"Shift work" improves survival and reduces intensive care unit use in seriously injured patients

We assessed whether a trauma service model with an emphasis on continuity of care by using "shift work" will improve trauma outcomes and cost. This was a case-control cohort study that took place at a university-affiliated Level I trauma center. All patients (n=4283) evaluated for traumatic injuries between May 1, 2002 and April 30, 2004 were included. During Period I (May 1, 2002 to April 30, 2003), a rotating off-service team provided initial management between 5:00 PM and 7:00 AM. The "day team" provided all other care and was responsible for continuity of care. In Period II (May 1, 2003 to April 30, 2004), a dedicated trauma service consisting of two resident teams evaluated all injured patients. Variables included hospital and intensive care unit length of stay (LOS), mechanical ventilation requirements, hospital mortality, and hospital care costs. Demographics and injury mechanism for both periods were similar, but Injury Severity Score (ISS) in Period II was greater (ISS, 8.2% vs. 7.2%, P < 0.0001; ISS > 15, 18.5% vs. 15.4%). In the more severely injured (ISS > 15), patients in Period II had shorter hospital LOS (8.6 vs. 9.7 days, P = 0.98), a shorter ICU LOS (5.5 vs. 7.7 days, P = 0.039), shorter mechanical ventilator requirements (5.5 vs. 7.7 days, P = 0.32), improved hospital mortality rate (19.9% vs. 26.8%, P = 0.029), and decreased hospital costs (19,146 dollars vs. 21,274 dollars, P = 0.36). On multivariate analysis, factors affecting mortality and LOS included age, initial vital signs, injury type, and ISS. Overall, the two trauma service models resulted in similar outcomes. Although multivariate analysis revealed that treatment period did not affect mortality, our study revealed improved patient survival and reduction in LOS and cost for the severely injured in Period II.     

Laparoscopic versus open incisional hernia repair

BACKGROUND: To analyze hospital resource utilization for laparoscopic vs open incisional hernia repair including the postoperative period. METHODS: Prospectively collected administrative data for incisional hernia repairs were examined. A total of 884 incisional hernia repairs were examined for trends in type of approach over time. Starting October 2001, detailed records were available, and examined for operating room (OR) time, cost data, length of stay (LOS), and 30-day postoperative hospital encounters. RESULTS: Of the total, 469 incisional hernias were approached laparoscopically (53%) and 415 open (47%). Laparoscopic repair had shorter LOS (1 +/- 0.2 days vs 2 +/- 0.6 days), longer OR time (149 +/- 4 min vs 89 +/- 4 min), higher supply costs (2,237 dollars +/- 71 dollars vs 664 dollars +/- 113 dollars), slightly lower total hospital cost (6,396 dollars +/- 477 dollars vs 7,197 dollars +/- 1,819 dollars), and slightly more postoperative hospital encounters (15% vs 13%). Use of laparoscopy increased over time (37% in 2000 vs 68% in 2004). CONCLUSIONS: Laparoscopic incisional hernia repair is becoming increasingly popular, and not at increased cost to the health care system.     

Emergency and elective coronary artery bypass grafting: comparisons of risk profiles, postoperative outcomes, and resource requirements

OBJECTIVE: To investigate the association between preoperative risk factors and postoperative outcomes in emergency and elective coronary artery bypass graft (CABG) patients and to quantify resource requirements. DESIGN: Retrospective database review. SETTING: New York State SPARCS database. PARTICIPANTS: Data from 4,001 emergency and 7,489 elective CABG patients were evaluated retrospectively. INTERVENTIONS: Data were compared between groups using chi-squares, t tests, and logistic regression analysis. MEASUREMENTS AND MAIN RESULTS: Preoperatively, 47.1% of patients in the emergency group had unstable angina and 34.1% had acute myocardial infarction compared with 33.9% and 15.2% in the elective group, respectively (p < 0.0001). There were no marked differences in the preoperative noncardiac risk factors between groups. The mortality rate was 4.7% in the emergency group and 2.6% in the elective group (p < 0.0001). The emergency group had more postoperative cardiac complications (18.3% v 8.3%, p < 0.0001). The length of hospital stay in the emergency group was 17.5 +/- 15.8 days (median 14 days) compared with 12.9 +/- 15.1 days (median 9 days) in the elective group (p < 0.00001). Total hospital charges in the emergency and elective groups were 46,700 US dollars +/- 42,400 US dollars (median 35,600 US dollars ) and 34,800 US dollars +/- 36,400 US dollars (median 26,500 US dollars) (p < 0.00001), respectively. The median total cost was 26,300 US dollars for emergency and 19,600 US dollars for elective group (p < 0.00001). CONCLUSION: Patients undergoing emergency CABG had greater postoperative morbidity and mortality, longer LOS, and higher total costs than patients undergoing elective surgery. This difference is predictable on the basis of preoperative cardiac risk factors. Emergency operations have a major impact on the rates of morbidity, mortality, and use of resources.     

