Cost-utility analysis of emergency department thoracotomy for trauma victims

BACKGROUND: Our objective was to assess the cost-effectiveness of emergency department thoracotomy (EDT) performed on both penetrating and blunt trauma victims, using both published survival and outcome data and previously unaccounted for data on the cost of occupational exposure. METHODS: Cost-utility analysis was performed using decision-analytic models constructed for both penetrating and blunt trauma scenarios. Survival and impairment data, the rates and costs of occupational exposure, and the utilities of neurologic impairment and provider seroconversion were all based on published literature. Costs of EDT were estimated using the National Inpatient Sample (NIS) from the Health Care Utilization Project database. One-way sensitivity analyses on input parameters and probabilistic sensitivity analyses using Monte Carlo simulations were performed. RESULTS: The incremental cost-effectiveness ratio of EDT for penetrating trauma was $16,125 per quality-adjusted life year (QALY), and less than $50,000 per QALY with a 93.4% probability. The incremental cost-effectiveness ratio for blunt trauma was $163,136 per QALY, and less than $50,000 per QALY with a 37% probability. Neither model was sensitive to provider exposure. The penetrating model was insensitive to the probability of neurologically intact survival, the utility adjustment, procedure costs, and long-term care. The blunt model was sensitive to the probabilities of survival and of neurologic impairment. CONCLUSIONS: EDT is cost-effective for penetrating trauma, and not cost-effective for blunt trauma given current rates of survival and impairment. Occupational exposure does not significantly impact the cost-effectiveness of the procedure.     

Cervical spine evaluation in urban trauma centers: lowering institutional costs and complications through helical CT scan

BACKGROUND: In the evaluation of the cervical spine (c-spine), helical CT scan has higher sensitivity and specificity than plain radiographs in the moderate- and high-risk trauma population, but is more costly. We hypothesize that institutional costs associated with missed injuries make helical CT scan the least costly approach. STUDY DESIGN: A cost-minimization study was performed using decision analysis examining helical CT scan versus radiographic evaluation of the c-spine. Parameter estimates were obtained from the literature for probability of c-spine injury, probability of paralysis after missed injury, plain film sensitivity and specificity, CT scan sensitivity and specificity, and settlement cost of missed injuries resulting in paralysis. Institutional costs of CT scan and plain radiography were used. Sensitivity analyses tested robustness of strategy preference, accounted for parameter variability, and determined threshold values for individual parameters on strategy preference. RESULTS: C-spine evaluation with helical CT scan has an expected cost of US 554 dollars per patient compared with US 2,142 dollars for plain films. CT scan is the least costly alternative if threshold values exceed US 58,180 dollars for institutional settlement costs, 0.9% for probability of c-spine fracture, and 1.7% for probability of paralysis. Plain films are least costly if CT scan costs surpass US 1,918 dollars or plain film sensitivity exceeds 90%. CONCLUSIONS: Helical CT scan is the preferred initial screening test for detection of cervical spine fractures among moderate- to high-risk patients seen in urban trauma centers, reducing the incidence of paralysis resulting from false-negative imaging studies and institutional costs, when settlement costs are taken into account.     

Alcohol interventions for trauma patients treated in emergency departments and hospitals: a cost benefit analysis

OBJECTIVE: To determine if brief alcohol interventions in trauma centers reduce health care costs. SUMMARY BACKGROUND DATA: Alcohol-use disorders are the leading cause of injury. Brief interventions in trauma patients reduce subsequent alcohol intake and injury recidivism but have not yet been widely implemented. METHODS: This was a cost-benefit analysis. The study population consisted of injured patients treated in an emergency department or admitted to a hospital. The analysis was restricted to direct injury-related medical costs only so that it would be most meaningful to hospitals, insurers, and government agencies responsible for health care costs. Underlying assumptions used to arrive at future benefits, including costs, injury rates, and intervention effectiveness, were derived from published nationwide databases, epidemiologic, and clinical trial data. Model parameters were examined with 1-way sensitivity analyses, and the cost-benefit ratio was calculated. Monte Carlo analysis was used to determine the strategy-selection confidence intervals. RESULTS: An estimated 27% of all injured adult patients are candidates for a brief alcohol intervention. The net cost savings of the intervention was 89 US dollars per patient screened, or 330 US dollars for each patient offered an intervention. The benefit in reduced health expenditures resulted in savings of 3.81 US dollars for every 1.00 US dollar spent on screening and intervention. This finding was robust to various assumptions regarding probability of accepting an intervention, cost of screening and intervention, and risk of injury recidivism. Monte Carlo simulations found that offering a brief intervention would save health care costs in 91.5% of simulated runs. If interventions were routinely offered to eligible injured adult patients nationwide, the potential net savings could approach 1.82 billion US dollars annually. CONCLUSIONS: Screening and brief intervention for alcohol problems in trauma patients is cost-effective and should be routinely implemented.     

