How to determine cost data from patientcompleted questionnaires?
Dr. Thomas Reinhold
UNIVERSITÄTSMEDIZIN BERLIN
Overview
§  Background and Definitions
§  Measuring costs from Patients questionnaires
§  Inpatient costs
§  Costs on drugs
§  Outpatient costs
§  Indirect costs
§  Conclusion
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Medical supply processes
Cost of the treatment, measurable
Benefits of treatment options
in monetary terms:
Measurable in monetary terms:
•  Direct costs
•  Direct benefit
•  Indirect costs
•  Indirect benefit
Non-monetary measure:
Non-monetary measure:
(Intangible costs)
Morbidity parameters
Mortality
(Intangible benefits effects)
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Direct and Indirect costs - definition
Direct costs
…can be traced directly to a cost object such as a disease or a treatment. In
health economics direct costs can be distinguished in two categories:
§  direct medical costs (costs include consumed healthcare resources)
§  direct non-medical costs (typical are patients out-of-pocket expenses, for
instance travel costs to the hospital)
Indirect costs (costs that affect the national GDP)
The main component of indirect costs are costs due to time lost at work due to
illness or death, i.e. production losses. Indirect costs of a disease that could be
averted by an intervention are considered in cost-effectiveness analysis or
cost-utility analysis when performing the analysis from the societal
perspective.
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Direct and Indirect costs - examples
–  Direct medical costs
• 
• 
• 
• 
• 
• 
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drugs
physician visits
Inpatient stays
adjuvants and remedies
rehabilitation services
Patients expenditures
…
-  Direct non-medical costs
•  patients expenditures on travel
•  home help
•  …
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–  Indirect costs
•  incapacity to work
•  premature death
•  early retirement
Specificity of costs
•  Disease related costs
–  Costs directly associated to a specific disease
–  e.g. antithrombotic drugs for patients after myocardial
infarction
–  Best for evaluation of a specific treatment
•  Overall costs
–  Complete health care costs independent from a specific
disease
–  e.g. costs for all medications (including e.g. pain drugs)
for patients after myocardial infarction
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Patient questionnaires
•  a planned set of questions used to collect data
•  It can be sent to the respondents by mail or used as the basis of a
personal interview
•  The biggest problem is to keep the size of the questionnaire small
enough in order to keep a high response rate
•  It is also desirable to couch the questions so that the responses can
be easily categorized and the results computerized.
Be aware the response rate and the danger
of patient selection!
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Retrospective vs. Prospective design
today
Retrospective design Prospective design
„What ressources you „Please document what is your
consumed during the last ressource consumption during the
X months?“ next X months!“
• 
• 
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Danger of recall bias
Differential recall bias
Simple, easy and cheaply
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• 
• 
• 
• 
More Comprehensive
More expensive
Close meshed
Longer waiting time for completed
questionnaires
time
General comments
•  Ways of cost-determination differ deeply depending
on the structure of health care system!
•  2 principal approaches:
–  Bottom-up cost approach:
•  method of making cost-estimates for every disease/treatment by
summarizing single costs-components to provide a total cost estimate.
•  Appropriate method to measure costs from patient-completed
questionnaires
•  ∑(Number of single ressource units consumed * units costs)
–  Opposite: Top-down cost approach:
•  Based on total costs associated with a disease/treatment the single units
costs were determined
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Overview
§  Background and Definitions
§  Measuring costs from Patients questionnaires
§  Inpatient costs
§  Costs on drugs
§  Outpatient costs
§  Indirect costs
§  Conclusion
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What we do…
How we (Charité
University Medical
Center) extract costs from
patient completed
questionnaires?
What costs patients
suffering from chronic
low back pain occurred
during the last months?
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Direct Costs – overview Germany
Year 2010
Inpatient
Treatment
Medication
Outpatient
Treatment
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Overview
§  Background and Definitions
§  Measuring costs from Patients questionnaires
§  Inpatient costs
§  Costs on drugs
§  Outpatient costs
§  Indirect costs
§  Conclusion
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Inpatient treatments
•  Ideally the patient provides detailed
information on
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– 
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– 
Medical inpatient treatments received
Time the doctor (and nurses) invests for treatment and care
Consumables used
Medication received during hospital stay
Etc.
