Utilization of hospital resources by alcoholic and nonalcoholic patients

Objective:To measure any difference in the utilization of hospital resources between alcoholic patients and nonalcoholic patients (controls) in a department of internal medicine. Design:Prospective comparative study. Alcoholics were identified as patients with Michigan Alcoholism Screening Test (MAST) scores of ≥8. Controls were defined as patients with MAST scores of ≤4, and matched with alcoholics for sex, age, and time of admission. The length of stay, as well as several indicators of utilization of diagnostic and therapeutic procedures, was used for the comparison of resource utilization. Setting:General wards of internal medicine of a 1,000-bed city and teaching hospital in Lausanne, Switzerland. Participants:One bundred and three alcoholic patients and 103 controls aged 20–75 years, admitted from September 1, 1988, to March 18, 1989. Results:Alcoholics had the same lengths of stay (16 days), durations of intravenous infusions (six days), and durations of bladder catheterization (one day). Statistically nonsignificant differences were found between alcoholics and nonalcoholics regarding the charges for routine laboratory examinations [693 vs. 734 Swiss francs (Sfrs)], antibiotic therapies (218 vs. 145 Sfrs), and x-ray procedures (568 vs. 774 Sfrs; p=0.06). The average number of electrocardiograms (two vs. five; p<0.005) and the duration of intensive care unit (ICU) stay (one vs. two days; p<0.05) were significantly lower for alcoholics than for controls. A total hospital charges index was also lower for alcoholics than for controls (11,900 Sfrs vs. 12,800 Sfrs), but not significantly. Conclusion:The authors’ results suggest that alcoholics do not use more hospital resources per admission than do nonalcoholics. Moreover, alcoholics tend to use less frequently some procedures, such as the ICU, electrocardiography, and x-ray examinations. Several hypotheses are developed to explain these results in relation to those of previous studies, which showed more use of medical care by alcoholics than by nonalcoholics. Support by a grant from the Swiss National Research Foundation (no 3200-009282) and by a grant from the “Fondation du 450^eme Anniversaire de l’Université de Lausanne.”     

The Management of 38 Anastomotic Leaks After 1,684 Intestinal Resections

Purpose This study was designed to evaluate the management of anastomotic leaks and assess the impact of outpatient leak presentation on clinical outcome. Methods Thirty-eight patients with clinical anastomotic leaks from 1,684 adult patients undergoing large and small intestinal anastomosis in a tertiary referral center between January 1, 2003 and September 1, 2005 were studied. All pediatric patients and adult patients with esophageal and gastric leaks were excluded. Charts were reviewed for information on anastomotic leak management, discharge status before leak presentation, length of stay, readmissions, and mortality. Results The overall leak rate was 2.3 percent. Eighty-seven percent of patients (n = 33) were managed operatively. Forty-two percent of patients (n = 16) were discharged after initial operation and presented as outpatients with anastomotic leak. The discharge and inpatient groups were comparable in respect to total length of stay (26.9 vs. 33.4 days) and number of readmissions (2 vs. 1.5). The overall mortality of 5 percent (n = 2) originated from the discharge group. A greater percentage of discharge patients required intensive care unit stays for more than two weeks (25 vs. 14 percent) and very long hospital admissions lasting more than two months (31 vs. 9 percent). A smaller percentage of the discharge group patients had their ostomies reversed (31 vs. 50 percent). Conclusions The primary management of clinical anastomotic leak remains intestinal diversion. Although length of stay was shorter in the discharge group, the number of patients who experienced significant intensive care unit stays and very long hospital stays was greater. Within the discharge group, mortality was higher and fewer patients had their ostomies reversed.     

Determinants of resource utilization for patients admitted for evaluation of acute chest pain

