RESUMO
BACKGROUND: This study aimed to characterize the association of preoperative acute cholangitis (PAC) with surgical outcomes and healthcare costs. METHODS: Patients who underwent pancreaticoduodenectomy (PD) between 2013 and 2021 were identified using 100% Medicare Standard Analytic Files. PAC was defined as the occurrence of at least 1 episode of acute cholangitis within the year preceding surgery. Multivariable regression analyses were used to compare postoperative outcomes and costs relative to PAC. RESULTS: Among 23,455 Medicare beneficiaries who underwent PD, 2,217 patients (9.5%) had at least 1 episode of PAC. Most patients (n = 14,729 [62.8%]) underwent PD for a malignant indication. On multivariable analyses, PAC was associated with elevated odds of surgical site infection (odds ratio [OR], 1.14; 95% CI, 1.01-1.29), sepsis (OR, 1.17; 95% CI, 1.01-1.37), extended length of stay (OR, 1.13; 95% CI, 1.01-1.26), and readmission within 90 days (OR, 1.14; 95% CI, 1.04-1.26). Patients with a history of PAC before PD had a reduced likelihood of achieving a postoperative textbook outcome (OR, 0.83; 95% CI, 0.75-0.92) along with 87.8% and 18.4% higher associated preoperative and postoperative healthcare costs, respectively (all P < .001). Overall costs increased substantially among patients with more than 1 PAC episode ($59,893 [95% CI, $57,827-$61,959] for no episode vs $77,922 [95% CI, $73,854-$81,990] for 1 episode vs $101,205 [95% CI, $94,871-$107,539] for multiple episodes). CONCLUSION: Approximately 1 in 10 patients undergoing PD experienced an antecedent PAC episode, which was associated with adverse surgical outcomes and greater healthcare expenditures.
Assuntos
Colangite , Pancreaticoduodenectomia , Humanos , Pancreaticoduodenectomia/economia , Pancreaticoduodenectomia/efeitos adversos , Colangite/economia , Colangite/cirurgia , Masculino , Feminino , Idoso , Estados Unidos , Gastos em Saúde/estatística & dados numéricos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Idoso de 80 Anos ou mais , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Período Pré-Operatório , Infecção da Ferida Cirúrgica/economia , Infecção da Ferida Cirúrgica/epidemiologia , Readmissão do Paciente/estatística & dados numéricos , Readmissão do Paciente/economia , Medicare/economia , Sepse/economia , Doença Aguda , Estudos Retrospectivos , Custos de Cuidados de Saúde/estatística & dados numéricos , Resultado do TratamentoRESUMO
OBJECTIVE: To evaluate inter-hospital variation in 90-day total episode spending for sepsis, estimate the relative contributions of each component of spending, and identify drivers of spending across the distribution of episode spending on sepsis care. DATA SOURCES/STUDY SETTING: Medicare fee-for-service claims for beneficiaries (n=324,694) discharged from acute care hospitals for sepsis, defined by MS-DRG, between October 2014 and September 2018. RESEARCH DESIGN: Multiple linear regression with hospital-level fixed effects was used to identify average hospital differences in 90-day episode spending. Separate multiple linear regression and quantile regression models were used to evaluate drivers of spending across the episode spending distribution. RESULTS: The mean total episode spending among hospitals in the most expensive quartile was $30,500 compared with $23,150 for the least expensive hospitals ( P <0.001). Postacute care spending among the most expensive hospitals was almost double that of least expensive hospitals ($7,045 vs. $3,742), accounting for 51% of the total difference in episode spending between the most expensive and least expensive hospitals. Female patients, patients with more comorbidities, urban hospitals, and BPCI-A-participating hospitals were associated with significantly increased episode spending, with the effect increasing at the right tail of the spending distribution. CONCLUSION: Inter-hospital variation in 90-day episode spending on sepsis care is driven primarily by differences in post-acute care spending.
Assuntos
Planos de Pagamento por Serviço Prestado , Gastos em Saúde , Medicare , Sepse , Humanos , Sepse/economia , Sepse/terapia , Estados Unidos , Feminino , Masculino , Medicare/economia , Medicare/estatística & dados numéricos , Idoso , Planos de Pagamento por Serviço Prestado/economia , Gastos em Saúde/estatística & dados numéricos , Idoso de 80 Anos ou mais , Hospitais/estatística & dados numéricos , Custos Hospitalares/estatística & dados numéricos , Cuidado PeriódicoRESUMO
BACKGROUND: Sepsis affects 1.7 million patients in the US annually, is one of the leading causes of mortality, and is a major driver of US healthcare costs. African American/Black and LatinX populations experience higher rates of sepsis complications, deviations from standard care, and readmissions compared with Non-Hispanic White populations. Despite clear evidence of structural racism in sepsis care and outcomes, there are no prospective interventions to mitigate structural racism in sepsis care, nor are we aware of studies that report reductions in racial inequities in sepsis care as an outcome. Therefore, we will deliver and evaluate a coalition-based intervention to equip health systems and their surrounding communities to mitigate structural racism, driving measurable reductions in inequities in sepsis outcomes. This paper presents the theoretical foundation for the study, summarizes key elements of the intervention, and describes the methodology to evaluate the intervention. METHODS: Our aims are to: (1) deliver a coalition-based leadership intervention in eight U.S. health systems and their surrounding communities; (2) evaluate the impact of the intervention on organizational culture using a longitudinal, convergent mixed methods approach, and (3) evaluate the impact of the intervention on reduction of racial inequities in three clinical outcomes: a) early identification (time to antibiotic), b) clinical management (in-hospital sepsis mortality) and c) standards-based follow up (same-hospital, all-cause sepsis readmissions) using interrupted time series analysis. DISCUSSION: This study is aligned with calls to action by the NIH and the Sepsis Alliance to address inequities in sepsis care and outcomes. It is the first to intervene to mitigate effects of structural racism by developing the domains of organizational culture that are required for anti-racist action, with implications for inequities in complex health outcomes beyond sepsis.
