Comparative cost-effectiveness of two interventions to promote work functioning by targeting mental health complaints among nurses: Pragmatic cluster randomised trial

Background

The specific job demands of working in a hospital may place nurses at elevated risk for developing distress, anxiety and depression. Screening followed by referral to early interventions may reduce the incidence of these health problems and promote work functioning.

Objective

To evaluate the comparative cost-effectiveness of two strategies to promote work functioning among nurses by reducing symptoms of mental health complaints. Three conditions were compared: the control condition consisted of online screening for mental health problems without feedback about the screening results. The occupational physician condition consisted of screening, feedback and referral to the occupational physician for screen-positive nurses. The third condition included screening, feedback, and referral to e-mental health.

Design

The study was designed as an economic evaluation alongside a pragmatic cluster randomised controlled trial with randomisation at hospital-ward level.

Setting and participants

The study included 617 nurses in one academic medical centre in the Netherlands.

Methods

Treatment response was defined as an improvement on the Nurses Work Functioning Questionnaire of at least 40% between baseline and follow-up. Total per-participant costs encompassed intervention costs, direct medical and non-medical costs, and indirect costs stemming from lost productivity due to absenteeism and presenteeism. All costs were indexed for the year 2011.

Results

At 6 months follow-up, significant improvement in work functioning occurred in 20%, 24% and 16% of the participating nurses in the control condition, the occupational physician condition and the e-mental health condition, respectively. In these conditions the total average annualised costs were €1752, €1266 and €1375 per nurse. The median incremental cost-effectiveness ratio for the occupational physician condition versus the control condition was dominant, suggesting cost savings of €5049 per treatment responder. The incremental cost-effectiveness ratio for the e-mental health condition versus the control condition was estimated at €4054 (added costs) per treatment responder. Sensitivity analyses attested to the robustness of these findings.

Conclusions

The occupational physician condition resulted in greater treatment responses for less costs relative to the control condition and can therefore be recommended. The e-mental health condition produced less treatment response than the control condition and cannot be recommended as an intervention to improve work functioning among nurses.     

The frequency and cost of redundant laboratory testing for transferred ED patients

Introduction

Health care costs continue to rise; reducing unnecessary laboratory testing may reduce costs. The goal of this study was to calculate the frequency and estimated costs of repeat normal laboratory testing of patients transferred to a tertiary care emergency department (ED).

Methods

This was a retrospective cohort study of patients transferred to a tertiary care, level -one trauma ED with an annual census of 90,000 patients. We defined “repeat normal testing” as laboratory tests repeated within 8 hours that were normal at both the sending hospital and the receiving tertiary care hospital. We estimated the charges associated with repeat normal laboratory testing for 11 common ED tests: basic metabolic panel, calcium, magnesium, phosphorus, lipase, thyroids stimulating hormone, prothrombin time, partial thromboplastin time, complete blood count, liver function test, and urine analysis.

Results

Two hundred thirty-two patients were transferred to the receiving tertiary care hospital from within the hospital’s network from May 1, 2011, to October 31, 2011. On average, each transferred patient had one repeat normal laboratory test (245/232 = 1.06). For all laboratory tests, repeat normal testing occurred at least 40% of the time. Extrapolating the data, the total yearly estimated charges of all repeat normal testing was $580,526.

Conclusion

This study provides the first analysis of the frequency of repeated laboratory testing for all transferred ED patients and indicates that repeat normal testing represents a significant cost. Future research needs to determine if such repeat testing is indeed clinically appropriate or redundant.     

Cost-Effectiveness of Supported Employment for Veterans With Spinal Cord Injuries

Objective

To estimate the cost-effectiveness of a supported employment (SE) intervention that had been previously found effective in veterans with spinal cord injuries (SCIs).

Design

Cost-effectiveness analysis, using cost and quality-of-life data gathered in a trial of SE for veterans with SCI.

Setting

SCI centers in the Veterans Health Administration.

Participants

Subjects (N=157) who completed a study of SE in 6 SCI centers. Subjects were randomly assigned to the intervention of SE (n=81) or treatment as usual (n=76).

Intervention

A vocational rehabilitation program of SE for veterans with SCI.

Main Outcome Measures

Costs and quality-adjusted life years, which were estimated from the Veterans Rand 36-Item Health Survey, extrapolated to Veterans Rand 6 Dimension utilities.