Emergency department resuscitative thoracotomy for nontorso injuries

BACKGROUND: Resuscitative thoracotomy performed in the emergency department (EDT) continues to have clear indications in patients sustaining trauma to the torso, particularly penetrating injuries. However, adjunctive use of aortic cross-clamping during EDT for hemorrhagic shock also may be useful in the acute resuscitation of patient with nontorso injuries (NTI). We questioned the utility of EDT in patients with nontorso trauma. METHODS: Patients undergoing EDT have been prospectively followed since 1977 at our regional level I trauma center. RESULTS: During the 26-year study period, 959 patients underwent EDT; 27 (3%) of these patients underwent EDT for penetrating NTI. Three (11%) of these patients survived to leave the hospital, with only 1 patient sustaining mild neurologic deficit. The mechanism of injury in the survivors was stab wound to the neck (1), gunshot wound to the neck (1), and extremity vascular injury (1). All survivors of EDT for NTI underwent prehospital cardiopulmonary resuscitation and successful endotracheal intubation in the field. There were no survivors of EDT for penetrating injury to the head. CONCLUSIONS: Resuscitative EDT with aortic cross-clamping is a potential adjunct in the acute resuscitation of NTI involving penetrating neck or extremity vascular injuries.     

Cost-effective use of breast biopsy techniques in a Veterans health care system

BACKGROUND: Breast health has become an increasingly important issue among the veteran population. Options for the evaluation of a breast mass or a suspicious mammographic finding include open surgical biopsy at the Veterans Affairs (VA) hospital or percutaneous image-guided biopsy at an affiliated academic institution. We examined the costs and trends in the use of surgical versus percutaneous image-guided biopsy procedures in this diagnostic algorithm. METHODS: A retrospective review was performed of 62 patients who presented to the VA General Surgery Clinic with a breast mass or abnormal mammogram from 2003 to 2005. The Massachusetts Utilization Multiprogramming System and the Decision Support System software packages were used to track costs of procedures, by Current Procedure Terminology code and date of service, performed at the affiliated academic institution and at the VA hospital. These data were analyzed and described using the R statistical computing environment. RESULTS: Forty-six patients were evaluated using open biopsy techniques in the VA operating room, including 8 incisional biopsies, 21 excisional biopsies, and 17 needle-localization excisional biopsies. Sixteen patients were evaluated using minimally invasive biopsies at the affiliated academic institution, including 3 ultrasound-guided cyst aspirations, 6 ultrasound-guided core biopsies/vacuum-assisted core biopsies, 10 stereotactic breast biopsies, and 1 fine-needle aspiration. The average cost to evaluate a breast mass or abnormal mammographic finding in the operating room was 4,368.00 dollars (SD, 2,586.00 dollars), with a median cost of 3,479.00 dollars. The average cost to evaluate a breast mass or mammographic abnormality using percutaneous image-guided procedures was 1,267.00 dollars (SD, 536.00 dollars), with a median of 1,239.00 dollars. From 2003 to 2005, the proportion of percutaneous biopsies increased from 13% to 48%, whereas the proportion of open biopsies decreased from 88% to 52%. CONCLUSIONS: Over a recent 3-year period, we observed a 3.8-fold increase in the use of percutaneous image-guided techniques for the evaluation of breast lesions in the VA Tennessee Valley Healthcare System. Diagnosis by percutaneous techniques allows planning for a definitive surgery if a lesion is malignant or possible avoidance of a surgical intervention if the lesion is benign. Our data show that the costs associated with open biopsy techniques exceed those associated with percutaneous biopsies. For VA hospitals with available resources, the option of image-guided percutaneous biopsy techniques is a cost-effective alternative to open surgical biopsy.     

Emergency thoracotomy in trauma: rationale, risks, and realities.