Assuntos
Racismo/prevenção & controle , Sepse/terapia , Negro ou Afro-Americano , Custos de Cuidados de Saúde , Hispânico ou Latino , Humanos , Estudos Longitudinais , Sepse/economia , Sepse/etnologia , Sepse/prevenção & controle , Racismo Sistêmico/prevenção & controle , Estados UnidosRESUMO
Sepsis, an important and preventable cause of death in the newborn, is associated with high out of pocket hospitalization costs for the parents/guardians. The government of Nepal's Free Newborn Care (FNC) service that covers hospitalization costs has set a maximum limit of Nepalese rupees (NPR) 8000 i.e. USD 73.5, the basis of which is unclear. We aimed to estimate the costs of treatment in neonates and young infants fulfilling clinical criteria for sepsis, defined as clinical severe infection (CSI) to identify determinants of increased cost. This study assessed costs for treatment of 206 infants 3-59 days old, enrolled in a clinical trial, and admitted to the Kanti Children's Hospital in Nepal through June 2017 to December 2018. Total costs were derived as the sum of direct costs for bed charges, investigations, and medicines and indirect costs calculated by using work time loss of parents. We estimated treatment costs for CSI, the proportion exceeding NPR 8000 and performed multivariable linear regression to identify determinants of high cost. Of the 206 infants, 138 (67%) were neonates (3-28 days). The median (IQR) direct costs for treatment of CSI in neonates and young infants (29-59 days) were USD 111.7 (69.8-155.5) and 65.17 (43.4-98.5) respectively. The direct costs exceeded NPR 8000 (USD 73.5) in 69% of neonates with CSI. Age <29 days, moderate malnutrition, presence of any sign of critical illness and documented treatment failure were found to be important determinants of high costs for treatment of CSI. According to this study, the average treatment cost for a newborn with CSI in a public tertiary level hospital is substantial. The maximum limit offered for free newborn care in public hospitals needs to be revised for better acceptance and successful implementation of the FNC service to avert catastrophic health expenditures in developing countries like Nepal. Trial Registration: CTRI/2017/02/007966 (Registered on: 27/02/2017).
Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitalização/economia , Centros de Atenção Terciária/economia , Honorários e Preços/estatística & dados numéricos , Governo , Custos de Cuidados de Saúde/tendências , Gastos em Saúde/estatística & dados numéricos , Gastos em Saúde/tendências , Custos Hospitalares/tendências , Hospitais Públicos/economia , Humanos , Lactente , Recém-Nascido , Nepal , Sepse/economiaRESUMO
Importance: Sepsis survivorship is associated with postsepsis morbidity, but epidemiological data from population-based cohorts are lacking. Objective: To quantify the frequency and co-occurrence of new diagnoses consistent with postsepsis morbidity and mortality as well as new nursing care dependency and total health care costs after sepsis. Design, Setting, and Participants: This retrospective cohort study based on nationwide health claims data included a population-based cohort of 23.0 million beneficiaries of a large German health insurance provider. Patients aged 15 years and older with incident hospital-treated sepsis in 2013 to 2014 were included. Data were analyzed from January 2009 to December 2017. Exposures: Sepsis, identified by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) hospital discharge codes. Main Outcomes and Measures: New medical, psychological, and cognitive diagnoses; long-term mortality; dependency on nursing care; and overall health care costs in survivors at 1 to 12, 13 to 24, and 25 to 36 months after hospital discharge. Results: Among 23.0 million eligible individuals, we identified 159â¯684 patients hospitalized with sepsis in 2013 to 2014. The mean (SD) age was 73.8 (12.8) years, and 75â¯809 (47.5%; 95% CI, 47.2%-47.7%) were female patients. In-hospital mortality was 27.0% (43â¯177 patients; 95% CI, 26.8%-27.3%). Among 116â¯507 hospital survivors, 86â¯578 (74.3%; 95% CI, 74.1%-74.6%) had a new diagnosis in the first year post sepsis; 28â¯405 (24.4%; 95% CI, 24.1%-24.6%) had diagnoses co-occurring in medical, psychological, or cognitive domains; and 23â¯572 of 74â¯878 survivors (31.5%; 95% CI, 31.1%-31.8%) without prior nursing care dependency were newly dependent on nursing care. In total, 35â¯765 survivors (30.7%; 95% CI, 30.4%-31.0%) died within the first year. In the second and third year, 53â¯089 (65.8%; 95% CI, 65.4%-66.1%) and 40â¯959 (59.4%; 95% CI, 59.0%-59.8%) had new diagnoses, respectively. Health care costs for sepsis hospital survivors for 3 years post sepsis totaled a mean of 29â¯088/patient ($32â¯868/patient) (SD, 44â¯195 [$49â¯938]). New postsepsis morbidity (>1 new diagnosis) was more common in survivors of severe sepsis (75.6% [95% CI, 75.1%-76.0%]) than nonsevere sepsis (73.7% [95% CI, 73.4%-74.0%]; P < .001) and more common in survivors treated in the intensive care unit (78.3% [95% CI, 77.8%-78.7%]) than in those not treated in the intensive care unit (72.8% [95% CI, 72.5%-73.1%]; P < .001). Postsepsis morbidity was 68.5% (95% CI, 67.5%-69.5%) among survivors without prior morbidity and 56.1% (95% CI, 54.2%-57.9%) in survivors younger than 40 years. Conclusions and Relevance: In this study, new medical, psychological, and cognitive diagnoses consistent with postsepsis morbidity were common after sepsis, including among patients with less severe sepsis, no prior diagnoses, and younger age. This calls for more efforts to elucidate the underlying mechanisms, define optimal screening for common new diagnoses, and test interventions to prevent and treat postsepsis morbidity.