Objective:To identify determinants of resource utilization among patients with suspected acute myocardial infarction. Design:Prospective cohort study, with prospective collection of detailed clinical data and retrospective collection of nonclinical data and resource utilization data. Setting:Urban, tertiary-care, teaching hospital. Patient population:992 consecutive patients over the age of 30 years, admitted from the emergency department for evaluation of acute chest pain unexplained by obvious trauma or chest roentgenographic abnormality, were eligible for the study. After excluding patients who had left against medical advice, who had been transferred to another bospital, or who had incomplete utilization data, 903 patients were included in the analyses. Measurements and outcomes:The authors evaluated the effects of 22 clinical and nonclinical factors on resource use. Resource use was primarily evaluated by length of stay; charges were evaluated in secondary analyses. Results:In the entire study population, increased length of stay was associated with a diagnosis of acute myocardial infarction or angina, severity of complications, use of invasive and noninvasive testing, and initial triage to the coronary care unit. In the 424 (47%) patients who had had completely uncomplicated courses after admission, high coefficients of variability were found for length of stay (0.88) and for total charges (0.78). In these uncomplicated patients, increased length of stay was associated with the use of noninvasive cardiac testing (66% longer for patients undergoing echocardiography or radionuclide ventriculography, and 46% longer for patients undergoing exercise tests or ambulatory arrhythmia monitoring), initial triage to the coronary care unit (23% longer), admission at the end of the week (21% longer), and insurance coverage other than Blue Cross/Blue Shield or a commercial carrier (21% for self-pay, 25% for Medicaid, and 48% for Medicare). Conclusions:These findings indicate that after adjustment for important clinical factors, nonclinical factors had a significant impact on length of stay among a large group of uncomplicated patients. Interventions aimed at reducing logistic difficulties in the performance of noninvasive testing and decreasing the number of low-risk patients who are triaged to coronary care unit beds may decrease resource utilization. Received from the Divisions of Clinical Epidemiology and General Medicine and the Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School; and the Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts. Presented in part at the annual meeting of the American Federation for Clinical Research, April 28 – May 2, 1989, Washington, DC. Supported in part by grants from the National Center for Health Services Research (HS 05927), the Robert Wood Johnson Foundation, Princeton, NJ (678105), the John A. Hartford Foundation, New York, NY (83102-2H), and the Agency for Health Care Policy and Research (1-PO1-HS06431-02 and HS 06452-02). Dr. Lee is the recipient of an Established Investigator Award (900119) from the American Heart Association. Dr. Udvarhelyi is the recipient of a Medical Foundation Fellowship award.     

Controlled trial of multidisciplinary care teams for acutely ill medical inpatients: enhanced multidisciplinary care

Background: Acute hospital general medicine services care for ageing complex patients, using the skills of a range of health‐care providers. Evidence suggests that comprehensive early assessment and discharge planning may improve efficiency and outcomes of care in older medical patients. Aim: To enhance assessment, communication, care and discharge planning by restructuring consistent, patient‐centred multidisciplinary teams in a general medicine service. Methods: Prospective controlled trial enrolling 1538 consecutive medical inpatients. Intervention units with additional allied health staff formed consistent multidisciplinary teams aligned with inpatient admitting units rather than wards; implemented improved communication processes for early information collection and sharing between disciplines; and specified shared explicit discharge goals. Control units continued traditional, referral‐based multidisciplinary models with existing staffing levels. Results: Access to allied health services was significantly enhanced. There was a trend to reduced index length of stay in the intervention units (7.3 days vs 7.8 days in control units, P = 0.18), with no change in 6‐month readmissions. In‐hospital mortality was reduced from 6.4 to 3.9% (P = 0.03); less patients experienced functional decline in hospital (P = 0.04) and patients’ ratings of health status improved (P = 0.02). Additional staffing costs were balanced by potential bed‐day savings. Conclusion: This model of enhanced multidisciplinary inpatient care has provided sustainable efficiency gains for the hospital and improved patient outcomes.     

Factors associated with a protracted hospital stay after hip fracture surgery in Japan

Aim: Hip fracture is a major injury in the elderly and has a high impact on quality of life and use of health‐care resources. In this study, we aimed to identify the factors related to prolonged hospital stay and poor outcome after hip fracture surgery. Methods: We evaluated data from 8920 cases at 398 acute‐care hospitals in Japan. Multivariate logistic regression analysis was used to determine the factors associated with the length of postoperative hospital stay. Results: A shorter postoperative hospital stay was associated with admission to a high surgical volume hospital (P < 0.001). On the other hand, a longer postoperative hospital stay was associated with infective complications, admission to a private hospital, an interval of more than 3 days between admission and surgery (P < 0.001 for all), and an interval of more than 1 day between surgery and start of rehabilitation (P = 0.01). Further analysis revealed that infective complications were more likely in older patients (P = 0.003) and patients with comorbidities (P = 0.03). Conclusion: The results imply that hospital stay, and, therefore, use of medical resources, can be decreased by performing surgeries shortly after patients are admitted, preventing postoperative infections, and starting rehabilitation on the next day of the surgery. One of the limitations of our study was that data of the length of hospital stay at transferred hospitals were not available. Therefore, further prospective studies will be needed to address significance of early surgery and rehabilitation. Geriatr Gerontol Int 2011; 11: 474–481.     

