Outcomes of multisite antimicrobial stewardship programme implementation with a shared clinical decision support system.

Background: Studies evaluating antimicrobial stewardship programmes (ASPs) supported by computerized clinical decision support systems (CDSSs) have predominantly been conducted in single site metropolitan hospitals. Objectives: To examine outcomes of multisite ASP implementation supported by a centrally deployed CDSS. Methods: An interrupted time series study was conducted across five hospitals in New South Wales, Australia, from 2010 to 2014. Outcomes analysed were: effect of the intervention on targeted antimicrobial use, antimicrobial costs and healthcare-associated Clostridium difficile infection (HCA-CDI) rates. Infection-related length of stay (LOS) and standardized mortality ratios (SMRs) were also assessed. Results: Post-intervention, antimicrobials targeted for increased use rose from 223 to 293 defined daily doses (DDDs)/1000 occupied bed days (OBDs)/month (+32%, P < 0.01). Conversely, antimicrobials targeted for decreased use fell from 254 to 196 DDDs/1000 OBDs/month (-23%; P < 0.01). These effects diminished over time. Antimicrobial costs decreased initially (-AUD$64551/month; P < 0.01), then increased (+AUD$7273/month; P < 0.01). HCA-CDI rates decreased post-intervention (-0.2 cases/10 000 OBDs/month; P < 0.01). Proportional LOS reductions for key infections (respiratory from 4.8 to 4.3 days, P < 0.01; septicaemia 6.8 to 6.1 days, P < 0.01) were similar to background LOS reductions (2.1 to 1.9 days). Similarly, infection-related SMRs (observed/expected deaths) decreased (respiratory from 1.1 to 0.75; septicaemia 1.25 to 0.8; background rate 1.19 to 0.90. Conclusions: Implementation of a collaborative multisite ASP supported by a centrally deployed CDSS was associated with changes in targeted antimicrobial use, decreased antimicrobial costs, decreased HCA-CDI rates, and no observable increase in LOS or mortality. Ongoing targeted interventions are suggested to promote sustainability.

Acute costs and predictors of higher treatment costs of trauma in New South Wales, Australia.

BACKGROUND: Accurate economic data are fundamental for improving current funding models and ultimately in promoting the efficient delivery of services. The financial burden of a high trauma casemix to designated trauma centres in Australia has not been previously determined, and there is some evidence that the episode funding model used in Australia results in the underfunding of trauma. AIM: To describe the costs of acute trauma admissions in trauma centres, identify predictors of higher treatment costs and cost variance in New South Wales (NSW), Australia. MATERIALS AND METHODS: Data linkage of admitted trauma patient and financial data provided by 12 Level 1 NSW trauma centres for the 08/09 financial year was performed. Demographic, injury details and injury scores were obtained from trauma registries. Individual patient general ledger costs (actual trauma patient costs), Australian Refined Diagnostic Related Groups (AR-DRG) and state-wide average costs (which form the basis of funding) were obtained. The actual costs incurred by the hospital were then compared with the state-wide AR-DRG average costs. Multivariable multiple linear regression was used for identifying predictors of costs. RESULTS: There were 17,522 patients, the average per patient cost was $10,603 and the median was $4628 (interquartile range: $2179-10,148). The actual costs incurred by trauma centres were on average $134 per bed day above AR-DRG costs-determined costs. Falls, road trauma and violence were the highest causes of total cost. Motor cyclists and pedestrians had higher median costs than motor vehicle occupants. As a result of greater numbers, patients with minor injury had comparable total costs with those generated by patients with severe injury. However the median cost of severely injured patients was nearly four times greater. The count of body regions injured, sex, length of stay, serious traumatic brain injury and admission to the Intensive Care Unit were significantly associated with increased costs (p<0.001). CONCLUSION: This multicentre trauma costing study demonstrated the feasibility of trauma registry and financial data linkage. Discrepancies between the observed costs of care in these 12 trauma centres and the NSW average AR-DRG costs suggest that trauma care is currently underfunded in NSW.

Major trauma: the unseen financial burden to trauma centres, a descriptive multicentre analysis.

OBJECTIVE: This research examines the existing funding model for in-hospital trauma patient episodes in New South Wales (NSW), Australia and identifies factors that cause above-average treatment costs. Accurate information on the treatment costs of injury is needed to guide health-funding strategy and prevent inadvertent underfunding of specialist trauma centres, which treat a high trauma casemix. METHODS: Admitted trauma patient data provided by 12 trauma centres were linked with financial data for 2008-09. Actual costs incurred by each hospital were compared with state-wide Australian Refined Diagnostic Related Groups (AR-DRG) average costs. Patient episodes where actual cost was higher than AR-DRG cost allocation were examined. RESULTS: There were 16693 patients at a total cost of AU$178.7million. The total costs incurred by trauma centres were $14.7million above the NSW peer-group average cost estimates. There were 10 AR-DRG where the total cost variance was greater than $500000. The AR-DRG with the largest proportion of patients were the upper limb injury categories, many of whom had multiple body regions injured and/or a traumatic brain injury (P<0.001). CONCLUSIONS: AR-DRG classifications do not adequately describe the trauma patient episode and are not commensurate with the expense of trauma treatment. A revision of AR-DRG used for trauma is needed. WHAT IS KNOWN ABOUT THIS TOPIC? Severely injured trauma patients often have multiple injuries, in more than one body region and the determination of appropriate AR-DRG can be difficult. Pilot research suggests that the AR-DRG do not accurately represent the care that is required for these patients. WHAT DOES THIS PAPER ADD? This is the first multicentre analysis of treatment costs and coding variance for major trauma in Australia. This research identifies the limitations of the current AR-DRGS and those that are particularly problematic. The value of linking trauma registry and financial data within each trauma centre is demonstrated. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Further work should be conducted between trauma services, clinical coding and finance departments to improve the accuracy of clinical coding, review funding models and ensure that AR-DRG allocation is commensurate with the expense of trauma treatment.

