Naslov
Direct medical costs of childhood epilepsy in University Hospital Centre Rijeka, Croatia

Autori
Boban, Marko

Vrsta, podvrsta i kategorija rada
Ocjenski radovi, diplomski rad, diplomski

Fakultet
TEMPUS AHEAD Executive MBA

Mjesto
Zagreb, Hrvatska

Datum
27.11

Godina
2007

Stranica
73

Mentor
Prpic, Igor ; Heijman Wim

Ključne riječi
cost of illness; epilepsy; antiepileptic drug; drug utilisation pattern

Sažetak
Health sector represents major consumer of the gross domestic product in most of the countries. Objective to raise system efficiency outspreaded on all levels of health system, from creating the sustainable national master budgets, to the hospitals and departments.Budgets for health system became fixed in vast majority of countries, so more rational approach in delineate and allocation of defined finances is now a stipulation. Managing hospitals engages the most important allocation of health expenditures in any country, bearing in mind the fact that both demand for hospital care and costs of services constantly rise. Chronic diseases signify important source of costs national health systems budgets, for the reason that they are common in population, more frequently in need for medical interventions at secondary and tertiary level that are more expensive. In absolute figures and on extended life-time perspective, chronic diseases that are affecting children are of major interest, since they generate large direct medical costs, direct- non medical costs and indirect medical costs. Epilepsy is one of the commonest chronic neurological conditions worldwide. Each year new 50 to 120 cases appear in 100.000 general population sample. Lifetime expectancy of seizures in an individual is estimated to be around 5%. In Croatia estimations are that 45.000 people suffer from epilepsy. Incidence is doubled during childhood and adolescence. For the most epilepsy is not causative-curable disease, but long term fairly controllable condition with use of antiepileptic drugs (AED). Fundamental retested perspective confirmed that better understanding in economic aspects of disease ; in this case epilepsy raises quality standards of medical care and management. Economical analyses in epilepsy are focused either on production efficiency, or on allocate efficiency. Study settings in this thesis are concentrated on the direct medical costs of epilepsy model from clinical practice in children and adolescents. Epilepsy at that age is twice- common than in general population and further more, it is a chronic disease treated for years at the most expensive medical facilities on tertiary level of health system organization. Children with epilepsy are as a rule treated in general, clinical hospitals or university hospitals institutions that are related to compulsory health insurance, meaning that they do not pay any costs out of their pockets regarding specific medical care, so financing is purely by health insurance i.e. government spending. Costs of epilepsy for the EU in 2004 are estimated to be 15.5 billion of euros, of which 2.8 billion for direct medical costs and 400 millions of euro for antiepileptic drugs. Costs per case in this study varied from 2.000-11.500 euro, and 33 euro per European inhabitant. Primer objective was to identify mostly consumed and acme priced subgroup of costs, serving as a first step towards rationalization, better cost- benefit and potential basis to reduce expenditures arriving by performing at higher levels of cost- effectiveness. Since great deal of chronic diseases has similar pattern, this model could be applied for estimating costs for different health problems, and performing cost-of-illness studies as asthma, diabetes etc.Furthermore, we wanted to study unmodifyable impact of child’s age and epilepsy type as source of the direct costs. Study on direct medical costs regarding childhood epilepsy was provided at tertiary medical facility, University Hospital Centre of Rijeka. We performed prospective ; prevalence based “bottom- up” analyses of direct medical costs of epilepsy regarding children and adolescents. Bottom up estimations of costs calculate number and type of health care and social services consumed by individual patients derived from observational studies of patients samples, offering more precise estimate on individual patients costs, with variability among cases. Study design was created following agreed recommendations of International League Against Epilepsy (ILAE), subcommission for cost of epilepsy research. Population sample was formed of 69 children and adolescents hospitalized due to convulsive disorders (epilepsy) diagnostic, treatment and follow up at the Department of Paediatrics, Department of Neurology and specialized Outpatient clinics which are all integral part of the University Hospital Centre Rijeka. Patients were prospectively followed up for one successive year from the date of initial contact related to epilepsy management, which was typically upon diagnostics procedures. Data were collected from hospital and outpatients accounting