Money well spent: a comparison of hospital operating margin for laparoscopic and open colectomies

BACKGROUND: Cost analysis after laparoscopic colectomy has been examined, although reports evaluating the effects of laparoscopy on hospital operating margin are lacking. We compared several cost/revenue measures, including hospital operating margin, between open and laparoscopic colectomies at an academic center. METHODS: Our cost-accounting database was queried for laparoscopic partial (LPC) and total colectomies (LTC), and open partial (OPC) and total colectomies (OTC) to analyze net revenue, total costs, and total hospital operating margin over a 4-year period. Laparoscopic and open colectomy cases were compared, with mean operating margin as the primary outcome. RESULTS: From July, 2002 through May, 2006, 842 patients were included for analysis with 138 undergoing laparoscopic colectomy. Net revenue was higher in the LTC group compared with open (US dollars 30,300 vs US dollars 26,800 [P = .02]), and lower in the LPC group (US dollars 15,300 vs US dollars 21,300 open [P < .0001]). Total costs were reduced in both the LPC and LTC groups compared with open [US dollars 11,700 vs US dollars 17,600 [P < .0001] and US dollars 18,000 vs US dollars 19,400 [P = .0019], respectively). LPC resulted in a similar HOM (US dollars 3,602) compared with OPC (US dollars 3,647; P = .35). LTC resulted in a higher HOM (US dollars 12,300) compared with OTC (US dollars 7,400; P = .02). CONCLUSIONS: LTC generates a significantly higher hospital operating margin than an OTC, although the margins are similar for LPC and OPC.     

Cost comparison of hand assisted laparoscopic nephrectomy and open nephrectomy: analysis of individual parameters

PURPOSE: Hand assisted laparoscopic nephrectomy (HAL) is an effective approach to nephrectomy that is less morbid than open nephrectomy (ON). In response to budgetary pressure at our large county hospital we reviewed the published experience and identified the cost components of HAL that could be targeted to decrease procedure cost. MATERIALS AND METHODS: A comprehensive literature review of HAL and ON was performed and certain parameters were abstracted, including operative (OR) time, operative equipment and hospital stay (LOS). Using these data the projected overall cost and individual cost centers at our institution for HAL and ON were compared. Decision tree analysis models were devised to estimate the cost of each treatment using computer software. One and 2-way sensitivity analyses were performed to evaluate the effect of individual treatment variables on overall cost. RESULTS: The literature showed 6 and 9 reports on 127 and 419 patients for ON and HAL, respectively. LOS was 5 and 3 days for ON and HAL, respectively. OR time was 169 and 204 minutes for ON and HAL, respectively. Based on a review of the costs at our institution ON was a less costly procedure by $205 ($6,882 vs $7,087 US dollars). The slight cost superiority of the open approach was due to significantly lower costs associated with operating room time and equipment. On the other hand, HAL demonstrated a cost advantage for LOS. One-way sensitivity analyses showed that HAL was less costly if HAL OR time was less than 184 minutes, LOS following HAL was less than 2.5 days or HAL OR supply costs were less than $718 US dollars. Two-way sensitivity analysis demonstrated that HAL was cost advantageous if performed in less than 3 hours and the patient was discharged home within 3 postoperative days. CONCLUSIONS: Primary cost variables for nephrectomy include OR time, LOS stay and equipment cost. Using published data and decision tree analysis ON is slightly less costly by $205 US dollars than HAL at our institution. However, HAL can be more cost-effective than ON when OR time and LOS are low. Our model identifies several measures that can be used at any institution to render HAL economically superior to ON.     