Determinants of postoperative stay in patients with colorectal cancer

The easiest way to reduce the cost of hospital care for patients is to reduce the length of hospital stay. Multivariate analysis was used to identify potentially alterable factors affecting postoperative length of stay for 320 consecutive colorectal cancer patients undergoing elective surgery during a three-year period. Prolonged postoperative stays were noted for patients over age 69. Significantly longer stays were seen for men than for women (13.9vs. 11.9 days,P=.012). Operative procedure significantly influenced postoperative stay: left hemicolectomies, anterior resections with colostomy, abdominoperineal resections, and subtotal coloectomies were associated with significantly longer stays than right, transverse, sigmoid, and anterior resections without colostomy (P<.001). Complications increased the mean postoperative stay from 11.4 to 19.7 days (P<.001) and stay increased progressively with the number of blood transfusions received from 11.1 days for no blood to 21.6 days for more than four units (P<.001). Severity of disease, as reflected by Dukes' stage, tumor differentiation, and tumor size, was not related to postoperative stay. In the latter half of the study, postoperative stay declined, accompanied by a decline in the use of blood and a shift in the procedures performed for rectal carcinoma away from abdominoperineal resection toward anterior resection without colostomy. Diagnosis-related group (DRG) relative weights for procedure, age, and complications are at variance with these findings. Supported in part by NCI-NIH Grant 1 R01-CA-35558-01 and The Frieda and George Zinberg Foundation.     

Factors predicting a hospital stay of over 3 days in patients with acute exacerbation of chronic obstructive pulmonary disease

Abstract. de la Iglesia F, Valiño P, Pita S, Ramos V, Pellicer C, Nicolás R, Diz‐Lois F (Juan Canalejo Hospital, A Coruña, Spain). Factors predicting a hospital stay of over 3 days in patients with acute exacerbation of chronic obstructive pulmonary disease. J Intern Med 2002; 251: 500–507. Objective. To investigate the factors predicting a hospital stay of over 3 days in patients who required hospitalization for acute exacerbation of chronic obstructive pulmonary disease (COPD). Design and setting. A cross‐sectional tudy was done at a tertiary hospital serving an area of 500 000 inhabitants. Subjects. A total of 273 patients (α=0.05; accuracy=5.94%) who had been admitted consecutively to the Short Stay Medical Unit at the Juan Canalejo Hospital in A Coruña, from February 1998 to March 1999, with a diagnosis focusing on exacerbation of COPD. Methods. Demographic variables, past medical history, symptoms, arterial blood gases, functional tests, treatment and the cause of exacerbation were studied in each patient. The hospital stay was dichotomized into ≤3 vs. >3 days. The prognostic factors of a hospital stay were determined by log regression. Results. The mean stay was 4.6 ± 5.1 days (range: 1–64). After monitoring the associated covariables, the following were found to have an independent effect on the prediction of a hospital stay of over 3 days: weekend admissions (OR=4.17; 95% CI: 2.42–7.18), the presence of cor pulmonale (OR=2.19; 95% CI: 1.27–3.78), and the respiratory rate on admission (OR=1.09; 95% CI: 1.03–1.14). Arterial blood gases and functional tests showed no independent effect. Conclusions. The factors having an independent prognostic value in determining the length of hospital stays in patients with COPD are weekend admission, cor pulmonale and respiratory rate. Additional studies are required to validate these findings.     

Use of Multidisciplinary Rounds to Simultaneously Improve Quality Outcomes,Enhance Resident Education,and Shorten Length of Stay

BACKGROUND Hospital-based clinicians and educators face a difficult challenge trying to simultaneously improve measurable quality, educate residents in line with ACGME core competencies, while also attending to fiscal concerns such as hospital length of stay (LOS). OBJECTIVE The purpose of this study was to determine the effect of multidisciplinary rounds (MDR) on quality core measure performance, resident education, and hospital length of stay. DESIGN Pre and post observational study assessing the impact of MDR during its first year of implementation. SETTING The Norwalk Hospital is a 328-bed, university-affiliated community teaching hospital in an urban setting with a total of 44 Internal Medicine residents. METHODS Joint Commission on Accreditation of Healthcare Organizations (JCAHO) core measure performance was obtained on a monthly basis for selected heart failure (CHF), pneumonia, and acute myocardial infarction (AMI) measures addressed on the general medical service. Resident knowledge and attitudes about MDR were determined by an anonymous questionnaire. LOS and monthly core measure performance rates were adjusted for patient characteristics and secular trends using linear spline logistic regression modeling. RESULTS Institution of MDR was associated with a significant improvement in quality core measure performance in targeted areas of CHF from 65% to 76% (p < .001), AMI from 89% to 96% (p = .004), pneumonia from 27% to 70% (p < .001), and all combined from 59% to 78% (p < .001). Adjusted overall monthly performance rates also improved during MDR (odds ratio [OR] 1.09, CI 1.06–1.12, p < .001). Residents reported substantial improvements in core measure knowledge, systems-based care, and communication after institution of MDR (p < .001). Residents also agreed that MDR improved efficiency, delivery of evidence-based care, and relationships with involved disciplines. Adjusted average LOS decreased 0.5 (95% CI 0.1–0.8) days for patients with a target core measure diagnosis of either CHF, pneumonia, or AMI (p < .01 ) and by 0.6 (95% CI 0.5–0.7) days for all medicine DRGs (p < .001). CONCLUSIONS Resident-centered MDR is an effective process using no additional resources that simultaneously improves quality of care while enhancing resident education and is associated with shortened length of stay. This study was presented in part in workshop and oral format at the 27th Society of General Internal Medicine Annual Meeting, May 12–15, 2004, Chicago, IL     

