Comparison of hospital length of stay between hospitalized non-valvular atrial fibrillation patients treated with either apixaban or warfarin

Background. Hospital length of stay (LOS) is an important cost driver for hospitals and payers alike. Hospitalized non-valvular atrial fibrillation (NVAF) patients treated with apixaban may have shorter LOS than those treated with warfarin because of the absence of need for INR monitoring in apixaban. Thus, this study compared hospital LOS between hospitalized NVAF patients treated with either apixaban or warfarin. Methods. This was a retrospective, observational cohort study based on a large US database including diagnosis, procedure, and drug administration information from >600 acute-care hospitals. Patients selected for study were aged ≥18 years and had a hospitalization record with an ICD-9-CM diagnosis code for atrial fibrillation (AF) in any position from 1 January 2013 to 28 February 2014 (index hospitalization). Patients with diagnoses indicative of rheumatic mitral valvular heart disease or a valve replacement procedure during index hospitalization were excluded. Patients were required to have been treated with either apixaban or warfarin, and not treated with rivaroxaban or dabigatran, during index hospitalization. Apixaban patients were propensity score (PS) matched to warfarin patients at a 1:1 ratio, using patient demographic/clinical and hospital characteristics. The study outcome was hospital LOS, calculated as discharge date minus admission date; a sensitivity analysis calculated hospital LOS as discharge date minus first anticoagulant administration date. Sub-analyses were conducted among patients with a primary diagnosis of AF. Results. The study included 832 apixaban patients matched to 832 warfarin patients. Mean [standard deviation (SD)] and median hospital LOS were significantly (p < 0.001) shorter in apixaban patients (4.5 [4.2] and 3 days) than in warfarin patients (5.4 [5.0] and 4). Results were consistent in the sensitivity and sub-analyses. Conclusions. Among NVAF patients, apixaban treatment was associated with shorter hospital LOS when compared with warfarin treatment. These findings may have important clinical and economic implications for hospitals, payers, and patients.     

Asthma And Depression

Abstract

Thromboprophylaxis with oral anticoagulants (OACs) is an important but under-used element of atrial fibrillation (AF) treatment. Reduction of stroke risk with anticoagulants comes at the price of increased bleeding risk. Patients with AF receiving anticoagulants require heightened attention with transition from one care setting to another. Patients presenting for emergency care of anticoagulant-related bleeding should be triaged for the severity and source of the bleeding using appropriate measures, such as discontinuing the OAC, administering vitamin K, when appropriate, to reverse warfarin-induced bleeding, or administering clotting factors for emergent bleeding. Reversal of OACs in patients admitted to the hospital for surgery can be managed similarly to patients with bleeding, depending on the urgency of the surgical procedure. Patients with AF who are admitted for conditions unrelated to AF should be assessed for adequacy of stroke risk prophylaxis and bleeding risk. Newly diagnosed AF should be treated in nearly all patients with either warfarin or a newer anticoagulant. Patient education is critically important with all anticoagulants. Close adherence to the prescribed regimen, regular international normalized ratio testing for warfarin, and understanding the stroke risk conferred by both AF and aging are goals for all patients receiving OACs. Detailed handoff from the hospitalist to the patient's primary care physician is required for good continuity of care. Monitoring by an anticoagulation clinic is the best arrangement for most patients. The elderly, or particularly frail or debilitated patients who are transferring to long-term care, need a detailed transfer of information between settings, education for the patient and family, and medication reconciliation. Communication and coordination of care among outpatient, emergency, inpatient, and long-term care settings are vital for patients with AF who are receiving anticoagulants to balance stroke prevention and bleeding risk.     

