[Review of reimbursement for instrumental techniques used for assisted coughing and thoracic expansion. A French National Health Authority assessment (HAS)]. / Avis sur le remboursement de techniques instrumentales d'aide à la toux et à la mobilisation thoracique. Une évaluation de la Haute Autorité de santé (HAS).

INTRODUCTION: In France, children with neuromuscular diseases and patients with traumatic spinal cord injuries receive reimbursement for home use of intermittent positive-pressure breathing and mechanical in-exsufflators devices. The aim of the study was to update the indications for reimbursement for these both devices. METHODS: A literature review was conducted with several bibliographic databases using the main keywords: intermittent positive-pressure breathing, mechanical insufflation, mechanically-assisted cough, airway clearance. Nine health professionals were interviewed during two meetings. One health professional was interviewed via a questionnaire. An estimation of the population treated with in-exsufflators or intermittent positive-pressure breathing was undertaken from consumer data available for all beneficiaries of the health insurance system. STATE OF THE ART: The review identified 111 references which included 14 clinical practice guidelines, two systematic reviews and one randomized controlled trial. Some clinical data were available. Clinical practice guidelines were in favor of using intermittent positive-pressure breathing and in-exsufflators in patients with neuromuscular disease and spinal cord injuries. The healthcare professionals emphasized the need to reimburse the patient for home use of intermittent positive-pressure breathing and in-exsufflators. The patient population treated in the identified clinical situations was estimated at 3100 per year. CONCLUSIONS: Despite the low level of evidence and after interviewing healthcare professionals, the Haute Autorité de santé (HAS) recommended reimbursement of the costs of in-exsufflators (assisted coughing) and intermittent positive-pressure breathing (thoracic expansion) devices in adults and children with neurological and neuromuscular disease, including spinal cord injury.

Cost-effectiveness of heat and moisture exchangers compared to usual care for pulmonary rehabilitation after total laryngectomy in Poland.

The beneficial physical and psychosocial effects of heat and moisture exchangers (HMEs) for pulmonary rehabilitation of laryngectomy patients are well evidenced. However, cost-effectiveness in terms of costs per additional quality-adjusted life years (QALYs) has not yet been investigated. Therefore, a model-based cost-effectiveness analysis of using HMEs versus usual care (UC) (including stoma covers, suction system and/or external humidifier) for patients after laryngectomy was performed. Primary outcomes were costs, QALYs and incremental cost-effectiveness ratio (ICER). Secondary outcomes were pulmonary infections, and sleeping problems. The analysis was performed from a health care perspective of Poland, using a time horizon of 10 years and cycle length of 1 year. Transition probabilities were derived from various sources, amongst others a Polish randomized clinical trial. Quality of life data was derived from an Italian study on similar patients. Data on frequencies and mortality-related tracheobronchitis and/or pneumonia were derived from a Europe-wide survey amongst head and neck cancer experts. Substantial differences in quality-adjusted survival between the use of HMEs (3.63 QALYs) versus UC (2.95 QALYs) were observed. Total health care costs/patient were 39,553 PLN (9465 Euro) for the HME strategy and 4889 PLN (1168 Euro) for the UC strategy. HME use resulted in fewer pulmonary infections, and less sleeping problems. We could conclude that given the Polish threshold of 99,000 PLN/QALY, using HMEs is cost-effective compared to UC, resulting in 51,326 PLN/QALY (12,264 Euro/QALY) gained for patients after total laryngectomy. For the hospital period alone (2 weeks), HMEs were cost-saving: less costly and more effective.