Prospective,Randomized, Controlled Trial Between a Pathway of Controlled Rehabilitation With Early Ambulation and Diet and Traditional Postoperative Care After Laparotomy and Intestinal Resection

INTRODUCTION: In an era of dwindling hospital resources and increasing medical costs, safe reduction in postoperative stay has become a major focus to optimize utilization of healthcare resources. Although several protocols have been reported to reduce postoperative stay, no Level I evidence exists for their use in routine clinical practice. METHODS: Sixty-four patients undergoing laparotomy and intestinal or rectal resection were randomly assigned to a pathway of controlled rehabilitation with early ambulation and diet or to traditional postoperative care. Time to discharge from hospital, complication and readmission rates, pain level, quality of life, and patient satisfaction scores were determined at the time of discharge and at 10 and 30 days after surgery. Subgroups were defined to evaluate those who derived the optimal benefit from the protocol. RESULTS: Pathway patients spent less total time in the hospital after surgery (5.4 vs. 7.1 days; P = 0.02) and less time in the hospital during the primary admission than traditional patients. Patients younger than 70 years old had greater benefits than the overall study group (5 vs. 7.1 days; P = 0.01). Patients treated by surgeons with the most experience with the pathway spent significantly less time in the hospital than did those whose surgeons were less experienced with the pathway (P = 0.01). There was no difference between pathway and traditional patients for readmission or complication rates, pain score, quality of life after surgery, or overall satisfaction with the hospital stay. CONCLUSIONS: Patients scheduled for a laparotomy and major intestinal or rectal resection are suitable for management by a pathway of controlled rehabilitation with early ambulation and diet. Pathway patients have a shorter hospital stay, with no adverse effect on patient satisfaction, pain scores, or complication rates. Patients younger than 70 years of age derive the optimal benefit, and increased surgeon experience improves outcome.     

南阳地区某医院急性ST段抬高型心肌梗死住院时长研究

目的探索影响南阳地区急性ST段抬高型心肌梗死(STEMI)住院时长的因素。方法应用南阳市中心医院心血管内科参加的中国冠心病医疗结果评价和临床转化研究(简称China PEACE)回顾性急性心肌梗死(AMI)注册登记研究的数据,从中随机抽取2001年、2006年、2011年及2016年四个年份STEMI的病例共计462例。按照患者住院时长进行排序,分为高住院时长组147例(n=147),中住院时长组166例(n=166)及低住院时长组149例(n=149)。分析住院时长的影响因素。结果与低住院时长组相比,高住院时长组中女性、心率>100次/min、收缩压<100 mmHg(1 mmHg=0.133kPa)的比例高,差异有统计学意义(P<0.05)。与低住院时长组相比,中、高住院时长组中合并糖尿病的比例高,差异有统计学意义(P<0.05)。与低住院时长组相比,中、高住院时长组中择期经皮冠状动脉介入治疗(PCI)的比例高,差异有统计学意义(P<0.05)。与低住院时长组相比,中住院时长组中β-受体阻滞剂的应用比例高,差异有统计学意义(P<0.05)。结论该院STEMI患者的住院时长受性别、糖尿病病史、血压、心率、择期PCI等多种因素的影响,进一步提高临床诊疗能力来减少影响因素,从而缩短住院时长是改善该院STEMI患者诊疗效率的关键。     

