Initial experience with the subcutaneous implantable cardioverter-defibrillator with the real costs of hospitalization analysis in a single Polish center.

BACKGROUND: The recent introduction of an entirely subcutaneous implantable cardioverter-defibril-lator (S-ICD) represents an important progress in the defibrillation technology towards a less invasive approach. This is a single-center observational study of S-ICD implantations in Poland. METHODS: The S-ICD was implanted in 11 patients with standard indications for an ICD. Patients in whom the device was implanted were evaluated for adverse events and device function at hospital discharge. All hospitalization costs were calculated and summed up for all patients. Costs were divided into following categories: medical materials, pharmaceuticals, operating theatre staff, cardiology depart-ment staff, laboratory tests, non-laboratory tests and additional non-medical costs. RESULTS: The mean age of patients was 51.6 ± 16.4 years, 9 were men and 2 were women. Four pa-tients had atrial fibrillation as the basal rhythm, 1 patient had atrial flutter and 6 patients had sinus rhythm. All patients had at least one condition that precluded the use of a traditional ICD system or the S-ICD was preferred due to other conditions, i.e. a history complicated transvenous ICD therapy (18%), anticipated higher risk of infection (27%), lack or difficult vascular access (18%), young age and anticipated high cumulated risk of lifetime device therapy (36%). The mean duration of the im-plantation procedure was 2 h. One patient developed a postoperative pocket hematoma. Mean total time of hospitalization was 28 (6-92) days. Average cost of hospitalization per patient was 21,014.29 EUR (minimal = 19,332.71 EUR and maximal = 24,824.14 EUR). CONCLUSIONS: S-ICD implantation appears to provide a viable alternative to transvenous ICD, espe-cially for patients without pacing requirements.

Multicenter, randomized trial of quantitative pretest probability to reduce unnecessary medical radiation exposure in emergency department patients with chest pain and dyspnea.

BACKGROUND: Use of pretest probability can reduce unnecessary testing. We hypothesize that quantitative pretest probability, linked to evidence-based management strategies, can reduce unnecessary radiation exposure and cost in low-risk patients with symptoms suggestive of acute coronary syndrome and pulmonary embolism. METHODS AND RESULTS: This was a prospective, 4-center, randomized controlled trial of decision support effectiveness. Subjects were adults with chest pain and dyspnea, nondiagnostic ECGs, and no obvious diagnosis. The clinician provided data needed to compute pretest probabilities from a Web-based system. Clinicians randomized to the intervention group received the pretest probability estimates for both acute coronary syndrome and pulmonary embolism and suggested clinical actions designed to lower radiation exposure and cost. The control group received nothing. Patients were followed for 90 days. The primary outcome and sample size of 550 was predicated on a significant reduction in the proportion of healthy patients exposed to >5 mSv chest radiation. A total of 550 patients were randomized, and 541 had complete data. The proportion with >5 mSv to the chest and no significant cardiopulmonary diagnosis within 90 days was reduced from 33% to 25% (P=0.038). The intervention group had significantly lower median chest radiation exposure (0.06 versus 0.34 mSv; P=0.037, Mann-Whitney U test) and lower median costs ($934 versus $1275; P=0.018) for medical care. Adverse events occurred in 16% of controls and 11% in the intervention group (P=0.06). CONCLUSIONS: Provision of pretest probability and prescriptive advice reduced radiation exposure and cost of care in low-risk ambulatory patients with symptoms of acute coronary syndrome and pulmonary embolism. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01059500.

The universal bed model for patient care improves outcome and lowers cost in cardiac surgery.

OBJECTIVE: With the escalating demands to increase the efficiency and decrease the cost, innovations in postoperative cardiac surgical patient care are needed. The universal bed model is an innovative care delivery system that allows patient care to be managed in one setting from postoperation to discharge. We hypothesized that the universal bed model in the context of cardiac surgery would improve outcomes and efficacy. METHODS: A total of 610 consecutive patients were admitted to the universal bed unit and prospectively entered into the Society of Thoracic Surgeons National Cardiac Database. Intensive care unit level of care was determined by acuity and staffing needs. Telemetry was employed from admission to discharge, and multidisciplinary rounds were conducted twice daily. Postoperative outcomes were recorded during hospital stay, and comparisons were made with the Society of Thoracic Surgeons National Cardiac Database using identical variables over the same period of time. RESULTS: Decreased ventilation time, intensive care unit and hospital stay, and reduction in the incidence of atrial fibrillation and infectious complications yielded a financial benefit in the universal bed group compared with the traditional model of admission. Stroke rate and in-hospital mortality were the same compared with regional and national centers. Compared with regional centers, there was an average cost savings between $6200 and $9500 per patient depending on the operation. Patient care satisfaction by independent survey was in the 99th percentile. CONCLUSIONS: The universal bed patient care model allows for expedient and efficacious care as measured by decreased length of intensive care unit and hospital stay, improved postoperative outcomes, patient satisfaction, and cost savings.

