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



1
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

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

- 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.


4
- 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

population throughout life. Acute appendicitis can occur at any
age, rarely in children under 3 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,


6

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


7
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
3 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



9
CHAPTER 3: RESULTS
3.1. Actual costs in surgical treatment of acute appendicitis at
Son La provincal General Hospital
Table 3.8. Summary depreciation costs of this hospital in
2012-2013 (Unit: million VND)
Costs

2012

2013

Overall

Depreciation of
buildings
Depreciation of
medical
equipments
Other
depreciation

3,624.419

3,831.257

7,455.676


Table 3.9. ecurrent costs of hospital 2012-2013 (million VND)
Costs

Workforce
Electricity
Water
Stationery,
information, fuel
Maintenance
Conferences,
training
Total

2012

2013

Overall

26,737.980 32,690.285 59,428.265

Percentage
(%)

80.1

682.235

879.193 1,561.428


10
Table 3.10. Steps to allocate costs to departments of Hospital in
2012-2013
Unit: million VND
Costs

2012

2013

Overall

Allocating directly the
capital costs and
37,818.698 47,070.058 84,888.756
human resources to
each department (1)
Allocation of shared
capital costs and
12,198.713 12,985.853 25,184.566
recurrent costs (2)
Reallocation of
functional departments 12,135.113 16,050.541 28,185.654
costs (LS, CLS) (3) *
Total (1 and 2)
50,017.411 60,055.911 110,073.322
Note *: This section only reallocates between departments, so it is
not be included in the total)
The total cost allocated to facilties in two years is over 100
billion VND, of which nearly 84.888 billion VND is allocated

0.997
1.046
0.720
0.871


11
Medical
0.031
0.039
0.035
0.035
0.035
examination
Total
3.599
3.544
3.611
3.539
3.573
Table 3.21. Mean of direct costs from patients in 2012-2013
Unit: million VND
By surgical
By years
techniques
Total
Types of costs
Open Laparoscopic
(n=322)
2012 2013

Services
Laparoscopic
Laparoscopic
surgery
surgery
surgery
surgery
(n=74)

Surgery
Bed days for
treatment
Examination
Direct costs
for patients
Total

surgery (n=92)

(n=75)

(n=81)

(n=149)

surgery (n=173)

2.966
0.839


0.035
2.121

6.077

5.489

7.276

5.854

6.680

5.660


12
3.2. The economic burden on patients with surgery for acute
appendicitis at Son La Provincial General Hospital (20122013)
3.2.1. Total costs
Table 3.23. Total costs for the treatment of acute appendicitis
Unit: million VND
Median
Proportion
Costs group
X ± SD
(25%-75%)
(%)
4.033
4.316 ±

0.702
5.363
5.661 ±
100
Total costs
(3.568-6.775)
3.128
The median cost of treatment for an acute appendicitis
patient was 5.363 million VND; Of this amount, direct medical
expenses were 4.033 million VND, direct non-medical expenses
was 0.650 million VND and indirect costs were 0.450 million
VND.
Total costs of treatment was 5.661 million VND per a
patient; of which, 76.8% are direct medical expenses, 12.5% are
out-of-pocket and 10.7% are indirect costs.


13
3.2.2. Direct costs for treatment of patients

*: The difference was statistically significant between total direct
costs and out-of-pocket costs mong groups
Figure 3.2. Mean value and direct cost structures for treatment of
patients
On average, each patient had to pay 5.1 million VND
directly for treatment (43.8% for self-payment). Total direct costs
for treatment and out-of-pocket spending were statistically
significant at p
according to target groups
Unit: million VND
Median (25%Objects
p*
X ± SD
75%)
1.408
2012
1.903±1.349.0
(0.852-2.795)
By year
0,05
laparoscopic
1.468
method
2.150±1.691
surgery
(0.925-2.648)
Having health


Cost for
one
Average Cost/income
treatment income/day
ratio
state

Patients who was paid fully
costs by Health Insurance 650.0
36.0
18.1
(n=10)
Patients and Health insurance
1,959.5
94.4
20.8
paid the fee together (n=265)
Patients paid all costs by
4,478.0
107.7
41.6
themselves (n=57)
Total
2,270.7
94.9
23.9
On average, each patient must used 23.9 days of income to
pay the cost of treating acute appendicitis.
Table 3.38. Comparison costs between payment of patients

0.296
0.178
-0.002


16
Surgical costs
2.667
1.045
0.610
1.012
Cộng
6.132
2.854
1.459
1.819
The difference between the cost of hospital and patient
and health insurance payments for an acute appendicitis case was
1.819 million VND. The difference mainly focused on two costs
for surgery (1.012 million VND) and expenses for examination,
bed (687 thousand VND).