An internist joins the surgery service

Objective: To determine the effect of internist comanagement of cardiothoracic surgical patients on patient outcome and resource utilization. Design: Before/after comparison. Setting: Tertiary care university-affiliated Veterans Affairs hospital. Patients: 165 patients (86 before the intervention and 79 after the intervention) undergoing cardiothoracic surgery. Interventions: All patients were seen preoperatively and at least daily through discharge by a comanaging staff internist who was a full-time member of the surgical team. Main outcome measures: Length of stay, in-hospital mortality, and laboratory and radiology utilization. Results: Significant shortening of postoperative length of stay (18.1 days before and 12.1 days after, p=0.05) and total length of stay (27.2 days before and 19.7 days after, p=0.03) was noted. The inhospital mortality rate for the patients undergoing surgery was 8.1% before the intervention versus 2.5% afterward (p=0.17). There were significant reductions in the total number of x-rays (p=0.02) and nearly significant reductions in total laboratory test utilization (p=0.06). Referring physicians and surgeons both believed that the contribution of the internist was important. Conclusions: The addition of an internist to the cardiothoracic surgery service at a tertiary care teaching center was associated with decreased resource utilization and possible improved outcomes. Before becoming more widely adopted, this intervention deserves further exploration at other sites using stronger study designs.     

Complications of care in a medical intensive care unit

Objective:To determine the frequency and nature of complications of care in the medical intensive care unit (MICU). Design:Prospective, observational study. Setting:Seven-bed MICU in a teaching and referral VA hospital. Patients:295 consecutive patients admitted to the MICU during a ten-month study period. Interventions:None. Measurements and main results:Forty-two patients (14%, 95% confidence interval 13%, 16%) experienced one or more complications during their MICU stays. Compared with other MICU patients, those experiencing complications tended to be older (mean age ± SD: 63.6±10.1 years vs 59.3±14.0 years, p<0.02) and more acutely ill (mean Acute Physiology Score ± SD: 18.3±8.0 vs 12.5±8.0, p=0.0001). These patients also had significantly longer MICU lengths of stay (mean ± SD: 12.3±14.7 days vs 3.1±4 days, p<0.0001) and higher hospital mortality rates (67% vs 27%, p<0.001). The 67% mortality rate among patients with complications significantly exceeded the expected mortality rate of 46% (calculated from the APACHE risk equation). Conclusion:Complications of care in the MICU are not rare and may independently contribute to in-hospital mortality. The potential for complications must be recognized when considering ICU care.     

Outcomes of patients with alcohol use disorders experiencing healthcare-associated infections

Background: Healthcare‐associated infections (HAI) affect 1.7 million patients annually in the United States, and patients with alcohol use disorders (AUD) are at increased risk of developing HAI. HAI have been shown to substantially increase the hospital length of stay, mortality, and cost. In a cohort of patients with HAI, we sought to determine mortality, cost, and hospital length of stay attributable to AUD. Methods: Using the Nationwide Inpatient Sample for the year 2007, the largest all‐payer database of hospitalized patients comprising approximately 1,000 hospitals, we performed a retrospective cohort study of all patients who developed healthcare‐associated pneumonia or sepsis. We excluded patients who were transferred from another healthcare facility, who were diagnosed with community‐acquired infections, immunosuppression, or cancer. Logistic regression was computed to calculate attributable mortality. Linear regression analyses were computed to determine cost and hospital length of stay α = 10^?10. Results: A total of 149,892 patients developed HAI, and 8,830 (5.9%) had a codiagnosis of AUD. Patients with AUD were younger, more likely to be men, less likely to be Asian, and more likely to be Hispanic. Patients with AUD were more likely to have tobacco dependence, less likely to be electively admitted to the hospital, and less likely to undergo surgery. They also had lower severity of illness, lower income, and were more likely to be in academic medical centers. Logistic regression revealed that AUD was an independent predictor of increased mortality: Odds ratio = 1.71, 95% confidence interval (CI) [1.626; 1.799], p < 10^?10. Linear regression demonstrated that AUD independently predicted increased hospital length of stay by 2 days: Patients with AUD had a length of stay of 13 days, 95% CI [12.4; 13.6] compared with 11 days, 95% CI [11.1; 11.4] for patients without AUD, p < 10^?10. Linear regression also revealed that patients with AUD had a higher hospital cost: $34,826, 95% CI [32,415.71; 37,416.52] for patients with AUD compared with $27,167, 95% CI [25,703.18; 28,714.05] for patients without AUD, p < 10^?10. Conclusions: Patients with AUD who experience HAI have worse outcomes compared with patients without AUD. Patients with AUD have higher mortality, longer hospital length of stay, and higher costs. Studies aimed at decreasing the morbidity and mortality of HAI in patients with AUD are warranted.     

