Philippine Institute for Development Studies
Costs of In-patient Hospital Care for Bronchopneumonia and Acute Myocardial Infarction in Manila Tessa L. Tan-Torres DISCUSSION PAPER SERIES NO. 95-12
The PIDS Discussion Paper Series constitutes studies that are preliminary and subject to further revisions. They are being circulated in a limited number of copies only for purposes of soliciting comments and suggestions for further refinements. The studies under the Series are unedited and unreviewed. The views and opinions expressed are those of the author(s) and do not necessarily reflect those of the Institute. Not for quotation without permission from the author(s) and the Institute.
June 1995 For comments, suggestions or further inquiries please contact: The Research Information Staff, Philippine Institute for Development Studies 3rd Floor, NEDA sa Makati Building, 106 Amorsolo Street, Legaspi Village, Makati City, Philippines Tel Nos: 8924059 and 8935705; Fax No: 8939589; E-mail: publications@pidsnet.pids.gov.ph Or visit our website at http://www.pids.gov.ph
1
Costs of In-patient Hospital Care for Bronchopneumonia and Acute Myocardial infarction in Manila
Tessa L. Tan-Torres, M.D., M.Sc. December, 1994
2
ABSTRACT COSTS OF IN-PATIENT HOSPITAL ACUTE MYOCARDIAL INFARCTION Clinical Epidemiology Unit, College of Medicine.
CARE
FgR BRONCHOPNEUMONIA AND IN MANILA. T Tan-Torres. University of the Philippines
OBJECTIVES: i. to describe the mean age of patients, hospital outcomes, frequency of utilization of tests, cost of medications and length of stay for pneumonia
their median (acute
myocardial infarction) in selected hospitals in Metro Manila; 2. using a standard set of prices, compare the median costs of hospitalization for pneumonia (and AMI) in the different hospitals; 3. if there is a difference, to estimate the contribution of three hospital descriptors: level of care (1,2,3), ownership (private and government) and teaching status (teaching and non-teaching) 4. if the descriptor contributed an increase, to determine the extent of increase in the cost categories of '_diagnosis, treatment and hospital stay. SAMPLE: First Stage: Hospitals who had participated in a previous survey constituted the sampling frame. A hospital was selected if it represented different descriptors (e.g. primary, government, non-teaching) and the administrator agreed to allow access to patient records. Second Stage: 200 consecutive patients who were admitted to the hospital with the diagnosis of pneumonia or AMI were included. METHODS: Charts were reviewed to get utilization data on diagnostic tests, medications, procedures and length of stay. Standardized costs were obtained from a previous study which derived costs by estimatiDg actual resource use. The data were analyzed using descriptive statistics of medians and ranges. Comparison between groups was performed with Kruskalwallis test. RESULTS: For Pneumonia: • There were 6 hospitals in the pneumonia first and
data set which could second level of care
demonstrate contrasts for government-owned,
between private
and government-owned in secondary and tertiary care levels. Mean age ranged from l.lz:to 1.9 years. Death rates ranged from 0-7.9%. Length of stay varied from 2.5 to 6 days, number of diagnostic tests performed ranged from 2.4 to 12 and costs of treatment ranged from P929 to P2959. For the same level of
3 care, government hospitals had higher total costs of hospitalization (P<0.05) and for private hospitals, a higher level of care was associated with a higher cost of { hospitalization (P<0.05). For Acute Myocardial Infarction: Fouri tertiary care, teaching hospitals entered the study. The only contrast possiblewas private versus government. Mean age ranged from 49 to 53 years and death rates varied from 2.6 to 10.3%. Length of stay ranged from 8.3 to 12.3 days, diagnostic tests from 20 to 33 tests and treatment costs from P522 to P729. The private hospital had lower hospitalization costs compared to the government hospitals. CONCLUSIONS: Data collected in the pneumonia data set are consistent with current literature of obtaining higher costs in government-owned and higher level facilities. Most of the additional costs occurred in length of stay and diagnostic tests. For AMI, there were higher costs and higher mortality rates seen in the government hospital. No information could be obtained on the role of teaching versus hospitals as no contrasts were obtained ineither RECOMMENDATIONS: i. recommend the use algorithms to standardize care efficiency; 2. enrol more patients in a prospective study tq allow including standardizing for severity
non-teaching data set. of validated
and possibly, and additional better data of illness
increase hospitals collection
4
INTRODUCTION: Hospital care, by the nature of its _ technology, is very resource-intensive. Over the past ten years, it has accounted for not less than 60% of. the budgetary outlay of the Department of Health (i). In 1990, approximately P5 million was allocated for hospitals. Compared to expenditures for primary care interventions .like i_nunization, this amount benefits fewer individuals. Considering the disproportionately large sums of money spe_t on the hospitals, it is imperative that the practices in the hospital are constantly _ examined and reviewed for effectiveness and efficiency. As a first step, the costs of hospitalizing ill individuals, can be determined and the impact of hospitalization on the patients' health status documented. Data can subsequently be aggregated for analysis to answer questions on resource utilization, practice patterns and patient outcomes. What is the cost of treating a patient with pneumonia in a tertiary care. setting? What if the care was provided in a lower level facility? Is it less costly? Is it, at least, equally effective? Would a teaching hospital produce better patient outcomes compared to a non-teaching hospital? Would they carry out more tests? Are there differences in the cost and quality of care being provided in a private versus a government hospital? What would account for these differences, if any? The information obtained can provide policymakers with a basis for planning and financing services within the hospital sector. It can suggest areas where policy action is needed, define which policies will have better chances of successful implementation and indicate where more studies have to be u_dertaken. Conceptual
Framework:
To systematically framework in fig.
explore the issues 1 will be used.
raised,
the
conceptual
5
PHYSICIAN Hospital: ownership level of
__PATIENT ISeverity
---
status
TOTAL
COST
Number
x
(Diagnosis,
cost
of
summing
hospitalization
the
products
therapeutic cost
of
TC=NdxCdx where: = coCal
N=
number
C=
cos t diagnostic
tx
=
therapeutic
ho
= hotel
rate
is
the
tests
will
decisions
illness
of
can
units
including
Algebraically,
be
(of
"hotel" this
Hotel)
can
obtained
diagnostic sEay)
be
interventions, or
room
and
utilization
N
who
be are
or
and
the
represented
by
done
and
procedures
board.
depends
on
the
's condition. to the use of
actually
writes
what
primarily
including
down
The resources
the
medications
influenced
physician
orders
will
by
the
be
and
of
th_
his
physician (2). He for
which
given.
existing
His
standards
in. his area (3), adjusted for the level of severity of the patient. In general, the more severe the more intensive the use of resources in
management
by
+ NhoCho
of the patient as the gatekeeper
person
of care illness illness,
number
Treatment,
interventions
stay
of
assessment functions
an
Cost
cost
dx _
The
of
unit.
