Simonovska Valentina, Spasovski Mome, Elena Kosevska. University of Ss Cyril and Methodius, Skopje, Macedonia

Transcription

1 Journal of US-China Public Administration, ISSN June 2014, Vol. 11, No. 6, D DAVID PUBLISHING The Average Treatment and Its Cost, Age, and Gender of Patients With Ischemic Heart Diseases Simonovska Valentina, Spasovski Mome, Elena Kosevska University of Ss Cyril and Methodius, Skopje, Macedonia Ensuring efficient treatment of patients in hospital care, with precise management of resources and cost planning. Goals: Dividing the patients with ischemic heart diseases into five groups with the highest cost of treatment, and determining the link among the cost of treatment and the average length of hospital stay, age, and gender of these patients. Materials and methods: Standardized reports of 10,040 patients from three hospitals in Macedonia from 2010 to 2012 were used. The databases were processed in SPSS 17, and the ANOVA and the Chi-square test were applied. Results and discussion: There is a statistically significant difference between the groups which have different cost of treatment and the average length of their treatment (F = and p = 0.000) and a statistically significant difference between the five most expensive groups of patients in terms of their gender (Chi-square = , df = 4, and p = 0.000). Furthermore, there are statistically significant differences between patients with different cost of treatment in terms of their age (F = and p = 0.000). Conclusion: The most expensive patients have the longest average hospital stay. Keywords: cost, ischemic heart disease, hospital care The global economic crisis provokes the need of a detailed economic analysis during the making of key decisions in the health care system (King, Lapsley, Mitchell, & Moyes, 1994). It becomes clearer that the individual health care through the insurance coverage can affect the ability of others to receive the necessary care (Kirton & Hazlehurst, 1991). The expenses for health care both in our country and in the other countries around the world continue to increase, and the analyses show that they are increasing with a higher rate than the one of the inflation and the workers salaries (Tunis, 2004; Agency for Healthcare Research and Quality, 2000). The financial pressure enforces difficult decisions like whether to increase premiums or reduce benefits to policy holders or to divert resources (Laughlin, 1991). Clinicians attempting to identify the clinical intervention that best suits the patient, separate this decision from any thoughts on what indirect effect it can have to the cost of treatment (Brock, 2003). It is inappropriate to take into account only the individual decisions by medical personnel, but it is necessary to observe all complex parts of clinical presentation and the Corresponding author: Simonovska Valentina, MD, MSci, assistant of professor, Institute of Social Medicine, Medical Faculty, University of Ss Cyril and Methodius, Skopje; research fields: public health, health policies, social medicine, chronic non-communicable diseases, and health care finances and management. valentina.simonovska@gmail.com. Spasovski Mome, MD, Ph.D., professor, Institute of Social Medicine, Medical Faculty, University of Ss Cyril and Methodius, Skopje; research fields: public health, health policies, health care systems, social medicine, chronic non-communicable diseases, and health care finances and management. mome_spasovski@yahoo.com. Elena Kosevska, MD, Ph.D., associate professor, Institute of Social Medicine, Medical Faculty, University of Ss Cyril and Methodius, Skopje; research fields: public health, health policies, health care systems, social medicine, chronic non-communicable diseases, and health promotion. kosevska@yahoo.com.

