Direct hospital costs for patients with inflammatory bowel disease in a Canadian tertiary care university hospital

OBJECTIVE: We set out to determine the direct costs of hospitalizations of patients with Crohn's disease and ulcerative colitis admitted to a university-affiliated tertiary care hospital and to contrast the costs of medical versus surgical inpatient care, Crohn's disease versus ulcerative colitis, and to identify dominant components of inpatient costs. METHODS: We used a patient-specific case costing system at Saint Boniface General Hospital, Winnipeg, Manitoba, for fiscal years 1994 and 1995. We extracted all inpatients whose hospital discharge abstracts included ICD-9-CM codes 555 (Crohn's disease) and 556 (ulcerative colitis) among the top eight discharge diagnoses, and performed a chart review on all cases to ensure that the hospitalization was for inflammatory bowel disease and the diagnoses were accurate. We analyzed cases based on their disease diagnosis, primary mode of therapy associated with the hospitalization (medical vs surgical), and their major diagnosis-related group (DRG). This study evaluated direct patient care costs only and costs are expressed in Canadian dollars. RESULTS: Of 362 hospital admissions, 325 were eligible and of these admissions 275 belonged to the digestive system DRGs. Seventy-one (37%) were admitted more than once during the 2 yr of the study, accounting for 202 (62%) of the total number of admissions. The mean cost per admission of all cases of Crohn's disease was $3,149 (95% confidence interval [CI], $2,665-$3,634) and for ulcerative colitis was $3,726 (95% CI $3,008-$4,445). Surgical therapy cases accounted for 49.8% of all admissions, 57.8% of all hospital days, and 60.5% of all costs. Patients treated surgically had more costly hospitalizations than those treated medically, particularly when analyzing only nontotal parenteral nutrition (TPN) cases. Surgical treatment admissions were significantly more costly for ulcerative colitis digestive DRG admissions than Crohn's disease. The nondigestive DRG admissions were more costly than the digestive DRGs in all categories although this was only statistically different among medically treated Crohn's disease. Patients treated medically were similarly costly whether they had Crohn's disease or ulcerative colitis. There was no significant difference in cost per admission among cases admitted multiple times, compared with those admitted only once. TPN cases accounted for 9.5% of cases but 27.1% of costs. TPN-associated hospitalizations were more costly than non-TPN-use hospitalizations but these costs were primarily driven by duration of stay rather than TPN use itself. For all cases, the top five cost categories in descending order were nursing unit bed-days, drugs and pharmacy, diagnostic lab tests, operating room, and diagnostic imaging and endoscopy. CONCLUSIONS: Using our system we could determine direct costs for inpatients with inflammatory bowel disease and the factors that determined increased costs. Medical therapy admissions were similarly costly between Crohn's disease and ulcerative colitis; however, surgical therapy admissions were costlier among ulcerative colitis patients. Admissions for nondigestive DRGs were more costly than those for digestive DRGs. TPN use identified a sicker group of patients who remained in the hospital longer than nonusers and, not surprisingly, these were the costliest patients.     

Hospital costs, resource characteristics, and the dynamics of death for patients with hypertension

A great deal of interest has begun to focus on outcome data for hospitals. We analyzed hospital resource consumption for 4289 patients with hypertension by outcome (ie, survivors vs mortalities). The 211 mortalities had a much greater intensity of hospital resource utilization and a substantial financial risk under diagnosis related group (DRG) pricing schemes compared with the 4078 survivors. Only mortalities within one week of admission to the hospital were profitable under DRGs. A long hospital length of stay (LOS) for mortalities was very unprofitable (mortalities with greater than 60-day LOS generated a $40,673 loss per patient). Patients admitted under emergency conditions who died tended to have a shorter hospital LOS and less financial risk under DRGs compared with those who were not emergency admissions and died. Mortalities referred from other clinical services tended to have greater resource utilization and financial risk under DRGs compared with nonreferred mortalities. These data suggest notable inequities in the DRG prospective payment system vis-à-vis patients who died with hypertension. They also demonstrated variables predictive of greater hospital resource utilization for patients who died with hypertension, including longer hospital LOS, nonemergency admission, and referral from another clinical service.     