Cost-effectiveness of zoledronic acid for the prevention of skeletal complications in patients with prostate cancer

PURPOSE: We estimated the cost-effectiveness of zoledronic acid vs placebo for decreasing skeletal complications in men with prostate cancer. MATERIALS AND METHODS: We performed a cost-effectiveness analysis alongside a multinational clinical trial of zoledronic acid. Cost estimation was based on prospectively collected resource use data for 85.3% of enrolled patients. Cost-effectiveness ratios were based on within-trial data on clinical outcomes, quality of life and study medication cost. RESULTS: Patients receiving zoledronic acid experienced fewer hospital days during a mean followup of 9 months (average 5.6 vs 8.0 days; p = 0.1910). Mean direct costs excluding study medication were US dollars 5365 for patients receiving zoledronic acid and US dollars 5689 for patients receiving placebo, a difference of US dollars 324 (95% CI US dollars 1781 to US dollars 1146). The global average cost of zoledronic acid plus its administration during the trial was US dollars 5677 (US dollars 450 per dose). The nominal cost per skeletal complication avoided was US dollars 112300 (95% CI US dollars 6900 to US dollars 48700) and the cost per additional patient free of skeletal complications was US dollars 51400 (95% CI US dollars 26900 to US dollars 243700). Nominal within-trial cost per quality adjusted life-year was US dollars 159200, which varied widely in sensitivity analyses. CONCLUSIONS: The nominal base case estimate of the cost per quality adjusted life-year for zoledronic acid in the prevention of skeletal complications of prostate cancer is consistent with that of bisphosphonates in breast cancer. However, the cost-effectiveness ratios for bisphosphonates are higher than commonly cited thresholds for conferring cost-effectiveness.     

National trends in health care utilization and racial and socioeconomic disparities in pediatric pyogenic arthritis

PURPOSE: To determine national trends and putative racial and socioeconomic disparities in health care utilization in pediatric patients with pyogenic arthritis over a 13-year period. STUDY DESIGN: We assessed trends in length of hospital stay, hospital disposition, and inflation-adjusted charges for pediatric patients hospitalized with pyogenic arthritis based on 13 consecutive years (1988-2000) of the Nationwide Inpatient Sample. Patients with an International Classification of Diseases, Ninth Revision code of pyogenic arthritis were selected for this study. Trends in health care utilization were analyzed, stratified by age, prematurity, joint location, socioeconomic status, and race. RESULTS: The median length of stay (LOS) decreased from 10 to 5 days in 1988 and 2000, respectively (P < 0.05). Whites had a shorter mean LOS (7.8 days) than nonwhites (10.7 days; P < 0.05). For both whites and nonwhites, LOS decreased significantly (P < 0.05), but the difference between the 2 groups remained constant. For patients with a higher socioeconomic status, LOS was shorter (P'< 0.05). The percentage of patients discharged to home'health care increased from 3.8% in 1988 to 18.9% in 2000 (P'< 0.05), but the increase was much greater for whites than nonwhites (P < 0.05). Inflation adjusted total charges increased over time, from a median total charge of 10,098 dollars in 1988 to a median total charge of 11,155 dollars in 2000 (P < 0.05). CONCLUSIONS: There was a trend toward decreased health care utilization, but no decrease in charges for pediatric pyogenic arthritis from 1988 to 2000. Racial disparities still exist, with little improvement over time.     

In-house trauma attendings: is there a difference?

INTRODUCTION: Outcomes of patients who met trauma activation criteria were examined before and after implementation of in-house attending call. MATERIALS AND METHODS: Outcomes for the out-of-house period (OH) (February 1, 2001 to October 31, 2002) were compared with the in-house period (IH) (November 1, 2002 to June 30, 2004). Measures included overall mortality, length of stay (LOS) in the hospital, intensive care unit (ICU) and emergency department, and preventable deaths. RESULTS: A total of 2,019 trauma activations were studied (1,036 OH, 983 IH). The groups were equivalent on admission. There was no difference in hospital LOS, ICU LOS, ventilator days, or overall mortality. Preventable deaths occurred in 8.1% of the OH group and in 1.0% of the IH group (P < .02). CONCLUSIONS: Aggregate statistics and the use of surrogate markers to determine outcomes may not accurately portray the impact of attending surgeons on the quality of care. Implementation of in-house call resulted in a decreased incidence of preventable deaths.     

