MINISTRY OF EDUCATION AND TRAINING – MINISTRY OF DEFENCE VIETNAM MILITATY MEDICAL UNIVERSITY NGUYEN DUC TOAN PH VĂN BÁU RESEARCH OF TREATMENT COSTS FOR ACUTE APPENDICITIS AT SON LA PROVINCIAL GENERAL HOSPITAL Major: Medical Management Code : 972 08 01 SUMMARY OF DOCTOR OF MEDICINE THESIS Hanoi – 2019 INTRODUCTION In Vietnam, The policy on partial collection fees in State-owned medical examination and treatment establishments has been implemented since 1989; Then was the health insurance policy (1992) Revenue from hospital fees and health insurance is considered a public finance source, the proportion is increasing more and gradually becoming a major source of revenue, contributing significantly to increased the investment for higher capacity and quality to suppling the medical services of public hospitals However, the cost bracket currently does not include the full cost components that limit the autonomy of hospitals, while the Government subsidizes both the rich and the poor people This requires some researches to find out the methods to calculate service costs by evidence-based services for public hospitals Therefore, we choose cost analysis for the treatment of acute appendicitis at Son La Provncial General Hospital, both from the hospital as well as patients, to provide additional information for the evaluation of medical services cost The research question: what is the actual cost for a patients of acute appendicitis treatment at a provincial general hospital? What is the difference between the actual cost of the hospital and the cost which patients have to pay (direct or through health insurance)? Has the Government budget subsidized the components that have not been included in the service fee yet? To provide information that will provide the basis guides for accurating calculation of the medical services cost Objectives of the study: To analyze the actual cost of surgical treatment for acute appendicitis at Son La Provincial General Hospital (2012-2013) To analyze the economic burden on patients with surgical treatment of acute appendicitis at Son La Provincial General Hospital (2012-2013) THE NEW CONTRIBUTIONS OF THESIS Scientific significance: Healthcare reforms aimed at increasing the accessibility and quality of health services which require transparency in both quality and service pricing This requires hospitals have to develop a good costing system and procedures, and improve pricing models to more accurately reflect the cost of providing services to patients Finalization and transparency of the costing system to determine the right price helps the patient to make better informed choices in the use of services, and helps the hospital manage the finances better Reducing costs to increase competitiveness in terms of price and quality of services to improve the quality of health services in health care facilities Practical significance: Applying the correct methodology to calculate the actual costs of the hospital for medical services which will help the clinic know and calculate the actual cost of the hospital, the difference between the actual cost of hospital and the cost of the patient must be paid (directly or through health insurance); Government budget subsidies for components on service charges; Health insurance pays for health care facilities and the calculation methodology will help to form the basis guides for package payments for health services (group of illness cases), financial transparency and fairness in medical examination and treatment New points of this thesis: Described the method of analysing and calculating the actual cost of Son La Provincial General Hospital (Level II) for a medical service (surgical treatment of acute appendicitis) in 2012-2013, determined the actual cost of services that has not previously been calculated, as the basis for calculating actual costs for other services; Determining the cost burden of surgical patients to treated for acute appendicitis at the hospital, thereby obtaining the method of calculating the actual cost of patients when seeking medical treatment at public health facilities THESIS STRUCTURE The thesis consists of 118 pages excluding references and appendix with 44 tables, 04 charts and 06 pictures Introduction: pages Overview: 34 pages; Methodology: 22 pages; Results: 31 pages; Discussion: 26 pages; Conclusion: 02 pages and 01 page for recommendation CHAPTER 1: OVERVIEW 1.1 Some concepts of cost and medical costs 1.1.1 Medical costs In health economics, the cost of a health facility is the total resource that funds the health facility must spend to create a particular health product or service Costs and prices of health services are two different but have organic correlation with each other Medical costs are the basis to evaluate health services prices Generally, the health services prices = average cost for health services + profits of health centers (subsidized or paid user) 1.1.2 Classification of medical costs 1.1.2.1 From the service provider - According to the functions, medical costs are classified into two groups, including direct costs and indirect costs; - According to the nature of costs: fixed costs and variable costs; - By input types: capital costs or investment costs, recurrent costs; - According to the relationship between costs and products, the total costs, average costs and marginal costs are often referred 1.1.2.2 From the health service users - From the perspective of the user, the cost of health implies spending and is more costly than cost and can be divided into: - Direct costs, including: direct medical expenses such as expenses for examination, testing, surgical procedures, drug costs; and direct medical expenses: expenses for travel, meals during treatment, expenses for medical staff, etc - Indirect costs, including costs lost due to loss of income because of premature death or reduced productivity, sickness, illness - In addition, many authors also refer to another type of cost that is intangible, related to distress, anxiety and the quality of life resulting from illness, diseases or in the treatment process 1.1.3 Cost calculation 1.1.3.1 Principles of calculating medical costs The general principle: calculate correctly, adequately and accurately - The cost calculation must be based on high quality data to ensure the reliability of the calculation results - All expenditures of the health facility must be included in the calculation to produce reliable and comparable results - The process of computation should show the link between the activities and the resources used to create the health service - The calculation process must be transparent and allow for detailed analysis - The cost calculation must focus on the material value of resources - Ensuring consistently between services, allowing comparisons of costs within the health facility and between health facilities - There is coordination