Hospital Costs, Resource Characteristics, and the Dynamics of Death for Hospitalized Gastroenterology Patients

The federal Medicare diagnosis-related group (DRG) hospital payment system has been on-line for 5 yr with no major adverse effects on either access or quality of care. The hospital industry contends that DRGs are underpaying for hospital care, especially for certain types of patients. Analysis of 2,500 gastroenterology patients by outcome (i.e., survivors vs mortalities) demonstrated that the 122 mortalities had a much greater intensity of hospital resource utilization, and generated substantial financial risk under DRG pricing schemes, compared with the 2,378 survivors. Only mortalities that occurred within 1 wk of admission to the hospital were profitable under DRGs. A long hospital length of stay (LOS) for mortalities was very unprofitable (mortalities with more than a 60-day LOS generated $20,210 loss per patient). Emergency gastroenterology admissions who died had greater financial risk under DRGs, compared to nonemergency mortalities. Those mortalities referred to gastroenterology from other clinical services tended to have greater resource utilization and financial risk under DRGs, compared with nonreferred mortalities. These data suggest significant inequities in the current DRG prospective payment system vis-a-vis gastrotenterology mortalities. Predictive variables of greater hospital resource utilization for gastroenterology mortalities include longer hospital lengths of stay, emergency admission, and referral from another clinical service. If equity of DRG payment is not improved by the federal government, certain groups of patients likely to be mortalities may suffer a decline in access and/or the quality of medical care in the future.     

Intensive management of high‐utilizing adults with sickle cell disease lowers admissions

A minority of super‐utilizing adults with sickle cell disease (SCD) account for a disproportionate number of emergency department (ED) and hospital admissions. We performed a retrospective cohort study comparing the rate of admission before and after the opening of a clinic for adults with SCD. Unique to this clinic was an intensive management strategy, focusing on super‐utilizing adults with 12 or more admissions per year. ED/hospital and 30 days re‐admission rates were compared, 1 year pre‐ and post‐intervention, for those adults who established in the clinic. Prior to the intervention, 17 super‐utilizers, comprising 15% of the pre‐intervention cohort (n = 115), accounted for 58% of the total admissions and had an admission rate of 28 per patient‐year. When pre‐ and post‐intervention years were compared, rate of ED/hospital admission per patient‐year for super‐utilizers decreased from 27.9 to 13.5 (P < 0.001), while there was not a significant reduction for the entire cohort (7.1 vs. 6.1, P = 0.84). Similarly, the decrease in rate of 30 day re‐admission was larger for the super‐utilizers (13.5 per patient‐year to 1.8, P < 0.001), than the whole cohort (2.6 per patient‐year to 0.7, P = 0.006). Among the super‐utilizers, the reduced rate of admission from the pre‐ to post‐clinic intervention year equated to 252 fewer ED/hospital admissions and 227 fewer 30 day re‐admissions. This management strategy focusing on super‐utilizing adults with SCD lowered admission and 30 day re‐admission rate. Am. J. Hematol. 90:215–219, 2015. © 2014 Wiley Periodicals, Inc.     

Hospital costs, resource characteristics, and the dynamics of death for hospitalized patients in cardiology Diagnosis-Related Groups

A number of complex health policy questions face the nation regarding the Diagnosis-Related Group (DRG) prospective hospital payment system. An ongoing debate ensues at the federal level of the utility of improving the DRG system, given the "budget neutrality" provision of the DRG law. We analyzed hospital resource consumption for 5809 cardiology inpatients by outcome (i.e., survival vs death). Hospital resource use was greater and financial risk under DRG pricing schemes was substantial for the 312 deaths compared with the 5497 survivors. Only cases in which the patient died within 1 week of admission to the hospital were profitable under DRGs. A long hospital length of stay for patients who eventually died was very unprofitable (those who died after more than a 60-day hospital length of stay generated a $24,688 loss per patient). Patients who died after emergency admission tended to have a similar hospital length of stay and to be similar financial risk under DRGs, compared with nonemergency patients who died. Those patients who had been referred from other clinical services and who died caused greater resource use and financial risk under DRGs, compared with patients who were not referred and who died. These data suggest significant inequities in the current DRG prospective payment system for patients in cardiology DRGs who die. Variables predictive of greater hospital resource use for cardiology patients who die include longer hospital lengths of stay and referral from another clinical service. Health policy leaders should attempt to improve the equity of cardiology DRGs regarding outcome in the future.     

