VIETNAM MILITATY MEDICAL UNIVERSITYNGUYEN DUC TOAN PH VĂN BÁU RESEARCH OF TREATMENT COSTS FOR ACUTE APPENDICITIS AT SON LA PROVINCIAL GENERAL HOSPITAL Major: Medical Management Code : 9
Trang 1VIETNAM MILITATY MEDICAL UNIVERSITY
NGUYEN DUC TOAN
PH VĂN BÁU
RESEARCH OF TREATMENT COSTS FOR ACUTE APPENDICITIS AT SON LA PROVINCIAL GENERAL HOSPITAL
Major: Medical Management Code : 972 08 01
SUMMARY OF DOCTOR OF MEDICINE THESIS
Hanoi – 2019
Trang 3In Vietnam, The policy on partial collection fees in State-ownedmedical examination and treatment establishments has beenimplemented since 1989; Then was the health insurance policy(1992) Revenue from hospital fees and health insurance isconsidered a public finance source, the proportion is increasingmore and gradually becoming a major source of revenue,contributing significantly to increased the investment for highercapacity and quality to suppling the medical services of publichospitals
However, the cost bracket currently does not include the full costcomponents that limit the autonomy of hospitals, while theGovernment subsidizes both the rich and the poor people Thisrequires some researches to find out the methods to calculateservice costs by evidence-based services for public hospitals.Therefore, we choose cost analysis for the treatment of acuteappendicitis at Son La Provncial General Hospital, both from thehospital as well as patients, to provide additional information forthe evaluation of medical services cost The research question:what is the actual cost for a patients of acute appendicitistreatment at a provincial general hospital? What is the differencebetween the actual cost of the hospital and the cost which patientshave to pay (direct or through health insurance)? Has theGovernment budget subsidized the components that have not beenincluded in the service fee yet? To provide information that willprovide the basis guides for accurating calculation of the medicalservices cost
Objectives of the study:
1 To analyze the actual cost of surgical treatment for acute appendicitis at Son La Provincial General Hospital (2012-2013).
2 To analyze the economic burden on patients with surgical treatment of acute appendicitis at Son La Provincial General Hospital (2012-2013)
Trang 4THE NEW CONTRIBUTIONS OF THESIS
Scientific significance: Healthcare reforms aimed at
increasing the accessibility and quality of health services whichrequire transparency in both quality and service pricing Thisrequires hospitals have to develop a good costing system andprocedures, and improve pricing models to more accuratelyreflect the cost of providing services to patients Finalization andtransparency of the costing system to determine the right pricehelps the patient to make better informed choices in the use ofservices, and helps the hospital manage the finances better.Reducing costs to increase competitiveness in terms of price andquality of services to improve the quality of health services inhealth care facilities
Practical significance: Applying the correct methodology to
calculate the actual costs of the hospital for medical serviceswhich will help the clinic know and calculate the actual cost ofthe hospital, the difference between the actual cost of hospitaland the cost of the patient must be paid (directly or through healthinsurance); Government budget subsidies for components onservice charges; Health insurance pays for health care facilitiesand the calculation methodology will help to form the basisguides for package payments for health services (group of illnesscases), financial transparency and fairness in medical examinationand treatment
New points of this thesis: Described the method of analysing
and calculating the actual cost of Son La Provincial GeneralHospital (Level II) for a medical service (surgical treatment ofacute appendicitis) in 2012-2013, determined the actual cost ofservices that has not previously been calculated, as the basis forcalculating actual costs for other services; Determining the costburden of surgical patients to treated for acute appendicitis at thehospital, thereby obtaining the method of calculating the actualcost of patients when seeking medical treatment at public healthfacilities
THESIS STRUCTURE
Trang 5The thesis consists of 118 pages excluding references andappendix with 44 tables, 04 charts and 06 pictures Introduction: 2pages Overview: 34 pages; Methodology: 22 pages; Results: 31pages; Discussion: 26 pages; Conclusion: 02 pages and 01 pagefor recommendation.
CHAPTER 1: OVERVIEW 1.1 Some concepts of cost and medical costs
1.1.1 Medical costs
In health economics, the cost of a health facility is thetotal resource that funds the health facility must spend to create aparticular health product or service
Costs and prices of health services are two different buthave organic correlation with each other Medical costs are thebasis to evaluate health services prices Generally, the healthservices prices = average cost for health services + profits ofhealth centers (subsidized or paid user)
1.1.2 Classification of medical costs
1.1.2.1 From the service provider
- According to the functions, medical costs are classified intotwo groups, including direct costs and indirect costs;
- According to the nature of costs: fixed costs and variablecosts;
- By input types: capital costs or investment costs, recurrentcosts;
- According to the relationship between costs and products,the total costs, average costs and marginal costs are oftenreferred
1.1.2.2 From the health service users.
- From the perspective of the user, the cost of health impliesspending and is more costly than cost and can be divided into:
- Direct costs, including: direct medical expenses such asexpenses for examination, testing, surgical procedures, drug costs;and direct medical expenses: expenses for travel, meals duringtreatment, expenses for medical staff, etc
Trang 6- Indirect costs, including costs lost due to loss of incomebecause of premature death or reduced productivity, sickness,illness.
