National Institute of Science and Technology for Health Technology Assessment (IATS)- CNPq/Brazil (project: 465518/2014-1), R. Ramiro Barcelos, 2350 - Santa Cecília, Porto Alegre - RS 90035-903, Brazil.
School of Technology, Pontifícia Universidade Católica do Rio Grande do Sul, Av. Ipiranga, Prédio 30 - Bloco F, 6681 - Partenon, Porto Alegre - RS 90619-900, Brazil.
Health Policy Plan. 2022 Oct 12;37(9):1098-1106. doi: 10.1093/heapol/czac058.
The unsustainable increases in healthcare expenses and waste have motivated the migration of reimbursement strategies from volume to value. Value-based healthcare requires detailed comprehension of cost information at the patient level. This study introduces a clinical risk- and outcome-adjusted cost estimate model for stroke care sustained on time-driven activity-based costing (TDABC). In a cohort and multicentre study, a TDABC tool was developed to evaluate the costs per stroke patient, allowing us to identify and describe differences in cost by clinical risk at hospital arrival, treatment strategies and modified Rankin Score (mRS) at discharge. The clinical risk was confirmed by multivariate analysis and considered patients' National Institute for Health Stroke Scale and age. Descriptive cost analyses were conducted, followed by univariate and multivariate models to evaluate the risk levels, therapies and mRS stratification effect in costs. Then, the risk-adjusted cost estimate model for ischaemic stroke treatment was introduced. All the hospitals collected routine prospective data from consecutive patients admitted with ischaemic stroke diagnosis confirmed. A total of 822 patients were included. The median cost was I$2210 (interquartile range: I$1163-4504). Fifty percent of the patients registered a favourable outcome mRS (0-2), costing less at all risk levels, while patients with the worst mRS (5-6) registered higher costs. Those undergoing mechanical thrombectomy had an incremental cost for all three risk levels, but this difference was lower for high-risk patients. Estimated costs were compared to observed costs per risk group, and there were no significant differences in most groups, validating the risk and outcome-adjusted cost estimate model. By introducing a risk-adjusted cost estimate model, this study elucidates how healthcare delivery systems can generate local cost information to support value-based reimbursement strategies employing the data collection instruments and analysis developed in this study.
医疗费用和浪费的持续增长促使报销策略从数量向价值转变。基于价值的医疗需要详细了解患者层面的成本信息。本研究引入了一种基于时间驱动作业成本法（TDABC）的临床风险和结果调整的卒中护理成本估算模型。在一项队列和多中心研究中，开发了一种 TDABC 工具来评估每位卒中患者的成本，使我们能够通过入院时的临床风险、治疗策略和出院时的改良 Rankin 评分（mRS）来识别和描述成本差异。临床风险通过多变量分析确认，并考虑患者的国立卫生研究院卒中量表和年龄。进行了描述性成本分析，然后进行单变量和多变量模型，以评估风险水平、治疗方法和 mRS 分层对成本的影响。然后，引入了缺血性卒中治疗的风险调整成本估算模型。所有医院均从连续入院的缺血性卒中确诊患者中收集常规前瞻性数据。共纳入 822 例患者。中位成本为 2210 欧元（四分位距：1163-4504 欧元）。50%的患者 mRS 评分良好（0-2），所有风险水平的成本都较低，而 mRS 评分最差的患者（5-6）的成本较高。接受机械取栓治疗的患者在所有三个风险水平的成本都有增量，但高危患者的差异较小。估计成本与每个风险组的观察成本进行比较，大多数组之间没有显著差异，验证了风险和结果调整的成本估算模型。通过引入风险调整成本估算模型，本研究阐明了医疗保健提供系统如何利用本研究开发的数据收集工具和分析生成本地成本信息，以支持采用基于价值的报销策略。