Assuntos
Causas de Morte , Custos de Cuidados de Saúde , Cuidados de Enfermagem , Sepse/economia , Sepse/epidemiologia , Idoso , Cognição , Feminino , Alemanha/epidemiologia , Mortalidade Hospitalar , Hospitalização , Humanos , Unidades de Terapia Intensiva , Classificação Internacional de Doenças , Assistência de Longa Duração , Masculino , Transtornos Mentais/epidemiologia , Transtornos Mentais/etiologia , Pessoa de Meia-Idade , Morbidade , Casas de Saúde , Alta do Paciente , Estudos Retrospectivos , Sepse/mortalidade , Índice de Gravidade de Doença , Sobreviventes/psicologiaRESUMO
OBJECTIVES: To provide updated information on the burdens of sepsis during acute inpatient admissions for Medicare beneficiaries. DESIGN: Analysis of paid Medicare claims via the Centers for Medicare and Medicaid Services DataLink Project. SETTING: All U.S. acute-care hospitals, excluding federally operated hospitals (Veterans Administration and Defense Health Agency). PATIENTS: All Medicare beneficiaries, January 2012-February 2020, with an explicit sepsis diagnostic code assigned during an inpatient admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The count of Medicare Part A/B (fee-for-service) plus Medicare Advantage inpatient sepsis admissions rose from 981,027 (CY2012) to 1,700,433 (CY 2019). The proportion of total admissions with sepsis in the Medicare Advantage population rose from 21.43% to 35.39%, reflecting the increasing beneficiary proportion enrolled in Medicare Advantage. In CY2019, 6-month mortality rates in Medicare fee-for-service beneficiaries for sepsis continued to decline, but remained high: 59.9% for septic shock, 35.5% for severe sepsis, 30.8% for sepsis attributed to a specific organism, and 26.5% for unspecified sepsis. Total fee-for-service-only inpatient hospital costs rose from $17.79B (CY2012) to $22.98B (CY2019). We estimated that the aggregate cost of sepsis hospital care for the entire U.S. population was at least $57.47B in 2019. Inclusion of 14 months' (January 2019-February 2020) newer data exposed new trends: the cost per patient, number of admissions, and fraction of patients with sepsis labeled as present on admission inflected around November 2015, coincident with the change to International Classification of Diseases, 10th Edition, and introduction of the Severe Sepsis and Septic Shock Management Bundle (SEP-1) metric. CONCLUSIONS: Sepsis among Medicare beneficiaries precoronavirus disease 2019 imposed immense burdens upon patients, their families, and the taxpayers.
Assuntos
Medicare/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Sepse/diagnóstico , Planos de Pagamento por Serviço Prestado/economia , Hospitalização/estatística & dados numéricos , Humanos , Sepse/economia , Sepse/epidemiologia , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Cancer patients are at significant risk of developing sepsis due to underlying malignancy and necessary treatments. Little is known about the economic burden of sepsis in this high-risk population. We estimate the short- and long-term healthcare costs of care of cancer patients with and without sepsis using individual-level linked-administrative data. METHODS: We conducted a population-based matched cohort study of cancer patients aged ≥18, diagnosed between 2010 and 2017. Cases were identified if diagnosed with sepsis during the study period, and were matched 1:1 by age, sex, cancer type and other variables to controls without sepsis. Mean costs (2018 Canadian dollars) for patients with and without sepsis up to 5 years were estimated adjusted using survival probabilities at partitioned intervals. We estimated excess cost associated with sepsis presented as a cost difference between the two cohorts. Haematological and solid cancers were analysed separately. RESULTS: 77,483 cancer patients with sepsis were identified and matched. 64.3% of the cohort were aged ≥65, 46.3% female and 17.8% with haematological malignancies. Among solid tumour patients, the excess cost of care among patients who developed sepsis was $29,081 (95%CI, $28,404-$29,757) in the first year, rising to $60,714 (95%CI, $59,729-$61,698) over 5 years. This was higher for haematology patients; $46,154 (95%CI, $45,505-$46,804) in year 1, increasing to $75,931 (95%CI, $74,895-$76,968). CONCLUSIONS: Sepsis imposes substantial economic burden and can result in a doubling of cancer care costs, particularly during the first year of cancer diagnosis. These estimates are helpful in improving our understanding of burden of sepsis along the cancer pathway and to deploy targeted strategies to alleviate this burden.