Results

Average cost for the SE intervention was $1821. In 1 year of follow-up, estimated total costs, including health care utilization and travel expenses, and average quality-adjusted life years were not significantly different between groups, suggesting the Spinal Cord Injury Vocational Integration Program intervention was not cost-effective compared with usual care.

Conclusions

An intensive program of SE for veterans with SCI, which is more effective in achieving competitive employment, is not cost-effective after 1 year of follow-up. Longer follow-up and a larger study sample will be necessary to determine whether SE yields benefits and is cost-effective in the long run for a population with SCI.     

Determinants and costs of community nursing in patients with type 2 diabetes from a community-based observational study: The Fremantle Diabetes Study

Background

Despite widespread use, there is little information on the extent and impact of community nursing to patients with type 2 diabetes.

Objective

To determine the incidence, predictors and costs of community nursing provision to patients with type 2 diabetes in a large community-based representative study of diabetes in an urban Australian setting.

Design

Prospective observational study utilising data linkage.

Setting

Postcode defined region in Fremantle, Australia.

Participants

All patients with type 2 diabetes enrolled in the Fremantle Diabetes Study between 1993 and 1996.

Methods

Eligible patients were followed from July 1997, when home nursing data first became available, to death or census in November 2007. Home nursing data from the major community nursing service provider were linked with data from the Fremantle Diabetes Study. Cox and zero-inflated negative binomial (ZINB) regression modelling was used to identify predictors of incident home visits and visit frequency, respectively. Direct costs were estimated from the service provider's unit costs.

Results

During a mean ± SD 8.6 ± 2.9 years of follow-up, 27.8% of 825 patients (aged 65.2 ± 10.3 years at study entry; 51.2% male) received 21,878 home nursing visits (median frequency 31 [interquartile range 9–85] visits, range 1–1446 visits). In Cox and ZINB models, predictors of home nursing included older age, physical disability measures and macrovascular and microvascular complications. Insulin use was an important predictor of the frequency of visits whilst ethnic and economic factors predicted lower frequency. The estimated cost of home nursing, extrapolated nationally, adds 5% to the total Australian direct health care costs of diabetes.

Conclusions

Home nursing is frequently utilized in the management of type 2 diabetes with considerable individual variation in the use of this service. Given the associated costs, further research into how home nursing can best be employed is indicated.     

Cost savings with interventions to reduce aerosolized bronchodilator use in mechanically ventilated patients

Purpose

The purpose of this evaluation is to describe the cost savings associated with multimodal interventions aimed at reducing aerosolized bronchodilator use in mechanically ventilated patients without adversely affecting costs associated with length of stay (LOS).

Materials and methods

Subjects were included in the analysis if they were aged more than 18 years, on mechanical ventilation in the intensive care unit, and received aerosolized bronchodilators. Patients were excluded if they had reversible airway disease, an indication needing bronchodilator therapy. Patient data were obtained using the University Health System Consortium Clinical Data Base/Resource Manager (Chicago, IL) to compare outcomes during two 6-month periods separated by a 4-month intervention phase aimed to reduce bronchodilator use.

Results

There were no significant differences in age, sex, and LOS (observed and expected) between the preintervention and postintervention phases. Based on whole acquisition costs, the total cost of bronchodilators dispensed to the adult intensive care units over the 6-month postintervention phase was reduced by $56 960 compared with the 6-month preintervention phase ($120 562 vs $63 602, respectively).

Conclusions

Multimodal efforts to restrict aerosolized bronchodilator therapy in mechanically ventilated patients were successful and led to sustained reductions in use that was associated with substantial reductions in cost, without affecting LOS.     

Cost effectiveness of a benzodiazepine vs a nonbenzodiazepine-based sedation regimen for mechanically ventilated,critically ill adults

Purpose

Nonbenzodiazepine sedation (eg, dexmedetomidine or propofol) may be more cost effective than benzodiazepine (BZ) sedation despite its higher acquisition cost.

Materials and methods

A cost effectiveness (CE) analysis of noncardiac surgery, critically ill adults requiring at least 1 day of mechanical ventilation (MV) and administered either BZ or non-BZ sedation, that cycled health states and costs daily using a Markov model accounting for daily MV use until intensive care unit (ICU) discharge, was conducted from a third-party perspective. Transition probabilities were obtained from a published meta-analysis, and costs were estimated from best evidence. Sensitivity analyses were run for all extubation and discharge probabilities, for different cost estimates and for the specific non-BZ administered.