Emergency department thoracotomy (EDT) may serve as a life-saving tool when performed for the right indications, in selected patients, and in the hands of a trained surgeon. Critically injured patients 'in extremis' arrive at an increasing rate in the trauma bay, as an effect of improved pre-hospital trauma systems and rapid transport. Any patient in near, or full cardiovascular shock prompts the trauma surgeon to rapidly perform a thoracotomy. The EDT procedure is managed best by surgeons familiar with, and experienced in, penetrating cardiothoracic injuries. However, the geographical differences in trauma epidemiology lends no, or only scarce, experience with this procedure in most European trauma centres. Consequently, mandatory training is imperative for success. The rationale for performing an EDT is to: (I) resuscitate the agonal patient with penetrating cardiothoracic injuries; (II) release cardiac tamponade by evacuation of pericardial blood; (III) immediately control hemorrhage and repair cardiac or pulmonary injury; (IV) perform open cardiac massage; and (V) place a thoracic aortic cross-clamp to redistribute the remaining blood volume, and perfuse the carotids and coronary arteries. The prevalence rates of blood-borne viruses reported in critically injured patients in the USA (10-20%) exceed the prevalence in the Nordic countries (HIV prevalence < 1% in general population). However, risk is not negligible and mandated universal precautions are needed. The literature is rich in series describing the use of EDT, however, the best evidence is derived from a few prospective trials. EDT saves about one in every five patients with isolated penetrating cardiac injury, while > 98% die after blunt injury. Based on an updated review of the current available literature, this paper presents the current evidence regarding the rationale, risk, and outcomes for employing EDT in the field of trauma surgery.     

The acute medical care costs of fall-related injuries among the U.S. older adults

OBJECTIVES: Falls in the older adults are a major public health concern. The growing population of adults 65 years or older, advances in medical care and changes in the costs of care motivated our study of the acute health care costs of fall-related injuries among the older adults in the United States of America. DESIGN AND SETTINGS: The Market Scan Medicare Supplemental database 1998 was used to estimate reimbursed costs for hospital, emergency department (ED), and outpatient clinic treatments for unintentional falls among older adults. RESULTS: A fall on the same level due to slipping, tripping, or stumbling was the most common mechanism of injury (28%). Mean hospitalisation cost was 17,483 US dollars(S.D.: 22,426 US dollars) in 2004 US dollars. Femur fracture was the most expensive type of injury (18,638 US dollars, S.D.: 19,990 US dollars). The mean reimbursement cost of an ED visit was 236 US dollars and 412 US dollars for an outpatient clinic visit. CONCLUSION: The magnitude of the economic and social costs of falls in older adults underscores the need for active research in the field of falls prevention.     

Outcomes after emergency department thoracotomy for penetrating cardiac injuries: a new perspective

Previous reports have described penetrating cardiac injuries as the anatomic injury with the greatest opportunity for emergency department thoracotomy (EDT) survival. We hypothesize that actual survival rates are lower than that initially reported. A retrospective review of our EDT experience was performed. Data collected included injury mechanism and location, presence of measurable ED vital signs, initial ED cardiac rhythm, GCS, method of transportation, and survival. Logistic regression analysis identified predictors of survival. Ninety-four of 237 patients presented penetrating cardiac injuries after EDT. Eighty-nine patients (95%) were males. Measurable ED vital signs were present in 15 patients (16%). Cardiac injuries were caused by GSW in 82 patients (87%) and SW in 12 patients (13%). Fifteen patients (16%) survived EDT and were taken to the operating room, while eight patients (8%) survived their entire hospitalization. All survivors were neurologically intact. Survival rates were 5% for GSW and 33% for SW. Mechanism of injury (SW), prehospital transportation by police, higher GCS, sinus tachycardia, and measurable ED vital signs were associated with improved survival. In urban trauma centers where firearm injuries are much more common than stabbings, the presence of a penetrating cardiac injury may no longer be considered a predictor of survival after EDT.     

Survival after emergency department thoracotomy: review of published data from the past 25 years