Remote diagnosis of congenital heart disease: the impact of telemedicine.

OBJECTIVES: To determine the accuracy of remote diagnosis of congenital heart disease (CHD) by real-time transmission of echocardiographic images via integrated services digital network (ISDN) lines, to assess the impact on patient management and examine cost implications. DESIGN: Prospective comparison of echocardiograms on infants with suspected significant CHD performed as follows: (1) hands-on evaluation and echocardiogram by a paediatrician at a district general hospital (DGH) followed by (2) transmission of the echocardiogram via ISDN 6 with guidance from a paediatric cardiologist and finally (3) hands-on evaluation and echocardiogram by a paediatric cardiologist. The economic analysis compares the cost of patient care associated with the telemedicine service with a hypothetical control group. SETTING: Neonatal units of three DGH and a UK regional paediatric cardiology unit. RESULTS: Echocardiograms were transmitted on 124 infants. In five cases scans were inadequate for diagnosis. Of the remaining 119 tele-echocardiograms, a follow-up echocardiogram was performed on 109/119 (92%). Major CHD was diagnosed in 39/109 infants (36%) and minor CHD in 45 (41%). The tele-echo diagnosis was accurate in 96% of cases (kappa=0.89). Unnecessary transfer to the regional unit was avoided in 93/124 patients (75%). Despite relatively high implementation costs, telemedicine care was substantially cheaper than standard care. Each DGH potentially saved money by utilising the telemedicine service (mean saving: pound728/patient). CONCLUSIONS: CHD is accurately diagnosed by realtime transmission of echocardiograms performed by paediatricians under live guidance and interpretation by a paediatric cardiologist. Remote diagnosis and exclusion of CHD affects patient management and may be cost saving.

COTS technologies for telemedicine applications.

PURPOSE: To demonstrate a simple low-cost system for tele-echocardiology, focused on paediatric cardiology applications. METHODS: The system was realized using open-source software and COTS technologies. It is based on the transmission of two simultaneous video streams, obtained by direct digitization of the output of an ultrasound machine and by a netcam showing the examination that is taking place. These streams are then embedded into a web page so they are accessible, together with basic video controls, via a standard web browser. The system can also record video streams on a server for further use. RESULTS: The system was tested on a small group of neonatal cases with suspected cardiopathies for a preliminary assessment of its features and diagnostic capabilities. Both the clinical and technological results were encouraging and are leading the way for further experimentation. CONCLUSIONS: The presented system can transfer clinical images and videos in an efficient way and in real time. It can be used in the same hospital to support internal consultancy requests, in remote areas using Internet connections and for didactic purposes using low cost COTS appliances and simple interfaces for end users. The solution proposed can be extended to control different medical appliances in those remote hospitals.

Implementation of a process-orientated multidisciplinary approach (POMA), a system of cost-effective healthcare delivery within a cardiac surgical unit.

BACKGROUND: The process-orientated multidisciplinary approach (POMA) is a means of delivering consultant-led healthcare from the first outpatient clinic visit through to discharge, bringing together clinical and operational management that can result in effective resource utilisation and improved patient care. METHODS: Prospectively collected data from patients undergoing primary isolated coronary artery bypass graft (CABG) were collected before and after the application of POMA (246 and 260 patients, respectively). The impact of POMA was analysed on the number of cancellations (NOC), postoperative clinical incidents (POCI), postoperative length of stay (PLOS) and cost in the practice of one consultant surgeon. Data were obtained from our clinical database (PATS-Dendrite), which is used risk stratify patients and prospectively to collect clinical/operative data and outcomes. RESULTS: Patients were matched for all variables except for the European Cardiac Surgical Risk Score (EuroSCORE) which was 1.93 for pre-POMA patients and 2.73 for post-POMA patients (p<0.05). Cancellations significantly decreased from 4.5% (n = 11, pre-POMA) to 0.4% (n = 1, post-POMA) (p<0.05). POCI significantly decreased from 44.3% (n = 109, pre-POMA) to 36.2% (n = 94, post-POMA) (p<0.05). PLOS significantly decreased from 6.3 (pre-POMA) to 6.1 days (post-POMA) (p = 0.002). Regression analysis showed that implementation of POMA was the only significant factor in the reduction of POCI and PLOS (p<0.05). POMA resulted in an overall saving of 285,868 pound (400,215 euro; US $508,845) calculated using the 2005 National Health Service (NHS) tariffs. CONCLUSIONS: The implementation of POMA was the only significant known (or measured) factor that improved the operational efficiency and clinical outcome of a single surgeon's practice. The authors believe the principles deserve to be studied further to see if the results can be replicated.