+ NtxCtx
TC
for
interventions,
each
illness
care
teaching
The
of
of the the
patient. l
The
standards
defining environment
the
of type can
care of be
in
a
given
hospital described
area
the in
can
physician terms
be
approximated
practises of
in.
availability
by The of
6 technology, efficiency
presence of external (dis)incentives and teaching/training star.us.
to
improve
The availability of technology simply_ means that if it _S there, it can be used. For example_ a device called a pulse oximeter monitors the amount of oxygen in the blood and can be used to assist anesthesiologists providing general anesthesia to a patient. The device can d%termine the adequacy of respiration in a patient more precisely than clinical observation. This increase in precision theoretically should lead to better patient outcomes. A randomized trial has not demonstrated any difference in patient outcomes in terms of perioperative complications and deaths but 80% of anesthesiologists felt more secure with the device and 18% of them could recall an episode where the use of the oximeter had helped to avoid a serious incident. Despite the absence of impact on the patients, in North America (4). The
availability
of
convincing the pulse
technology
information oximeter is
defines
the
with regard to now widely used
level
of
care
which
can be provided to patients: Higher level hospitals have high import intensities (ratio of total imports generated to gross output) and cost more to maintain. In Malawi, average costs per inpatient in a general hospital is at least twice the cost in a district hospital (5). The ownership of the use. Supplier-induced documented r_diation
technology demand
is
available also a phenomenon
empirically. Physicians who therapy machines, may practise
increase utilization rates beyond of patients being seen (6).
those
influences which has
own equipment, "self-referral', expected
for
the
its been e.g. and type
Viewed in a different light, privately-owned hospitals may be managed more efficiently than those owned by the government. Theoretically, administrators or physicians will have an incentive to provide services of a given quality at a minimum cOSt if they have "rights to the future profits resulting from _he operation of the hospital". Among future
governm_ profits
hospitals, the and performance
connection between is n_bulous and in
rights fact,
to the
7 government hospital has a stated mission of providing medical care to all (as a last resort) which might conflict with the aim of maximizing the value of their future income (7). :
?
In Lesotho, average cost per inpatient in a public hospital was three times higher than that in a private hospital (5). However, case studies of transfer of public hospitals from local governments to more autonomou_ agencies in the US were not able to show any clear gains iniop_rating efficiency (7). In Malawi, there was also no difference demonstrated (5). Finally, standards of practice associated with academic settings usually imply higher rates of utilization. Teaching physicians may order a test because of the need to document a phenomenon, whether or not documentation of such phenomenon can influence the patient's outcome. Residents and training fellows, due to inexperience and inadequate supervision, may order more tests unnecessarily (7,8). There is some evidence to show that costs increase proportionately with expansion of a teaching program (7). To test the soundness of the model, two illnesses were selected for study, acute myocardial infarction (AMI) and bronchopneumonia (BPN). The two were selected to represent the opposite poles of an epidemiologic transition, infectious and degenerative. In addition, pneumonia is primarily a disease of children and myocardial infarction, a disease of adults. Finally, both diseases have widely accepted clinical grading systems which can be applied to assess severity of illness for purposes of controlling this variable. Acute
Myocardial
Infarction:
Acute myocardial infarction or 'heart attack' as it is more commonly known, is the medical term used when a portion of the muscles of the heart dies because of lack of oxygen. This is usually due to blockage, by deposits or inflammation, of the blood vessels supplying the area effectively preventing the continuous flow of blood bringing the oxygen. Mortality total of diseases
rate due to 9006 deaths of the heart
AMI is 22.6/100,000 population with a reported. It is classified under which is the leading cause of death in
8 the country in 1993. The five year second leading cause of death (9).
average
puts
it
as
the
There are no national figures for morbidity due to AMI. An ongoing cohort study on AMI started in 1992 by the Philippine Heart Association and the Philippine College of Physicians reveals a case fatality rate of 12% with a range of 6-24%. This is based on the data from 600iAMI patients admitted to various hospitals, mainly in Metro Manila (personal communication, Dr. A. Dans). Applying this case fatality rate on the 9006 deaths, there would have been at least 75,050 individuals who suffered an AMI in 1990. Admittedly, this is a very crude approximation of the burden of illness due to AMI. However, it clearly constitutes a major burden, particularly on the males during their productive years (see figure 2). Acute myocardial infarction strikes suddenly and the individuals are usually unprepared for the financial burden that it imposes. Individuals who suffer an AMI and reach a hospital alive (10% don't) are hospitalized, usually in an intensive care or coronary care unit. In the United States, 1988 figures suggest that approximately one million individuals suffer an AMI with Medicare charges reaching an average of $7,200 per initial hospitalization using conventional treatment (I0). The advent of invasive diagnostic and therapeutic procedures like angioplasty or coronary artery bypass surgery (operative repair or replacement of blocked blood vessels) and the introduction of thrombolytic therapy ("clot-busters" for the blocked blood vessel) have made available a new array of effective and expensive choices for the m@nagement of these patients (ii). Given patients standardized for age and other demographic characteristics, variation in use of procedures, e.g. coronary arterybypass grafting (12), has been demonstrated in North America. Availability of on-site facilities to perform these procedures increases the odds of the procedure being performed by seven times for angioplasty, five times for cardiac catheterization and two times for bypass surgery (13).
9 The teaching status of a hospital may also influence resource utilization. However, a recent study on the influence of teaching status on costs of care speciffc to the diagnosis of acute myocardial infarction showed that patients in a teaching service had a median length of stay shorter by 0.5 days (p=0.009) and hospital charges lesser by $1,653 (p=0.07) compared to patients on a non-teaching service in the same hospital. Patients on the teaching service also had 15% fewer cardiac catheterizations and 9% fewer revascularization procedures. Results were obtained after adjusting for demographic characteristics and severity of illness based on clinical parameters. This surprising finding was hypothesized to be due to the increasing awareness of clinicians about costs starting in the early 80's and the rigorous assessment of severity of illness based on clinical parameters specific to AMI. Previous studies illustrating increased costs associated with teaching hospitals were carried out mostly prior to the 80's. Also, among the more recent studies, severity of illness was controlled using DRG (diagnosis-related groups) case mix adjustment. This might not have been sensitive enough to truly adjust for severity o_ illness. Extraneous sources of variation were also minimized by the use of one hospital with teaching and non-teaching services (14). Bronchopneumonia: Bronchopneumonia in childre_ under the age of five years is a leading cause of death among children in developing countries (15). In the Philippines, a cohort of children in this age group in 709 households was followed up from 1985 to 1987 to determine the incidence of pneumonia. The incidence of pneumonia, both moderate and. severe cases was 0.5childyear (16). Of this, 4-13% would require hospitalization (17). If the population at risk in 1990 was 8,505,079 (9), a minimum of 170,101 children needed to be hospitalized for severe pneumonia. There are very few studies on costs of treatment of pneumonia in children (18). The large economic burden of illness due to pneumonia is due more to the frequency with which the
i0 condition
occurs
rather
than
to
use
of
expensive
technology,
e.g. a small ticket item which adds up to a large amount. A local study on hospital costs in a rural area in 1989, estimated the cost of hospitalization to be P2,144 for five days (17). The care of children with acute respiratory infections is included in the care of the sick child, a cost-effective package recommended in'the World Development Report 1993 (19_). ,i OBJECTIVES: This project I. describe
was carried out to: the mean age of patients,
their
hospital
outcomes,
frequency of utilization of tests, mean costs of medications and length of stay for pneumonia (and acute myocardial infarction) in different hospitals in Metro Manila; 2. using a standard (and hospital specific) set of prices, compare the mean costs of hospitalization for pneumonia (and acute myocardial infarction) between the different hospitals; 3. if there is a difference between the mean costs of hospitalization of pneumonia (and acute myocardial infarction), estimate the contribution of each descriptor (level of care, government ownership and teaching status) to the base cost of hospitalization in a private, primary, non-teaching hospital; 4. if the descriptor contributed an increase in the base cost, determine the extent of increase in each of the different cost categories hotel). METHODOLOGY Sampling Hospital
(diagnostic,
therapeutic,
and
length
of
to
time
available,
stay
or
: : Selection:
Due
the
short
selection
of hospitals was limited to those in Metro Manila which already had participated in the hospital survey of the Philippine Institute of Development Studies baseline projects for health financing (annex I) . One hospital representing each of the different combinations of hospital descriptors (e.g. primary, private, non-teaching enroled into the study provide access to data
or tertiary, government, teaching) was after the hospital administrator agreed to from hospital charts and their charges.
