Cost of extracorporeal membrane oxygenation: evidence from the Rikshospitalet University Hospital, Oslo, Norway.

OBJECTIVE: The main objective is to describe and analyse hospital costs of the extracorporeal membrane oxygenation (ECMO) procedure. STUDY SAMPLE AND METHODOLOGY: Between January and December 2007, 14 ECMO patients were consecutively included in the study. Costs at the patient level were registered prospectively, while overhead costs were registered retrospectively. Patient costs were obtained from patient records and time-motion studies and included personnel resources, diagnostic and laboratory tests, radiology and operating room procedures, medication and blood products. Overhead costs were allocated to clinical departments and further to the individual patients by predefined keys. To achieve estimates of total costs, patient-specific costs and patient-specified overhead costs were summarised. RESULTS: The mean estimated cost for the ECMO procedure was 73,122 USD (SD 34,786) and median 62,545 USD (range: 34,121-154,817). The mean estimated total hospital costs, including pre- and post-ECMO procedures, was 213,246 USD (SD 12,265), median 191,436 USD (range: 59,871-405,497). On average, 82% of costs for the total hospital stay were related to personnel use, and blood products constituted 7%, lab and radiology 2.5%, disposable items 3% and medication 1.5%. The mean duration of an ECMO procedure was 9.5 days (range: 4-23 days) and the average total length of stay in hospital was 51.5 days (range: 6-123 days). The cost data were converted from Norwegian kroner (NOK) to US dollars (USD), with an exchange rate of 1 USD=5.5 NOK. CONCLUSION: ECMO procedure is a resource-demanding procedure.

Costs and reimbursement gaps after implementation of third-generation left ventricular assist devices.

BACKGROUND: The purpose of this study was to compare and contrast total hospital costs and subsequent reimbursement of implementing a new program using a third-generation left ventricular assist device (LVAD) in Norway. METHODS: Between July 2005 and March 2008, the total costs of treatment for 9 patients were examined. Costs were calculated for three periods-the pre-implantation LVAD phase, the LVAD implantation phase and the post-implantation LVAD phase-as well as for total hospital care. Patient-specific costs were obtained prospectively from patient records and included personnel resources, medication, blood products, blood chemistry and microbiology, imaging, and procedure costs including operating room costs. Overhead costs were registered retrospectively and allocated to the specific patient by pre-defined allocation keys. Finally, patient-specific costs and overhead costs were aggregated into total patient costs. RESULTS: The average total patient cost in 2007 U.S. dollars was $735,342 and the median was $613,087 (range $342,581 to $1,256,026). The mean length of stay was 77 days (range 40 to 127 days). For the LVAD implantation phase, the mean cost was $457,795 and median cost was $458,611 (range $246,239 to $677,680). The mean length of stay for the LVAD implantation phase was 55 days (range 25 to 125 days). The diagnosis-related group (DRG) reimbursement (2007) was $143,192. CONCLUSIONS: There is significant discrepancy between actual hospital costs and the current Norwegian DRG reimbursement for the LVAD procedure. This discrepancy can be partly explained by excessive costs related to the introduction of a new program with new technology. Costly innovations should be considered in price setting of reimbursement for novel technology.

Thoracic aortic aneurysm repair. Direct hospital cost and Diagnosis Related Group reimbursement.

OBJECTIVE: The main objective of this study was to analyze direct hospital cost and to compare cost with existing DRG reimbursement for open repair of thoracic and thoraco-abdominal aortic disease. STUDY SAMPLE AND METHODOLOGY: Between January 2003 and September 2003, the cost of treatment for 24 surgical procedures on ascending aorta and arch, descending or thoraco-abdominal aortic disease were examined prospectively. Seven patients had urgent or emergency surgeries. Ten had sternotomies for disease of the ascending aorta and aortic arch; two had left thoracotomies and three thoraco-laparotomy incisions with procedures performed on x-corporeal circulation. Nine other patients had more distal thoraco-abdominal aortic operations with a clamp-and-sew technique. Micro-cost analysis was performed on each hospital stay, in addition overhead hospital costs were allocated to each procedure. RESULTS: The patients were grouped by discharge diagnosis (ICD-10) and surgical procedure performed (NCSP) into Norwegian DRG code. Patient with surgery on ascending aorta & aortic arch were allocated to DRG 108 (n=9) or 483 (tracheostomy, n=1) while patient with surgery on descending or thoraco-abdominal aorta were allocated to DRG 108 (n=3), 110 (n=4), 111 (n=4) or 483 (tracheostomy, n=3). The mean EuroSCORE for patients with proximal aortic disease was 11 (5-18), and the length of stay was 5 days (range 3-8 days), spending 2 days (range 1-7 days) in thoracic intensive care unit. For patients with distal aortic disease the mean Euroscore was 7 (2-14), and the mean length of stay 10 days (range 4-23 days) with a mean 4 days (range 1-13 days) in intensive care unit. Eight patients developed medical problems requiring new surgical procedures or prolonged ICU stay. The average direct hospital cost for proximal aortic surgery was USD 15,877 (USD 1=NOK 7.5) while the respective 100% DRG reimbursement including one patient needing a tracheostomy, was 19 803 USD. For patients with distal aortic disease, average direct hospital cost was 23 005 USD and DRG reimbursement including patients needing a tracheostomy was 31543 USD. CONCLUSION: Our results underscore previous findings that these patients are resource intensive. This study shows that Norwegian 100% DRG reimbursement did over-compensate observed total hospital costs in this cohort. Detailed analysis showed that this was due to the higher DRG reimbursement for patients needing prolonged ventilatory support. Thus the actual DRG reimbursement seems to be relevant to the tertiary hospital actual costs when these complicated patients are considered as a group. It remains however unclear whether this reimbursement is sufficient to support the scientific infrastructure for new knowledge and skills needed for the further refinement of treatment.

A comparison of hospital costs with reimbursement received for patients undergoing the Norwood procedure for hypoplasia of the left heart.

OBJECTIVES: To determine whether the present system of reimbursement, based on diagnosis-related groups and regular financial budgeting, covers the costs incurred during hospitalisation of 7 children undergoing the three stages of the Norwood sequence for surgical treatment of hypoplastic left heart syndrome. METHODS: Between January and September 2003, 7 patients underwent initial surgical palliation with the Norwood procedure at the Rikshospitalet University Hospital. A prospective methodology was developed by our group to measure the costs associated with each individual patient. The patients were closely observed, and the relevant data was collected during their stay in hospital. The stay was divided into four different periods of requirements of resources, defined as heavy intensive care, light intensive care, intermediate care, and ordinary care. At each stage, we recorded the number of staff involved and the duration of surgery and other major procedures, as well as the cost of pharmaceuticals and other consumables. Based on these data, we calculated the cost for each patient. These costs were compared with the corresponding revenue received by the hospital for each of the patients. RESULTS: We found the total mean cost for the three stages of the Norwood sequence was 138,934 American dollars, while the corresponding revenue received by the hospital was 43,735 American dollars. During this period, one patient died during the first stage of the Norwood sequence. CONCLUSIONS: Our study shows that steps involved in the Norwood sequence are low-volume but high-cost procedures. The reimbursement received by our hospital for the procedures was less than one-third of the recorded costs.