Ten years after the initiation of congenital heart surgery in Guatemala: observations after a one year fellowship in the pediatric cardiac unit in a low income country.

High-tech medicine in a low income country remains a controversial issue. In September 1997, a congenital heart surgery program was initiated in Guatemala by Aldo Castañeda, emeritus Harvard Professor of Surgery and surgeon-in-chief at the Children's Hospital Boston. He trained 3 young pediatric cardiac surgeons and in addition assembled a team of pediatric cardiologists, intensivists, anesthesiologists, nurses and the necessary technical staff to develop a pediatric cardiac program in Guatemala. Faced with limited governmental financial support, he set up the Aldo Castañeda Foundation to ensure sustainability of the program. Now, 10 years after the initiation of this program, the pediatric cardiovascular unit (UNICARP) offers diagnosis as well as medical and surgical therapy to children born with a congenital heart malformation in Guatemala and neighboring countries. In addition, UNICARP offers training opportunities for young surgeons from abroad. The experience of one such trainee from Switzerland is highlighted in this report.

U.S. trends in CABG hospital volume: the effect of adding cardiac surgery programs.

Hospital coronary artery bypass graft (CABG) volume is inversely related to mortality--with low-volume hospitals having the highest mortality. Medicare data (1992-2003) show that the number of CABG procedures increased from 158,000 in 1992 to a peak of 190,000 in 1996 and then fell to 152,000 in 2003, while the number of hospitals performing CABG increased steadily. Predictably, the proportion of CABG procedures performed at low-volume hospitals increased, and the proportion in high-volume hospitals declined. An unintended consequence of starting new cardiac surgery programs is declining CABG hospital volume--a side effect that might increase mortality.

Surgeons' economic profiles: can we get the "right" answers?

Hospitals and payers use economic profiling to evaluate physician and surgeon performance. However, there is significant variation in the data sources and analytic methods that are used. We used information from a hospital's cardiac surgery and cost accounting information systems to create surgeon economic profiles. Three scenarios were examined: (1) surgeon modeled as fixed effect with no patient-mix adjustment; (2) surgeon modeled as fixed effect with patient-mix adjustment; (3) and surgeon modeled as random effect with patient-mix adjustment. We included 574 patients undergoing coronary artery bypass surgery at Baptist Medical Center, Oklahoma City, OK between July 1, 1995 and April 30, 1996. We found that profiles reporting unadjusted average surgeon costs may incorrectly identify high- and low-cost outliers. Adjusting for patient-mix differences and treating surgeons as random effects was the preferred approach. These results demonstrate the need for hospitals to reexamine their economic profiling methods.

Could your financial health be heading for heart break?

A new type of stent may alter demand and affect the financial performance of cardiovascular programs. Patients electing angioplasty instead of CABG as the preferred initial treatment for coronary stenosis may increase. The need for CABG procedures to correct restenosis following angioplasty may decline.

The determinants of HMOs' contracting with hospitals for bypass surgery.

OBJECTIVE: Selective contracting with health care providers is one of the mechanisms HMOs (Health Maintenance Organizations) use to lower health care costs for their enrollees. However, are HMOs compromising quality to lower costs? To address this and other questions we identify factors that influence HMOs' selective contracting for coronary artery bypass surgery (CABG). STUDY DESIGN: Using a logistic regression analysis, we estimated the effects of hospitals' quality, costliness, and geographic convenience on HMOs' decision to contract with a hospital for CABG services. We also estimated the impact of HMO characteristics and market characteristics on HMOs' contracting decision. DATA SOURCES: A 1997 survey of a nationally representative sample of 50 HMOs that could have potentially contracted with 447 hospitals. PRINCIPAL FINDINGS: About 44 percent of the HMO-hospital pairs had a contract. We found that the probability of an HMO contracting with a hospital increased as hospital quality increased and decreased as distance increased. Hospital costliness had a negative but borderline significant (0.10 < p < 0.05) effect on the probability of a contract across all types of HMOs. However, this effect was much larger for IPA (Independent Practice Association)-model HMOs than for either group/staff or network HMOs. An increase in HMO competition increased the probability of a contract while an increase in hospital competition decreased the probability of a contract. HMO penetration did not affect the probability of contracting. HMO characteristics also had significant effects on contracting decisions. CONCLUSIONS: The results suggest that HMOs value quality, geographic convenience, and costliness, and that the importance of quality and costliness vary with HMO. Greater HMO competition encourages broader hospital networks whereas greater hospital competition leads to more restrictive networks.

