The effects of a low-cost intervention program on hospital costs

OBJECTIVE: To assess the impact of a low-cost education and feedback intervention designed to change physicians' utilization behavior on general medicine services. DESIGN: Prospective, nonequivalent control group study of 1,432 admissions on four general medicine services over 12 months. Two services were randomly selected to receive the intervention. The other two served as controls. Admissions alternated between control and intervention services each day. Results were casemix-adjusted using diagnosis-related groups (DRGs). Three internists blinded to patient study group assignment assessed quality of care using a structured implicit instrument. SETTING: Four general medicine services at a university hospital. INTERVENTIONS: A brief orientation, a pamphlet of cost strategies and common charges, detailed interim bills, and information about projected length of stay and usual hospital reimbursement for each patient. PATIENTS/PARTICIPANTS: Each service was staffed by a full-time internal medicine faculty member, one third-year and two first-year internal medicine houseofficers, three medical students, and a clinical pharmacist. Physicians were assigned to services for one-month periods by a physician unaware of the study design. To prevent crossover, houseofficers assigned to a service returned to the same service for all subsequent general medical inpatient assignments. MEASUREMENTS AND MAIN RESULTS: Geometric mean length of stay was 0.44 days (7.8%) shorter for the intervention services than for the control services (p less than 0.01), and geometric mean charges were $341 (7.1%) less (p less than 0.01). Effects persisted despite using a more precise cost estimate or casemix adjustment. Intervention houseofficers demonstrated superior cost-related attitudes but no difference in knowledge of charges. Audits of quality of care detected no significant difference between groups. CONCLUSION: This low-intensity intervention reduced length of stay and charges, even under the cost-constrained context of the prospective payment system.     

The addition of decision support into computerized physician order entry reduces red blood cell transfusion resource utilization in the intensive care unit

Computerized physician order entry (CPOE) has the potential for cost containment in critically ill patients through practice standardization and elimination of unnecessary interventions. Previous study demonstrated the beneficial short-term effect of adding a decision support for red blood cell (RBC) transfusion into the hospital CPOE. We evaluated the effect of such intervention on RBC resource utilization during the two-year study period. From the institutional APACHE III database we identified 2,200 patients with anemia, but no active bleeding on admission: 1,100 during a year before and 1,100 during a year after the intervention. The mean number of RBC transfusions per patient decreased from 1.5 +/- 1.9 units to 1.3 +/- 1.8 units after the intervention (P = 0.045). RBC transfusion cost decreased from $616,442 to $556,226 after the intervention. Hospital length of stay and adjusted hospital mortality did not differ before and after protocol implementation. In conclusion, the implementation of an evidenced-based decision support system through a CPOE can decrease RBC transfusion resource utilization in critically ill patients.     

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 association between residents’ work-rounds styles and the process and outcome of medical care

Objective: To determine whether the manner in which residents conduct work rounds is associated with the adequacy of their care processes and the outcomes of their patients. Methods: Two types of data were collected: time and motion data for residents (n=12) during work rounds, and clinical and outcome data for the patients they cared for during the observation period (n=211). Five residents were classified as data gatherers because they spent twice as much time gathering clinical data about their patients as they spent engaging in other activities. Three physicians blinded to the resident’s identity rated the quality of the care process and assessed the frequency of undesirable events occurring during the stay and after discharge. Results: A data-gathering style was associated with higher quality of care as judged by both process and outcomes. The data gatherers were more likely to comply with the “stability of medications before discharge” criterion (86% of the data gatherers’ cases vs 73% of others’, p=0.07), and their patients were less likely to have unanticipated problems, in that fewer required calls from nurses (20% vs 37%, p<0.01) and visits by on-call housestaff (33% vs 50%, p=0.01). The data gatherers’ patients were less likely to be readmitted within 30 days (14% vs 38%, p<0.01). Conclusions: A data-gathering work-rounds style is associated with better process and outcome. Residency programs should provide formal instruction to trainees in the conduct of work rounds. Received from the General Medicine Section, Veterans Affairs Medical Center, and Baylor College of Medicine, Houston, Texas. Presented in poster form at the annual meeting of the Society of General Internal Medicine, Arlington, Virginia, April 28–30, 1993. Supported in part by the Houston Center for Quality of Care and Utilization Studies, a Veterans Affairs Health Services Research and Development Field Program.     

