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Background: The burden of chronic illnesses, including cardiovascular disease and diabetes, is increasing in low- and middle-income countries. However, health systems often struggle to meet the needs of chronically ill patients. Affordability is crucial in ensuring access to quality healthcare for patients with diabetes mellitus (DM) and evaluating healthcare costs. Therefore, this study aimed to assess the affordability of health services and identify associated factors among DM patients receiving regular follow-ups at Dessie Comprehensive Specialized Hospital in Northeast Ethiopia, 2023., Methods: A cross-sectional study was conducted among 392 DM patients at Dessie Comprehensive Specialized Hospital (DCSH) from July 1 to 30, 2023. Data was collected using a structured questionnaire and chart review checklist. Systematic random sampling was employed, and the data were analyzed using EPI INFO version 7 and SPSS version 26. The outcome variable, affordability of health services, was measured by five items using a structured questionnaire. Logistic regression analysis was performed to identify significant factors associated at 95% confidence interval using odds ratio., Results: Most participants were married (74.2%), and 55.9% were male. Among the DM patients, 211 (53.83%) found the health services affordable, with an interval of 48.85-58.72% at a 95% confidence interval with a p-value less than 0.05. Factors significantly associated with healthcare affordability included marital status, family size, average monthly income, and brand prescription., Conclusion: The study revealed that healthcare services were affordable for approximately half of the DM patients. However, this level of affordability falls short of the ideal standard. Improving the affordability and accessibility of healthcare services for DM patients, particularly those from low-income backgrounds, is crucial to ensuring better health outcomes., Competing Interests: Declarations. Ethics approval and consent to participate: Ethical clearance was obtained from the Ethical Review committee of College of Medicine and Health Sciences at Wollo University, with reference number CMHS/789/2016, on July 1, 2023, and supporting letter was taken from the Dessie Comprehensive Specialized Hospital in the study area. The study was conducted following the ethical principles of the Declaration of Helsinki. This study adhered to ethical guidelines, ensuring the study participants’ privacy, confidentiality, and voluntary participation. Written informed consent was obtained from all participants before data collection. Participants were informed of their right to withdraw from the study at any time without any consequences. Confidentiality was maintained throughout the study. The study protocol was submitted to the relevant ethical review committee of College of Medicine and Health Sciences at Wollo University for approval. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Study Design: Retrospective Cohort Study., Objective: To explore the differences in Medicare reimbursement for lumbar fusion performed at an orthopaedic specialty hospital (OSH) and a tertiary referral center and to elucidate drivers of Medicare reimbursement differences., Summary of Background Data: To provide more cost-efficient care, appropriately selected patients are increasingly being transitioned to OSHs for lumbar fusion procedures. There are no studies directly comparing reimbursement of lumbar fusion between tertiary referral centers (TRC) and OSHs., Methods: Reimbursement data for a tertiary referral center and an orthopaedic specialty hospital were compiled through the Centers for Medicare and Medicaid Services. Any patient with lumbar fusions between January 2014 and December 2018 were identified. OSH patients were matched to TRC patients by demographic and surgical variables. Outcomes analyzed were reimbursement data, procedure data, 90-day complications and readmissions, operating room times, and length of stay (LOS)., Results: A total of 114 patients were included in the final cohort. The tertiary referral center had higher post-trigger ($13,554 vs. $8,541, P <0.001) and total episode ($49,973 vs. $43,512, P <0.010) reimbursements. Lumbar fusion performed at an OSH was predictive of shorter OR time (β=0.77, P <0.001), shorter procedure time (β=0.71, P <0.001), and shorter LOS (β=0.53, P <0.001). There were no significant differences in complications (9.21% vs. 15.8%, P =0.353) or readmission rates (3.95% vs. 7.89%, P =0.374) between the 2 hospitals; however, our study is underpowered for complications and readmissions., Conclusion: Lumbar fusion performed at an OSH, compared with a tertiary referral center, is associated with significant Medicare cost savings, shorter perioperative times, decreased LOS, and decreased utilization of post-acute resources., Level of Evidence: 3., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Victims of burn have particular characteristics such as high vulnerability, expensive treatment, and cost of burn services. Thus, the financing of burn services is crucially important. The purpose of the present work is to recognize the financing challenges in Iranian specialized burn hospitals (SBHs)., Methods: In the present qualitative descriptive research, purposive sampling was used for selecting key informants with maximum variation at local, provincial, and national levels. Semi-structured interviews were used for data collection. Interviews were continued as long as the saturation point was achieved at the 21 st interview. We employed conventional content analysis using an inductive data-driven coding process and theme development for the analysis of the transcribed documents by MAXQDA Analytics Pro 2018 (VERBI GmbH Release 18.2.0 Berlin)., Results: We extracted 3 themes and 12 sub-themes, including resource mobilization (the poor burnt victims, unique feature of the single- SBH, high direct and indirect costs, and poor intra-sectoral advocacy), insurance coverage for burn care (incomplete breadth of population coverage, inadequate depth of benefits package and coverage of costs, and reimbursements of burn care) and mechanism of financial resource allocation (unsuitable payment system, less sustainable budgeting, inappropriate tariffing for burning services, top-down budgeting approach, and politicized budget process)., Conclusions: We suggest that health policy-makers in Iran could modify the SBHs financing system by improving resource mobilization, scaling up insurance coverage for burns, and optimizing the allocation of financial resources. Besides, we propose several points for policy entry to address SBHs financial difficulties. These points are serious attention to vulnerable and the poor burn patients, provision of burn care in multi-specialized hospitals, strengthening intra-collaboration, revision of tariffs, and payments for burn services, and preservation and realization of burn budgeting., (Copyright © 2020 Elsevier Ltd and ISBI. All rights reserved.)

