To develop an empirically grounded, activity-based tariff framework for Hospital at Home (HaH) services using time-driven activity-based costing (TDABC) and micro-costing to support transparent and equitable reimbursement for acute elderly care delivered at home.

Microcosting study embedded within a randomised controlled trial (RCT) comparing HaH with conventional hospital admission in Denmark.

Three municipalities in the Central Denmark Region in collaboration with emergency department physicians at a regional hospital.

A consecutive subsample of 107 elderly acute patients enrolled in the RCT between June 2022 and February 2024. Resource use for HaH activities was measured prospectively using microcosting logs, time-motion observations and administrative records.

Empirically derived tariffs per HaH visit (first and subsequent) calculated using an eight-step TDABC framework incorporating process mapping, resource identification, capacity cost rates and time equations. Sensitivity analyses tested robustness to variation in key cost drivers.

The mean total tariff was 338.89 (95% CI 310.94 to 351.49) for first visits and 207.81 (95% CI 200.70 to 215.69) for subsequent visits, including treatment and transport components. Staff time was the principal cost driver, while equipment, overhead and travel reimbursement had smaller effects. The framework accommodates variation in staffing, geography and visit intensity and can be used to estimate total costs across diverse HaH pathways.

A transparent and reproducible tariff-development framework for HaH services was established using TDABC and microcosting. The model aligns reimbursement with actual resource use and care complexity and provides a transferable template for economic evaluation and operational planning.

NCT05360914.

To test the feasibility of identifying and quantifying resource use for a Hospital-at-Home (HaH) model in Danish municipalities, we used a micro-costing approach. Additionally, we aimed to generate a transparent activity and time dataset. This dataset will support subsequent tariff development with time-driven activity-based costing and feed into the economic evaluation of an ongoing randomised controlled trial (RCT).

Prospective pilot feasibility study.

Three municipalities in the Central Denmark Region in collaboration with emergency department specialists and general practitioners.

56 elderly acute patients treated in HaH during the pilot phase.

Feasibility of micro-costing data collection (completeness, consistency and acceptability to staff) and descriptive resource-use quantities by activity and provider group. No price assignment or cost estimates are reported.

Patients received a mean of 3.8 HaH treatment days with 7.8 acute team visits and 3.9 municipal-staff visits per treatment course. The acute team spent a mean of 742 min per patient across treatment activities, communication, documentation and transport, while municipal care staff recorded a mean of 213 min. Intravenous medicine administration and vital sign assessments were the most frequent activities. Data completeness and consistency improved over time through co-design and feedback.

Detailed resource-use measurement using provider logs was feasible in a municipal HaH model and produced an activity and time dataset suitable for tariff development. Findings are context-specific and not generalisable due to the small sample. The micro-costing log refined through the pilot will be applied in an RCT, where time and activity data will be used to construct a tariff using time-driven activity-based costing.

Postoperative pulmonary complications (PPCs) are common after cardiac surgery and are associated with significant morbidity and mortality. Lung-protective ventilation strategies have been proposed to reduce PPCs, but the optimal level of positive end-expiratory pressure (PEEP) and the use of alveolar recruitment manoeuvres (RMs) remain controversial.

In this investigator-initiated, multicentre, open, randomised, parallel-group, superiority clinical trial, elective cardiac surgery patients at risk of PPCs will be assigned to one of two intraoperative ventilation strategies: (1) an open-lung ventilation strategy with protective ventilation, moderate PEEP and RMs or (2) a standard protective ventilation with low PEEP and no RM. The primary outcome will be a composite of prolonged (>24 hour) postoperative mechanical ventilation, reintubation for any cause or hospital-acquired pneumonia within 7 days of surgery, or death within 28 days of surgery. Data will be analysed on an intention-to-treat basis.

The VACARM (impact of intraoperatiVe moderAte positive end-expiratory pressure with reCruitment mAnoeuvres versus low positive end-expiRatory pressure on major postoperative pulMonary complications and death after on-pump cardiac surgery in high-risk patients) trial has been approved by an independent ethics committee for all study centres. Recruitment began in July 2021. Results will be published in international peer-reviewed medical journals.

ClinicalTrials.gov NCT04408495.