2 472 COST, AGE, AND GENDER OF PATIENTS WITH ISCHEMIC HEART DISEASES social context in deciding which the best medical care is for the patient (Neumann, 2004). In addition, patients with their participation in the decision-making process can have an uncritical perspective, having in mind that they are constantly exposed to an increasing direct marketing and unreliable information regarding health from the internet and other sources which are of questionable objectivity and quality (Leone & Van Horne, 1999). Also, clinicians receive a rather large portion of information from commercial structures and the media, which might not show a balanced perspective on the value that medical alternatives have (Kaplan & Norton, 1992). The assessment of the work that health care workers do in the health care facilities is based on their education, experience, and expertise (Mak & Roush, 1996). The losses that the health system of the Republic of Macedonia has suffered over the past decades represent a challenge for the multiple reforms. The last reform of the health care system in Macedonia is based on quality and economical competition of tasks. To achieve this basic principle is necessary to achieve: rational spending, cost reduction, increased efficiency in the use of available resources (material and human), and rational planning of the type and scope of services. A higher quality of health care services to insured persons can be provided through independence in the operation of health care facilities, increased accountability, equal cost of the same health care services in all health facilities in the Republic of Macedonia for the same diagnostic groups and equal distribution of resources according to the health care services. In order to estimate the cost of the most common diseases in the Republic of Macedonia, it is necessary to take into account the total cost generated in the course of their treatment in hospital care. Cardiovascular diseases are the leading cause of death in the United States, and they are responsible for 17% of the national health care expense. As the age of the population increases, this cost increases significantly. Considered to be one of the most expensive diseases, they represent a large economic burden for a lot of health care systems, through the direct cost that is created with their hospital treatment, medication expenditure, other medical supplies, and also the indirect cost which is caused by early death, short-term or long-term loss of productivity. According to the State Statistical Office of the Republic of Macedonia, the most common cause of death in our country is diseases of the circulatory system. The largest percentage in this various group of diseases goes to the ischemic heart diseases. The diseases of the circulatory system in the Republic of Macedonia represent a serious problem to the public health system, because the health indicators with which the health conditions are being monitored, show that in the hospital morbidity in the Republic of Macedonia in the year of 2008, a total of 14.1% go to the diseases of the circulatory system. In 2009, the specific rate of morbidity for diseases of the circulatory system in the Republic of Macedonia was on a population of 10,000. The average length of treatment of one case with a disease of the circulatory system is 9.3 days. There was an increase in the number of treated patients in the inpatient division in 2010 compared with 2009, by 11.1% in diseases of the circulatory system. In 2010, the rate of morbidity for diseases of the circulatory system in the Republic of Macedonia was on a population of 10,000. The average length of treatment of one case of hospitalized patient with a disease of the circulatory system is eight days. For more than 10 years, the diseases of the circulatory system have represented a major social and medical problem in the Republic of Macedonia, a claim that is supported by the data that reveal the number of inpatients. The rate of hospital discharges in the year 2000 in the Republic of Macedonia for patients with ischemic heart diseases was on a population of 10,000, whereas in 2010, it was on a population of 10,000. An especially negative tendency is the occupancy by the younger age

3 COST, AGE, AND GENDER OF PATIENTS WITH ISCHEMIC HEART DISEASES 473 groups, the large number of hospital days, the emergence of disability, early retirement and high cost of treatment as well as early death. Rational management of resources, reduction of the expenses, the increasing efficiency by using the resources at hand (material and human) and objective planning of the type and size of the services, and with that determining the conditions of treatment of ischemic heart diseases, all of these represent the basic principles on which the work of the specialized health care facilities for heart diseases in Republic of Macedonia is based. The acute hospital care is composed of several different activities (analyses, diagnostics, and treatment), which the patient undergoes during his hospital treatment. In this research, the authors followed the course of the hospitalization, which lasts more than 24 hours of continuous hospital stay, and includes overnight stay and usage of a bed 1. The average length of treatment represents a correlation between the number of hospital days and the number of treated patients. GOALS To determine the five most expensive groups of patients with ischemic heart diseases by the cost that is generated during their hospital treatment, according to the diagnostically related groups (DRG) of diseases model. To determine the influence of the average length of treatment on the expenses that these five groups of patients generate during the course of their hospital treatment. To determine whether there is a statistically significant difference between the age and gender of this type of patients and the determined cost that they generate in the course of their hospital treatment. Materials and Methods Target population for conducting of this research was single DRG reports of patients which have a confirmed main diagnosis of ischemic heart disease, which according to ICD-10 (The International Classification of Diseases-10) classification of diseases and related conditions, includes the I20-I25 categories of diseases. The result data refer to an individual DRG report for every patient treated in hospital care on the territory of Republic of Macedonia, or reports for treated patients who have a confirmed main diagnosis of ischemic heart disease in three specialized heart hospitals in Republic of Macedonia. Exception criteria: All patients that stayed in a hospital less than 24 hours were excluded. Size of the sample: Digital records of DRG reports for a total of 10,040 patients for the year 2010, 2011, and 2012 were processed in the course of this research. The research is retrospective, and is carried out in the building of the Health Insurance Fund of Republic of Macedonia, in the period from September 25 to December 5 in the year Statistical Analysis A database was formed from the received data. The databases were entered in Excel The databases were processed in the statistical program statistical package SPSS 17 for Windows. For the analysis of the data, the following statistical analyses were used: 1 Retrieved from