Assuntos
Efeitos Psicossociais da Doença , Custos de Cuidados de Saúde , Neoplasias/complicações , Neoplasias/economia , Sepse/complicações , Sepse/economia , Adolescente , Adulto , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
RATIONALE: The purpose of this research is to determine and develop a valid analytical method that can be easily implemented by providers to evaluate whether they should join the bundled payments for care improvement (BPCI) advanced bundled payment program, and analyze the projected impacts of BPCI advanced payment on their margins. METHODS: We have developed a decision tree model that incorporates the types of sepsis encountered and the resultant typical complications and associated costs. RESULTS: The initial cost of a sepsis episode was $30,386. Since Medicare requires that there is a 3% cost reduction under BPCI, we applied the model with a 3% cost reduction across the board. Since the model considers probabilities of the complications and readmission, there was actually a 3.36% reduction in costs when the 3% reduction was added to the model. We applied 2-way sensitivity analysis to the intensive care unit (ICU) long and short costs. We used the unbundled cost at the high end, and a 10% reduction at the low end. Per patient episode cost varied between $28,117 and $29,658. This is a 5.2% difference between low and high end. Next, we looked at varying the hospital bed (non-ICU) costs. Here the resultant cost varied between $28,708 and $29,099. This is only a 1.34% difference between low and high ends. Finally, we applied a sensitivity analysis varying the attending physician and the intensivist reimbursement fees. The result was a cost that varied between $29,191 and $29,366 which is a difference of only 0.595%. CONCLUSION: This is the precise environment where decision tree analysis modeling is essential. This analysis can guide the hospital in just how to allocate resources in light of the new BPCI advanced payment model.
Assuntos
Árvores de Decisões , Medicare/organização & administração , Pacotes de Assistência ao Paciente/economia , Sepse/economia , Sepse/terapia , Custos Hospitalares , Humanos , Unidades de Terapia Intensiva/economia , Medicare/economia , Modelos Econométricos , Readmissão do Paciente/economia , Sepse/complicações , Estados UnidosRESUMO
The aim of this study was to estimate the trends and burdens associated with systemic therapy-related hospitalizations, using nationally representative data. National Inpatient Sample data from 2005 to 2016 was used to identify systemic therapy-related complications using ICD-9 and ICD-10 external causes-of-injury codes. The primary outcome was hospitalization rates, while secondary outcomes were cost and in-hospital mortality. Overall, there were 443,222,223 hospitalizations during the study period, of which 2,419,722 were due to complications of systemic therapy. The average annual percentage change of these hospitalizations was 8.1%, compared to - 0.5% for general hospitalizations. The three most common causes for hospitalization were anemia (12.8%), neutropenia (10.8%), and sepsis (7.8%). Hospitalization rates had the highest relative increases for sepsis (1.9-fold) and acute kidney injury (1.6-fold), and the highest relative decrease for dehydration (0.21-fold) and fever of unknown origin (0.35-fold). Complications with the highest total charges were anemia ($4.6 billion), neutropenia ($3.0 billion), and sepsis ($2.5 billion). The leading causes of in-hospital mortality associated with systemic therapy were sepsis (15.8%), pneumonia (7.6%), and acute kidney injury (7.0%). Promoting initiatives such as rule OP-35, improving access to and providing coordinated care, developing systems leading to early identification and management of symptoms, and expanding urgent care access, can decrease these hospitalizations and the burden they carry on the healthcare system.
Assuntos
Anemia/complicações , Hospitalização , Neoplasias/complicações , Neoplasias/terapia , Neutropenia/complicações , Sepse/complicações , Idoso , Anemia/economia , Anemia/terapia , Bases de Dados Factuais , Feminino , Febre/complicações , Custos de Cuidados de Saúde , Mortalidade Hospitalar , Humanos , Pacientes Internados , Masculino , Pessoa de Meia-Idade , Neoplasias/economia , Neutropenia/economia , Neutropenia/terapia , Pneumonia/complicações , Estudos Retrospectivos , Sepse/economia , Sepse/terapia , Estados UnidosRESUMO
Rationale: Crisis standards of care (CSCs) guide critical care resource allocation during crises. Most recommend ranking patients on the basis of their expected in-hospital mortality using the Sequential Organ Failure Assessment (SOFA) score, but it is unknown how SOFA or other acuity scores perform among patients of different races. Objectives: To test the prognostic accuracy of the SOFA score and version 2 of the Laboratory-based Acute Physiology Score (LAPS2) among Black and white patients. Methods: We included Black and white patients admitted for sepsis or acute respiratory failure at 27 hospitals. We calculated the discrimination and calibration for in-hospital mortality of SOFA, LAPS2, and modified versions of each, including categorical SOFA groups recommended in a popular CSC and a SOFA score without creatinine to reduce the influence of race. Measurements and Main Results: Of 113,158 patients, 27,644 (24.4%) identified as Black. The LAPS2 demonstrated higher discrimination (area under the receiver operating characteristic curve [AUC], 0.76; 95% confidence interval [CI], 0.76-0.77) than the SOFA score (AUC, 0.68; 95% CI, 0.68-0.69). The LAPS2 was also better calibrated than the SOFA score, but both underestimated in-hospital mortality for white patients and overestimated in-hospital mortality for Black patients. Thus, in a simulation using observed mortality, 81.6% of Black patients were included in lower-priority CSC categories, and 9.4% of all Black patients were erroneously excluded from receiving the highest prioritization. The SOFA score without creatinine reduced racial miscalibration. Conclusions: Using SOFA in CSCs may lead to racial disparities in resource allocation. More equitable mortality prediction scores are needed.