The Identifier Concept: Clinical Parameters to Stratify Hospital Costs within Gastroenterology DRGs

Prospective payment systems using the diagnostic related group (DRG) payment mechanism are changing the incentives offered to hospitals. We studied hospital costs of all gastroenterological (GI) patients (n = 2500) treated during a 2-yr period at our academic medical center. We showed that patients within GI DRGs could be grouped regarding hospital costs by four clinical variables: intensive care unit or emergency admission, and blood or plasma product consumption. Patients within each DRG with the variable usually had higher total hospital costs, a longer stay in the hospital, a greater number of diagnoses, more outliers, and a poorer outcome than patients without the variables. As the variables accumulated, these differences became more pronounced. This study demonstrated that hospital costs may be stratified within GI DRGs by clinical parameters that occur during the patient's hospital stay. These four variables could identify higher cost patients within a DRG; cost containment could then be directed at these patients with, hopefully, resultant savings.     

DRG prospective, "all payor systems," financial risk, and hospital cost in pulmonary medicine non CC stratified DRGs

Previous work by our group had suggested that some pulmonary medicine diagnosis-related group (DRGs) did not adequately compensate for patients with multiple complications and comorbidities. Congress has recommended no major changes to pulmonary medicine DRGs along these lines. The purpose of this study was to analyze resource consumption in any of the seven noncomplicating conditions (CC), stratified pulmonary medicine DRGs using the new DRG prospective "all payor system" in effect at our hospital. Analysis of 858 pulmonary medicine patients by payor (Medicare, Medicaid, Blue Cross, and commercial insurance) in these non-CC stratified pulmonary medicine DRGs for a three-year period demonstrated that patients with more CCs per DRG for each payor generated higher total hospital costs, a longer hospital length of stay, a greater percentage of procedures per patient, financial risk under DRG payment, more outliers, and a higher mortality, compared to patients in these same DRGs with fewer CCs. Both hospital length of stay and total cost per patient (adjusted for DRG weight index) increased with CCs. Financial risk per patient under DRGs also increased as CCs accumulated. These findings suggest that new prospective DRG "all payor systems" may be inequitable to certain groups of patients or types of hospitals vis-a-vis the non-CC stratified pulmonary medicine DRGs. Many pulmonary medicine DRGs should be stratified by the numbers and types of CCs to more equitably reimburse hospitals under DRG all-payor systems.     

Reduced Rate of Hospital Presentations for Heart Failure During the COVID-19 Pandemic in Toronto,Canada

Coronavirus disease 2019 (COVID-19) has resulted in public health measures and health care reconfigurations likely to have impact on chronic disease care. We aimed to assess the volume and characteristics of patients presenting to hospitals with acute decompensated heart failure (ADHF) during the 2020 COVID-19 pandemic compared with a time-matched 2019 cohort. Patients presenting to hospitals with ADHF from March 1, to April 19, 2020 and 2019 in an urban hospital were examined. Multivariable logistic-regression models were used to evaluate the difference in probability of ADHF-related hospitalization between the 2 years. During the COVID-19 pandemic, a total of 1106 emergency department (ED) visits for dyspnea or peripheral edema were recorded, compared with 800 ED visits in 2019. A decrease in ADHF-related ED visits of 43.5% (14.8%-79.4%, P = 0.002) and ADHF-related admissions of 39.3% (8.6%-78.5%, P = 0.009) was observed compared with 2019. Patients with ADHF presenting to hospitals (n = 128) were similar in age, sex, and comorbidities compared with the 2019 cohort (n = 186); however, a higher proportion had recent diagnoses of heart failure. Upon ED presentation, the relative probability of hospitalization or admission to intensive care was not statistically different. There was a trend toward higher in-hospital mortality in 2020. The decline in ADHF-related hospitalizations raises the timely question of how patients with heart failure are managing beyond the acute-care setting and reinforces the need for public education on the availability and safety of emergency services throughout the COVID-19 pandemic.     

Coping with DRGs--a nursing home's experience

The introduction of prospective payment system (PPS) based on diagnostic related groups (DRGs) has had a significant impact on hospitals. To determine the impact of PPS on nursing homes, the authors studied the activity of a Veterans Administration teaching nursing home (admissions, acute hospital transfers, and discharges) during 1 year preceding implementation of DRGs and for 3 consecutive years following implementation of DRGs. In 1983, pre-DRGs, a total of 36 patients, were admitted to the nursing home. Following implementation of DRGs, a sevenfold increase was noted in the number of patients admitted when comparing 1983 and 1986, with the monthly average of patients admitted increasing from 3 in 1983 to 9.7, 22, and 23.8 in 1984, 1985, and 1986, respectively. Associated with the increase in patients admitted following DRGs was an increase in patients requiring transfer to the acute hospital, within 30 days of admission to the nursing home. In 1986, approximately 27% of patients admitted to the nursing home required transfer to the acute hospital within 30 days of their admission. The number of patients discharged from the nursing home also increased following DRGs. None of the patients admitted to the nursing home in 1983 were discharged within 30 days of admission. Subsequent to introduction of DRGs, an average of two patients per month were discharged within 30 days of nursing home admission.(ABSTRACT TRUNCATED AT 250 WORDS)     