Level of care was based on th_ classification Bureau of Licensing and Regulation. Teaching
provided by hospitals
the are
ii those
with
medicine
residency
training
accredited
Specifically,
by
one
descriptions
programs
their
hospital
in
respective each
was
pediatrics
specialty
seiected
care
level,
private
primary
care
i evel,
government
secondary
care
secondary
level,
care
level,
private,
teaching
tertiary
care
level,
private,
non-teaching
tertiary
care
level,
government,
teaching
tertiary
care
lev_l,
government,
non-teaching.
SamDlinq of
age
2.
presence
3.
x-ray
4.
admission
200
less
patients
than of
hours
admission
were
inclusion
2.
electrocardiogram
3.
no
onset
of
in
date
The
inclusion
and
of
were
to
per
hospital
was
the
following:
set.
The
years;
on
admission;
I,
1989.
respirators
excluded for
(<24
from
acute
with
cut-off
(not
that temporal standards of
hours) reading on
or
the
who
died
within
48
study.
myocardial
of
infarction
April
were
the
respect to
exceed
were
trained
pre-tested
.=. senior
mm
Hg).or
tales
examination;
were of ago) of
new
medical
to guidelines
designed
comparable
severity 5. years
changes due to entry care were minimized.
and
infarction;
<90
1989.
hospital to
myocardial
physical
i,
pain
pressure
criteria
each
chest
acute
blood
exclusion in
severe
admitting
after
Chart Abstractinq; â&#x20AC;˘Two teams of doctors using
of
(systolic
patients
particularly
exposure)
were five
April
attached
the "lungs)
admission
charts,
to
pneumonia
after
hypocension
4.
date
disease
pneumonia
equal
criteria
recent
sample
per
:
I.
(fluid
for or
date
who
following
â&#x20AC;˘
cough;
reading
Patients
The
following
:
criteria
I_
of
the
government
level,
inclusion
fit
private
care
target
boards.
to
tertiary
A
internal
:
primary
Patient
and
abstract and
illness. was
to
with
assemble each
The
instituted
technology
students data forms
admission to
and
(with
ensure
changing
clinical
from (annex
a
other,
the 2).
One
12 supervisor
per
research
team
of
stay,
medications
length
and
!dentifÂĽinq, of and
the
room, served
outcome
stay date
General
data
use
and
Valuing
of
of
diagnostic
tests,
Inputs: generated, This was
days
in
based on the date of checked by comparing
admitting
and ward and The cost of
(PGH)
from
The
characteristics,
the the
section total length
derived using the costs of a day in care unit and ward as determined
came
abstraction.
patient
discharge,
was computer of discharge.
number
Hospital
prices
of
on
procedures.
intensive care (diet orders).
cost) was intensive
accuracy data
on
special
total
the
recorded
Measurinq
The length admission with
checked
assistants
study
the
of
resource
different
or
number of of stay
th@ in
use.
meals (hotel
emergency room, a Philippine
A
hospitals'
emergency
second
set
charges
for
of
ward
patients. The frequency of use of diagnostic tests results attached in the chart and from the Recording
was
through PGH
the
study
second
The
done
computer,
which
set
using
and
management
(e.g.
Cardiovascular
purchase
price hospitals
of
the
respective
generate
any
of
The the
the
list two were
reviewing
the
using
sets
two
hospital's
one
of of when
generated
set
resource
from
the
and
the
use
used
to
determine
Medications
set
of
prices
General
set).
then
A
set
the
different
costs.
The
and
recorded
used,
the
pharmacy
of
was
applied
prices,
charges
hospitals,â&#x20AC;˘was Philippines
quarter,
grouped
etc) Hospital,
second
a price
were
1994) was
the
not
used
Index
provided available
of the
through
sources. obtained doctor's of
charges. the
on
anti-infectives,
(first price
prices:
were
patient.
pharmacies set
were
actual sheet.
hospital.
pages
Philippines
(standard
of based
each
first
Specialties
Procedures
summing
the
Costs
sets cost
of
drugs,
another
manufacturer's
two
fluids
of
of
all
Medical
the
test.
the
charges
Costs.
to to
per
using
the
medical
as
use
determined
medication
directly
as
was based from doctor's orders
prices, The
diagnostic,
from orders the total
the
first
pages.
Costs
standard costs
therapeutlc
page PGH
per and
of were
set
patient hotel
the
chart
again
and
the
were costs.
and
by
obtained respective
obtained
by
13 Inconsistencies and determining fidelity data entry.
outliers of chart
were checked as to abstraction, recording
accuracy by and computer
ANALYSIS: Descriptive deviations,
statistics (means, medians, percentiles, skewness, kurtosis and distributions) were
standard generated.
Analysis of variance with Pairwise comparison was done to determine the comparability Of sroups of patients in the different hospitals with respect to age. Proportions of patients With other co-existing disease were also documented. Patient outcomes were reported in terms of proportions of dead, alive, with complications or discharged against medical advice. Kruskal-Wallis determine if
test with pairwise comparison there are differences in
hospitalization
among
Revision
of
Protocol:
was also done median costs
to of
the hospitals. '
After a survey of the hospitals concerned and an interview of the hospital administrators, it was evident that in Metro Manila, all tertiary care hospitals have accredited residency training programs in internal medicine and pediatrics. There are no tertiary care hospitals which are non-teaching in the metropolis. Also, _overnment, primary care level hospitals are merely lyingin hospitals which do not admit patients for illnesses like pneumonia. Thus, for pneumonia, there were only 6 hospitals studied with the secondary care, private hospital category represented by two hospitals. Patients with myocardial infarctions seen at lower level facilities are immediately referred to tertiary care level facilÂŁ_les. Thus, three hospitals were studied with one hospital contributing patients to both government and private categories or a total of two hospitals per category and two categories, private and government tertiary _are, teaching hospitals.
14
RESULTS: Pneumonia: The hospitals included were:
(descriptions
i. Primary Care, Bagbaguin Family hospital
with
Pediatrics 2.
and
Secondary
Pasay
City
100%
3.
Care,
392
4.
Care,
Secondary
Clinica
for
Tertiary
University (no report
ten
Tertiary
The
Philippine
City
of
for
reports)
is
these
an
beds
pediatrics
a
100-bed
beds
are
pediatrics
8-bed
are in
for
1991.
in
hospital for
with
pediatrics
a and
1991.
I in
beds
for
in
Novaliches,
Quezon
pediatrics.
City
There
is
a 50-
were
1839
1991. II
Hospital 12
pediatrics
Care,
is
these
(CGH)
Private
beds in
(CAGH) for
in
Sta.
Crux,
pediatrics.
Manila
There
is
were
256
1991.