Impacto económico de la resistencia a la meticilina en pacientes con bacteriemia por Staphylococcus aureus en hospitales de Bogotá / Economic burden of methicillin-resistant Staphylococcus aureus bacteremia in critical care patients in hospitals in Bogotá

Introducción. Las infecciones por microorganismos resistentes, especialmente las que involucran el torrente sanguíneo, se asocian a un mayor uso de recursos. Sus estimaciones son variables y dependen de la metodología utilizada. Staphylococcus aureus es el agente de sangre aislado con mayor frecuencia en nuestro medio. No existe información sobre el costo asociado con la atención de bacteriemias por S. aureus resistente a meticilina en nuestro país. Objetivo. Presentar una aproximación del costo de atención de las bacteriemias por S. aureus resistente a la meticilina en nueve hospitales de Bogotá. Materiales y métodos. Se incluyeron 204 pacientes en un estudio de cohortes multicéntrico en una razón de 1:1 según la resistencia. Se aproximaron los costos médicos directos con base en las facturas del período de hospitalización; en cuanto al período de la bacteriemia, los costos detallados se calcularon aplicando las tarifas estandarizadas. Resultados. No se encontraron diferencias significativas en las características clínicas y demográficas de los grupos, salvo en los antecedentes de la bacteriemia. El 53 % de los sujetos falleció durante la hospitalización. La estancia y el valor total facturado por la hospitalización fueron significativamente mayores en el grupo con bacteriemia por S. aureus resistente a la meticilina, así como los costos de la estancia en cuidados intensivos, de los antibióticos, los líquidos parenterales, los exámenes de laboratorio y la terapia respiratoria. El incremento crudo del costo de la atención asociado con la resistencia a meticilina fue de 31 % y, el ajustado, de 70 %. Conclusión. Este estudio constituye un respaldo a los tomadores de decisiones para la búsqueda y la financiación de programas de prevención de infecciones causadas por microorganismos resistentes.

Introduction: Resistant infections, especially those involving the bloodstream, are associated with a greater use of resources. Their estimates are variable and depend on the methodology used. Staphylococcus aureus is the main pathogen isolated in blood in our hospitals. There is no consolidated data about economic implications of methicillin-resistant S. aureus infection. Objective: To describe the cost of care of methicillin-resistant S. aureus bacteremia in a reference population from nine hospitals in Bogotá. Materials y methods: A multicenter cohort study included 204 patients in a 1:1 ratio according to resistance. Direct medical costs were calculated from hospitalization bills, while the bacteremia period was calculated by applying microcosting based on standard fares. Results: We found no significant differences between groups in demographic and clinical characteristics, except for resistance risk factors. Fifty-three percent of patients died during hospitalization. Hospital stay and total invoiced value during hospitalization were significantly higher in the group with methicillin-resistant S. aureus bacteremia. For this group, higher costs in ICU stay, antibiotics use, intravenous fluids, laboratory tests and respiratory support were recorded. A crude increase of 31% and an adjusted increase of 70% in care costs associated with methicillin resistance were registered. Conclusion: Our study supports decision makers in finding and funding infection prevention programs, especially those infections caused by resistant organisms.

Complications nearly double the cost of care after pancreaticoduodenectomy.

BACKGROUND: Despite considerable data focused on the morbidity of pancreaticoduodenectomy (PD), the financial impact of complications has been infrequently analyzed. This study evaluates the impact of the most common complications associated with PD on the cost of care. Additionally, we identified cost centers that were significantly affected by complications. METHODS: A retrospective analysis of a prospective database in a network of community-based teaching hospitals was performed. All patients (n = 145) who underwent PD were included for years 2005 to 2009. Of these, 144 had complete in-hospital cost data. Complications were assessed and classified into major and minor categories according to Dindo et al. Forty-nine cost centers were analyzed for their association with the cost of complications. Univariate and multivariate linear regression analyses were performed. Significance was reported for P < .05. RESULTS: The median cost for PD was $30,937. Patients with major complications had significantly higher median cost compared with those without ($56,224 vs $29,038; P < .001). Independent predictors of increased cost included reoperation; sepsis; pancreatic fistula; bile leak; delayed gastric emptying; and pulmonary, renal, and thromboembolic complications. Cost center analysis showed significant added charges for patients with major complications for blood bank ($1,018), clinical laboratory ($3,731), a computed tomography scan ($4,742), diagnostic imaging ($697), intensive care unit ($4,986), pharmacy ($33,850) and respiratory therapy ($1,090) (P < .05, all). CONCLUSIONS: This study identified the major complications of PD, which are significantly associated with a higher cost. Substantial cost center increases were associated with major complications, particularly in pharmacy ($33,850). Measures aimed at limiting complications through centralization of care or care pathways may reduce the overall cost of care for patients after pancreatic resection.