Establishment and maintenance of vascular access in incident hemodialysis patients: a prospective cost analysis

Despite the importance of hemodialysis vascular access, the cost of vascular access care has not been studied in detail. A prospective cost analysis was performed among incident hemodialysis patients to determine the cost of vascular access care overall and on the basis of access type. Detailed clinical and demographic information, as well as data on access type, was collected for all local incident hemodialysis patients between July 1, 1999, and November 1, 2001. A comprehensive measure of total vascular access costs, including surgery, radiology, hospitalization for access complications, physician costs, costs for management of outpatient bacteremia, and vascular access monitoring costs, was obtained. Costs are reported in 2002 Canadian dollars (1 CAN dollar = 0.69 US dollar). A total of 239 consecutive incident hemodialysis patients were identified, 49, 157, and 33 of whom were dialyzed exclusively with a catheter or had a native arteriovenous fistula or synthetic graft attempted, respectively. In year 1, 18.4% of all hospital admissions were for vascular access-related complications. The mean cost of all vascular access care in year 1 was 6890 CAN dollars(median 4020 dollars; interquartile range [IQR] 2440 dollars to 7540 dollars). The mean cost of access care per patient-year at risk for maintaining a catheter exclusively, attempting an arteriovenous fistula, or attempting a graft was 9180 dollars (median 3812 dollars; IQR 2250 dollars to 7762 dollars), 7989 dollars (median 4641 dollars ; IQR 3035 dollars to 8832 dollars), and 11,685 dollars (median 8152 dollars; IQR 3395 dollars to 12,908 dollars), respectively (P = 0.01). Vascular access care is responsible for a significant proportion of health care costs in the first year of hemodialysis. These results support clinical practice guidelines that recommend preferential placement of a native fistula.     

Complications following surgical intervention for stress urinary incontinence: a national perspective

AIMS: Stress urinary incontinence (SUI) impacts many women. Treatment is primarily surgical. Post-operative morbidity considerably affects individuals and the health care system. Our objective is to describe complications following surgery for SUI and how they affect resource utilization. METHODS: Utilizing the Nationwide Inpatient Sample (a nationally representative dataset), 147,473 patients who underwent surgery for SUI from 1988 to 2000 were identified by ICD-9 codes. Comorbid conditions/complications were extracted using ICD-9 codes, including complication rates, length of stay (LOS), hospital charges, and discharge status. RESULTS: Overall complication rate was 13.0% (not equal to sum of complication sub-types, as each woman may have had = 1 complication), with 2.8% bleeding, 1.4% surgical injury, 4.3% urinary/renal, 4.4% infectious, 0.1% wound, 1.1% pulmonary insufficiency, 0.5% myocardial infarction, 0.2% thromboembolic. The "gold standard" surgical technique for SUI, the pubovaginal sling, had the lowest morbidity at 12.5%. Mean LOS increased with morbidity: from 2.9 to 4.1 to 6.1 days for those with 0, 1, and =2 complications respectively (P < 0.001). Similarly, inflation-adjusted hospital charges increased with morbidity: from 7,918 dollars to 9,828 dollars to 15,181 dollars for those with 0, 1, and =2 complications respectively (P < 0.001). The percentage of patients requiring post-discharge subacute or home care increased with morbidity: from 4.4% to 8.4% to 14.3% for those with 0, 1, and =2 complications (P < 0.001). CONCLUSIONS: A substantial percentage of women experience complications following surgery for SUI. Post-operative morbidity leads to dramatically increased resource utilization. Prospective studies are needed to identify pre-operative risk factors and intraoperative process measures to optimize the quality of care.     

Establishment of a clinical pathway as an effective tool to reduce hospitalization and charges after video-assisted thoracoscopic pulmonary resection.