BACKGROUND: Emergency department thoracotomy (EDT) has become standard therapy for patients who acutely arrest after injury. Patient selection is vitally important to achieve optimal outcomes without wasting valuable resources. The aim of this study was to determine the main factors that most influence survival after EDT. STUDY DESIGN: Twenty-four studies that included 4,620 cases from institutions that reported EDT for both blunt and penetrating trauma during the past 25 years were reviewed. The primary outcomes analyzed were in-hospital survival rates. RESULTS: EDT had an overall survival rate of 7.4%. Normal neurologic outcomes were noted in 92.4% of surviving patients. Factors reported as influencing outcomes were the mechanism of injury (MOI), location of major injury (LOMI), and signs of life (SOL). Survival rates for MOI were 8.8% for penetrating injuries and 1.4% for blunt injuries. When penetrating injuries were further separated, the survival rates were 16.8% for stab wounds and 4.3% for gunshot wounds. For the LOMI, survival rates were 10.7% for thoracic injuries, 4.5% for abdominal injuries, and 0.7% for multiple injuries. If the LOMI was the heart, the survival rate was the highest at 19.4%. The third factor influencing outcomes was SOL. If SOL were present on arrival at the hospital, survival rate was 11.5% in contrast to 2.6% if none were present. SOL present during transport resulted in a survival rate of 8.9%. Absence of SOL in the field yielded a survival rate of 1.2%. There was no clear single independent preoperative factor that could uniformly predict death. CONCLUSIONS: The best survival results are seen in patients who undergo EDT for thoracic stab injuries and who arrive with SOL in the emergency department. All three factors-MOI, LOMI, and SOL-should be taken into account when deciding whether to perform EDT. Uniform reporting guidelines are needed to further elucidate the role of EDT taking into account the combination of MOI, LOMI, and SOL.     

Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes

In the past three decades there has been a significant clinical shift in the performance of emergency department thoracotomy (EDT), from a nearly obligatory procedure before declaring any trauma patient to select patients undergoing EDT. The value of EDT in resuscitation of the patient in profound shock but not yet dead is unquestionable. Its indiscriminate use, however, renders it a low-yield and high-cost procedure. Overall analysis of the available literature indicates that the success of EDT approximates 35% in the patient arriving in shock with a penetrating cardiac wound, and 15% for all penetrating wounds. Conversely, patient outcome is relatively poor when EDT is done for blunt trauma; 2% survival in patients in shock and less than 1% survival with no vital signs. Patients undergoing CPR upon arrival to the emergency department should be stratified based upon injury and transport time to determine the utility of EDT. The optimal application of EDT requires a thorough understanding of its physiologic objectives, technical maneuvers, and the cardiovascular and metabolic consequences.     

A cost-effectiveness analysis of intraoperative cholangiography in the prevention of bile duct injury during laparoscopic cholecystectomy

BACKGROUND: Recent population-based studies have demonstrated that the use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) is associated with a decrease in the rate of common bile duct (CBD) injury. The cost implications of a management strategy involving routine IOC use have not been adequately evaluated. STUDY DESIGN: Decision analytic models were developed to analyze costs and benefits of routine IOC use during LC. The models were used to calculate the cost per life saved, cost per CBD injury avoided, and incremental cost of IOC when used routinely. Transition probabilities, costs, and outcomes were derived from published sources. Sensitivity analyses were used to account for uncertainty in these estimates. RESULTS: Using base-case estimates, management of patients undergoing LC with routine IOC would cost 100 dollars more per LC. Routine IOC would prevent 2.5 deaths for every 10,000 patients at a cost of 390,000 dollars per life saved (13,900 dollars per life year saved). The cost per CBD injury avoided with IOC use is 87,143 dollars. The cost per CBD injury avoided is less for procedures done in high-risk patients (approximately 8,000 dollars) or by less experienced surgeons (approximately 61,000 dollars). CONCLUSIONS: These models describe settings where the cost of IOC and the reduction in CBD injury rates make routine IOC use cost effective. Routine IOC use among less experienced surgeons and in high-risk operations is the most cost effective, but the cost implications of routine use for the general population should also be considered cost effective.     

Is emergency department resuscitative thoracotomy futile care for the critically injured patient requiring prehospital cardiopulmonary resuscitation?

BACKGROUND: Documented prehospital asystole justifies termination of resuscitation, but recently it has been proposed to extend this policy to patients in the field with pulseless electrical activity. Consequently, we questioned whether resuscitative thoracotomy is warranted in the critically injured patient who fails to respond to prehospital CPR. STUDY DESIGN: A prospective database of all emergency department resuscitative thoracotomies (EDT) performed at our Level I trauma center has been maintained since January 1977. These registry data were augmented by a review of prehospital paramedic records for all survivors of EDT to verify length of CPR. RESULTS: During the 26-year study period, 959 patients underwent EDT. Of the 62 patients who survived to leave the hospital, 26 (42%) required prehospital CPR. The injury mechanism in these 26 patients was stab wounds in 18 (69%), gunshot wounds in 4 (15%), and blunt trauma in 4 (15%). The duration of prehospital CPR ranged from 3 to 15 minutes and in 7 patients CPR exceeded 10 minutes. Five survivors had asystole documented at the time of EDT; four of these patients had good functional outcomes at discharge. Each of these patients had pericardial tamponade from ventricular stab wounds. Patients with blunt trauma had uniformly dismal neurologic outcomes. CONCLUSIONS: EDT after prehospital CPR can be used to salvage select critically injured patients. Based on these data, we propose that resuscitative thoracotomy is futile care in patients with blunt trauma requiring prehospital CPR longer than 5 minutes, and in patients with penetrating trauma with more than 15 minutes of prehospital CPR. EDT is warranted in those patients with penetrating trauma with less than 15 minutes of prehospital CPR, and should be performed despite documented asystole on arrival if pericardial tamponade is the proximate event.     