A Cost Analysis of Colonoscopy using Microcosting and Time-and-motion Techniques

Background The cost of an individual colonoscopy is an important determinant of the overall cost and cost-effectiveness of colorectal cancer screening. Published cost estimates vary widely and typically report institutional costs derived from gross-costing methods. Objective Perform a cost analysis of colonoscopy using micro-costing and time-and-motion techniques to determine the total societal cost of colonoscopy, which includes direct health care costs as well as direct non-health care costs and costs related to patients’ time. The design is prospective cohort. The participants were 276 contacted, eligible patients who underwent colonoscopy between July 2001 and June 2002, at either a Veterans’ Affairs Medical Center or a University Hospital in the Southeastern United States. Major results The median direct health care cost for colonoscopy was $379 (25%, 75%; $343, $433). The median direct non-health care and patient time costs were $226 (25%, 75%; $187, $323) and $274 (25%, 75%; $186, $368), respectively. The median total societal cost of colonoscopy was $923 (25%, 75%; $805, $1047). The median direct health care, direct non-health care, patient time costs, and total costs at the VA were $391, $288, $274, and $958, respectively; analogous costs at the University Hospital were $376, $189, $368, and $905, respectively. Conclusion Microcosting techniques and time-and-motion studies can produce accurate, detailed cost estimates for complex medical interventions. Cost estimates that inform health policy decisions or cost-effectiveness analyses should use total costs from the societal perspective. Societal cost estimates, which include patient and caregiver time costs, may affect colonoscopy screening rates.     

Gender and utilization of ancillary services

OBJECTIVE: To determine whether gender is associated with the use of ancillary services in hospitalized patients. DESIGN: A retrospective study of laboratory and radiology tests ordered for medical and surgical inpatients over 16-month and 20-month periods, respectively. Obstetric patients were excluded. MEASUREMENTS AND MAIN RESULTS: Number of clinical laboratory and radiology tests per admission, their associated charges, and total charges per admission were measured. In crude analyses, women had 16.5% fewer clinical laboratory tests (p < .0001) with 18.8% lower associated charges (p < .0001) and 24.4% fewer radiology tests (p < .0001) with 15.6% lower associated charges (p < .0001) than men. Total changes for the admission were lower for women in both the clinical laboratory study period ($16,178 vs $18,912, p < .0001) and the radiology study period ($14,621 vs $18,182, p < .0001). When adjusted for age, race, insurance status, service, diagnosis-related-group weight, and length of stay, these differences were smaller but persisted: women had 3.7% fewer laboratory tests performed (p < .001) with 4.8% lower associated charges (p < .001). In similarly adjusted analyses for radiology studies, women received 10.4% fewer radiology examinations (p < .001), with 4.1% lower associated charges (p < .01). There were no significant differences in the adjusted total charges in the laboratory group ($17,450 vs $17,655, p=.20) and only a marginally significant difference in the radiology group ($16,278 vs $16,498, p = .05). When we compared ancillary utilization within the five largest diagnosis-related groups, these differences persisted. CONCLUSIONS: Men receive more ancillary services than women, even after adjusting for potential confounders. This study was supported by research grant R01-HS07107-01 from the Agency for Health Care Policy and Research. Dr. Jha was supported in part by the Carl W. Walter fund of Harvard Medical School.     