- In addition, many authors also refer to another type of costthat is intangible, related to distress, anxiety and the quality of liferesulting from illness, diseases or in the treatment process
1.1.3 Cost calculation
1.1.3.1 Principles of calculating medical costs
The general principle: calculate correctly, adequately andaccurately
- The cost calculation must be based on high quality data toensure the reliability of the calculation results
- All expenditures of the health facility must be included inthe calculation to produce reliable and comparable results
- The process of computation should show the link betweenthe activities and the resources used to create the health service
- The calculation process must be transparent and allow fordetailed analysis
- The cost calculation must focus on the material value of resources
- Ensuring consistently between services, allowing
comparisons of costs within the health facility and between healthfacilities
- There is coordination between the clinical and non-clinicalcomponents and encourage the full use of information in the costcalculation
1.3.2 Approaches to calculate medical costs
There are many methods and techniques which wereapplied to calculate healthcare costs There are two mainapproaches: top-down allocation (macro-method) and bottom-upapproach (micro-method):
- Top-down costing method (macro approach or total costapproach) by allocating total budgets (expenditures) for eachdepartment and service to estimate the average cost per service
Trang 7- Calculating costs from the bottom up (calculate microcosts) through calculations, summing the cost for each input used
to create a service or otherwise calculate the cost from thecollection Collecting data each cost item of each individual
1.2 Health finance for public hospitals in Vietnam
Health financing is an important part of the health systemwith four main objectives: (1) Mobilizing adequate resources forhealth care; (2) Equitable and efficient resource allocation andmanagement; (3) Encourage improved quality and efficiency ofservice delivery and (4) Protect people from financial risks caused
by medical costs
1.3 Acute appendicitis and acute appendicitis treatment
Acute appendicitis is the most common surgical emergency,with a rate of 4-5 people per 1000 people and about 6-7% of thepopulation throughout life Acute appendicitis can occur at anyage, rarely in children under 3 years of age, increasing and mostcommon in adolescence, especially in the age group of 20-40, andthen aged according to age The disease can be seen in bothgenders, male is higher than female, male / female ratio is 3/2 inyoung and 1/1 in elderly
When there is a definite diagnosis of acute appendicitis,the unique treatment is emergency surgical resection of theappendicitis as soon as possible, because the more it is late, thehigher risk of complications patients get At present, surgery forappendectomy may be done by conventional open surgery orLaparoscopic surgery
1.4 Study on the cost of treating acute appendicitis in the world and in Vietnam
- Worldwide: The cost of health care services has beenstudied extensively, both in high-income countries as well as inlow- and middle-income countries, from providers and serviceusers Among them, there were many studies on the cost of acuteappendicitis treatment, both macro and micro These studies notonly addressed the cost of acute appendicitis but also analyzed
Trang 8both the clinical outcome and the cost-effectiveness between twomethods: open surgery and Laparoscopic surgery.