Spiral computed tomography for the initial evaluation of spine trauma: A new standard of care?

BACKGROUND: Although spiral computed tomographic scanning (SCT) is frequently used for spinal imaging in injured patients, many trauma centers continue to rely on plain film radiography (PFR). The purpose of this study was to determine the effects of a trauma center's transition from PFR to SCT for initial spine evaluation in trauma patients by comparing diagnostic sensitivity, time required for radiographic imaging, costs, charges, and radiation exposure. METHODS: Registry-based review of all trauma patients evaluated for spinal trauma during two three-month intervals, one before (1999, "X-ray Group"), and one after (2002, "CT Group") adopting SCT as the initial spinal imaging method. Demographic data, mechanism of injury, Injury Severity Score (ISS), the presence and location of spine fractures, and the results of all spine imaging were recorded. The dates and diagnostic sensitivity for spine fractures, time for initial imaging, costs, and charges were compared between groups. Radiation exposure associated with both SCT and PFR of the spine was measured. RESULTS: There were 254 patients in the X-ray Group and 319 in the CT Group, with similar demographic data, ISS, mechanism of injury, and incidence of spine fractures. Sensitivity in the detection of spine fractures was 70% (14 out of 20) in the X-ray Group compared with 100% (34 out of 34) for the CT Group (p < 0.001). Mean time in the radiology department during initial evaluation decreased significantly in the CT Group compared with the X-ray Group (1.0 hours vs. 1.9 hours; p < 0.001). SCT of the spine was associated with higher mean overall spinal imaging charges than PFR (4,386 dollars vs. 513 dollars, p < 0.001), but a similar mean overall spinal imaging cost per patient (172 dollars vs. 164 dollars). Radiation exposure was higher with SCT versus PFR for cervical spine imaging (26 mSv vs. 4 mSv) but SCT involved lower levels of exposure than PFR for thoracolumbar imaging (13 mSv vs. 26 mSv). CONCLUSIONS: SCT is a more rapid and sensitive modality for evaluating the spine compared with PFR and is obtained at a similar cost. The advantages of SCT suggest that this readily available diagnostic modality may replace PFR as the standard of care for the initial evaluation of the spine in trauma patients.     

The occupational risk to dental anesthesiologists of acquiring 3 bloodborne pathogens

OBJECTIVE: To estimate the occupational risk to dental anesthesiologists of contracting 3 bloodborne pathogens: hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency virus (HIV). METHODS: Through an anonymously returned, mailed questionnaire, dental anesthesiologists in Canada and the United States provided information regarding percutaneous and mucocutaneous contacts with contaminated fluid during the treatment of patients under deep sedation and general anesthesia as well as other general practice information. A mathematical model was applied to determine the occupational risk. RESULTS: Of the 101 (65%) returned questionnaires, 98 reported having treated patients within the previous 6 months. Of these, 41 (42%) had at least one percutaneous accident (89 accidents in total), and the projected mean annual injury rate for dental anesthesiologists overall was 1.82. The most common causes of injury were burs, intraoral needles, and dental instruments. Operator error during use was associated with 31% of reported accidents. Significantly more injuries were reported by those who also reported a mucocutaneous contact and by those working more than 25 hours per week. The projected mean annual number of mucocutaneous exposures was 0.88 for dental anesthesiologists overall. CONCLUSIONS: The calculated annual risk to the average dental anesthesiologist of acquiring HBV (if not immune), HCV, and HIV following percutaneous injury was very low for all infections (HBV the most; HIV the least). The risk of contracting HIV following mucocutaneous contact was extremely low.     

