 482, €42 567, and €184 533 respectively, in comparison to RC with total costs of €21 871 and a gain of QALYs of 5.01. Monte Carlo simulation identified HIVEC as the treatment of choice under assumption of a WTP of <€50 000. CONCLUSION: Considering a WTP of <€50 000/QALY, gemcitabine/docetaxel and HIVEC are highly cost-effective therapeutic options in BCG-refractory NMIBC, while RC remains the cheapest option. At its current price, pembrolizumab would only be cost-effective assuming a price reduction of at least 70%.

[Analysis of Efficency, Cost Structure and Revenues of ALT Free Flaps in Extremity Reconstruction]. / Analyse der Effizienz, Kostenstruktur und Erlössituation von freien ALT-Lappenplastiken zur Extremitätenrekonstruktion.

Microvascular reconstructions can be lengthy procedures lasting the entire day. As a result of unforeseeable events, the standardization of these procedures can be challenging. Moreover, the length of these procedures varies strongly, which impedes adequate scheduling and, therefore, optimal capacity utilization. Within the years 2018-2020, the duration of ALT free flap extremity reconstructions was correlated with the experience of the microsurgeon (category 1:<50 free flaps life-time experience, category 2: 50-200, category 3:>200) and comorbidities. The resulting costs were compared with the matrix of the German DRG Institute InEK. The surgical experience of the microsurgeon had a significant impact on the duration of surgery in extremity reconstruction. In due consideration of potential complications, category 2 microsurgeons were 45 minutes faster and category 3 microsurgeons were 167 minutes faster than category 1 microsurgeons. Comorbidities, by contrast, did not have a significant impact on procedure duration. Cost analysis revealed deficits for these procedures in relation to the InEK matrix. However, an additional analysis showed that the duration of surgery was within the German average while costs for personnel/OR minute were slightly below the average. According to this calculation, costs for microsurgical training were approximately 1000€/case. The reimbursement for flaps in extremity reconstruction is not entirely mapped in the German DRG system. Given the longer procedure times, microsurgical training is associated with higher costs. Defining the duration of microsurgery based on the level of expertise should result in improved adherence to schedule and more efficient utilization of the valuable operating room time.

Value Improvement by Assessing IR Care via Time-Driven Activity-Based Costing.

PURPOSE: To evaluate time-driven activity-based costing (TDABC) in interventional radiology for image-guided vascular malformation treatment as an example. MATERIALS AND METHODS: Retrospective analysis was performed on consecutive vascular malformation treatment cycles [67 venous malformations (VMs) and 11 arteriovenous malformations (AVMs)] in a university hospital in 2018. All activities were integrated with a process map, and spent resources were assigned accordingly. TDABC uses 2 parameters: (i) practical capacity cost rate, calculated as 80% of theoretical capacity, and (ii) time consumption of each resource determined by interviews (23 items). Thereby, the total costs were calculated. Treatment cycles were modified according to identified resource waste and TDABC-guided negotiations with health insurance. RESULTS: Total personnel time required was higher for AVM (1,191 min) than for VM (637 min) treatment. The interventional procedure comprised the major part (46%) of personnel time required in AVM, whereas it comprised 19% in VM treatment. Materials represented the major cost type in AVM (75%) and VM (45%) treatments. TDABC-based treatment process modification led to a decrease in personnel time need of 16% and 30% and a cost reduction of 5.5% and 15.7% for AVM and VM treatments, respectively. TDABC-guided cost reduction and TDABC-informed negotiations improved profit from -56% to +40% and from +41% to +69% for AVM and VM treatments, respectively. CONCLUSIONS: TDABC facilitated the precise costing of interventional radiologic treatment cycles and optimized internal processes, cost reduction, and revenues. Hence, TDABC is a promising tool to determine the denominator of interventional radiology's value.

Physician-leaders and hospital performance revisited.

Reflecting the increasing relevance of quality outcomes for hospital payments, some hospital boards have promoted physicians into top-management positions. So far, however, the literature regarding the impact of physician leadership on care quality or cost is limited. The aim of this study is to examine the link between the educational background of a hospital's CEO and its performance in terms of medical quality and financial success. Examining data of 370 German hospitals for the year 2016, this study uses the second largest sample of its kind and the largest for a single country. Multivariate regression analysis with matching is used to model the effect of the CEO's education, controlling for tenure, competition, hospital size and ownership. We find that physician-led hospitals have lower in-hospital mortality rates for pneumonia and higher patient satisfaction (at the 5% and 1% significance level, respectively). In contrast, institutions led by managers with economics or business degrees have better financial performance (at the 10% significance level) and superior outcomes for hip and knee surgeries (at the 1% and 10% significance level). Our findings support prior results regarding financial outcomes and mortality. However, including a broad spectrum of measures for clinical quality, we draw a more nuanced picture that does not point to the straightforward interpretation that physician CEOs lead to superior medical quality.