Problem: Medical education academies have been instrumental in providing greater recognition of and promotion for clinician-educators. However, producing education scholarship is essential for clinician-scholar-educator career advancement. Grant funding for education research and protected time to produce scholarship are still lacking for interested physicians, in part due to institutional budget constraints and competing priorities., Approach: The Hospital for Special Surgery Academy of Rheumatology Medical Educators was founded in 2011 to promote education scholarship through grants awarded to educators interested in research. Educators were asked to submit proposals aimed at the development of new teaching programs and curricular change. Selected applicants received up to $50,000 per year for one year. Grant money was obtained through directed fundraising from donors. Information from annual grant updates and survey responses from grant recipients in 2017 were used to assess the academy's effectiveness., Outcomes: Since 2012, 32 grants have been awarded, totaling $954,045 in funding. Recipients have produced national meeting abstracts, posters, oral presentations, and manuscripts and created unique curricula and electronic learning tools for medical students, residents, fellows, faculty, and patients. Four educators with demonstrated interest and research outcomes were identified during the pilot and received additional funding and support from a dedicated education research assistant., Next Steps: The academy and the innovations grants program highlight the talents of under-supported and under-recognized teaching faculty by allowing them to distinguish themselves academically as clinician-scholar-educators. The success of these educators emphasizes the clear advantages of a formalized structure to achieve the hospital's education goals. Next steps include providing support for a rheumatology fellow to develop an education research career rather than one in bench, clinical, or translational research., (Copyright © 2020 by the Association of American Medical Colleges.)

Background: The Alliance of Dedicated Cancer Centers is an organization of 11 leading cancer institutions and affiliated hospitals that are exempt from the Medicare prospective system hospital reimbursement policies. Because of their focus on cancer care and participation in innovative cancer treatment methods and protocols, these hospitals are reimbursed based on their actual billings. The perceived lack of incentive to meet a predetermined target price and reduce costs has spurred criticism of the value of cancer care at these institutions. The rationale of our study was to better understand whether dedicated cancer centers (DCCs) deliver high-value care for patients undergoing surgical treatment of spinal metastases., Question/purpose: Is there a difference in 90-day complications and reimbursements between patients undergoing surgical treatment (decompression or fusion) for spinal metastases at DCCs and those treated at nonDCC hospitals?, Methods: The 2005 to 2014 100% Medicare Standard Analytical Files database was queried using ICD-9 procedure and diagnosis codes to identify patients undergoing decompression (03.0, 03.09, and 03.4) and/or fusion (81.0X) for spinal metastases (198.5). The database does not allow us to exclude the possibility that some patients were treated with fusion for stabilization of the spine without decompression, although this is likely an uncommon event. Patients undergoing vertebroplasty or kyphoplasty for metastatic disease were excluded. The Medicare hospital provider identification numbers were used to identify the 11 DCCs. The study cohort was categorized into two groups: DCCs and nonDCCs. Although spinal metastases are known to occur among nonMedicare and younger patients, the payment policies of these DCCs are only applicable to Medicare beneficiaries. Therefore, to keep the study objective relevant to current policy and value-based discussions, we performed the analysis using the Medicare dataset. After applying the inclusion and exclusion criteria, we included 17,776 patients in the study, 6% (1138 of 17,776) of whom underwent surgery at one of the 11 DCCs. Compared with the nonDCC group, DCC group hospitals operated on a younger patient population and on more patients with primary renal cancers. In addition, DCCs were more likely to be high-volume facilities with National Cancer Institute designations and have a voluntary or government ownership model. Patients undergoing surgery for spinal metastases at DCCs were more likely to have spinal decompression with fusion than those at nonDCCs (40% versus 22%; p < 0.001) and had a greater length and extent of fusion (at least four levels of fusion; 34% versus 29%; p = 0.001). Patients at DCCs were also more likely than those at nonDCCs to receive postoperative adjunct treatments such as radiation (16% versus 13.5%; p = 0.008) and chemotherapy (17% versus 9%; p < 0.001), although this difference is small and we do not know if this meets a minimum clinically important difference. To account for differences in patients presenting at both types of facilities, multivariate logistic regression mixed-model analyses were used to compare rates of 90-day complications and 90-day mortality between DCC and nonDCC hospitals. Controls were implemented for baseline clinical characteristics, procedural factors, and hospital-level factors (such as random effects). Generalized linear regression mixed-modeling was used to evaluate differences in total 90-day reimbursements between DCCs and nonDCCs., Results: After adjusting for differences in baseline demographics, procedural factors, and hospital-level factors, patients undergoing surgery at DCCs had lower odds of experiencing sepsis (6.5% versus 10%; odds ratio 0.54 [95% confidence interval 0.40 to 0.74]; p < 0.001), urinary tract infections (19% versus 28%; OR 0.61 [95% CI 0.50 to 0.74]; p < 0.001), renal complications (9% versus 13%; OR 0.55 [95% CI 0.42 to 0.72]; p < 0.001), emergency department visits (27% versus 31%; OR 0.78 [95% CI 0.64 to 0.93]; p = 0.01), and mortality (39% versus 49%; OR 0.75 [95% CI 0.62 to 0.89]; p = 0.001) within 90 days of the procedure compared with patients treated at nonDCCs. Undergoing surgery at a DCC (90-day reimbursement of USD 54,588 ± USD 42,914) compared with nonDCCs (90-day reimbursement of USD 49,454 ± USD 38,174) was also associated with reduced 90-day risk-adjusted reimbursements (USD -14,802 [standard error 1362] ; p < 0.001)., Conclusion: Based on our findings, it appears that DCCs offer high-value care, as evidenced by lower complication rates and reduced reimbursements after surgery for spinal metastases. A better understanding of the processes of care adopted at these institutions is needed so that additional cancer centers may also be able to deliver similar care for patients with metastatic spine disease., Level of Evidence: Level III, therapeutic study., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

Background: People living with HIV and multiple comorbidities have high rates of health service use. This study evaluates system usage before and after admission to a community facility focused on HIV care., Methods: We used Ontario administrative health databases to conduct a pre-post comparison of rates and costs of hospital admissions, emergency department visits, and family physician and home care visits among medically complex people with HIV in the year before and after admission to Casey House, an HIV-specific hospital in Toronto, for all individuals admitted between April 2009 and March 2015. Negative binomial regression was used to compare rates of health care utilization. We used Wilcoxon rank sum tests to compare associated health care costs, standardized to 2015 Canadian dollars. To contextualize our findings, we present rates and costs of health service use among Ontario residents living with HIV., Results: During the study period, 268 people living with HIV were admitted to Casey House. Emergency department use declined from 4.6 to 2.5 visits per person-year ( p = 0.02) after discharge from Casey House, and hospitalization rates declined from 1.4 to 1.1 admissions per person-year ( p = 0.05). Conversely, home care visits increased from 24.3 to 35.6 visits per person-year ( p = 0.01) and family physician visits increased from 18.3 to 22.6 visits per person-year ( p < 0.001) in the year after discharge. These changes were associated with reduced overall costs to the health care system. The reduction in overall costs was not significant ( p = 0.2); however, costs of emergency department visits ( p < 0.001) and physician visits ( p < 0.001) were significantly less., Interpretation: Health care utilization by people with HIV was significantly different before and after admission to a community hospital focused on HIV care. This has implications for health care in other complex patient populations., Competing Interests: Competing interests: Ann Stewart holds a grant from Gilead Pharmaceuticals, for research on hepatitis C, outside the submitted work. Soo Chan Carusone is employed by Casey House as director of research. No other competing interests were declared., (© 2021 CMA Joule Inc. or its licensors.)