Results

When non-BZ rather than BZ sedation was used, the incremental cost-effectiveness ratio to avert 1 ICU day while MV or while either MV or non-MV was $3406 and $3136, respectively. The base-case analysis revealed that non-BZ sedation (vs BZ sedation) resulted in higher drug costs ($1327 vs $65) but lower total ICU costs (percent accounted for MV need): $35 380 (71.0%) vs $45 394 (70.6%). Sensitivity analysis revealed that BZ sedation would only be less costly if the daily rate of extubation was at least 16%, and the daily rate of ICU discharge without MV was at least 77%. The incremental CE ratio to avert 1 ICU day while MV or non-MV was similar between the dexmedetomidine and propofol non-BZ options.

Conclusions

Among MV adults, non-BZ sedation has a more favorable CE ratio than BZ sedation over most cost estimates.     

Emergency physician knowledge of reimbursement rates associated with emergency medical care

Study Objective

We investigated emergency physician knowledge of the Centers for Medicare & Medicaid Services (CMS) reimbursement for common tests ordered and procedures performed in the emergency department (ED), determined the relative accuracy of their estimation, and reported the impact of perceived costs on physicians' ordering and prescribing behavior.

Methods

We distributed an online survey to 189 emergency physicians in 11 EDs across multiple institutions. The survey asked respondents to estimate reimbursement rates for a limited set of medical tests and procedures, rate their level of current cost knowledge, and determine the effect of health expenditures on their medical decision making. We calculated relative accuracy of cost knowledge as a percent difference of participant estimation of cost from the CMS reimbursement rate.

Results

Ninety-seven physicians participated in the study. Most respondents (65%) perceived their knowledge of costs as inadequate, and 39.3% indicated that beliefs about cost impacted their ordering behavior. Eighty percent of physicians surveyed were unable to estimate 25% of the costs within ± 25%, and no physicians estimated at least 50% of costs within 25% of the CMS reimbursement and only 17.3% of medical services were estimated correctly within ± 25% by 1 or more physicians.

Conclusion

Most emergency physicians indicated they should consider cost in their decision making but have a limited knowledge of cost estimates used by CMS to calculate reimbursement rates. Interventions that are easily accessible and applicable in the ED setting are needed to educate physicians about costs, reimbursement, and charges associated with the care they deliver.     

A Cost-Effectiveness Analysis of Parecoxib in the Management of Postoperative Pain in the Greek Health Care Setting

Background

Postoperative pain management represents a significant factor of morbidity and reduced quality of life for patients, as well as a situation that substantially increases perioperative costs. Available analgesia treatments improve patient outcomes and reduce resource use associated with pain management, although with varying costs and adverse effects.

Objectives

The aim of this analysis was to assess the costs and patient outcomes of parecoxib used in combination with opioids versus use of opioids alone (monotherapy) in the postoperative treatment of surgical patients in Greece.

Methods

A model comparing parecoxib plus opioid treatment versus opioids alone was developed that simulated the first 3 days postsurgery. Clinical efficacy was based on a Phase III, randomized, double-blind, clinical trial that also provided the frequencies of the occurrence of clinically meaningful events (CMEs) related to opioid use for both treatment arms. Resource use associated with each CME was elicited via strictly structured questionnaire-based interviews conducted by a panel of experts (surgeons and anesthesiologists), and costs were determined from the perspective of Social Insurance in Greece (2012 euros). Treatment effectiveness was calculated in summed pain intensity scores. A series of 1-way sensitivity analyses were conducted to check the robustness of the outcomes.

Results

Patients treated with parecoxib plus opioids had lower summed pain intensity scores (59.20 vs 80.80) and fewer CMEs (0.62 vs 1.04 per patient) compared with opioids alone for a 3-day period. This outcome led to a full offset of the excess cost of the addition of parecoxib and led to potential savings of €858 per patient compared with opioid use alone. Savings were mainly attributable to decreased CMEs due to reduced intensive care unit and general ward bed-days as well as to reduced physician and nurse time. Results were sensitive with regard to probabilities of occurrence or co-occurrence of CMEs (≥2 CMEs occurring simultaneously), although only to a small extent. Medication costs had a minimal impact on the results of the sensitivity analysis.

Conclusions

Parecoxib may be a useful addition to opioid treatment by improving postoperative analgesic management, reducing opioid-related adverse events, and lowering per-patient treatment costs.     