OBJECTIVE: The purpose of this study was to assess the effect of establishing a clinical pathway based on the length of hospitalization, hospital charges, and the outcome for video-assisted thoracoscopic pulmonary resection (VATPR). METHODS: We retrospectively analyzed consecutive patients who were diagnosed as having primary lung cancer, metastatic lung cancer, or a nodule that was suspected to be malignant and thus was operated on using VATPR during the 1-year period before (n = 105) and after (n = 113) pathway implementation. RESULTS: The mean economic cost and total hospital stay before and after pathway implementation were about dollars 14439 and dollars 13093 (US), and 29.4 and 18.6 days, respectively. These figures were significantly lower after pathway implementation than before establishment of the pathway. CONCLUSION: A clinical pathway is thus considered useful for reducing the length of total hospital stay and the costs associated with VATPR while maintaining high-quality postoperative care.     

Spinal surgery in children with idiopathic and neuromuscular scoliosis. What's the difference?

We compared children who were hospitalized for the management of idiopathic scoliosis (IS) and neuromuscular scoliosis (NMS) via analysis of the 2000 Healthcare Cost and Utilization Project Kid Inpatient Database. Children with NMS had longer lengths of stay (9.2 vs. 6.1 days, P < 0.001), higher total charges (66,953 US dollars vs. 47,463 US dollars, P < 0.001), more diagnoses (6.3 vs. 2.5, P < 0.001), and more total procedures (4.2 vs. 3.0, P < 0.001) than did children with IS. Children with NMS more frequently developed pneumonia (3.5% vs. 0.7%, P < 0.001), respiratory failure (24.1% vs. 9.2%, P < 0.001), urinary tract infections (5.3% vs. 0.7%, P < 0.001), and surgical wound infections (1.3% vs. 0.3%, P < 0.001). Overall, 1570 children with NMS underwent spinal surgery, totaling to 105 US dollars million in hospital charges and 14,444 hospital days. We conclude that children with NMS experience significantly more complicated and costly hospitalizations than do children with IS. These results may add information on preoperative care, surgical decision-making, discussions of informed consent, and the provision of anticipatory guidance for children and their caregivers.     

Impact of chronic obstructive pulmonary disease on elective and emergency abdominal aortic aneurysm repair

OBJECTIVE: Chronic obstructive pulmonary disease (COPD) is associated with abdominal aortic aneurysm (AAA) expansion and is considered by some to be a relative contraindication to conventional aortic surgery. This study was undertaken to determine if COPD increases operative death, morbidity, intensive care unit (ICU) length of stay (LOS), and hospital LOS, after AAA repair. METHODS: Data from national administrative records supplemented with laboratory data previously obtained for a system-wide study were analyzed in a retrospective review of 1053 consecutive patients (264 with and 789 without COPD) undergoing operation for intact or ruptured AAAs in Veterans Administration Hospitals from 1997 to 1998. Bivariate comparisons and multivariate regression were used to evaluate the impact of COPD on the number of days of ventilation, ICU LOS, total hospital LOS, and death, while controlling for other known risk factors, including acute myocardial infarction, renal failure, and age. RESULTS: The mortality rate in elective aneurysm patients did not differ (P =.99) between patients with (3.7%) or without COPD (3.7%). However, elective AAA repair was associated with longer hospital LOS (14.4 vs 12.3 days, P =.01), longer ICU LOS (6.5 vs 5.4 days, P =.01), and a higher incidence of requiring 96 hours or more ventilation (6.9% vs 3.6%, P =.02) in patients with COPD. Ruptured AAA affected 4.9% of patients and was strongly associated with COPD (P =.02); however, COPD did not result in a statistically significant increase in death (P =.25). CONCLUSIONS: Although COPD does not appear to increase operative death, it is associated with an increased risk of rupture. Elective repair of AAA should not be deferred in patients with COPD despite their higher LOSs and need for postoperative ventilation.     