Prospective evaluation of an emergency department protocol to prevent hospitalization in mild acute pancreatitis: Outcomes and predictors of discharge

BackgroundWhile acute pancreatitis (AP) contributes significantly to hospitalizations and costs, most cases are mild with minimal complications. In 2016, we piloted an observation pathway in the emergency department (ED) for mild AP and showed reduced admissions and length of stay (LOS) without increased readmissions or mortality. After 5 years of implementation, we evaluated outcomes of the ED pathway and identified predictors of successful discharge.MethodsWe reviewed a prospectively enrolled cohort of patients with mild AP presenting to a tertiary care center ED between 10/2016 and 9/2021, evaluating LOS, charges, imaging, and 30-day readmission, and assessed predictors of successful ED discharge. Patients were divided into two main groups: successfully discharged via the ED pathway (“ED cohort”) and admitted to the hospital (“admission cohort”), with subgroups to compare outcomes, and multivariate analysis to determine predictors of discharge.ResultsOf 619 AP patients, 419 had mild AP (109 ED cohort, 310 admission cohort). The ED cohort was younger (age 49.3 vs 56.3,p < 0.001), had lower Charlson Comorbidity Index (CCI) (1.30 vs 2.43, p < 0.001), shorter LOS (12.3 h vs 116 h, p < 0.001), lower charges (mean $6768 vs $19886, p < 0.001) and less imaging, without differences in 30-day readmissions. Increasing age (OR: 0.97; p < 0.001), increasing CCI (OR: 0.75; p < 0.001) and biliary AP (OR: 0.10; p < 0.001) were associated with decreased ED discharge, while idiopathic AP had increased ED discharge (OR: 7.8; p < 0.001).ConclusionsAfter appropriate triage, patients with mild AP (age <50, CCI <2, idiopathic AP) can safely discharge from the ED with improved outcomes and cost savings.     

Perceived Helpfulness of Physicians’ Communication Behavior and Breast Cancer Patients’ Level of Trust Over Time

OBJECTIVE  We evaluated the association between physicians’ communication behavior and breast cancer patients’ trust in their physicians. DESIGN  Longitudinal survey conducted at baseline, 2-month, and 5-month follow-up during first year of diagnosis. PARTICIPANTS  Newly diagnosed breast cancer patients (N = 246). MEASUREMENTS  We collected data on patient perceptions of the helpfulness of informational, emotional, and decision-making support provided by physicians and patients’ trust. Linear regression models evaluated the association of concurrent and prior levels of physician support with patients’ trust. RESULTS  At baseline, patients who received helpful informational, emotional, and decision-making support from physicians reported greater trust (p < 0.05, p < 0.001, and p < 0.01, respectively). At the 2-month assessment, baseline informational support and informational and emotional support at 2-months were associated with greater trust (p < 0.05, p < 0.01, and p < 0.05, respectively). At the 5-month assessment, only helpful emotional support from physicians at 5 months was associated with greater trust (p < 0.01). Interestingly, while perceived helpfulness of all three types of physician support decreased significantly over time, patient trust remained high and unchanged. CONCLUSIONS  Findings suggest that while informational and decision-making support may be more important to patient trust early in the course of treatment, emotional support from physicians may be important to maintain trust throughout the initial year of diagnosis.     

Comparison of Transfemoral Transcatheter Aortic Valve Replacement Performed in the Catheterization Laboratory (Minimalist Approach) Versus Hybrid Operating Room (Standard Approach): Outcomes and Cost Analysis