Assuntos
Negro ou Afro-Americano/estatística & dados numéricos , Alocação de Recursos para a Atenção à Saúde/economia , Alocação de Recursos para a Atenção à Saúde/estatística & dados numéricos , Equidade em Saúde/economia , Equidade em Saúde/estatística & dados numéricos , Mortalidade Hospitalar/tendências , População Branca/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , California/epidemiologia , Estudos de Coortes , Feminino , Previsões , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Fatores Raciais , Síndrome do Desconforto Respiratório/economia , Síndrome do Desconforto Respiratório/epidemiologia , Síndrome do Desconforto Respiratório/terapia , Estudos Retrospectivos , Sepse/economia , Sepse/epidemiologia , Sepse/terapiaRESUMO
AIM: To explore the population-at-risk and potential cost of a sepsis episode in New Zealand. METHOD: Retrospective analysis of the National Minimum Data Set using two code-based algorithms selecting (i) an inclusive cohort of hospitalised patients diagnosed with a 'major infection' with the potential to cause sepsis and (ii) a restricted subset of these patients with a high likelihood of clinical sepsis based on the presence of both a primary admission diagnosis of infection and at least one sepsis-associated organ failure. RESULTS: In 2016, 24% of all inpatient episodes were associated with diagnosis of a major infection. The sepsis coding algorithm identified a subset of 1,868 discharges. The median (IQR) reimbursement associated with these episodes was $10,381 ($6,093-$10,964). In both groups, 30-day readmission was common (26.7% and 11% respectively). CONCLUSIONS: Infectious diseases with the potential to cause sepsis are common among hospital inpatients. Direct treatment costs are high for those who present with or progress to sepsis due to these infections.
Assuntos
Algoritmos , Custos de Cuidados de Saúde/estatística & dados numéricos , Unidades de Terapia Intensiva/economia , Sepse/economia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Incidência , Lactente , Recém-Nascido , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Nova Zelândia/epidemiologia , Estudos Retrospectivos , Sepse/epidemiologia , Sepse/terapia , Índice de Gravidade de Doença , Adulto JovemRESUMO
OBJECTIVE: To describe the patient population, priority diseases and outcomes in newborns admitted <48 hours old to neonatal units in both Kenya and Nigeria. STUDY DESIGN: In a network of seven secondary and tertiary level neonatal units in Nigeria and Kenya, we captured anonymised data on all admissions <48 hours of age over a 6-month period. RESULTS: 2280 newborns were admitted. Mean birthweight was 2.3 kg (SD 0.9); 57.0% (1214/2128) infants were low birthweight (LBW; <2.5kg) and 22.6% (480/2128) were very LBW (VLBW; <1.5 kg). Median gestation was 36 weeks (interquartile range 32, 39) and 21.6% (483/2236) infants were very preterm (gestation <32 weeks). The most common morbidities were jaundice (987/2262, 43.6%), suspected sepsis (955/2280, 41.9%), respiratory conditions (817/2280, 35.8%) and birth asphyxia (547/2280, 24.0%). 18.7% (423/2262) newborns died; mortality was very high amongst VLBW (222/472, 47%) and very preterm infants (197/483, 40.8%). Factors independently associated with mortality were gestation <28 weeks (adjusted odds ratio 11.58; 95% confidence interval 4.73-28.39), VLBW (6.92; 4.06-11.79), congenital anomaly (4.93; 2.42-10.05), abdominal condition (2.86; 1.40-5.83), birth asphyxia (2.44; 1.52-3.92), respiratory condition (1.46; 1.08-2.28) and maternal antibiotics within 24 hours before or after birth (1.91; 1.28-2.85). Mortality was reduced if mothers received a partial (0.51; 0.28-0.93) or full treatment course (0.44; 0.21-0.92) of dexamethasone before preterm delivery. CONCLUSION: Greater efforts are needed to address the very high burden of illnesses and mortality in hospitalized newborns in sub-Saharan Africa. Interventions need to address priority issues during pregnancy and delivery as well as in the newborn.