Private
of Santo submitted
6.
of
Private
with
Care,
q_o
admissions
for
General
hospital
admissions 5.
Care,
hospital
_ Caloocan
in
(PCGH)
Twenty
pediatrics
Arellano
50-bed
230
BLR
Government
Hospital
for
1991
rate.
Hospital
with
admissions
were
admissions
General
hospital
(BFH)
occupancy
rate.
Secondary
bed
70%
General
were
Casaul
Private Hospital
there
occupancy
there
a
a
from
Tomas (UST) to BRL).
is
a
502-bed
(private)
hospital
Government
General
Hospital
a 93% occupancy rate. pediatrics and there were
(PGH)
is
a
936-bed
Eighty-nine of these 1,844 admissions in 1991.
hospital beds
with
are
for
mean
age
Patients: Pneumonia ranging
is from
significant Death rates (see
a
table
disease I.i
to
of 1.9
ver_ years.
difference in _he ranged from 0-7.9% !).
young
children There
is
with a
a
statistically
age between these two extremes. with the highest rate is the PCGH
15
Resource
Use
Length
of
longest
stay
private
being
just
Again,
by
of
of by
standardized
care was
care
Within
the
same
private
of
biggest
category
No
influence
frequently
in UST
PGH,
had
standardized
tertiary
care
1/6
median
hospitals,
For with
hospitalization private
higher
care,
hospitals,
costs
for
was
total
highest a
(p<0.000)
counterpart
charges
was
higher
o For
always
cost
the more
were
higher
for
43-64%
Costs: of
of the total costs. diagnostic costs and costs.
of
government
of
BFH
with
hospitals.
Categories The
cost
hospitals.
level
stay
of
The
the
the The
hospitals.
PGH.
for
having
hospital.
PGH.
most
private as
PGH
care,
total
the
stay
used
the
associated
same level of care, expensive (p<0.003).
in
of
median
forl tertiary
of
higher
levels
with
government lengths
tests
was
level
of
by
days
of
were
then
6
shorter
length
diagnostic
lower
to
another
have the
and
medications
followed The
of
2.5
PCGH,
tests
PCGH
number
by
hospitals
a third
2) :
from
followed
diagnostic
followed the
table
varied
stay,
three
cost
(see
discernible of
ownership
costs,
The these
therapeutic,
smallest accounted
pattern or
category of form 4-12%
could
levels
of
accounted
be
determined
care.
(See
costs was the of the total regarding
table
3 and
the fig.
9) Acute
Myocardial
Infarction:
The
hospitals
i_
Philippine
included General
2.
University
of
3. Philippine sections treated All
hospitals
Santo
in
Tomas
had
myocardial
years with mean from 2.6 in UST
study
coronary
were
with with
Heart Center separately.
Patients: Acute
the
Hospital
care
139
502
with
the beds
beds both
following: for for
medicine;
pay
patients;
private
and
charity
units. ._
infarction
struck
people
during
ages from 49 to 53 years. to 10.3% in PGH (table 4).
their
Death
productive
rates
ranged
16 Resource
Use
Length
Of
(Table stay
(private). PGH
ranged
Highest
with
33
medications PHC
from
number
lowest
in
was
lowest
for
P729.
maximum
at P5,975 reached up
charity)
because
Charges
were
12.3 of
and
(private)
(private)
5):
the
lowest
in
PGH
at
with
P522
median
occasional
was
days
used
the
of
and
was
PHC
also
in
cost
of
highest
seen
in
!still
lowest
in
for
PHC
in PGH. (private
thrombolytic
highest
in
Median
hi_he_t seen in the PHC
use
P5,696
8.3
20.
_ith
cost
to the P100,000
PGH,
;to tests
(private)
compared to over
of
PGH
diagnostic
PHC
Total
in
The and
therapies.
PHC
(private),
P12,947.
Categories of Costs Most of the costs costs_
Hotel
with
costs
(22-50%).
25%
of
of
the
effect
DISCUSSION There
was
able
to
level
enough
show
of
more
AND
care
costly
mostly
seen
usually
at
the
that
the
acute
variation was
between
Heart
discretion
very
expensive,
as
phenomenon
The
of
General Hospital mean that, being is getting that
the
a
data
the
set
of
level
of
data
care,
to
set,
the
most
of
in
the
PHC
hospital,
and
is
was
are
which
patients
and
is
costs which
consistent
the
was
higher
government
tests
there
Hospital some
drugs,
university
of
which with
physician
cost
General
categories
difference
attending
Despite
pattern
pneumonia
diagnostic
and
costs
contributed
associated
The
infarction hospitals
also
in
discernible
different
costs
same
but
no
therapeutic
share
:
subsidized
thrombolytic in
the
stay'and
Philippine
costs.
the
higher
the
of
(private).
expensive
lowest
The
between
the
Center
is
hospitals. of
myocardial
seen
in
for
length
usually offered at government hospitals.
In
on
by
major
lowest
RECOMMENDATIONS were
for
next
There
descriptors
private
in
the
were
costs."
there
and than
for
costs
the
variation
that
and Table 6): were accounted
accounted
Diagnostic
approximately in the costs.
(figure_ (35-44%)
in
not
is the
enough
contrast
the
Philippine
patients
receiving
(private) PGH,
was
had the
the most
pneumonia.
the
highest
costs
being
seen
at
the
Philippine
may mean that_it is not efficient or may also a government tertiary care referral center, it patients in a more severe state and
inclusion/exclusion
criteria
were
not
stringent
17 enough the
to
ensure
a uniform
different
hospitals.
was
a huge
There
also
thus precluding inclusion/exclusion patterns This
of
care
dataset
by
objective
4.
consistent cannot
be
i.
To
The
and
use
standardize the
of
3.
not
existing the
variance, more
care;
hospitals
role deserve
a
on
be
a
to
hospitalsi
that again, or simply
the that
itself. meaningful
answer
appears
literature for
admitted
within
pneumonia
This
is
but,
robust
of
to
have be
to
to
by
be
itself,
conclusion.
which
patients applied
of university closer study.
of of on
be to
may
be
important
are
expensive
time
in
cost
with
to
added
(20,21)
particularly
collection systems
patients
algorithms
therapy
Prospective
4. The hospitals
allow
world
have
within a small window myocardial infarction;
scoring
even
hosplita_
set
basis
more
validated
standardization illness
costs,
to
This may mean insufficient
the
data
patients
recommended:
thrombolytic
effective an acute
does
provide
are
in
within
specific
the to
decrease
the study Contrasts;
vary
itself
with
following
variation
of
use of means. criteria were
may
The
used
The
2.
the
cohort
data
more entry
versus
the
gain
the
into
adequate
recommended withregard and
natural may
detailed to
entered
to
are
only
history
allow
to
of
better
severity
of
hospital.
non-university
teaching
18
Acknowledgments: The
author
thanks
the
following:
I. the hospitals who agreed to open patients' data to be included in the 2. Drs. Mark Reysio-Cruz and team of co-doctors and senior data
from
patients'
their charts study;
and
allow
their
Jomar Makalinao who supervised a medical students to collect the
charts;
3. Prof. A. Amarillo for the statistical analysis Mike Alba, Jesus Sarol, Cynthia Cordero and Rachel providing statistical advice ; 4. who
Ms. Marie Manalo and Dr. assisted in the generation
Cito Maramba, of tables;
5. the
Philippine funding for
Development
Institute for the study.
research
Studies
and Profs. Delino for
associates,
for
providing
19 REFERENCES: i.
Solon
O,
Financing
Gamboa
in
the
R,
Schwartz
PHilippines.