Spinal muscular atrophy type 1: are proactive respiratory interventions associated with longer survival?

CONTEXT: Spinal muscular atrophy type 1, an autosomal recessive motor neuron disease, is a leading genetic cause of death in infancy and early childhood. OBJECTIVE: To determine whether the early initiation of noninvasive respiratory interventions is associated with longer survival. DESIGN: Single-institution retrospective cohort study identified children with spinal muscular atrophy type 1 from January 1, 2002 to May 1, 2009 who were followed for 2.3 mean yrs. SETTING: Tertiary care children's hospital and outpatient clinics in a vertically integrated healthcare system. PATIENTS OR OTHER PARTICIPANTS: Forty-nine children with spinal muscular atrophy type 1 were grouped according to the level of respiratory support their caregivers chose within the first 3 months after diagnosis: proactive respiratory care (n = 26) and supportive care (n = 23). INTERVENTIONS: Proactive respiratory care included bilevel noninvasive ventilation during sleep and twice a day cough assist while supportive respiratory care included suctioning, with or without supplemental oxygen. MEASUREMENTS AND MAIN RESULTS: Kaplan-Meier survival curves were assessed based on intention to treat. Children treated with early proactive respiratory support had statistically longer survival compared to supportive care (log rank 0.047); however, the adjusted hazard ratio for survival was not statistically different (2.44 [95% confidence interval 0.84-7.1]). Children in the proactive group were more likely to be hospitalized for respiratory insufficiency (83% vs. 46%) and had shortened time after diagnosis until first hospital admission for respiratory insufficiency (median 118 vs. 979 days). CONCLUSION: Longer survival time with spinal muscular atrophy type 1 is associated with early, noninvasive respiratory care interventions after diagnosis.

[Costs of hospitalisation for exacerbations of COPD in patients receiving domiciliary rehabilitation]. / Coût des hospitalisations dues à une exacerbation de patients BPCO réhabilités à domicile.

INTRODUCTION: The aim of this study was to estimate the costs related to hospitalisation for exacerbations of COPD in patients who received domiciliary rehabilitation. METHODS: The hospital costs (obtained from the health insurance office of Bayonne) of 31 patients suffering from COPD of all stages, were analysed for the year of rehabilitation and for the preceding year. All the patients had access to the same management programme in a health care system: domiciliary bicycle ergometry, collective gymnastics, dietary advice, psychological support and education. RESULTS: The analysis of the costs of respiratory care revealed two populations: a minority in whom costs were increased (two end of life situations requiring palliative care and two severe episodes requiring intensive care), and a majority in whom domiciliary rehabilitation led to a reduction of over 60% in the costs related to hospitalisation. CONCLUSIONS: Respiratory rehabilitation reduces the costs of hospitalisation secondary to exacerbations in patients suffering from COPD but does not reduce the high costs related to severe episodes of respiratory failure or terminal care. It is important that rehabilitation is adapted to the needs of each patient until the end of his life.

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

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

Microvascular reconstruction and tracheotomy are significant determinants of resource utilization in head and neck surgery.