Assuntos
Asfixia Neonatal/diagnóstico , Efeitos Psicossociais da Doença , Sepse/diagnóstico , Adolescente , Adulto , Asfixia Neonatal/economia , Asfixia Neonatal/epidemiologia , Peso ao Nascer , Feminino , Idade Gestacional , Hospitalização , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Icterícia/diagnóstico , Quênia/epidemiologia , Masculino , Nigéria/epidemiologia , Fatores de Risco , Sepse/economia , Adulto JovemRESUMO
OBJECTIVE: To describe patient and hospital characteristics associated with in-hospital mortality, length of stay (LOS), and charges for children with severe sepsis or septic shock who often require specialized organ-supportive technology to enhance outcomes, availability of which might vary across hospitals. DESIGN: Retrospective study among children hospitalized for severe sepsis or septic shock, using the 2012 Kids' Inpatient Database. Multivariate regression methods identified factors associated with mortality, LOS, and charges. MEASUREMENTS AND MAIN RESULTS: Of an estimated 11 972 hospitalizations for pediatric severe sepsis or septic shock, most hospitalizations (85%) were to urban teaching hospitals. Hospitalizations were more frequent among neonates and older adolescents than other age groups. Mortality was 17%, average LOS was 24 days, and average hospital charges were US$314 950. Higher mortality was associated with neonates, cumulative organ dysfunction, more comorbidities, and cardiopulmonary resuscitation. Longer hospitalization and higher charges were associated with neonates, more comorbidities, higher illness severity, invasive medical technology, and urban hospitals. CONCLUSIONS: Efforts to mitigate the substantial in-hospital mortality and resource use observed in pediatric severe sepsis or septic shock should be age-specific and focused on the influence of comorbidities and organ dysfunction on outcomes. Future research should elucidate reasons for higher resource use at urban hospitals.
Assuntos
Sepse , Choque Séptico , Adolescente , Criança , Comorbidade , Preços Hospitalares , Mortalidade Hospitalar , Humanos , Recém-Nascido , Tempo de Internação , Estudos Retrospectivos , Sepse/economia , Sepse/mortalidade , Choque Séptico/economia , Choque Séptico/mortalidadeRESUMO
OBJECTIVES: To examine long-term mortality, resource utilization, and healthcare costs in sepsis patients compared to hospitalized nonsepsis controls. DESIGN: Propensity-matched population-based cohort study using administrative data. SETTING: Ontario, Canada. PATIENTS: We identified a cohort of adults (≥ 18) admitted to hospitals in Ontario between April 1, 2012, and March 31, 2016, with follow-up to March 31, 2017. Sepsis patients were flagged using a validated International Classification of Diseases, 10th Revision-coded algorithm (Sepsis-2 definition), including cases with organ dysfunction (severe sepsis) and without (nonsevere). Remaining hospitalized patients were potential controls. Cases and controls were matched 1:1 on propensity score, age, sex, admission type, and admission date. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Differences in mortality, rehospitalization, hospital length of stay, and healthcare costs were estimated, adjusting for remaining confounders using Cox regression and generalized estimating equations. Of 270,669 sepsis cases, 196,922 (73%) were successfully matched: 64,204 had severe and 132,718 nonsevere sepsis (infection without organ dysfunction). Over follow-up (median 2.0 yr), severe sepsis patients had higher mortality rates than controls (hazard ratio, 1.66; 95% CI, 1.63-1.68). Both severe and nonsevere sepsis patients had higher rehospitalization rates than controls (hazard ratio, 1.53; 95% CI, 1.50-1.55 and hazard ratio, 1.41; 95% CI, 1.40-1.43, respectively). Incremental costs (Canadian dollar 2018) in sepsis cases versus controls at 1-year were: $29,238 (95% CI, $28,568-$29,913) for severe and $9,475 (95% CI, $9,150-$9,727) for nonsevere sepsis. CONCLUSIONS: Severe sepsis was associated with substantially higher long-term risk of death, rehospitalization, and healthcare costs, highlighting the need for effective postdischarge care for sepsis survivors.
Assuntos
Assistência ao Convalescente/economia , Mortalidade Hospitalar/tendências , Unidades de Terapia Intensiva/economia , Alta do Paciente/economia , Sepse/economia , Sepse/mortalidade , Adulto , Idoso , Estudos de Coortes , Infecção Hospitalar/economia , Humanos , Cobertura do Seguro/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Ontário , Readmissão do Paciente/economia , Pontuação de Propensão , Modelos de Riscos Proporcionais , Sepse/terapiaRESUMO
OBJECTIVES: Initial evidence suggests that state-level regulatory mandates for sepsis quality improvement are associated with decreased sepsis mortality. However, sepsis mandates require financial investments on the part of hospitals and may lead to increased spending. We evaluated the effects of the 2013 New York State sepsis regulations on the costs of care for patients hospitalized with sepsis. DESIGN: Retrospective cohort study using state discharge data from the U.S. Healthcare Costs and Utilization Project and a comparative interrupted time series analytic approach. Costs were calculated from admission-level charge data using hospital-specific cost-to-charge ratios. SETTING: General, short stay, acute care hospitals in New York, and four control states: Florida, Massachusetts, Maryland, and New Jersey. PATIENTS: All patients hospitalized with sepsis between January 1, 2011, and September 30, 2015. INTERVENTIONS: The 2013 New York mandate that all hospitals develop and implement protocols for sepsis identification and treatment, educate staff, and report performance data to the state. MEASUREMENTS AND MAIN RESULTS: The analysis included 1,026,664 admissions in 520 hospitals. Mean unadjusted costs per hospitalization in New York State were $42,036 ± $60,940 in the pre-regulation period and $39,719 ± $59,063 in the post-regulation period, compared with $34,642 ± $52,403 pre-regulation and $31,414 ± $48,155 post-regulation in control states. In the comparative interrupted time series analysis, the regulations were not associated with a significant difference in risk-adjusted mean cost per hospitalization (p = 0.12) or risk-adjusted mean cost per hospital day (p = 0.44). For example, in the 10th quarter after implementation of the regulations, risk-adjusted mean cost per hospitalization was $3,627 (95% CI, -$681 to $7,934) more than expected in New York State relative to control states. CONCLUSIONS: Mandated protocolized sepsis care was not associated with significant changes in hospital costs in patients hospitalized with sepsis in New York State.
