Hospital Costs of Renal Transplant Management

Hospital Costs of Renal Transplant Management N. Chaumard, P. Fagnoni, V. Nerich, S. Limat, A. Dussaucy, J.-M. Chalopin, H. Bittard, and M.-C. Woronoff-Lemsi ABSTRACT Renal transplantation is considered to be a cost-effective therapy, but hospital medical costs are not accurately known. The aim of this work was to evaluate the costs of hospital stay for renal transplantation. This retrospective study included all patients who underwent renal transplantation between January 1, 2004, and December 31, 2005, in our University hospital. The incurred costs were determined using our center’s analytical accounting (AA). The mean local cost was then compared with the median national cost of hospitalization for renal transplantation, based on a sample of participating centers contributing to the National Cost Scale (NCS) per homogenous diagnosis-related group (DRG). These mean costs were weighed against the financing obtained by national rates of the case-mix based payment system (termed T2A). Data were collected from 77 patients. Their mean length of stay was 19.4 days. AA determined the cost of management to be €14,100 per patient. National economic approaches were significantly higher: €16,389 for NCS and €17,369 for national rates. Thus, the specific DRG rate (case mix index) of renal transplantation covers the expenses incurred by our center. These results are rather interesting; however, it is unlike those obtained for the management of other diseases such as acute myeloid leukemia, where T2A underestimates the actual cost by 2– 4 times. Last, the hospital budget and T2A must be considered as a whole. The fact that DRGs with favorable and unfavorable pricing balance out should be taken into account.

S

INCE 2004, the system of global financial allocation for French health care centers has disappeared in favor of financing based on the type and volume of the accomplished activity, the case-mix– based payment system (termed T2A). In 2006, T2A accounted for 35% of functioning credits for public health care centers (50% in 2007). In 2008, this proportion will reach 100%.1 Measuring activity and costs in health care centers in the public sector is becoming crucial. In France, the budget devoted to organ harvesting and transplantation accounts for a considerable portion of hospital expenses. Renal transplantation accounts for 61% of all organ transplants. The demand is constantly rising, with 3.4 candidates for each usable transplant in 2005.2 Renal transplantation provides the patient with a better quality of life. The results are better than maintenance dialysis in terms of morbidity, mortality, and quality of life.3 This is due to the reduced risk of transplant rejection through innovative immunosuppressant strategies, particularly the extensive use of induction treatments in the period

immediately after transplantation.4 These immunosuppressive agents for induction therapy represent an important cost, although they are only used for a short time. It should be noted that they are not included in the list of hospital medicinal products that are billed over and above the case mix index. In France, there are few specific, quantified data available on the costs involved in the initial management of kidney transplantation. From the Pharmacy Department (N.C., P.F., V.N., S.L., M.-C.W.-L.), University Hospital of Besançon, Hospital J. Minjoz; the Inserm U 645, EA-2284 IFR-133 (P.F., V.N., S.L., J.-M.C., H.B., M.-C.W.-L.), Besancon, University of Franche-Comte; the Medical Information Department (A.D.), the Nephrology Unit (J.M.C.), and the Urology Unit (H.B.), University Hospital of Besançon, Hospital St Jacques, Besancon, France. Address reprint requests to Marie-Christine Woronoff-Lemsi, Inserm U 645, EA-2284 IFR-133, Besancon, F-25000, University of Franche-Comte, Besancon, France. E-mail: marie-christine. [email protected]

0041-1345/08/$–see front matter doi:10.1016/j.transproceed.2008.03.177

© 2008 Published by Elsevier Inc. 360 Park Avenue South, New York, NY 10010-1710

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Transplantation Proceedings, 40, 3440 –3444 (2008)

HOSPITAL COSTS

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Table 1. Daily Cost of Hospitalization Per Operating Unit

Operating Unit

Day of Hospitalization: Partial Cost (€)

Medical Staff Costs Per Day (€)

Day of Hospitalization: Total Cost (€)

Urology ICU Urology Nephrology ICU Nephrology Hemodialysis Surgical ICU Medical ICU

1,138 280 597 362 390 1,307 —

136 51 143 43 25 196 —

1,274 331 740 405 415 1,503 1,476

Abbreviation: ICU, intensive care unit. From an analytical accounting of Besancon University Hospital, 2005.