17
CHAPTER 4
DISCUSSION
4.1. Actual costs of treating acute appendicitis at Son La
Provincial General Hospital (2012-2013)
4.2.1. Total mean cost of hospital for treatment
For the total cost, the results showed that the total cost of the


18
and between hospitals in the same country. With the low average
income of Vietnam, the cost of treating acute appendicitis in a
provincial general hospital in the mountainous region in this study
was generally lower than in most other countries in the world.
4.2.2. Costs of treatment by surgery methods
In our study, compared between two sugical treatment
methods, the median cost of treatment for a acute appendicitis
patient by laparoscopic surgery was 5.660 million VND, lower
than that of the two surgical treatments. The cost of open surgery
was 6.680 million VND.
Many studies have suggested that endoscopic surgery for
acute appendicitis wass more expensive than open-label surgery.
One of them was the combined the study of McGrath and et al.
(2011) on nearly 2.9 million cases of acute appendicitis who were
treated during 1998-2008. The results of the study showed that
although laparoscopic surgery reduced hospital stay and
complication rate, the cost of treatment was statistically
significantly more expensive than surgical treatment, both for
acute appendicitis cases have no complications as well as
complications. The difference in cost was reduced when the
patients have complications after surgery. After correcting for the
condition (simple or complex), the mean cost for a patient was $
19,978 for laparoscopic surgery alone, $28,103 for laparoscopic
surgery open surgery compared with only $15,714 with open
surgery (p
appendicitis treatment, the total cost of treatment for patients in
our study was higher than that of Lu Van Trang et al. (2011) in
provincial hospital An Giang in 2010-2011 with 2.402 million
VND (for both open surgery and laparoscopic surgery)
Total cost of treatment in our study in 2013 increased
significantly compared to 2012, from 3.661 million to 6.661
million. This increase was mainly due to direct costs of health
(from 2.661 million VND to 4.884 million VND), especially the
cost of health insurance (from 1.645 million VND to 3.939
million VND). This was partly due to changes in the application
of health service pricing rules between these two years in Son La
province.
4.3.2. Direct costs for treatment
The average cost of treatment for acute appendicitis patients
was 5.084 million VND/patient. Of which, the direct medical


20
expense was 4.316 million VND; corresponding to 76.8% of total
costs and 84.9% of total direct costs.
The direct cost of acute appendicitis treatment in our study
was higher than that of Truong Tan Minh (4.427 million VND)
and Lu Van Trang (2.402 million VND).
The role of health insurance in reducing the burden of
payment for treatment was clearly demonstrated in health
insurance coverage for the vast majority of all direct expenses for
the treatment of patients, other than medical expenses.
4.3.3. Pay out of pocket for treatment
The burden of medical expenses was usually reflected in the
level of out-of-pocket payments. The results showed that the

time of the study, Son La Procincial General Hospital was still a
partial autonomous unit and the price of general medical services
and surgical treatment services for patients with acute appendicitis
only up to 3/7 factors, applied in accordance with Circular
04/2012 of the Ministry of Health - Ministry of Finance and
Resolution 24/2012 of the People's Council of Son La province.


22
CONCLUSSION
1. Analysis of the actual cost of surgery for acute appendicitis
at Son La General Hospital (2012-2013).

The average actual cost of hospital for one case of acute
appendicitis treatment in two years was 6.132 million VND (in 2012:
5.751 million VND, in 2013: 6.538 million VND); The cost of open
surgery was 6.680 million VND (2012: 6.077 million VND, 2013:
7.276 million VND), the laparoscopic surgery cost was 5.660 million
VND (2012: 5.489 million VND, 2013: 5.854 million VND). Hospital
expenses included: medical fee (32.3%), depreciation of medical
equipment fee (20.0%), labor fee (14.8%), and bed fee (14.2%). With
Laparoscopic surgery: depreciation of medical equipment cost (1.559
million VND), tests cost (0.507 million VND), maintenance cost (0.305
million VND) were higher than open surgery (0.840, 0.431 and 0.186
million). With open surgery, some expenses accounted for the highest
rate, included: medicine cost (38.0%), bed cost (15.7%), labor cost
(12.6%). With laparoscopic surgery, depreciation of medical equipment
cost (27.5%), medicine cost (26.5%), bed cost (12.7%), labor cost
(12.4%).


surgery (1.012 million VND) and examination fee, bed fee (687.000
VND).