But:
•  Usually patient are not willing / not able to document their
inpatient in such detailedness!
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Inpatient stays
12. April to 18. April
2011
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6 nights
Severe pain in the lower back
German DRG System
•  Germanys hospital treatments are paid by a case-based lump
sum
•  Within the DRG-system the mean costs per stay are known
(mean costs = 3,000 Euro)
•  The mean duration of hospital stay is well know (= 8.5
days)
•  Mean costs per hospital-day = 3,000 Euro / 8.5 days = 353
Euro
•  Mean inpatient costs =
Number of hospital days (6 days) * 353 Euro = 2,118 Euro
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Inpatient stays
2,118 Euro
12. April to 18. April
2011
6 nights
Severe pain in the lower back
Usable for adjusting of costmeasurement, but often unprecice
patient-report
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Overview
§  Background and Definitions
§  Measuring costs from Patients questionnaires
§  Inpatient costs
§  Costs on drugs
§  Outpatient costs
§  Indirect costs
§  Conclusion
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Costs of Medication
•  Ideally the patient provides detailed
information on
– 
– 
– 
– 
– 
the manufacturer,
the name of the medication
the package-size
the kind of application
the units consumed (e.g. number of pills)
•  Drug costs = number of pills * Cost per pill
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German Drug Price List
Cost per pill = Total package costs / number of pills included
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Costs of Medication
•  Ideally the patient provides detailed
information on
– 
– 
– 
– 
– 
the manufacturer,
the name of the medication
the package-size
the kind of application
the units consumed (e.g. pills)
But:
Usually patient are not willing / not able to document their
drug usage in such detailedness!
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Costs of Medication
Ibuprofen
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I dont
know???
20 days
Drug costs using DDDs
•  DDD – daily defined dosis
–  Developed by WHO Collaborating Centre for
Drug Statistics Methodology
–  the assumed average maintenance dose per day for
a drug used for its main indication in adults
–  a unit of measurement that does not necessarily
reflect the recommended or prescribed daily dose
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Drug costs using DDDs
0,58 Euro
=
mean costs for 1 Daily
defined dosis of Ibuprofen
*
Number of medication-days
(20 days)
=
Expected medication costs
(11.6 Euro)
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Overview
§  Background and Definitions
§  Measuring costs from Patients questionnaires
§  Inpatient costs
§  Costs on drugs
§  Outpatient costs
§  Indirect costs
§  Conclusion
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Outpatient visits
•  Ideally the patient provides detailed
information on
– 
– 
– 
– 
Medical treatments received
Time the doctor invests for treatment
Consumables used
Etc.
But:
•  Usually patient are not willing / not able to document their
outpatient visits in such detailedness!
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Outpatient visits
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Outpatient visits
Mean costs per visit from third
party payers perspective
general practitioner
internist
otorhinolaryngologist
dermatologist
naturopathic specialist
psychologist
nutrition specialist
other specialists
Provided by the German Association of Statutory Health Insurance Physicians
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15,09 €
32,59 €
23,42 €
14,72 €
15,09 €
32,76 €
25,00 €
21,68 €
Overview
§  Background and Definitions
§  Measuring costs from Patients questionnaires
§  Inpatient costs
§  Costs on drugs
§  Outpatient costs
§  Indirect costs
§  Conclusion
UNIVERSITÄTSMEDIZIN BERLIN
Indirect costs
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Human Capital Approach
Value of humans life = value of his productivity (equates his monetary
earnings)
•  productivity losses from early death or morbidity (indirect costs)
•  for society as a whole, mortality or morbidity represents a loss in national
output
Problems:
•  People who are not working for pay
(e.g., homemakers, students, retirees)
are valued at 0!
•  Implies that people with higher wages
have higher social value.
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Indirect costs
If not employed –
no indirect costs measurable
Indirect costs =
Number of days with work incapacity *
Mean daily income per working day (approx. 78
Euro in Germany)
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Conclusions
•  Information collected directly from patients are not
comparable in precision compared to e.g. doctors
reports, but are more comprehensive…
•  In principle, patient completed questionnaires are
usable for measuring patients health care costs
•  To get more precise cost information secondary data
use or combined data sources seem useful
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Thanks for your attention
非常感谢您的关注
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