Physician staffing in the emergency departments of public teaching hospitals: a national survey.

STUDY HYPOTHESIS: To evaluate factors influencing emergency physician staffing patterns in an important subset of US hospitals. DESIGN: Survey of emergency department directors and hospital administrators. PARTICIPANTS: Member institutions of the National Association of Public Hospitals and the Council of Teaching Hospitals. MEASUREMENTS: Of 498 hospitals enrolled, two mailings and telephone follow-up yielded 277 replies (56% response rate). To adjust for differences in ED size and volume, levels of staffing were converted to full-time equivalents (FTEs) per 10,000 annual ED visits. RESULTS: Responding institutions included 160 private and 115 public hospitals, 74 of which were Veterans Administration hospitals. Formal medical school affiliation was noted by 86% of responding institutions, and 82 (30%) supported emergency medicine residency programs. Full-time attending emergency physician staffing varied widely, from less than one to more than three FTEs per 10,000 visits; however, mean levels of staffing at public hospitals did not differ significantly from private institutions (2.7 +/- 1.6 vs 2.5 +/- 3.1, respectively; P = .50). Three of four hospitals reported using part-time emergency physician attending but only 33% used nurse practitioners or physicians' assistants. Two thirds of responding hospitals used rotating house officers-in-training. Of note, hospitals that supported emergency medicine residency programs reported significantly higher levels of staffing by housestaff (2.2 +/- 1.8 vs 1.0 +/- 1.2 FTEs/10,000 visits; P less than .0004), but levels of total staffing by full- and part-time attending physicians were virtually identical (2.69 +/- 1.6 vs 2.67 +/- 2.6 FTEs/10,000 visits; respectively; P = .95). Marked variability in levels and patterns of ED staffing at public and teaching hospitals currently exists, but the differences are not explained by hospital ownership. The reasons for such variations and their implications for patient care must be explored.     

A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department--the DEED II study

OBJECTIVES: To study the effects of comprehensive geriatric assessment (CGA) and multidisciplinary intervention on elderly patients sent home from the emergency department (ED). DESIGN: Prospective, randomized, controlled trial with 18 months of follow-up. SETTING: Large medical school-affiliated public hospital in an urban setting in Sydney, Australia. PARTICIPANTS: A total of 739 patients aged 75 and older discharged home from the ED were randomized into two groups. INTERVENTION: Patients randomized to the treatment group underwent initial CGA and were followed at home for up to 28 days by a hospital-based multidisciplinary outreach team. The team implemented or coordinated recommendations. The control group received usual care. MEASUREMENTS: The primary outcome measure was all admissions, to the hospital within 30 days of the initial ED visit. Secondary outcome measures were elective and emergency admissions, and nursing home admissions and mortality. Additional outcomes included physical function (Barthel Index (total possible score=20) and instrumental activities of daily living (/12) and cognitive function (mental status questionnaire (/10)). RESULTS: Intervention patients had a lower rate of all admissions to the hospital during the first 30 days after the initial ED visit (16.5% vs 22.2%; P=.048), a lower rate of emergency admissions during the 18-month follow-up (44.4% vs 54.3%; P=.007), and longer time to first emergency admission (382 vs 348 days; P=.011). There was no difference in admission to nursing homes or mortality. Patients randomized to the intervention group maintained a greater degree of physical and mental function (Barthel Index change from baseline at 6 months: -0.25 vs -0.75; P<.001; mental status questionnaire change from baseline at 12 months: -0.21 vs -0.64; P<.001). CONCLUSION: CGA and multidisciplinary intervention can improve health outcomes of older people at risk of deteriorating health and admission to hospital. Patients aged 75 and older should be referred for CGA after an ED visit.     