4 474 COST, AGE, AND GENDER OF PATIENTS WITH ISCHEMIC HEART DISEASES (1) The ANOVA test, in order to determine whether there is a statistically significant difference between the five groups of patients with different cost and the average length of their treatment; (2) The Chi-square test for determining a statistically significant difference between the five groups of patients that have the highest cost in terms of their gender; (3) The ANOVA test, in order to determine whether there are statistically significant differences between patients with different cost of treatment and their age. Discussion From the final data, it can be said that the most expensive first group of patients in health care with participation of 27.4% or 2,747 patients have angina pectoris and intervention of coronarography, which generated an individual cost of 24, MKD. They are followed by the second group of patients with 25.8% participation, patients who have angina pectoris, with coronarography and stent, with an individual cost of 68, MKD. In the third group of patients, with participation of 20.1% are the patients with 11, MKD of individual cost, which have undergone myocardial perfusive scintigraphy. In the fourth group of the most expensive patients, with participation of 17.3% are the patients with acute transmural myocardial infarction of the anterior wall with stent, who generated an individual cost of 80, MKD. The last group of patients consisted of patients with unstable angina, only with coronarography, and they participate with 9.5%, or with 28, MKD of individual cost (see Table 1). The ANOVA test has shown that there is a statistically significant difference between the groups of patients with different cost and the average length of their treatment (F = and p = 0.000) (see Table 2). The Chi-square test has shown a statistically significant difference between the five groups of patients with the highest cost in terms of their gender (Chi-square = , df = 4, and p = 0.000). When it comes to the percentages, it can be seen that the number of male and female patients in the group with myocardial perfusive scintigraphy and the group with angina pectoris with coronarography is almost equal. The differences come to light in the group with: angina pectoris, unstable, only with angiography (72.9% male and 27.1% female); angina pectoris with coronary angiography and stent (76.0% male and 24.0% female); and acute transmural myocardial infarction of the anterior wall with stent (75.5% male and 24.5% female) (see Table 4). The second ANOVA test has shown that there are statistically significant differences between patients with different cost of treatment and their age (F = and p = 0.000). The patients with the cost of 28, MKD are the oldest and have an average of 62 years, the second is the patients with 68, MKD of cost and an average of 60 years, and they are followed by the patients with a cost of 11, MKD and an average of 59.7 years, and the last are the patients with 24, MKD and an average of 59.2 years (see Table 5). The Australian National Health Research which was carried out in the period from 2004 to 2005 showed that 80% of adult Australians that are older than 65, there were three or more chronic conditions which were the cause of more frequent and longer hospital treatments. Co-morbidity and the length of treatment, according to this and other similar researches in USA and Canada, as well as in our country, are cause for increased usage of the resources for health care (Center for Healthcare Research & Transformation, Jiang, Russo, & Barrett, 2010). In one research in the Netherlands was also confirmed that patients who suffer from diabetes and ischemic heart disease or hypertension, generate greater medical expense (Agency for Healthcare Research and Quality,

5 COST, AGE, AND GENDER OF PATIENTS WITH ISCHEMIC HEART DISEASES ). Furthermore, there was an increase in cost with patients who have one confirmed heart disease from $2,788 to $27,763 with patients who have confirmed presence of three or more chronic conditions, and more frequent and longer hospital visits (Chenhall & Langfield-Smith, 1998). Certain researches carried out in the USA in January 2010 by the Center for Research and Transformations in Health Care, in which it is said that patients which have co-morbidity in terms of presence of several chronic conditions or presence of risk factors, cost seven times more than ones who have only one chronic condition. In Michigan, the coronary artery disease, diabetes, and the chronic obstructive disease were one of the most common causes of doubling the health care cost, of patients that had these conditions as a confirmed co-morbidity. Table 1 Five Groups of Patients With the Highest Cost of Treatment, Their Frequency of Appearance and Their Participation in Percentage Procedures and diagnosis ICD-10-code DRG-code Price (MKD) Frequency Percentage (%) Acute transmural myocardial infarction I21.0 of anterior wall with stent F10Z 80, , Angina pectoris, unspecified, with stent I20.9 F15Z 68, , Unstable angina, only coronarography I20.0 F42A 28, Angina pectoris, unspecified, with coronarography I20.9 F42B 24, , Myocardial perfusive scintigraphy I20.9 F66B 11, , Total 10, Table 2 ANOVA Test for Five Groups of Patients and Average Length of Treatment Sum of squares df Mean square F Sig. Between groups 13, , Within groups 180, , Total 193, ,039 Conclusions What we can conclude from this research is that the patients with angina pectoris with a coronarography, and an individual cost of 24, MKD, have the highest cost of treatment because they are large by number, and not because of their individual cost. The ANOVA test shows that there is a statistically significant difference between the groups of patients with different cost of treatment and the average length of their treatment (F = and p = 0.000). This test indicates that the patients with the highest cost (80, MKD) on average, are the ones with the longest hospital stay (M = 4.85). Next are the patients with the cost of 28, MKD, and they have the tendency to stay in the hospital for a little longer than two days (M = 2.34). After them, there are the patients with the cost of 11, MKD, they tend to stay in the hospital for approximately two days (M = 2.02). In addition, patients with the cost of 68, MKD have an average hospital stay of M = 1.98 days. Patients with the cost of 24, MKD have the shortest hospital stay, M = 1.54 days (see Table 3). The Chi-square test has shown that there is a statistically significant difference between the five groups of patients that have the highest cost of treatment in terms of their gender, and in that differences, the number of male patients is greater than the number of female patients (see Table 4).