All pumped up over cardiology.

Cardiovascular services are one of the few remaining profit centers for hospitals, and as baby boomers age, the need for such care is skyrocketing. A good cardiology program enhances a hospital's reputation and patient volume. However, the pressures to expand and the cost of swiftly changing technology put hospitals that are trying to keep up in a tight squeeze, which raises the question: is the pulse of change in cardiology too rapid?

The effect of a 'fast-track' unit on the performance of a cardiothoracic department.

OBJECTIVE: The objective of this study was to describe the impact of a 'fast-track' unit, combined with a computerised system for information collection and analysis, on the clinical practice and finance of a cardiothoracic department over the first 12 month period of its application. METHODS: Within 12 months, starting December 1996, 642 major cardiothoracic cases were performed at the Cardiothoracic Department, St Mary's Hospital, London, after the establishment of a 3-bed 'fast-track' unit, which was supported by a computerised system for admission planning and a pre-admission clinic. The main outcome measures were operating numbers, financial income, patient recovery and operative mortality. RESULTS: The 'fast-track' unit resulted in an increase of the operating numbers (11.3% increase in major cardiac cases) and income (38%), as compared with the year before. Some 525 patients out of 642 (81.8%) were scheduled for the 'fast-track' unit and 492 (93.7%) were successfully 'fast-tracked'. Coronary artery bypass grafting operations had the lowest 'fast-track' failure and mortality rates. Re-do operations and complex coronary procedures presented a high 'fast-track' failure rate of approximately 20-25%. Low cardiac output, postoperative bleeding and respiratory problems were the most frequent causes for 'fast-track' failure. CONCLUSIONS: The development of a 'fast-track' unit, supported by a computerised system for information collection and analysis and a pre-admission clinic, has resulted in a substantial improvement of operating numbers and financial income, without adversely affecting the clinical results. This task demanded close collaboration between a dedicated list manager and a designated member of the medical team. Patient selection with appropriate 'fast-track,' criteria may improve further the efficiency of 'fast-track' units in the future.

The algebra of healthcare reform: hospital-physician economic alignment.

In summary the tertiary care programs in this nation are trapped in a difficult dilemma. On one side is the ongoing reduction in provider revenue driven by real and powerful market forces. On the other side is a traditional payment system governed by necessary laws that inhibit meaningful re-engineering of tertiary care delivery. If a remedy to this situation cannot be created then it is very likely that all aspects of quality as defined earlier will suffer. It is our hope that by very careful construction of a relationship, with attention to applicable statutes and careful measurement of utilization and quality, a limited business alignment of a hospital and a group of tertiary physicians can be approved in the care of Medicare, Medicaid and all federally funded patients.

Academic medical center, community hospital partner to market center of excellence.

Northwest Hospital in Seattle and the University of Washington Medical Center both had strong cardiology centers. Northwest, however, needed to build its cardiac surgery services, so it entered into partnership with the university to create a new center of excellence in the highly competitive Seattle area.

[The "Heart Area" of Juan Canalejo Hospital Complex. A new approach to clinical management]. / El "área del corazón" del complejo hospitalario Juan Canalejo. Una nueva forma de gestión clínica.

The present work describes the process by which the pilot project of clinical management of the Hospital Complex Juan Canalejo, designated as "Heart Area", was implemented. In the first section, the needs and reasons that led to the undertaking of this project are explained. The project's objectives and operative strategies are listed. In the Material and Methods section, three basic aspects of the "Heart Area" are described: selection criteria of the "Area", its structure and function, and its foundation and development. In the Results section, we compare the activity undertaken in the "Area" to the situation present prior to its implementation, in relation to quality and costs. Finally, in the Conclusions, we comment on the important implications that our project can have within the Hospital Complex Juan Canalejo as well as in the health care field in general.