某院质量与安全管理团队建设成效评估

结合本院等级评审实践,从推进质量与安全管理规章制度规范化、以绩效考核强化质量与安全团队制度执行两方面入手,探讨基于质量与安全管理团队建设的医疗综合质量提升措施,并对措施实施前后平均住院日、医疗收费的药占比进行比较,对存在的问题进行分析。     

Atrial Fibrillation as an Ischemic Stroke Clinical and Economic Burden Modifier: A 15-Year Nationwide Study

Background

Atrial fibrillation (AF) is a major risk factor for ischemic stroke (IS). Patients with AF may undergo preventive therapy. Although the AF impact in the clinical burden of IS has been studied, information is lacking in Southern Europe and there are no studies about the impact in potential years of life lost. Moreover, no nationwide or long-term study analyzed the economic burden of IS stratified by AF.

The Impact of Atrial Fibrillation on the Cost of Stroke: The Berlin Acute Stroke Study

OBJECTIVES: Atrial fibrillation (AF) is an important risk factor for stroke. The primary purpose of this study was to determine the resource use for patients admitted to hospital with acute stroke and to calculate stroke-related direct costs, stratifying the results according to the presence of AF as a risk factor. METHODS: Data from 558 consecutive patients hospitalized with confirmed acute stroke between August 2000 and July 2001 were analyzed as part of the Berlin Acute Stroke Study. Sociodemographic variables were assessed by direct interview, while hospital data were derived from patient medical records. Patients or their carers completed a follow-up questionnaire about resource utilization and absenteeism from work during the 12-month period after hospital admission. RESULTS: Out of the 367 patients with follow-up data and ECG findings, 71 (19%) had AF. Patients with AF were generally older, more likely to be female, and had more severe strokes compared with those without AF. Mean direct costs per patient were significantly higher in those with AF-related strokes (EURO 11,799 vs EURO 8817 for non-AF-related strokes; P < 0.001). After adjustment for confounding factors, direct costs were comparable in the two groups, except for acute hospitalization costs, which remained significantly higher in the group with AF (P < 0.05). CONCLUSION: Medical care for stroke patients with AF is associated with higher costs compared with those without AF; this is explained mainly by confounding factors and driven essentially by a significant difference in acute hospitalization costs.     

Hospital Length of Stay and Cost: A Multilevel Modeling Analysis

Despite concern over compromised medical care resulting from a recent decline in the length of hospitalizations, little attention has been given to the extent to which this strategy has led to cost savings for hospitals. This article examines this issue using a multilevel modeling methodology that examines patient costs as they relate to both patient and hospital level characteristics. The analysis reveals an estimated elasticity of patient length of stay of 0.755 and of 0.326 for hospital level average length of stay. It appears from these results that the strategy of reducing the lengths of hospitalizations has saved considerably on hospital costs.     

Use of oral anticoagulants in atrial fibrillation is highly variable and only weakly associated with estimated stroke risk: Cross-sectional population database study

Background: Current international guidelines promote the use of stroke risk stratification tools to inform decision making about oral anticoagulant (OAC) use in atrial fibrillation (AF).

Objectives: To examine (a) differences between CHADS₂ and CHA₂DS₂VASc in classifying stroke risk in a primary care population of AF patients; (b) patterns of use of antithrombotics by stroke risk; and (c) patient and practice characteristics associated with use of oral anticoagulants in patients with AF.

Methods: Cross-sectional multilevel modelling study of all patients with AF and without rheumatic heart disease or valve replacement (n = 21 564) from 315 Scottish General Practices.

Results: (a) CHADS₂ characterized 30.3% in the intermediate and 53.8% in the high-risk category, compared to CHA₂DS₂VASC only 9.7% intermediate and 85.1% high-risk. (b) Of included patients, 17.8% were currently not prescribed any antithrombotic and 43.3% were on OAC. OAC use was only weakly related to stroke risk. (c) Patients with paroxysmal AF and those with dementia and previous peptic ulcer (adjusted ORs 0.26, 0.25 and 0.79) were less likely to be prescribed OAC. OAC use varied over five-fold between practices after adjustment for patient case mix, with remote and non-training practices and those with high levels of high-risk prescribing being more likely to prescribe OAC.