ObjectivesThe aim of this study was to compare transfemoral transcatheter aortic valve replacement (TF TAVR) performed in a catheterization laboratory (minimalist approach [MA]) with TF TAVR performed in a hybrid operating room (standard approach [SA]).BackgroundA MA-TF TAVR can be performed without general anesthesia, transesophageal echocardiography, or a surgical hybrid room. The outcomes and cost of MA-TF TAVR compared with those of the SA have not been described.MethodsPatients who underwent elective, percutaneous TF TAVR using the Edwards Sapien valve (Edwards Lifesciences, Irvine, California) were studied. Baseline characteristics, outcomes, and hospital costs of MA-TF TAVR and SA-TF TAVR were compared.ResultsA total of 142 patients were studied (MA-TF TAVR, n = 70 and SA-TF TAVR, n = 72). There were no differences in baseline comorbidities (Society of Thoracic Surgeons score, 10.6 ± 4.3 vs. 11.4 ± 5.8; p = 0.35). All procedures in the MA-TF TAVR group were successful; 1 patient was intubated. Three patients in the SA-TF TAVR group had procedure-related death. Procedure room time (150 ± 48 min vs. 218 ± 56 min, p < 0.001), total intensive care unit time (22 h vs. 28 h, p < 0.001), length of stay from procedure to discharge (3 days vs. 5 days, p < 0.001), and cost ($45,485 ± 14,397 vs. $55,377 ± 22,587, p < 0.001) were significantly less in the MA-TF TAVR group. Mortality at 30 days was not significantly different in the MA-TF TAVR group (0 vs. 6%, p = 0.12) and 30-day stroke/transient ischemic attack was similar (4.3% vs. 1.4%, p = 0.35). Moderate or severe paravalvular leak and device success were similar in the MA-TF TAVR and SA-TF TAVR groups (3% vs. 5.8%, p = 0.4 and 90% vs. 88%, p = 0.79, respectively) at 30 days. At a median follow-up of 435 days, there was no significant difference in survival (MA-TF TAVR, 83% vs. SA-TF TAVR, 82%; p = 0.639).ConclusionsMA-TF TAVR can be performed with minimal morbidity and mortality and equivalent effectiveness compared with SA-TF TAVR. The shorter length of stay and lower resource use with MA-TF TAVR significantly lowers hospital costs.     

Cost effectiveness in the detection of renal artery stenosis

Cost effectivenesses of four tests for diagnosing renal artery stenosis were examined. Sensitivity, specificity, cost per patient, and cost per stenosis found for a variety of diagnostic strategies using these tests were retrospectively evaluated using clinical data from 605 hypertensive patients. Cost effectiveness of a given strategy was found to depend on the sequence in which the tests were performed, but to be relatively independent of the exact cost of the tests. Auscultation for a systolic/diastolic abdominal bruit was the most cost-effective test for beginning a diagnostic strategy and showed a 99.6% specificity for stenosis. When the patient has a systolic bruit only or no bruit, plasma renin activity measurement should guide the clinician’s choice of whether to test further with intravenous pyelography or renal arteriography. Diagnosis of renal artery stenosis using these tests is estimated to cost between $2,300 and $6,200 per stenosis found, depending on the prevalence of renal artery stenosis. Supported in part by USPHS grants HL-14159, Specialized Center of Research (SCOR) in Hypertension and RR-00750, General Clinical Research Center. Dr. England was supported by a Robert Wood Johnson Faculty Fellowship in Health Care Finance during the latter part of this project.     

Predicting emergency readmissions for patients discharged from the medical service of a teaching hospital

Emergency readmissions among patients discharged from the medical service of an acute-care teaching hospital were analyzed. Using the multivariate technique of recursive partitioning, the authors developed and validated a model to predict readmission based on diagnoses and other clinical factors. Of the 4,769 patients in the validation series, 19% were readmitted within 90 days. Twenty-six per cent of the readmissions occurred within ten days of discharge, and 57% within 30 days. Readmitted patients were older, had longer hospitalizations, and had greater hospital charges (p<0.01). The discharge diagnoses of AIDS, renal disease, and cancer were associated with increased risks of read-mission regardless of patients’ demographics or test results. The relative risks (95% confidence interval) associated with these diagnoses were: AIDS, 3.3 (1.4–7.8); renal disease, 2.3 (1.7–3.0); cancer, 2.8 (2.4–3.4). Other patients at increased risk were those with diabetes, anemia, and elevated creatinine (2.1; 1.6–2.8) and those with heart failure and elevated anion gaps (2.2; 1.7–2.8). For patients without one of these diagnoses, a normal albumin and no prior admission within 60 days identified patients at reduced risk for readmission (0.4; 0.3–0.4). Thus, commonly available clinical data identify patients at increased risk for emergency readmission. Risk factor profiles should alert physicians to these patients, as intensive intervention may be appropriate. Future studies should test the impacts of clinical interventions designed to reduce emergency readmissions. Received from the Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School. Beth Israel Hospital; the Charles A.Dana Research Institute and Harvard Thorndike Laboratory of Beth Israel Hospital; and the Center for Clinical Computing, Department of Medicine, Harvard Medical School. Beth Israel and Brigham and Women’s Hospitals, Boston, Massachusetts. Presented in part at the meeting of the American Federation for Clinical Research, Washington, DC, May 1986. Supported in part by grants HS04928 from the National Center for Health Services Research and LM 04260 from the National Library of Medicine.     