Assuntos
Protocolos Clínicos/normas , Custos Hospitalares/estatística & dados numéricos , Melhoria de Qualidade/organização & administração , Sepse/economia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Número de Leitos em Hospital , Humanos , Capacitação em Serviço , Análise de Séries Temporais Interrompida , Tempo de Internação , Masculino , Pessoa de Meia-Idade , New York , Propriedade , Alta do Paciente/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade/economia , Características de Residência , Estudos Retrospectivos , Estados UnidosRESUMO
BACKGROUND: The optimal chemotherapy regimen for treating HIV associated NHL in low resource settings is unknown. We conducted a retrospective study to describe survival rates, treatment response rates and adverse events in patients with HIV associated NHL treated with CHOP and dose adjusted-EPOCH regimens at the Uganda Cancer Institute. METHODS: A retrospective study of patients diagnosed with HIV and lymphoma and treated at the Uganda Cancer Institute from 2016 to 2018 was done. RESULTS: One hundred eight patients treated with CHOP and 12 patients treated with DA-EPOCH were analysed. Patients completing 6 or more cycles of chemotherapy were 51 (47%) in the CHOP group and 8 (67%) in the DA-EPOCH group. One year overall survival (OS) rate in patients treated with CHOP was 54.5% (95% CI, 42.8-64.8) and 80.2% (95% CI, 40.3-94.8) in those treated with DA-EPOCH. Factors associated with favourable survival were BMI 18.5-24.9 kg/m2, (p = 0.03) and completion of 6 or more cycles of chemotherapy, (p < 0.001). The overall response rate was 40% in the CHOP group and 59% in the DA-EPOCH group. Severe adverse events occurred in 19 (18%) patients in the CHOP group and 3 (25%) in the DA-EPOCH group; these were neutropenia (CHOP = 13, 12%; DA-EPOCH = 2, 17%), anaemia (CHOP = 12, 12%; DA-EPOCH = 1, 8%), thrombocytopenia (CHOP = 7, 6%; DA-EPOCH = 0), sepsis (CHOP = 1), treatment related death (DA-EPOCH = 1) and hepatic encephalopathy (CHOP = 1). CONCLUSION: Treatment of HIV associated NHL with curative intent using CHOP and infusional DA-EPOCH is feasible in low resource settings and associated with > 50% 1 year survival.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Infecções por HIV/complicações , Linfoma Difuso de Grandes Células B/tratamento farmacológico , Adulto , Anemia/induzido quimicamente , Anemia/economia , Anemia/epidemiologia , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Protocolos de Quimioterapia Combinada Antineoplásica/economia , Ciclofosfamida/administração & dosagem , Ciclofosfamida/efeitos adversos , Ciclofosfamida/economia , Doxorrubicina/administração & dosagem , Doxorrubicina/efeitos adversos , Doxorrubicina/economia , Esquema de Medicação , Etoposídeo/administração & dosagem , Etoposídeo/efeitos adversos , Etoposídeo/economia , Feminino , Infecções por HIV/imunologia , Encefalopatia Hepática/induzido quimicamente , Encefalopatia Hepática/economia , Encefalopatia Hepática/epidemiologia , Humanos , Infusões Intravenosas/economia , Infusões Intravenosas/métodos , Linfoma Difuso de Grandes Células B/economia , Linfoma Difuso de Grandes Células B/imunologia , Linfoma Difuso de Grandes Células B/mortalidade , Masculino , Pessoa de Meia-Idade , Neutropenia/induzido quimicamente , Neutropenia/economia , Neutropenia/epidemiologia , Prednisona/administração & dosagem , Prednisona/efeitos adversos , Prednisona/economia , Estudos Retrospectivos , Sepse/induzido quimicamente , Sepse/economia , Sepse/epidemiologia , Taxa de Sobrevida , Trombocitopenia/induzido quimicamente , Trombocitopenia/economia , Trombocitopenia/epidemiologia , Fatores de Tempo , Resultado do Tratamento , Uganda/epidemiologia , Vincristina/administração & dosagem , Vincristina/efeitos adversos , Vincristina/economiaRESUMO
OBJECTIVES: Identification and outcomes in patients with sepsis have improved over the years, but little data are available in patients with trauma who develop sepsis. We aimed to examine the cost and epidemiology of sepsis in patients hospitalized after trauma. DESIGN: Retrospective cohort study. PATIENTS: National Inpatient Sample. INTERVENTIONS: Sepsis was identified between 2012 and 2016 using implicit and explicit International Classification of Diseases, Ninth and Tenth Revision codes. Analyses were stratified by injury severity score greater than or equal to 15. Annual trends were modeled using generalized linear models. Survey-adjusted logistic regression was used to compare the odds for in-hospital mortality, and the average marginal effects were calculated to compare the cost of hospitalization with and without sepsis. MEASUREMENTS AND MAIN RESULTS: There were 320,450 (SE = 3,642) traumatic injury discharges from U.S. hospitals with sepsis between 2012 and 2016, representing 6.0% (95% CI, 5.9-6.0%) of the total trauma population (n = 5,329,714; SE = 47,447). In-hospital mortality associated with sepsis after trauma did not change over the study period (p > 0.40). In adjusted analysis, severe (injury severity score ≥ 15) and nonsevere injured septic patients had an odds ratio of 1.39 (95% CI, 1.31-1.47) and 4.32 (95% CI, 4.06-4.59) for in-hospital mortality, respectively. The adjusted marginal cost for sepsis compared with nonsepsis was $16,646 (95% CI, $16,294-$16,997), and it was greater than the marginal cost for severe injury compared with nonsevere injury $8,851 (95% CI, $8,366-$8,796). CONCLUSIONS: While national trends for sepsis mortality have improved over the years, our analysis of National Inpatient Sample did not support this trend in the trauma population. The odds risk for death after sepsis and the cost of care remained high regardless of severity of injury. More rigor is needed in tracking sepsis after trauma and evaluating the effectiveness of hospital mandates and policies to improve sepsis care in patients after trauma.