BACKGROUND: Successful "critical pathway" design and implementation are dependent on appropriate patient stratification according to those factors that are primary determinants of resource utilization. OBJECTIVES: To test the validity of our previously reported critical pathway design and to determine whether tracheotomy and microvascular reconstruction (MR) are primary determinants of resource utilization. DESIGN: Cost-effectiveness analysis. SETTING: Tertiary referral academic institution. METHODS: Retrospective analysis of data from 133 head and neck surgery cases in which the treatment regimen was based on critical pathways over a 26-month period. OUTCOME MEASURES: Length of stay and total patient charges were used as indices of resource utilization. One-way analysis of variance and t tests were used for statistical analysis of significance. RESULTS: Ninety patients (67.7%) underwent MR; 43 (32. 3%) did not. Seventy-five patients (56.4%) underwent tracheotomy; 58 (43.6%) did not. Four patient groups were constructed in decreasing order of complexity as follows: group 1, patients who underwent both tracheotomy and MR (n = 58); group 2, patients who underwent MR alone (n = 32); group 3, patients who underwent tracheotomy alone (n = 17); and group 4, patients who did not undergo either procedure (n = 26). Both tracheotomy and MR were found to be independent determinants of resource utilization and were additive when both were present. The length of stay varied from 8.4 days (in patients who underwent both procedures) to 6.7 days (in patients who did not undergo either procedure), with intermediate values in cases in which only 1 procedure was performed. The total charges varied in a similar manner from a high of $33,371 to a low of $19,994. Subanalysis with respect to intensive care unit, ward, and operating room charges showed a similar stratification. CONCLUSION: Tracheotomy and MR are both significant determinants of charges and length of stay in head and neck surgery cases and must be considered in the design of strategies to promote efficient resource utilization.

The patient level cost of asthma in adults in south central Ontario. Pharmacy Medication Monitoring Program Advisory Board.

OBJECTIVE: To assess the annual cost of asthma per adult patient from the perspectives of society, the Ontario Ministry of Health and the patient. DESIGN: Prospective cost of illness evaluation. SETTING: Ambulatory out-patients residing in southern central Ontario. POPULATION STUDIED: Nine hundred and forty patients with asthma over 15 years of age studied between May 1995 and April 1996. OUTCOME MEASURES: Direct costs, such as respiratory-related visits to general/family practitioners, respiratory specialists, emergency rooms, hospital admissions, laboratory tests, prescription medications, dispensing fees, devices and out-of-pocket expenses, were calculated. Indirect costs, such as absences from work or usual activities, and travel and waiting time, were studied. MAIN RESULTS: Unadjusted annual costs were $2,550 per patient. Hospitalizations and medications each accounted for 22% of the total cost and indirect costs 50% of the total costs. More severe disease, older age, smoking, drug plan availability and retirement were significant predictors of costs. Annual costs per patient varied from $1,255 (95% CI $1,061 to $1,485) in young nonsmokers with no drug plan and mild disease to $5,032 (95% CI $4,347 to $5,825) in older smokers with drug plans and severe disease. Clinically important reductions in the quality of life occurred with increasing severity. CONCLUSIONS: Interventions aimed at reducing productivity losses, admissions to hospital and medication costs may result in savings to society, the provincial government and the patient. The quality of policy and allocation decisions may be enhanced by cost of illness estimates that are comprehensive, precise and incorporate multiple perspectives.

Inhaled nitric oxide: clinical applications, indications, and toxicology.

PURPOSE: Although the analogy of nitric oxide (NO) to Endothelium-derived Relaxing Factor remains controversial, medical use of exogenous NO gas by inhalation has grown exponentially. This review presents the mechanisms of action of inhaled NO in pulmonary hypertension, hypoxaemia, inflammation and oedema, as well as its therapeutic and diagnostic indications with emphasis on acute respiratory distress syndrome (ARDS) and toxicology. SOURCE: Two medical databases (Current Contents, Medline) were searched for citations containing the above-mentioned key words to December 1996. Moreover, many presentations in congresses such as 4th International Meeting of Biology of Nitric Oxide, 52nd and 53rd Annual Meeting of Canadian Anaesthetists' Society or 10th Annual Meeting of European Association of Cardiothoracic Anaesthesiologists were used. PRINCIPAL FINDINGS: Inhaled NO is now recognized as an invaluable tool in neonatal and paediatric critical care, and for heart/lung surgery. Other clinical applications in adults, such as chronic obstructive pulmonary disease and ARDS, require a cautious approach. The inhaled NO therapy is fairly inexpensive, but it would seem that it is not indicated for everybody with regards to the paradigm of its efficiency and potential toxicity. The recent discovery of its anti-inflammatory and extrapulmonary effects open new horizons for future applications. CONCLUSION: Clinical use of inhaled NO was mostly reported in case series, properly designed clinical trials must now be performed to establish its real therapeutic role. These trials would permit adequate selection of the cardiopulmonary disorders, and subsequently the patients that would maximally benefit from inhaled NO therapy.