Medical subspecialty training and interest in cost containment education

To investigate academic physicians’ interest in learning methods to reduce health care costs, we asked the faculty and housestaff of a university-based department of internal medicine to rate their interest in 30 potential topics for medical grand rounds, a traditional forum for continuing medical education. The 30 topics were equally divided among clinical, research and cost-containment categories. The 29 housestaff and the 41 subspecialty faculty members clearly favored clinical and research topics over cost-containment topics (p<0.001). On the other hand, the nine general internists considered the cost-containment topics as attractive as the clinical and research topics and ranked them higher than did both the subspecialists (p<0.001) and the housestaff (p<0.05). Efforts to alter costs in academic medical centers may be hampered by the relative disinterest in cost-containment education among house officers and subspecialists, who are responsible for most of the health care delivery in this setting. Received from the Department of Medicine, University of Connecticut Health Center and Veterans Administration Medical Center, Farmington and Newington, Connecticut.     

Use of a Geriatric Home Visit Experience to Teach Medical Students the Functional Status Assessment

INTRODUCTION  Functional status measures strongly predict hospital outcomes and mortality, yet teaching of these measures is often missing from medical schools’ curricula. To address this deficiency, we developed a Geriatric Home-based Assessment (GHA) module for third-year medical students. The module was composed of a workshop and two to three home visits. OBJECTIVE  To determine whether the GHA module would improve students’ knowledge and proficiency in the functional status assessment. PROGRAM EVALUATION  Students completed a validated questionnaire and evaluated a standardized patient in an Observed Structured Clinical Examination (OSCE). Scores from students completing the GHA were compared to the scores of students without this experience. RESULTS  Thirty-one students participated in the GHA module, and 19 students were in the control group. The mean score on the written assessment was 87% among GHA students vs. 46% in the control group (p < 0.001). The mean clinical examination score of the intervention group was also better than that of the control group (76% vs. 46%, p < 0.001). CONCLUSIONS  Our GHA module was effective in improving students’ knowledge and proficiency in the functional status assessment. “Hands on” experiences like the GHA allow students to develop a solid foundation for assessing functional status and mobility.     

Analysis of 90-day cost for open versus minimally invasive distal pancreatectomy

Background

Minimally invasive distal pancreatectomy (MIDP) is associated with improved peri-operative outcomes compared to the open approach, though cost-effectiveness of MIDP remains unclear.

Laparoscopic Resection in Rectal Cancer Patients: Outcome and Cost-Benefit Analysis

Purpose This study was designed to evaluate the impact of laparoscopic rectal resection on short-term postoperative morbidity and costs. Methods A total of 168 patients with rectal cancer were randomly assigned to laparoscopic (n = 83) or open (n = 85) resection. Outcome parameters were: postoperative morbidity, length of hospital stay, quality of life, long-term survival, and local recurrences. The mean follow-up period was 53.6 months. Cost-benefit analysis was based on hospital costs. Results Operative time was 53 minutes longer in the laparoscopic group (P < 0.0001). Postoperative morbidity rate was 28.9 percent in the laparoscopic vs. 40 percent in the open group (P = 0.18). The mean length of hospital stay was 10 (4.9) days in the laparoscopic group and 13.6 (10) days in the open group (P = 0.004). Local recurrence rate and five-year survival were similar in both groups; however, the limited number of patients does not allow firm conclusions. Quality of life was better in the laparoscopic group only in the first year after surgery (P < 0.0001). The additional charge in the laparoscopic group was $1,748 per patient randomized ($1,194 the result of surgical instruments and $554 the result of longer operative time). The saving in the laparoscopic group was $1,396 per patient randomized ($647 the result of shorter length of hospital stay and $749 the result of the lower cost of postoperative complications). The net balance resulted in $351 extra cost per patient randomly allocated to the laparoscopic group. Conclusions Short-term postoperative morbidity was similar in the two groups. Laparoscopic resection reduced length of hospital stay, improved first-year quality of life, and slightly increased hospital costs. Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7, 2006.     