Conclusion: Evidence was found of both underuse and overuse of OAC in patients with AF. Promoting instruments for stroke risk assessment in AF is a plausible but untested strategy to improve decision making in AF, and its impact on OAC prescribing and patient outcomes should be evaluated in pragmatic trials.     

Improving Front-End Flow in an Urban Academic Medical Center Emergency Department: The Emergency Department Discharge Facilitator Team

Length of stay (LOS) is an important determinant of patient satisfaction and overall emergency department (ED) operational efficiency. In an effort to reduce length of stay for low-acuity “treated and released” patients, our department created a discharge facilitator team (DFT) composed of an attending physician, physician assistant, and registered nurse. The DFT identified patients who could be rapidly treated and released in the low-acuity treatment Adult Urgent Care Center (AUCC) and provided them rapid treatment and discharge. To assess the efficacy of the DFT, linear regression was used to compare AUCC LOS at times the team was and was not active. Patients seen by the DFT had a LOS that was 35 % shorter than other AUCC patients. There was a 28-min reduction in AUCC LOS during periods where the DFT was active (95% CI 22 to 33 min). We conclude that the establishment of a DFT was associated with a significant reduction in LOS for all low-acuity patients. Other academic medical centers may consider implementing a similar program in order to reduce LOS and improve ED throughput for low acuity patients.     

Factors Associated with Extended Length of Stay for Patients Presenting to an Urban Psychiatric Emergency Service: A Case-Control Study

This study assessed factors associated with extended length of stay (ELOS) for patients presenting to a psychiatric emergency service (PES). Two hundred six subjects with a length of stay of 24 h or longer were compared with time-matched controls (patients that presented directly after the ELOS patient). Binary logistic regression was used to identify risk factors for ELOS. ELOS was associated with suicidal ideation, disposition to an inpatient unit, homicidal ideation, lack of insurance, homelessness, male gender, past history of psychiatric hospitalization, diagnosis of substance abuse, significant psychiatric co-morbidity (represented by three or more Axis I diagnoses), and diagnosis of a psychotic disorder. Lack of insurance, suicidal ideation, disposition to inpatient unit, and homicidal ideation all made nonredundant contributions to predicting stays of 24 h or longer.     

Modelling the neonatal system: A joint analysis of length of stay and patient pathways

In the United Kingdom, one in seven babies require specialist neonatal care after birth, with a noticeable increase in demand. Coupled with budgeting constraints and lack of investment means that neonatal units are struggling. This will inevitably have an impact on baby's length of stay (LoS) and the performance of the service. Models have previously been developed to capture individual babies' pathways to investigate the longitudinal cycle of care. However, no models have been developed to examine the joint analysis of LoS and babies' pathways. LoS at each stage of care is a critical driver of both the clinical outcomes and economic performance of the neonatal system. Using the generalized linear mixed modelling approach, extended to accommodate multiple outcomes, the association between neonate's pathway to discharge and LoS is examined. Using the data about 1002 neonates, we noticed that there is a high positive association between baby's pathway and total LoS, suggesting that discharge policies needs to be looked at more carefully. A novel statistical approach that examined the association of key outcomes and how it evolved over time is developed. Its applicability can be extended to other types of long-term care or diseases, such as heart failure and stroke.     

Determinants of Maternity Length of Stay: A Gamma Mixture Risk-Adjusted Model

With obstetrical delivery being the most frequent cause for hospital admissions, it is important to determine health- and patient-related characteristics affecting maternity length of stay (LOS). Although the average inpatient LOS has decreased steadily over the years, the issue of the appropriate LOS after delivery is complex and hotly debated, especially since the introduction of the mandatory minimum-stay legislation in the USA. The purpose of this paper is to identity factors associated with maternity LOS and to model variations in LOS. A Gamma mixture risk-adjusted model is proposed in order to analyze heterogeneity of maternity LOS within obstetrical Diagnosis Related Groups (DRGs). The determination of pertinent factors would benefit hospital administrators and clinicians to manage LOS and expenditures efficiently.     