The objective of this single-center, retrospective study was to evaluate the cost of hospital stay for renal transplantation. The costs incurred by our center for renal transplant hospitalizations in 2004 and 2005 were evaluated through the analytical accounting (AA) system of our hospital. This local cost was compared with the national cost of renal transplant hospitalization, defined for a diagnosis-related group (DRG) by the National Cost Scale (NCS) based on a sampling of centers. In parallel, these hospital costs of renal transplant hospitalization were compared with the financing obtained by national rates of the DRG of hospital stays from the case-mix– based payment system.5,6 PATIENTS AND METHODS Study Population The study population included all patients who received a renal transplant between January 1, 2004, and December 31, 2005. The exclusion criteria were patients who had undergone a double transplantation. Medical and economic data were collected retrospectively for all hospitalizations of transplanted patients between 2004 and 2005. The available renal transplant files and computerized databases were used to obtain the characteristics, length of hospitalization for renal transplantation, and the related DRG for each hospitalized patient. Among the characteristics of transplanted patients, the following were studied specifically: cytomegalovirus (CMV) and Epstein-Burr Virus (EBV) serologic state of the donor and the recipient; characteristics of the transplant, duration of cold ischemia, and complications encountered during the hospitalization.

Economic Evaluation Our viewpoint used was that of health insurance, limited to hospital costs. The study was performed on a patient’s hospital stay for “renal transplantation,” from the first day of hospitalization (day of the transplant) to discharge after transplantation. Data were therefore collected from admission to discharge. The number of days of hospitalization was established for each of the moves to the various operating units. For each patient, we determined the number of dialysis sessions. The hospital stay for renal transplantation corresponded to DRG called “Renal transplantation.”7 First, the costs incurred by our center were evaluated for each transplant patient between January 1, 2004, and December 31, 2005, based on the 2005 AA. This evaluation provided a detailed account of the operating costs of the units in which patients were hospitalized; the work unit was

1 days. The daily cost of hospitalization corresponded to direct charges, including medical expenses, boarding expenses, staff pay, laundry, and maintenance as well as induced charges of medical/ technical and logistical costs, including organizational costs. Daily pharmaceutical expenses were defined for each operating unit. Expenses for the medical staff were defined by the Management Center using 2005 AA. These expenses were divided for each operating unit, based on the distribution of medical staff (Table I). Expenses related to management of each patient included in the economic analysis therefore represented the sum of all partial costs of hospitalization and those related to pay for the medical staff in each of the operating units: urology, nephrology, hemodialysis and the intensive care unit. At the national level, the cost of hospital disease management is estimated based on data from several centers provided by the hospital discharge system (called PMSI). The PMSI is a tool to measure hospital activity, used for budgeting purposes, making it possible to create the NCS. Every year, the NCS sets, for each DRG, a median cost observed on a sample of participating hospitals (50 centers). Hospitalization for renal transplantation represents a national cost of €16,389 for a mean stay of 19.5 days, according to the 2005 NCS.7 Since 2004, the financing of French public and private health care centers has begun to shift toward the case-mix– based payment system. Activity data provided by the hospital discharge system (PMSI) is no longer used only for purposes of modulating budget bases, but now directly determines hospital financing. The national hospitalization rates for 2005 are fixed by decree for every DRG of stay. This DRG rate informs the financing for this activity if the T2A is used at 100%; in 2006, the T2A represented 35% of the expenses for hospital management, and in 2008 100%. Hospital stay for renal transplantation is allocated at €15,973, corresponding to DRG 8904. Costs of hospitalization for each stay are calculated according to the instructions of the January 31, 2005, decree relating to the classification and management of hospitalization acts for medical, surgical, obstetric, and odontologic activities. Therefore, hospitalization costs for 1 patient correspond to the hospitalization rate with additional items, such as daily supplement for extreme lengths of stay, that is, ⬎46 days of hospitalization for Table 2. Characteristics of Transplant Patients Characteristics

Age (y) Mean ⫾ SD Median (min value–max value) Gender (M/F) Weight, kg (mean ⫾ SD) CMV serology, recipient–donor compatibility (%) EBV serology, recipient–donor compatibility (%) Type of transplant, n (%) Cadaver Living Unknown Duration of cold ischemia (min) Mean ⫾ SD Median (min value–max value) Acute rejection episodes, n (%) Time of rejection (d) Mean ⫾ SD Median (min value–max value)

Patients (n ⫽ 77)

48 ⫾ 13 50 (19–75) 53/24 70.5 ⫾ 13.9 41 (53) 62 (81) 76 (99) 0 1 (1) 1084 ⫾ 442 1045 (480–2940) 13 (17) 18 ⫾ 9 15 (9–36)

Abbreviations: max, maximum; min, minimum; SD, standard deviation.