Outcome Analysis of Blood Product Transfusion in Trauma Patients: A Prospective,Risk-Adjusted Study

BACKGROUND: Studies have confirmed adverse outcome associated with transfusion of packed red blood cells (PRBCs) in trauma; however, little data are available regarding other blood product transfusion, such as fresh frozen plasma (FFP) and platelets. The objective of this study was to examine risk-adjusted outcome in trauma with stratification by blood product type. METHODS: Prospective data were collected daily for 1,172 consecutive trauma patients admitted to the intensive care unit (ICU) during a 2-year period, including transfusion rates of blood products (PRBCs, FFP, platelets). Outcome assessment included infection rate, ventilator days (Vdays), ICU and hospital length of stay (LOS), and mortality. RESULTS: Blood products were transfused in 786 (67%) patients. The study cohort had a mean age of 43 +/- 21 years and Injury Severity Score (ISS) of 24 +/- 13. Although the majority of patients were men, women were more likely to be transfused (p < 0.001). Mean transfusion rates of PRBCs (5.5 +/- 9.6 U), FFP (5.4 +/- 11.4), and platelets (3.7 +/- 11.1) were high. Univariate analysis identified that blood product transfusion (any type) was associated with a significantly greater infection rate (34% vs. 9.4%; p < 0.001), hospital LOS (18.6 vs. 9 days; p < 0.001), ICU LOS (13.7 vs. 7.4 days; p < 0.001), Vdays (12.9 vs. 6.3 days; p < 0.001), and mortality (19% vs. 8.3%; p < 0.001). Multivariate analysis (risk-adjusted for severity of injury by ISS, age, sex, and race, and stratified by blood product type) confirmed that risk of infection increased by 5%, and hospital LOS, ICU LOS, and Vdays increased by 0.64, 0.42, and 0.47 days, respectively, for every unit of PRBCs given. Risk of death increased by 3.5% for every unit of FFP transfused. CONCLUSION: There is a dose-dependent correlation between blood product transfusion and adverse outcome (increased mortality and infection) in trauma patients.     

Profitable versus unprofitable expansion of trauma and critical care surgery

BACKGROUND: The American Association for the Surgery of Trauma has proposed that the specialty of trauma and critical care include emergency surgery. We assessed whether this change will have an impact on the financial challenges that this specialty confronts, including inadequate reimbursement for efforts exerted. METHODS: Over a 2-year period, we collected financial data on 6 trauma and critical care surgeons. Three included emergency surgery as part of their practice, but no private elective component. The other 3 included both emergency surgery and a private elective component. RESULTS: Trauma and critical care surgeons who had included emergency surgery but no private elective component had significantly lower charges (5,941,482 US dollars vs 9,209,535 US dollars), collections (1,439,913 US dollars vs 2,973,319 US dollars), generated relative value units (50,440 vs 80,327), generated reimbursement per relative value units (28.55 US dollars vs 37.02 US dollars), and margins (0.20 US dollars vs 1.48 US dollars) than their counterparts who had an elective surgery component. CONCLUSION: The addition of emergency surgery did not improve the financial viability of trauma and critical care as a specialty. Without significant hospital or governmental financial support, the only viable financial option is to develop a substantial private practice that cross-subsidizes the practice of trauma and critical care. The appropriate professional bodies should incorporate changes in work processes that will allow the specialty to survive professionally but also financially.     

Surgical repair of bladder exstrophy in the modern era: contemporary practice patterns and the role of hospital case volume

PURPOSE: Bladder exstrophy is a rare condition, and data are lacking regarding practice patterns in its surgical management. We used a large nationwide database to investigate practice patterns of bladder exstrophy repair. MATERIALS AND METHODS: We used the Nationwide Inpatient Sample (1988 to 2000) to identify patients who underwent surgical repair of bladder exstrophy (International Classification of Disease-9 code 578.6). We analyzed factors affecting practice patterns and outcomes. Hospital volume was based on caseload during the highest volume year of study participation (high volume 5 or more, mid volume 3 to 4 and low volume less than 3 cases). RESULTS: We identified 407 cases. Approximately half of the patients (53.2%) were hospitalized within 24 hours of birth, although 28% of patients were older than 1 year. Of the patients 54% were male. Exstrophy repair is extremely resource intensive. In this series mean length of hospital stay (LOS) was 24.6 +/- 22.8 days, and mean inflation adjusted hospital charges were 62,302 dollars (median 39,978 dollars). High volume hospitals (HVHs) had lower hospital charges (37,370 dollars) than mid volume (51,778 dollars) or low volume hospitals (LVHs, 50,474 dollars, p = 0.0095). On multivariate regression HVHs had lower charges even after controlling for other significant predictors, including LOS (p <0.0001). Patients at HVHs were more likely to undergo osteotomy (p = 0.007). Six patients died after exstrophy repair (1.5%), all of whom had been born prematurely (p <0.0001). Although death was more likely at LVHs, this was due to the fact that more patients at LVHs were born prematurely (4.2% at HVHs vs 5.9% at mid volume hospitals and 11.1% at LVHs, p = 0.027). CONCLUSIONS: Bladder exstrophy repair carries a high risk of morbidity and is resource intensive. Variations between high and low volume hospitals in practice patterns and case mix may contribute to observed differences in resource use, LOS and clinical outcomes.     