Diagnosis related group 'all payor' hospital payment and medical diseases. Financial risk and hospital cost in medical noncomplicating condition-stratified diagnosis related groups

There are many health policy issues related to diagnosis-related group (DRG) hospital payment. Previous work by our group had suggested that some DRGs did not adequately comorbidities. Despite recommendations by federal advisory committees, the secretary of Health and Human Services has proposed no major changes to DRGs along these lines. We analyze resource consumption in any of the 88 non-complicating condition (CC)-stratified medical DRGs using the DRG prospective "all payor system" in effect at our hospital. Analysis of 12,340 medical patients by payor (Medicare, Medicaid, Blue Cross, and commercial insurance) in these non-CC-stratified medical DRGs for a three-year period demonstrated that patients with more CCs per DRG for each payor generated higher total hospital costs, a longer hospital length of stay, a greater percentage of procedures per patient, higher financial risk under DRG payment, and a higher mortality, compared with patients in these same DRGs with fewer CCs. These findings suggest that new prospective DRG all payor systems may be inequitable to certain groups of patients or types of hospitals vis-à-vis the non-CC-stratified medical DRGs. Health policy leaders should be encouraged to stratify many medical DRGs by the numbers and types of CCs to more equitably reimburse hospitals under DRG all payor systems.     

Feasibility, indications and immediate results of direct angioplasty without thrombolysis during the acute period of myocardial infarction]

Between June 1988 and November 1991, 64 out of 200 consecutive admissions (32%) before the 6th hour of myocardial infarction underwent angioplasty of first intention. Fifty men and 14 women (average age 62 +/- 11 years) benefitted from this 24 hour emergency interventional cardiology service. The indication was formal in 22% of patients because of a contra-indication to thrombolysis (N = 40) or cardiogenic shock (N = 4); in 6%, the choice was logical because of diagnostic uncertainty (N = 12); it was a deliberate choice in 4% of cases (N = 8). Successful angioplasty was defined as reperfusion of the occluded artery without circulatory delay or > 50% residual stenosis. Arterial recanalisation was attempted in all patients (associated with intraaortic balloon pumping in 3 cases) and was successful in 59 patients (92%) within 231 +/- 100 minutes of the onset of chest pain and within 49 +/- 29 minutes of hospital admission. The outcome was uncomplicated without any other intervention in 81% of patients (48/59). Three reocclusions were observed, two of which were symptomatic and treated successfully by repeat emergency angioplasty. Six surgical revascularisations were necessary (2 emergency, 4 secondary). One major complication related to the angioplasty was observed (haemopericardium). Global hospital mortality was 9% (6/64): three of the 4 patients admitted in cardiogenic shock, 3 of the 40 high risk patients with contra-indications to thrombolytic therapy, none of the 20 patients considered to be at low risk (uncertain diagnosis and deliberate choice).(ABSTRACT TRUNCATED AT 250 WORDS)     

Changes in hospitalization patterns among patients with congenital heart disease during the transition from adolescence to adulthood.

OBJECTIVES: This study was designed to evaluate hospitalization patterns of congenital heart disease (CHD) patients surrounding the transition from adolescence to adulthood. BACKGROUND: Few population data exist on hospitalizations among adolescent and adult CHD patients. METHODS: Patients ages 12 to 44 years with CHD were selected from the 2000 to 2003 California hospital discharge database. Patient demographics, hospitalization patterns, emergency department (ED) admissions, CHD complexity, and insurance patterns were described. Data were analyzed in 3-year age increments and compared between patients over and under age 21. Predictors of admission via the ED were determined using multivariate regression analysis. RESULTS: There were 9,017 hospitalizations at 368 hospitals. For patients ages 12 to 20 years, 12 hospitals accounted for 70% of hospitalizations; for patients ages 21 to 44 years, 25 hospitals accounted for only 44.8% of cases. Regarding insurance, 53% of admissions were private, 44% public, and <4% were self-pay. Sixty-five percent of patients had complex CHD and 19% had a cardiac procedure during hospitalization. The proportion of patients admitted via the ED nearly doubled surrounding the transition to adulthood. The positive predictors of admission via the ED included public insurance, self-pay, and age >17 years, whereas having a procedure and being female decreased the likelihood. CONCLUSIONS: Congenital heart disease hospitalizations occur at a wide variety of hospitals and disperse as patients enter adulthood. Those without private insurance and >17 years old are at higher risk of being admitted via the ED. These findings require further investigation to examine access to care and possible disparities, as they are important for future healthcare planning.     