Objective The aim of this study was to estimate the difference between treatment costs in acute care settings and the level of funding public hospitals would receive under the activity-based funding model. Methods Patients aged ≥16 years who had sustained an incident traumatic spinal cord injury (TSCI) between June 2013 and June 2016 in New South Wales were included in the study. Patients were identified from record-linked health data. Costs were estimated using two approaches: (1) using District Network Return (DNR) data; and (2) based on national weighted activity units (NWAU) assigned to activity-based funding activity. The funding gap in acute care treatment costs for TSCI patients was determined as the difference in cost estimates between the two approaches. Results Over the study period, 534 patients sustained an acute incident TSCI, accounting for 811 acute care hospital separations within index episodes. The total acute care treatment cost was estimated at A$40.5 million and A$29.9 million using the DNR- and NWAU-based methods respectively. The funding gap in total costs was greatest for the specialist spinal cord injury unit (SCIU) colocated with a major trauma service (MTS), at A$4.4 million over the study period. Conclusions The findings of this study suggest a substantial gap in funding for resource-intensive patients with TSCI in specialist hospitals under current DRG-based funding methods. What is known about the topic? DRG-based funding methods underestimate the treatment costs at the hospital level for patients with complex resource-intensive needs. This underestimation of true direct costs can lead to under-resourcing of those hospitals providing specialist services. What does this paper add? This study provides evidence of a difference between true direct costs in acute care settings and the level of funding hospitals would receive if funded according to the National Efficient Price and NWAU for patients with TSCI. The findings provide evidence of a shortfall in the casemix funding to public hospitals under the activity-based funding for resource-intensive care, such as patients with TSCI. Specifically, depending on the classification system, the principal referral hospitals, the SCIU colocated with an MTS and stand-alone SCIU were underfunded, whereas other non-specialist hospitals were overfunded for the acute care treatment of patients with TSCI. What are the implications for practitioners? Although health care financing mechanisms may vary internationally, the results of this study are applicable to other hospital payment systems based on diagnosis-related groups that describe patients of similar clinical characteristics and resource use. Such evidence is believed to be useful in understanding the adequacy of hospital payments and informing payment reform efforts. These findings may have service redesign policy implications and provide evidence for additional loadings for specialist hospitals treating low-volume, resource-intensive patients.

Background: Lower-extremity arthroplasty constitutes the largest burden on health-care spending of any Medicare diagnosis group. Demand for upper extremity arthroplasty also continues to rise. It is necessary to better understand costs as health care shifts toward a bundled-payment accounting approach. We aimed (1) to identify whether variation exists in total cost for different types of joint arthroplasty, and, if so, (2) to determine which cost parameters drive this variation., Methods: The cost of the episode of inpatient care for 22,215 total joint arthroplasties was calculated by implementing time-driven activity-based costing (TDABC) at a single orthopaedic specialty hospital from 2015 to 2018. Implant price, supply costs, personnel costs, and length of stay for total knee, total hip, anatomic total shoulder, reverse total shoulder, total elbow, and total ankle arthroplasty were analyzed. Individual cost parameters were compared with total cost and volume., Results: Higher implant cost appeared to correlate with higher total costs and represented 53.8% of the total cost for an inpatient care cycle. Total knee arthroplasty was the least-expensive and highest-volume procedure, whereas total elbow arthroplasty had the lowest volume and highest cost (1.65 times more than that of total knee arthroplasty). Length of stay was correlated with increased personnel cost but did not have a significant effect on total cost., Conclusions: Total inpatient cost at our orthopaedic specialty hospital varied by up to a factor of 1.65 between different fields of arthroplasty. The highest-volume procedures-total knee and hip arthroplasty-were the least expensive, driven predominantly by lower implant purchase prices., Clinical Relevance: We are not aware of any previous studies that have accurately compared cost structures across upper and lower-extremity arthroplasty with a uniform methodology. The present study, because of its uniform accounting process, provides reliable data that will allow clinicians to better understand cost relationships between different procedures.