Outcomes and costs of acute treatment of traumatic brain injury

BACKGROUND: Although there are nearly a quarter of a million hospitalizations for traumatic brain injury (TBI) in the United States each year, data on the outcomes and costs of TBI treatment in the acute-care setting are limited. METHODS: Using a large, geographically diverse, multihospital database, we examined inpatient records for persons aged 16 years or older who were hospitalized for TBI between January 1, 1997, and June 30, 1999. Patients were stratified by TBI severity using an adaptation of the Abbreviated Injury Scale for administrative data (ICD/AIS), as follows: 2 = "moderate"; 3 = "serious"; 4 = "severe"; and 5 = "critical." Patient characteristics, patterns of treatment, and outcomes and costs were examined by injury severity and mechanism of injury. RESULTS: Of 8,717 study subjects identified, 12.5% had moderate, 44.8% had serious, 29.6% had severe, and 13.2% had critical TBI. Falls were the most common reported cause of injury (40.8%), followed by motor vehicle crashes (39.3%), blows to the head (11.3%), and gunshot wounds (2.4%). Average length of stay in hospital ranged from 6.7 days for moderate TBI to 17.5 days for critical TBI. The overall rate of death in hospital was relatively low among patients with moderate (1.3%), serious (5.7%), and severe (8.7%) TBIs, but much higher among the most critically injured patients (52.0%). Costs of hospitalization averaged 8,189 dollars for moderate, 14,603 dollars for serious, 16,788 dollars for severe, and 33,537 dollars for critical TBI. Costs also varied by injury type, averaging 20,084 dollars for gunshot wounds, 20,522 dollars for motor vehicle crashes, 15,860 dollars for falls, and 19,949 dollars for blows to the head. CONCLUSION: The economic burden of TBI in the acute-care setting is substantial; treatment outcomes and costs vary considerably by TBI severity and mechanism of injury.     

Reappraisal of emergency room thoracotomy in a changing environment

The efficacy of resuscitative emergency room thoracotomy (ERT), particularly in blunt injury, has been questioned. Wide application of the procedure may not be cost effective. The risk of exposure and lethal infection to medical personnel during ERT is considerable. For the past decade, the policy at this institution has been to perform ERT on all moribund patients sustaining penetrating torso injury and all patients sustaining blunt injury with any evidence of cardiac electrical activity. To evaluate whether such a liberal policy is currently justified, the charts of all patients undergoing ERT over a 4-year period were reviewed. One hundred twelve patients underwent ERT; 24 (21%) sustained penetrating injury, 88 (79%) blunt injury. The overall survival rate was 1.8%. Penetrating injury had a 4.2% survival and blunt injury 1.1%. No patients with CPR initiated at the scene and required throughout transport survived. In those patients with both blood pressure and spontaneous respirations present in the field, survival rate was 11.8%. Survival rate in patients manifesting sinus rhythm or ventricular fibrillation upon arrival at the ER was 6.4%. No survivors were noted among patients coming to the hospital with an idioventricular rhythm or asystole. The total hospital charges for patients undergoing ERT exceeded reimbursement by $59,565. Screening for HIV and hepatitis could be documented in only two patients; both were negative. Liberal performance of ERT has dismal results, incurs monetary loss, and affords a greater potential for exposure to lethal infection. Emergency room thoracotomy is justified only when vital signs or a resuscitatible cardiac rhythm are present in the field or ER and deteriorate shortly before thoracotomy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Health care costs associated with traumatic brain injury and psychiatric illness in adults

A cohort design was used to determine the contribution of traumatic brain injury (TBI) and psychiatric illness to health care costs for adolescents and adults in the 3 years following mild or moderate-to-severe TBI compared to a matched cohort without TBI, controlling for confounders. In all, 3756 subjects 15 years or older from a large health maintenance organization database were examined. We identified subjects who sustained a TBI in 1993 (n=939) and selected three control subjects per TBI-exposed subject (n=2817), matched for age, sex, and enrollment at the time of injury. Unadjusted mean costs in 2009-adjusted dollars were compared using Kruskal-Wallis tests and Mann-Whitney U tests, and adjusted mean costs were compared using gamma regression analyses. Average costs were 76% higher in the 3 years after injury for the mild TBI group, and 5.75 times greater for the moderate-to-severe TBI group compared to controls. The presence of psychiatric illness was associated with more than doubling of total costs for both inpatient and outpatient non-mental health care. Gamma regression analyses confirmed significantly higher costs in patients with TBI or psychiatric illness. A significant interaction between moderate-to-severe TBI and psychiatric illness indicated a 3.39 times greater cost among patients with both exposures compared with those exposed to moderate-to-severe TBI without psychiatric illness. TBI and psychiatric illness were each associated with significant increases in health care costs; those with the combination of moderate-to-severe TBI and psychiatric illness had much higher costs than any other group.     

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.