DISCUSSION
We performed an analysis of costs using micro-costing techniques to
determine and compare the costs associated with the diagnostic
evaluation of ambulatory patients managed at two different quick
diagnosis units in Barcelona. Our study showed that the mean cost per
patient was moderately but nonsignificantly higher in the unit of the
tertiary hospital compared to the unit of the secondary center. However,
costs
of personnel and indirect costs of the former were significantly higher,
and this was true both for the monetary value and the percent
contribution of these costs to the
mean cost per patient.
Although quick diagnosis units have multiplied across tertiary and
secondary Spanish hospitals during the last 15 years, reported
investigations about their role as an alternative ambulatory care model
to inpatient admission come just from a few centers [6,9,15,18,19].
A recent comparative study between the units reported in this study
revealed that the overall clinical efficiency and performance of both in
the diagnostic evaluation of patients with predefined referral criteria
and suspected serious conditions were similar [15]. In general,
observational studies have concluded that the clinical efficiency of
quick diagnosis units is similar to that of conventional hospitalization
for diagnostic purposes but that the costs associated with the
ambulatory management of these patients are lower than the costs applied
to the same conditions in the inpatient setting
[7,9,11-13,15,20,21]. Two systematic reviews by authors from the
United States investigated all reported articles about quick diagnosis
units and found that the average savings from fixed costs of
hospitalization ranged from \euro1,764 to \euro2,514 per patient in
the quick diagnosis unit model compared to inpatient matched controls.
Further, an economic saving of 7 to 8.76 inpatient beds per day was
reported [5,8].
As far as we can tell, ours is the
first study to compare the costs associated with the diagnostic
assessment of patients managed at different
quick diagnosis units.
Though limited to the Spanish public system, a healthcare model similar
to quick diagnosis units was
implemented nationally in Scandinavian countries in the early 2010s. The
differentiated approach consisted of an urgent referral pathway for
patients with unspecific, serious symptoms, who were referred from
primary care centers to the so-called ‘diagnostic centre’, a unit
staffed with several specialists and equipped with a sort of facilities
for diagnostic investigations. Although results from several studies of
patients evaluated through this pathway showed high-quality indicators
[22,23], no reports analyzing the associated costs have been
published.
The differences in the costs of personnel and indirect costs observed in
our study must be interpreted considering the similarities and
differences of the two units and their respective hospitals.
Patients managed at the tertiary
hospital are often referred from smaller, secondary hospitals including
the second-level hospital reported here. Unlike the latter, the
tertiary hospital has a full
complement of services, highly specialized staff, and high technological
equipment. Although the clinical indications for referral and working
procedures of both units are
similar,
the volume of patients evaluated, the number of staff, and the
contribution of staff time in the unit of the tertiary center are
considerably greater.
A salient finding of our study was the similarity of the mean cost per
visit between the two units (\euro183 for the Tertiary vs. \euro185
for the Secondary Unit). Yet the
mean
ratio of successive/first visits
was significantly higher in the former (3.1 vs. 2.1, respectively).
Therefore, although not statistically significant, the reported
differences in the mean cost per patient between the Tertiary and
the Secondary Unit (577.5 ± 219.6
vs. 394.7 ± 92.58, respectively; P =0.0559) ought to be mainly
ascribed to the higher number of
total visits in the former. Despite these differences,
however, patients from the
tertiary center unit needed
significantly less days to be diagnosed than
those from
the Secondary Unit (8 vs. 12 days,
respectively; P <0.0001). As previously reported
[5,8], time to diagnosis is considered an indicator of
high-healthcare quality in quick diagnosis units.
The analysis of clinical data revealed some notable
differences. The
emergency department was the
referral source of 61% of patients from
the Tertiary but only 17% of
patients of the Secondary Unit and
these differences were more pronounced for patients referred for
symptoms suggestive of cancer and patients with a diagnosis of cancer,
with approximately 65% of them being referred from the emergency
department in the Tertiary vs. 16% in the
Secondary Unit. Compared to
patients from the secondary center
unit, those from the
Tertiary
Unit were more likely to be referred with cancer suggestive symptoms and
have a final diagnosis of malignancy. In general, patients from the
Secondary Unit presented with less
severe and ‘urgent’ conditions than those from the Tertiary Unit
including, among others, unexplained tiredness, laboratory test
abnormalities, and osteoarticular symptoms. This different pattern was
reflected by the fact that primary care centers and not the emergency
department were the main source of referral of patients to the unit of
the second-level hospital. A former study showed that, with a lower
number of total visits and a longer time to diagnosis, patients
from this unit required fewer investigations to achieve a diagnosis than
patients from the unit of the third level center [15]. Taken
together, these results suggest that a greater complexity of the medical
disorders evaluated at the tertiary center unit most likely accounted
for the differences in the mean ratio of successive/first visits and,
consequently, the differences in the mean cost per patient between the
two units.