Background: In 2010, the Affordable Care Act introduced new restrictions on the expansion of physician-owned hospitals (POHs) due to concerns over financial incentives and increased costs. The purpose of this study is to determine whether joint ventures between tertiary care and specialty hospitals (SHs) allowing physician ownership (POHs) have improved outcomes and lower cost following THA and TKA., Methods: After institutional review board approval, a retrospective review of consecutive series of primary THA and TKA patients from 2015 to 2016 across a single institution comprised of 14 full-service hospitals and 2 SHs owned as a joint venture between physicians and their health system partners. Ninety-day episode-of-care claims cost data from Medicare and a single private insurer were reviewed with the collection of the same demographic data, medical comorbidities, and readmission rates for both the SHs and non-SHs. A multivariate regression analysis was performed to determine the independent effect of the SHs on episode-of-care costs., Results: Of the 6537 patients in the study, 1936 patients underwent a total joint arthroplasty at an SH (29.6%). Patients undergoing a procedure at an SH had shorter lengths of stay (1.29 days vs 2.23 days for Medicare, 1.15 vs 1.86 for private payer, both P < .001), were less likely to be readmitted (4% vs 7% for Medicare, P = .001), and had lower mean 90-day episode-of-care costs ($16,661 vs $20,579 for Medicare, $26,166 vs $35,222 for private payers, both P < .001). When controlling for the medical comorbidities and demographic variables, undergoing THA or TKA at an SH was associated with a decrease in overall episode costs ($3266 for Medicare, $13,132 for private payer, both P < .001)., Conclusion: Even after adjusting for a healthier patient population, the joint venture partnership with health systems and physician-owned SHs demonstrated lower 90-day episode-of-care costs than non-SHs following THA and TKA. Policymakers and practices should consider these data when considering the current care pathways., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Total joint arthroplasty (TJA) volumes have risen in the past decade, resulting in increased national spending. Prior studies indicate that TJA performed at higher-volume hospitals result in better patient outcomes at lower costs. The purpose of this study is to determine whether increased orthopedic specialization has similar effects., Methods: Centers for Medicare and Medicaid Services Inpatient Charge Data queries identified 2677 hospitals that performed TJA in 2015. Hospitals were assigned an orthopedic specialization ratio (OSR), defined as the ratio of musculoskeletal discharges to total discharges. Average covered charges (ACC), average total payments, and average Medicare payments (AMP) of TJA were extracted. TJA-specific, risk-adjusted complication and readmission scores were obtained from the Centers for Medicare and Medicaid Services Hospital Compare database. Comparisons between orthopedic specialty hospitals and nonspecialty hospitals performing TJA were made with Student t-tests. Regression models analyzed the relationship between OSR, volume and cost, payments, readmission rate score, and complication rate score., Results: Orthopedic specialty hospitals had lower ACC, average total payments, AMP, readmission, and complication scores than nonspecialty hospitals (all P < .001). Regression models showed that as the OSR increased from 0 to 1.0, ACC decreased by $19,242.83 and AMP decreased by $2310.75 (P < .001). Readmission score decreased by 0.349 and complication score decreased by 0.346 (P < .001) when controlling for volume as the OSR increased from 0 to 1., Conclusion: Hospitals with increased OSR appear to perform TJA for Medicare patients at a lower cost with lower complication and readmission risk. It may be beneficial to consider the OSR when determining the ideal settings for TJA., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Diabetes mellitus is considered a public health issue worldwide, with a high prevalence. It is a direct cause of death, disability, and high health costs. In addition, it generates a series of complications of variable types and degrees that have frequent negative effects on the quality of life of the people who suffer from it. Efficiency in public health implies a reduction in costs and improvements in citizens' quality of life. With the twofold aim of rationalizing costs and promoting an improvement in the care of people with diabetes, we propose a project: a Diabetes Day Hospital (DDH) in Extremadura (Spain). This involves a new organizational model which has already been implemented in other European regions, generating satisfactory results. This study includes details on the structure and operation of the DDH, as well as the expected costs. The DDH allows for a proper coordination among the parties involved in the monitoring and treatment of the disease, and reduces the costs derived from unnecessary admissions and chronic complications. Results show that efficiency in the regional health system could be improved and a significant amount of money could be saved.

Prospective payment systems fund hospitals based on a fixed-price regime that does not directly distinguish between specialist and general hospitals. We investigate whether current prospective payments in England compensate for differences in costs between specialist orthopaedic hospitals and trauma and orthopaedics departments in general hospitals. We employ reference cost data for a sample of hospitals providing services in the trauma and orthopaedics specialty. Our regression results suggest that specialist orthopaedic hospitals have on average 13% lower profit margins. Under the assumption of break-even for the average trauma and orthopaedics department, two of the three specialist orthopaedic hospitals appear to make a loss on their activity. The same holds true for 33% of departments in our sample. Patient age and severity are the main drivers of such differences.

Cardiovascular disease (CVD) is a leading cause of post-liver transplant death, and variable care patterns may affect outcomes. We aimed to describe epidemiology and outcomes of inpatient CVD care across US hospitals. Using a merged data set from the 2002-2011 Nationwide Inpatient Sample and the American Hospital Association Annual Survey, we evaluated liver transplant patients admitted primarily with myocardial infarction (MI), stroke (cerebrovascular accident [CVA]), congestive heart failure (CHF), dysrhythmias, cardiac arrest (CA), or malignant hypertension. Patient-level data include demographics, Charlson comorbidity index, and CVD diagnoses. Facility-level variables included ownership status, payer-mix, hospital resources, teaching status, and physician/nursing-to-bed ratios. We used generalized estimating equations to evaluate patient- and hospital-level factors associated with mortality. There were 4763 hospitalizations that occurred in 153 facilities (transplant hospitals, n = 80). CVD hospitalizations increased overall by 115% over the decade (P < 0.01). CVA and MI declined over time (both P < 0.05), but CHF and dysrhythmia grew significantly (both P < 0.03); a total of 19% of hospitalizations were for multiple CVD diagnoses. Transplant hospitals had lower comorbidity patients (P < 0.001) and greater resource intensity including presence of cardiac intensive care unit, interventional radiology, operating rooms, teaching status, and nursing density (all P < 0.01). Transplant and nontransplant hospitals had similar unadjusted mortality (overall, 3.9%, P = 0.55; by diagnosis, all P > 0.07). Transplant hospitals had significantly longer overall length of stay, higher total costs, and more high-cost hospitalizations (all P < 0.05). After risk adjustment, transplant hospitals were associated with higher mortality and high-cost hospitalizations. In conclusion, CVD after liver transplant is evolving and responsible for growing rates of inpatient care. Transplant hospitals are associated with poor outcomes, even after risk adjustment for patient and hospital characteristics, which may be attributable to selective referral of certain patient phenotypes but could also be related to differences in quality of care. Further study is warranted., (© 2018 by the American Association for the Study of Liver Diseases.)

Background: Kidney transplant recipients (KTR) are at increased risk of requiring colorectal resection compared to the general population. Given the need for lifelong immunosuppression and the physiologic impact of years of renal replacement, we hypothesized that colorectal resection may be riskier for this unique population., Methods: We investigated the differences in mortality, morbidity, length of stay (LOS), and cost between 2410 KTR and 1,433,437 non-KTR undergoing colorectal resection at both transplant and non-transplant centers using the National Inpatient Sample between 2000 and 2013, adjusting for patient and hospital level factors., Results: In hospital, mortality was higher for KTR in comparison to non-KTR (11.1 vs 4.3%, p < 0.001; adjusted odds ratio [aOR] 2.68 3.59 4.81 ) as were overall complications (38.5 vs 31.5%, p = 0.001; aOR 1.08 1.30 1.56 ). LOS was significantly longer (10 vs 7 days, p < 0.001; ratio 1.42 1.53 1.65 ) and cost was significantly greater ($23,056 vs $14,139, p < 0.001; ratio 1.42 1.54 1.63 ) for KTR compared to non-KTR. While LOS was longer for KTR undergoing resection at transplant centers compared to non-transplant centers (aOR 1.68 vs 1.53, p = 0.03), there were no statistically significant differences in mortality, overall morbidity, or cost by center type., Conclusions: KTR have higher mortality, higher incidence of overall complications, longer LOS, and higher cost than non-KTR following colorectal resection, regardless of center type. Physicians should consider these elevated risks when planning for surgery in the KTR population and counsel patients accordingly.