services. Total costs were calculated by thorough summing consumed resources sourcing through three main costs categories (hospital + outpatient + AED). Cost data were presented as total, average and per-patient-per-year. Descriptive statistic was used for analyses of the sample and specific patient subgroups. Student’s t-test and analysis of variance or nonparametric Kruskal-Wallis or Mann-Whitney) tests, where appropriate, were used to test significance of differences among groups. Children with unclassified epilepsy were excluded from the statistical analysis due to a few patients in sample. The total annual cost per patient was 1.293.0 euros (€). Among all costs groups together, the highest annual source of costs were consumed during hospital admissions (942.99 €) followed by drug treatment (240.06 €) and the least through outpatient specialist consultations (121.21 €). Main components of the total cost were same for each studied group of patients, i.e. hospital admission followed by drug treatment and outpatient visits. Compared to developed countries patients in our settings had greater number of days in hospital in a hospitalization (average 12.3 days) with more hospital admissions (average 1.25), so group that represented hospital costs was the greatest share (72%) of consumed resources. Although, result proportionally and in absolute figures is still in the line with most studies mentioned, even in different settings childhood or grown up patients, hospitalization as the ultimate basis of costs may well be appointed for further analyses and possible rational cutbacks. Obtained results clearly showed that costs fluctuated extensively in relation to child’s age when epilepsy firstly occurred. As younger was the child, the costs were higher. Preschool children (<= 5 years of age) had statistically significant elevated costs through all studied parameters. Annual cost per patient in children younger than 5 year of age was 2.290 €, almost double to general mean and 2.5 times more than in school-aged children and adolescents. Economic side of the treatment is also important step in making decisions of AED regimen, principally in transitional country as Croatia. Major gain would be lessening or remaining length of stay in two thirds of patients (younger than 5 and 6-10), offering 6 hospital days per patient from the most expensive group (n= 18 patients) giving 6x18=108 annually. Regarding the total cost figures reduction would be: 1.328, 12 + 0 + (- 73, 26) + 330, 26 = 1.585, 12 per patient, respectively for the groups <5 (n=18), 6-10 (n=33), 11-18(n=18), general mean 0-18 (n=69). Patients that do not respond properly to treatment would still have plenty of allocated resources gained from 75% of patients that could be treated according to proposed ratio. Moreover, they would be able to use hospital beds in case of urgency due to their availability from cutbacks (108/year, see above), and certainly by using more of outpatient services which are substantially cheaper than hospital costs, still offering most of hospital services at decreased cost utility levels. Decreasing marginal costs of additional medical services are in this scenario used only when necessary to increase marginal utility up to satisfying level that offers desired clinical outcome. Theoretical savings on incidence based settings would be proximately calculated on at least 1.268.096 of government funds regarding each year’s newborn population, counting birth rate to be proximately 40.000 and epilepsy 2% i.e. 800 patients out theoretical 45.000 (1.7%). In prevalence based calculations, covering whole childhood population with epilepsy i.e. younger than 18 are representing about 20.9 % of total population i.e. 927.430, giving 46.371, 5 patients with childhood epilepsy on national level. Potential savings would be significantly greater (73.504.392, 08 ), but due to limitations of study settings (incidence based), and different marginal costs in consecutive years could not be given without greater bias. Perspective in this thesis is highly conservative regarding cut-downs, not representing maximal savings, but reasonably achievable without greater organizational intervention that are applied in clinical practice in developed countries and proved to be evidence- based. Model that we used in this thesis calculated the direct medical costs of illness, with two outputs ; costs and health faced to inputs in terms of hospital services, outpatient services and pharmaceuticals. It is particularly valuable for organizational management of chronic diseases and conditions. Due to their commonness, constantly elevated need of medical services, burdened with larger complications of disease and treatment, along with decreased educative and working potential this group represents extensive consumer of national health budget i.e. government spendings. In regard to particularities of specific disease and possible treatments we could find substantial differences.

Izvorni jezik
Engleski

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