Type of complications

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CHAUMARD, FAGNONI, NERICH ET AL

47); nephrology (n ⫽ 27); urology (n ⫽ 6); or the medical (n ⫽ 1) or surgical (n ⫽ 2) intensive care units. Some of them went home directly (n ⫽ 14). For the 77 observed stays, the mean length was 19.4 days, (range, 8 – 80).

11

Surgical complications

72

Anemia 25

Infection 13

Adverse events

13

Acute rejection 0

10

20

30

40

50

60

70

80

Number of patients

Fig 1. Complications encountered during renal transplantation hospital stay (n ⫽ 77). this DRG, amounting to €648 (called EXH extra charges) and daily supplement for any day spent in intensive care, amounting to €833 (called SRA extra charges).

Statistical Analysis Costs obtained due to different economic views—the AA system, NCS, national hospitalization prices—were compared in pairs. Cost comparisons were done during the stay for renal transplantation; each patient was considered to be its own control. The paired Student’s t-test was used with a significance cutoff at .05.

RESULTS Patient Characteristics

Between January 1, 2004, and December 31, 2005, 78 patients underwent renal transplantation. The study included 77 recipients of renal transplants; 1 patient was excluded due to a double liver and kidney transplant. The patient characteristics are presented in Table 2. The complications during the transplantation hospital stay may be immunologic (transplant rejection), surgical, medical (infection, anemia), or iatrogenic (Fig 1). The most commonly observed complication was anemia in 95% of patients, which was managed by parenteral administration of iron supplements, epoetin, and/or blood transfusions. The frequency of acute rejection episodes was 17%. Rejection appeared at an average of day 18 (⫾ 9 days). Acute rejection was treated with high doses of corticosteroids or mono- or polyclonal antibodies. Hospital Stays

Each patient had a single stay (DRG 27ZC06Z), which corresponds to hospitalization in various units and/or departments (Table 3). Coming out of the urologic theater, transplanted patients were systematically managed by the urology intensive care department (n ⫽ 77), where they remained for a mean duration of 11 days, (range, 5–28). Then, according to the clinical evolution, patients were transferred to other units: to nephrology intensive care (n ⫽

Economic Evaluation

The analytical accounting of the Teaching Hospital evaluated the cost of management of a hospital stay for renal transplantation at €14,100 (Table 4). This cost was representative of the actual expenses incurred by our center. The NCS evaluated a stay for renal transplantation at €16,389. Financing for a renal transplant hospital stay by the 2005 DRG rate was €17,369. This cost reflected the total amount of the receipts assigned to this activity if T2A is used at 100%. Among all the stays studied, 3 required a supplement for an extended hospital stay, amounting to €2,592, €30,456, and €59,616. Three extra charges for high dependent area were 2,499€ and 4,165€ for 2 out of the 3. Renal transplantation stay financing with the case mix index rate of DRG 2005 is 17,369 €. A significant difference was demonstrated between our center’s AA and the national economic values, compared in pairs (Table 4). The greatest difference was observed between observational data from our AA and the financing obtained using 2005 DRG (T2A) rates, amounting to as much as €3,296 (Table 5). In contrast, the differences between national economic approaches were not significant. DISCUSSION

AA provides a detailed breakdown of management costs that is closest to actual expenses incurred in a health care center. The mean cost of renal transplant hospitalizations in our center was €14,100. The mean 19.4 day duration of stay was consistent with that evaluated by the 2005 NCS (19.5 days). It is difficult to transpose this economic estimate to the medical/economic conclusions of studies performed in other countries, considering the differences in medical practice and health care system organizations. Nevertheless, it is interesting to compare our results with those obtained in various centers in Europe (Table 6). In the Netherlands, the cost of management for renal transplantation is 2–2.5 times less expensive than the cost of heart and liver transplantation.9 In Finland, a study comparing the costs of various methods of chronic terminal renal failure maintenance therapy (hemodialysis, peritoneal dialysis, and renal transplantation) showed that maintenance of a renal transplantation was more economical than the dialysis systems.10 These 3 studies (Belgian, Dutch, and

Table 3. Classification and Mean Durations of Stay DRG V9 no.