Analysis of Inpatient Use of Fresh Frozen Plasma and Other Therapies and Associated Outcomes in Patients with Major Bleeds from Vitamin K Antagonism

Objective

We conducted an observational study of outcomes and costs associated with fresh frozen plasma (FFP) use in patients receiving warfarin with intracerebral, gastrointestinal, or musculoskeletal bleeding.

Methods

Patients who had at least 1 International Classification of Diseases, Ninth Revision code indicative of anticoagulation history, received ≥1 unit FFP, and had patient costs >$0 were identified from a database of >600 US hospitals. The main outcome was transfusion of additional blood products (eg, cryoprecipitate, red blood cells, or platelets) or vitamin K. Further outcomes included administration of other bleeding-related therapies (eg, recombinant activated factor VII, albumin, or crystalloids), incidence of fluid overload, days in the intensive care unit, discharge status, and total hospital costs.

Results

The most frequently administered products were vitamin K and red blood cells, given to 55.6% to 61.0% and 19.2% to 29.3% of patients, respectively. The number of FFP units transfused correlated highly with fluid overload (r > 0.91) and was associated with inpatient mortality, nonhome discharge, and intensive care unit admittance. For both inpatient mortality and nonhome discharge, the odds ratio was significant when ≥4 units FFP were transfused (P < 0.05). A dose of >2 units FFP was associated with an increased probability of an intensive care unit stay (P < 0.05). Total costs were greater among patients receiving >2 units FFP compared with patients who received 1 unit FFP (P < 0.001), with a substantial increase in costs incurred when ≥4 units FFP were transfused.

Conclusions

In patients with warfarin-related bleeding, inpatient mortality, nonhome discharge, intensive care unit admission, and hospital costs were associated with the number of units of FFP transfused.     

Cost-Effectiveness of Everolimus for Second-Line Treatment of Metastatic Renal Cell Carcinoma in Serbia

Background

New targeted therapeutics for metastatic renal cell carcinoma (mRCC) enable an increment in progression-free survival (PFS) ranging from 2 to 6 months. Compared with best supportive care, everolimus demonstrated an additional PFS of 3 months in patients with mRCC whose disease had progressed on sunitinib and/or sorafenib. The only targeted therapy for mRCC currently reimbursed in Serbia is sunitinib.

Objective

The aim of this study was to estimate the cost-effectiveness and the budget impact of the introduction of everolimus in Serbia in comparison to best supportive care, for mRCC patients refractory to sunitinib.

Methods

A Markov model was designed corresponding with Serbian treatment protocols. A health care payer perspective was taken, including direct costs only. Treated and untreated cohorts were followed up over 18 cycles, each cycle lasting 8 weeks, which covered the lifetime horizon of mRCC patients refractory to the first-line treatment. Annual discounted rates of 1.5% for effectiveness and 3% for costs were applied. Transitions between health states were modeled by time-dependent probabilities extracted from published Kaplan-Meier curves of PFS and overall survival (OS). Utility values were obtained from the appraisals of other mRCC treatments. One-way and probabilistic sensitivity analyses were done to test the robustness and uncertainty of the base–case estimate. Lastly, the potential impacts of everolimus on the overall health care expenditures on annual and 4-year bases were estimated in the budget-impact analysis.

Results

The incremental cost-effectiveness ratio for everolimus was estimated at €86,978 per quality-adjusted life-year. Sensitivity analysis identified the hazard multiplier, a statistical approximator of OS gain, as the main driver of everolimus cost-effectiveness. Furthermore, probabilistic sensitivity analyses revealed a wide 95% CI around the base–case incremental cost-effectiveness ratio estimate (€32,594–€425,258 per quality-adjusted life-year). Finally, an average annual budgetary impact of everolimus in first 4 years after its potential reimbursement would be around €270,000, contributing to <1% of the total budget in Serbian oncology.

Conclusions

Everolimus as a second-line treatment of mRCC is not likely to be a cost-effective option under the present conditions in Serbia, with a relatively limited impact on its budget in oncology. A major constraint on the estimation of the cost-effectiveness of everolimus relates to the uncertainty around the everolimus effect on extending OS. However, prior to a final decision on the acceptance/rejection of everolimus, reassessment of the whole therapeutic group might be needed to construct an economically rational treatment strategy within the mRCC field.     