HFDP
2.
Reagan
Md.
New 3.
England Greer
Journal of Medicine AL. The State of
Physicians
Science:The Diffusion International Journal 1988;4:5-26. 4.
Moller
JT,
Evaluation
of
Mills
Part II. Costs 1990;5:203-218.
The
New
and
England
Compassion:Conflicting
S, Brecher
Espersen
Sector
1992. Challenge.
the
State
of
the
into Practice. in Health Care
et.al.
20,802
Randomized
patients:If. Complications.
EP,
of
Health
Medicine M, for
1989,
Journal
Ii. Harrison DC. American Journal
Policy
1992;
p.
Countries and
Planning
Physicians' in Radiation
327:1497-501.
et.al.
(eds).
Public
Competition
Hospitals.
Michigan.
19-21. the Attending Physician on Costs. Journal of Medical
EJ,
Sakin
Thrombolytic of
JW,
1990.
American
Health
et.al.
Therapy College
Cost
for of
Cost Containment in Medicine: of Cardiology 1985; 56:10C-15C.
G, Grumbach K, Luft Surgery in the United Medical
Association
HS, et.al. States and 1993;
13. Blustein J. High of Service Availability
Technology Cardiac on Service Use
Journal
Medical
the
Developing
Consequences of - Joint Ventures
Henderson Roles
Topol
Infarction. i2:58a-68a.
American
Income.
in
Health Statistics, of Health.
of
12. Anderson Artery Bypass
of
Hospitals
59:789-98.
Philippine Department
of
March,
Complex
K,
in
The Influence of Medical Education
1984;
Steinberg,
of
Press
Implications
the
C,
Administration
8. Jones K. Indirect Graduate
of
A
Postoperative
Journal
Altman
I0.
2.
Health
Technoiogies Assessment
Sunshine JH_. Care Facilities
and
9. Service,
and
Sources
7.
Education
A.
1987;317:1731-4. the Art _ersus
Oximetry
Economics
6. Mitchell JM, Ownership of Health
Health
Monograph
Gatekeepers:
NW,
Pulse
Herrin
1993;78:445-53.
A.
Therapy.
and
New Medical of Technology
Events
Anesthesiology
as
Johannessen
Perioperative 5.
of
JB
American
Association
Intelligence and
Acute
Procedure Myocardial
Cardiology Why
1988;
Cardiology.
Use of Canada.
Coronary Journal
269:1661-6. Procedures: the Impact in New York State. 1993;
270:344-9.
20 14. Udharhelyi IS, Status and Resource Infarction:A
New
Education. 15., Bull
Rosborough Use for
Look
American
at
Journal
Bulla A, Hitze KL. WHO 1978;56:481-98.
16.
Tupasi
T,
Respiratory
de
Tract
Leon
17.
RITM
ARI
Operational
lesson
Program: In
The
The
Health. 20
in
WH0/ARI.
in Metro
the
Philippine
Journal
Medical
ial.
A
Patterns
Reviews
of
a
Acute
Study
of
of
Review. of
A_Longitudinal
Implementation D.
Acute (Eds.)
University Bases
in
Infectious Workshop
an
ARI
on
Control
Internal
Report
the
the for
Infections. Health
Sector
1990
Medicine
Investing
Recommendations
at
Management Acute
1993:
in
1993.
WHO
Children
for
Respiratory Evolving
Press,
for
in
Algorithms of
e_.
Development
Algorithms
Clinical
Graduate
1990;80:I095-II00.
Proceedings
Countries.
of Pneumonia 1991.
Problems:
S,
Teaching Myocardial
Infections:
Manila.
WH
World
Technical
of
Health
Children::
Shepard
Oxford
D.
Lupisan
Mosley
Bank.
Oxford.
Morales
and
and
Public
et.al. Acute
Experienbe.1990.
Developing
World
Management Facilities, 21.
SK
DT
Priorities 19.
ARI
Costs
Respiratory !
Group.
from
Bohol
Stansfield Jamison
of
L, in
Study
Indirect
Acute
Infection
a Depressed Community Diseases 1990;12:940-949.
18.
the
T, Lofgren RP, Patients with
First of
the
Health
Common
Medical
Myocardial 1994;
on
Level
32:51-53.
Infarction.
21
Table
i.
Mean
with
Age
and
Pneumonia
Outcomes by
of
Admissions
Hospital
Hospital
N
Age
+ s.d.
% deaths
3G
164
1.55
+
1.15
4.3
3P
II0
1.89
+
1.33
0.0
2G
165
1.07
+
1.02
7.9
2P
192
1.54
+
1.35
2.6
IP
85
1.73
+
1.38
0.0
"'_1_!,.£
_,,
COMPARISON OF RESOURCE USE FOR PNEUMONIA BY HOSPITAL
3G
3P
2G
2P
1P
160
110
165
192
85
Hotel (days)
6.3 + 4.8
5.0 ._2.4
5.5 32.8
3.0 + 1.4
2.5 + 1.3
Dxtic (tests)
12.0 ± 12.1
2.4 + 1.2
5.1 ±:1.8
4.5 ± 1.6
4.2 ± 1.1
Txtic (P) Range
250 0 - 5186
442 0 - 3861
165 0 - 2478
142 0 - 805
232 50 - 1096
Stand (P) Range
2959 340 - 58,734
2685 604 - 21,050
1818 238 - 10,638
1267 423 - 10,524
929 478 - 2458
Charges (P) Range
2926 340 -58,734
5310 1895 - 28,380
769 233 - 6330
1505 605 - 7920
1591 557 - 5812
'
N
23
Table
3.
Pnellmonia
Median by
Total
Category
By
Costs
for
Hospital
r
Hospital
Hotel
Diagnosti6:
(%) 3G
(%)
0.33
+ 0.17
0.32
+ 0.14
2G
0.49
+ 0.16
0.08
2P
0.37
+ 0.12
0.09
IP
0.43
+ 0.11
3p
,
0.12
Therapeutic
(%) 0.55
+ 0.22
0.64
+
+ 0.04
0.43
+ 0.18
+ 0.06
0.53
+ 0.15
0,.12 + 0.04
0.45
+ 0.10
0 04 +
+ 0,10
0.03
0.16
Table with
4.
Mean
Age
Myocardial
Hospital
and, Outcomes
Infarction
N
by
age
+ sd
3G
107
48.6
+ 10.6
3P
38
51.5
+
â&#x20AC;˘3G
iii
53.4
+
3P
96
53.6
of
Admissions
Hospital
% deaths i0.3
%
9.7
2.6
%
I0.2
6.3
%
+ 10.4
8.3
%
;,is" •l_BZ,e+ 5"- COMPARISONOF RESOURCE USE FOR ACUTE MYOCARDIAL INFARCTION BY HOSPITAL 3G
3G*
3P*
,3P
107
1111
96
38
Hotel (days)
12.3 + 5.6
9.5 :I:3.9
8.3.± 4.9
9.6 ± 5.0
Dxtic (tests)
33.7 + 12.7
23 + .12.2
20 + 8.4
21.3 ± 8.8
Txtic (P) Range
522 73 - 4782
564 0 - 4986
729 0 - 9122
873 0 - 4650
Stand (P) Range
7115 2104 - 15,388
6238 983 - 117,718
5975 825 - 133094.1
6538 820 - 32,575
Charges (P) Range
5696 1522 - 27,690
11,724 1578 .4 117,576
12,947 2920 - 181,827
10,965 3971 - 40,084
N
Table
6.