Aims: In this observational study, we investigated whether specialized care improves outcomes for acute pancreatitis (AP)., Methods: Consecutive patients admitted to two university hospitals with AP were enrolled in this study between 1 January 2016 and 31 December 2016 (Center A: specialized center; Center B: general hospital). Data on demographic characteristics and AP etiology, severity, mortality and quality of care (enteral nutrition and antibiotic use) were extracted from the Hungarian Acute Pancreatitis Registry. An independent sample t-test, Mann-Whitney test, chi-squared test or Fisher's test were used for statistical analyses. Costs of care were calculated and compared in the two models of care., Results: There were 355 patients enrolled, 195 patients in the specialized center (Center A) and 160 patients in the general hospital (Center B). There was no difference in mean age (57.02 +/-17.16 vs. 57.31 +/-16.50 P=0.872) and sex ratio (56% males vs. 57% males, P=0.837) between centres, allowing a comparison without selection bias. Center A had lower mortality (n=2, 1.03% vs. n=16, 6.25%, p=0.007), more patients received enteral feeding (n=179, 91.8%, vs. n=36, 22.5%, p<0.001) and fewer patients were treated with antibiotics (n=85, 43.6% vs. n=123, 76.9%, p=0.001). In Center A the median length of hospitalization was shorter (Me 6, IQR 5-9 vs. Me 8, IQR 6-11, p=0.02) and the costs of care were by 25% lower., Conclusion: Our data suggests that treatment of AP in specialized centers reduces mortality, length of hospitalization and thus might reduce the costs.

This paper develops and tests a dynamic model of hospital focus. It does so by tracing the performance trajectories of specialist and general hospitals to identify whether a performance gap exists and whether it widens or shrinks over time. Our longitudinal analyses of all hospital organizations within the English National Health Service (NHS) reveal not only a notable performance gap between specialist and general hospitals in particular with regards to patient satisfaction that widens over time, but also the emergence of a gap especially with regards to hospital staff job satisfaction. These findings reflect the considerable potential of specialization as a means to enhance hospital effectiveness. However, they also alert health policy makers to the threat of a widening performance gap between specialist and general hospitals with potential negative repercussions at the patient and health system level.

Background: Since 2011, specialty hospitals in South Korea have been known for providing high- quality care in specific clinical areas. Much research related to specialty hospitals and their performance in many such areas has been performed, but investigations about their performance in obstetrics and gynecology are lacking. Thus, we aimed to compare specialty vs. non-specialty hospitals with respect to mode of obstetric delivery, especially the costs and length of stay related to Cesarean section (CS) procedures, and to provide evidence to policy-makers for evaluating the success of hospitals that specialize in obstetric and gynecological (OBGYN) care., Methods: We obtained National Health Insurance claim data from 2012 to 2014, which included information from 418,141 OBGYN cases at 214 hospitals. We used a generalized estimating equation model to identify a potential association between the likelihood of CS at specialty hospitals compared with other hospitals. We also evaluated medical costs and length of stay in specialty hospitals according to type of delivery., Results: We found that 150,256 (35.9%) total deliveries were performed by CS. The odds ratio of CS was significantly lower in specialty hospitals (OR: 0.95, 95% CI: 0.93-0.96compared to other hospitals Medical costs (0.74%) and length of stay (1%) in CS cases increased in specialty hospitals, although length of stay following vaginal delivery was lower (0.57%) in specialty hospitals compared with other hospitals., Conclusions: We determined that specialty hospitals are significantly associated with a lower likelihood of CS delivery and shorter length of stay after vaginal delivery. Although they are also associated with higher costs for delivery, the increased cost could be due to the high level of intensive care provided, which leads to improve quality of care. Policy-makers should consider incentive programs to maintain performance of specialty hospitals and promote efficiency that could reduce medical costs accrued by patients.

The Mogan Mt.Sanatorium for Pulmonary Tuberculosis, founded in 1927, was the first tuberculosis sanatorium in modern China, with an initial intention of "treating and caring the diseased, not seeking profits" , and its name was then changed to Mogan Mountain Sanatorium in 1931. During the early period of Anti-Japanese War, it became an asylum for refugees and carrying out charitable rehabilitation activity.In May 1939, the Sanatorium was compelled to close because of the bombardment of Japanese aircraft, andonly formally opened in 1948 until today. The patients in the Sanatorium included politicians, wealthy businessmen and academic elites. It laid equal stress on natural convalesce and medication, together with moral solicitude. The funds of the Sanatorium came from convalesce charges, patients' grant-in-aid, Boxer Indemnity and exhibition of calligraphy and painting of celebrity, etc.By means of advertisements, Sanatorium noticedits expansion of medical works, and changes of doctor, announcements of the curative effects to absorb patients. As a novel thingin the early 20(th) century, the appearance of sanatorium was a product of development of health sense, enhancement of health idea and awakening the consciousness of sovereignty of the people.

Background: The aim of this study is to analyze the production of 76 specialist hospitals for the morbidly obese in Brazil's public healthcare system (SUS) from 2010 to 2014 in terms of quantity and costs of bariatric surgery and its complications., Methods: Secondary data from the SUS Hospital Information System and the National Healthcare Establishments Registry were used. Current spending on bariatric surgery and its medical and postoperative complications were analyzed., Results: There was a 60 % rise in the number of surgeries between 2010 and 2014. This increase was not homogeneous among the hospitals studied, since only 19 performed the minimum number of surgeries required. Women accounted for 85 % of the surgeries carried out, and 32 % were aged between 35 and 44 years. The Roux-en-Y technique was the most widely used (93.7 % of the total), followed by sleeve gastrectomy. The ratio between the occurrence of medical complications and total number of surgeries performed in each hospital varied significantly (between 0 and 5.97 %) but was lower for postoperative complications, ranging from 0 to 1.7 %. There was a nominal increase of 44 % in average expenditure on postoperative complications between 2013 and 2014, while the average cost of medical complications decreased by 8.7 % in the same period., Conclusions: Despite the rise in the number of bariatric surgeries in Brazil, there is still a high demand for surgeries that is not being met, while most specialist hospitals fail to perform the minimum number of surgeries stipulated by the Ministry of Health.