Efficacy of Low Molecular Weight Heparin in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease Receiving Ventilatory Support

Introduction: Severe and acute exacerbation of chronic obstructive pulmonary disease (COPD) is associated with a high mortality. Since COPD is an airway inflammatory disease, and heparin has shown anti-inflammatory effects in previous studies, we evaluated the clinical effect of low molecular weight heparin (LMWH; nadroparin) in COPD patients admitted into the hospital due to acute exacerbations. Methods: Sixty-six patients admitted to the intensive care unit (ICU) were randomly divided into control group (n = 33) and LMWH group (n = 33). The control group received conventional treatment, including oxygen therapy (non-invasive or conventional mechanical ventilation), anti-infection, atomization expectorant, spasmolysis, anti-asthmatics, and nutritional support. The LMWH group received the same treatment plus LMWH for 1 week. The levels of plasma C-reactive protein, interleukin-6, and fibrinogen were measured. The main outcomes were duration of mechanical ventilation, length of ICU stay, and hospital stay. Results: There were no significant differences between the groups with respect to demographics, severity of illness, and gas exchange variables. The levels of plasma C-reactive protein, interleukin-6, and fibrinogen were significantly decreased in the LMWH group. LMWH significantly reduced the mean duration of mechanical ventilation (6.6 days vs. 3.8 days; p < 0.01), the length of ICU stay (8.5 days vs. 5.6 days; p < 0.01) and hospital stay (14.3 days vs. 11.3 days; p < 0.01). Conclusions: The addition of LMWH to standard therapy benefits COPD patients with acute exacerbation.     

Acute heart failure care and beyond

Background: East Lancashire Hospitals NHS Trust reorganized its services in October 2007 with acute admissions sent to one site which allowed the development of a 24/7 Consultant delivered cardiology service.

Methods: A retrospective analysis of all patients admitted with an acute coronary syndrome between two periods: Group 1: October 2006 to September 2007 and Group 2: October 2007 and September 2008. We looked at the following end points—length of stay, in-hospital and 30 day all cause mortality.

Results: 633 patients in group 1 and 748 patients in group 2. There was significant reduction in length of stay from a median (IQ range) 7 (5–11) days to 5 (3–9) days; P < 0.0001. The in-hospital mortality reduced from 15.8% (n = 100) to 7.6% (n = 56); P < 0.0001. The mortality at 30 days reduced from 15.2% (n = 96) to 8.3% (n = 62); P < 0.0001. These reductions remained significant after adjustment for demographic and risk factor variables.

Conclusion: A 24/7 Consultant Cardiologist delivered cardiac care is associated with marked reductions in all cause mortality following admission with acute coronary syndromes. This improvement occurred with a significant reduction in hospital length of stay.     

Clinical Outcomes and Cost Analysis of a “Fast Track” Postoperative Care Pathway for Ileal Pouch-Anal Anastomosis. A Case Control Study

Purpose Traditional length of hospital stay after ileal pouch-anal anastomosis is 8 to 15 days. Fast track rehabilitation programs reduce stay, but there are concerns that readmission and complication rates may be increased. This study evaluated a fast track pathway after ileoanal pouch surgery. Methods One hundred three consecutive patients underwent ileal pouch-anal anastomosis on two colorectal services using a fast track protocol with early ambulation, diet, and defined discharge criteria. Direct hospital costs and 30-day and long-term complication data were collected. Patients were matched to controls managed with traditional care pathways by other colorectal staff. Results Matching was established for 97 patients. Fast track patients had shorter hospital stay than controls (median 4 vs. 5 days; mean 5.0 vs. 5.9, P = 0.012). Readmission and recurrent operation rates were similar (24 vs. 20 percent, P = 0.49, and 9 vs. 10 percent, P = 0.8, fast track vs. control, respectively). Median direct costs per patient (US$) within 30 days were lower with fast track (5692 vs. 6672, P = 0.001), primarily because of reductions in postoperative management expenses. Complication rates, including pouch failure, bowel obstruction, pouchitis, and anastomotic stricture were comparable. Early discharge (≤ 5 days from surgery) occurred in 79 (77 percent) fast track patients. Failure with early discharge was associated with male gender, reoperations, and anastomotic complications. Conclusions Fast track protocol after ileoanal pouch surgery reduces length of stay and hospital costs without increasing complication rates. Successful early discharge usually signals a benign postoperative course. Presented at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005.     