27C06Z

Short Name of DRG

Cost of DRG NCS 2005 (€)

National Mean Duration of Stay (d)

No. of Stays Observed

Mean Duration of Stays Observed (d)

Renal transplantation

16,389

19.5

77

19.4

Abbreviations: DRG, diagnosis-related group; NCS, National Cost Scale.

HOSPITAL COSTS

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Table 4. Evaluation of Mean Costs Per Patient in Renal Transplantation According to Various Methods of Evaluation Method of Evaluation

Mean Cost Per Patient (€)

Analytical accounting National Cost Scale DRG hospitalization rate, 2005

14,100 ⫾ 8789 [6836–60;671] 16,389 17,369 ⫾ 7602 [15,973–75,589]

Comparisons in P t-Test

.025

⬍10⫺3

*

*P ⬎ .05 (not significant).

Finnish) are difficult to compare with our results but make it possible to identify the costs of management of renal transplantation in various health care systems.8 –10 The methods vary, with follow-ups between 6 months and 3 years after surgery, and a varying number of patients from 1 study to another. Comparison of yearly post renal transplant costs in the Belgian and Finnish studies (€37,792 vs €60,240) showed a difference in the level of expenses observed for each health care system (Table 6). The costs of renal transplantation management at 3 years seem to converge more for the Dutch and Finnish studies (€70,723 vs €76,327). Last, it should be noted that these works were not performed over the same period; there was nearly a 10-year difference between some of the results. If the expenses incurred by our center are compared with national costs and national rates for a renal transplant stay, the differences were significant. National values showed the cost of a renal transplant hospital stay to be €2,000 –€3,300 higher than our reference cost. In contrast, there was no significant difference between national values (NCS) and the rates administered by DRG (T2A). Although the use of an AA system is probably the best method to estimate the actual cost of management, it does not take into account which disease is treated. It provides a “daily price” per operating unit, which does not distinguish between transplant and nontransplant patients, who do not require the same level of resources. It should also be emphasized that AA may vary considerably from 1 health care center to another, due to their methods of analysis and distribution of costs. One of the limits of this work may be the lack of specifically assessed pharmaceutical costs based on the amount for each patient. However, our study relied on a detailed breakdown of AA per operating unit and not per management center, thereby coming as close as possible to the actual expenses for transfusions and medicinal products. Another limit is the arbitrary assignment of the “Renal transplantation” DRG. Field surveys have revealed errors Table 5. Comparison of Hospitalization Costs in Renal Transplantation Management by Different Economic Approaches Methods of Evaluation Compared (A vs B)

Mean Difference (€) (MA ⫺ MB)

P

AA vs NCS AA vs RatesDRG2005 RatesDRG2005 vs NCS

⫺2,289 ⫺3,269 980

.025 ⬍10⫺3 .26 (NS)

Abbreviations: AA, analytical accounting; DRG, diagnosis-related group; NCS, National Cost Score; NS, not significant.

in DRG coding, mainly related to possible confusion between primary diagnosis, related diagnosis and associated diagnosis.11,12 Such an error at the time of coding may classify a given stay in an incorrect DRG using the classification algorithm. Coding error for a study conducted on breast cancer was estimated to be 6.5%13 and the rate of changes in DRG was 15% after review of files in a study conducted on heart diseases.14 In studies conducted in oncohematology at our hospital in 2004, nearly 25% of hospital stays were placed in generic DRGs not consuming the same level of resources.15 This observation demonstrates the importance of coding quality, which depends to a great extent on the quality of data collection about the patient’s hospital stay. An incorrectly completed hospital discharge system (PMSI) can have an impact on a center’s budget and can lead to a loss of representation on the Regional Health Organization. In our case, the renal transplantation DRG is specific. Therefore, it would be interesting to verify the quality of coding and the financial impact of the 77 hospital stays of our transplant patients. Finally, the evaluation of the actual cost of expenses for renal transplantation in our center using an AA system was much lower (⫺€3,269) than financing by national DRG rates. In contrast, studies conducted locally on the management of acute myelogenous leukemia demonstrated an underestimate of costs incurred at 2- to 4-fold using national methods.15 It is therefore necessary to consider the hospital budget and T2A as a whole taking into account the fact that DRGs with favorable pricing and DRGs with unfavorable pricing may balance out in the end. In conclusion, consideration of economic constraints in health care is now a reality. Renal transplantation is a difficult multidisciplinary procedure in terms of both treatment (immunosuppressants, monoclonal or polyclonal antibodies, transfusions) and consumed resources. This study investigated the direct medical costs of renal transplantation management according to various economic views. A “reference” cost of a hospital stay for renal transplantation was evaluated at €14,100 through our AA system, which is based on actual expense data from the center, provides costs that best reflect the actual incurred expenses. A significant difference was demonstrated between AA and each of the national economic approaches. The local cost of a hospital stay for renal transplantation is €2,000 –€3,300 lower than the national values. In contrast, there was no significant difference between national expenses evaluated by the NCS and the financing set by DRG/T2A rates for the activity of “Renal transplantation.” Thus, the specific renal transplantation DRG seems favor-