Cost-efficiency of myocardial contrast echocardiography in patients presenting to the emergency department with chest pain of suspected cardiac origin and a nondiagnostic electrocardiogram

Assessment of patients presenting to the emergency department (ED) with suspected cardiac chest pain and a nondiagnostic electrocardiogram (ECG) is lengthy and costly. It was hypothesized that myocardial contrast echocardiography (MCE) can be cost-efficient in such patients by detecting those with chest pain that is noncardiac in nature. Accordingly, cost-efficiency was evaluated in 957 patients presenting to the ED with suspected cardiac chest pain, but no ST-segment elevation on the ECG, who underwent MCE. Economic outcome calculations were based on costs estimated from national average Medicare charges adjusted by a cost-charge ratio. Based on routine clinical criteria, 641 patients (67%) were admitted to the hospital, whereas 316 (33%) were discharged directly from the ED. The average cost per patient using routine evaluation was $5,000. Patients with normal MCE results (n = 523) had a very low primary event rate (death, acute myocardial infarction) of 0.6% within 24 hours after presentation, making it relatively safe to discharge patients directly from the ED with a normal MCE result. Hence, if MCE had been used for decision making, 523 patients (55%) would have been discharged directly from the ED and 434 (45%) would have been admitted to the hospital. Preventing unnecessary admissions and tests would have saved an average of $900 per patient, in addition to reducing their ED stay. In conclusion, by excluding cardiac causes in patients presenting to the ED with chest pain and a nondiagnostic ECG, MCE can prevent unnecessary admissions and downstream resource utilization, making it a cost-efficient tool in the evaluation of these patients.     

Reduced readmission rate for alternating diagnoses of heart failure and pulmonary disease after implementation of B-type natriuretic peptide testing

BACKGROUND: Patients with heart failure (HF) or pulmonary diseases (PD) present with similar symptoms. Effective disease management requires an accurate diagnosis. B-type natriuretic peptide (BNP) is increased in patients with HF and is normal in PD patients without cardiac involvement. OBJECTIVE: To determine if the readmission rate for patients with either HF or PD who later present with the alternate diagnosis (PD or HF) is decreased with the implementation of BNP testing at one hospital. METHODS: We retrospectively determined the impact of BNP testing on reducing diagnostic ambiguities for patients admitted to an emergency department (ED) with these diseases. We compared a HF DRG (Diagnostic Related Group) (#428) and PD DRGs (#480-496) before vs. 1 and 2 y after implementation of BNP testing. RESULTS: In a 12-month period before BNP, there were 42 total visits (15 cases) where a patient presented with a HF DRG and returned within 6 months with a PD DRG, and 41 visits (14 cases) where there was a PD-->HF readmission. One year after BNP implementation, the corresponding number of visits decreased 52% to 20 visits (15 cases) for HF-->PD, and 73% to 11 visits (8 cases) for PD-->HF readmissions. A similar reduction in readmissions was observed in the second year after BNP testing. The total number of HF and PD cases in 1999 (1029 patients) was similar to 2001 (985), and was higher in 2002 (1350) during these time intervals. The ED length-of-stay (LOS) was slightly higher for the HF-->PD cases with BNP testing, whereas there was no change in LOS for the PD-->HF cases. CONCLUSION: We hypothesize that prior to BNP implementation, there may have been diagnostic ambiguities in the initial diagnosis of HF or PD, which contributed to a repeat visit for the alternate diagnosis (PD or HF). With BNP testing, the apparent number of inappropriate visits decreased. Reducing unnecessary ED admissions helps justify the costs for implementing BNP testing in the hospital.     

Effect of Hospitalists on Length of Stay in the Medicare Population: Variation According to Hospital and Patient Characteristics

OBJECTIVES: To assess how shorter length of stay (LOS) associated with hospitalist care than with care by other physicians varied according to patient and hospital characteristics and to explore whether these differences in LOS changed over time in the Medicare population. DESIGN: Retrospective cohort study using data from a 5% national sample of Medicare beneficiaries. SETTING: Hospital. PARTICIPANTS: To examine temporal trends, 1,981,654 Medicare admissions in 2001 to 2006 at 5,036 U.S. hospitals were used. To examine the influence of patient and hospital characteristics, 314,590 admissions in 2006 were used. MEASUREMENTS: Hospital LOS. RESULTS: In multivariable analyses controlling for patient and hospital characteristics, differences in LOS associated with hospitalist care increased from 0.02 fewer days in 2001/02 to 0.22 days in 2003/04 to 0.35 days in 2005/06. For 2006 admissions, differences in LOS were greater in older patients and patients with a higher diagnosis‐related group (DRG) weight. The differences were three times as great for medical as for surgical DRGs, with greater differences in LOS at nonprofit than for‐profit hospitals and at community than teaching hospitals. CONCLUSION: The shorter LOS associated with hospitalist care would appear to be greatest in older, complicated, nonsurgical patients cared for at community hospitals.     