Increased incidence of heater-related burn injury during a power crisis

HYPOTHESIS: Recent power shortages in California resulted in rolling blackouts and increased utility prices. Residents turned to alternative heating devices, such as space heaters, to decrease utility bills. Our hypothesis is that the incidence of heater-related injuries increased owing to the use of alternative heating methods during the power crisis. DESIGN: Retrospective case-series database and medical record review of all burn admissions for the 4 months of November through February for the period 1998-2002. SETTING: Regional pediatric and adult burn unit in northern California. PATIENTS: Patients admitted during the study interval with burn injury. MAIN OUTCOME MEASURES: Parameters recorded included patient demographics, cause of burn, total body surface area burn, number of operative procedures, and hospital length of stay during each of the 4 months in the interval. RESULTS: A total of 512 patients were admitted during all 4-month intervals. During the power crisis there were significant increases in the number of hospital admissions (151 in 2000-2001 vs 117 in 1998-1999, 124 in 1999-2000, and 152 in 2001-2002) and heater-related burn admissions (36 in 2000-2001 vs 25 in 1998-1999, 26 in 1999-2000, and 29 in 2001-2002). The percentage total body surface area burn (mean +/- SEM, 24.0% +/- 4.6% in 2000-2001 vs 16.5% in 1998-1999, 12.3% in 1999-2000, and 12.0% in 2001-2002), hospital length of stay (15.0 days in 2000-2001 vs 9.9 days in 1998-1999, 12.3 days in 1999-2000, and 7.0 days 2001-2002), and the number of operations (55 in 2000-2001 vs 7 in 1998-1999, 18 in 1999-2000, and 19 in 2001-2002) also increased during the crisis. CONCLUSIONS: The number of heater-related burn admissions, as well as their magnitude, increased during the energy crisis, resulting in increased resource use and health care costs. The economic stresses of the power shortage had societal costs that extended far beyond the price of electricity.     

Advantages of laparoscopic appendectomy in the elderly

Laparoscopic appendectomy (LA) has gained in popularity in recent years. The number of elderly patients undergoing appendectomy has increased as that segment of the population has increased in number; however, the utility and benefits of LA in the elderly population are not well established. We hypothesized that LA in the elderly has distinctive advantages in perioperative outcomes over open appendectomy (OA). We queried the 1997 to 2003 North Carolina Hospital Association Patient Data System for all patients with the primary ICD-9 procedure code for OA and LA. Patients > or = 65 years of age (elderly) were identified and reviewed. Outcomes including length of stay (LOS), charges, complications, discharge location, and mortality were compared between the groups. There were 29,244 appendectomies performed in adult patients (>18 years old) with 2,722 of these in the elderly. The annual percentage of LA performed in the elderly increased from 1997 to 2003 (11.9-26.9%, P < 0.0001). When compared with OA, elderly patients undergoing LA had a shorter LOS (4.6 vs 7.3 days, P = 0.0001), a higher rate of discharge to home (91.4 vs 78.9%, P = 0.0001) as opposed to a step-down facility, fewer complications (13.0 vs 22.4%, P = 0.0001), and a lower mortality rate (0.4 vs 2.1%, P = 0.007). When LA was compared with OA in elderly patients with perforated appendicitis, LA resulted in a shorter LOS (6.8 vs 9.0 days, P = 0.0001), a higher rate of discharge to home (86.6 vs 70.9%, P = 0.0001), but equivalent total charges (dollars 22,334 vs dollars 23,855, P = 0.93) and mortality (1.0 vs 2.98%, P = 0.10). When elderly patients that underwent LA were compared with adult patients (18-64 years old), they had higher total charges (dollars 16,670 vs dollars 11,160, P = 0.0001) but equivalent mortality (0.37 vs 0.15%, P = 0.20). The use of laparoscopy in the elderly has significantly increased in recent years. In general, the safety and efficacy of LA is demonstrated by a reduction in mortality, complications, and LOS when compared with OA. The laparoscopic approach to the perforated appendix in the elderly patient has advantages over OA in terms of decreased LOS and a higher rate of discharge to home as opposed to rehabilitation centers, nursing homes, or skilled nursing care. When compared with all younger adults, the laparoscopic approach in the elderly was associated with equal mortality rates even though hospitalization charges were higher. Laparoscopy may be the preferred approach in elderly patients who require appendectomy.     