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CHAUMARD, FAGNONI, NERICH ET AL Table 6. Comparison of Costs of Renal Transplantation Management in Several Studies Chaib-Eddour et al (Belgium, 2005)8

Type of study Alternative compared Posttransplant duration of observation (yrs) Perspective Study period No. of patients No. of days of hospitalization Mean cost of management 6 Months 1st year 3 years

Oostenbrink et al (Netherlands, 2005)9

Salonen et al (Finland, 2003)10

Retrospective — 1

Retrospective Heart and liver transplantation 3

Retrospective Hemodialysis, intraperitoneal dialysis 3

Health insurance (health care payer) 1997–2000 (3 yrs) 143 29

Hospital (Erasmus MC Medical Institute) 1995–2001 (6 yrs) 295 (CD)/179 (LD) 58.4/46

Health insurance (health care payer)

— €37,792 —

— — €70,723/€76,577

1991–1996 (5 yrs) 55 ND €44,005 €52,538 €76,327

*

Abbreviations: CD, cadaver donor; LD, living donor. *Conversion rate for 2003: $1 ⫽ €1.15.

able when compared with the cost evaluation by our AA method. The evaluation of hospital stays for renal transplantation must be correctly classified in this DRG using the PMSI algorithm. Last, the hospital budget and casemix– based payment systems should be considered as a whole. Without a global approach, a productivist attitude may develop, which could create a situation where hospitals give priority to DRGs with higher rates. REFERENCES 1. Chauvin G: Procedure-based tarification: from reality to utopia. Med Dimension 1:8, 2006 2. Agence de la biomédicine: Activity report of organ harvests and transplants in France in 2006. Kidney graft activity. Available: www.efg.sante.fr 3. Jungers P: End-stage renal disease: prevention and treatment. 2nd ed. Paris: Flammarion; 2001 4. Durand D, Abbal M, Rischmann P, et al: Kidney transplantation—Results and indications. Practicer’s Review 51:404, 2001 5. Woronoff-Lemsi MC, Demoly P, Le Pen C: Pharmacoeconomic approach and example of the French hospital system. J Pharm Clin 19:53, 2000

6. Woronoff-Lemsi MC, Limat S, Husson MC: Pharmacoeconomic approach: cost estimates of therapeutic strategies and study methodology. Dossier du CNHIM XXI:40, 2000 7. Technical Agency of Hospital Information: French diagnosis related group (DRG) classification, year 2005. Available: www. atih.sante.fr 8. Chaib-Eddour D, Chaib-Eddour H, Malaise J, et al: Cost of renal transplant in Belgium. Transplant Proc 37:2819, 2005 9. Oostenbrink JB, Kok ET, Verheul RM: A comparative study of resource use and costs of renal, liver and heart transplantation. Transplant Int 18:437, 2005 10. Salonen T, Beina T, Oksa H, et al: Cost analysis of renal replacement therapies in Finland. Am J Kidney Dis 42:1228, 2003 11. Borella L: PMSI: assessment of hospital activity. Gest Hospit 287, 2000 12. Labor Ministry: PMSI, Medical economic analysis. Information Hospit 1996:1–72 13. Borella L, Paraponaris A: Macro-economic assessment of hospital costs, micro-economic analysis of breast cancer. Rev Epidemiol Sante Publique 50:581, 2002 14. Holstein L, Taright N, Lepage E, et al: Quality of codage PMSI. Rev Epidemiol Sante Publique 50:593, 2002 15. Fagnoni P, et al. Cost of hospital-based management of acute myeloid leukemia: from analytical to procedure-based tarification. Bull Cancer 93:813, 2006