Benefits associated with a respiratory care assessment-treatment program: results of a pilot study.

BACKGROUND: During the months of July, August, and September 1993, we implemented a respiratory care assessment-treatment pilot study on the orthopedic surgery floor in our hospital. The purpose of the study was to determine feasibility and establish cost-effective treatment plans with quality patient outcomes, while maintaining appropriate communications with physicians and nursing staff. STUDY DEVELOPMENT & IMPLEMENTATION: The study's Task Force developed protocols for oxygen therapy, aerosolized medication therapy, volume expansion therapy, and bronchial hygiene therapy using the American Association for Respiratory Care's Clinical Practice Guidelines as supporting documents. Meetings were held with the orthopedic surgeons and nursing staff to inform them of the key components of the pilot program. Ten patient evaluators were trained to assess patients and implement treatment plans. EVALUATION METHODS: A reference book was established that contained the protocols and support material. Patient outcomes were evaluated using previously established quality assurance plans. The length of stay, procedural volume, and cost data were collected. EVALUATION RESULTS: More than 50% of the orders received during the pilot program were for "Respiratory Care Protocol." This allowed the patient care evaluator the flexibility to initiate one of the approved protocols if indicated. No changes in patient outcomes were noted and average length of stay remained unchanged during the pilot study compared to the base period. Treatment volumes decreased, resulting in identified cost savings of $5,318 during the study. Nurses and physicians supported protocol implementation, and increased communication among caregivers was documented. We believe that professionalism of the RCPs was enhanced without compromising the ultimate decision-making responsibilities of the physician. CONCLUSIONS: The use of respiratory care protocols is an acceptable method of developing clinically effective and fiscally responsible care plans. RCPs at our hospital were able to implement care plans that resulted in cost savings without a measured change in patient outcomes. Approval has been extended from the Executive Committee of the medical staff to expand hospital-wide.

Perioperative respiratory therapy (PORT). A program of preoperative risk assessment and individualized postoperative care.

In an effort to contain the expense of respiratory therapy modalities as well as to provide the level of respiratory care most appropriate for postoperative patients, we devised a perioperative respiratory therapy program (PORT). We describe the response of 1,476 consecutive patients treated by our Respiratory Care Department prior to and during the first year of PORT. Surgical procedures were divided into ten categories. The PORT group had significantly lower cost than the non-PORT group in two of the categories, with a significantly higher cost in one. We describe the advantages of PORT, which were identified by participating surgeons, respiratory therapists, and patients. We present a simple, bedside, risk assessment form which enabled us to predict the risk of postoperative pulmonary complications and to provide more aggressive respiratory therapy interventions to higher-risk patients.

Can postoperative pulmonary complications after elective cholecystectomy be predicted?

To determine predictors of postoperative morbidity in elective cholecystectomy patients, the authors examined prospectively the consequences of age, sex, active and past smoking, respiratory history, obesity, type of surgical incision, and preoperative pulmonary function, upon the incidence of postoperative pulmonary complications and length of hospitalization. They identified 31 (14.8%) complications in 209 patients; 21 had atelectasis, 8 purulent bronchitis, and 2 pneumonia. These patients averaged 1.5 days longer in the hospital (p less than 0.001 by analysis of variance) than control patients. Abnormal spirometry (MEFV) and the single-breath nitrogen test (SBN2) were significant predictors of postoperative pulmonary complications (p less than 0.001 by discriminant analysis method). Active smoking and history of respiratory disease were associated with abnormal small airway function (p less than 0.001 by chisquare test), but did not predict postoperative morbidity. By analysis of variance, only a reduction in preoperative FVC emerged as predictive of prolonged hospitalization (p less than 0.001). These results were used to determine if the selection of patients by preoperative pulmonary function testing permits more cost-effective administration of respiratory therapy (RT) services. Neither the MEFV nor SBN2 had sufficient specificity to enhance the cost effectiveness of postoperative RT.