Median
Myocardial
Infarction
_0spitai
'
Hotel
Total by
Costs Category
Diagnostic
for by
Acute
Hospital
Therapeutic
,.
(%)
(_)
C%).
3G
.40
+
.ii
.25
+
.Ii
.35
+
.16
3G*
.28
+
.ll
.22
+
.12
.50
+
19
3P*
.37
+
.14
.25
+
.13
.38
+
.30
JP
.30 +
.18
.26
+..19
.44
+
.27
>7O 65-69 83-64 55-59 5O-54
L.
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I_'{_lxIGUkD_3 HArF.FX:.'_ h,SL[!AI, _At_TI I,_IA_I_E,)OCIO_,5H,ISPIIAI.lll,'d_POLq'_l{ r{ANII.A ;,1(, LAi:Oi,lttSPIi',_llI_O)I_I'I;P.411_[I ,'L_)iII,A 'HY8ICIAII' rjIAGIIOSrIC IIIJVIC6S !'HIc[EI_rlA_II.A {AF_N il_Sl VIAl ,_AN II.A (_,lq I_IH_CIII,/,'rE IIOS?IT,I;, P,_HIG
??tDJI_V ZI/I1AIIY IH3XII'( I)l_)' IIIuARY l_1).(_.I
PRY'I'. nVl', PHI', HIVT. FRII', PllV['.
I._'_Y'S jlli_){f GHI_6JAI. il';._l'[lAl, Irllc1"l_ll.lJ_,4 I_P,l)l£4l, rl.lXir
PAI;IG IIIIlil'INI,UPA
l_lll_i_YPRH', lMl),q_1_ PITH',
',A,_}E3 _ENUALIIOHPI[_I, l[}l_j{l)_ IJ_I(h_AL. HOS_IIA; 'l_. I_OICICA )IEI)I_,_I, t?LIlIIC AIkYI{_FOl.Y_i_l)[(' l(oHf'lf/,l. _$kUl. GXXERkl. am{l{Pllkl ,Lql, II{_AY _IIRI)LflOUT'Ilk6
Q,ll, IN{IRll? PRVI, C_l,llOClkll ' I{IOII_Y Pl_Vl'. I_ARII_IIIA ])¢I)A{IYPRVI", II,IVAI, IrII_,3 2NI)A_Y HVL I/tlVkl.lL'llE_I/¢1/I_' PRVI, llkltkll 21{I{AHY PRVI,
A_?- L4L_XAQ OIPllO_P11,41. eaI_I_QI/K l_llLfltY PITY1', 7116 -I !;_'_.Ll(ht,,5 f,P./,L_AL I_SI'11'AL l,',lVAI, iflllhl IlflIAItY PR'il, j_l_., -I .41_I,4itFP' [IOL'I'_/_J II_;,_PI'[,_I, llhj, Q.L 0,L 2k'll,_llY PI{VT, '17H -I _0. I_III0 O_ SAI' ,(Nri{lllq I_AI. lill_?. I'ASI6 21_l_V PI_VI. 1_11_ l _._fUAI, GD!81_AL llOSPIIAL Q,C, ]_¢O_RY PI_YT, 1J6 _t? .I¢,IL *_[ii[_AL ll,ffPil_, I/.C, TERIl_{IY I/I)VT. 50,_ -I _. ,;[;E_L HO,_l'lhl ,l,r. TEf_TI_.,_I GOVT, I_8:12 -I Ii..}l,_i_ li.{e.Oi_l,,iT!?, ._',_'i{_;_.L _{I:,_P'ifl, l. ,j}{.fl:j(j,_6' IE_TI_.RIGOVT. _JO_ lI,5 xrl_L41,,"tlll.i_H_,jiio,51l!_{. Q,('. I'[gfIARY GOVT, 3015 -I
-I -1 -i l -1 -I -I "l -i
xw ;,X/.AF_,: 1+,:;; ;;_ S;'I.. cROg,_AIIILA I'61_TIA._Y GOVT, ,,_f,O M_i,,,A. '/_141Ek }'lJNl:,) . TE{Ii'I_"GOVI". :Ii,. IHt.}'_l_O_ [. VILLan;F,'ll_l_ljl. HO,_PITAL tAL,)O,'.A,_ TZRTIA{IInOVI, hIILFPi};ES CI[[LJI_EX'_ ' '_ ...... " ,IE_.CA,... 6,_, I_ Q.r. !'ERTI AR'! f, OVT. OSEJ_81f_ HEt,JRIAL _Elfi(IAI, CEIII'E!_ _ANII.A 1'l_llflltRl GOFT,
-I -I -I -1 -1
50J.i -1 106H, -I 154a -I ll_lll_,h_i ?l_ll -1
IJLO_/({ _L)III_I ,ilk.Y, _{I. HE"{OHIJl, HOSPITal,H{RIKIN_ I'ERT[ARYOIVT, _15_ -i ?..lOSl5._AHF.LLA Hii_ORIAL HOSFII'_L 3'I'A, _:RUZ, IIAHILR TI_111"1_11_ GOVI', 7_t,I -I HILIPPI,_F OHII(IFF.bIC _'kXlF{_ Q,IL. [gHIA._I'G_V:f, -I -I {, I_[HAII_ _Ei_()PI_L_MP, Mr.AI, ,bNlr.H Q,¢L IE{_TIAHYGOVf, _?_u -I ArIOI_L _l_EV ll(_li"llljl_. Q.!' f)!Id'l_Yf,I)Yf. -I -I 3?IT_I.IIGHtV)tll.i_ -I {EI_T[,_RY GOYf, I_12f,. .l _ILIPPI)i£ ll!aHl;l.'dl6g Q.L'. T_RFIX_Y GOVI'. _._J -I. HILIf'FI_'_,(_S_ZL H')P_PITAL I,l,4.Vll.a IHTJ,_y "torT. lllh;,zq 11080 HEAP.CH I)ISI"{TUIH F'OP TRqPICAL M_;/[I:ll_, l(iltlrllll,!irl, TP, RI'IAI_Y_OH,. ):)61 .l _._f AV£,I_£DIL'_L rF,HE_ Q,IJ. I'_I_I'I_KI' GOVT, 2?t_O -1 01_ _ r,I,XICAIjil) G{_N_,_4[ IInSPIT/,L, F_ HA[IATI T_._fII_YGOVT. 12115 ..1 , _r, ";Vllj_ i,,l_ _[_l'i_l lff,(LTH _I*IIIUI, UYO_"G Tl_Hflli{/Y GOYl', -I -I
-I -I -i .i -I -I -I .I -i -I -I -I
31
Vii=_al,_.gg. ;¢_.;,'I;'W, AFt'il/blr'AI, I'£_iT!ll UirF._.r!l( II(_..... ,:,Ii'r $;,(_i_WIIr)_FIiAL _,1,_ % i J, fi.r ,_I. tt;li_.St:t_F:kA,..,',r:T^_.l._,'. :IE,tLT'_'_A'_ '(C_.ITAL ::.,HX E . ,';'{I,._ II_P!,'A(. IIEi(A_O, ;AT.J v. _6LUTA_ _;_,_I_R I.'IC.