Objective: To determine the effect of heart attack patients' access to intensive treatment on mortality and costs., Data Sources: Administrative data of 4,920 patients with acute myocardial infarction from the Austrian Social Security Database and the Upper Austrian Sickness Fund for the period 2002-2011., Study Design: As treatment intensity in a hospital largely depends on whether it has a catheterization laboratory, we explore the effects of patients' initial admission to such specialized percutaneous coronary intervention (PCI) hospitals. To account for the nonrandom selection of patients into hospitals, we exploit individuals' place of residence as a source of exogenous variation in an instrumental variable framework., Principal Findings: We find that the initial admission to PCI hospitals increases patients' survival chances substantially. The effect on 3-year mortality is -9.5 percentage points. Subgroup analysis shows the strongest effects in relative terms for patients below the age of 65. We do not find significant effects on long-term inpatient costs and only marginal increases in outpatient costs., Conclusions: Our findings suggest that place of residence affects the access of patients to invasive heart attack treatment and therefore their chance of survival. We conclude that that providing more patients immediate access to PCI hospitals should be beneficial., (© Health Research and Educational Trust.)

The U.S. hospital industry has recently witnessed a number of policy changes aimed at aligning hospital payments to costs and these can be traced to significant concerns regarding selection of profitable patients and procedures by physician-owned specialty hospitals. The policy responses to specialty hospitals have alternated between payment system reforms and outright moratoriums on hospital operations including one in the recently enacted Affordable Care Act. A key issue is whether physician-owned specialty hospitals pose financial strain on the larger group of general hospitals through cream-skimming of profitable patients, yet there is no study that conducts a systematic analysis relating such selection behavior by physician-owners to financial impacts within hospital markets. The current paper takes into account heterogeneity in specialty hospital behavior and finds some evidence of their adverse impact on profit margins of competitor hospitals, especially for-profit hospitals. There is also some evidence of hospital consolidation in response to competitive pressures by specialty hospitals. Overall, these findings underline the importance of the payment reforms aimed at correcting distortions in the reimbursement system that generate incentives for risk-selection among providers groups. The identification techniques will also inform empirical analysis on future data testing the efficacy of these payment reforms.

Look beyond the NHS's headline deficit and it soon becomes clear that efficiencies and productivity can only do so much.

This article deploys a well-established theoretical model from the accountability literature to the domain of bioethics. Specifically, homeopathy is identified as a controversial industry and the strategic action of advocates to secure moral legitimacy and attract public funding is explored. The Glasgow Homeopathic Hospital (GHH) is used as the location to examine legitimizing strategies, from gaining legitimacy as a National Health Service (NHS) hospital in 1948, followed by maintaining and repairing legitimacy in response to government enquires in 2000 and 2010. An analysis of legitimizing strategies leads to the conclusion that advocates have been unsuccessful in maintaining and repairing moral legitimacy for homeopathy, thus threatening continued public funding for this unscientific medical modality. This is an encouraging development towards open and transparent NHS accountability for targeting limited public resources in pursuit of maximizing society's health and well-being. Policy implications and areas for future research are suggested., (© 2016 John Wiley & Sons Ltd.)

This study evaluates the cost-effectiveness of the project of PET center’s creation in the structure of specialized institution. To analyze the effectiveness and stability of obtained results there are used estimations of discounted factors, the flow and the amount of investments and the income at different discount rates. The figures revealed that the project should generate revenue as at zero discount rate it pays off.

Background: China is transitioning towards concentrating tuberculosis (TB) diagnostic and treatment services in hospitals, while the Centers of Disease Control and Prevention (CDC) system will retain important public health functions. Patient expenditure incurred through hospitalization may lead to barriers to TB care or interruption of treatment., Methodology/principal Findings: We conducted a national survey of TB specialized hospitals to determine hospitalization fees and hospital bed utilization in 1999, 2004, and 2009. Hospitalization of TB patients increased 185.3% from 1999 to 2009. While the average hospitalization fees also increased, the proportion of those fees in relation to GDP per capita decreased. Hospitalization fees differed across the three regions (eastern, central, and western). Using a least standard difference (LSD) paired analysis, in 2004, the difference in hospitalization fees was significant when comparing eastern and central provinces (p<0.001) as well as to western provinces (p<0.001). In 2009, the difference remained statistically significant when comparing eastern province hospitalization fees with central provinces (p<0.001) and western provinces (p = 0.008). In 2004 and 2009, the cost associated with hospitalization as a proportion of GDP per capita was highest in the western region. The average in-patient stay decreased from 33 days in 1999 to 26 and 27 days in 2004 and 2009 respectively. Finally, hospital bed utilization in all three regions increased over this period., Conclusions/significance: Our findings show that both the total number of in-patients and hospitalization fees increased from 1999 to 2009, though the proportion of hospitalization fees to GDP per capita decreased. As diagnostic services move to hospitals, regulatory and monitoring mechanisms should be established, and hospitals should make use of the experience garnered by the CDC system through continued strong collaborations. Infrastructure and social protection mechanisms in high burden areas, such as in the western region, should be strengthened.

The demand for spinal surgery and its costs have both risen over the past decade. In 2008 the aggregate hospital bill for surgical care of all spinal procedures was reported to be $33.9 billion. One key driver of rising costs is spinal implants. In 2011 our institution implemented a cost containment programme for spinal implants which was designed to reduce the prices of individual spinal implants and to reduce the inter-surgeon variation in implant costs. Between February 2012 and January 2013, our spinal surgeons performed 1493 spinal procedures using implants from eight different vendors. By applying market analysis and implant cost data from the previous year, we established references prices for each individual type of spinal implant, regardless of vendor, who were required to meet these unit prices. We found that despite the complexity of spinal surgery and the initial reluctance of vendors to reduce prices, significant savings were made to the medical centre., (©2015 The British Editorial Society of Bone & Joint Surgery.)

The announced major reforms will most probably not have an impact on hospital financing before 2016. Nevertheless, the numerous minor changes in the legislative framework and the new version of the German diagnosis-related groups (G-DRG) system can be important for hospitals specialized in rheumatology. The following article presents the relevant changes and discusses the consequences for hospitals specialized in rheumatology.