6 476 COST, AGE, AND GENDER OF PATIENTS WITH ISCHEMIC HEART DISEASES The ANOVA test has shown that there are statistically significant differences between patients with different cost of treatment and their age, the youngest (58.7 years) are those patients with the highest individual cost (80, MKD) (see Table 6). Table 3 Average Value and Standard Deviation of the Average Length of Treatment for Five Groups of Patients With the Highest Cost of Treatment Refprice M N SD 11, MKD (myocardial perfusive scintigraphy) , , MKD (angina pectoris, unspecified, with coronarography) , , MKD (unstable angina, only coronarography) , MKD (angina pectoris, unspecified, with stent) , , MKD (acute transmural myocardial infarction of anterior wall with stent) , Total , Table 4 Chi-Square Test for Distribution of Five Groups of Patients With Highest Cost of Treatment According to Gender Refprice Total Gender Male Female Total 11, MKD (myocardial perfusive scintigraphy) Total 1, ,015 % Total 1,636 1,111 2,747 24, MKD (angina pectoris, unspecified, with coronarography) % , MKD (unstable angina, only coronarography) Total % , MKD (angina pectoris, unspecified, with stent) Total 1, ,588 % , MKD (acute transmural myocardial infarction of anterior Total 1, ,738 wall with stent) % Total 6,715 3,325 10,040 % Table 5 ANOVA Test for the Age Structure of Give Groups of Patients With the Highest Cost Sum of squares df Mean square F Sig. Between groups 9, , Within groups 991, , Total 1,000, ,039 Table 6 Average Value and Standard Deviation for the Age Structure of Five Groups of Patients With the Highest Cost Refprice M N SD 11, MKD (myocardial perfusive scintigraphy) , , MKD (angina pectoris, unspecified, with coronarography) , , MKD (unstable angina, only coronarography) , MKD (angina pectoris, unspecified, with stent) , , MKD (acute transmural myocardial infarction of anterior wall with stent) , Total ,

7 COST, AGE, AND GENDER OF PATIENTS WITH ISCHEMIC HEART DISEASES 477 References Agency for Healthcare Research and Quality. (2000). Clinical classifications software, fact sheet. Retrieved from Agency for Healthcare Research and Quality. (2006). The high concentration of U.S. health care expenditures. Research in Action, 19, 4. Brock, T. H. (2003). CMS investigates outlier payments. Healthcare Financial Management, 57(2), Center for Healthcare Research & Transformation, Jiang, H. J., Russo, C. A., & Barrett, M. L. (2010). Health care cost drivers: Chronic disease, comorbidity, and health risk factors in the U.S. and Michigan. Retrieved from Chenhall, R., & Langfield-Smith, K. (1998). Performance measure within organizational change program. Management Accounting Research, 9, Grundy, S. M., Balady, G. J., Criqui, M. H., Fletcher, G., Greenland, P., Hiratzka, L. F., Smith, S. C. Jr. (1998). Primary prevention of coronary heart disease: Guidance from Framingham: A statement for healthcare professionals from the AHA Task Force on risk reduction. American Heart Association. Circulation, 97, Kaplan, R. S., & Norton, D. P. (1992). The balanced scorecard Measures that drive performance. Harvard Business Review, 70(1), King, M., Lapsley, I., Mitchell, F., & Moyes, J. (1994). Costing needs and practices in changing environment: The potential for ABC in the NHS. Financial Accountability and Management, 10(2), Kirton, R., & Hazlehurst. (1991). Activity based costing at the Luton and Dunstable Hospital, CIMA. Diseases, treatment patterns and costs. In A. M. Garber (Ed.), Frontiers in health policy research. Cambridge, M.A.: MIT Press. Laughlin, R. (1991). Environmental disturbances and organizational transitions and transformations: Some alternative models. Organization Studies, 12(2), Leone, A. J., & Van Horne, R. L. (1999). Earnings management in not-for-profit institutions: Evidence from hospitals. Working Paper. Simon School, University of Rochester. Mak, Y., & Roush, M. J. (1996). Managing activity costs with flexible budgeting and variance analysis. Accounting Horizons, 10, Neumann, P. J. (2004). Why don t Americans use cost-effectiveness analysis? The American Journal of Managed Care, 10, Tunis, S. R. (2004). Economic analysis in healthcare decisions. The American Journal of Managed Care, 10,