A Comprehensive Hip Fracture Program Reduces Complication Rates and Mortality

OBJECTIVES: To evaluate the rate of postoperative complications, length of stay, and 1‐year mortality before and after introduction of a comprehensive multidisciplinary fast‐track treatment and care program for hip fracture patients (the optimized program). DESIGN: Retrospective chart review with historical control. SETTING: Orthopedic ward (110 beds) at a university hospital (700 beds). PARTICIPANTS: Five hundred thirty‐five consecutive patients aged 40 and older (94%≥60) hospitalized for hip fracture between January 1, 2003, and March 31, 2004. Three hundred and thirty‐six patients (70.3%) were community dwellers before the fracture and 159 (29.7%) were admitted from nursing homes. INTERVENTION: The fast‐track treatment and care program included a switch from systemic opiates to a local femoral nerve catheter block; an earlier assessment by the anesthesiologist; and a more‐systematic approach to nutrition, fluid and oxygen therapy, and urinary retention. RESULTS: In the intervention group, the rate of any in‐hospital postoperative complication was reduced from 33% to 20% (odds ratio=0.61, 95% confidence interval=0.4–0.9; P=.002). Rates of confusion (P=.02), pneumonia (P=.03), and urinary tract infection (P<.001) were lower in the intervention group than in the control group, and length of stay was 15.8 days in the control group, versus 9.7 days in the intervention group (P<.001). For community dwellers, 12‐month mortality was 23% in the control group versus 12% in the intervention group (P=.02). Overall 12‐month mortality was 29% in the control group and 23% in the intervention group (P=.2). CONCLUSION: The optimized hip fracture program reduced the rate of in‐hospital postoperative complications and mortality. Randomized clinical trials are needed to confirm these results and elucidate the elements of the program that have the greatest effect on clinical outcomes and mortality.     

Diagnosis-Related Group Assignment in Laparoscopic and Open Colectomy: Financial Implications for Payer and Provider

PURPOSE In carefully matched patients, the length of hospital stay after laparoscopic colectomy is shorter than after open surgery. Higher operating room costs for laparoscopic surgery are offset by lower costs for hospitalization because of less utilization of pharmacy, laboratory, and nursing services. Clinical outcome is comparable. We examined the effect of the surgical approach for colectomy (open vs. laparoscopic) regarding the reasons for disease-related group assignment to disease-related group 148, and institutional cost under Part A of the U.S. Medicare system.METHODS Colectomy patients were assigned to either disease-related group 148 (colorectal resection with complications) or disease-related group 149 (colorectal resection without complications) with significant institutional reimbursement implications (disease-related group 149, $8,310; disease-related group 148, $20,291). A total of 100 consecutive disease-related group 148 patients undergoing laparoscopic colectomy from July 2000 to September 2002 were identified from a prospective database and case-matched with 100 patients undergoing open colectomy. Patients were matched for gender, age, operative procedure, and pathology. A certified coder determined the reason(s) for disease-related group 148 assignment, which were grouped into: preoperative comorbidity, a combination of preoperative comorbidity/postoperative complications, or postoperative complications alone.RESULTS Significantly more lapararoscopy patients were assigned to disease-related group 148 solely because of preoperative comorbidities (62 percent vs. 21 percent; P < 0.0001). Significantly more patients in the open surgery group were classified as disease-related group 148 solely because of postoperative complications (22 percent vs. 42 percent; P < 0.0001). An additional group of patients were assigned to the disease-related group 148 category based on a combination of preoperative and postoperative diagnoses (16 percent vs. 37 percent). The mean direct hospital costs were significantly less for laparoscopy patients ($3971 vs. $5997; P = 0.0095). Increased cost to Part A of Medicare for 20 open surgery patients who migrated to disease-related group 148 because of postoperative complications was $239,620.CONCLUSIONS Our data are the first to demonstrate that disease related group assignment can change solely because of a differential rate of postoperative complications for two competing operative techniques. This change occurred at twice the rate for open colectomy and resulted in significantly increased cost to the insurer under a prospective payment program. The savings to the institution coupled with the shortened length of stay offset the potential loss in revenue to the institution.Read at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.     