Because of expanding indications and improvements in supportive care, the utilization of blood and marrow cell transplantation (BMT) to treat various conditions is increasing exponentially, and currently more than 60,000 BMTs are performed annually worldwide. By the year 2030, it is projected that the number of BMT survivors will increase 5-fold, potentially resulting in one half of a million survivors in the United States alone. As the majority of survivors now live beyond the first 2 years after BMT, they are prone to a unique set of complications and late effects. Until recently, BMT experts assumed responsibility for almost all of the care for these survivors, but now oncologists/hematologists, pediatricians, and internists are involved frequently in offering specialized care and preventive services to these survivors. To integrate and translate into clinical practice the unique BMT survivorship issues with current preventive guidelines, a team effort is required. This can be facilitated by a dedicated "long-term-follow-up (LTFU)" clinic that provides lifelong care for BMT survivors. In this review, we first illustrate with clinical vignettes the need for LTFU and then focus upon the following: (1) types of LTFU clinic models, (2) challenges and possible solutions to the establishment of LTFU clinic, and (3) vulnerable transition periods., (Copyright © 2015 American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.)

The demographic developments will lead to an exponential increase of cardiovascular diseases. Additionally, technical developments of conservative and invasive treatment modalities will be added to distinguished, organ-orientated therapeutic concepts. This will also require a new orientation of vascular services. This concept implies that specific contents are referred to and contained in partner specialties. Since the heart and vascular system function as an anatomic and functional union, implementation of vascular medicine within cardiovascular centres represents a logical consequence., (Georg Thieme Verlag KG Stuttgart · New York.)

Humanitarian cleft surgery has long been provided by teams from resource-rich countries traveling for short-term missions to resource-poor countries. After identifying an area of durable unmet need through surgical missions, Operation Smile constructed a permanent center for cleft care in Northeast India. The Operation Smile Guwahati Comprehensive Cleft Care Center (GCCCC) uses a high-volume subspecialized institution to provide safe, quality, comprehensive, and cost-effective cleft care to a highly vulnerable patient population in Assam, India. The purpose of this study was to profile the expenses of several cleft missions carried out in Assam and to compare these to the expenditures of the permanent comprehensive cleft care center. We reviewed financial data from 4 Operation Smile missions in Assam between December 2009 and February 2011 and from the GCCCC for the 2012-2013 fiscal year. Expenses from the 2 models were categorized and compared. In the studied period, 33% of the mission expenses were spent locally compared to 94% of those of the center. The largest expenses in the mission model were air travel (48.8%) and hotel expenses (21.6%) for the team, whereas salaries (46.3%) and infrastructure costs (19.8%) made up the largest fractions of expenses in the center model. The evolution from mission-based care to a specialty hospital model in Guwahati incorporated a transition from vertical inputs to investments in infrastructure and human capital to create a sustainable local care delivery system.

Craniofacial surgery, in the strictest sense, is the surgery of structures above and behind the maxilla. Craniofacial surgery is not new to India and has been around for more than 4 decades now since the 1970s. Keeping in mind the promotion of the specialty in India, an Indian Craniofacial Foundation was launched in the year 2012 at the Annual Meeting of the Association of Plastic Surgeons of India. To develop a craniofacial center in India, the primary requirement is a source of funding. Several craniofacial centers, which are already running successfully in India, have amply demonstrated that this can be done in several ways. We would like to discuss here the 2 models of craniofacial service delivery and training that the authors have seen and experienced firsthand.

: Disorders that affect communication are multifaceted and have significant impact throughout the life cycle, leading to different needs at different stages of life. This article describes the development of a comprehensive program that provides services for the whole range of patients with communication and problems over the life span.

Importance: It is unknown whether hospital transfer rates for patients with acute myocardial infarction admitted to nonprocedure hospitals (facilities that do not provide catheterization) vary and whether these rates further influence revascularization rates, length of stay, and mortality., Objectives: To examine hospital differences in transfer rates for elderly patients with acute myocardial infarction across nonprocedure hospitals and to determine whether these rates are associated with revascularization rates, length of stay, and mortality., Design, Setting, and Participants: We used Medicare claims data from January 1, 2006, to December 31, 2008, to assess transfer rates in nonprocedure hospitals, stratified according to transfer rates as low (≤ 20%), mid-low (>20%-30%), mid-high (>30%-40%), or high (>40%). Data were analyzed for 55,962 Medicare fee-for-service patients admitted to 901 nonprocedure US hospitals with more than 25 admissions per year for acute myocardial infarction., Main Outcomes and Measures: We compared rates of catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery during hospitalization and within 60 days, as well as hospital total length of stay, across groups. We measured risk-standardized mortality rates at 30 days and 1 year. RESULTS The median transfer rate was 29.4% (interquartile range [25th-75th percentile], 21.8%-37.8%). Higher transfer rates were associated with higher rates of catheterization (P < .001), percutaneous coronary intervention (P < .001), and coronary artery bypass graft surgery (P < .001). Median length of stay was not meaningfully different across the groups. There was no meaningful evidence of associations between transfer rates and risk-standardized mortality at 30 days (mean [SD], 22.3% [2.6%], 22.1% [2.3%], 22.3% [2.4%], and 21.7% [2.1%], respectively; P = .054) or 1 year (43.9% [2.3%], 43.6% [2.2%], 43.5% [2.4%], and 42.8% [2.2%], respectively; P < .001) for low, mid-low, mid-high, and high transfer groups., Conclusions and Relevance: Nonprocedure hospitals vary substantially in their use of the transfer process for elderly patients admitted with acute myocardial infarction. High-transfer hospitals had greater use of invasive cardiac procedures after admission compared with low-transfer hospitals. However, higher transfer rates were not associated with a significantly lower risk-standardized mortality rate at 30 days. Moreover, at 1 year there was only a 1.1% difference (42.8% vs 43.9%) between hospitals with higher and lower transfer rates. These findings suggest that, as a single intervention, promoting the transfer of patients admitted with acute myocardial infarction may not improve hospital outcomes.

Case management has recently been advanced as a valuable component in achieving quality patient care that is also cost-effective. At St. Michael's Hospital, in Toronto, Ontario, case managers from a variety of professional backgrounds are central to a new care initiative--Rapid Assessment and Planning to Inform Disposition (RAPID)--in the General Internal Medicine (GIM) Unit that is designed to improve patient care and reconcile high emergency department volumes through "smart bed spacing." Involved in both planning and RAPID, GIM's case managers are the link between patient care and utilization management. These stewards of finite resources strive to make the best use of dollars spent while maintaining a commitment to quality care. Collaborating closely with physicians and others across the hospital, GIM's case managers have been instrumental in bringing about significant improvements in care coordination, utilization management and process redesign., (Copyright © 2014 Longwoods Publishing.)