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.! .- I -i .I .t •i ' -;
_UI_,',, HF',;?IAi, _iT[,ie.lI eUITF, I. U.C. TSIIIIAIIY PlIYI', ilO,.I:)(l -[ 1'_LO?SA)'FO<J X_DICU,rt_F_,R i)_:. rRlll?l_tllT PI_VI'. )J;7_: -! I#IXITY t_ElllkL IIOSPIFJL ,_[A. AXI,_IAIilLA TIH!.FIAIIY l'liVr. -) ;, ?URTI@6) I'IU'IORIAI, IIO_PITH. _Ai,oOCA_ T_TI4,!_ MIVT, -) -I i_A)f C1411.[S il, g_E.llt_' [i')SFIFAI, ,.IAII?#LOL', .'IAIIJLA IBRTIA)Y ['_VT. ,ii,'" -; ?6U-)'I_FI'I 3AIIPALUC, HAIf/I,.A TU(IIAU ?)VY. 67)I -I LlllOl_ M;._AY_AY I%_,,?iAL _([i, iCA{('E_TF, R ,I,C, T_:_IAU F')V?, )%s,) -I ,7_ O(,AtlH_ .'il_,'i)_)AL ,"I[_:I_IL t'Elil_) ,_FA. _SA, _AglI, l T_IITIA_,I PIiY6, )):6 -I _i', CLA))'_ l(,)_pirk_ _ _(,_u.lr.tl EAICA_J TI6_TIAIIY }'RYl'. -i -: IITA. TERIfILI F._._EIAL )fii3PIrAt iHAIR) O.C. I,_RIIAI(I ?)V?. 2n)S "l .a_..I_SU.)(,, DEL,;APU 1_6_91_1AI, _tiJ$;IFA{, U.r. T_:_TIA_,Y i_l.f[. 6_li .. /ATII'(A llEl)!_Ab C/HFEP 'IAL_IIZU_LA ,'I.H.FEPTIARY _.'RVT, 7U,: -I I'EItPF.IUAI. _EL_ !v)?.PIFA/ _A_PALOr, _t_,_lL,t ?IIRi'IARY PkVF, -; -i ,?T, _l_.'_ 5_)IEAAJ. _l',:ffllA), .(Afi_ilLI}C, ,ittJll,,t ll(lITlAlll E'_(VT. l'i,,I -' A)ID _.DICAt. C611T)'i( )n, t "i 7XIT_.O _}oClOR',1 _,1_C8 I'I,)PO_.AII,I7()l(OO T[llltAl(/ PIi_T, -i +H) D_!LY Cl,;i(:e f_C_)it)RAT6._, ._)A. C_.U), IIA)II+A /_RTIItWY?RVT, )l_) *I _t' ?,?_3cI(}/(_,iPITAL IIiU_)I; F6,RTIA_7?RV7, ',_,$1. -I ;)1__,EYlCL.C,TY!;;,_;,p_,II,,._PFF,_,_. _A_/;),_L!II IIN; l'_,_liAkY I'P'[/. ;IT;I -: :lxlibl O_;C;'(ylL7 it_.YJ_/A_. ,Ui_ ,i.¢, IFI(:IARI' PI(_I, ,?7_, -' i. )lJ)TlWI_IE l'_l.'t;;._,'llJl:,(i ;I,I;,';,/,i. ,,;l)l .I;IAll 7_,T)A)I I'I_VI'. I'l;, _ -[ _Jili.,! _Yurll Riie;._il_i. ,IAIIiI.A ffPi'II77b)il, !.;it"I I ;:'. [li/).i vriill;Ai, i.'_.),iE i w.'. :.It.H:iH() I'l(V_. lllll: I /(771(A;.t'ri,'lF.i <'lA)lll.J _ll4ii; 'f'F..lll'fli(7. Pni'l'. ,(,.._ '_UPlJ_,l _i_ l.:,lY)i)_;t 1!,6f'iTA,. :flA. _t.;ii, _A_lll.X II..EFIAI:/ 7x'tl, :;lii; l )l';.f.ri,, _.[UiCA.FUUgIIArPi_V Ilu.t.PilJl. )iJI.i,ll##.il T{I('PI_.)Ii' Pl('tl, l';),l!, -I t_tILUI,6)I,S _f.!:l,:l. Cf.Xll:.fPllll,.i. _!.¢, ll_i'lll'.l I')'i]. ',lib ." ';_PITui, _i_ICl?, rUIfR 9,e, I-TPTI_)'PPVF. ;Y,l;, -? _'t.Yi_I_iUII n_.l,PdEDICAi. '.'UI_'F.i I.A7II_VA_ II.:IlllJlIIY PtVi'. i:$_ ?UYYUf CII? _DUIf, ALi.'l.Rl'kP. :J.,'. lEli/lAlt' ?RVT. .I -I _,J)tll.l _IA.VIIAYtlII_ _k]lij_lPlllt, i'lflY II{i(IIARI/ ?)tl, ,," _,' ,i :ill)it:IF. Gf;lilll I_u3PIFAE SJJ, _))q./.,ItltlltJ ll.,PTIA_i' PIVI. _,'t.,_ -I 46DICAI, t'E,'ll'[_ llLkllj?)6 I'AI,AI(_/IH.. F_)l'll_)'., Ifiti3, -I -! •_ ,l"l_( I)6UI!I_ f;Um:AI'I,IIAL i'A;_Ai IEI(:I'IAII" PIYF, -,. •i i.l_U/19ll I0)i, IiUI_PlIAI. :l_;.Dfl tJElitilA(.!Y,;_i'IIAI..i),)",l'i")ibJll'.l_ illi;,j.ll/lith: ikl411Alii Pb'/f, i,?',,. .: FIU'HIIAL _IJI/'IR_,',:llIIAI .__l',., ',:;i ilfll'ttI.'I.., _J.tl!l,l lb,lcIIAli/ iY_7, ;, JlI:;(PI[AI. UF lift( llllAi/l ,h2i(I.<l " ,O./fl'AI.,Jl;, lIAllllX II6)TIAIIY )l'Yf. "._,'1 -! HAl(Alli_FlYll.'ll.I;_llll',_ i!AIAI; l,;),:llA)_'Y ;RF;. ,,,i' T_,: ijlEliiJO.JHII_IPIIAI. i:,)._i',l_A'l'l(,_ .;,Ui..l'k) !_YI'IAI{7 ,'_l't'l', /,:'_ -"
.( -I -i -1 +,
.I -I -1 -1 -i -.7 -I -I -I -I .i -) "i .I *I -I l it -I -i -i .I -I i .' i .i -1 -I .' .I -I -I -;. l *i : -; i -I
(;(_st. of illness Avute NyooardJa/ I l)tlt'J :, l"'l'P+kl'fF,: llC):gP] 'l"AI........................ ,(;IIAIITIIU : AGE (years): I)ATEADH : I)ATEIil .St:ll : II I AGtI(,),S1o": I. i.ypjca.l, r-llesl, paJtl 2. 2x illt':rease i,i ,-.nzymes 3. evo luLio_,at'y I_(:G t)TIIERL)X t : I. EA]II/IIA._ ¢oode: 1 :: Yes, )
•
Is
__ __ '-0 = No) DXI
I_KG (JXR ,6gri t-BS/EBS UI+.LC _C]TD C
'l ,.flaP']
BIJ I'l
CR CA P IIA It CfIOL T+; AHYLA+;}'7 ..... 2-1) e,- li,) _4/o 2.-1)_
,++
,'1
I)X'l'J C. lJXJ CBC t' I,ATEI, L.:T I,_SR O(;(:UI,T UIRINALYS/S__
_>('}l,+. .)