Impact of anatomical subtype and medical comorbidities on hospitalizations in adults with single ventricle congenital heart disease

Background

Most patients with single ventricle congenital heart disease (SV) are now expected to survive to adulthood. Medical comorbidities are common in SV.

Methods

We used data from 43 pediatric hospitals in the 2004 to 2011 Pediatric Health Information System database to identify patients ≥ 18 years of age admitted with International Classification of Diseases-9th Revision codes for a diagnosis of either hypoplastic left heart syndrome (HLHS), tricuspid atresia (TA) or common ventricle (CV). Primary (PD) and secondary diagnoses (SD), length of stay (LOS) and hospital charges were determined. Multilevel models were used to evaluate differences in demographics, diagnoses, and admission outcomes among the three subgroups (HLHS, TA, and CV). Interactions of charges with PD and admission year were examined using ANOVA.

Results

There were 801 SV patients with 1330 admissions during the study period. Mean age was 24.8 ± 6.2 years (55% male) and mean LOS was 6.8 ± 11.3 days. Total hospital charges were $135 million with mean charge per admission of $101,131 ± 205,808. The mean charge per day was $15,407 ± 16,437. Hospital charges correlated with PD group (p < 0.001). Admission rate remained stable (~ 180/year) from 2006 to 2011. LOS decreased (p = 0.0308) and hospital charges per day increased across the study period (p < 0.001). PD was non-cardiac in 28% of admissions. Liver-related conditions were more common in patients with HLHS (p < 0.001).

Conclusions

Hospitalization costs in adults with SV are significant and are impacted by comorbid medical conditions. Hospitalization rates for adults with SV are not increasing. Gastroenterologic comorbidities including protein-losing enteropathy (PLE) are common in HLHS.     

Laparoscopic Restorative Proctocolectomy with Ileal S-Pouch

Purpose  Restorative proctocolectomy has revolutionized the surgical management of ulcerative colitis and familial polyposis syndromes. Though now evolved to include laparoscopy, this approach has not included alternative pouch designs such as ileal S-pouch reconstruction. This comparative analysis evaluated the combination of laparoscopic-assisted total proctocolectomy with an ileal S-pouch design. Methods  One hundred fifty-six (65 laparoscopic-assisted) total proctocolectomy and ileal S-pouch-anal anastomosis procedures performed between 2003 to 2007 were identified from a prospective surgical database. Operative time, length of incision, length of hospital stay, complications, and return of bowel function were examined. A cost analysis including preoperative through postoperative hospital stay and operating room and postanesthesia care unit costs was performed. Results  The laparoscopic-assisted total proctocolectomy and ileal S-pouch-anal anastomosis procedures were performed for ulcerative colitis in 60 cases and familial adenomatous polyposis in the remaining 5 patients. Four conversions to open technique occurred (6 percent). Comparing laparoscopic and open procedures, the laparoscopic approach took longer to perform than the open technique (mean 451 minutes vs. 347 minutes open; P < 0.001). The mean hospital stay was 6.3 days in the laparoscopic group vs. 8.2 days in the open group (P < 0.001). A detailed cost analysis revealed similar overall costs between the laparoscopic ($18,700) and open approaches ($18,500). Conclusion  Use of a laparoscopic total proctocolectomy with ileal S-pouch-anal anastomosis reconstruction minimizes incision size and shortens hospital stay. At a teaching academic institution, the laparoscopic approach requires longer operative times yet a negligible cost disadvantage.     