Attributable costs of patients with candidemia and potential implications of polymerase chain reaction–based pathogen detection on antifungal therapy in patients with sepsis

Purpose

The purposes of this study were to calculate attributable costs of candidemia in patients with severe sepsis and to obtain preliminary data regarding the potential effects of polymerase chain reaction–based pathogen detection on antifungal therapy for these patients.

Methods

Patients treated between 2004 and 2010 because of severe sepsis were included into this retrospective analysis. The hospital management provided annual fixed costs per patient-day; data for variable intensive care unit costs were taken from the literature. Multiplex polymerase chain reaction (PCR) was used (VYOO®, SIRS-Lab, Jena, Germany) for pathogen detection in the blood.

Results

Thirty-two patients with candidemia were identified. Of 874 patients with sepsis, propensity score matching found 32 corresponding patients with sepsis but without candida infection but similar risk factors for developing candidemia. Attributable costs of candidemia were 7713.79 Euro (cost increase, 19.4%). Initiation of antifungal therapy was reduced from 67.5 (52.4, 90) hours in the group, where candida infection was determined by blood culture, to 31.0 (28.0, 37.5; P < .01) hours after detection by multiplex PCR.

Conclusions

Candidemia increases costs of care in patients with septic shock. Polymerase chain reaction–based pathogen detection significantly reduces the time to initiation of antifungal therapy. This might impact on the clinical course of the disease but need to be confirmed in further trials.     

Survival and health care costs until hospital discharge of patients treated with onsite, dispatched or without automated external defibrillator

Background

This study aimed to determine whether automated external defibrillator (AED) use during resuscitation is associated with lower in-hospital health care costs.

Methods

For this observational prospective study, we included all treated out-of-hospital cardiac arrests of suspected cardiac cause. Clinical, survival and cost data were collected from July 2005 until March 2008. Cost data were based on hospital transport, duration of admission in hospital wards, diagnostics and interventions. We divided the study population in three groups based on AED use: (1) onsite AED, (2) dispatched AED, (3) no AED. The endpoint was survival to discharge. P < 0.05 is indicated by *.

Results

Of the 2126 included patients, 136 were treated with an onsite AED, 365 with a dispatched AED and 1625 without AED. Overall (95% confidence interval [CI]) survival rate was 43% (35-51%), 16% (13-20%) and 14% (12-16%), respectively*. Per 100 survivors, the mean duration admitted at intensive care unit [ICU] were 267 (166-374), 495 (344-658), and 537 (450-609) days, respectively*; total duration of hospital admission was 2188 (1800-2594), 3132 (2573-3797), and 2765 (2519-3050) days, respectively*. Mean costs per survivor for hospital stay were €9233 (€7351-€11,280), €14,194 (€11,656-€17,254), and €13,693 (€12,226-€15,166), respectively*; total health care costs were €29,575 (€24,695-€34,183), €34,533 (€29,832-€39,487) and €31,772 (€29,217-€34,385), respectively. For both survivors and non-survivors, total costs per patient were €14,727 (€11,957-€18,324), €7703 (€6141-€9366) and €6580 (€5875-€7238), respectively*.

Conclusions

Onsite AED use was associated with higher survival rates. Surviving patients of the onsite AED group had lower total costs, mainly due to the shorter ICU stay.     

Economic Evaluation of Primary Prevention of Cardiovascular Diseases in Mild Hypertension: A Scenario Analysis for the Netherlands

Background

In the Netherlands, antihypertensive treatment for patients with mild hypertension is recommended if the 10-year cardiovascular disease (CVD) risk exceeds 20%. Recent evidence suggests that lifelong CVD risk estimates might be more informative than 10-year ones. In addition, the cost of antihypertensive treatment in the Netherlands has decreased during the last decade.

Objective

The aim of this study is to estimate the cost-effectiveness of lowering systolic blood pressure (SBP) in patients ineligible for treatment in both a 10-year and a lifetime horizon.

Methods

A Markov model was developed to assess the cost-effectiveness of SBP reduction compared with no reduction in patients with mild hypertension and low CVD risk. Modified SCORE (Systematic Coronary Risk Evaluation) risk estimates were used to predict fatal and nonfatal CVD events. We analyzed scenarios for different age groups, sexes, and SBP reductions. Specifically, SBP reductions due to hydrochlorothiazide (HCT) 25 mg and hypothetical reductions with HCT 12.5 mg-losartan 50 mg combination were assumed. Parameter uncertainty was assessed through a probabilistic sensitivity analysis.