In 2011, the Korean government designated hospitals with certain structural characteristics as specialty hospitals. This study compared the inpatient charges and length of stay of patients with joint diseases treated at these specialty hospitals with those of patients treated at small general hospitals. In addition, the study investigated whether the designation of certain hospitals as specialty hospitals had an effect on inpatient charges and length of stay. Multi-level models were used to perform regression analyses on inpatient claims data (N=268,809) for 2010-2012 because of the hierarchical structure of the data. The inpatient charge at specialty hospitals was 19% greater than that at small general hospitals, but the length of stay was 21% shorter. After adjusting for patient and hospital level confounders, specialty hospitals had a higher inpatient charge (34.6%) and a reduced length of stay (31.7%). However, the effect of specialty hospital designation on inpatient charge (2.7% higher) and length of stay (2.3% longer) was relatively smaller. Among the patient characteristics, female gender, age, and severity of illness were positively associated with inpatient charge and length of stay. In terms of location, hospitals in metropolitan area had higher inpatient charges (5.5%), but much shorter length of stay (-14%). Several structural factors, such as occupancy rate, bed size, number of outpatients and nurses were positively associated with both inpatient charges and length of stay. However, number of specialists was positively associated with inpatient charges, but negatively associated with length of stay. In sum, this study found that specialty hospitals treating joint diseases tend to incur higher charges but produce shorter length of stay, compared to their counterparts. Specialty hospitals' overcharging behaviors, although shorter length of stay, suggest that policy makers could introduce bundled payments for the joint procedures. To promote a successful specialty hospital system, a broader discussion and investigation that includes quality measures as well as real cost of care should be initiated., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Asylum closures over recent decades resulted in mental health services being increasingly sited in the community. However, under provision of highly supported accommodation led to service users being placed away from their local area in 'out-of-area treatments' (OATs). OATs have raised major concerns in relation to enabling service users' recovery, owing to limitations in promoting autonomy, social dislocation and costs. In 2004, an OATs project was set up in a London Borough to address these concerns. In the first 4 years, the project succeeded in relocating 22 service users to less restrictive environments locally. This study aims to explore the outcome of relocation from service users' perspective. A qualitative methodology was utilized. Semi-structured interviews were carried out with seven service users who relocated. All seven service users shared a strong aspiration for independent living but there was associated loneliness. Five welcomed increased contact with family and friends, but lacked social confidence, inhibiting social inclusion. Service users with long-term and consistent care managers were more able to address fears. Five out of seven service users concluded that relocation increased their autonomy thus enhanced their quality of life., (© 2012 John Wiley & Sons Ltd.)

Objective: To clarify advance measures for business continuity taken by disaster base hospitals involved in the Great East Japan Earthquake., Methods: The predisaster situation regarding stockpiles was abstracted from a 2010 survey. Timing of electricity and water restoration and sufficiency of supplies to continue operations were investigated through materials from Miyagi Prefecture disaster medicine headquarters (prefectural medical headquarters) and disaster base hospitals (14 hospitals) in Miyagi Prefecture after the East Japan earthquake., Results: The number of hospitals with less than 1 day of stockpiles in reserve before the disaster was 7 (50%) for electricity supplies, 8 (57.1%) for water, 6 (42.9%) for medical goods, and 6 (42.9%) for food. After the disaster, restoration of electricity and water did not occur until the second day or later at 8 of 13 (61.5%) hospitals, respectively. By the fourth postdisaster day, 14 hospitals had requested supplies from the prefectural medical headquarters: 9 (64.3%) for electricity supplies, 2 (14.3%) for water trucks, 9 (64.3%) for medical goods, and 6 (42.9%) for food., Conclusions: The lack of supplies needed to continue operations in disaster base hospitals following the disaster clearly indicated that current business continuity plans require revision.

Objective: The Affordable Care Act mandates the Prospective Payment System (PPS)-Exempt Cancer Hospitals Quality Reporting program. These 11 hospitals (which are paid fee-for-service rather than on a DRG system) began reporting measures (2 general safety, 2 breast, 1 colon) in 2013. Given this reporting mandate, we set out to determine whether the PPS-exempt gynecologic oncology programs could identify quality measures specific to the care of our patients., Methods: A list of 12 quality measures specific to gynecologic oncology was created (from sources including the National Quality Forum and the SGO). Measures already in use were not included. The list was ranked by the gynecologic oncology program directors at the PPS-exempt hospitals. Descriptive statistics (including mean and SD for rankings) were utilized., Results: Despite mandatory reporting of quality measures for PPS-exempt cancer hospitals, little consensus exists regarding specific gynecologic cancer measures. Documentation of debulking status, cancer survival, and offering minimally invasive surgery (for endometrial cancer) and intraperitoneal chemotherapy (for ovarian cancer) are important, but with widely variable responses (when ranked 1-12, standard deviations are 2-3). General issues regarding adherence to guidelines for the use of GCSF, documentation of functional status, and tracking of patient satisfaction scores were ranked the lowest. Three of the directors reported that their compensation is partially linked to quality outcomes., Conclusions: There is wide variability in ranking of quality measures, and may relate to provider or institutional factors. Despite the mandatory reporting in PPS-exempt cancer hospitals, work remains to define gynecologic cancer quality measures., (Copyright © 2013 The Authors. Published by Elsevier Inc. All rights reserved.)

English health policy has moved towards establishing specialist multi-disciplinary teams to care for patients suffering rare or particularly complex conditions. But the healthcare resource groups (HRGs), which form the basis of the prospective payment system for hospitals, do not explicitly account for specialist treatment. There is a risk, then, that hospitals in which specialist teams are based might be financially disadvantaged if patients requiring specialised care are more expensive to treat than others allocated to the same HRG. To assess this we estimate the additional costs associated with receipt of specialised care. We analyse costs for 12,154,599 patients treated in 163 English hospitals in fiscal year 2008/09 according to the type of specialised care received, if any. We account for the distributional features of patient cost data, and estimate ordinary least squares and generalised linear regression models with random effects to isolate what influence the hospital itself has on costs. We find that, for nineteen types of specialised care, patients do not have higher costs than others allocated to the same HRG. However, costs are higher if a patient has cancer, spinal, neurosciences, cystic fibrosis, children's, rheumatology, colorectal or orthopaedic specialised services. Hospitals might be paid a surcharge for providing these forms of specialised care. We also find substantial variation in the average cost of treatment across the hospital sector, due neither to the provision of specialised care nor to other characteristics of each hospital's patients., (Copyright © 2013 Elsevier Ltd. All rights reserved.)