The economic benefit of organizational restructuring of the cardiothoracic intensive care unit

OBJECTIVES: Compare cost/benefits of organizational restructuring of the cardiac intensive care unit (CICU). DESIGN: Prospective, with a retrospective control period. SETTING: Academic medical center. Participants: Sixty-six CICU patients (prospective) and 57 patients who received care before restructuring (retrospective) were compared. Entrance criteria were constant for both study periods. INTERVENTIONS: The CICU was restructured from a level III ICU to a level I ICU with the initiation of a consultant CICU service. The CICU service provided an attending physician dedicated to ICU care daily. All cardiac patients admitted into the CICU received consultation by the CICU service. MEASUREMENTS AND MAIN RESULTS: The average postoperative intubation time decreased during the intervention period (61% extubated within 6 hours v 12%, p = 0.004). Pharmacy, radiology, laboratory, and ICU costs decreased 279 US dollars (p = 0.004), 196 US dollars (p = 0.003), 190 US dollars (p = 0.15), and 470 US dollars (p = 0.12), respectively. The ICU length of stay (0.28 days shorter) as well as the overall postsurgery stay (0.54 days shorter) were reduced in the intervention period (p = 0.11 and 0.10, respectively). CONCLUSIONS: The CICU service significantly reduced both total ICU-related costs ($1,173/patient) and overall costs (2,285 US dollars/patient) during the intervention period. Professional fees only reduced overall savings by 8%. These results indicate that organizational restructuring of the CICU to newer models can reduce costs associated with cardiac surgery.     

Laparoscopic nephrectomy: new standard of care?

OBJECTIVE: The pace of implementation of a laparoscopic nephrectomy programme is affected by factors including surgical expertise, case load, learning curves and outcome audits. We report our experience in introducing a laparoscopic nephrectomy programme over a 3-year period. METHODS: From January 2001 to December 2003, 187 nephrectomies were performed (105 by conventional surgery, 82 by laparoscopy). Hand-assisted laparoscopy was used predominantly. The indications for surgery, factors affecting the approach and outcome parameters were studied. A cost comparison was made between patients with similar-sized renal tumours undergoing laparoscopic versus open surgery. RESULTS: Most operations were performed for malignancy in both the open (70%) and laparoscopic (67%) surgery groups. The laparoscopic approach was most commonly used in upper tract transitional cell cancers (TCCs; 70% of 30 patients) and benign pathologies (49% of 35 patients), followed by radical nephrectomies (34% of 99 patients) and donor nephrectomies (44% of 23 patients). There was a rapid rise in laparoscopic surgeries, from 30% in 2001 to 58% in 2002. The median hospital stay was 5.8 days in the laparoscopic group and 8.1 days in the open surgery group. The procedure cost for laparoscopic surgery was 4,943 dollars compared with 4,479 dollars for open surgery. However, due to a shorter hospital stay, the total hospital cost was slightly lower in the laparoscopic group (7,500 dollars versus 7,907 dollars). CONCLUSION: The laparoscopic approach for various renal pathologies was quickly established with a rapid increase in the number of laparoscopic procedures.