Benefits of implementing a rapid access clinic in a high-volume inflammatory bowel disease center:Access,resource utilization and outcomes

BACKGROUND Emergency situations in inflammatory bowel diseases(IBD)put significant burden on both the patient and the healthcare system.AIM To prospectively measure Quality-of-Care indicators and resource utilization after the implementation of the new rapid access clinic service(RAC)at a tertiary IBD center.METHODS Patient access,resource utilization and outcome parameters were collected from consecutive patients contacting the RAC between July 2017 and March 2019 in this observational study.For comparing resource utilization and healthcare costs,emergency department(ED)visits of IBD patients with no access to RAC services were evaluated between January 2018 and January 2019.Time to appointment,diagnostic methods,change in medical therapy,unplanned ED visits,hospitalizations and surgical admissions were calculated and compared.RESULTS 488 patients(Crohn’s disease:68.4%/ulcerative colitis:31.6%)contacted the RAC with a valid medical reason.Median time to visit with an IBD specialist following the index contact was 2 d.Patients had objective clinical and laboratory assessment(C-reactive protein and fecal calprotectin in 91%and 73%).Fast-track colonoscopy/sigmoidoscopy was performed in 24.6%of the patients,while computed tomography/magnetic resonance imaging in only 8.1%.Medical therapy was changed in 54.4%.ED visits within 30 d following the RAC visit occurred in 8.8%(unplanned ED visit rate:5.9%).Diagnostic procedures and resource utilization at the ED(n=135 patients)were substantially different compared to RAC users:Abdominal computed tomography was more frequent(65.7%,P<0.001),coupled with multiple specialist consults,more frequent hospital admission(P<0.001),higher steroid initiation(P<0.001).Average medical cost estimates of diagnostic procedures and services per patient was$403 CAD vs$1885 CAD comparing all RAC and ED visits.CONCLUSION Implementation of a RAC improved patient care by facilitating easier access to IBD specific medical care,optimized resource utilization and helped avoiding ED visits and subsequent hospitalizations.     

Predictors of emergency department visit disposition for patients with chronic obstructive pulmonary disease

STUDY OBJECTIVES: The study objective was to validate among patients with chronic obstructive pulmonary disease (COPD) clinical predictors of emergency department (ED) disposition (admission vs discharge) found in a previous study. We hypothesized that the initial heart rate (HR) at presentation and the number of nebulizer treatments would predict visit disposition adequately and that existing triage criteria would not. METHODS: In this correlational study, all ED visits to a university medical center related to a diagnosis of COPD over a 2-year period were identified and reviewed retrospectively (N = 114 patients and 226 visits). Associations of clinical predictors with visit disposition was by contingency table or receiver operating characteristic curve analysis. RESULTS: The overall admission rate was 60.2%. An initial HR slightly greater than normal limits (HR >/= 106 vs HR 相似文献   

Age, resource consumption, and outcome for medical patients at an academic medical center

At the national level debate is growing about the effects of the diagnosis related group (DRG) hospital payment system on patient access and quality of care. Recent changes to the DRG system have dropped any stratification by age and have delayed any other major change to improve payment equity. We characterized hospital resource consumption and outcome by age for all medical admissions (N = 31,838) to a large academic medical center (January 1, 1985, through December 31, 1987) using the DRG format. Mean hospital cost per patient, hospital length of stay, percentage of outliers, and mortality increased with age. The mean DRG case-mix index and the number of diagnostic codes per patient also rose with age. The DRG payment for all patients would have produced an aggregate profit of $34,426,951 ($1081 profit per patient); however, patients aged 71 years or older generated loses (the highest with patients aged 85 years or older--a $2177 loss per patient). As the financial position of American hospitals continues to deteriorate, these data suggest that the current DRG payment scheme may be inequitable for the medical patient aged 71 years or older, thus providing financial disincentives to treat the elderly medical patient and perhaps limiting their access and quality of care in the future.