Is Laparoscopic Colectomy Applicable to Patients With Body Mass Index >30? A Case-Matched Comparative Study With Open Colectomy

PURPOSE The benefits of early postoperative recovery, reduced postoperative pain, pulmonary dysfunction, and hospitalization after laparoscopic colectomy may improve outcome over open colectomy in obese patients. This case-matched study compares outcomes after open and laparoscopic colectomy.METHODS A total of 94 laparoscopic colectomy patients with a body mass index >30 (Jan 1999–June 2003) were identified from a prospective database and matched to open colectomy cases for age, gender, body mass index, American Society of Anesthesiologists class, procedure, indication, and date of surgery. Operating time, length of stay, conversion, intraoperative and postoperative complications, reoperation, 30-day readmission rate, and costs were compared. Data are presented as means ± standard deviations, and appropriate statistical tests were used.RESULTS The two groups were matched for age (P = 0.06), gender (P = 1), American Society of Anesthesiologists class (P = 0.2), body mass index (P = 0.4), indication for surgery (P = 1), and procedure (P = 1). By using intention-to-treat–type analysis, there was no difference in median operating time (100 vs. 110 (mean, 123 vs. 112) minutes; P = 0.1), complications (21 vs. 24 percent; P = 0.74), readmission (17 vs. 10.6 percent; P = 0.3), reoperation rates (6.4 vs. 4.3 percent; P = 0.75), or direct costs (median, $3,368 vs. $3,552; mean, $4,003 vs. $4,037; P = 0.14) between laparoscopic colectomy or open colectomy; however, the median length of stay (3 vs. 5.5 (mean, 3.8 vs. 5.8) days; P = 0.0001) was significantly shorter after laparoscopic colectomy. Twenty-eight patients required conversion for adhesions (n = 11), bleeding (n = 3), obesity-hindering vision or dissection (n = 9), large phlegmon or tumor (n = 4), and ureteric injury (n = 1). The mean operating time for conversions was 142 minutes and length of stay was 6.4 days. Compared with laparoscopically completed cases, the median length of stay (5 vs. 2 (mean, 6.4 vs. 2.8) days; P = 0.0001) and median operating times (150 vs. 95 (mean, 142 vs. 115) minutes; P = 0.02) were significantly higher in the converted group, but there was no difference in the complication (P = 0.8), readmission (P = 1), or reoperation (P = 0.7) rates. Compared with open colectomy, the operating time (P = 0.02) was significantly higher in the converted group but there were no significant differences in the length of stay (P = 0.18), complication (P = 1), readmission (P = 0.35), or reoperative (P = 1) rates.CONCLUSIONS Laparoscopic colectomy can be performed safely in obese patients, with shorter postoperative recovery than that with open colectomy. Although obesity is associated with a high conversion rate, outcome in these converted cases is comparable to the matched open cases.Read at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.     

Comorbidity as a correlate of length of stay for hospitalized patients with acute chest pain

OBJECTIVE: To determine whether comorbid medical conditions as measured with the Charlson Comorbidity Index are independent correlates of length of stay after adjusting for other clinical and socioeconomic data. DESIGN: Prospective cohort study. SETTING: Urban teaching hospital. PATIENTS: All 1,261 patient aged 30 years or more who were admitted to this hospital after coming to the emergency department with acute chest pain between October 1990 and May 1992. MEASUREMENTS AND OUTCOMES: Clinical data including comorbid medical conditions used in the Charlson index were prospectively recorded by the evaluating physician at the time of admission or by a research nurse who was blinded to the subsequent events. History of myocardial infarction was excluded from the calculation of the Charlson index score. Charlson index scores were 0 to 1 for 921 patients (73%), 2 to 3 for 263 (21%), and greater than 3 for 77 (6%). Unadjusted mean (±SD) lengths of stay in these groups were 4.4±5.2, 5.2±5.9, and 7.5±9.3 days, respectively. In multiple linear regression analysis, compared with Charlson index scores of 0 to 1, scores of 2 to 3 and greater than 3 were significant (p<.01) independent correlates of the log transformation of length of stay after adjusting for clinical data from the initial presentation and subsequent course (modelR ²=.510). In an analysis restricted to the 795 patients without clinical complications, a Charlson index score greater than 3 was an independent correlate of length of stay compared with scores of 0 to 1 (p<.01). Individual comorbid conditions were not significant correlates of length of stay after controlling for Charlson index score. CONCLUSIONS: In this population of patients with acute chest pain, comorbidity as measured with the Charlson index was independently associated with length of stay after adjustment for other clinical data. After adjusting for the Charlson index, no separate comorbid condition was significantly correlated with length of stay. These findings suggest that the Charlson index can be used to adjust for comorbidities in analyses of length of stay for patients with this condition. From the Section for Clinical Epidemiology, the Division of General Medicine, the Cardiovascular Division, the Department Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Mass., and Iizuka Hospital, Iizuka, Japan. Supported by a grant from the Agency for Health Care Policy and Research (RO1 HS06452), Rockville, MD, and the Aso-Nesson Research Fund. Dr. Lee is an Established Investigator (9001119) of the American Heart Association.