Assuntos
Gastos em Saúde/estatística & dados numéricos , Sepse/economia , Sepse/epidemiologia , Ferimentos e Lesões/epidemiologia , Idoso , Comorbidade , Feminino , Mortalidade Hospitalar/tendências , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Características de Residência , Estudos Retrospectivos , Fatores de Risco , Sepse/mortalidade , Fatores Socioeconômicos , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: In the United States in 2014 approximately 1.7 million adults were hospitalized with sepsis, resulting in about 270,000 deaths. Malnutrition in hospitalized patients contributes to increased morbidity, mortality, and costs, especially in the critically ill population. AIM: Our goal was to investigate the prevalence of malnutrition in sepsis and the impact it has on clinical and financial outcomes in our most critically ill patients. METHODS: We implemented nutritional screening by a registered dietitian of 1000 patients admitted with sepsis to specialized care units. We calculated the prevalence of malnutrition, and compared outcomes including mortality, length of stay, and financial costs. RESULTS: About 10% of patients with sepsis admitted to our specialized care units were diagnosed with malnutrition on admission after implementation of mandatory assessment. CONCLUSIONS: Although mortality did not reach statistical significance, these patients had more comorbidities, longer hospital stays, and higher total costs.
Assuntos
Tempo de Internação/economia , Desnutrição , Avaliação Nutricional , Estado Nutricional , Sepse , Idoso , Estado Terminal , Feminino , Humanos , Masculino , Desnutrição/economia , Desnutrição/epidemiologia , Desnutrição/mortalidade , Prevalência , Prognóstico , Sepse/economia , Sepse/epidemiologia , Sepse/mortalidadeRESUMO
To investigate the healthcare expenditures and length of stay (LOS) of sepsis-related hospitalizations in Taiwan.This is a retrospective claim database study. Data were obtained from the two-million-sample longitudinal health and welfare database (LHWD). Adult patients hospitalized with sepsis between 2010 and 2014 were identified by International Classification of Diseases 9th Edition Clinical Modification (ICD-9-CM) codes, and these patients were divided into three levels of sepsis severity. The amount and distribution of their total medical expenditures were investigated.In total, 62,517 patients with 97,790 sepsis-related hospitalizations were included in the present study. It was found that ward fees and medicines comprised the largest component of expenses for sepsis-related hospitalizations. In addition, our study results indicated that the median sepsis-related hospitalization cost was 66.4 thousand New Taiwan Dollar (NT dollars) in 2014, and a significant temporal change was found between 2010 and 2014. The median LOS in a hospital and in an intensive care unit were 11 and 7 days, respectively. Both expenditures and LOS were found to increase with sepsis severity.This study provides an updated and better understanding of the costs and LOS of sepsis-related hospitalizations in Taiwan. It was found that ward fees and medicine fees were the major components of hospital costs.
Assuntos
Hospitalização/economia , Sepse/economia , Cuidados Críticos/economia , Gastos em Saúde/estatística & dados numéricos , Custos Hospitalares/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Estudos Longitudinais , Estudos Retrospectivos , Índice de Gravidade de Doença , TaiwanRESUMO
OBJECTIVES: This study aimed to determine the burden of sepsis with focal infections in the resource-limited context of Indonesia and to propose national prices for sepsis reimbursement. METHODS: A retrospective observational study was conducted from 2013-2016 on cost of surviving and non-surviving sepsis patients from a payer perspective using inpatient billing records in four hospitals. The national burden of sepsis was calculated and proposed national prices for reimbursement were developed. RESULTS: Of the 14,076 sepsis patients, 5,876 (41.7%) survived and 8,200 (58.3%) died. The mean hospital costs incurred per surviving and deceased sepsis patient were US$1,011 (SE ± 23.4) and US$1,406 (SE ± 27.8), respectively. The national burden of sepsis in 100,000 patients was estimated to be US$130 million. Sepsis patients with multifocal infections and a single focal lower-respiratory tract infection (LRTI) were estimated as being the two with the highest economic burden (US$48 million and US$33 million, respectively, within 100,000 sepsis patients). Sepsis with cardiovascular infection was estimated to warrant the highest proposed national price for reimbursement (US$4,256). CONCLUSIONS: Multifocal infections and LRTIs are the major focal infections with the highest burden of sepsis. This study showed varying cost estimates for sepsis, necessitating a new reimbursement system with adjustment of the national prices taking the particular foci into account.