The cost-effectiveness of physician staffed Helicopter Emergency Medical Service (HEMS) transport to a major trauma centre in NSW, Australia.

BACKGROUND AND CONTEXT: Helicopter Emergency Medical Services (HEMS) are highly resource-intensive facilities that are well established as part of trauma systems in many high-income countries. We evaluated the cost-effectiveness of a physician-staffed HEMS intervention in combination with treatment at a major trauma centre versus ground ambulance or indirect transport (via a referral hospital) in New South Wales (NSW), Australia. METHODS: Cost and effectiveness estimates were derived from a cohort of trauma patients arriving at St George Hospital in NSW, Australia during an 11-year period. Adjusted estimates of in-hospital mortality were derived using logistic regression and adjusted hospital costs were estimated through a general linear model incorporating a gamma distribution and log link. These estimates along with other assumptions were incorporated into a Markov model with an annual cycle length to estimate a cost per life saved and a cost per life-year saved at one year and over a patient's lifetime respectively in three patient groups (all patients; patients with serious injury [Injury Severity Score>12]; patients with traumatic brain injury [TBI]). RESULTS: Results showed HEMS to be more costly but more effective at reducing in-hospital mortality leading to a cost per life saved of $1,566,379, $533,781 and $519,787 in all patients, patients with serious injury and patients with TBI respectively. When modelled over a patient's lifetime, the improved mortality associated with HEMS led to a cost per life year saved of $96,524, $50,035 and $49,159 in the three patient groups respectively. Sensitivity analyses revealed a higher probability of HEMS being cost-effective in patients with serious injury and TBI. CONCLUSION: Our investigation confirms a HEMS intervention is associated with improved mortality in trauma patients, especially in patients with serious injury and TBI. The improved benefit of HEMS in patients with serious injury and TBI leads to improved estimated cost-effectiveness.

Do AR-DRGs adequately describe the trauma patient episode in New South Wales, Australia?

The use of Diagnosis Related Groups (DRGs) may not be an accurate tool to provide reimbursement for trauma services. This study aimed to determine whether Australian Refined Diagnosis Related Groups (AR-DRGs) adequately describe the trauma patient episode and to identify AR-DRG groupings where reimbursement was not commensurate with actual cost. The AR-DRG allocated costs and actual costs of a sample of 206 trauma patient episodes were reviewed during a three-month period. Of the AR-DRG groups identified in the patient episodes, 62.8% were not commensurate with actual cost incurred, equating to an overall loss of $113,921 from under-funded acute trauma patient episodes over a three-month period. Assault-related penetrating trauma, traffic-related and sport-related incidents were all inadequately reimbursed using AR-DRGs compared with the actual cost of treatment. Cases involving female patients, patients aged 45 years or less and those with moderate injuries were similarly underfunded. AR-DRGs are not adequate to describe the extent of injuries experienced by trauma patients and there is a need to investigate alternative funding models for trauma services.

The cost and compensability of trauma patients.

Injury in Australia was responsible for 400 000 hospitalisations in 2002. This study aimed to examine the direct costs of trauma patients in a Level 1 trauma centre and determine the compensability of those patients. Data on all admitted patients (206) filling trauma criteria were collected prospectively over a 3-month period (November 2006 to January 2007). A 10-question survey was completed on each patient to record mechanism of injury, third party private health insurance or workers compensation, and direct costs were also obtained. 30% of trauma admissions had an injury severity score (ISS)> 15 (n = 62; median ISS =9; range, 1-56). Median length of stay was 3 days (range, 1-126). Almost half (47%) of the patients were involved in road trauma, and 29% in falls. More than half (53.4%) were eligible for compensation (21.8% of patients had full hospital health insurance cover, 21.4% third party insurance and 9.2% workers compensation). The mechanism of injury with the highest median cost per patient was assault, followed by pedal cyclists, pedestrians then motor vehicle collisions.

Coding errors and the trauma patient--is nursing case management the solution?

The aim was to investigate the accuracy of clinical information coding and the financial consequence for trauma patients at a tertiary trauma centre using the resources of trauma nursing case managers. Clinical data for admitted trauma patients in August and September 2000 were compared with data routinely obtained by trauma case managers on their daily rounds. We audited patient injuries, in-hospital complications, investigations, and procedures. Clinical information records requiring alteration were returned to the clinical information manager with additional information and re-entered into the clinical information database. 100 trauma patient records (15% of admissions for 2000) were audited. 28% of recoded records had to have their diagnosis related group (DRG) changed, which resulted in the identification of additional funding of over $39,000. We conclude that the implementation of episode funding for acute episodes, such as the complex trauma patient, is placing increased importance on accuracy of coding. The validity of coding is dependent on legible, comprehensive and complete documentation and is improved dramatically by using nursing case manager patient progress summaries.