between the clinical and non-clinical components and encourage the full use of information in the cost calculation 1.3.2 Approaches to calculate medical costs There are many methods and techniques which were applied to calculate healthcare costs There are two main approaches: top-down allocation (macro-method) and bottom-up approach (micro-method): - Top-down costing method (macro approach or total cost approach) by allocating total budgets (expenditures) for each department and service to estimate the average cost per service - Calculating costs from the bottom up (calculate micro costs) through calculations, summing the cost for each input used to create a service or otherwise calculate the cost from the collection Collecting data each cost item of each individual 1.2 Health finance for public hospitals in Vietnam Health financing is an important part of the health system with four main objectives: (1) Mobilizing adequate resources for health care; (2) Equitable and efficient resource allocation and management; (3) Encourage improved quality and efficiency of service delivery and (4) Protect people from financial risks caused by medical costs 1.3 Acute appendicitis and acute appendicitis treatment Acute appendicitis is the most common surgical emergency, with a rate of 4-5 people per 1000 people and about 6-7% of the population throughout life Acute appendicitis can occur at any age, rarely in children under years of age, increasing and most common in adolescence, especially in the age group of 20-40, and then aged according to age The disease can be seen in both genders, male is higher than female, male / female ratio is 3/2 in young and 1/1 in elderly When there is a definite diagnosis of acute appendicitis, the unique treatment is emergency surgical resection of the appendicitis as soon as possible, because the more it is late, the higher risk of complications patients get At present, surgery for appendectomy may be done by conventional open surgery or Laparoscopic surgery 1.4 Study on the cost of treating acute appendicitis in the world and in Vietnam - Worldwide: The cost of health care services has been studied extensively, both in high-income countries as well as in low- and middle-income countries, from providers and service users Among them, there were many studies on the cost of acute appendicitis treatment, both macro and micro These studies not only addressed the cost of acute appendicitis but also analyzed both the clinical outcome and the cost-effectiveness between two methods: open surgery and Laparoscopic surgery - In Vietnam: There are not many studies on medical costs, especially the systematic studies of the actual costs in a hospital for a disease or a technical service Some studies have calculated the cost of residential treatment for some diseases but almost no research is available for acute appendicitis With other diseases, there is not yet a single study that evaluates the costs simultaneously in both of the healthcare setting and the service user Most studies only estimated the medical costs from the user 1.5 About Son La Provincial General Hospital 1.5.1 Organizational structure and functions 1.5.2 Financial resources of the hospital 1.5.3 Surgical procedure for the treatment of acute appendicitis Adhere to the surgical procedures of acute appendicitis issued by the Ministry of Health CHAPTER 2: METHODOLOGY OF STUDY 2.1 Time and place of study The study was conducted in Son La province General Hospital at two years in total (2012 and 2013) 2.2 Study subjects: - 322 patients operated acute appendicitis surgery (including open surgery and Laparoscopic surgery) at Son La provincial general hospital from 01/01/2012 to 31/12/2013, excluding the patients who not agree to participate in the study - All records, accounting books, financial reports of the hospital in 2012-2013, medical records, bills of treatment, of all patients with surgery treatment 2.3 Study method 2.3.1 Study design A cross sectional study with retrospective available data collection 2.3.2 Data collection techniques 2.3.2.1 Collecting the available information - Based on books of financial accounting, financial statements of 2012 and 2013 to calculate the correct and full expenses of this hospital from which to base the analysis of actual expenses of the hospital for treatment acute appendicitis surgery - Using the medical records of the patients to collect administrative information, disease history, progression of appendicitis as well as details of the patient's medical history and surgery during stay hospital, treatment outcome and status of hospital discharge, treatment costs of patients 2.3.2.2 Patient interview Performed at the hospital during treatment or at home, within months after patients discharge The interview tool is a structured questionnaire In case the patient does not know the cost information, the interviewers will interview patients's primary care provider 2.3.4 Framework theory and cost analysis methods Applying Riewpaiboon's theory of hospital cost allocation; Combining both methods of cost allocation from top to bottom and bottom to top Direct and indirect costs for patients are aggregated and used for descriptive analysis, comparative distribution and median costs of patients in assessing the payment burden for different groups of patients 2.3.5 Contents and variables of study 2.3.4.1 Group of independent variables Including general information on demographic characteristics, socio-economic conditions, illness and treatment of patients 2.3.4.2 First objects’s variables - Cost of capital, there is the cost of depreciation of buildings, facilities and equipment of the hospital - Regular expenses for hospital activities: electricity and water, wages - Direct costs for treatment include expenses for medicines, consumables, tests/tricks 2.3.4.3 Second objects’s variables - Direct costs for health services: expenses which the patients (directly and through health insurance) pay to the hospital; - Non-medical expenses are costs that patients and their family members have to pay to other facilities outside the hospital for patients's treatment at the hospital such as meals, rest, travel - Indirect Costs: is the cost of lost earnings due to a leave of absence for treatment (with patients) or visitation (with a family member), estimated by the number of days off, multiplied by the average daily income of each object 2.4 Data management and analysis Using HOSPICA cost analysis software, cost per item, each service is calculated and presented in average; Stata software version 14.0 and presented as descriptive statistics such as mean and median (quartile ranged 25-27%) Mann-Wtihney nonparametric statistical tests were used to compare the distribution and median costs in the assessment of the payment burden for the treatment of the patient The difference was statistically significant with p