Results

In a 10-year horizon, in scenarios of SBP reduction with HCT 25 mg, the incremental cost-effectiveness ratio (ICER) estimates for men varied across different ages in the range of €6032 to €58,217 per life-year gained, whereas for women ICER estimates were in the range of €12,345 to €361,064 per life-year gained. In a lifetime horizon, the cost-effectiveness estimates were favorable for both sexes. In scenarios of hypothetical SBP reductions, more favorable ICER estimates compared with no reduction were found. A large uncertainty around the cost-effectiveness estimates was observed among all scenarios.

Conclusion

Larger SBP reductions were found to be cost-effective in both a 10-year and lifetime horizon. These findings might call for more aggressive SBP reductions in patients with mild hypertension. However, a high level of uncertainty surrounds these cost-effectiveness estimates because they are based on CVD risk prediction modeling.     

Cost-effectiveness of a nurse facilitated,cognitive behavioural self-management programme compared with usual care using a CBT manual alone for patients with heart failure: secondary analysis of data from the SEMAPHFOR trial

Objective

To assess the cost-effectiveness of a nurse facilitated, cognitive behavioural self-management programme for patients with heart failure compared with usual care including the un-facilitated access to the same manual, from the perspective of the NHS.

Design

Data were obtained from a pragmatic, multi-centre, randomized controlled ‘open’ trial conducted in seven centres in the UK between 2006 and 2008. Effectiveness was estimated as Quality-Adjusted Life Years. Resource use was measured prospectively on all patients using information provided by patients in postal questionnaires, case-note review, electronic record review and interviews with patients. Unit costs were obtained from the literature and applied to the relevant resource use to estimate total costs. Multiple imputation was used to handle missing data.

Results

There were no substantial differences in the utility scores between treatment groups in all follow-up assessments, in the use of medication or outpatient visits and both groups report a similar frequency of contact with health care professionals. After controlling for baseline utility and using imputed dataset, treatment was associated with a reduction in QALY of 0.004 and a additional cost of £69.49. The probability that the intervention is cost-effective for thresholds between £20,000 and £30,000 is around 45%.

Conclusions

There is little evidence that the addition of the intervention had any effect on costs or outcomes. The uncertainty around both estimates of cost and effectiveness mean that it is not reasonable to make recommendations based on cost-effectiveness alone.     

The impact of age and gender on resource utilization and profitability in ED patients seen and released

Objective

To determine how age and gender impact resource utilization and profitability in patients seen and released from an Emergency Department (ED).

Methods

Billing data for patients seen and released from an Emergency Department (ED) with > 100,000 annual visits between 2003 and 2009 were collected. Resource utilization was measured by length of stay (placement in ED bed to leaving the bed) and direct clinical costs (e.g., ED nursing salary and benefits, pharmacy and supply costs, etc.) estimated using relative value unit cost accounting. The primary outcome of profitability was defined as contribution margin per hour. A patient's contribution margin by insurance type (excluding self-pay) was determined by subtracting direct clinical costs from facility contractual revenue. Results are expressed as medians and US dollars.

Results

In 523 882 outpatient ED encounters, as patients' aged, length of stay and direct clinical cost increased while the contribution margin and contribution margin by hour decreased. Women of childbearing age (15-44) had higher median length of stay (2.1 hours), direct clinical cost ($149), and contribution margin per hour ($103/hour) than men of same age (1.7, $131, $85/hour, respectively). Resource utilization and profitability by gender were similar in children and adults over 45.

Conclusion

Resource utilization increased and profitability decreased with increasing age in patients seen and released from an ED. The care of women of childbearing age resulted in higher resource utilization and higher profitability than men of the same age. No differences in resource utilization or profitability by gender were observed in children and adults over 45.     

An analysis of medicine costs of adult patients on a critical care unit

Purpose

To evaluate the costs of medicines used to treat critically ill patients in an intensive care environment and to correlate this with severity of illness and mortality.

Materials and Methods

The study was conducted at a London Teaching Hospital Critical Care Unit. Data were collected for patients who were either discharged or died during September 2011 and stayed longer than 48 hours. The drug cost was related to 150 drugs that were then related to patient's acuity and outcome.