- In Vietnam: There are not many studies on medical costs,especially the systematic studies of the actual costs in a hospitalfor a disease or a technical service Some studies have calculatedthe cost of residential treatment for some diseases but almost noresearch is available for acute appendicitis With other diseases,there is not yet a single study that evaluates the costssimultaneously in both of the healthcare setting and the serviceuser Most studies only estimated the medical costs from the user
1.5 About Son La Provincial General Hospital
1.5.1 Organizational structure and functions
1.5.2 Financial resources of the hospital
1.5.3 Surgical procedure for the treatment of acute appendicitis
Adhere to the surgical procedures of acute appendicitis issued
by the Ministry of Health
CHAPTER 2: METHODOLOGY OF STUDY
2.1 Time and place of study
The study was conducted in Son La province GeneralHospital at two years in total (2012 and 2013)
2.2 Study subjects:
- 322 patients operated acute appendicitis surgery (includingopen surgery and Laparoscopic surgery) at Son La provincialgeneral hospital from 01/01/2012 to 31/12/2013, excluding thepatients who do not agree to participate in the study
- All records, accounting books, financial reports of thehospital in 2012-2013, medical records, bills of treatment, of allpatients with surgery treatment
2.3 Study method
2.3.1 Study design
A cross sectional study with retrospective available datacollection
2.3.2 Data collection techniques
2.3.2.1 Collecting the available information
Trang 9- Based on books of financial accounting, financial statements
of 2012 and 2013 to calculate the correct and full expenses of thishospital from which to base the analysis of actual expenses of thehospital for treatment acute appendicitis surgery
- Using the medical records of the patients to collectadministrative information, disease history, progression ofappendicitis as well as details of the patient's medical history andsurgery during stay hospital, treatment outcome and status ofhospital discharge, treatment costs of patients
2.3.2.2 Patient interview
Performed at the hospital during treatment or at home, within
3 months after patients discharge The interview tool is astructured questionnaire In case the patient does not know thecost information, the interviewers will interview patients'sprimary care provider
2.3.4 Framework theory and cost analysis methods
Applying Riewpaiboon's theory of hospital cost allocation;Combining both methods of cost allocation from top to bottomand bottom to top
Direct and indirect costs for patients are aggregated and usedfor descriptive analysis, comparative distribution and mediancosts of patients in assessing the payment burden for differentgroups of patients
2.3.5 Contents and variables of study
2.3.4.1 Group of independent variables
Including general information on demographiccharacteristics, socio-economic conditions, illness and treatment
of patients
2.3.4.2 First objects’s variables
- Cost of capital, there is the cost of depreciation of buildings,facilities and equipment of the hospital
- Regular expenses for hospital activities: electricity andwater, wages
Trang 10- Direct costs for treatment include expenses for medicines,consumables, tests/tricks.
2.3.4.3 Second objects’s variables
- Direct costs for health services: expenses which the patients(directly and through health insurance) pay to the hospital;
- Non-medical expenses are costs that patients and theirfamily members have to pay to other facilities outside the hospitalfor patients's treatment at the hospital such as meals, rest, travel
- Indirect Costs: is the cost of lost earnings due to a leave ofabsence for treatment (with patients) or visitation (with a familymember), estimated by the number of days off, multiplied by theaverage daily income of each object
2.4 Data management and analysis
Using HOSPICA cost analysis software, cost per item, eachservice is calculated and presented in average; Stata softwareversion 14.0 and presented as descriptive statistics such as meanand median (quartile ranged 25-27%) Mann-Wtihney non-parametric statistical tests were used to compare the distributionand median costs in the assessment of the payment burden for thetreatment of the patient The difference was statisticallysignificant with p <0.05
Trang 11Table 3.9 ecurrent costs of hospital 2012-2013 (million VND)
Costs 2012 2013 Overall Percentag
e (%)
Workforce 26,737.980 32,690.285 59,428.265 80.1Electricity 682.235 879.193 1,561.428 2.1
Stationery,
information, fuel 2,860.287 3,704.532 6,564.819 8.8Maintenance 2,887.950 2,345.428 5,233.378 7.1Conferences,
100
Trang 12Table 3.10 Steps to allocate costs to departments of Hospital in
2012-2013
Unit: million VND
Costs 2012 2013 Overall
Allocating directly the
capital costs and
not be included in the total)
The total cost allocated to facilties in two years is over 100
billion VND, of which nearly 84.888 billion VND is allocated
directly and over 25.184 billion VND is allocated indirectly for
general using Of these, more than 28.185 billion VND was
reallocated by management, administration and functional
departments to clinical and paraclinic departments
Table 3.19 Average cost for treatment services allocated by
departments (Unit: million VND)
Services
To year To surgical
technique Total
(n=322)
2012(n=166)
2013(n=156)
PTM(n=149)
PTNS(n=173)Surgery 2.816 2.508 2.530 2.784 2.667
Trang 13Bed days 0.752 0.997 1.046 0.720 0.871Medical
(n=166)
2013(n=156)
Opensurgery(n=149)
Laparoscopicsurgery(n=173)Medicine costs 1.590 2.398 2.541 1.499 1.981Consumables
costs
0.091 0.123 0.097 0.115 0.106
Tests costs 0.470 0.473 0.431 0.507 0.472
Table 3.22 Costs for a treatment of acute appendicitis patient by
surgical method over years
Unit: million VND
Services
Open surgery (n=74)
Laparoscopic surgery (n=92)
Open surgery (n=75)
Laparoscopic surgery (n=81)
Open surgery (n=149)
Laparoscopic surgery (n=173)Surgery 2.966 2.696 2.100 2.885 2.530 2.784Bed days for
treatment
0.839 0.682 1.251 0.762 1.046 0.720
Examination 0.031 0.031 0.039 0.039 0.035 0.035Direct costs
for patients
2.241 2.080 3.886 2.168 3.069 2.121