Impact of Chronic Total Occlusions on Outcomes of Patients With Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention: A Propensity-Score-Matched Analysis Using the National Inpatient Sample Database

BackgroundThere is limited data on the impact of chronic total occlusions (CTOs) on the outcomes of patients presenting with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) in the contemporary era.MethodsWe queried the National Inpatient Sample between October 2015 and December 2017 using the International Classification of Diseases, Tenth revision codes to identify hospitalized AMI patients undergoing PCI. A 1:1 propensity-score matched analysis was performed to compare in-hospital outcomes of patients with and without CTOs.ResultsAmong 576,760 admissions identified during the study period, 51,225(8.8 %) had CTO and 525,535 (91.1 %) did not. After 1:1 propensity-score matching, each matched group contained 51,210 admissions. In-hospital mortality was significantly higher in the CTO group compared with the non-CTO group (4.7 % vs 3 %, p < 0.0001). In the CTO group, hospital length of stay was longer (median 3 vs 2 days, p = 0.001) and lower percentage of patients were discharged to home (78.8 % vs 81.1 %, p < 0.0001), compared with the non-CTO group. Median cost of hospital stay was also higher in the CTO group compared with the non-CTO group ($20,921 vs $19,856, p < 0.0001).ConclusionsIn this propensity-score matched analysis of a large US inpatient database, the presence of CTOs in AMI patients undergoing PCI identified a higher risk cohort with in higher in-hospital mortality, longer hospital length of stay and higher hospitalization cost.     

Relation between length of hospital stay and costs of care for patients with community-acquired pneumonia

PURPOSE: Patients with pneumonia often remain hospitalized after becoming clinically stable, without demonstrated benefits on outcome. The purposes of this study were to assess the relation between length of hospital stay and daily medical care costs and to estimate the potential cost savings associated with a reduced length of stay for patients with pneumonia. SUBJECTS AND METHODS: As part of a prospective study of adults hospitalized with community-acquired pneumonia at a community hospital and two university teaching hospitals, daily medical care costs were estimated by multiplying individual charges by department-specific cost-to-charge ratios obtained from each hospital's Medicare cost reports. RESULTS: The median total cost of hospitalization for all 982 inpatients was $5, 942, with a median daily cost of $836, including $491 (59%) for room and $345 (41%) for non-room costs. Average daily non-room costs were 282% greater on the first hospital day, 59% greater on the second day, and 19% greater on the third day than the average daily cost throughout the hospitalization (all P <0.05), and were 14% to 72% lower on the last 3 days of hospitalization. Average daily room costs remained relatively constant throughout the hospital stay, with the exception of the day of discharge. A projected mean savings of $680 was associated with a 1-day reduction in length of stay. CONCLUSIONS: Despite institutional differences in total costs, patterns of daily resource use throughout hospitalization were similar at all institutions. A 1-day reduction in length of stay might yield substantial cost-savings.     

Modification of residents’ behavior by preceptor feedback of patient satisfaction

The authors tested the effect of preceptor feedback to residents of patients’ ratings of perceived art and technical quality of care on residents’ subsequent performances. New ambulatory patients were asked to complete questionnaires measuring satisfaction with physician behavior during initial encounters. Sixty-eight residents were evaluated by 424 patients over a six-month period. Continuing residents with the lowest scores were assigned to a feedback or a non-feedback group. Residents in the feedback group were individually shown their mean scores on each item, as well as scores for all residents, and were then advised of physicians’ behaviors that could increase patient satisfaction. During a subsequent six-month survey of new patients, scores in the feedback group improved more than those in the non-feedback group in art of care, technical quality, and total patient satisfaction (p<0.001). Received from the Department of Medicine, UCLA Center for the Health Sciences, Los Angeles, California. Presented at the Plenary Session of the National Meeting of the Society for Research and Education in Primary Care Internal Medicine, May 1985. Supported by USPHS Grant #19157.