._ _
.,<'Lr_,._s LesL Otllersl 'I'XTI C AIIAI,/PYRET I C,S fiI,LIII':WI'AI1Y C VS/l) i lJ IIg'l' tCS RF,SP I Rk'l'O RY
I:orn, ]zlfaretion
1
SGO'I' LOll CPK-HB C,PK k I I_Phos IlL)f, I,l)[, 'I'YI+,I, ll(, IIA'I'Cll
I4/
fig
_ _
'l'l_a tlium OLiver,2
Dl kGfltJSl L_1 ...............
....
O'i'llI(lll_X
.........
I'I l'3.I ROll IJ SC:i.II ,k t/ IIO Ill iUtl Ig$/(J(' P ll{l"
MI'I' J.I+,> J O'l' I ¢.a O'l'llJi [( C.IIl,:tlO (;l,]tf.['l'OIl R/llAllY H_'f'ABtJL r SIt V 1T/li 1:I:I -[II/'I'R TT fOPl F+YE/F,AI_ Hf)WI'II/TII flOAT DF,till A VAC.,I (, Ill+,./;-;EIIA :e,
................
...........
z+-_ .........
.........
...............
_
..........
[ VI' I_W1")) I"I!B(; O'I'I[_[(S
._ ......
-
SIlPFLIES '.I VT _ _ tlc)T FC 02( 10<)0 [,iLel'._) )
O'I'llg_S
5peci l'_
I" i'o_:erl)I
f'y
:
At)giot_,lasl.y ._ _ TP I .... PP]. _. _ ,_;I,)'el._I.r, lc izta:;(: 'I'I,A _.. ("AI_G .... II()_';I'I'I'AI, l':ll I ,",11 WAI+I)
I)AYL')
I)I F,','I'IIAY[.; II YF_I;:F'A I'I)A Y"; ()FI)AY',_ It l I,KI)AY:: Itl,:ril)A Y" :_l'l,:(' IAI,I)AY_; Ill'(),,:l,':,a l i,I I) ,l
,',))11'1,
I
::1 ..... i l' y
:f)IIIII':IIT:; :
Cost of lllI,ess Form Pn eu mon ia ID[IO: PT[iAIIE: HOSPITAL : CHARTNO : AGE _years): DATEADII: _ _ - _ _ - _ _ DATEDISCH: - _ - _ - - - _ DIAGNOSIS: i. _ough 2. RR>50/min 3. chest indrawing_ OTHERDXI : DEATH/HAA (Code: i = Yes, 0 = No) DXTIC DXI CBC _ _ HB/H _1 PLATELET _ _ ESR _ _ FECALYSlS _ _ OCCULT URINALYSIS__ BUll _ _ CR NA K _ _ CL. __ TXTIC ANAL/PYRETICS ALIMENTARY CVS/DIURETICS RESPI RA'rORY NEUROHUSCULAR HORMONES/OCF ANTIBIOTICS OTHER CHEHO O'ENITOU RINA RY METABOLISM ViT/MIN NUTRITION EYE/EAR [_OUTII/TII [{OAT DEI!MA VACC IN ES/,_I., RA IVF ' FWB ,
PRBC OTHERS SUPPLIES IVT
sputum ,G/S sputum C/S .ABG _ _ CXR F/RBS- blood c/s aspirate g/s aspirate-c/s OTHERSI OT[IE[IS2 OXIHETRY __ __
DIAGNOSIS1
_ _
__
OTI{ERDX
__
.:-
NGT FC
__
02(I000 OTHERS
Liters) Specify
i
HOS?ITAL ER ICU WARD
DAYS _ _
RESPIRATOR STEAH NEBULE PT
_ _ __
P_OCEDI PRDCED2
....
DIETDAYS }{YPERALDAYS OFDAYS MII,KDAYS REGDAYS SPECIALDAYS tlPO/clearliq
D
__
OUTCOIIE _'.-, (code: COHPLI Specify:
O=,lone, II if present,
9-not
evaluable)
CO Mt'lEI'VI'S :
Dat._:
RA: ¢
.... ._ _
GUIDELI[IES _: _"UT AS'I'E_.JSK AT UFPER . (4tlESTLUtlS RI_GAI_.DIItG DATA IN *
Costs
will.
be
expressed
IN
COSTILIG
LEFT }IAItD CURNBR 'FILE FORH. in
1994
1F
'l'llBRli
AHE
pesos.
Diag_os_s ,.,f AIII depends on: presence of 2 ,mr of tile following: -crushing che._t pain, retrosternal, >[5 rain, witlt diaphoresis -CPK-HB elevated >2x normal within first 24 l,ours -Evolutionary F,KG changes (on at least 2 }:CGs) - development wave, ST elev:_tion, 't'wave inversion. *
l)ata to be collected: diagnostic - units of use therapeutic (including pr'oeedures) of drugs by diagnosis
, Ij._eof If you can't data colleeLion * of
,g99 vs 0 as say, code _orm.
* for all contai_lers e,l.c Ii da.y.
_irst
IV drugs and additives; as 24 hours only. will
* if amount consumed in terms of smallest prepat-ation should be used not a fraction thereof. ['or P't'sessions,
count
- cost
code. 'if definitely as 999. Do not leave
for all U'I'tlF,_S, ,;ode others in times jn the last t_o blanks.
number
being used (not just exercises; under others in. therapeutics. inhalation, nebulization, etc.
SUIII;;
of
two
consider have to
medicines/group
blanks
shelf include
and
the
number
life of opened a new oust for
is very at its
small, the unit price,
l.f instruments
are
e.g, ultrasound), note and put This is also the case with steam
* Code for procedure: I - CVP insertion 2 - traeheosto,,y 9 -.others:specify *
For
....
IVF :
!JSE I/0 charting as ['irst source of data If no i/0 charting: use 1 liter/day if on regulartiiet/OF/HYPERAL, use 3 liters/day if on _IPO [IOTE: if renal or oa_'diac patient: use'order _IO'fE.:a lack of precision within the order acceptable.
q
not done, code as O. any blanks in the
mg or ml but costed
sessions,
of
of
sheet. of 250
ml
is
still
-*. For FC, check if present (FC) in vital signs sheet, assume 1 FC per HDs *, If with IVF, impute one set of IVT per 7 HDs. .*. .for 02 : imputeonly at 2-3 litees/min (unless specified in orders) for hour s.
* For hospital days: Round off to lo_rer number or equal to 12 hours.
if < 12 hours
and
*. for diet: clear liquids, code as [IFO soft diet, ¢or.leas regular diet low diet, code as regular diet â&#x20AC;˘ high diet, code as special diet ].f out on pass, code as ['I_0 "i: for CoiJirlg _:,fmeal days, should have same kind to be coded as such. * Clreck ord,_r_ ollly for: 1. _nitial order for.lVF 2. initial order for U2 3. orders .fr,_, biopsies and procedures 4. PT sessiolls/radiotl|erapy and other i
at
7
4
to liigher nulnber if >
least
ancillary
2 meals
procedures.
of
tile