A prospective study of prolonged stay in the intensive care unit: predictors and impact on resource utilization.

OBJECTIVE: To evaluate the predictors of prolonged Intensive Care Unit (ICU) stay and the impact on resource utilization. DESIGN: Prospective study. SETTING: Adult medical/surgical ICU in a tertiary-care teaching hospital. STUDY PARTICIPANTS: All admissions to the ICU (numbering 947) over a 20-month period were enrolled. Data on demographic and clinical profile, length of stay, and outcome were collected prospectively. The ICU length of stay and mechanical ventilation days were used as surrogate parameters for resource utilization. Potential predictors were analyzed for possible association with prolonged ICU stay (length of stay > 14 days). RESULTS: Patients with prolonged ICU stay formed only 11% of patients, but utilized 45.1% of ICU days and 55.5% of mechanical ventilation days. Non-elective admissions, readmissions, respiratory or trauma-related reasons for admission, and first 24-hour evidence of infection, oliguria, coagulopathy, and the need for mechanical ventilation or vasopressor therapy had significant association with prolonged ICU stay. Mean APACHE II and SAPS II were slightly higher in patients with prolonged stay. ICU outcome was comparable to patients with < or = 14 days ICU stay. CONCLUSIONS: Patients with prolonged ICU stay form a small proportion of ICU patients, yet they consume a significant share of the ICU resources. The outcome of this group of patients is comparable to that of shorter stay patients. The predictors identified in the study can be used in targeting this group to improve resource utilization and efficiency of ICU care.     

Impact of Diet on Mortality From Stroke: Results From the U.S. Multiethnic Cohort Study

Objectives: Stroke is the fourth leading cause of death in the United States and stroke mortality rates vary by ethnicity. The purpose of this study was to examine the associations between food group consumption and risk of death from stroke among 5 ethnic groups in the United States.

Methods: The Multiethnic Cohort includes >215,000 participants, the majority of whom are African American, Native Hawaiian, Japanese American, Latino, and Caucasian men and women recruited by mail survey in Hawaii and Los Angeles in 1993–1996. Deaths from stroke were identified by linkage to the state death files and the U.S. National Death Index. Diet was assessed using a validated food frequency questionnaire. Associations were examined using multivariable Cox proportional hazards models, stratified by ethnicity and gender.

Results: A total of 860 deaths from stroke were identified among the cohort participants. Vegetable intake was associated with a significant reduction in risk for fatal stroke among African American women (relative risk [RR] = 0.60; 95% CI: 0.36–0.99). Among Japanese American women only, high fruit intake was significantly associated with a risk reduction for stroke mortality (RR = 0.43; 95% confidence interval [CI]: 0.22–0.85), whereas meat intake increased risk (RR = 2.36; 95% CI: 1.31–4.26). Among men, a significant reduction in stroke mortality was observed among Native Hawaiians (RR = 0.26; 95% CI: 0.07–0.95). After pooling the data for the ethnic groups, the findings support an elevated risk for high meat intake among women overall (RR = 1.56; 95% CI: 1.12–2.16); no significant effects of dietary intake on risk for fatal stroke were observed among men.

Conclusions: Although some variations were observed for the associations between diet and stroke mortality among ethnic groups, the findings suggest that these differences are not substantial and may be due to dietary intake of specific food subgroups. Additional investigations including dietary subgroups and nutrients sources are needed to clarify these findings.     

美军医学人文教育的特点及启示

医学人文精神是医学的灵魂。随着医学模式的转变,世界各国医学院校更加重视医学生人文精神的培育。本文通过考察美军医学院校人文教育的做法,认为其人文教育具有四个特点：课程设置因材施教、教学内容学科交叉、教育过程贯穿始终、教育效果突出实用;对我军医医学人文精神培育具有重要的启示和借鉴意义。     

Traveling Abroad for Medical Care: U.S. Medical Tourists' Expectations and Perceptions of Service Quality

The SERVQUAL scale has been widely used to measure service quality in the health care industry. This research is the first study that used SERVQUAL to assess U.S. medical tourists' expectations and perceptions of the service quality of health care facilities located outside the United States. Based on a sample of U.S. consumers, who had traveled abroad for medical care, the results indicated that there were significant differences between U.S. medical tourists' perceived level of service provided and their expectations of the service that should be provided for four of the five dimensions of service quality. Reliability had the largest service quality gap followed by assurance, tangibles, and empathy. Responsiveness was the only dimension without a significantly different gap score. The study establishes a foundation for future research on service quality in the rapidly growing medical tourism industry.     