Results

The median daily drug cost of the 85 patients was £26. The highest cost patients in the 85th percentile had significantly higher daily drug costs (median, £403) and higher scores for patient acuity. Patients with hematologic malignancy had a median daily drug cost (£561) more than 20 times higher than those without. A regression analysis based on patient's diversity explained 93% of the variance in the daily drug cost.

Conclusions

Although the median daily drug cost for an adult critically ill patient was low, this cost significantly escalated with patient acuity and hematologic malignancy. A reference method has been designed for an in-depth evaluation of daily drug cost that could be used to compare expenditure in other units.     

Apathy and Health-Related Quality of Life in Stroke

Objective

To examine differences in health-related quality of life (HRQOL) in stroke survivors with and without apathy.

Design

Cross-sectional study.

Setting

Acute stroke unit in a regional hospital.

Participants

Stroke survivors (N=391) recruited from the acute stroke unit.

Interventions

Not applicable.

Main Outcome Measures

Participants were divided into apathy and nonapathy groups. Participants who scored ≥36 on the Apathy Evaluation Scale, clinician's version formed the apathy group. HRQOL was measured with the 2 component scores, mental component summary (MCS) and physical component summary (PCS), of the Medical Outcomes Study 12-Item Short-Form Health Survey (SF-12). Demographic and clinical information were obtained with the National Institutes of Health Stroke Scale (NIHSS), Barthel Index (BI), Mini-Mental State Examination (MMSE), and Geriatric Depression Scale (GDS).

Results

Thirty-six (9%) participants had apathy. The apathy group had significantly lower MCS and PCS scores. After adjusting for sex, education, diabetes mellitus, and NIHSS, MMSE, GDS, and BI scores, the MCS score in the apathy group remained significantly lower.

Conclusions

Apathy has a significant negative effect on HRQOL in stroke survivors, particularly on their mental health. Interventions for apathy could improve the HRQOL of stroke survivors.     

Acute Respiratory Failure during Routine Blood Transfusion: A Case Report and Review of the Literature

Background

Transfusion medicine is a common practice in the emergency department (ED) and other outpatient settings, and may be complicated by a low rate of potentially fatal transfusion-related reactions.

Objectives

This article presents a case of transfusion-related acute lung injury (TRALI) diagnosed and treated in the ED and reviews the differential diagnosis of acute transfusion reactions.

Case Report

A 74-year-old woman presented to the ED from the hospital's transfusion center with fever and respiratory distress immediately after the start of her second unit of red blood cell transfusion. Chest radiograph demonstrated a pattern consistent with acute respiratory distress syndrome (ARDS). After 48 h of respiratory support and antibiotic therapy, the patient's condition improved.

Conclusion

TRALI is a clinical diagnosis with presentation similar to that of ARDS. Prompt differentiation from other transfusion reactions and initiation of appropriate treatment is crucial in minimizing the morbidity and mortality associated with this syndrome.     

Quick diagnosis units: avoiding referrals from primary care to the ED and hospitalizations

Purpose

The aim of the present study was to determine whether quick diagnosis units (QDUs) can safely and efficiently avoid emergency department (ED) visits and hospitalizations.

Patients and Methods

We included a prospective cohort of 4170 consecutive patients and a retrospective cohort of 3030 hospitalized patients. Medical records of hospitalized patients were reviewed to determine whether patients were stable enough for outpatient diagnostic workup. We studied primary care (PC) and ED referral patterns in two 25-month periods. Hospital and QDU costs were analyzed by microcosting techniques, and a survey was evaluated using care preferences.

Results

From December 2007 to December 2009, 66% QDU patients were referred from PC to ED and 25% from PC to QDU. From January 2010 to January 2012, 35% QDU patients were referred from PC to ED and 53% from PC to QDU (P < .0001). During the first period, 36% ED patients were referred to QDU and 65% (retrospective cohort) were hospitalized, compared with 64% and 35%, respectively, during the second period (P < .0001). Between 84% and 91% of hospitalized patients were stable for QDU workup, and their hospitalization might have been avoided. Cost per process was €3241.11 in hospitalized patients and €726.47 in QDU patients. Most patients preferred the QDU model and were reluctant to first being transferred to ED.

Conclusions

An increasing number of PC and ED patients were referred to the QDU. Hospitalizations might have been avoided in at least 84% of patients. Although QDU and hospitalization are similarly effective in reaching a diagnosis, the QDU model incurs fewer costs.