Moving the Brazilian ischaemic stroke pathway to a value-based care: introduction of a risk-adjusted cost estimate model for stroke treatment

Abstract

The unsustainable increases in healthcare expenses and waste have motivated the migration of reimbursement strategies from volume to value. Value-based health care requires detailed comprehension of cost information at the patient level. This study introduces a clinical risk- and outcome-adjusted cost estimate model for stroke care sustained on time-driven activity-based costing (TDABC). In a cohort and multicenter study, a TDABC tool was developed to evaluate the costs per stroke patient, allowing us to identify and describe differences in cost by clinical risk at hospital arrival, treatment strategies, and modified Rankin Score (mRS) at discharge. The clinical risk was confirmed by multivariate analysis and considered patients’ National Institute for Health Stroke Scale and age. Descriptive cost analyses were conducted, followed by univariate and multivariate models to evaluate the risk levels, therapies, and mRS stratification effect in costs. Then, the risk-adjusted cost estimate model for ischemic stroke treatment was introduced. All the hospitals collected routine prospective data from consecutive patients admitted with ischemic stroke diagnosis confirmed. A total of 822 patients were included. The median cost was I$2,210 (IQR: I$1,163-4,504). Fifty percent of the patients registered a favorable outcome mRS (0-2), costing less at all risk levels, while patients with the worst mRS (5-6) registered higher costs. Those undergoing mechanical thrombectomy had an incremental cost for all three risk levels, but this difference was lower for high-risk patients. Estimated costs were compared to observed costs per risk group, and there were no significant differences in most groups, validating the risk and outcome adjusted cost estimate model. By introducing a risk-adjusted cost estimate model, this study elucidates how healthcare delivery systems can generate local cost information to support value-based reimbursement strategies employing the data collection instruments and analysis developed in this study.

Is it possible to automate the discovery of process maps for the time-driven activity-based costing method? A systematic review

“…Regarding the use of electronic data in healthcare, one systematic review in 2017 identified a study where the process maps were created based on electronic medical records involving surgeries and medical care procedures [ 3 ]. In our review, the electronic medical records were used to construct the process maps identified in 23 studies [ 5 , 16 , 22 , 24 – 26 , 29 , 32 , 34 , 36 , 43 , 47 , 48 , 58 , 59 , 61 , 66 , 74 , 75 , 77 , 78 , 82 , 84 ], proving that using medical data from electronic medical records has enhanced and provided support to the process.…”

“…Regarding the other types of construction, we identified the process maps of a study performed in Canada that created a model for a clinical pathway of a patient submitted to a routine outpatient endoscopic sinus surgery for estimating the cost of this procedure on the patient [ 72 ]. In a study performed in Brazil, five main perspectives were analyzed, and the process maps were complemented by the clinical analysis of the protocols in the ischemic stroke condition [ 61 ]. The details of how the process maps were constructed in each study are shown in Table 4 .…”

“…It is worth mentioning that applying process mining and discovering process models do not rule out the validity of specialized professionals in this field, nor the involvement of a multidisciplinary team at institutions. There were 23 studies in our review that validated process maps [ 14 – 16 , 18 , 22 , 23 , 26 , 33 , 38 , 39 , 46 , 48 , 58 , 61 , 63 – 66 , 68 , 75 , 77 , 78 , 80 ].…”

Variation in Ischemic Stroke Payments in the USA: A Medicare Beneficiary Study

“…Ten countries are participating in this venture, utilizing real-world data to examine the costs associated with patient resource consumption. The methodology used for this project was based on prior studies conducted in Brazil, two of which yielded financial information for the implementation of mechanical thrombectomy in public healthcare systems [22,23], and another introduced a risk-adjusted cost estimate model to sustain the redesign of a reimbursement strategy based on value specific for the ischemic stroke pathway [24]. The experience from those previous projects highlighted the value of having accurate and real-world about patients' resource consumption from the healthcare systems.…”

“…Furthermore, monitoring more accurate stroke cost information and clinical outcomes are of utmost importance to establish trust in value agreements to a highly prevalent disease. Technological advances allowing healthcare systems to estimate costs similar to the one created in Brazil [24] might facilitate a solution to the health cost crisis.…”