美国老年医疗保险处方药补偿改革的新动向

本文是根据近期美国报刊针对美国老年医疗保险处方药补偿改革的报道做一综述,是卫生政策分析的一个很好的案例,它有助于加深了解美国两党在新政策出台前面临的政治斗争和各利益集团的矛盾。     

The characteristics of very short stay ICU admissions and implications for optimizing ICU resource utilization: the Saudi experience.

OBJECTIVE: Patients with very short stays (<24 hours) in intensive care units (ICUs) constitute a distinct group with a high turnover rate and a unique patient mix. Our aim was to study their characteristics with the aim of developing strategic approaches for better and more appropriate utilization of ICU resources. DESIGN: Prospective cohort study. SETTING: Adult medical/surgical ICU in a tertiary care teaching hospital. STUDY PARTICIPANTS: All admissions in an adult ICU from March 1999 to February 2001 and staying <24 hours were enrolled. Relevant data were collected on these patients, their course and outcome, and analyzed after categorizing patients according to: (i) the nature of admission; and (ii) risk of death (ROD) estimated by Mortality Probability Model II(0). RESULTS: Patients staying <24 hours (n = 304) formed 27.8% of all ICU admissions, with an ICU mortality rate of 26.3%. Only 45.4% of them utilized ICU-specific procedures. Around one-third (32.6%) were elective admissions comprising younger patients, with a significantly lower prevalence of chronic illness, a lower ROD, and utilization of less ICU-specific procedures, with very few mortalities. When stratified using RODs into low-, intermediate-, and high-risk groups, significant differences were found with respect to age, nature of ICU admission, presence of chronic illness, utilization of ICU-specific procedures, having do-not-resuscitate (DNR) orders, length of ICU stay, and ICU and hospital outcomes. CONCLUSIONS: Our study has provided crucial input for the study of strategic change towards more optimal utilization of scarce ICU resources. Implementing protocols to target ICU care to patients most likely to benefit, making DNR decisions early in the hospital stay, and operating an Intermediate Care Unit have been proposed as strategic approaches.     

Waste in the U.S. Health Care System: A Conceptual Framework

Context: Health care costs in the United States are much higher than those in industrial countries with similar or better health system performance. Wasteful spending has many undesirable consequences that could be alleviated through waste reduction. This article proposes a conceptual framework to guide researchers and policymakers in evaluating waste, implementing waste‐reduction strategies, and reducing the burden of unnecessary health care spending. Methods: This article divides health care waste into administrative, operational, and clinical waste and provides an overview of each. It explains how researchers have used both high‐level and sector‐ or procedure‐specific comparisons to quantify such waste, and it discusses examples and challenges in both waste measurement and waste reduction. Findings: Waste is caused by factors such as health insurance and medical uncertainties that encourage the production of inefficient and low‐value services. Various efforts to reduce such waste have encountered challenges, such as the high costs of initial investment, unintended administrative complexities, and trade‐offs among patients', payers', and providers' interests. While categorizing waste may help identify and measure general types and sources of waste, successful reduction strategies must integrate the administrative, operational, and clinical components of care, and proceed by identifying goals, changing systemic incentives, and making specific process improvements. Conclusions: Classifying, identifying, and measuring waste elucidate its causes, clarify systemic goals, and specify potential health care reforms that—by improving the market for health insurance and health care—will generate incentives for better efficiency and thus ultimately decrease waste in the U.S. health care system.